Role Of Surgery In Management of Neck Nodes 2 - Copy.pptx

ROLE OF SURGERY IN
MANAGEMENT OF NECK NODES
Dr Cheshta Sharma
JR - 1
Moderator- Dr Aditya Singla

Anatomy Of The Neck
The side of the neck is roughly quadrilateral in
outline.
 Anterior - by anterior median line.
 Posterior - by the anterior border of
trapezius.
 Superior - by the base of mandible, a line
joining angle of the mandible to mastoid
process, and superior nuchal line.
 Inferior - by the clavicle
 This quadrilateral space is divided obliquely
by the sternocleidomastoid muscle into the
anterior and posterior triangles.

ANATOMY OF THE NECK
• Region of body between lower border of mandible and suprasternal
notch and upper border of clavical
• structures in the neck :
a. Glands: Thyroid , parathyroid
b. Thymus: Involutes at puberty
c. Arteries: Subclavian and carotid
d. Veins: Subclavian, internal jugular, brachiocephalic
e. Nerves: Glossopharyngeal, vagus, accessory , hypoglossal
f. Sympathetic trunk: It has three cervical ganglia
g. Lymph nodes and thoracic duct.
h. Styloid apparatus.

LAYERS OF NECK
• Skin
• Superficial fascia
• Deep fascia
• Muscles, blood and lymphatics supply and nerves

SKIN
• The skin of the neck is supplied by the second, third and fourth
cervical nerves.
• The anterolateral part is supplied by anterior primary rami through
the
(i) anterior cutaneous,
(ii) great auricular,
(iii) lesser occipital,
(iv) supraclavicular nerves.
• A broad band of skin over the posterior part is supplied by dorsal or
posterior primary rami

SUPERFICIAL FASCIA
Superficial fascia contains areolar tissue with platysma.
Lying deep to platysma are –
• cutaneous nerves,
• superficial veins ,
• lymph vessels,
• lymph nodes and small arteries

Platysma
• Origin - Fascia overlying pectoralis major and deltoid muscle
• Insertion - Lower border of mandible
• Nerve supply - Cervical branch of facial nerve
• Action - Depresses mandible

DEEP CERVICAL FASCIA
• The deep fascia of the neck is condensed to form the
following layers:
1 Investing layer
2 Pretracheal fascia
3 Prevertebral fascia
4 Carotid sheath
5 Buccopharyngeal fascia
6 Pharyngobasilar fascia

DEEP CERVICAL FASCIA
 Investing layer
• It lies deep to the platysma, and
surrounds the neck like a collar.
• Superiorly - a. External occipital
protuberance
b. Superior nuchal line
c. Mastoid process, styloid
process
d. External acoustic meatus,
tympanic plate
e. Base of the mandible.

INVESTING LAYER
• Inferiorly
a. Spine of scapula
b. Acromion process,
c. Clavicle, and
d. Manubrium.
•Posteriorly
a. Ligamentum nuchae, and
b. Spine of seventh cervical vertebra.
•Anteriorly
a. Symphysis menti
b. Hyoid bone.
Both above and below the hyoid bone

PRETRACHEAL FASCIA
• It encloses and suspends the thyroid gland and forms its false
capsule.
 Attachments
Superiorly
• Hyoid bone in the median plane
• Oblique line of thyroid cartilage—laterally
• Cricoid cartilage—more laterally

PRETRACHEAL FASCIA
INFERIORLY
• Below the thyroid gland, it encloses the inferior
thyroid, passes behind the brachiocephalic veins, and
finally blends with the arch of the aorta and fibrous
pericardium.
On Either Side
• It forms the front of the carotid sheath,
• fuses with the fascia deep to the sternocleidomastoid

PREVERTEBRAL FASCIA
It lies in front of the prevertebral muscles, and forms the
floor of the posterior triangle of the neck.
Attachments and Relations
 Superiorly
• It is attached to the base of the skull.
 Inferiorly
• It extends into the superior mediastinum where it splits
into anterior and posterior layers.

PREVERTEBRAL FASCIA
 Anteriorly
• separated from the pharynx and buccopharyngeal fascia by
the retropharyngeal space containing loose areolar tissue.
• In the lower part of neck, prevertebral and
buccopharyngeal fasciae fuse.
• Lymph nodes lie in the retropharyngeal space.
 Laterally
• It lies deep to the trapezius and is attached to fascia of
sternocleidomastoid muscle.

CAROTID SHEATH
• It is a condensation of the
fibroareolar tissue around the main
vessels of the neck.
• formed on anterior aspect by
pretracheal fascia and on posterior
aspect by prevertebral fascia
Contents –
• common or internal carotid arteries
• internal jugular vein and vagus nerve
• It is thin over the vein
• IX, XI, XII nerves

RETROPHARYNGEAL SPACE
 Situation: Dead space behind pharynx.
 Function: Acts as a bursa for expansion of pharynx during
deglutition.
 Boundaries: Anterior: Buccopharyngeal fascia
Posterior: Prevertebral fascia.
The two get fused.

BUCCOPHARYNGEAL FASCIA
• This fascia covers all the constrictor muscles externally and
extends onto the superficial aspect of the buccinator muscle
and is attached to pharyngeal tubercle.
• Retropharyngeal space lies posterior to buccopharyngeal
fascia.

PHARYNGOBASILAR FASCIA
• This fascia is especially thickened
between the upper border of
superior constrictor muscle and
the base of the skull.
• It lies deep to the pharyngeal
muscles

RETROPHARYNGEAL SPACE
 Sides: Carotid sheath
 Superior: Base of skull
 Inferior: Open and continuous with superior mediastinum.
 Contents: Retropharyngeal lymph nodes,pharyngeal plexus of
vessels and nerves, loose areolar tissue.
 Clinical Pus collection due to lymph node
 Anatomy: abscess which lies in paramedian postion. It should be
differentiated from cold abscess of spine of cervical vertebrae
which is seen in median plane.

LATERAL PHARYNGEAL SPACE
 Situation: Side of pharynx
 Boundaries:
 Medial: Pharynx
 Posterolateral: Parotid gland
 Anterolateral: Medial pterygoid
 Posterior: Carotid sheath
 Contents: Branches of maxillary artery ,Fibrofatty tissue
 Clinical Anatomy- Pus collection/Ludwig’s angina

TRIANGLES OF THE NECK
AND
NECK MUSCLES

ANTERIOR TRIANGLE OF NECK
 subdivided (by the digastric muscle and the superior belly of
the omohyoid) into:
• Submental,
• Digastric,
• Carotid, and
• Muscular triangles

MUSCLES OF THE NECK
• Infrahyoid muscles (these muscles may also be
regarded arbitrarily as forming the floor of the
muscular triangle)
INFRAHYOID
MUSCLES
STERNOHYOID OMOHYOID STERNOTHYROID
THYROHYOID

• Infrahyoid muscles are ribbon like , arranged in 2 layers :
A. Superficial layer -
sternohyoid (medially)
superior belly of omohyoid
B. Deep layer -
sternothyroid (below)
thyrohyoid (above)
MUSCLES OF THE NECK

STERNOCLEIDOMASTOID
 Origin-
• Sternal head is tendinous and arises from the superolateral part of
the front of the manubrium sterni
• Clavicular head is musculotendinous and arises from the medial
one-third of the superior surface of the clavicle
 Insertion -
• By a thick tendon into the lateral surface of mastoid process, from
its tip to superior border.
• By a thin aponeurosis into the lateral half of the superior nuchal
line of the occipital bone

STERNOCLEIDOMASTOID
 Nerve supply - spinal accessory nerve provides the motor supply
• Branches from the ventral rami of C2 and C3 are proprioceptive
 Action –
• 1 When one muscle contracts:
• a. It turns the chin to the opposite side
• b. It can also tilt the head towards the shoulder of same side.
• 2 When both muscles contract together:
• a. They draw the head forwards, as in eating and in lifting the head from a
pillow.
• b. With the longus colli, they flex the neck against resistance.
• c. It also helps in forced inspiration

STERNOCLEIDOMASTOID
• Arterial supply—
• one branch each from superior thyroid artery and
suprascapular artery
• two branches from the occipital artery.
• Veins follow the arteries

NERVES OF SURGICAL IMPORTANCE
IN NECK

NERVES OF SURGICAL IMPORTANCE
IN NECK
• MARGINAL MANDIBULAR NERVE
• GLOSSOPHARYNGEAL NERVE
• VAGUS NERVE
• HYPOGLOSSAL NERVE
• ACCESSORY NERVE

MARGINAL MANDIBULAR NERVE
• M/C injured in level IB dissection
• Landmark- 1cm anterior and inferior to angle of mandible ,
mandibular notch
• Subplatysmal
• Deep to fascia of submandibular gland
• Superficial to facial vein

GLOSSOPHARYNGEAL NERVE— CN IX
• Exits the cranial cavity via anterior part of jugular foramen
Course :
• It runs between internal carotid artery and internal jugular
vein,
• Between internal carotid and external carotid arteries, where
it curves round the lateral border of stylopharyngeus muscle.
• As it reaches submandibular region, it passes deep to
hyoglossus muscle to reach the area of palatine tonsil and
base of the tongue

GLOSSOPHARYNGEAL NERVE
• Branches :
1 )Tympanic branch courses through middle ear and gives
secretomotor root to otic ganglion.
2 )Carotid branch for carotid body and carotid sinus.
3 )Muscular for stylopharyngeus muscle.
4 )Carries taste from vallate papillae of tongue.
5 )Carries general sensations from posterior one-third of tongue
and palatine tonsil.
6 )Branch to pharyngeal plexus

VAGUS NERVE—X
• Vagus leaves the cranial cavity
through jugular foramen lying
posterior to IX nerve.
• Soon it is joined course by cranial
root of XI nerve.
• In the neck, the nerve lies in the
carotid sheath, medial to internal
jugular vein and posterior to
internal carotid and common
carotid arteries
• Then it passes through thorax and
abdomen.

• Branches in Neck :-
Meningeal
Auricular
Pharyngeal
Right recurrent laryngeal in neck
left one in thorax.
all intrinsic muscles of larynx,
sensory to mucous membrane of larynx
below vocal cords.
VAGUS NERVE—X

HYPOGLOSSAL NERVE
• Motor nerve
• Cell bodies in nuclues in medulla
• Exits sull via hypoglossal canal
• Lies deep to ica, ijv, cn ix , x , xi
• Curves 90 degrees , passes b/w ijv and ica
• Surrounded by veinous plexus
• Iatrogenic injury m/c site – floor of submadibular triangle just
deep to the duct

ACCESSORY NERVE—XI NERVE
• Leaves the cranial cavity through the jugular foramen.
• It is made up of a cranial root and a spinal root. The two roots
join in jugular foramen, but again separate as it passes out of
the foramen
• Cranial root joins X nerve and gets distributed with it
• spinal root descends between internal jugular vein and
internal carotid artery
• DESCENDS OBLIQUELY IN LEVELS II DIVIDES IT INTO IIA AND IIB

• Then lies superficial to internal jugular vein to reach anterior
border of sternocleidomastoid muscle.
• It enters the muscle, supplies it and leaves the muscle at its
posterior border a little above its middle.
• Then it passes downwards and backwards in the posterior
triangle of neck.
• Finally, it leaves posterior triangle by passing deep to
trapezius
• Thus , the spinal root of XI nerve supplies:
Sternocleidomastoid and trapezius muscles
ACCESSORY NERVE—XI NERVE

RISK OF LYMPH NODE METASTASES
Influenced by :
• The location of the primary tumor,
• Histologic differentiation,
• Size of the lesion,
• LVI/PNI
• DOI

LYMPH NODE METASTASES
As tumor grows within a lymph node,
• the node becomes indurated
• more rounded
• enlarged.
• Tumor eventually extends through the capsule of the lymph
node and invades surrounding structures.
• Extension to neurovascular bundles is common and may
produce a mass that is fixed to palpation.

• The most commonly involved lymph nodes in the head and
neck are the level II lymph nodes, followed by the level III
lymph nodes.
• Lesions that are well lateralized almost always spread first to
the ipsilateral neck nodes.
• Lesions on or near the midline as well as lateralized base of
tongue and nasopharyngeal lesions may spread to both sides
of the neck.

• Patients with clinically positive lymph nodes on the ipsilateral
side of the neck may be at risk for contralateral lymph node
spread if the metastatic masses produce significant
obstruction of the lymphatic trunks.
• In addition, patients who have undergone previous surgery on
one side of the neck develop shunting of lymph across the
submental region to the opposite side of the neck.
• When contralateral lymph node metastases occur, the level II
lymph nodes are most frequently involved, followed by the
level III and level IV lymph node groups

CLINICAL STAGING OF NECK NODES

PATHOLOGICAL STAGING OF NECK
NODES

INCIDENCE OF OCCULT NECK NODES IN
HNC
SITE IPSILATERAL LN CONTRALATERAL LN
ORAL CAVITY 25% 3%
OROPHARYNX 20% 15- 30%
HYPOPHARYNX AND
LARYNX
30-50% 40-60%

HISTORY OF NECK NODES MANAGEMENT
 19TH CENTURY
• 1880 - Kocher advocated wide margin lymphadectomy
• 1881 - Kocher and packard recommended dissection of
submandibular triangle for lingual carcinomas
• 1885 - Butlin questions RND for oral N0 disease
• 1888 - Jawdynski described en bloc resection with resection
of carotid, IJV, SCM.

 20TH CENTURY
• 1901 - Solis- Cohen advocated lymphadenectomy for N0
laryngeal carcinoma
• 1926 - Barlett and Collander advocated preservation of CN XI
, IJV, SCM , Platysma , Stylohyoid, Digastric
• 1933 - Blair and Brown advocated removal of CN XI

• 1951 - Martin advocated RND in N+ cases
• 1952 - Suarez described functional neck dissection  preservation
of SCM, Omohyoid, Submandibular gland, IJV, CN XI. Enabled
preservation of carotid
• 1960s - MD Anderson advocated selective ND of highest risk nodal
basins
• 1967 - Bocca and Pignataro describe functional neck dissection
• 1975 - Bocca establish oncologic safety of FND compared to RND

• Credit for neck dissection as a curative procedure for cervical
metastases belongs to george washington crile from the
cleveland clinic
• In 1900, he performed different types of neck dissections and
subsequently described the classic operation of the radical
neck dissection (rnd) in his seminal article of 1905 published
in the transactions of the southern surgical and gynecological
association.
• This operation is the basis of all neck dissections, with
subsequent surgeries framed as modifications of this initial
operation.

• Hayes Martin from Memorial Sloan-Kettering Cancer
Center described the stepwise procedure of RND in his
classic article in 1951.
• However, this operative procedure is not without
significant morbidity
• It results in a cosmetic deformity and dysfunction of
shoulder movement due to en bloc resection of the
accessory nerve, sternocleidomastoid muscle, internal
jugular vein, and the tail of the parotid gland.

• Argentinian surgeon oswaldo suarez was the first to
describe functional neck dissection in 1963, now called
modified radical neck dissection (MRND).
• Described the removal of all five lymph node levels in
the neck
• Preserving the spinal accessory nerve,
sternocleidomastoid muscle, and internal jugular vein
to limit any functional disability in the shoulder

TYPES OF VARIOUS TYPES OF NECK
DISSECTION
• Radical Neck Dissection (RND)
• Modified RND TYPE I, II, III
• Supraomohyoid dissection
• B/L dissection
• Selective neck dissection
• Extended neck dissection

RADICAL NECK DISSECTION (RND)
Structures removed :
• Lymph nodes from level I-V,
• ipsilateral sternocleidomastoid muscle (SCM),
• internal jugular vein (IJV),
• spinal accessory nerve (SAN)
• the parotid tail is rarely included in modern RND.
• RND is indicated when there is bulky nodal disease in the neck
with extensive soft tissue involvement due to extra-capsular
spread

RADICAL NECK DISSECTION (RND)
• The only indication to remove nonlymphatic structures in the
neck (nerves, muscles, internal jugular vein, etc.) is direct
involvement of the structure by a cancerous node

MODIFIED RADICAL NECK DISSECTION
• AKA functional neck dissection
• Removal of lymph nodes in levels I to V
• Preservation of at least one of the following structures:
o Spinal accessory nerve,
o Sternocleidomastoid muscle, or
o Internal jugular vein.
• This approach is used when the nodal burden is advanced
with high-risk spread to level V or invasion of nonlymphatic
structures

TYPE I (MRND-I)
Structures removed :-
• Lymph nodes from level I-V,
• Ipsilateral sternocleidomastoid muscle,
• Internal jugular vein are,
Preservation of the spinal accessory nerve.
Indications for mrnd-i is in bulky nodal disease
With extracapsular spread involving the SCM and IJV,
Where the accessory nerve is free of disease.

TYPE II (MRND-II)
• Removal of lymph nodes from level I-V
• Ipsilateral sternocleidomastoid muscle,
• Preservation of IJV and accessory nerve.
• Indications : bulky nodal disease with SCM involvement but
sparing the IJV or accessory nerve.

TYPE III (MRND-III)
• Removed : lymph nodes from level I-V
• Preservation of SCM, IJV, and SAN.
• Indicated in metastatic disease with limited extracapsular
spread and the ij, scm, and accessory nerve can all be
dissected free
• This procedure has an indication for thyroid cancer and upper
aerodigestive carcinomas with positive lateral neck nodes but
limited extracapsular spread

SUPRAOMOHYOID NECK DISSECTION
(SOHD)
• Lymph nodes removed are levels I– III,
• Sparing of IJV, SCM, and accessory nerve.
• Indicated in the N0 neck for primary SCC

SELECTIVE NECK DISSECTION
• Most commonly performed surgical neck treatment of neck
lymphatics is now the selective neck dissection.
• This preservs all nonlymphatic structures and only removing
the high-risk lymphatic levels.
• The advantage of this approach is that it maintains function,
minimizes morbidity, and does not compromise oncologic
treatment.

• The levels to be removed are determined by site of cancer.
• Levels I to III are addressed for oral cavity cancers.
• Levels II to IV are included for treatment of oropharyngeal,
laryngeal, and hypopharyngeal cancers.
• If nodes suspicious for metastases are encountered in areas
outside of the planned neck dissection, the selective neck
dissection should be converted to a modified radical neck
dissection

• Removal of lymph nodes in levels Ib–IV,
• Sparing of IJV, SCM, and SAN.
• Indicated in N0 neck for SCC of the lateral tongue, oral cavity,
anterior floor of mouth, or for N1 disease in these primary
sites

LATERAL NECK DISSECTION
 also technically a selective neck dissection
• Removal of lymph nodes from levels II-IV with sparing of IJV,
SCM, and accessory nerve.
• Indications –
• any N-stage neck without significant extracapsular spread for
SCC of larynx and hypopharynx,
• for differentiated thyroid carcinoma,
• melanoma with a positive sentinel lymph node that drains to
these nodal basins.
• Certain primary parotid malignancies also warrant this
operation

POSTERO-LATERAL NECK DISSECTION
Removal of levels II–V, suboccipital, retroauricular nodes
Sparing of IJV, SCM, and SAN.
Indications –
• any N-stage neck SCC
• cutaneous melanoma with high-risk features or melanoma
with a positive sentinel node where the primary site is
posterior to the ear

BILATERAL NECK DISSECTIONS
• May be performed simultaneously or separately (staged) in patients
with bilateral neck disease as long as one internal jugular vein can
be preserved.
• If both internal jugular veins need to be sacrificed, at least one
should be reconstructed with a vein graft (e.g., saphenous vain or
femoral vein).
• If both internal jugular veins sacrificed, patient is at high risk of
cerebral edema, extreme facial edema, and potentially blindness
• Nodes Levels I to IV removed

EXTENDED NECK DISSECTION
• Removal of additional lymphatic groups (parotid, occipital,
level VI, mediastinal, retropharyngeal)
Or
• Non-lymphatic structures (skin, muscle, nerve, blood vessels
etc.) that are not usually included otherwise

Anaesthesia and positioning
• Done under general anaesthesia
• Without muscle relaxation (as eliciting movement on
mechanical or electrical stimulation of the marginal
mandibular, hypoglossal and accessory nerves assist with
locating and preserving these nerves)
• The patient is placed in a supine position with the neck
extended and turned to the opposite side
MODIFIED NECK DISSECTION:
OPERATIVE STEPS

Incisions and flaps
Take into consideration :
• Access that may be required to resect the primary tumour,
• Cosmetic factors,
• Blood supply to the flaps.
Flaps are elevated in a subplatysmal plane with a knife or with
Monopolar electrocautery.
Making the flaps too thin may compromise the blood supply to
the skin flaps.
MODIFIED NECK DISSECTION:
OPERATIVE STEPS

INCISION
Transverse skin incision
• Commonly used for MND done in
association with cancers of the
oral cavity, oropharynx, nasal
cavity sinuses and skin cancers of
the midface.
• The transverse skin incision can
be extended across to the
opposite side with bilateral neck
dissections or can be extended
superiorly to split the lower lip in
the midline to gain access to the
oral cavity

• Hockey stick incision -
• Can be extended into a
preauricular skin crease
• Particularly useful for combined
parotidectomy and neck
dissection
INCISION

STEPS IN RND
• A horizontal incision placed in a skin crease at about the level
of the hyoid bone.
• The incision is made through skin, subcutaneous fat, and
platysma muscle.
• Anteriorly, flaps should be raised to the lateral border of the
strap muscles.
• Identify the external jugular vein and greater auricular nerve
overlying the sternocleidomastoid muscle (scm)

• Superior flap elevated with cautery until the submandibular
salivary gland is identified.
• Posteriorly, the skin flaps should be raised to the anterior
border of the trapezius
• The submandibular gland fascia incised inferiorly over the
gland to avoid injury to the marginal mandibular nerve
• resect the fat and lymph nodes from the submental triangle
(Level Ia).
STEPS IN RND

• A subplatysmal dissection extended to the
opposite anterior belly of digastric muscle,
taking care not to injure the anterior jugular
veins.
• The submental triangle is resected inferiorly
to the hyoid bone with electrocautery.
• The deep plane of dissection is the
mylohyoid muscles
STEPS IN RND

• Anterior border of the SCM is identified, and the muscle is
retracted posteriorly
• Carotid sheath is identified deep to the muscle.
• The IJV will be identified as superficial and lateral to the
carotid.
• The sternal and clavicular heads of the SCM are then divided.
• The omohyoid muscle divided.
STEPS IN RND

• inferior end of the internal jugular is isolated and ligated,
• SCM and IJ are then reflected superiorly, allowing access to
the supraclavicular lymph nodes and the floor of the neck
• deep layer of deep cervical fascia overlying the anterior
scalene muscle is left intact to protect the phrenic nerve.
STEPS IN RND

• brachial plexus identified and should be protected
• SCM, IJV, and lymph nodes are then rolled superiorly to the
level of the hyoid bone.
• removal of all nodal contents from level V to be reflected
anteriorly
• At this time, the surgeon may choose to save the root of CN XI
and the trapezius branch. The CN XI branch to the SCM is
sectioned, allowing further reflection of the SCM
STEPS IN RND

• Tendons of the digastric and stylohyoid muscles are divided
while protecting the hypoglossal nerve (CN XII), allowing for
access to the superior aspect of the IJV and the
submandibular region contents
• Facial artery and vein are ligated on the inferior aspect of the
submandibular gland.
• The submandibular gland and associated lymph nodes are
then reflected superiorly and raised off of the mylohyoid
STEPS IN RND

• Mylohyoid is retracted anteriorly to reveal the course of CN XII
along with the lingual nerve and submandibular duct.
• The duct and submandibular ganglion are then ligated,
preserving the lingual nerve.
• Submandibular gland is then dissected free from the
mandible and reflected posteriorly, exposing the superior
aspect of the ijv. The IJV is then ligated high in the neck
STEPS IN RND

• Dissection continues through the inferior 1/3 of the parotid--
or parotid tail-- being careful to avoid injury to the main trunk
of the facial nerve.
• Dissection then continues through the superior aspect of the
SCM at the mastoid tip, allowing for en bloc removal of the
specimen
• Neck is then irrigated, and surgical drains are placed.
• The wound is closed in layers, which include the platysma,
dermis, and skin.
STEPS IN RND

COMPLICATIONS OF NECK DISSECTION
• Wound dehiscence  Most common
• Hematoma
• Seroma
• Lymphedema
• Wound infection
• Skin flap necrosis
• Chyle leak
• Damage to cranial nerves V, VII, X, XI, and XII
• Internal jugular vein rupture
• Carotid rupture

COMPLICATIONS OF NECK DISSECTION
• The incidence of complications higher when neck dissection
combined with resection of the primary lesion or when it
follows a course of radiation therapy (RT).
• The postoperative mortality rate for unilateral neck dissection
after RT was 3% for patients treated between 1964 and 1982
• This figure is now <1% due to better techniques and
management

CONTRAINDICATIONS TO SURGERY
Relative contraindications:-
• Severe cardiopulmonary disease,
• COPD with poor functional status
• Preoperative imaging showing deep infiltration of the tumor
in the prevertebral space, scalene muscles, levator scapula
muscle, phrenic nerve, and brachial plexus are not suitable
candidates
• The primary tumor that is uncontrollable.
• Distant metastatic disease

RELATIVE CONTRAINDICATIONS
• Decision to add a neck dissection after RT for multiple
unilateral positive nodes or bilateral lymph node disease is
individualized
• It is based on the diameter of the largest node, node fixation,
and number of clinically positive nodes in the neck.
• If clinically positive lymph nodes disappear completely during
RT, the likelihood of control by RT alone is improved and a
neck dissection may be withheld

ABSOLUTE CONTRAINDICATION
• Tumor encasement of the carotid artery (many authors view
this as 'unresectable disease,' as resection and grafting does
not confer a survival or local control advantage, even if it is
technically possible)
• Fixed neck mass in the deep neck muscles, prevertebral fascia,
and/or skull base involvement (unresectable disease)
• Patient unfit for general anesthesia and resection

SLN BIOPSY
• An ancillary diagnostic method for assessing the presence of
occult metastatic disease in a N0 neck.
• Minimally invasive technique eliminates the need for a neck
dissection
• Procedure based on the identification and evaluation of
echelon nodes (i.e. First station or levels I and II) for
metastatic spread;

• Shoaib et al. suggested a protocol involving preoperative
lymphoscintigraphy, intraoperative blue dye and gamma
probe localisation
• Technique based on observing the route of lymphatic flow via
imaging after the injection of a radioactive contrast agent
near the primary tumour
• Flow and direction of the lymph visualised preoperatively by
means of lymphoscintigraphy or single-photon emission
computed tomography (spect)
SLN BIOPSY

Lymphoscintigraphy reveals
• SLNs associated with the primary tumour,
• unexpected lymphatic drainage patterns
• lymphatic vessels associated with different lymphatic drainage
basins
To enhance the detection rate, blue dye is often
used in combination with radioisotopes
SLN BIOPSY

• During the surgery, a handheld gamma probe is used for
radionuclide detection to trace the SLN perioperatively
• A gamma camera is used for dynamic monitoring of lymphatic
drainage.
• The site of the radioactive lymph nodes marked using a
gamma camera
• ex vivo radioactivity of the nodes and surgical bed is checked
after removing the nodes
• Histopathological evaluation, immunohistochemistry and
molecular markers are then used to evaluate the nodes
SLN BIOPSY

• SLNB is usually performed at the same time as surgical
resection of tumor.
• detect disease in sentinel nodes ipsilateral or contralateral to
the primary tumor, depending upon the lateralization of the
primary tumor and the pattern of lymphatic drainage
identified on lymphoscintigraphy
• can be used for tumors with depth of invasion (DOI) <3 mm or
tumors that are midline or approaching midline (regardless of
DOI)
SLN BIOPSY

• If the SLNB is negative for disease, it can often replace a planned elective
neck dissection, and the neck can be observed.
• If the SLNB is positive for disease, nodal dissection can subsequently be
performed either unilaterally or bilaterally, depending upon the results of
the SLNB.
• If the SLNB is positive for disease on the ipsilateral side only, we perform a
unilateral neck dissection.
• If the SLNB is positive for disease on the contralateral side or if bilateral
drainage is observed by lymphoscintigraphy, we perform a bilateral neck
dissection
SLN BIOPSY

CLINICAL APPROACH
STAGE-WISE AND SITE- WISE NECK
NODES MANAGEMENT

TREATMENT OF STAGE I AND II (EARLY)
HEAD AND NECK CANCER: THE ORAL
CAVITY
• Elective neck dissection
• Sentinel lymph node biopsy

Elective neck dissection —
• Minimum 18 lymph nodes to be removed in HNC.
• supraomohyoid neck dissection (levels I to III plus IV)
• for subsites other than oral tongue, levels I to III
Treatment Of Stage I And II (Early) Head
And Neck Cancer: The Oral Cavity

• For patients with T1 lower lip cancers, observation rather than
elective neck dissection
• For superficial lower lip cancers with DOI <3 mm, SLNB rather
than observation.
• For T2 or larger lower lip cancers, elective neck dissection
rather than observation or SLNB include levels IA and IB
(suprahyoid dissection) since lower lip cancers usually do not
metastasize to lower cervical nodes without first
invading submental, and submandibular lymph nodes
LOWER LIP

• Upper lip – For patients with early-stage upper lip squamous
carcinomas, elective neck dissection level I – IV due to the
aggressive nature of these tumors.
• Lower alveolar ridge and retromolar trigone — For all
patients regardless of size, elective neck dissection, including
levels I to IV given the particularly high incidence of occult
nodal metastases
TREATMENT OF STAGE I AND II (EARLY
STAGE )

• Elective neck dissection removal of level 1- 3
• Particularly for those with T2 disease or greater.
• Challenge in this location - oral mucosa is very thin over the
bone, and bone invasion can occur relatively easily, upstaging
the cancer to T4 disease.
• For these reasons, SLNB is particularly challenging for these
tumors and is less preferred.
TREATMENT OF STAGE I AND II (EARLY) UPPER
ALVEOLAR RIDGE AND HARD PALATE

• Elective neck dissection removal of level I to III.
• Additionally, the facial lymph nodes adjacent to the facial
artery and vein at the mandibular ramus are at high risk of
metastasis, and particular attention should be paid to this
area during surgery
BUCCAL MUCOSA

Treatment approach is based on
• tumor size
• DOI
• proximity to midline.
• DOI is one of the most important factors that determines both
disease staging and management of the neck.
• While other retrospective studies suggest a DOI threshold of 4
mm, we use 3 mm as an appropriate cutoff.
ORAL TONGUE AND FLOOR OF MOUTH

Depth of invasion >3 mm, tumor lateralized —
• Early-stage, lateralized oral tongue tumors with DOI >3 mm
either unilateral elective neck dissection levels I to III/IV or
SLNB (with further surgery if sentinel node involvement)
• Patients may have "skip metastases" with involvement of level
III or IV, without involvement of levels I and II.
• Elective neck dissection of levels I to IV may be more
appropriate than a supraomohyoid dissection of levels I to III.

Depth of invasion >3 mm, tumor midline or
approaching midline
• either bilateral elective neck dissection level I- IV or SLNB
(with further surgery in the case of sentinel node
involvement)

Depth of invasion ≤3 mm, tumor lateralized
• Most superficial oral tongue cancers (eg, ≤1 mm DOI) may be
offered observation.
• SLNB rather than proceeding directly to a unilateral elective
neck dissection.
• If such expertise is not available, then do a unilateral elective
neck dissection

Depth of invasion ≤3 mm, tumor midline or approaching
midline
• Early-stage tumors with DOI ≤3 mm SLNB rather than
proceeding directly to a bilateral elective neck dissection,
• If such expertise is not available, a bilateral elective neck
dissection to be done

TREATMENT OF LOCOREGIONALLY ADVANCED
(STAGE III AND IV) HEAD AND NECK CANCER:
THE ORAL CAVITY
Treatment of the neck is indicated in -
• Stage III and IV oral cavity cancer
• Have clinically involved lymph node(s) in the neck
• Or significant risk of subclinical nodal involvement due to the
size and extent of the primary tumor

• Usually includes unilateral or bilateral neck dissection with
adjuvant RT to the neck, when indicated.
• NCCN (national comprehensive cancer network) allows for RT
in patients with a single pathologically positive lymph node.
• American society of clinical oncology (ASCO) limits RT in this
scenario to patients with high-risk features such as perineural
invasion, lymphovascular space invasion, or a T3/4 primary
TREATMENT OF LOCOREGIONALLY ADVANCED (STAGE
III AND IV) HEAD AND NECK CANCER: THE ORAL
CAVITY

• Elective lymph node dissection for clinically N0 tumors should
include at least 18 lymph nodes.
• Limiting the extent of dissection reduces surgical morbidity,
particularly if level V is excluded
• Selective dissection including levels I to III, a supraomohyoid
neck dissection, is typically sufficient for clinically N0 oral
cavity cancer, as level IV and V nodes are rarely involved
without clinical disease at other levels
• This dissection includes the submandibular gland but
preserves the spinal accessory nerve, the internal jugular vein,
and the sternocleidomastoid muscle
CAVITY

• Some cancers of the oral tongue involve level IV lymph nodes
without disease being present in levels I to III, a phenomenon
known as "skip metastases“
• Level IV lymph nodes are included for therapeutic dissection
of clinically positive nodes.
• Patients with clinically involved regional lymph nodes may
benefit from a complete modified neck dissection
CAVITY

• Contralateral metastases, and hence the need for bilateral
neck treatment, are more likely when tumors approach or
cross the midline
• In addition, ventral oral tongue and floor of mouth cancers
are at very high risk for bilateral nodal involvement.
• If adjuvant RT is planned for the ipsilateral neck, some groups
advocate RT to the contralateral clinically undissected N0 neck
rather than neck dissection
CAVITY

• Bilateral neck dissection + bilateral neck RT  high risk of
lymphedema
• Surgical sparing of the jugular vein - most important aspect of
preventing edema in patients undergoing b/l neck dissection
CAVITY

TREATMENT OF EARLY (STAGE I AND II) HEAD
AND NECK CANCER: THE OROPHARYNX
• Risk of occult neck metastases in a patient with early (T1/T2)
oropharyngeal cancer and a clinically negative neck is
relatively high.
• Elective treatment of the neck is usually indicated.
• Elective treatment of the neck can be accomplished with
either nodal dissection or RT
• Patients undergoing primary surgery should be evaluated for
appropriate ipsilateral or bilateral neck dissections to
accurately stage the neck

• Early tonsil cancers without soft palate or base of tongue
involvement are considered lateralized primaries
Elective nodal treatment :-
• Either selective neck dissection (levels II to IV) in patients
undergoing primary surgery (transoral or open)
Or
• Ipsilateral neck RT in patients undergoing definitive RT

• Midline structures which can have bilateral lymphatic
drainage :-
• Base of tongue,
• Soft palate,
• Posterior pharyngeal wall primary tumors
Address both sides of the neck  B/L neck dissection.

• Midline tumors managed with definitive RT , bilateral neck
irradiation is recommended.
• Primary surgery of midline tumors  bilateral selective neck
dissection including levels II to IV

HEAD AND NECK CANCER: THE OROPHARYNX
 Complex, choice of treatment depends on
• the treatment modality used for the primary tumor (neck
dissection and/or RT),
• disease extent,
• response to therapy.
• The risk of residual occult disease must be also balanced
against the complications of treatment

• Patients receiving surgical management of their primary
oropharyngeal cancer, the initial surgical approach to the neck
is determined by the extent of regional clinical lymph node
involvement

• Clinically negative cervical nodes (N0) –regardless of T stage ,
selective neck dissection including at least levels II to IV rather
than observation.
• Bilateral treatment indicated for midline lesions (ie, base of
tongue),
• Ipsilateral neck treatment is sufficient for lateralized lesions
(ie, tonsil).

Early clinical nodal disease (single node ≤3 cm) –
• N1, metastasis in a single node ≤3 cm, selective neck
dissection (including levels I to IV)
• Patients with HPV associated tumors with a single node
involving level II, neck dissection limited to level II to IV lymph
nodes due to low risk of disease involvement.
• This approach also avoids damage to the marginal mandibular
branch of cranial nerve VII that could occur with level I lymph
node dissection.

Clinical N2 or N3 disease –
Suggest a comprehensive neck dissection

TREATMENT OF EARLY (STAGE I AND II)
HEAD AND NECK CANCER: THE LARYNX
• Early stage glottic cancer and clinically negative neck nodes,
expectant management with observation of the neck rather
than elective treatment with either RT or neck dissection.
• The glottic larynx possesses minimal lymphatic drainage, and
nodal involvement is rare.
• Elective treatment of the neck with either surgery or RT is not
indicated

Supraglottic regional lymph nodes —
• Supraglottis is a midline structure with rich bilateral lymphatic
drainage
• Occult and bilateral neck lymph node metastases frequent
among patients with a clinically negative neck,
• Early stage supraglottic cancer (T1 or T2 disease) treated with
either primary RT or surgery, bilateral elective neck treatment
of the upper, middle, and lower internal jugular nodes (levels
IIA, III, and IV) is indicated
AND NECK CANCER: THE LARYNX

• Patients receiving RT to the primary tumor should also receive
elective neck RT directed at the associated bilateral neck
draining lymph node basins
• Patients receiving surgery to the primary tumor should also be
treated with either staging neck dissection (performed
concurrently with resection of the primary tumor) or
postoperative elective neck dissection.
AND NECK CANCER: THE LARYNX

Subglottic regional lymph nodes —
Primary subglottic tumors drain to the
• prelaryngeal (Delphian)
• pretracheal nodes,
• paratracheal and
• inferior jugular nodes,
• in some cases to the mediastinal nodes
TREATMENT OF EARLY (STAGE I AND II) HEAD AND
NECK CANCER: THE LARYNX

• Patients receiving RT to the primary tumor  elective
nodal RT to its associated draining lymph node basins,
including the upper, middle, and lower internal jugular
nodes (levels IIA, III, and IV) and the anterior compartment
nodes (level VI).
• Patients receiving surgery to the primary tumor should also
be treated with pretracheal and bilateral paratracheal
nodal dissection, with or without postoperative neck RT
TREATMENT OF EARLY (STAGE I AND II) HEAD AND
NECK CANCER: THE LARYNX

III AND IV) HEAD AND NECK CANCER: THE LARYNX
AND HYPOPHARYNX
• Patients managed with primary surgery — Bilateral
prophylactic selective neck dissection, including levels II to IV,
is recommended for patients with T3 and T4 tumors with
clinically negative cervical nodes (N0) or early nodal disease
(N1)
• RT is an alternative treatment for patients with N0 or N1
lymph nodes, particularly if the primary site requires adjuvant
RT.

• Primary surgery for laryngeal or hypopharyngeal cancers with
clinically involved cervical lymph nodes should have a neck
dissection
• With N2 or N3 disease, modified or radical neck dissection if
the nodes are invading the jugular vein, accessory nerve, or
sternocleidomastoid muscle.
• If the nodes are mobile and tissue planes preserved, may
perform selective neck dissections, if feasible, to preserve
contour and function, and to minimize the risks of
cervicofacial lymphedema.
AND HYPOPHARYNX

• All patients with pathologically confirmed lymph node
involvement should undergo postoperative RT
• Concurrent chemotherapy if adverse pathologic factors are
present
AND HYPOPHARYNX

Patients treated with chemoradiation —
• Pts with cervical lymph node involvement at presentation and
are treated with definitive radiation therapy (RT) or
chemoradiation, management of residual abnormalities in the
neck can be difficult
• For patients with complete regression documented clinically
and by structural (computed tomography [CT], magnetic
resonance imaging [MRI]) and functional (positron emission
tomography [PET]) imaging, observation is generally indicated
AND HYPOPHARYNX

• Salvage surgery is indicated in the absence of an adequate
response
• Those with persistent equivocal or positive findings on PET/CT
should undergo neck dissection
AND HYPOPHARYNX

TREATMENT OF EARLY STAGE
HYPOPHARYNX
• High incidence of occult cervical node metastasis (30 to 50
percent)
• Clinically node-negative hypopharyngeal cancer patients,
either elective neck dissection or radiation therapy for initial
treatment in patients undergoing resection or irradiation of
the primary site, respectively.

• Hypopharynx has an extensive lymphatic drainage pattern
• May vary depending on the specific site of the tumor within
the hypopharynx
• Hypopharyngeal cancers may spread to multiple lymph node
levels, and bilateral spread is common.
• The pyriform sinus drains to levels II through IV
(jugulodigastric chain), level V (posterior triangle), and the
retropharyngeal lymph nodes
HYPOPHARYNX

• Pyriform sinus apex also commonly drains to level VI .
• The posterior pharyngeal wall drains to levels II and III, and
the retropharyngeal lymph nodes.
• The postcricoid space drains to levels III and V, and the
paratracheal nodes.
HYPOPHARYNX

 Most commonly involved lymph nodes in the clinical N0
neck are
• level II (relative frequency 67 to 75 percent)
• level III (33 to 75 percent)
• level VI (9 to 14 percent)
• and level IV (0 to 7 percent)
• In the clinical N0 neck, retropharyngeal lymph nodes are
involved in up to 15 percent of cases and are more
common with primary tumors of the posterior pharyngeal
wall
HYPOPHARYNX

If surgery is used to treat the primary tumor-
• Bilateral selective neck dissection of levels II, III, and IV should
be performed for N0 presentations.
• For tumors invading the pyriform sinus apex, we also offer
dissection of level VI lymph nodes
HYPOPHARYNX

 For patients who undergo definitive RT to the primary tumor,
the neck is treated with RT.
• The entire bilateral neck, including the retropharyngeal and
supraclavicular nodes, should be part of the treatment
volume, even in patients with early tumors and clinically
negative neck.
HYPOPHARYNX

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