Neck, Cervical Metastases, Surgery Workup

  • Author: Pankaj Chaturvedi, MBBS, MS; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Oct 22, 2010
 

Laboratory Studies

Workup is aimed at establishing the cytologic and histologic diagnosis of the neck mass, establishing the primary carcinoma, evaluating the extent of local (neck) disease, evaluating the extent of systemic spread, and assessing operative fitness (if operation is necessary).

CBC count and differential count provide a baseline hematologic status. Patients with carcinoma of the stomach, carcinoma of the colon, and advanced cancers of the head and neck may present with anemia.

A blood glucose test is useful to screen patients with diabetes mellitus.

Any alteration in the liver enzyme profile can be used to predict either coexisting liver primary disease (eg, cirrhosis, hepatitis) or a liver metastasis. Liver enzyme profiles are also important to determine anesthetic fitness.

BUN and creatinine levels are important to determine anesthetic fitness.

Prothrombin time (PT) and activated partial thromboplastin time (aPTT) are used to assess any possible bleeding diathesis preoperatively.

Electrolyte levels are important, especially in patients with advanced head and neck cancer who have been devoid of oral feeding for a long time.

Determine the patient's blood group.

Perform a urinalysis.

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Imaging Studies

Chest radiography can reveal either a primary tumor in a lung or synchronous pulmonary metastasis. Excluding any other coexisting pulmonary pathology is important.

Esophagography (barium swallow) may be helpful in evaluating a hypopharyngeal, postcricoid, and/or esophageal primary tumor.

Ultrasonography is easy and reproducible and is an outpatient procedure. It is an inexpensive investigation, easy to use by a radiologist, and can be used bedside. Most radiologists are well trained in ultrasonography, and only a little more training is required for assessing the neck nodal status. Ultrasonographically guided aspiration cytology can be performed to determine the cause of cervical neck metastasis. It has a specificity nearing 100%. Doppler study can be performed to assess the status of neck vessels.

CT scanning and MRI can be used to reduce the risk of occult disease to 12%. MRI and CT scanning have demonstrated greater sensitivity in the detection of nodes smaller than 1-1.5 cm. CT scanning is the most commonly used investigation to evaluate and stage the disease.

CT scan criteria for assessing nodal metastases include increased size (>1.5 cm for jugulodigastric and submandibular nodes, >1.0 cm for all other cervical nodes, >0.8 cm for retropharyngeal nodes). Unfortunately, lymph node size does not always correlate with metastatic disease.

Other CT scan criteria for assessing nodal metastases are ill defined or irregular bordered mass, rounded shape, central necrosis, and nodal grouping (3 or more nodes in the range of 6-15 mm). The node periphery is usually thick and enhances with contrast. Obliteration of the fat line around the carotid sheath is a sign of sheath infiltration.

CT scanning is more precise than MRI in demonstrating tumor necrosis and extracapsular spread.

MRI tends to reveal retropharyngeal node involvement better than CT scanning does.

Contrast agents (eg, iron oxide) during MRI have demonstrated encouraging results of reduced signal intensity in normal nodes (compared to involved nodes) after contrast administration.

18-F-fluorodeoxyglucose (FDG)-positron emission tomography (PET)/CT: Several studies suggest that FDG-PET/CT is superior to CT alone for neck node involvement. Confirmatory trials to substantiate the accuracy of FDG-PET/CT neck staging are still awaited. Patients who have achieved a complete response at the primary site but have a residual abnormality in the neck may benefit by PET–CT because it is more sensitive and specific than CT alone.

Sentinel node (SN) biopsy - Few studies have validated the sentinel node hypothesis for oral and oropharyngeal cancer. The role of SN biopsy in the management of the N0 neck in such patients has yet to be established through prospective trials.

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Other Tests

If tumor involvement of the carotid artery is possible, perform 4-vessel cerebral angiography to evaluate the status of the contralateral carotid, intracerebral circulation, and carotid back pressure; also, perform a balloon occlusion test.

Evaluate weight and nutritional status, especially in patients with head and neck cancer.

Perform electrocardiography.

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Diagnostic Procedures

Fine-needle aspiration cytology, which is the first and probably most important procedure for further management, can be used to differentiate inflammatory, benign, and malignant pathologies and can provide cytologic distinction (eg, SCCA, adenocarcinoma, germ cell tumor, lymphoma).

Immunocytochemistry can further aid in locating a primary carcinoma.

The primary tumor can be located by palpation, or, in difficult cases, ultrasonographic guidance can be helpful.

Indirect laryngoscopy/fiberoptic nasopharyngolaryngoscopy is used to detect and evaluate a possible primary carcinoma in the head and neck.

Panendoscopy is used to exclude a second primary tumor or to detect the primary tumor if it is not easily detectable. This helps in obtaining a biopsy. The pyriform sinus, base of tongue, nasopharynx, and tonsils are some of the notorious areas of occult tumors, and these areas may require random biopsy if the primary carcinoma site is unknown.

A true-cut or an open biopsy is indicated when needle aspiration cytology findings are inconclusive.

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Histologic Findings

Most patients (60-85%) with neck metastases have SCCA; second most common is adenocarcinoma (occurring in 13-22% of patients). Undifferentiated carcinomas and melanomas account for 10% of patients with neck metastases, and 8% of such patients have cervical metastasis. Very rarely, other occult malignant neoplasms, such as sarcomas and germ cell tumors, metastasize to the neck.

Fine-needle aspiration cytology or a biopsy of the neck mass helps in predicting the primary carcinoma site, such as SCCA from upper aerodigestive tract, nasopharyngeal carcinoma, thyroid carcinomas, skin cancer of the head and neck, and breast cancers.

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Staging

Cervical metastases of the neck are staged as follows:

  • NX: Regional lymph nodes cannot be assessed.
  • N0: No regional lymph node metastasis is observed.
  • N1: Metastasis is observed in a single ipsilateral lymph node, measuring 3 cm or less in greatest dimension.
  • N2a: Metastasis in a single ipsilateral lymph node is observed and measures more than 3 cm but less than 6 cm in greatest dimension.
  • N2b: Metastasis is found in multiple ipsilateral lymph nodes; none of the nodes measure greater than 6 cm in their greatest dimension.
  • N2c: Metastasis in bilateral or contralateral nodes is observed; no nodes are larger than 6 cm in their greatest dimension.
  • N3: Metastasis is observed in a lymph node that measures greater than 6 cm in its greatest dimension.
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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 Care Center, William Beaumont Hospital

Nafisa K Kuwajerwala, MD is a member of the following medical societies: American College of Surgeons, American Society of Breast Disease, and American Society of Breast Surgeons

Disclosure: Nothing to disclose.

Vishal U S Rao, MBBS, MS  Assistant Professor, Department of Head and Neck Surgery, Kidwai Memorial Institute of Oncology; Consultant Oncologist-Head and Neck Surgeon, Fortis-Wockhardt Hospital and Apollo Hospital, India

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Nader Sadeghi, MD, FRCS(C)  Professor of Surgery, Director of Head and Neck Surgery, George Washington University School of Medicine and Health Sciences

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.

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; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting

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. 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].

  11. 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://onlinelibrary.wiley.com/doi/10.1002/hed.20228/full.

  12. 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].

  13. Ross G.L.,Soutar D.S. Sentinel Node Biopsy in Head and Neck Cancer: Preliminary Results of a Multicenter Trial'. Annals of Surgical Oncology. 11(7):690–696. [Medline].

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

  15. 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].

  16. Brizel DM, Prosnitz RG, Hunter S, Fisher SR, Clough RL, Downey MA. Necessity for adjuvant neck dissection in setting of concurrent chemoradiation for advanced head-and-neck cancer. Int J Radiat Oncol Biol Phys. Apr 1 2004;58(5):1418-23. [Medline].

  17. Brizel DM, Prosnitz RG, Hunter S, et al. Necessity for adjuvant neck dissection in setting of concurrent chemoradiation for advanced head-and-neck cancer. Int J Radiat Oncol Biol Phys. Apr 1 2004;58(5):1418-23. [Medline].

  18. Connell CA, Corry J, Milner AD, Hogg A, Hicks RJ, Rischin D. Clinical impact of, and prognostic stratification by, F-18 FDG PET/CT in head and neck mucosal squamous cell carcinoma. Head Neck. Nov 2007;29(11):986-95. [Medline].

  19. Wee JT, Anderson BO, Corry J, D'Cruz A, Soo KC, Qian CN. Management of the neck after chemoradiotherapy for head and neck cancers in Asia: consensus statement from the Asian Oncology Summit 2009. Lancet Oncol. Nov 2009;10(11):1086-92. [Medline].

  20. van der Putten L, van den Broek GB, de Bree R, et al. Effectiveness of salvage selective and modified radical neck dissection for regional pathologic lymphadenopathy after chemoradiation. Head Neck. May 2009;31(5):593-603. [Medline].

  21. Rao VU, Shenoy AM. Adjuvant neck dissection after chemoradiotherapy. Lancet Oncol. Mar 2010;11(3):223-4. [Medline].

  22. 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].

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

  24. 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].

  25. 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].

  26. 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].

  27. 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].

  28. 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].

  29. 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].

  30. 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].

  31. 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].

  32. 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].

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

  34. 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].

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

  36. 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].

  37. 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].

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

  39. 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].

  40. 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].

  41. 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].

  42. 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].

  43. 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].

 
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Anatomy following a Type III modified neck dissection.
Levels of neck nodes.
 
 
 
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