metatstatic neck disease

1. METASTATIC NECK DISEASE
BY : DR MANJUBASHINI
SUPERVISOR : MS YATI
ENT SELAYANG

2. INTRODUCTION
 When cancer cells spread to cervical lymph nodes its called neck
metastasis
 Metastatic cervical lymphadenopathy is the most important
prognostic factor in head & neck SCC
 Cures rate drop in half when there is regional lymph node
involvement

3. TOPOGRAPHY OF CERVICAL LN
LEVEL I : Submental (IA) and Submandibular (IB)
nodes
IA – submental nodes which lie in the submental
triangle, i.e. between right & left anterior bellies of
digastric muscles & the hyoid bone
IB – submandibular nodes, lying between anterior &
posterior bellies of digastric muscle & the lower
border of the body of mandible

5. Cervical LN & areas drained
Submental (IA)
- Greatest risk of harbouring metastases from floor of
mouth, anterior oral tongue, anterior mandibular
alveolar ridge & lower lip
Submandibular (IB)
- oral cavity, anterior nasal cavity, soft tissue structure
of midface & submandibular glands

6. LEVEL II : Upper Jugular Nodes
Located along the upper third of jugular vein, i.e.
between the skull base above and the level of lower
border of hyoid bone (or bifurcation of carotid
artery) below.
Anterior to CN XI (IIA)
Posterior to CN XI (IIB)

8. Cervical LN & areas drained
Upper jugular (level IIA & IIB)
- Oral cavity, nasal cavity, nasopharynx, oropharynx,
hypopharynx, larynx & parotid gland

9. Level III : Middle jugular nodes
Located along the middle third jugular vein,
from the level of hyoid bone above, to the
level of lower border of cricoid cartilage ( or
where omohyoid muscle crosses the jugular
vein) below.

11. Cervical LN & areas drained
Middle jugular (level III)
- Oral cavity, nasopharynx, oropharynx,
hypopharynx, larynx

12. LEVEL IV : Lower Jugular Nodes
Located along the lower third of jugular vein,
from lower border of cricoid cartilage to the
clavicle
Virchow’s node is included into this level

14. Cervical LN & areas drained
Lower jugular (level IV)
- hypopharynx, thyroid, cervical esophagus &
larynx

15. Level V : Posterior Cervical group
 Located in the posterior triangle
 Include lymph nodes of spinal accessory chain, transverse
cervical nodes & supraclavicular nodes
 Further divided into upper, middle & lower, corresponding to
planes that define levels II, III & IV
 Above the level of intermediate tendon of omohyoid (VA)
 Below the level of intermediate tendon of omohyoid (VB)

17. Cervical LN & areas drained
Posterior triangle group (level VA & VB)
- nasopharynx, oropharynx & cutaneous
structures of posterior scalp & neck

18. Level VI : Anterior Compartment Nodes
Located between the medial border of SCM (
or carotid sheaths) on each side, hyoid bone
above & suprasternal notch below
Includes prelaryngeal, pretracheal &
paratracheal nodes

20. Cervical LN & areas drained
Anterior compartment group (level VI)
- Thyroid gland, subglottic, apex of pyriform
sinus & cervical esophagus

21. Level VII : nodes of upper mediastinum
Located below the suprasternal notch &
include nodes of the upper mediastinum

22. Clinical staging of cervical LN
 Nx – regional LN cant be assessed
 N0 – no regional LN metastases
 N1 – single ipsilateral LN ( < or = 3cm) & ENE negative
 N2a – single ipsilateral LN ( 3-6 cm), not larger than 6cm in greatest
dimension & ENE negative
 N2b – multiple ipsilateral LN ( 3-6 cm), not larger than 6 cm in greatest
dimension & ENE negative
 N2c – bilateral or contralateral LN ( 3-6 cm) & ENE negative
 N3a – Any LN > 6 cm in greatest dimension & ENE negative
 N3b – metastases in any nodes(s) and clinically overt ENE positive

23. Assessment of cervical lymphadenopathy
1. History & clinical examination (accuracy of 77%)
2. Fine needle aspiration cytology in occult primary (90%)
3. Open/ Core biopsy (anaplastic/lymphoma)
4. USG Neck (70%)
- Absent hilar echoes

24. 5. CT scan Neck with contrast (83%)
- Short axis diameter larger than 1 cm
- Cluster of three or more borderline enlarged nodes larger
than 0.8cm
- Nodal necrosis or patchy enhancement within the nodes
- Rim enhancement

25. MRI with I/V contrast (83%)
- N0 neck
- ENE
- Deep invasion

26.  CT – PET
- Occult primary
- Residual disease
- Recurrence

27. Management of metastatic neck disease
1) Radiotherapy
2) Surgery
3) Pre or post operative radiotherapy

28. Indications of radiotherapy
1. Primary tumour treated with radiotherapy i.e. NPC
2. Post operative radiotherapy
3. Prophylactic N0 – oral cavity, supraglottic larynx
4. Palliative

29. Classification of neck dissection techniques
Radical neck dissection
Modified radical neck dissection
Selective neck dissection
Extended radical neck dissection

30. Radical Neck dissection
 Structures removed
- Level (I – V)
- IJV
- SCM
- Spinal accessory nerve

31. Modified Radical neck dissection
Structures removed
- Level I –V
- One of non lymphatic is preserved
Type 1 – accessory spinal nerve
Type 2 – accessory spinal n. + IJV
Type 3 – accessory spinal n. + IJV + SCM

32. Selective Neck dissection
 One or more LN level preserved
1. Supraomohyoid – I – III
2. Extended supraomohyoid (anterolateral) – I – IV
3. Lateral – II – IV
4. Posterolateral – II – V
5. Anterior or central – VI ( perithyroid, delphian, trachea-
oesophageal & anterosuperior mediastinum)

33. Extended radical neck dissection
Additional LN groups or non lymphatic

34. Contraindications of neck dissection
Patient unfit for surgery
Primary not treatable (irresectable)
- Adherent to common or internal carotid a.
- Invasion of skull base
Extensive bilateral neck disease
Distant metastases

35. N1
 Primary treated with surgery  MRND (I)
 Primary treated with radiation  neck irradiation
 Upstaging after pathological assessment  adjuvant
radiotherapy
 Chemoradiation followed by neck dissection (residual disease)

36. N2a & N2b
 Primary treated with surgery  comprehensive neck
dissection
 Adjuvant RT (success rate >10%)
 Adjuvant chemo – radiation in ENE
 Primary treated with RT  residual salvage surgery

37. N2c
5 percent of head & neck cancers
Common primary site tongue base, supraglottic &
hypopharynx
If operable (radical neck dissection + conservative
neck dissection on less involved site) +adjuvant
radiotherapy
Chemo- radiation

38. N3
Usually fixed to skin or underlying structure
High risk for distant metastases
Mostly incurable
Decision depends on stage of disease, presence or
absence of fixation & structure to which node is fixed

39. Occult Primary
 Carcinoma of unknown primary site (CUP) represents a heterogeneous
group of malignancies presenting with lymph node or distant metastases,
for which diagnostic work-up fails to identify the site of origin
 Neck lymph node metastases from occult primary constitute about 5%-10%
of all patients with carcinoma of unknown primary site.
 Metastases in the upper and middle neck (levels I-II-III-V) are generally
attributed to head and neck cancers, whereas the lower neck (level IV)
involvement is often associated with primaries below the clavicles
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2639847/

40.  Diagnostic procedures include a careful clinical evaluation and a fiberoptic
endoscopic examination of the head and neck mucosa, biopsies from all
suspicious sites or blindly from the sites of possible origin of the primary,
computerized tomography scan, and magnetic resonance.
 The most frequent histological finding is Squamous Cell Carcinoma,
particularly when the upper neck is involved.
https://www.frontiersin.org/articles/10.3389/fonc.2020.593164/full

41. DIAGNOSTIC WORK UP
Diagnostic work-up (from the literature).
Clinical evaluation
Personal history, focusing on tumour history
Performance status, respiratory system and cardiovascular evaluation with ECG; additional exams at
the discretion of the physician
Complete ENT clinical and fibrescopic evaluation, careful examination of surgical scars
Imaging
Chest X-ray, Thyroid and neck US
FNA biopsy (slides review if biopsed elsewhere)
Exams following cyto/histopathological diagnosis:
Squamous cell carcinoma or undifferentiated carcinoma
MRI/CT
PET-CT

42. Unknown primary treatment
 T0N1M0
- Single modality treatment (neck dissection or radiotherapy)
 T0N2M0 & T0N3M0
- Neck dissection + adjuvant chemo-radiation

43. FOLLOW UP
 Follow-up examinations are scheduled on an individual basis
determined by the risk of recurrence, to survey for the
appearance of the primary tumour, development of second
primary tumours, to deal with morbidity from treatment and
with comorbidity not directly related to the cancer itself.
 During radiation therapy periodic examinations by the head
and neck surgeon may be necessary in patients experiencing
difficulty with nutritional intake, airway or pain control.

44.  After all treatment is completed periodic examinations by the
radiation oncologist and a dentist in patients that received
radiation therapy are recommended.
 Thyroid function tests should be monitored if the patient
received radiation to the lower neck since up to 30% of
patients may develop subclinical or overt radiation-induced
hypothyroidism.

45. THANK YOU

46. REFERENCES
 Dhingra Diseases of Ear, Nose and Throat
 https://www.frontiersin.org/articles/10.3389/fonc.2020.593164/full
 https://www.theplasticsfella.com/lymph-nodes-of-the-neck/
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2639847/