Radical Neck Dissection Workup

Updated: Sep 08, 2017
  • Author: Antonio Riera March, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Workup

Laboratory Studies

Complete blood count

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

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.

Other useful tests include the following:

  • Liver enzyme profile

  • Glucose test: This study is useful preoperatively in patients with a history of diabetes.

  • BUN and creatinine testing

  • 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

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Imaging Studies

An esophagogram may be helpful in evaluating an occult esophageal primary tumor.

CT and MRI

CT scan and MRI may be used if they would help to define node status and further treatment planning. 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 and MRI is excellent in soft tissue resolution.

In general, CT is the radiologic technique most commonly used to evaluate the staging of the primary lesion, therefore, the neck should be included 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 has surpassed CT scanning as the preferred study in the evaluation of cancer at primary sites, eg., base of the tongue.

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.

Ultrasonography/Ultrasound

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

PET and PET/CT have 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.

The most recent diagnostic guidelines for the use of PET/CT in head and neck oncology are (1) detection of occult primary tumors, particularly in patients in which the conventional imaging tests are negative; (2) initial staging for detection of neck metastasis in the negative neck after evaluation with CT or MRI; (3) detection of distant metastasis in patients with advanced metastatic neck disease; and (4) detection of residual or recurrent disease.

If tumor involvement of the carotid artery is suspected, 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 and/or chest CT radiography to exclude metastatic disease in high-risk patients.

 

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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.

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Diagnostic Procedures

The historic and long-standing mirror laryngoscopy (indirect laryngoscopy) has been progressively supplanted by the use of the flexible nasopharyngolaryngoscopy, or rigid scopes to supplement the examination of the upper aero-digestive tract

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.

Transnasal esophagoscopy for screening has emerged in the last decade as safe and well tolerated by patients as an office procedure with topical anesthesia alone. The transnasal esophagoscopy instrumentation set has a suction port, a biopsy port and an insufflator. Therefore, transnasal esophagoscopy can be used for assessment of the esophagus and also for biopsy of suspicious lesions in the supraglottic area. Its role is expanding for use in outpatient "panendoscopy" and biopsy.

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.

Sentinel lymph node biopsy [12, 13, 14, 15] : A sentinel node is the first node of a particular group of nodes to receive the regional lymphatic flow from the primary site. The concept and the procedure for the sentinel lymph node biopsy in the evaluation of metastatic neck nodes in patients with head and neck squamous cell carcinoma is similar to the one used in the evaluation of nodal disease in skin melanoma. If the sentinel lymph node biopsy is negative, no further lymphadenectomy surgery is necessary. However, the sentinel lymph node biopsy applied to the mucosal cancer of the upper aerodigestive tract is still in the process of evaluation in research trials. Results in this regard are encouraging and useful- in particularly - in patients with clinical N0 neck and early carcinomas of oral cavity T1-T2. Nevertheless, its application in the assessment of neck metastasis is still not established and/or standardized in the clinical setting. [16]

Biotumor markers and molecular methods [17, 18] : New research techniques have been developed to detect micrometastasis of squamous cell carcinoma by using highly specific biotumor markers and molecular methods. The research is this regard is very active, with goals to impact diagnosis, prognosis, and therapy. However, the practical application, prognosis, and management significance is unknown until further studies are completed in prospective clinical trials. [19, 20, 21]  

 

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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.

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