Neck dissection: historical and current concepts

Oral Cancer Treatment Through the Ages: Part 2

PURPOSE

Understanding how oral cancer treatment evolved can pave the way for future management. The literature holds an expansive collection of historical findings regarding oral cancer, yet the authors were unable to find a comprehensive review of oral cancer treatment throughout the ages.

MATERIALS

A thorough literature review was carried out using multiple scientific databases and languages, as well as examination of historical archives. Articles were included for their relevance and their findings were assimilated.

RESULTS

Part two of this article considers the development of specific surgical concepts relating to head and neck cancer over the previous two centuries, including neck dissection and reconstruction, as well as exploration of non-surgical cancer therapies.

CONCLUSION

This paper demonstrates historical landmarks made in oral cancer treatment and the prominent figures who pioneered them, confirming that head and neck cancer surgeons of today have valuable lessons to learn from their previous counterparts.

Postoperative management in laryngeal cancer with subglottic extension and histologically negative nodes: which patients need adjuvant radiotherapy?

We conducted a study of 19 patients who had laryngeal cancer with subglottic extension (LCSE) and pathologically negative lymph nodes (pN0) following total laryngectomy and neck dissection (TLND). These patients had undergone surgery during a 17-year period from 1986 through 2002. Of this group, 9 did not receive postoperative radiotherapy (non-RT group) and 10 did (RT group). Adjuvant irradiation had been administered to those with additional histopathologic risk factors for recurrence. We found that recurrence rates in the neck were 44% in the non-RT group and 11% in the RT group (1 of 9 evaluable patients), and the corresponding 5-year disease-free survival rates were 51 and 89%. While both of these differences were clinically significant, neither was statistically significant (p = 0.29 and p = 0.14, respectively). The presence of LCSE was not known prior to or during TLND in 4 non-RT patients and in 7 RT patients; their corresponding neck recurrence rates were 50 and 0%. Two of 8 patients (25%) whose ipsilateral lobe of the thyroid gland was not removed experienced a stomal recurrence. We conclude that three factors can be used to identify patients with pN0 LCSE who may be candidates for adjuvant postoperative radiotherapy: (1) a failure to remove the ipsilateral thyroid gland lobe during TLND, (2) a failure to examine the level VI lymph node for metastatic disease status, and (3) unfavorable histopathologic findings.

Does the negative node count affect disease-free survival in early-stage oral cavity cancer?

PURPOSE

We performed a retrospective study to determine whether there is a relationship between disease-free survival and negative lymph node count in patients with resected early-stage oral cavity cancers.

MATERIALS AND METHODS

Of the 526 individuals diagnosed with carcinoma of the oral cavity between 1998 and 2005, 52 had undergone primary tumor resection and lymph node dissection of the neck for stage I or II disease. With a mean count of 27 examined negative nodes, these 52 patients were separated into groups with fewer than 27 or > or = 27 uninvolved lymph nodes and compared for disease-free survival.

RESULTS

The tumor recurred or progressed in 10 patients (19%) during a median follow-up of 27 months. The 2-year disease-free survival rates were 75% and 78% in individuals with fewer than 27 and > or = 27 uninvolved node counts, respectively (P > .78).

CONCLUSION

The removal of a greater number of regional, uninvolved cervical lymph nodes does not correlate with disease-free survival in this particular cohort of patients.

An outline of the history of head and neck oncology

This review analyzes the development of head and neck oncology as outlined in medical history articles. A systematic literature survey was conducted with the search engines "Google Scholar" and "PubMed" and the retrieved publications were cross-referenced. In addition, books and, when possible, original sources were consulted. While most of the material was obtained from publications from the modern era reviewing historical data, some of the information was derived from original source material. The obtained articles on the history of cancer were then analyzed for details on head and neck oncology. The cradle of oncology was located in ancient Egypt and Greece. The search showed that the first tumors treated in the head and neck were either cutaneous malignancies or cancers on the mucosal surfaces of the oral cavity. The origin, diagnosis and treatment of more deeply situated tumors of the larynx and hypopharynx remained obscure for many centuries. The medieval age brought little progress to medicine in general, and in head and neck oncology in particular, due to religious concerns. Renaissance medicine was characterized by advances in medicine and oncology made by systematic dissection studies of normal and pathologic anatomy. The 19th and 20th century reflect the development of head and neck oncology in the era of science based medicine. Almost all of our current understanding of head and neck oncology, our diagnostic methods and treatment strategies have been developed in these two centuries. The analysis showed that many oncologic problems, which occupy our minds today, were also concerns of our medical ancestors.

European Surgeons Were the First to Perform Neck Dissection

The history of the surgical treatment of cervical lymph node metastases began in the 19th century, and, unfortunately, the initial attempts at surgical treatment of neck metastases were disastrous. Although some European surgeons reported few cases of radical en bloc dissection, the first successful surgical procedure was performed and described in detail by Franciszek Jawdyński, a Polish surgeon, in 1888. George Washington Crile popularized and illustrated radical en bloc neck dissection in the early 20th century.

Neck dissection: then and now

The significance of metastatic disease in the lymph nodes of the neck as a critical independent prognostic factor in head and neck cancer has long been appreciated. Although 19th century surgeons attempted to remove involved cervical lymph nodes at the time of resection of the primary cancer, a systematic approach to en bloc removal of cervical lymph node disease, described in detail by Jawdyński in 1888 and popularized and illustrated by Crile in the early 20th century, provided consistent and more effective treatment, and forms the basis of our current techniques. During the first half of the 20th century, developments included preservation of the accessory nerve in selected cases, elective neck dissection performed in association with resection of various primary tumors, bilateral neck dissection and limited neck dissection. The greatest impetus to the status of radical neck dissection came from Martin, whose technique consisted of resection of all lymph nodes from level I-V together with the accessory nerve, internal jugular vein, sternocleidomastoid muscle and various other structures in a single block of resected tissue. Martin's technical precepts were followed until the latter part of the 20th century when modifications in technique began to find general acceptance. The first description of an effective technique of modified radical neck dissection was published in Spanish by Suárez, in 1963. This technique, which preserves important structures, such as the internal jugular vein, sternocleidomastoid muscle and accessory nerve, was refined and popularized by various authors who published their results in the English language literature during the period from 1964 through 1990 and beyond. Modified or "functional" neck dissection avoids much of the morbidity of radical neck dissection while achieving equivalent degrees of control of regional disease in properly selected cases. By the late 20th century, the concept of selective neck dissection, consisting of resection of only the nodal groups at greatest risk for metastasis from a given primary site, was studied and developed. These limited dissections are now widely employed for elective, and in properly selected cases, therapeutic treatment and staging of the neck, and have been proposed for limited cervical recurrences after various chemoradiation protocols. Prospective studies have demonstrated similar rates of neck recurrence and survival after elective selective neck dissection compared to elective modified radical neck dissection. Other modifications and factors applied to treatment of cervical lymph node disease include the use of adjuvant and neo-adjuvant radiation and chemotherapy, a revised system for classification of neck dissections, the identification of various adverse prognostic factors such as extracapsular spread and extranodal soft tissue deposits, application of sentinel lymph node biopsy to staging of the neck, the use of immunohistochemical and molecular techniques for identification of lymph node metastases not detectable by light microscopy, and the possibility of endoscopic neck dissection. The authors conclude that neck dissection, as evolved over the past century, is a fundamental tool in management of patients with head and neck cancer, but is still a work in progress.