Cervical Lymphadenectomy: General Considerations

1. INDICATIONS FOR NECK DISSECTION: SQUAMOUS CELL CARCINOMA (SCC)

1.
a. N 0 Neck Disease
i. When the risk of occult (undetectable) neck metastases is substantial
and irradiation is not to be used
ii. When the neck needs to be entered for
1. Access to tumor for removal
2. Access to donor vessels for free tissue transfer
b. N 1 or Greater Neck Disease 

2. INDICATIONS FOR NECK DISSECTION: NONSQUAMOUS CELL CARCINOMA

1.
a. Thyroid Cancer
i. Nodal metastases present (well-differentiated thyroid carcinoma)
ii. All cases of medullary thyroid cancer other than subclinical disease
identified through screening
b. Selected Cutaneous Malignancies With Potential for Cervical Metastases
(such as melanoma, Merkel cell carcinoma, and squamous cell carcinoma)
i. Merkel cell carcinoma
1. The N 0 neck usually treated with irradiation only
2. N+'ve disease treated with lymphadenectomy and irradiation
ii. Squamous cell carcinoma of the skin
1. In general, elective lymphadenectomy not performed
2. Indicated for N+'ve disease, usually with postoperative
irradiation
c. High-Grade Salivary Gland Malignancies
i. In general, there is no need for elective lymphadenectomy
(N 0 disease) because potential occult metastases will be addressed
by cervical extension of the irradiation used as adjuvant therapy for
all high-grade salivary gland malignancies.
ii. Controversy persists with some supporting elective neck dissection
for high-grade mucoepidermoid carcinoma and squamous cell
carcinoma of salivary gland origin. 
2. CONTRAINDICATIONS TO NECK DISSECTION

1.
a. These guidelines must be considered "relative contraindications" in that every
patient is evaluated and treated as a unique individual employing general
concepts for direction.
i. Rigidly fixed disease
ii. Vertebral involvement
iii. Involvement of the base of skull with or without intracranial disease
iv. Distant metastatic disease 

2. CONTROVERSIES: SQUAMOUS CELL CARCINOMA

1.
a. Elective Treatment of the Neck for Squamous Cell Carcinoma
i. Despite advances in imaging (CT, MRI, PET) and pathologic
assessment (ultrasound-guided FNA), the assessment for
metastases to the neck remains inaccurate. As a result, management
decisions for individual patients without clinically identifiable
metastases (N 0 status) are not based on certainty, but rather a
probability that occult spread to nodes has occurred. Investigators
have variably supported elective neck treatment when the estimated
rate of occult nodal metastases is 10%, 15%, 20%, or even 30%.
These percentages vary widely because they derive from a
subjective assessment balancing an uncertain gain with a poorly-
defined morbidity. The uncertain gain is an increase in survival from
treating occult disease before it becomes clinically apparent. The
poorly defined morbidity is the impact of extending treatment to
include a body part that has a high likelihood of being normal
(uninvolved with cancer). If the 20% occult metastatic rate is used to
select cases for elective treatment, then 80% of patients will receive
additional treatment needlessly. If the morbidity from treatment is
minor, then this "over-treatment" may be acceptable. The evolving
role for sentinel node biopsy may improve the management of the N0
neck.
ii. We employ elective neck dissection liberally in the management of
squamous cell carcinoma of the head and neck primarily as a
diagnostic tool to determine the need for postoperative irradiation.
When considered in this context, elective neck dissection is more
 morbid but also more accurate than CT, MRI, PET, or ultrasound with
FNA. Elective neck dissection, which is done selectively to minimize
the greater morbidity of a comprehensive (Levels I through V) neck
dissection, may occasionally also be therapeutic when a single small
nodal metastasis (N 1) is identified within the first echelon nodal
drainage.
iii. Elective neck irradiation rather than neck dissection is employed
when the tumor at the primary site is treated with irradiation and the
risk of occult nodal metastases is substantial. It is an accepted
principle to limit treatment to a single modality where possible. Single
modality therapy is most commonly employed for stage I, stage II,
and selected stage III cancers. Most stage III and stage IV cancers
are treated with combined modality therapy.
iv. Data is emerging that treatment of a neck that is clinically N 0 may be
more effective than observation in managing cases at high risk for
developing nodal metastases. It is this group of patients that are
currently targeted for either elective neck dissection or elective neck
irradiation. It should be noted, however, that evidence is still lacking
to definitively support elective treatment of a neck over observation
with treatment reserved for cases developing clinically apparent
disease.
b. Indications for Elective Treatment (Lymphadenectomy or Irradiation) of the
Neck for SCC
i. Indications at any site
1. Capillary-lymphatic space permeation: all cases
2. Perineural spread: most cases
a. These histologic findings identified following
resection at the primary site generally warrant
combined modality therapy (postoperative
irradiation). If these findings are at the site identified
before an elective neck is performed, elective
irradiation will supplant the need for elective neck
dissection. Extension of the radiation fields to include
the neck will occur in the course of treating the
primary site.
ii. Lip
1. Consider for T 3 , T 4 tumors
 2. Consider for tumors of any T classification involving the oral
commissure
3. Consider for any recurrent lip cancer
iii. Oral cavity
1. Most T 3 , T 4 tumors
2. Any T classification with depth of invasion >4 mm
3. Consider irradiation for all but the most superficial buccal
squamous cell carcinoma
4. Consider bilateral neck treatment for any tumor of the floor of
mouth, as well as those at other sites in the oral cavity
encroaching on the midline
iv. Oropharynx
1. Only the most superficial T 1 tumors are treated without
addressing occult neck metastases. The high risk of
involvement of the retropharyngeal nodes (not commonly
addressed by neck dissection) generally warrants elective
management of the neck with irradiation rather than surgery.
v. Nasopharynx
1. Irradiation, supplemented by chemotherapy, is the primary
treatment modality for the primary site and regional
metastases.
2. Persistent neck disease after irradiation may be addressed
surgically.
vi. Larynx
1. Supraglottic cancers: elective treatment of the neck is
suggested for all but the most superficial T 1suprahyoid
epiglottic cancers.
2. Glottic cancers: elective treatment of the neck is suggested
for all but T 1 and T 2 glottic cancers.
3. Subglottic cancers: elective treatment of the neck is
suggested for all cases.
vii. Hypopharynx
1. Elective treatment of the neck is suggested for all cases.
c. Role for Irradiation of Node Positive Disease
i. General rule: Metastases to neck nodes greater than 2 cm in size are
not readily cured with irradiation alone.
ii. Exceptions
1. Metastases from nasopharyngeal carcinomas
 2. Lymphoepitheliomas
iii. Controversy
1. If the primary site and neck with positive nodes is treated
with irradiation, is a subsequent neck dissection necessary
when there is a complete clinical response at the primary site
and in the neck based on CT imaging and clinical exam?
a. Generally accepted for cN 1 disease: no neck
dissection is needed.
b. Controversial for cN 2 or cN 3 disease (as assessed
prior to irradiation). An "elective" neck dissection is
needed after irradiation despite a complete clinical
response.
d. In-Continuity Versus Discontinuous Neck Dissection
i. Separate resection of the primary site tumor from the neck dissection
diminishes the morbidity incurred by removing normal intervening
structures. Discontinuous neck dissection has been supported by
some in the treatment of oral cavity cancers. Additional support for
this practice has developed with expanded use of laser resection
through a transoral approach in the oral cavity and endoscopic
resection at other sites. In contrast, others have identified a lower
recurrence rate and higher survival when the neck dissection is done
in-continuity with the primary tumor.
ii. We advocate an intermediate position wherein the intervening
lymphatics are removed between the primary site and the neck
dissection contents with preservation of uninvolved structures.
1. Standard continuous resection of tongue cancer: the primary
site and floor of mouth contents including mucosa, sublingual
glands, distal Wharton's duct, lingual nerve, mylohyoid, and
genioglossus are removed along with the contents of the
neck dissection.
2. Standard discontinuous neck dissection for tongue cancer:
the primary tumor is removed transorally, leaving the floor of
mouth contents in place. A neck dissection is done with the
upper border defined anatomically by the lower border of the
mandible and more practically by the submandibular
ganglion of the lingual nerve.
3. Intermediate approach
 a. The primary tumor is removed along with the floor of
mouth contents. In a fashion similar to aSelective
Neck Dissection sparing the sternocleidomastoid
muscle and spinal accessory nerve, the mylohyoid,
genioglossus, and lingual nerve are preserved. All
other tissue intervening between the primary site and
the neck dissection contents is removed.
b. This modified approach is appropriate in the absence
of a deeply infiltrating tumor with capillary lymphatic
space permeation. These more aggressive tumors
are resected en bloc through an incontinuity
approach.
e. Extent of Neck Dissection
i. Clinically N+'ve (N 1, N 2, N 3 )
1. Radical neck dissection is the standard
2. Exceptions
a. Preserve spinal accessory nerve when adequate
tumor removal is not compromised.
b. May consider selective Levels I, II, III, IV neck
dissection if a solitary small Level I lymph node is
involved (N 1).
c. When a radical neck dissection is done on the
contralateral side, the ipsilateral side may be
modified to limit the extent of dissection despite
clinically apparent disease in one of the anterior
levels.
ii. Clinically N 0
1. Lip: Levels I, II, III, IV (identify, dissect, and elevate marginal
mandibular nerve) to permit full removal of the perifacial
artery lymph nodes (prevascular and postvascular nodes).
2. Oral cavity: Levels I, II, III, IV
a. Anterior oral cavity: dissection of marginal
mandibular nerve is the same as for lip.
b. Posterior oral cavity: perifacial nodes are not at the
same risk for metastases. The marginal mandibular
nerve may be protected without full dissection
through its superior displacement with elevation of
 the posterior facial vein and submandibular gland
fascia.
3. Oropharynx: Levels I, II, III, IV
4. Larynx: Levels II, III, IV
5. Hypopharynx: Levels II, III, IV
iii. Special considerations
1. Supra-omohyoid dissection leaves Level IV behind. "Skip
metastases" to Level IV occur without identifiable intervening
metastases. The morbidity incurred from elevation of the
omohyoid to remove Level IV is limited to
a. Increased risk of chylous fistula
b. Increased risk of phrenic nerve injury
c. These risks are small; the additional 10 minutes
operating time to remove Level IV appears justified.
2. The supraspinal accessory segment of Level II that has been
labeled IIB by the Sloan Kettering group and IIA by the Iowa
group is rarely involved with metastatic disease from
squamous cell carcinoma of the upper aerodigestive tract
when the neck is clinically staged N 0. There were no cases
among the 44 studied at Sloan-Kettering and the 71 at
University of Iowa in which metastatic disease was confined
the supraspinal region of Level II without metastatic disease
elsewhere. When the neck dissection is done as a "biopsy"
to determine the need for subsequent irradiation, dissection
of this region may not be necessary. If neck metastases are
identified at other levels, then the postoperative irradiation
will be administered and adequately address microscopic
disease in this region. Less shoulder dysfunction is expected
from limiting dissection of Level II to clearing the spinal
accessory nerve and removing the adipo-lymphatic
compartment below it. 

2. PREOPERATIVE CONSIDERATIONS

1.
a. Tumor Board Discussion (see Tumor board protocol)
i. To assess alternatives to neck dissection
ii. To determine the extent of neck dissection likely to be necessary
b. CT/MRI
i. To identify subclinical (nonpalpable) neck disease; especially useful
in the obese or muscular neck
ii. To identify extent of gross disease:
1. Extracapsular spread of disease may be identifiable
2. Involvement of the carotid, internal jugular, neck
musculature, cranial nerves, base of skull, or mandible
c. Consultation
i. Radiation oncology
1. For all cases: to assist with disposition determined at tumor
board
2. For selected cases: to place afterload catheters
intraoperatively for brachytherapy
ii. Other services as dictated by comorbidity and extent of disease
1. Cardiothoracic surgery if extension of dissection inferior to
the clavicle is possible
2. Vascular surgery if carotid resection possible
d. Consent
i. Describe procedure including the benefits.
ii. Explain risks and potential complications:
1. Bleeding, transfusion, hematoma
2. Wound infection
3. Shoulder weakness, adhesive capsulitis, pain
4. Prolonged facial or neck edema especially with irradiation
5. Chylous fistula (at risk of Level IV dissection)
6. Deformity from neck scar, loss of fat, and possibly the SCM
7. Cranial nerve deficits (emphasize if disease is near a
particular nerve)
a. XI
b. X: hoarseness, dysphagia, aspiration
c. IX: dysphagia
d. XII: dysarthria, dysphagia
e. VII: marginal mandibular branch weakness and rare
total facial paralysis unless the neck disease is high
in zone II.
8. Anesthesia (numbness) of the neck skin, earlobe, and
possibly the tongue
9. Anesthetic risks (stroke, death, MI)
 10. Possibility of need for further surgery or other treatment
(XRT/chemotherapy)
e. Type and screen for transfusion if the neck dissection is done concurrently
with another procedure with expected blood loss. The uncomplicated neck
dissection in isolation should not require transfusion. 

2. CPT CODING

1.
a. See Neck dissection protocols 

2. SUGGESTED READING

1.
a. Baker SR, Krause CJ. Carcinoma of the lip. Laryngoscope. 1980;90:19-27.
b. Byers RM, Weber RS, Andrews T, McGill D, Kane R, Wolf P. Frequency and
therapeutic implications of "skip metastases" in the neck from squamous cell
carcinoma of the oral to ad Neck J. 1997;19:14-19.
c. Eisele DW, Clifford AR, Johns ME. Carcinoma of the oral cavity and pharynx.
In: Lee KJ, ed. Essential Otolaryngology. 6th ed. Norwalk, CT: Appleton &
Lange: 1995:535-554.
d. Fakih AR, Rao RS, Borges AM, Patel AR. Elective versus therapeutic neck
dissection in early carcinoma of the oral tongue. Am J Surg. 1989;158:309-
313.
e. Fletcher GH. Elective irradiation of subclinical disease in cancers of the head
and neck. Cancer. 1972;29:1454.
f. Hoffman H, Eschwege F, Krause C. Combined surgery and radiotherapy. In:,
Clark JR, Snow GB, eds. Multimodality Therapy for Head and Neck Cancer,
Stuttgart, New York: Georg Thieme Verlag. 1992:76-94.
g. Hoffman H, Funk G, Endres D. Evaluation and surgical treatment of tumors of
the salivary glands.) In: Stanley E. Thawley, et al, eds. Comprehensive
Management of Head and Neck Tumors. 2nd ed. 1999:1147-1182.
h. Hoffman HT, Karnell LH, Shah JP, Ariyan S, Brown GS, Fee WE, Glass AG,
Goepfert H, Ossoff RH, Fremgen AM. Hypopharyngeal cancer patient care
evaluation. Laryngoscope. 1997;107:1005-1017.
i. Jones KR, Lodge-Rigal D, Reddick RL, Tudo GE, Shockley WW. Prognostic
factors in the recurrence of stage I and II squamous cell cancer of the oral
cavity. Arch Otolaryngol Head Neck Surg. 1992;118:483-485.
 j. Kraus DH, Rosenberg DB, Davidson BJ, Shaha AR, Spiro RH, Strong EW,
Schantz SP, Shah JP. Suprasternal accessory lymph node metastases in
supra-omohyoid neck dissection. Am J Surg. 1996;172:646-649.
k. Leemans CR, Tiwari R, Nauta JJ, et al. Discontinuous versus incontinuity
neck dissection in carcinoma of the oral cavity. Arch Otolaryngol Head Neck
Surg. 1991;117:1003-1006.
l. Lindberg R. Distribution of cervical lymph node metastases from squamous
cell carcinoma of the upper respiratory and digestive tracts. Cancer.
1972;29:1446-1449.
m. Medina JE, l. Neck. In: Gluckman JL, ed. Renewal of Certification Study
Guide in Otolaryngology Head and Neck Surgery. Dubuque, Iowa:
Kendall/Hunt Publishing Co. 1998:433-490.
n. Spiro RG, Strong EW. Discontinuous partial glossectomy and radical neck
dissection in selected patients with epidermoid carcinoma of the mobile
tongue. Am J Surg. 126:544-546
o. Spiro RH, Huvos AG, Wong Gy, Spiro JD, Gnecco CA, Strong EW. Predictive
value of tumor thickness in squamous carcinoma confined to the tongue and
floor of the mouth. Am J Surg. 1986;152:345-350.
p. Talmi YP, Hoffman HT, Horowitz Z, McCulloch TM, Funk GF, Graham SM,
Peleg M, Yahalom R, Teicher S, Kronenberg J. Patterns of metastases to the
upper jugular lymph nodes (the "submuscular recess"). Head Neck.
1998;20:682-686.
q. Van den Brekel MWM, Casteligns JA, Reitsma LC, Leemans CR, van der
Waal I, Snow GB. Outcome of observing the N0 neck using
ultrasounographic-guided cytology for follow-up. Arch Otolaryngol Head Neck
Surg. 1999;125:153-156.
r. Vandenbrouck C, Sancho-Garnier H, Chassagne D, Saravane D, Cachin Y,
Micheau C. Elective versus therapeutic radical neck dissection in epidermoid
carcinoma of the oral cavity: results of a randomized clinical trial. Cancer.
1980;46:386-390.
s. Zitsch RP, Park CS, Renner GJ, Rea JL. Outcome analysis for lip carcinoma.
otolaryngology. Head Neck Surg. 1995;113:589-596.

(vm)