Radical Neck Dissection: (RND) Classification, Indication and Techniques

Introduction
Crile in 1906 introduced RND and is followed by Martin as a the classical procedure for the management of cervical lymph node metastasis Recently changes in classification and indication led to inconsistency
N0 in recent studies may require selective RND to reduce morbidity

Staging of Neck Nodes

NX: N0: N1: N2:
Regional lymph nodes can not be assessed
No regional lymph node metastasis Metastasis in a single ipsilateral lymph nodes, 3 cm or less in greatest dimension

N2a:

Metastasis in a single epsilateral lymph nodes, more than 3 cm but less than 6 cm

Staging of Neck Nodes

N2b:
Metastasis in multiple ipsilateral lymph nodes, not more than 6 cm

N2c:
Metastasis in bilateral or contralateral nodes not more than 6 cm in diameter

N3:
Metastasis in lymph nodes more than 6 cm in in greatest diameter
Meyers & Eugene: Operative Otolaryngology. 1997

Lymph Node Regions

Region I:
Submental and submandibular triangle
Ia: Submental triangle:
Bounded by the anterior belly of digastric and the mylohyoid muscle deep

Ib: Submandibular triangle:

Formed by the anterior and posterior belly of the digastric muscle and the body of the mandible
Memorial Sloan-kettering Cancer center

Lymph Node Regions

Region II IV:
Lymph nodes are associated with the Internal Jugular Vein (IJV) within the fibroadipose tissues that extend from the posterior border of sternocledomastoid muscle (SCM) medial to lateral border of the sternohyoid muscle
Memorial Sloan-kettering Cancer center

Lymph Node Regions

Region II:
Upper third including upper jugular, jugulodigastric and upper posterior cervical nodes Bounded by the digastric muscle superiorly and the hyoid bone or carotid bifurcation inferiorly
IIa:
nodes anterior to Spinal Accessory Nerve (SAN)

IIb:
nodes posterior to Spinal Accessory Nerve (SAN)
Memorial Sloan-kettering Cancer center

Lymph Node Regions

Region III:
Middle third jugular nodes from the carotid bifurcation to cricothyroid notch or omohyoid muscle

Region IV:
Lower third jugular nodes from omohyoid muscle superiorly to the clavicle inferiorly
Memorial Sloan-kettering Cancer center

Lymph Node Regions

Region V:
Lymph nodes of the posterior triangle along the lower half of the SAN and the transverse cervical artery Bounded by the anterior border of the trapezius posteriorly, the posterior border of SCM anteriorly and the clavicle inferiorly
Memorial Sloan-kettering Cancer center

Lymph Node Regions

Region VI:
Anterior compartment, lymph nodes surrounding the midline visceral structures that extend from the hyoid bone superiorly to the suprasternal notch inferiorly The lateral boundary is the medial border of the carotid sheath Perithyroid, paratracheal, and lymph nodes around the recurrent laryngeal nerve
Memorial Sloan-kettering Cancer center

Classification
The RND is classified according to the Academys Committee for Head & Neck Surgery & Oncology into four major type:
1. Radical Neck Dissection (RND) 2. Modified Radical Neck Dissection (MRND) 3. Selective Neck Dissection (SND)
1. 2. 3. 4. Supraomohyoid Posterolateral Lateral Anterior

4.

Extended Radical Neck Dissection (ERND)

Classification
Radical neck Dissection:
Removing all lymphatic tissues in regions I V and include removal of SAN, SCM and IJV

Modified radical neck dissection:

Excision of all lymph nodes removed with RND with preservation of one or more nonlymphatic structures, SAN, SCM and/or IJV
Subtype I: Preserve SAN Subtype II: Preserve SAN & SJV Subtype III: preserve SAN, SJV and SCM
Known as Functional neck dissection (Bocca)

Classification
Selective Neck dissection:
Any type of cervical lymphadenectomy with preservation of one or more lymph node groups Four subtype:
Supraomohyoid neck dissection Posterolateral neck dissection Lateral neck dissection Anterior neck dissection

Classification
Supraomohyoid neck dissection:
Removal of lymph nodes in regions I III The posterior limit is the cutaneous branches of the cervical plexus and posterior border of SCM The inferior limit is the superior belly of the omohyoid where it cross IJN

Posterolateral neck dissection

Removal of suboccipital, retroauricular, levels II V and level V Subtyped I III depending on the preservation of SAN, IJV and /or SCM Medina

Classification
Lateral neck dissection:
Remove lymph nodes in levels II IV

Anterior neck dissection:

Require the removal of the lymph nodes surrounding the visceral structure in the anterior aspect of the neck, level VI Superior limit, hyoid bone Inferior limit, suprasternal notch Laterally, the carotid sheath

Classification
Extended neck dissection:
Any previous dissection and including one or more additional lymph node groups and/or non-lymphatic tissues

Facts
General nodal metastasis produce the following fact:
The most important factor in prognosis of SCC of the upper aero-digestive tract is the status of cervical lymph nodes Cure rate drops 50% with involvement of the regional lymph nodes

Indications For ND
Radical neck dissection was believed by Martin to be the only method to control cervical lymphadenectomy Anderson found that preservation of SAN did not change the survival or tumor control in the neck
Actual 5-year survival and neck failure rate is:
RND: 63% and 12 % MRND: 71% and 12%

Indications
Radical Neck Dissection
1. Multiple clinically obvious cervical lymph node metastasis particularly of posterior triangle and closely related to SAN Large metastatic tumor mass or multiple matted in upper part of the neck
Tumor should not be dissected to preserve Structures

2.

Indications
Modified radical neck dissection
MRND Type I:
1. Clinically obvious neck lymph nodes metastasis and SAN not involved by tumor 2. Intraoperative decision just like preservation of the facial nerve in parotid surgery

Indications
MRND Type II:
1. Rarely planned 2. Intra-operative decision for tumor found adherent to SCM but away from SAN & IJV

MRND Type III:

Depend on the autopsy reports
1. 2. Lymph nodes were in the fibrofatty and do not share the same adventitia with blood vessels They are not found within the aponeurosis or glandular capsule of the submandibular Functional neck dissection

Indications
MRND Type III:
For treatment of N0 neck nodes Indicated for N1 mobile nodes and not greater than 2.5 3.0 cm
Contra-indicated in the presence of node fixation Result is difficult to interpret because of the use of radiation therapy

Indications
Selective/elective neck dissection:
For treatment of N0 neck nodes For N+ nodes when combined with radiotherapy
Adjuvant radiotherapy for patient with 2 4 positive nodes or extra-capsular spread

Supraomohyoid is indicated for SCC of oral cavity with N0 and N1 with palpable mobile nodes less than 3 cm and located in level I and II Upgrade intra-operatively following positive frozen section

Treatment option for N0 nodes

Observe Radiation therapy Elective neck dissection
Low morbidity Staging neck for possible extended surgery Need for post-operative radiotherapy

Rationale for S/END

Rate of occult metastasis in clinically negative nodes is 20 30% using clinical and radiographic findings
Ct scan combined with physical exam decreased the rate of occult metastasis to 12% This suggested lowering of the criteria for elective neck dissection
Friedman et al Laryngoscope 100; 54 59: 1990

Rationale for S/END

Anatomic studies showed that lymphatic drainage from the mucosal surfaces follow a constant and predictable route Lymph flow from SA chain to the jugular chain is unilateral
Shah. Ann Surg Oncol 1(6); 521-532: 1994

Rationale for S/END

Shah, in his study produced a compelling evidence of predictable nodal metastasis from SCC from upper aerodigastive tract
He found a specific pattern for nodal spread by location of primary NO in patients with oral cavity SCC:
7/1119 (3.5%) had nodal involvement outside supraomohyoid dissection 3 (1.5%) had isolated involvement outside level I - III
Friedman Laryngoscope 100; 54-59: 1990

Rationale for S/END

N+ nodes in patients with oral SCC:
50/246 had nodal metastasis outside level IV 10/246 had metastasis in level V

He examined nodal involvement in patients with nasopharynx and other upper parts of the aerodigastive tract Conclusion:
SCC of the oral cavity: Level I, II and III are at risk SCC nasopharynx and larynx Level II, III and IV are at risk
Shah Amer J Surg 160; 405-409: 1990 Shah Cancer July 1 ; 109-113: 1990

Rationale for S/END

Byers stated that SND combined with postoperative radiotherapy in selected patients with oral cavity SCC was adequate treatment with similar recurrence rate as those treated with MRND III Spiro reported 12% with supraomohyoid dissection in N1 nodes but not all of them received radiotherapy
Byers Head Neck Surg; Jan-Feb; 160-167: 1988

Selective/Elective Neck Dissection

A good option for N0 neck Not a suitable option for N+ neck Is used N+ neck when combined with radiotherapy Intra-operative frozen section evaluation is needed to confirm in cases of intraoperative palpable nodes

The anatomy
Skin:
Blood supply:
Descending branches:
The facial The submental Occipital

Ascending branches
Transverse cervical Suprascapular

The branches perforate the platysma muscle, anastomose to form superficial vertically-directed network of vessels

Skin incision is superiorly based apron-like incision from mastoid to mentum or to contralateral mastoid

The anatomy
Platysma muscle:
Wide, quadrangular sheet-like muscle Run obliquely from the upper part of the chest to lower face Skin flap is raised immediately deep to the muscle The posterior border is over or just anterior to IJV and great auricular nerve Does not cover the inferior part of the anterior triangle and the posterolateral neck

The anatomy
Sternocleidomastoid muscle: SCM
Differentiated from the platysma by the direction of its fibres Crossed by the IJV and the great auricular nerve from inferior to posterior deep to platysma The posterior border represent the posterior boundary of nodes level II - IV

The anatomy
Marginal Mandibular nerve: MMN
Located 1 cm in front of and below the angle of the mandible Deep to the superficial layer of the deep cervical fascia Superficial to adventitia of the anterior facial vein

The anatomy
Spinal Accessory nerve: SAN
Emerge from the jugular foramen medial to the digastric and stylohyoid muscles and lateral and posterior to IJV (30% medial to the vein and in 3 -5% split the nerve) It passes obliquely downward and backward to reach the medial surface of the SCM near the junction of its superior and middle thirds, Erbs point

The anatomy
Trapezius muscle:
Its anterior border is the posterior boundary of level V Difficult to identify because of its superficial position Dissect superficial to the fascia in order to preserve the cervical nerves

The anatomy
Digastric Muscle; Posterior belly:
Originate from a groove in the mastoid process, digastric ridge The marginal mandibular nerve lie superficial The external and internal carotid artery, hypoglossal and 11th cranial nerves and the IJV lie medial

The anatomy
Omohyoid muscle:
Made of two bellies, and is the anatomic separation of nodal levels III and IV The posterior belly is superficial to the brachial plexus, phrenic nerve and transverse cervical artery and vein The anterior belly is superficial to the IJV

The anatomy
Brachial Plexus & Phrenic nerve:
The plexus exit between the anterior and middle scalene muscles, pass inferiorly deep to the clavicle under the posterior belly of the omohyoid The phrenic nerve lie on top of the anterior scalene muscle and receive it is cervical supply from C3 C5

The anatomy
Thoracic duct:
Located in the lower let neck posterior to the jugular vein and anterior to phrenic nerve and transverse cervical artery Have a very thin wall and should be handled gently to avoid avulsion or tear leading to chyle leak

The anatomy
Exit via the hypoglossal canal near the jugular foramen Passes deep to the IJV and over the ICA and ECA and then deep and inferior to the digastric muscle and enveloped by a venous plexus, the ranine veins Pass deep to the fascia of the floor of the submandibular triangle before entering the tongue

Summary
Unified classification is relatively new Indication and the type of ND, specially for N0, is controversial The following surgical outline was suggested:
SCC oral cavity anterior to circumvalate papilla
Supraomohyoid

SCC Oropharynx, larynx and hypopharynx

level I- IV or level II-V

SCC with N+ nodes

RND

SCC with 2-4 positive nodes or extracapsular spread

RND and adjuvant therapy
Shah Cancer July 1;109-113: 1990