Neck dissection: an operation in evolution

Treatment Complications of Head and Neck Cancers and Rehabilitation Measures: A Narrative Review

Head and neck cancers (HNCs) are malignant tumors mainly from squamous cells in the head and neck tissues. Treatment involves a multidisciplinary approach with surgery, radiotherapy, and chemotherapy. However, the long-term prognosis for patients with advanced-stage tumors is guarded, with a median survival time of approximately 24 months. HNC patients have very high rates of depression and anxiety and the highest suicide rate among all cancers due to the intense and challenging nature of the treatment, underscoring the importance of our collective efforts. Rehabilitation success depends on various factors, including tumor, patient, and treatment-related factors. Patients may require post-treatment oral rehabilitation measures, including implants, obturators, and flexible dentures. These measures are crucial, but they often need to be more utilized. Patients may face challenges in maintaining oral hygiene and managing mucositis. Additionally, it is essential to address other intricacies such as trismus, xerostomia, gustatory dysfunctions, neuropathy, speech impairments, and psychological disturbances. Unfortunately, there is little literature on post-treatment rehabilitative measures. Despite its crucial role in improving patients' quality of life, rehabilitation often receives inadequate attention compared to treatment. Our narrative review, which covers various factors that affect rehabilitation, including oral rehabilitation measures and post-treatment complications, is anticipated to deliver practical insights to professionals and inspire positive changes in their regular practice.

Selective Neck Dissection for Node-Positive Oral Cavity Squamous Cell Carcinoma: A Retrospective Cohort Study

Introduction  Selective neck dissection in clinically node-negative neck is considered the standard of care for oral squamous cell carcinomas (SCCs). Controversy still prevails in node-positive disease regarding the extent of neck dissection. In our part of the world, comprehensive neck dissection is mostly considered to be the minimal optimal treatment for palpable neck disease.

Objective  To compare regional control and disease-specific survival between clinically node-positive and node-negative patients undergoing selective neck dissection for oral SCC.

Methods  This was a retrospective cohort study conducted in the department of ENT, Head and Neck surgery at a tertiary care hospital. All patients with biopsy-proven oral and lip SCC, with or without nodal disease, who underwent selective neck dissection between April 2006 and July 2015 were included in the study.

Results  During the study period, 111 patients with oral SCC underwent selective neck dissection, of whom 71 (62%) were clinically node-negative and 40 (38%) patients had clinically positive nodes in the neck. The mean follow-up was 16.62 months (standard deviation [SD]: 17.03). The overall regional control rates were 95 versus 96% for clinical negative versus positive nodes, respectively ( p  = 0.589). The disease-specific survival was 84.5% in the node negative group versus 82.5% in the node-positive group ( p  = 0.703).

Conclusion  Selective neck dissection in node-positive neck oral SCC has similar regional control rates when compared with node-negative neck SCC. The difference in disease-specific survival between the two groups is also not significant.

Endoscopic Cervical Lymph Node Dissection Using the Extra-cervical Anterior Chest Wall Approach: A New Technique

INTRODUCTION

This study aims to demonstrate the safety, surgical feasibility, and esthetic features of total endoscopic neck dissection (END) through anterior chest wall approach (ACWA) without creation of any neck incisions. Resection of their primary tumors followed by selective total END through ACWA using 3 ports (one 10-mm port for the camera and two 5-mm ports for the working instruments).

METHODS

From January 2020 to August 2020, 6 patients with a biopsy proven head and neck carcinoma underwent resection of their primary tumors followed by selective total END through ACWA using 3 ports (one 10-mm port for the camera and two 5-mm ports for the working instruments).

RESULTS

The selective neck dissection was successfully performed endoscopically in all cases with no conversion to open approach and with good visualization of the major neurovascular structures. The operative time for the END ranged from 120 to 170 minutes, with 10-50 mL estimated blood loss. No significant perioperative complications were encountered. The mean total number of cervical LN retrieved was 13.67 + 2.42, and the mean LNR was .01 + .13. All patients were discharged in the third postoperative day, and they were satisfied with the cosmetic outcome.

CONCLUSION

Selective total END through ACWA is technically feasible and safe with satisfactory cosmetic results. The absence of neck scars and magnification of the important neurovascular structures are the most obvious advantages of this innovative technique. It may be a valid alternative to conventional surgery when performed in selected patients. However, further research with longer follow up is needed to clarify the oncological safety and the real benefits of END in head and neck cancer patients.

The impact of sentinel lymph node biopsy on the quality of life in patients with oral cavity squamous cell carcinoma

INTRODUCTION

Sentinel lymph node biopsy is a proven method for staging the neck in patients with early oral cavity squamous cell carcinoma because it results in less comorbidity than the traditional method of selective neck dissection, with the same oncological results. However, the real effect of that method on the quality of life of such patients remains unknown.

OBJECTIVE

The present study aimed to evaluate the quality of life of patients with oral cavity squamous cell carcinoma T1/T2N0 submitted to sentinel lymph node biopsy compared to those that received selective neck dissection.

METHODS

Cross-sectional study including 24 patients, after a 36 month follow-up, 15 of them submitted to the sentinel lymph node biopsy and 9 to selective neck dissection. All patients answered the University of Washington quality of life questionnaire.

RESULTS

The evaluation of the questionnaires showed a late worsening of the domains appearance (p=0.035) and chewing (p=0.041), as well as a decrease of about 10% of general quality of life (p=0.025) in patients undergoing selective neck dissection ​​in comparison to those undergoing sentinel lymph node biopsy.

CONCLUSION

Patients with early-stage oral cavity squamous cell carcinoma undergoing sentinel lymph node biopsy presented better late results of general quality of life, mainly regarding appearance and chewing, when compared to patients submitted to selective neck dissection.

Predicting 90-Day Mortality in Locoregionally Advanced Head and Neck Squamous Cell Carcinoma after Curative Surgery

Purpose: To propose a risk classification scheme for locoregionally advanced (Stages III and IV) head and neck squamous cell carcinoma (LA-HNSCC) by using the Wu comorbidity score (WCS) to quantify the risk of curative surgeries, including tumor resection and radical neck dissection. Methods: This study included 55,080 patients with LA-HNSCC receiving curative surgery between 2006 and 2015 who were identified from the Taiwan Cancer Registry database; the patients were classified into two groups, mortality (n = 1287, mortality rate = 2.34%) and survival (n = 53,793, survival rate = 97.66%), according to the event of mortality within 90 days of surgery. Significant risk factors for mortality were identified using a stepwise multivariate Cox proportional hazards model. The WCS was calculated using the relative risk of each risk factor. The accuracy of the WCS was assessed using mortality rates in different risk strata. Results: Fifteen comorbidities significantly increased mortality risk after curative surgery. The patients were divided into low-risk (WCS, 0–6; 90-day mortality rate, 0–1.57%), intermediate-risk (7–11; 2.71–9.99%), high-risk (12–16; 17.30–20.00%), and very-high-risk (17–18 and >18; 46.15–50.00%) strata. The 90-day survival rates were 98.97, 95.85, 81.20, and 53.13% in the low-, intermediate-, high-, and very-high-risk patients, respectively (log-rank p < 0.0001). The five-year overall survival rates after surgery were 70.86, 48.62, 22.99, and 18.75% in the low-, intermediate-, high-, and very-high-risk patients, respectively (log-rank p < 0.0001). Conclusion: The WCS is an accurate tool for assessing curative-surgery-related 90-day mortality risk and overall survival in patients with LA-HNSCC.

Preservation of the External Jugular Venous Drainage System in Neck Dissection

OBJECTIVE: To investigate whether preserving the external jugular vein (EJV) in neck dissection reduces postoperative edema of the face and neck.

STUDY DESIGN: A prospective, randomized controlled trial.

SETTING: A tertiary hospital.

SUBJECTS AND METHODS: Thirty-eight subjects were randomly assigned to two groups: EJV preservation versus sacrifice during neck dissection after stratification according to the neck dissection extent and type, the previous treatment, the primary site, and the reconstruction type. The relative soft-tissue thickness was evaluated by follow-up computed tomography (CT) scans at one week and four to five weeks postoperatively and compared with preoperative findings. The preserved EJV patency was also determined by contrast enhancement of EJV on follow-up CT scans. In addition, the scores for pain/discomfort on the upper neck/face and laryngeal edema were recorded at each time point.

RESULTS: Relative soft-tissue thickness reached up to 160 percent of preoperative status at the hyoid and cricoid levels at one week postoperatively but resolved at four to five weeks. EJV preservation reduced the soft-tissue thickness significantly compared with EJV sacrifice ( P < 0.05) at one week postoperatively, particularly at the mandible and hyoid level. All preserved EJVs remained patent at one week, and 18 of 19 remained patent at four to five weeks. In addition, EJV preservation diminished the discomfort/pain of the upper neck/face compared with EJV sacrifice at one week ( P = 0.036). The extent of laryngeal edema did not differ between the two groups.

CONCLUSION: EJV preservation may reduce immediate postoperative neck edema and pain/discomfort related to neck dissection.