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

Management of the N0 Neck: Workup

Author: Ray G F Blanco, MD, Fellow, Head and Neck Surgical Oncology and Microvascular Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Medical Center
Coauthor(s): Lisa T Galati, MD, Assistant Professor, Division of Otolaryngology, Albany Medical Center; Gregory S Weinstein, MD, FACS, Professor and Vice-Chairman, Codirector for the Center for Head and Neck Cancer, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Hospital
Contributor Information and Disclosures

Updated: Aug 20, 2007

Workup

Imaging Studies

  • Imaging of the cervical lymphatics alters the estimated clinical stage in 20-30% of patients. Evaluation of Neck Nodes

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    Table
    ModalitySensitivitySpecificity
    Ultrasound50-58%75-82%
    CT40-68%78-92%
    MRI55-93%82-95%
    PET*87-90%80-93%
    CT-PET96%98.5%
    ModalitySensitivitySpecificity
    Ultrasound50-58%75-82%
    CT40-68%78-92%
    MRI55-93%82-95%
    PET*87-90%80-93%
    CT-PET96%98.5%
    *Positron emission tomography.
  • Regardless of the type of imaging chosen, cervical lymph node must be considered to harbor metastasis if the any of the following criteria are met:
    • Node larger than 1 cm (or >1.5 cm in the jugulodigastric area)
    • Round node instead of oval
    • Internal central or peripheral attenuation suggestive of necrosis
    • Poorly defined mass in the lymph node–bearing area
    • The combination of ill-defined borders and loss of plane between mass and normal adjacent neck structures
    • Retropharyngeal node larger than 1 cm
    • Extracapsular extension
  • Chest radiography: Chest radiography is standard in the pretreatment evaluation of patients with head and neck cancer.
    • The incidence of pulmonary malignancy in head and neck cancer is 4.5-14%. The risk of secondary lung malignancy is high if the primary tumor originates from the larynx or pharynx.
    • The risk of a metachronous lesion in laryngeal cancer is 0.6% per year.
    • Patients with head and neck cancer have up to a 20% lifetime risk of developing secondary malignancy.
  • Ultrasonography of the neck: Ultrasonography is safe, fast, and inexpensive and can differentiate cystic from solid. In some institutions, it is used for evaluation of nodal metastasis. Ultrasound interpretation requires an experienced radiologist and is operator dependent.
  • CT scanning of the neck with contrast
    • Lymph nodes on a CT scan are considered suspicious only if they measure more than 1 cm (1.5 cm in the jugulodigastric area), are round instead of oval, or contain a necrotic center.
    • While this information may be helpful, normal CT scan findings do not rule out the possibility of metastatic disease and must be correlated with the incidence of occult metastasis and the stage of the disease.
    • Contrast is important in assessing neck disease. Without contrast, discerning pathologic adenopathy can be difficult.
    • Tumors usually enhance more than the surrounding muscle because of contrast. This facilitates identification of the pathologic condition.
  • MRI of the neck with gadolinium
    • MRI is superior to CT scanning in differentiating soft tissues. This is particularly helpful in assessing the extent of the primary tumor into surrounding soft tissues, especially in patients whose area of investigation on CT scan is affected by dental fillings.
    • In studying lymph node metastases, MRI is as accurate as CT scanning, and neither study has shown a clear-cut benefit over the other.
    • The choice of MRI versus CT scanning should be based on which will yield the most information about the primary lesion. For example, if bony invasion is suspected, CT scanning would be the study of choice because MRI resolution of bone in some instances may be inferior to that of CT. If extension of the tumor into the cranial cavity or perineural invasion is suspected, MRI is the study of choice because of its ability to differentiate between soft tissues structures and tumor.
  • PET scan
    • PET scan is unreliable in salivary gland tumors and has limited spatial and anatomical resolution. PET scan imaging is well established in assessing recurrent head and neck cancer and in evaluating response to treatment.
    • However, the role of PET scanning in the initial staging of head and neck tumors is less certain. The PET detection rate in lymph nodes smaller than 1 cm is reported as 71%. A standard uptake value (SUV) of greater than 3 on a PET scan suggests malignancy.
  • CT-PET fusion: Studies suggest that fusion of CT scans and PET images has improved anatomical localization of abnormalities and tumors. It is useful in detecting recurrent cancer early, guiding biopsy, evaluating treatment results, and eliminating the need for additional imaging. Its role, however, in the initial staging of head and neck cancer with N0 neck remains to be proven.

Histologic Findings

Histology is important in determining the best treatment for patients with oral cavity cancer and an N0 neck. Tumors with an invasion depth of more than 3 mm have been shown to have a significantly higher rate of occult lymph node metastasis (>20%) and require prophylactic treatment of the neck. Although tumor thickness has been studied in other head and neck sites, including the larynx, this finding has proved to be significant only in the oral cavity cancer.

A study by Lim et al regarding predictive markers for late cervical metastasis in stage 1 and 2 invasive SCCA of the oral tongue showed that, in a univariate analysis, tumor thickness, Broder grade, nest shape, mode of invasion, Anne Roth score, Byrne score, and E-cadherin expression correlated with late cervical metastasis.1 Multivariate analysis in the same study also revealed that tumor thickness, mode of invasion, grade 3 or 4, and low E-cadherin expression were independent factors for cervical metastasis. Other variables for occult metastasis include age of over 65 years with advance T stage, vascular invasion, and perineural invasion.

More on Management of the N0 Neck

Overview: Management of the N0 Neck
Workup: Management of the N0 Neck
Treatment: Management of the N0 Neck
Follow-up: Management of the N0 Neck
References
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References

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Further Reading

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Keywords

management of the n0 neck, neck cancer, cancer of the head and neck, squamous cell carcinoma, SCC, lymph node metastases, oral cavity cancer

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Contributor Information and Disclosures

Author

Ray G F Blanco, MD, Fellow, Head and Neck Surgical Oncology and Microvascular Surgery, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Medical Center
Ray G F Blanco, MD is a member of the following medical societies: American Medical Association and Philippine Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Lisa T Galati, MD, Assistant Professor, Division of Otolaryngology, Albany Medical Center
Lisa T Galati, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery and Phi Beta Kappa
Disclosure: Nothing to disclose.

Gregory S Weinstein, MD, FACS, Professor and Vice-Chairman, Codirector for the Center for Head and Neck Cancer, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Hospital
Gregory S Weinstein, MD, FACS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Laryngological Rhinological and Otological Society, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Daniel J Kelley, MD, Consulting Staff, Eastern Shore ENT & Allergy Associates
Daniel J Kelley, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, American Laryngological Rhinological and Otological Society, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Karen Hall Calhoun, MD, Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Missouri
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 Medical Association, American Rhinologic Society, Society of University Otolaryngologists-Head and Neck Surgeons, 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: UST Grant/research funds Consulting

 
 
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