Neck Dissection.pptx

Neck Dissection-Dr Stanley John

1. NECK DISSECTION Dr Stanley John Cheriyan Oral & Maxillofacial Surgery

2. Introduction The term "neck dissection" refers to the removal of lymph nodes and lymph node bearing tissues of neck from the inferior border of the mandible to the clavicle ,as a treatment of head and neck malignancy.

3. How does tumor spread ? Spread of disease of oral cavity to neck -- palpable lymphadenopathy. Systemic homogenous spread rarely occurs in the lymphatics of the neck. early eradication of local and regional disease can prevent future systemic metastasis.

4. The regional lymph node groups draining a specific primary site is first echelon lymph nodes

5. The first echelon lymph nodes at highest risk from primary tumors in the oral cavity

6. Risk for nodal metastasis Various factors Site Size T stage Location of primary tumour Histomorphologic characteristics of primary tumor

7. Risk of nodal metastases increases in relation to location of the primary tumor

8. What is the rationale of treatment of squamous cell carcinoma ? SCC has a distinct predilection for lymphatic spread before distant systemic metastasis. early detection and eradication of local and regional lymphatics prevents future metastasis

9. Memorial sloan kettering Cancer centre leveling system

10. Division of neck levels by sublevels IA – submental nodes IB – submandibular nodes IIA & IIB – together comprising the upper jugular nodes III – middle jugular nodes IV – lower jugular nodes VA – Spinal accessory nodes VB – Transverse cervical and supraclavicular nodes VI – anterior compartment nodes

11. Clinical assessment and staging Important parameter for surgical management of the neck is the staging of the neck itself. Results of the staging procedure have lower level of certainty than biopsies

12. Assessment Clinical examination: 72% to 76% sensitivity CT and MRI : 84% to 92%

13. TNM Staging AJCC 8 th Edition TX Primary tumour cannot be assessed T0 No evidence of primary tumour Tis Carcinoma in situ T1 Tumour 2 cm or less in greatest dimension T2 Tumour more than 2 cm but not more than 4 cm in greatest dimension T3 Tumour more than 4 cm in greatest dimension T4a (lip) Tumour invades through cortical bone, inferior alveolar nerve, floor of mouth, or skin (chin or nose) T4a (oral cavity) Tumour invades through cortical bone, into deep/extrinsic muscle of tongue (genioglossus, hyoglossus, palatoglossus, and styloglossus), maxillary sinus, or skin of face T4b (lip and oral cavity) Tumour invades masticator space, pterygoid plates, or skull base; or encases internal carotid artery T — Primary tumour   1,2

14. NX Regional lymph nodes cannot be assessed N0 No regional lymph node metastasis N1 Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension N2 Metastasis as specified in N2a, 2b, 2c below N2a Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension N3 Metastasis in a lymph node more than 6 cm in greatest dimension N - Regional Lymph Nodes ## M - Distant metastasis M0 No distant metastasis M1 Distant metastasis

15. Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage II T2 N0 M0 Stage III T1, T2 N1 M0 T3 N0, N1 M0 Stage IVA T1, T2, T3 N2 M0 T4a N0, N1, N2 M0 Stage IVB Any T N3 M0 T4b Any N M0 Stage IVC Any T Any N M1 Stage grouping

16. TNM STAGING First reported by Pierre Denoix in the 1940s. The International Union against cancer (UICC) and AJCC eventually adapted the system It is important to realize that the TNM staging system is simply an anatomic staging system TNM Staging describes tumor burden in only two dimensions

17. A study of correlation of tumor thickness with risk of occult nodal metastasis –Spiro et al* *Spiro RH,Huvos AG, Wong GY ,Spiro JD, Strong EW .Predictive value of tumor thickness in SCC confined to the tongue and floor of the mouth Am J Surg 1986; 152: 345-350

18. The incidence of lymph node metastasis and survival in relation to the thickness of the primary lesions for T1 and T2 SCC of the oral tongue and floor of mouth

19. Patterns of cervical lymphatic metastasis lymphatic flow in the neck - consistent pattern - upper neck and then to the lower neck. This orderly lymphatic flow has been demonstrated by the work of Fisch and Sigel* * Cervical lymphatic system as visualized by lymphography  Annals of Otology, Rhinology and Laryngology 73: 869-872 .

20. Studies on Patterns of cervical lymph node metastasis – Jatin P Shah * The percentages represents percent of patients with N0 neck

21. Distribution of nodal metastasis in patients with N+ neck Studies on Patterns of cervical lymph node metastasis – Jatin P Shah

22. Further studies to support low level of metastasis to level V was confirmed -study by Davidson et al. an incidence of level V metastasis of 1% was found among 666 RND performed Inference: Metastasis to level V never occurred in the absence of clinically palpable nodes in other levels of neck.

23. History of neck dissections

24. Dr George Crile (1864-1943 ) In 1906 paper “ Exicision of cancer of the head and neck ” Gold standard procedure : “Radical Neck dissection”

25. Dr. Hayes Martin (1892-1977 ) In 1951 paper “Neck Dissection ” “ Routine prophylactic RND was impractical ”

26. Historical perspective on neck dissection RND should not be used for N0 neck, a philosophy that was largely observed in 2006. Nahum et al described a syndrome of pain following RND – “Shoulder Syndrome” * . * Nahum AM, Mullally W, Marmor L : A Syndrome resulting from radical neck dissection. Arch otolaryngol 74 : 82,1961

27. Historical perspective on neck dissection 1880 – Kocher – proposed removal of nodal metastasis 1906 – George crile – RND 1933 & 1941 – Blair and Martin popularised RND 1953 – Pietrantoni - recommended sparing SAN 1967-- Bocca and Pignataro described FND 1975- Bocca established oncologic safety compared to RND 1980 - Ballantyne –concept of selective neck dissection

28. Radical neck dissection (RND) Modified radical neck dissection (MRND) Selective neck dissection (SND) Supraomohyoid type Lateral type Posterolateral type Anterior compartment type Extended radical neck dissection Classifications Academy's classification

29. MEDINA CLASSIFICATION(1989 ) Comprehensive neck dissection Radical neck dissection (RND) Modified radical neck dissection (MRND) MRND I – Preserves spinal accessory nerve. MRND II – Spinal accessory and sternocleidomastoid muscle but sacrifices internal jugular vein. MRND III – Requires preservation of SAN, sternocleidomastoid muscle and internal jugular vein Selective neck dissection (SND ) Supraomohyoid neck dissection – I, II, III Jugular neck dissection – II, III, IV Anterior triangle neck dissection – I, II, III, IV Central compartment neck dissection – VI Posterolateral neck dissection – II, III, IV

30. Spiro’s classification Radical (4 or 5 node levels resected) Conventional RND MRND Extended RND Selective (3 node levels resected) SOHND Jugular dissection (level II-IV) Any other 3 levels Limited (no more than 2 node levels resected) Para tracheal node dissection Mediastinal node dissection Any other 1 or 2 node levels resected

31. Incisions Incisions classified into Vertical Horizontal The incisions used for neck dissections are Tri-radiate incision and its modification Hayes martin double ‘Y’ incision McFee incision

32. Basic needs of an incision are Good exposure of the neck and primary disease Ensure viability of the skin flaps. Avoid acute angles Protect carotid artery even in the cases of wound infection Facilitate reconstruction Adapt to the condition of patient especially after radiotherapy It should be cosmetically acceptable

33. Differences between incisions Transverse incision Vertical incision Have cosmetic advantage as they follow natural folds of the skin They intersect the natural folds of the skin Recovery of scar tissue in these folds are rapid and successful They tend to contract along their long axis – leads to deformity and restricted action. Easy to modify

34. Tri-radiate incision and its modifications Advantages Incision provides good exposure to surgical site. Disadvantages Flap necrosis is high due to disruption of vasculature of skin flaps Occurrence of flap separation at the trifurcation site.

35. Modification of Tri-radiate incision Schobinger (1957) Cramer & Culf (1969) Conley (1970)

36. Schobinger (1957) ‘Vertical limb instead of being straight should be curved posteriorly ’

37. Conley (1970) Suggested a posteriorly curving vertical incision rather than a horizontal incision

38. Hayes Martin Incision It is a paired ‘Y’ incision. Here the submandibular component is met by a vertical limb which below becomes continuous with an inverted ‘Y’ in the suprascapular region. This flap most often gets cyanosed. Flap necrosis and carotid exposure is more in this type of incision.

39. McFee Incision It avoids a vertical limb. Two horizontal incisions are used one in submandibular region and other in the suprascapular region.

40. Apron flaps Described by Latyschevsky and Freund 1960. Only a horizontal incision from mastoid to mentum gently curving inferiorly upto upper border of the thyroid cartilage is used. Advantages Carotid artery is well protected Disadvantages It will damage the ascending arterial and venous recovery Venous congestion and oedema might develop at the bottom corner

41. Hockey stick incision Lahey et al (1940) described. Modified for RND by Eckert & Byars 1952. It has a longitudinal and transverse incision B/L hockey stick incision allows the deglovement of the whole neck.

42. Radical Neck Dissection

43. Radical neck dissection Current indications for classical radical neck dissection. N3 disease Multiple gross metastases involving multiple levels. Recurrent metastatic disease in a previously irradiated neck. Grossly apparent extranodal spread with invasion of the spinal accessory nerve and /or internal jugular vein at the base of the skull Involvement of accessory chain lymph nodes by metastatic disease.

44. Modified Radical Neck Dissection (MRND) Excision of same lymph node bearing regions as RND with preservation of one or more nonlymphatic structures (SAN, SCM, IJV) Spared structure specifically named MRND is analogous to the “functional neck dissection” described by Bocca

45. Modified Radical Neck Dissection Three types (Medina 1989) commonly referred to not specifically named by committee. Type I: Preservation of SAN Type II: Preservation of SAN and IJV Type III: Preservation of SAN, IJV, and SCM ( “Functional neck dissection”)

46. MRND Type I Indications – Clinically obvious lymph node metastases – SAN not involved by tumor – Intraoperative decision Rationale – RND vs MRND Type I: – Actuarial 5-year survival and neck failure rates for RND (63% and 12%) not statistically different compared to MRND I (71% and 12%) (Andersen) – No difference in pattern of neck failure

47. MRND Type II Indications Rarely planned Intraoperative tumor found adherent to the SCM, but not IJV and SAN

48. MRND Type III Rationale – Suarez (1963) – necropsy and surgery specimens of larynx and hypopharynx – lymph nodes do not share the same adventitia as adjacent BV’s – Nodes not within muscular aponeurosis or glandular capsule (submandibular gland) – Sharpe (1981) showed ) 0% involvement of the SCM in 98 RND specimens despite 73 have nodal metastases – Survival approximates MRND Type I assuming IJV, and SCM not involved

49. Incision

50. Dissection of the posterior triangle begins at the anterior border of trapezius

51. Dissection of the posterior triangle medially leads to exposure of brachial plexus, phrenic nerve and cutaneous roots of the cervical plexus

52. Specimen reflected posteriorly and anterior flap elevated to expose the sternal head of SCMM

53. Sternocleidomastoid muscle is detached from the sternum and clavicle and retracted cephalad to expose the carotid sheath

54. Internal jugular vein is ligated and divided after common carotid and vagus nerve is exposed and retracted medially

55. Dissection proceeds cephalad along the carotid sheath up the skull base

56. The upper skin flap is now elevated preseving the mandibular branch of the facial nerve

57. Surgical field following RND

58. Two suction drains inserted

59. Contraindications for RND Uncontrollable cancer of the primary site Evidence of distant metastasis Fixed nodes unchanged by radiotherapy or chemotherapy Life expectancy of less than 3 months

60. Selective Neck Dissection Definition Cervical lymphadenectomy with preservation of one or more lymph node groups. Four common subtypes Supraomohyoid neck dissection Posterolateral neck dissection Lateral neck dissection Anterior neck dissection

61. SELECTIVE NECK DISSECTION Also known as an elective neck dissection Rate of occult metastasis in clinically negative neck 20-30% Indication: primary lesion with 20% or greater risk of occult metastasis Studies by Fisch and Sigel (1964) demonstrated predictable routes of lymphatic spread from mucosal surfaces of the H&N

62. Supraomohyoid neck dissection Indications Oral cavity carcinoma with N0 neck Boundaries – Vermillion border of lips to junction of hard and soft palate, circumvallate papillae Subsites - Lips, buccal mucosa, upper and lower alveolar ridges, retromolar trigone , hard palate, and anterior 2/3s of the tongue and FOM Medina recommends SOHND with T2-T4NO ,TXN1 (palpable node is <3cm, mobile, and in levels I or II)

63. SND: Lateral Type Indications N0 neck in carcinomas of the oropharynx, hypopharynx , supraglottis , and larynx Rationale – Hypopharynx - Occult metastases in 30-35% Johnson (1994) Medial pyriform (MP) vs. lateral pyriform carcinomas (LP) MP – 15% failed in the contralateral neck LP – 5% failed in the contralateral neck Johnson advocates bilateral SNDs for N0 MP carcinomas and ipsilateral SND for N0 LP carcinomas Bilateral SND is often indicated in the majority of hypopharyngeal tumors because of extensive submucosal spread and involvement of multiple subsites .

64. Posterolateral neck dissection

65. SND: Posterolateral Type Definition En bloc excision of lymph bearing tissues in Levels II-IV and additional node groups – suboccipital and postauricular . Indications : Cutaneous malignancies Melanoma Squamous cell carcinoma Merkel cell carcinoma Soft tissue sarcomas of the scalp and neck

66. Jugular neck dissection

67. Extended radical neck dissection Definition Any previous dissection which includes removal of one or more additional lymph node groups and/or non-lymphatic structures. Usually performed with N+ necks in MRND or RND when metastases invade structures usually preserved

68. Complications of RND Intra operative complications Post operative complications Late complications

69. Intra-operative complications Injury to phrenic nerve Injury to vagus nerve Brachial plexus injury Carotid injury Hypoglossal nerve injury Lingual nerve injury

70. Post operative complications Haemorrhage Lymph leak Dysphagia Carotid blow out Facial edema

71. Complications of ligating bilateral internal jugular vein simultaneously

72. Late complications Shoulder droop Shoulder pain Brachial neuralgia Neuroma Strictures