[Neck dissection for Head and Neck cancers: state of the art and classification]

The purposes of this article are to review the history and evolution of neck dissections, including an update on node levels and their anatomical landmark. A number of classification systems were proposed and subsequently established for neck dissection procedures. The system most often employed was published in 1991 by the American Head and Neck Society and American Academy of Otolaryngology- Head and Neck Surgery and revised in 2002 and 2008. According to this classification, neck dissections are grouped into four broad categories: radical neck dissection (RND), modified radical neck dissection (MRND), selective neck dissection (SND) and extended neck dissection (ERND). The choice between different surgeries depends on type and site of head and neck tumor as well nodal involvement.

An evaluation of the shoulder domain of the University of Washington quality of life scale

The aim of this study was to compare the shoulder domain in the University of Washington quality of life (UW-QoL) scale with two shoulder-specific questionnaires.

METHODS

We did a cross-sectional survey of 100 consecutive outpatients who had had operations on the head and neck for cancer using the UW-QoL, the neck dissection impairment index, and the shoulder disability questionnaire.

RESULTS

The types of neck dissection were none (n=12), unilateral selective (n=63), bilateral selective (n=17), and radical or modified radical (n=8). There were significant correlations among the three questionnaires. The worst scores were found in the group who had modified radical or radical neck dissection. Although responses were similar between those who had no neck dissection and those who had unilateral level 3 neck dissection, a few patients reported considerable dysfunction after selective neck dissection.

CONCLUSION

Although the UW-QoL shoulder domain is limited to one of four responses, our results support the conclusion that it is sufficiently sensitive to screen for dysfunction of the shoulder.

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.

[Radiological and surgical classification of head and neck lymph node anatomy]

OBJECTIVE

The purpose of this review is to present a systematic description of cervical lymph drainage by nodal level.

MATERIAL AND METHODS

We present, in French, the radiological and surgical classification of the cervical lymph nodes with numerous illustrations. A critical analysis of the advantages and limitations of this tool is presented together with practical guidelines.

RESULTS

This classification system is a useful tool for the evaluation of cervical metastases. It provides for more precise treatment and better understanding and communication between specialists, offering the standardization necessary for comparing results obtained by different teams and for multicenter studies.

CONCLUSION

This classification of cervical lymph nodes by level is a useful tool for the management of cervical node involvement in head and neck cancer.

[Historical outline on the nomenclature of neck lymph nodes as a basis of neck dissection classification]

BACKGROUND

The neck dissection classification is based considerably on the organization of the lymph nodes of the neck. Terminology and anatomical allocation of nearly 300 cervicofacial lymph nodes repeatedly changed since the beginning of the 20th century.

METHODS

Analysis of the literature on neck lymph node organization with reference to the development of the neck dissection classification.

RESULTS

The first fundamental nomenclature of the neck lymph nodes is founded on the work of Rouviére (1932). Suárez (1963) described the functional neck dissection on the basis of the fascial compartmentalization of the neck. Lindberg (1972) left the predominantly anatomically correlated grouping of the cervical lymph nodes as described by Rouviére and divided the lymphatic system of the neck on basis of pathophysiological mechanisms. The attention regarding the location of occult metastases led to the description of the selective neck dissection. Since the fundamental work of Shah et al. (1981) there was a multiplicity of more or less slight changes of the neck node regions. These changes were again basis for new neck dissection terminologies. A new classification was introduced in the year 2000 as the revised version of the American Head and Neck Society.

CONCLUSIONS

The revised version of the neck dissection classification can reduce former controversies, particularly regarding an optimized intraoperative allocation of the lymph nodes and a simplified terminology of the selective neck dissection. With the goal of a standardization of the neck dissection forms it remains to be seen if the proponents of the functional neck dissection after Suárez consider the extent of the neck dissection in patients with N0 neck in favor of the selective neck dissection.

[Classification of the neck dissections]

The distribution of the neck surgery dissections proposed by the Academy Committee for Head Neck Surgery and Oncology, Education of the Head Neck Surgery (year 1991) was discussed in this paper. The authors are in the agreement with proposed distribution and strongly recommend its implementation in Poland. The standard radical neck dissection according to Crile was accepted as the base of this distribution. Neck dissection similar to Crile's operation but with saving up important anatomical structures (n. XI., vena jugularis int., m.scm) was called modified radical neck dissection (type I-III). Excision of the lymphatic system from the well-defined regions of the neck with saving up nonlymphatic structures and/or group of lymphatic system same in Crile's operation with additional nonlymphatic structures and/or another lymphatic nodules nonmentioned in Crile's operation is called enlarged radical neck dissection.

The role of neck dissection in head and neck mucosal squamous cancer

The most clinically useful system of classification of neck lymph nodes is grouping into levels I-V. Anatomical, clinical and pathological studies demonstrate that although generally lymphatic flow is from above downwards, level I is often bypassed and level V is seldom involved. Neck dissection is classified into radical, modified radical, selective and extended radical neck dissections. Recent studies demonstrate that elective neck dissection is beneficial to the outcome of oral cancer patients, but not necessarily to laryngeal and pharyngeal cancer patients. Modified radical neck dissection is as effective as radical neck dissection when performed in the elective situation. Selective neck dissection in the form of supra-omohyoid neck dissection is useful as a staging procedure. Modified radical neck dissection is acceptable for the N1 neck provided postoperative radiotherapy is given.

Classification of neck dissection: current concepts and future considerations

In response to the increased number of neck dissection procedures and the lack of uniformity of terminology for describing these, several classification proposals have been made. The consensus report on neck dissection terminology by the American Academy of Otolaryngology-Head and Neck Surgery seems to have gained wide acceptance. This report outlines the Academy's classification system and its definitions for the lymph node groups. Other authors contributions are discussed and recommendations are suggested for future refinements to the classification system.

Effectiveness of selective neck dissection for management of the clinically negative neck

OBJECTIVE

To determine the effectiveness of selective neck dissection for management of the clinically negative neck in head and neck squamous cell carcinoma.

DESIGN

A retrospective comparison of patients treated electively with selective neck dissection and comprehensive neck dissection.

SETTING

Academic tertiary referral center.

PATIENTS

Patients with clinically negative necks and previously untreated head and neck squamous cell carcinoma.

INTERVENTION

Elective neck dissection, surgical treatment of the primary lesion, and postoperative radiotherapy as indicated.

OUTCOME MEASURES

Regional recurrence, distant metastasis, and disease-free survival.

RESULTS

Selective neck dissection was as effective as comprehensive procedures for staging the clinically negative neck. Occult metastases had a statistically significant effect on patient outcome as measured by distant metastasis.

CONCLUSION

Elective neck dissection provides invaluable staging information, which guides the decision for adjuvant therapy.

Management of cervical lymph nodes in squamous carcinomas of the head and neck

Due to the overwhelming prognostic significance of regional metastases, proper management of cervical lymph nodes in cases of squamous cell carcinoma of the head and neck is essential for an optimal outcome. Better understanding of the predictability of incidence and patterns of metastases of these tumors in recent years has led us away from the radical neck dissection as the only surgical therapeutic or staging procedure done on the neck. Recent studies suggest that selective removal of lymph node groups at risk in clinically negative necks, or modified neck dissections that save important structures, like the jugular vein, XI nerve, and sternocleidomastoid muscle, in clinically positive necks, are appropriate in many patients. Careful selection of the type of neck dissection and judicious use of postoperative radiation therapy can optimize cure rates as well as functional and cosmetic results.

Classification of neck dissection: variations on a new theme

BACKGROUND

Commencing in 1984, we initiated a head and neck service surgical database that included a classification system for neck dissection. The aim was to reduce the confusion in terminology resulting from growing interest in modifications of conventional radical neck dissection.

METHODS

We considered a neck dissection as radical when four or five lymph node levels were excised; this included patients who had an otherwise classical neck dissection for supraglottic larynx or hypopharyngeal cancer sparing level 1. Lymph-node levels removed, nonlymphatic structures preserved, and excised nonlymphatic structures not ordinarily included in a classical radical neck dissection were all specified by the operating surgeon. We defined as a selective neck dissection any lymphadenectomy that encompassed no more than three nodal levels, usually supraomohyoid (levels 1, 2, 3), or jugular (levels 2, 3, 4). We defined as a limited neck dissection any lymphadenectomy that involved removal of no more than two nodal levels.

RESULTS

At the 10-year mark, this database of 10,650 patients now includes 2,635 lymphadenectomies in 2,426 patients, the precise extent of which is accurately described in each patient.

CONCLUSIONS

The current classification of neck dissection does not cover all possibilities. If we define as radical those lymphadenectomies that resect four or five nodal levels and specify structures preserved or additional nonlymphatic structures sacrificed, we allow for the possibility that some procedures may be both modified and extended. Selective would describe the standard, three-level dissections (eg, supraomohyoid or jugular node dissections), and the term limited would be introduced to indicate a neck dissection that involves removal of no more than two nodal levels. Such a three-tiered classification would more accurately reflect the time and effort involved and provide a more equitable basis for reimbursement.

Standardizing neck dissection terminology. Official report of the Academy's Committee for Head and Neck Surgery and Oncology

The emergence of the multitude of modified techniques for neck dissection procedure has resulted in a nomenclature system that is nonuniform. To eliminate potential misinterpretation, overlap, and lack of standardization, the Academy's Committee for Head and Neck Surgery and Oncology, with input from the Education Committee of the American Society of Head and Neck Surgery, has developed a classification system for these procedures. This has now been adopted by the American Academy of Otolaryngology-Head and Neck Surgery. The classification is based on the following concepts: (1) radical neck dissection is the fundamental procedure with which all other neck dissections are compared, (2) modified radical neck dissection denotes preservation of one or more nonlymphatic structure(s), (3) selective neck dissection denotes preservation of one or more group(s) of lymph nodes, and (4) extended radical neck dissection denotes removal of one or more additional lymphatic and/or nonlymphatic structure(s). Adherence to the principles of this classification system to describe neck dissection techniques should provide an improved method of communication. Furthermore, the system provides a rational framework on which subsequent terminology can be added.