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

Radical Neck Dissection: Follow-up

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

Outcome and Prognosis

Outcome

Radical neck dissection results include the following:

  • In a neck with negative histologic findings, the recurrence rate is 3-7%.
  • In a neck with positive histologic findings, the recurrence rate is 20-70%.
  • Extracapsular spread commonly is found in small nodes (25%) and large nodes (75%). The extracapsular spread can decrease survival by half and can decrease the disease-free interval.
  • Macroscopic extracapsular spread is associated with a recurrence rate of 45%, and microscopic extracapsular spread is associated with a recurrence rate of 25%.
  • Perineural and perivascular invasion are associated with more aggressive tumor behavior.
  • Involvement of the tumor margins carries a poor prognosis and a high risk of recurrent neck disease.
  • Patients with several involved nodes (>4) have a worse prognosis than those with only one involved node.
  • Multiple levels of involvement are associated with a recurrence rate of 70%; only one level of involvement is associated with a recurrence rate of 35%.

Prognosis

In general, the characteristics of nodal metastasis that affect the prognosis in radical neck dissection include the following:

  • Extracapsular spread: This adversely affects the prognosis. The pathologist looks systematically for extracapsular spread, which is commonly encountered. Tumor spread beyond the capsule of a lymph node is the most important prognostic factor related to recurrence in the neck.
  • Perivascular and perineural invasion: Perineural and perivascular infiltration of the tumor is correlated with the risk of lymph node metastasis in the neck.
  • Sites of nodal involvement: The prognosis and survival rates are poor when multiple levels of neck nodes are involved. Posterior triangle and contralateral involvement is also an indication of poor prognosis.
  • Number of nodes: A greater number of involved lymph nodes portends a poorer prognosis. This leads to a higher risk of recurrence and a poorer survival rate.
  • Node fixation: Fixation is adherence to the surrounding structures. Adherence to the carotid artery or a muscle is an ominous sign. In general, fixation occurs with large masses and portends a poor prognosis.
  • Involvement of surgical margin: Positive surgical margins are common in advanced tumors and carry a poor prognosis.
  • Recurrent disease: Recurrent disease after surgical neck dissection is an ominous sign.
  • Degree of differentiation: The risk of cervical metastasis correlates with the grade of tumor differentiation at the primary site. Poorly differentiated tumors are more aggressive and carry a poor prognosis.

Future and Controversies

Controversies

Once the neck has metastatic disease, adequate treatment is essential. Preoperatively, no ideal method exists to identify metastatic disease clearly. Therefore, false-positive and false-negative results are common. Adequate treatment for metastatic neck disease is radiation therapy, surgery, or both.

In the last decade chemo/radiation therapy without surgery has been added to the armamentarium of treatment methodology for patients with head and neck cancer. This new methodology includes treatment of the primary tumor as well as the neck metastasis. Patients who demonstrate persistence neck disease following this nonoperative approach are then being offered surgery in the form of salvage neck dissection.

In general, the management is not standardized and varies between institutions, geographical areas, and surgeons. Initially, radical neck dissection was the operation used to control metastatic neck disease and an N0 neck. Now, most head and neck surgeons would agree that a radical neck dissection is not indicated in the absence of palpable neck metastasis or an N0 neck.

Modified radical neck dissections are adequate operations for palpable neck metastasis. The selection of a modified radical neck dissection is controversial because the decision to preserve nonlymphatic structures remains an intraoperative decision.

The N0 neck is a controversial subject. Many treatment choices exist, including whether to treat electively or to wait and observe, whether to perform surgery or radiation therapy, whether to operate on one side or both, and whether to use modified radical neck dissection or selective neck dissection. Indications need to be standardized.

Future

Future considerations in the management of neck metastasis include the following:

  • Develop better techniques for evaluation of neck metastasis.
  • Define and standardize the clinical criteria worldwide for a particular neck dissection.
  • Define and standardize indications for preoperative or postoperative radiation therapy of the neck.
  • Define and standardize indications for chemoradiation, before and after surgery.
  • Define and standardize indications for an N0 neck.
  • Define and standardize indications for an N+ neck.
  • Define and standardize the role of PET/CT in assessment and identification of neck metastasis.33,34
  • Investigate and analyze the prognostic factors.

 
Acknowledgments

The authors wish to acknowledge Joan Flaherty, RN, for her editorial assistance and Gustavo Díaz, MD, for taking the digital surgical photos.



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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