eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Head & Neck Surgery

Neck, Cervical Metastases, Surgery: Follow-up

Author: Pankaj Chaturvedi, MBBS, MS, Associate Professor, Head and Neck Surgery, Department of Surgical Oncology, Tata Memorial Hospital, India
Coauthor(s): Uma Chaturvedi, MD, MBBS, DPB, Lecturer, Department of Pathology, KJ Somaiya Hospital and Research Center, India; Thabet Abbarah, MD, FACS, Consulting Staff, Department of Otolaryngology, North Oakland Medical Centers; Nafisa K Kuwajerwala, MD, Staff Surgeon, Breast Oncology, William Beaumont Hospital; Gunateet Goswami, MD, Consulting Staff, Internal Medicine Associates, Mount Clemens, Michigan; Consulting Staff, Department of Cardiology, Henry Ford Hospital
Contributor Information and Disclosures

Updated: Jan 23, 2008

Outcome and Prognosis

Cervical metastasis is the single most important prognosticator in head and neck SCCA, and its presence indicates a roughly 50% reduction in the overall survival rate. The prevalence of lymphatic spread is greater than 20% for most of the SCCAs of the head and neck. A neck with histologically negative findings has a recurrence rate of 3-7%, and in contrast, a neck with histologically positive findings has a recurrence rate of 20-70%. Prognostic factors of cervical metastasis are site, size and number of metastatic nodes, and extracapsular spread.

Those patients with involvement beyond the first echelon of lymphatic drainage have a poorer prognosis (eg, a very low survival rate is observed if level V is involved in nonnasopharyngeal tumors). Posterior triangle and contralateral involvement are also indications of a poor prognosis.

The number of involved nodes significantly impacts the survival rate, with involvement of 2 or more nodes carrying a much higher frequency of distant metastasis and local recurrence. Involvement of several nodes (4 or more) is associated with a worse prognosis than involvement of only one node. Multiple levels of involvement are associated with a recurrence rate of 70%; only 1 level of involvement has a recurrence rate of 35%. A correlation exists between size and perineural and perivascular infiltration of the tumor.

Extracapsular spread is commonly found in 25% of small nodes and 75% of large nodes. It decreases the survival rate and the disease-free interval by one half. Macroscopic extracapsular spread has a recurrence rate of 45%, and microscopic spread has a recurrence rate of 25%.

Perineural and perivascular invasions are associated with more aggressive tumor behavior. Involvement of the tumor margins carries a poor prognosis and a high risk for recurrent neck disease. Node fixation, especially to the carotid artery or a muscle, is an ominous sign. Fixation occurs with large masses and denotes a poor prognosis. Degree of differentiation is a prognostic factor of cervical metastasis; poorly differentiated tumors are more aggressive and carry a poor prognosis. Lymphoid cell reaction and recurrent disease are other prognostic factors.

Future and Controversies

Sentinel node biopsy

Sentinel node biopsy was introduced in 1977 by Cabanas and has been worked upon since 1990, primarily in breast cancers and melanoma. Sentinel lymph node biopsy has not yet gained popularity in oral and oropharyngeal cancers. In recent years, however, a few multicenter trials and meta-analyses have reported positive results. These have encouraged many centers around the world to further research this aspect.

According to the sentinel node biopsy philosophy, if the first draining node of a primary has micrometastasis, the rest of the nodes are very likely to be affected. This is irrespective of lymphatic drainage of the site, however unconventional it may be. The procedure involves lymphoscintigraphy after the injection of radiocolloids, prior to the surgery. During surgery, a patent blue dye is injected to visually mark the node. Thereafter, an incision of the biopsy is taken and the node is traced by a gamma probe. This gamma probe is fitted with a collimator to exclude radiation from everywhere accept a small area. The identified node is dissected and sent for histopathogical examination and immunohistochemistry. If the sentinel node is found to be positive, a neck dissection is performed.

A multicenter trial (Ross et al) conducted from 1998 to 2002 reported sentinel node procedures in 227 patients of head and neck carcinoma.12 Of these 227 patients, 134 patients had T1/T2 lesions of the oral cavity and oropharynx. The sensitivity in these 134 patients was 93%. The study concluded that sentinel node biopsy can be used alone as a staging tool for oral and oropharyngeal squamous carcinomas. Some authors have reported 100% sensitivity.13 Hart et al reported 100% negative predictive value for SNB.14 However, the study involved only 20 patients. Paleri et al conducted a meta-analysis of sentinel node biopsy reports on 301 patients of the oral cavity and 46 patients of the oropharynx.15 This meta-analysis showed that the cumulative pay off for sentinel node biopsy alone as a staging procedure was 1% less than those with elective neck dissection in terms of recurrence and mortality rates. Identification rates with radiotracer dye was 97%.

Choice of colloid 

Two colloids are commonly used for lymphoscintigraphy in Europe: Albures and

Nanocoll. Albures has a mean particle size of 500 nm and is a slower-moving particle that remains in first echelon (sentinel) nodes but requires a high density of terminal lymphatic vessels at the injection site. For this reason, Albures is the colloid of choice in the tongue and floor of mouth. Nanocoll has a mean particle size of 50 nm and is a faster-moving colloid that finds lymphatic vessels despite injection into tissues with low densities of terminal lymphatics. However, it moves readily from sentinel nodes to subsequent echelon nodes and for these reasons Nanocoll is the colloid of choice in primary tumors that aren't located in the floor of the mouth or the tongue.   

Biopsy procedure

  • During surgery, 1-2 mL of patent blue V dye is injected throughout the normal mucosa and submucosa that surrounds the tumor. This should be performed prior to the skin incision. Ensure that the same injection sites are used for Patent blue V and the radiocolloid.
  • The primary tumor is removed with adequate margins. In case the primary tumor is not excised first, the problem of the scattered radiation from the primary tumor can be avoided by using lead plates and a well-collimated detector gamma probe. 
  • A suitable small incision is made in the neck in accordance with the marking done by the nuclear physician.
  • After cutting the deeper layers, a hand-held gamma probe is used to identify radioactive sentinel nodes. To reduce "shine through," a series of malleable, sterilized lead plates may be used to mask the injection site.
  • Radioactive nodes are excised and radioactivity within the node is confirmed ex vivo. 
  • Blue stained lymphatic pathways are followed to the first draining lymph, which is harvested.  Sentinel nodes are labeled according to their color and radioactivity. 
  • The anatomical level of sentinel nodes is noted. 

Pathology

Sentinel nodes are fixed in 10% neutral buffered formalin and, after fixation, are bisected through the hilum, if this is identifiable, or through the long axis of the node. If the thickness of the halves is more than 2 mm, the slices are further trimmed to provide additional 2 mm blocks. If the sentinel nodes are found to be free from tumor on initial histological examination, step-serial sections are prepared at an additional 6 levels in the block at approximately 150 μm intervals. One hematoxylin and eosin stained section is prepared at each level. If the nodes still appear histologically negative, an immediately adjacent section from each level is examined by immunocytochemistry, using the multicytokeratin antibody.

 


More on Neck, Cervical Metastases, Surgery

Overview: Neck, Cervical Metastases, Surgery
Workup: Neck, Cervical Metastases, Surgery
Treatment: Neck, Cervical Metastases, Surgery
Follow-up: Neck, Cervical Metastases, Surgery
Multimedia: Neck, Cervical Metastases, Surgery
References
[ CLOSE WINDOW ]

References

  1. Bocca E, Pignataro O, Sasaki CT. Functional neck dissection. A description of operative technique. Arch Otolaryngol. Sep 1980;106(9):524-7. [Medline].

  2. Bocca E, Pignataro O. A conservation technique in radical neck dissection. Ann Otol Rhinol Laryngol. Dec 1967;76(5):975-87. [Medline].

  3. Robbins KT, Medina JE, Wolfe GT, et al. Standardizing neck dissection terminology. Official report of the Academy''s Committee for Head and Neck Surgery and Oncology. Arch Otolaryngol Head Neck Surg. Jun 1991;117(6):601-5. [Medline].

  4. Carenfelt C, Eliasson K. Occurrence, duration and prognosis of unexpected accessory nerve paresis in radical neck dissection. Acta Otolaryngol. Nov-Dec 1980;90(5-6):470-3. [Medline].

  5. Carenfelt C, Eliasson K. Cervical metastases following radical neck dissection that preserved the spinal accessory nerve. Head Neck Surg. Jan-Feb 1980;2(3):181-4. [Medline].

  6. Kowalski LP, Magrin J, Waksman G, et al. Supraomohyoid neck dissection in the treatment of head and neck tumors. Survival results in 212 cases. Arch Otolaryngol Head Neck Surg. Sep 1993;119(9):958-63. [Medline].

  7. Byers RM, Wolf PF, Ballantyne AJ. Rationale for elective modified neck dissection. Head Neck Surg. Jan-Feb 1988;10(3):160-7. [Medline].

  8. Sobol S, Jensen C, Sawyer W 2nd, et al. Objective comparison of physical dysfunction after neck dissection. Am J Surg. Oct 1985;150(4):503-9. [Medline].

  9. Rassekh CH, Johnson JT, Myers EN. Accuracy of intraoperative staging of the NO neck in squamous cell carcinoma. Laryngoscope. Dec 1995;105(12 Pt 1):1334-6. [Medline].

  10. Medina JE, Byers RM. Supraomohyoid neck dissection: rationale, indications, and surgical technique. Head Neck. Mar-Apr 1989;11(2):111-22. [Medline].

  11. Shah JP, Candela FC, Poddar AK. The patterns of cervical lymph node metastases from squamous carcinoma of the oral cavity. Cancer. Jul 1 1990;66(1):109-13. [Medline].

  12. Weiss MH, Harrison LB, Isaacs RS. Use of decision analysis in planning a management strategy for the stage N0 neck. Arch Otolaryngol Head Neck Surg. Jul 1994;120(7):699-702. [Medline].

  13. Paleri V. Sentinel node biopsy in squamous cell cancer of the oral cavity and oral pharynx: A diagnostic Meta-analysis. Head Neck [serial online]. 27:739– 747. Available at http://www3.interscience.wiley.com/cgi-bin/fulltext/110574678/HTMLSTART.

  14. Mozzillo N, Chiesa F, Caracò C, Botti G, Lastoria S, Longo F, et al. Therapeutic implications of sentinel lymph node biopsy in the staging of oral cancer. Ann Surg Oncol. Mar 2004;11(3 Suppl):263S-6S. [Medline].

  15. Ross G.L.,Soutar D.S. Sentinel Node Biopsy in Head and Neck Cancer: Preliminary Results of a Multicenter Trial'. Annals of Surgical Oncology [serial online]. 11(7):690–696. Available at http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=retrieve&db=pubmed&list_uids=15197011&dopt=AbstractPlus.

  16. Andersen PE, Shah JP, Cambronero E, Spiro RH. The role of comprehensive neck dissection with preservation of the spinal accessory nerve in the clinically positive neck. Am J Surg. Nov 1994;168(5):499-502. [Medline].

  17. Bailey BJ. Head and Neck Surgery-Otolaryngology. 2nd ed. Baltimore, Md:. Lippincott-Raven;1998.

  18. Clayman GL, Johnson CJ 2nd, Morrison W, et al. The role of neck dissection after chemoradiotherapy for oropharyngeal cancer with advanced nodal disease. Arch Otolaryngol Head Neck Surg. Feb 2001;127(2):135-9. [Medline].

  19. Don DM, Anzai Y, Lufkin RB, et al. Evaluation of cervical lymph node metastases in squamous cell carcinoma of the head and neck. Laryngoscope. Jul 1995;105(7 Pt 1):669-74. [Medline].

  20. Hart RD, Nasser JG, Trites JR, Taylor SM, Bullock M, Barnes D. Sentinel lymph node biopsy in N0 squamous cell carcinoma of the oral cavity and oropharynx. Arch Otolaryngol Head Neck Surg. Jan 2005;131(1):34-8. [Medline].

  21. Henick DH, Silver CE, Heller KS, et al. Supraomohyoid neck dissection as a staging procedure for squamous cell carcinomas of the oral cavity and oropharynx. Head Neck. Mar-Apr 1995;17(2):119-23. [Medline].

  22. Houck JR, Medina JE. Management of cervical lymph nodes in squamous carcinomas of the head and neck. Semin Surg Oncol. May-Jun 1995;11(3):228-39. [Medline].

  23. Johnson JT. Carcinoma of the larynx: selective approach to the management of cervical lymphatics. Ear Nose Throat J. May 1994;73(5):303-5. [Medline].

  24. Kligerman J, Lima RA, Soares JR, et al. Supraomohyoid neck dissection in the treatment of T1/T2 squamous cell carcinoma of oral cavity. Am J Surg. Nov 1994;168(5):391-4. [Medline].

  25. Lindberg R. Distribution of cervical lymph node metastases from squamous cell carcinoma of the upper respiratory and digestive tracts. Cancer. Jun 1972;29(6):1446-9. [Medline].

  26. McGuirt WF Jr, Johnson JT, Myers EN, et al. Floor of mouth carcinoma. The management of the clinically negative neck. Arch Otolaryngol Head Neck Surg. Mar 1995;121(3):278-82. [Medline].

  27. Medina JE. A rational classification of neck dissections. Otolaryngol Head Neck Surg. Mar 1989;100(3):169-76. [Medline].

  28. Mendenhall WM, Million RR, Cassisi NJ. Squamous cell carcinoma of the head and neck treated with radiation therapy: the role of neck dissection for clinically positive neck nodes. Int J Radiat Oncol Biol Phys. May 1986;12(5):733-40. [Medline].

  29. Meyers EN. Operative Otolaryngology-Head and Neck Surgery. Philadelphia, Pa:. WB Saunders Co;1997.

  30. Nieuwenhuis EJ, van der Waal I, Leemans CR, et al. Histopathologic validation of the sentinel node concept in oral and oropharyngeal squamous cell carcinoma. Head Neck. Feb 2005;27(2):150-8. [Medline].

  31. Ramadan HH, Allen GC. The influence of elective neck dissection on neck relapse in NO supraglottic carcinoma. Am J Otolaryngol. Jul-Aug 1993;14(4):278-81. [Medline].

  32. Roy PH, Beahrs OH. Spinal accessory nerve in radical neck dissections. Am J Surg. Nov 1969;118(5):800-4. [Medline].

  33. Schwartz DL, Ford E, Rajendran J, et al. FDG-PET/CT imaging for preradiotherapy staging of head-and-neck squamous cell carcinoma. Int J Radiat Oncol Biol Phys. Jan 1 2005;61(1):129-36. [Medline].

  34. Shah JP. Patterns of cervical lymph node metastasis from squamous carcinomas of the upper aerodigestive tract. Am J Surg. Oct 1990;160(4):405-9. [Medline].

  35. Shah JP, Andersen PE. The impact of patterns of nodal metastasis on modifications of neck dissection. Ann Surg Oncol. Nov 1994;1(6):521-32. [Medline].

  36. Spiro RH, Gallo O, Shah JP. Selective jugular node dissection in patients with squamous carcinoma of the larynx or pharynx. Am J Surg. Oct 1993;166(4):399-402. [Medline].

  37. Spiro RH, Strong EW, Shah JP. Classification of neck dissection: variations on a new theme. Am J Surg. Nov 1994;168(5):415-8. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

radical neck dissection, RND, comprehensive neck dissection, modified neck dissection, MND, functional neck dissection, selective neck dissection, SND, squamous cell carcinomas, SCCA, cervical metastasis, lymphadenectomy, cervical lymphadenectomy, neck node metastasis, neck surgery, cervical metastases

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Pankaj Chaturvedi, MBBS, MS, Associate Professor, Head and Neck Surgery, Department of Surgical Oncology, Tata Memorial Hospital, India
Pankaj Chaturvedi, MBBS, MS is a member of the following medical societies: American Association for the Advancement of Science, American Head and Neck Society, Association of Surgeons of India, and Indian Academy of Tropical Parasitology
Disclosure: Nothing to disclose.

Coauthor(s)

Uma Chaturvedi, MD, MBBS, DPB, Lecturer, Department of Pathology, KJ Somaiya Hospital and Research Center, India
Disclosure: Nothing to disclose.

Thabet Abbarah, MD, FACS, Consulting Staff, Department of Otolaryngology, North Oakland Medical Centers
Thabet Abbarah, MD, FACS is a member of the following medical societies: American College of Surgeons
Disclosure: Nothing to disclose.

Nafisa K Kuwajerwala, MD, Staff Surgeon, Breast Oncology, William Beaumont Hospital
Nafisa K Kuwajerwala, MD is a member of the following medical societies: American College of Surgeons
Disclosure: Nothing to disclose.

Gunateet Goswami, MD, Consulting Staff, Internal Medicine Associates, Mount Clemens, Michigan; Consulting Staff, Department of Cardiology, Henry Ford Hospital
Gunateet Goswami, MD is a member of the following medical societies: American Medical Association, American Society of Echocardiography, and Michigan State Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Benoit J Gosselin, MD, FRCSC, Associate Professor of Surgery, Dartmouth Medical School; Director, Comprehensive Head and Neck Oncology Program, Norris Cotton Cancer Center; Staff Otolaryngologist, Division of Otolaryngology-Head and Neck Surgery, Dartmouth-Hitchcock Medical Center
Benoit J Gosselin, MD, FRCSC is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, American Medical Association, American Rhinologic Society, Canadian Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, College of Physicians and Surgeons of Ontario, New Hampshire Medical Society, North American Skull Base Society, and Ontario Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Nader Sadeghi, MD, FRCS(C), Associate Professor of Surgery, Director of Head and Neck Surgery, Division of Otolaryngology, George Washington University
Nader Sadeghi, MD, FRCS(C) is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, Federation of Medical Specialists in Quebec, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo  Consulting; Medvoy Ownership interest Management position

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.