Radical Neck Dissection

Radical Neck Dissection - Radical Neck Dissection: (RND)...

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Unformatted text preview: Radical Neck Dissection: (RND) Classification, Indication and Techniques Techniques Introduction Introduction • Crile in 1906 introduced RND and is Crile followed by Martin as a the classical procedure for the management of cervical lymph node metastasis cervical • Recently changes in classification and Recently indication led to inconsistency indication – N0 in recent studies may require selective RND to reduce morbidity RND Staging of Neck Nodes Staging • NX: – Regional lymph nodes can not be assessed • N0: – No regional lymph node metastasis • N1: – Metastasis in a single ipsilateral lymph nodes, Metastasis 3 cm or less in greatest dimension cm • N2: – N2a: • Metastasis in a single epsilateral lymph nodes, Metastasis more than 3 cm but less than 6 cm Staging of Neck Nodes Staging – N2b: • Metastasis in multiple ipsilateral lymph Metastasis nodes, not more than 6 cm – N2c: • Metastasis in bilateral or contralateral Metastasis nodes not more than 6 cm in diameter nodes • N3: – Metastasis in lymph nodes more than 6 Metastasis cm in in greatest diameter cm Meyers & Eugene: Operative Otolaryngology. 1997 Lymph Node Regions Lymph • Region I: – Submental and submandibular Submental triangle triangle • Ia: Submental triangle: – Bounded by the anterior belly of digastric Bounded and the mylohyoid muscle deep • Ib: Submandibular triangle: – Formed by the anterior and posterior belly Formed of the digastric muscle and the body of the mandible mandible Memorial Sloan-kettering Cancer center Lymph Node Regions Lymph • Region II – IV: – Lymph nodes are associated with the Lymph Internal Jugular Vein (IJV) within the fibroadipose tissues that extend from the posterior border of sternocledothe mastoid muscle (SCM) medial to mastoid lateral border of the sternohyoid muscle Memorial Sloan-kettering Cancer center Lymph Node Regions Lymph • Region II: – Upper third including upper jugular, Upper jugulodigastric and upper posterior cervical nodes nodes – Bounded by the digastric muscle superiorly Bounded and the hyoid bone or carotid bifurcation inferiorly inferiorly • IIa: – nodes anterior to Spinal Accessory Nerve (SAN) • IIb: – nodes posterior to Spinal Accessory Nerve (SAN) Memorial Sloan-kettering Cancer center Lymph Node Regions Lymph • Region III: – Middle third jugular nodes from the Middle carotid bifurcation to cricothyroid notch or omohyoid muscle notch • Region IV: – Lower third jugular nodes from Lower omohyoid muscle superiorly to the clavicle inferiorly clavicle Memorial Sloan-kettering Cancer center Lymph Node Regions Lymph • Region V: – Lymph nodes of the posterior triangle Lymph along the lower half of the SAN and the transverse cervical artery the – Bounded by the anterior border of the Bounded trapezius posteriorly, the posterior border of SCM anteriorly and the clavicle inferiorly clavicle Memorial Sloan-kettering Cancer center Lymph Node Regions Lymph • Region VI: – Anterior compartment, lymph nodes Anterior surrounding the midline visceral structures that extend from the hyoid bone superiorly to the suprasternal notch inferiorly the – The lateral boundary is the medial border of The the carotid sheath the – Perithyroid, paratracheal, and lymph nodes Perithyroid, around the recurrent laryngeal nerve around Memorial Sloan-kettering Cancer center Classification • The RND is classified according to the The Academy’s Committee for Head & Neck Surgery & Oncology into four major type: Surgery 1. Radical Neck Dissection (RND) (RND) 2. Modified Radical Neck Dissection (MRND) Modified (MRND) 3. Selective Neck Dissection (SND) Selective (SND) 1. 2. 3. 4. 4. Supraomohyoid Posterolateral Lateral Lateral Anterior 4. Extended Radical Neck Dissection (ERND) Extended (ERND) Classification Classification • Radical neck Dissection: – Removing all lymphatic tissues in regions I Removing V and include removal of SAN, SCM and IJV and • Modified radical neck dissection: – Excision of all lymph nodes removed with Excision RND with preservation of one or more nonRND lymphatic structures, SAN, SCM and/or IJV • Subtype I: Preserve SAN • Subtype II: Preserve SAN & SJV • Subtype III: preserve SAN, SJV and SCM Subtype – Known as Functional neck dissection (Bocca) Classification Classification • Selective Neck dissection: – Any type of cervical lymphadenectomy Any with preservation of one or more lymph node groups lymph – Four subtype: • • • • Supraomohyoid neck dissection Posterolateral neck dissection Lateral neck dissection Anterior neck dissection Classification Classification – Supraomohyoid neck dissection: • Removal of lymph nodes in regions I –III Removal • The posterior limit is the cutaneous branches of the The cervical plexus and posterior border of SCM cervical • The inferior limit is the superior belly of the The omohyoid where it cross IJN – Posterolateral neck dissection • Removal of suboccipital, retroauricular, levels II – Removal V and level V and • Subtyped I – III depending on the preservation of Subtyped SAN, IJV and /or SCM SAN, Medina Classification Classification – Lateral neck dissection: • Remove lymph nodes in levels II – IV Remove – Anterior neck dissection: • Require the removal of the lymph nodes Require surrounding the visceral structure in the anterior aspect of the neck, level VI anterior • Superior limit, hyoid bone • Inferior limit, suprasternal notch • Laterally, the carotid sheath Classification Classification • Extended neck dissection: – Any previous dissection and including Any one or more additional lymph node groups and/or non-lymphatic tissues groups Facts Facts • General nodal metastasis produce General the following fact: the – The most important factor in prognosis The of SCC of the upper aero-digestive tract is the status of cervical lymph nodes nodes – Cure rate drops 50% with involvement Cure of the regional lymph nodes of Indications For ND Indications • Radical neck dissection was believed by Radical Martin to be the only method to control cervical lymphadenectomy cervical • Anderson found that preservation of SAN Anderson did not change the survival or tumor control in the neck control – Actual 5-year survival and neck failure rate Actual is: is: • RND: 63% and 12 % • MRND: 71% and 12% MRND: Indications Indications • Radical Neck Dissection 1. Multiple clinically obvious cervical lymph Multiple node metastasis particularly of posterior triangle and closely related to SAN triangle 2. Large metastatic tumor mass or multiple Large matted in upper part of the neck matted • Tumor should not be dissected to preserve Tumor Structures Indications Indications • Modified radical neck dissection – MRND Type I: 1. Clinically obvious neck lymph nodes Clinically metastasis and SAN not involved by tumor tumor 2. Intraoperative decision just like Intraoperative preservation of the facial nerve in parotid surgery parotid Indications Indications • • MRND Type II: 1. Rarely planned 2. Intra-operative decision for tumor found Intra-operative adherent to SCM but away from SAN & IJV IJV – MRND Type III: Depend on the autopsy reports 1. 2. Lymph nodes were in the fibrofatty and do not Lymph share the same adventitia with blood vessels share They are not found within the aponeurosis or They glandular capsule of the submandibular “Functional neck dissection” Indications Indications • MRND Type III: – For treatment of N0 neck nodes – Indicated for N1 mobile nodes and not greater than 2.5 – 3.0 cm greater • Contra-indicated in the presence of node Contra-indicated fixation fixation • Result is difficult to interpret because of Result the use of radiation therapy Indications Indications • Selective/elective neck dissection: – For treatment of N0 neck nodes – For N+ nodes when combined with For radiotherapy radiotherapy • Adjuvant radiotherapy for patient with 2 – 4 positive Adjuvant nodes or extra-capsular spread nodes – Supraomohyoid is indicated for SCC of oral cavity with N0 and N1 with palpable mobile cavity nodes less than 3 cm and located in level I and II II – Upgrade intra-operatively following positive Upgrade frozen section frozen Treatment option for N0 nodes Treatment • • • Observe Radiation therapy Elective neck dissection – Low morbidity – Staging neck for possible extended Staging surgery surgery – Need for post-operative radiotherapy Rationale for S/END Rationale • Rate of occult metastasis in clinically Rate negative nodes is 20 – 30% using clinical and radiographic findings clinical – Ct scan combined with physical exam Ct decreased the rate of occult metastasis to 12% to – This suggested lowering of the criteria This for elective neck dissection for Friedman et al Laryngoscope 100; 54 – 59: 1990 Rationale for S/END Rationale • Anatomic studies showed that Anatomic lymphatic drainage from the mucosal surfaces follow a constant and predictable route and • Lymph flow from SA chain to the Lymph jugular chain is unilateral jugular Shah. Ann Surg Oncol 1(6); 521-532: 1994 Rationale for S/END Rationale • Shah, in his study produced a compelling evidence of predictable nodal metastasis from SCC from upper aerodigastive tract from – He found a specific pattern for nodal spread He by location of primary by • NO in patients with oral cavity SCC: – 7/1119 (3.5%) had nodal involvement outside supraomohyoid dissection supraomohyoid – 3 (1.5%) had isolated involvement outside level (1.5%) I - III III Friedman Laryngoscope 100; 54-59: 1990 Rationale for S/END Rationale – N+ nodes in patients with oral SCC: • 50/246 had nodal metastasis outside level IV • 10/246 had metastasis in level V – He examined nodal involvement in patients He with nasopharynx and other upper parts of the aerodigastive tract aerodigastive • Conclusion: – SCC of the oral cavity: • Level I, II and III are at risk – SCC nasopharynx and larynx • Level II, III and IV are at risk Shah Amer J Surg 160; 405-409: 1990 Shah Cancer July 1 ; 109-113: 1990 Rationale for S/END Rationale • Byers stated that SND combined with Byers postoperative radiotherapy in selected patients with oral cavity SCC was adequate treatment with similar recurrence rate as those treated with MRND III those • Spiro reported 12% with supraomohyoid Spiro dissection in N1 nodes but not all of them received radiotherapy received Byers Head Neck Surg; Jan-Feb; 160-167: 1988 Selective/Elective Neck Dissection Dissection • • • A good option for N0 neck Not a suitable option for N+ neck Is used N+ neck when combined Is with radiotherapy with • Intra-operative frozen section Intra-operative evaluation is needed to confirm in cases of intraoperative palpable nodes nodes The anatomy The • Skin: – Blood supply: • Descending branches: Descending – The facial The – The submental – Occipital • Ascending branches – Transverse cervical – Suprascapular – The branches perforate the platysma muscle, anastomose to The form superficial vertically-directed network of vessels form • Skin incision is superiorly based apron-like incision from mastoid to mentum or to contralateral mastoid The anatomy The • Platysma muscle: – Wide, quadrangular sheet-like muscle – Run obliquely from the upper part of the Run chest to lower face chest – Skin flap is raised immediately deep to the Skin muscle muscle – The posterior border is over or just anterior The to IJV and great auricular nerve to – Does not cover the inferior part of the Does anterior triangle and the posterolateral neck The anatomy The • Sternocleidomastoid muscle: SCM – Differentiated from the platysma by the Differentiated direction of its fibres direction – Crossed by the IJV and the great Crossed auricular nerve from inferior to posterior deep to platysma posterior – The posterior border represent the The posterior boundary of nodes level II - IV posterior The anatomy The • Marginal Mandibular nerve: MMN – Located 1 cm in front of and below Located the angle of the mandible the – Deep to the superficial layer of the Deep deep cervical fascia – Superficial to adventitia of the anterior Superficial facial vein The anatomy The • Spinal Accessory nerve: SAN – Emerge from the jugular foramen medial to Emerge the digastric and stylohyoid muscles and lateral and posterior to IJV (30% medial to the vein and in 3 -5% split the nerve) the – It passes obliquely downward and backward It to reach the medial surface of the SCM near the junction of its superior and middle thirds, Erb’s point Erb’s The anatomy The • Trapezius muscle: – Its anterior border is the posterior Its boundary of level V boundary – Difficult to identify because of its Difficult superficial position superficial – Dissect superficial to the fascia in order Dissect to preserve the cervical nerves The anatomy The • Digastric Muscle; Posterior belly: – Originate from a groove in the mastoid Originate process, digastric ridge process, – The marginal mandibular nerve lie The superficial – The external and internal carotid The artery, hypoglossal and 11th cranial artery, nerves and the IJV lie medial The anatomy The • Omohyoid muscle: – Made of two bellies, and is the Made anatomic separation of nodal levels III and IV and – The posterior belly is superficial to the The brachial plexus, phrenic nerve and transverse cervical artery and vein transverse – The anterior belly is superficial to the The IJV IJV The anatomy The • Brachial Plexus & Phrenic nerve: – The plexus exit between the anterior The and middle scalene muscles, pass inferiorly deep to the clavicle under the posterior belly of the omohyoid posterior – The phrenic nerve lie on top of the The anterior scalene muscle and receive it is cervical supply from C3 – C5 The anatomy The • Thoracic duct: – Located in the lower let neck posterior Located to the jugular vein and anterior to phrenic nerve and transverse cervical artery artery – Have a very thin wall and should be Have handled gently to avoid avulsion or tear leading to chyle leak tear The anatomy The • Exit via the hypoglossal canal near the Exit jugular foramen jugular • Passes deep to the IJV and over the ICA Passes and ECA and then deep and inferior to the digastric muscle and enveloped by a venous plexus, the ranine veins venous • Pass deep to the fascia of the floor of the Pass submandibular triangle before entering the tongue the Summary Summary • Unified classification is relatively new • Indication and the type of ND, specially for N0, Indication is controversial is • The following surgical outline was suggested: – SCC oral cavity anterior to circumvalate papilla • Supraomohyoid – SCC Oropharynx, larynx and hypopharynx • level I- IV or level II-V – SCC with N+ nodes SCC • RND RND – SCC with 2-4 positive nodes or extracapsular spread • RND and adjuvant therapy Shah Cancer July 1;109-113: 1990 ...
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This note was uploaded on 11/10/2011 for the course PDBIO 220 taught by Professor Tomco during the Winter '09 term at BYU.

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