Metastasis to the lymph nodes in the neck

Dr. Nico A. Lumintang, SpB(K)KL

Division of Head and Neck Surgery

Departement of Surgery
Faculty of Medicine University of Samratulangi
Manado

PIT IKABI XXIV, Lampung 07-11 Maret 2022

Level I : submental and submandibular
• Superiorly : mylohyoid muscle and mandible
• Inferiorly: Inferior border of the hyoid bone
• Anteriorly: platysma muscle
• Posteriorly: posterior border of the submandibular gland
There two sublevel:
- Level Ia (submental nodes)
- Level Ib (submandibular)
Level II : upper internal jugular (deep cervical)
chain
• Superiorly: base of the skull at the jugular fossa
• Infiriorly: inferior border of the hyoid bone
• Anteriorly: posterior border of the submandibukar gland
• Posterolaterally: posterior berder of the sternocleidomastoid muscle
• Medially: medial border of the internal carotid artery
There are two sublevels:
- Level IIa : posterior edge of the internal jugular vein
- Level Iib : separable by a fat plane from the internal jugular vein
Level III : middle internal jugular (deep
cervical) chain
• Superiorly: inferior border of the hyoid bone
• Inferiorly : inferior border of the cricoid cartilage
• Anteriorly : anterior border of the sternocleidomastoid muscle
• Posterolaterally: posterior border of the sternocleidomastoideus
muscle
• Medially : medial border of the common carotid artery
Level IV : lower internal jugular (deep cervica)
chain
• Superiorly : inferior border of the cricoid cartilage
• Inferiorly: level of the clavicle
• Anteriorly: anterior border of the sternocleidomastoideus muscle
• Posteriolaterally : oblique line drawn through the posterolateral edge
of the sternocleidomastoideus muscle and the lateral sdge of the
anterior scalene muscle
• Medially : medial border of the common carotid artery
Level V : posterior triangle
• Superiorly : skull base at the apex of the convergence
sternocleidomastoideus and trapezius muscle
• Inferiorly : level of the clavicle
• Anteriorly : posterior border of the sternocleidomastoideus muscle
• Posterolaterally: anterior border of the trapezius muscle
There are two sublevel:
- Level Va
- Level Vb
Level VI : central (anterior) compartment
• Superiorly : inferior border of hyoid bone
• Inferiorly : superior border of manubrium (suprasternal notch)
• Anteriorly : platysma muscle
• Posteriorly : trachea (medially) and prevertebral space (laterally)
• Laterally : medial borders of both common carotid arteries ( medial to
level III and IV)
• Includes anterior jugular, pretracheal,
paratracheal, prelaryngeal / precricoid
and perithyroideal nodes
Lymphatic system:
• Circulatory • Lymphatic fluid
• Immune • Lymphatic vessels
• Metabolic systems • Lymphatic cells
Lymphatic cells include
• Macrophage
• Dendritic cell
• Lymphocytes
• Lymphatic organs such as the spleen and thymus
The lymphatic transport system can subdivide
into five components
• capillaries,
• collecting vessels,
• lymph nodes,
• trunks,
• ducts.
Function
• The general function of the lymphatic system is to maintain fluid
balance, absorption, and transport of dietary fats, and assist the
immune system in providing a transport medium.
• It is through the lymphatic system that antigens, antibodies, and
immune cells are delivered to lymph nodes providing adaptive
immune protection.
Malignant lymphadenopathy in the cervical
• Primary :
- Hodgkin lymphoma
- Non-Hodgkin lymphoma
• Metastatic :squamous cell carcinomas of the skin and upper
aerodigestive tract or salivary/ thyroid gland carcinomas.
• Metastatic spread is typically along lymphatic channels from the head
and neck.
• But in 1% of cases originates more distally most commonly from the:
breast, lung, kidney, gastrointestinal tract, prostat, tests and cervix.
An important contribution of tumor and LN lymphangiogenesis to cancer metastasis. (A) Normal lymphatic tissue drainage through lymphatic capillaries, collecting
lymphatics, and LNs. (B) Lymphangiogenic factors produced by premetastatic tumors, including VEGF-C, VEGF-D, VEGF-A, and HGF, are taken up by peritumoral
lymphatic capillaries and are transported via the collecting lymphatics toward the tumor-draining SLN, where they act directly on preexisting lymphatic vessels to induce
LN lymphangiogenesis. Tumor-draining lymphatic vessels display an enlarged size and increased lymph flow and pulsing. (C) Once metastatic tumor cells have spread
to their draining LNs, they serve as a major source of lymphangiogenic factors. These promote the remodeling and SMC rearrangement of distant (post-SLN) lymphatic
vessels and lymphangiogen- esis in distant LNs and promote secondary metastasis, including organ metastasis, via the thoracic duct, which connects to the venous
circulation via the subclavian vein. CSC, cancer stem cell. The chemokines CCL21 and CXCL12, released by activated lymphatic endothelial cells (LECs) within SLNs,
might provide a niche for cancer cells with stem cell–like properties that express the receptors CCR7 and CXCR4.
Diagnostic
• USG
• USgFNAC
• Core biopsy
• CT / MRI
• Fluorodeoxyglucose positron emission tomography–computed
tomography (FDG/PET-CT)
 Risk classification by total risk score
0 – 1. Low risk (< 17% of metastasis)
2 – 4. Intermediate (17% - 78% of metastasis)
5–9 High risk > 78% of metastasis)

AJNR Am J Neuroradiol 40:1049 –54 Jun 2019 www.ajnr.org

Management
• Neck dissection
• Chemotherapy
• Radiotherapy
• Target cell therapy
Neck Dissection
• Selective Neck dissection:
- supraomohyoid neck dissection
- anterolateral neck dissection
- central compartment dissection

• Modified Radical Neck Dissection:

- MRND I  N XI are spared
- MRND II N XI, IJV are spared
- MRND III N XI, IJV , SCM are spared
• Radical Neck Disection
Management
• A debate has been ongoing for many years on how to manage
patients with a clinically negative neck: should all patients be treated
prophylactically with an elective neck dissection, or can the neck be
left untreated with a “watchful waiting” follow-up policy
Targeting Lymphatics for Cancer Therapeutics
Two major strategies
• Inhibition of lymphangiogenic signals to impede lymphangiogenesis
• Manipulation of the lymphatic system to promote priming of the anti-
tumoral immune response
• VEGFR3 showed reduced tumor-associated lymphatic formation,
tumor growth, and lymph node metastasis in mice
The incidence :
• occult metastasis in the SLNs was 40.9% (54 of 132):
• macrometastasis in 18.9% (25 of 132),
• micrometastasis (mi) in 15.2% (20 of 132),
• ITCs in 6.8% (9 of 132)
• 3% of patients with head and neck cancer may also carry hidden
metastatic papillary or follicular thyroid carcinoma
• Perie et al. re-evaluated the lymph nodes of patients who under-
gone neck dissection for their head and neck cancer and found 7.5 %
patients with simultaneous head and neck SCC and thyroid carcinoma
• In Vassilopulou–Sellin et al.’s research, the incidence of PTC
metastasis was reported 0.3% in resected head and neck lymph nodes
Complication RND
• Damage Nervus XI
• Infection
• Hemorhage
• Stroke
• Chylothorax
• Amaurosis
Müller von der Grün et al. Radiation Oncology (2017)
Lopez F, et al, 2015
Definition of cNO neck
• Absence of palpable adenopathy on physical examination
• Absence of visual adenopathy on CT or MRI or PET
Risk of micrometastases:
- T1 glottic carcinoma
- T1-2 lip cancers
-Thin 4 mm oral cavity cancers
 Treatment options for the NO neck
• Observation
• Neck dissection
• Radiation therapy
• Sentinel node dissection