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

Radical Neck Dissection: Workup

Author: Antonio Riera March, MD, FACS, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of Puerto Rico School of Medicine
Coauthor(s): Juan Trinidad Pinedo, MD, FACS, Ad-Honorem Professor, Department of Otolaryngology-Head and Neck Surgery, University of Puerto Rico Medical School
Contributor Information and Disclosures

Updated: Sep 15, 2009

Workup

Laboratory Studies

  • CBC count and differential: The CBC count is important because it gives the clinician a baseline regarding the patient's preoperative hematologic status. Patients with advanced cancers of the head and neck may present with preexisting anemia, which may require further characterization.
  • Prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR) measurements: These studies are especially important in patients with preexisting bleeding diathesis, with hepatitis, or who are taking anticoagulants. Prolonged study results may need to be reversed preoperatively.
  • Electrolyte tests
    • Preoperative evaluation is important in patients with head and neck cancers. Many present with other medical problems or take medications that affect their electrolyte status.
    • A subgroup of squamous cell cancers may result in paraneoplastic syndromes; the most common is the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). Management may necessitate consultation with an internist or an endocrinologist.
  • Liver enzyme profile is useful.
  • Glucose test: This study is useful preoperatively in patients with a history of diabetes.
  • BUN and creatinine testing is useful.
  • Blood type and screen: Because of refinements in the surgical techniques, blood loss has been significantly reduced in these procedures. In situations in which blood loss is expected to be significant, either typing and screening or typing and cross-matching are necessary.
  • Urinalysis is useful.

Imaging Studies

  • An esophagogram may be helpful in evaluating an occult esophageal primary tumor.
  • CT scan and MRI may be used if they would help to define node status and treatment planning further. They may be crucial in delineating the extent of bony structures, deep cervical musculature, and carotid artery circumferential involvement.
    • CT scanning with contrast can depict excellent anatomic details.
    • In general, CT is the radiologic technique most commonly used to evaluate the staging of the primary lesion; therefore, also include the neck in the examination.
    • Criteria for assessing nodal metastases with CT include increased size, a rounder shape, presence of central necrosis, and nodal grouping. The most accurate CT criterion for the presence of metastatic adenopathy is central necrosis. The node periphery is usually thick and enhances with contrast. CT scanning also reveals extracapsular spread by enhancement of the nodal capsule.
    • Some radiologists feel that CT demonstrates paratracheal node involvement better than MRI.
    • MRI reveals tumor necrosis and extracapsular spread with less precision than CT scan, but MRI is better for assessing enlarged lymph nodes that are not necessarily metastatic.
    • MRI may also be used in patients who are allergic to iodinated contrast.
    • According to some radiologists, MRI also appears to reveal retropharyngeal node involvement better than CT.
  • Some institutions use ultrasonography and ultrasound-guided aspiration cytology to determine cervical neck metastasis. Ultrasound-guided aspiration cytology has a specificity of nearly 100%.
  • PET has recently emerged as an adjunct in the diagnosis of lymph node metastasis.
    • In recent studies, PET has shown positive findings for lymph node metastasis when CT scan and MRI findings were negative. An FDG-PET scan provides physiologic and biochemical data. Glucose metabolism in neoplastic cells produces increased uptake on FDG-PET scanning, which correlates strongly with viable tumor cells. Therefore, FDG-PET may be helpful in the assessment of neck metastasis and even distant metastasis.
    • Additionally, PET scanning has shown the ability to differentiate active tumors from chronic fibrotic changes. Therefore, PET may become more useful than CT and MRI in the detection of recurrent head and neck cancer. Furthermore, the dual use of the PET and CT scanners produces fused PET and CT images, which can further enhance the results of the PET scan. The definitive role of PET and PET/CT scans is evolving and showing great potential in the assessment of metastatic neck disease, the early diagnosis of recurrent head and neck cancer, and the status of the neck after chemoradiotherapy.
  • If tumor involvement of the carotid artery is possible, a complete preoperative evaluation of the carotid system is indicated. This includes a balloon occlusion test and a 4-vessel cerebral angiography to evaluate the status of the contralateral carotid, intracerebral circulation, and carotid back pressure.
  • Perform chest radiography to exclude metastatic disease.

Other Tests

  • A complete physical examination is mandatory and includes evaluation of neurologic, cardiovascular, and respiratory status.
    • Palpate the patient's neck to define size, location, mobility, and degree of softness or hardness of any mass.
    • Evaluate the patient's weight and nutritional status.
  • Perform an ECG as indicated.
  • Evaluation by medical service personnel and further medical consultations may be indicated.

Diagnostic Procedures

  • Use mirror laryngoscopy, flexible nasopharyngolaryngoscopy, or both to supplement the examination.
  • When the primary tumor is known, perform a panendoscopy to exclude a second primary tumor. Performing biopsy of the primary lesion is necessary. When the primary tumor is not known, perform a panendoscopy to look for the primary tumor and to perform random biopsies of the pyriform sinus, base of tongue, and nasopharynx to exclude occult tumors. An ipsilateral tonsillectomy is also advocated; however, this has been the subject of controversy for many surgeons.
  • When the patient has a neck mass, a fine-needle aspiration biopsy for cytology evaluation may be useful in helping the clinician determine management.
  • An open biopsy of a neck node is indicated only when the previous measures of physical examination, needle aspiration biopsy, random biopsies, and endoscopy are inconclusive. To circumvent this situation, patients are asked to sign a consent form for a possible neck dissection when a frozen section diagnosis confirms the presence of malignancy in the open node biopsy specimen.

Histologic Findings

Biopsies of the primary site reveal the etiology of the initial mass and the characteristics of the tumor involved, such as squamous cell carcinoma of the upper aerodigestive tract, nasopharyngeal carcinoma, thyroid carcinomas, and skin cancer of the head and neck.

Fine-needle aspiration cytology of the neck confirms the pathology findings of the primary tumor. It also helps to determine the etiology of the cervical adenopathy when the patient has a neck metastasis from an occult primary tumor.

More on Radical Neck Dissection

Overview: Radical Neck Dissection
Workup: Radical Neck Dissection
Treatment: Radical Neck Dissection
Follow-up: Radical Neck Dissection
Multimedia: Radical Neck Dissection
References
Further Reading
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References

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Further Reading

Clinical guidelines

Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of head and neck cancer. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2006 Oct. 90 p.

American Society of Clinical Oncology, Pfister DG, Laurie SA, Weinstein GS, Mendenhall WM, Adelstein DJ, Ang KK, Clayman GL, Fisher SG, Forastiere AA, Harrison LB, Lefebvre JL, Leupold N, List MA, O'Malley BO, Patel S, Posner MR, Schwartz MA, Wolf GT. American Society of Clinical Oncology clinical practice guideline for the use of larynx-preservation strategies in the treatment of laryngeal cancer. J Clin Oncol 2006 Aug 1;24(22):3693-704. 35

Dutch Head and Neck Oncology Cooperative Group. Hypopharyngeal cancer. Amsterdam, The Netherlands: Association of Comprehensive Cancer Centres; 2007 Jan 9. 209 p.

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Keywords

radical neck dissection, complete neck dissection, block neck dissection, classic neck dissection, neck tumor, metastatic neck disease, neck lymph node metastasis, cervical lymphatic metastasis, head and neck squamous cell carcinoma, neck metastasis, classic neck dissection, neck cancer, oral cavity cancer, pharyngeal cancer, laryngeal cancer, thyroid cancer, thyroid carcinoma, skin cancer of the head and neck, nasopharyngeal carcinoma, neck mass, metastatic neck mass, cervical lymphadenopathy, modified radical neck dissection, cervical adenopathy, selective neck dissection, neck node cancer, metastatic cervical lymphatic spread, squamous cell carcinoma of the upper aerodigestive tract, radical neck dissection

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Contributor Information and Disclosures

Author

Antonio Riera March, MD, FACS, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of Puerto Rico School of Medicine
Antonio Riera March, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, American College of Surgeons, and Society for Ear, Nose and Throat Advances in Children
Disclosure: Nothing to disclose.

Coauthor(s)

Juan Trinidad Pinedo, MD, FACS, Ad-Honorem Professor, Department of Otolaryngology-Head and Neck Surgery, University of Puerto Rico Medical School
Juan Trinidad Pinedo, MD, FACS 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 College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, and Puerto Rico Medical Association
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

Karen Hall Calhoun, MD, Professor, Department of Otolaryngology-Head and Neck Surgery, The Ohio State University
Karen Hall Calhoun, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Medical Association, American Rhinologic Society, Association for Research in Otolaryngology, Society of University Otolaryngologists-Head and Neck Surgeons, Southern Medical Association, Texas Medical Association, and Texas Medical Association
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

 
 
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