10 Questions
What is the primary goal of modifying neck dissections?
To reduce the morbidity associated with radical neck dissection
What is the generally accepted procedure for an oral cavity primary without evidence of lymph node metastases?
Selective neck dissection removing lymph nodes from levels I to III
What is the purpose of including level IV in a selective neck dissection?
To decrease the risk of missed occult metastases
What is Type III in the context of neck dissections?
A type of neck dissection that preserves the spinal accessory nerve, sternocleidomastoid muscle, and internal jugular vein
What is the main difference between selective neck dissection and extended neck dissection?
Selective neck dissection removes one or more additional lymph node groups or nonlymphatic structures
What is the purpose of supraomohyoid neck dissection?
To eradicate occult metastatic disease in patients with oral cavity primary
What is the classification scheme used to name selective neck dissections?
Named after the cancer being treated and the node groups removed in parentheses
What is the significance of level IV in the context of oral cavity cancer?
It is associated with a higher risk of missed occult metastases if not removed
What is the primary goal of elective neck dissection?
To eradicate occult metastatic disease
What is the main difference between radical neck dissection and selective neck dissection?
Selective neck dissection preserves more lymph node groups
Study Notes
Removal of At-Risk Lymphatic Basins
- Serves two purposes: removing occult metastasis in patients at risk and removing macroscopic disease in patients with highly suspected metastasis
- Elective neck dissection is a more accurate term than prophylactic neck dissection when discussing removal of at-risk lymphatic basins in the absence of clinical evidence of metastasis
Classification of Neck Dissection
- Radical neck dissection:
- Refers to removal of all ipsilateral cervical lymph node groups from the inferior border of the mandible to the clavicle
- Includes removal of the internal jugular vein, sternocleidomastoid muscle, and spinal accessory nerve
- Encompasses levels I-V
- Modified radical neck dissection:
- Refers to removal of the same lymph node levels as radical neck dissection, but with preservation of the spinal accessory nerve, internal jugular vein, or sternocleidomastoid muscle
- Structures preserved should be named
- Can be subdivided into three types: Type I (preserves spinal accessory nerve), Type II (preserves spinal accessory nerve and sternocleidomastoid muscle)
- Selective neck dissection:
- Refers to preservation of one or more lymph node groups normally removed in a radical neck dissection
- Example: supraomohyoid neck dissection removes lymph nodes from levels I-III
- Named for the cancer being treated and node groups removed in parentheses
- Extended neck dissection:
- Refers to removal of one or more additional lymph node groups, nonlymphatic structures, or both, not encompassed by a radical neck dissection
- Example: mediastinal nodes or nonlymphatic structures such as the carotid artery or hypoglossal nerve
SCC of the Buccal Mucosa
- Represents approximately 10% of oral cavity cancers in the United States and 41% in India
- Can be deceptive in their clinical course due to intimacy with the buccal space and deeper structures
- Cancers that penetrate the buccinator muscle can be difficult to eradicate
- Patients may present with involvement of the pterygoid space posteriorly or the parotid gland laterally
- Extension superiorly or inferiorly can lead to invasion of the maxillary alveolus or mandibular alveolus, respectively
- Often arise in wide areas of damaged mucosa, making adequate excision resulting in complex defects of the cheek that can be difficult to reconstruct
- Primary radiation may be an option for smaller lesions
- Up to 50% of patients with buccal squamous cell carcinoma can present with neck metastases, with an occult disease rate in the neck of approximately 10%
- Elective treatment of the neck with radiation or surgery is indicated in T3 or T4 lesions, and consideration should be given to elective treatment of the neck in deep T1 (>4 mm) and larger T2 lesions
Neck Dissection and Survival Rates
- Appropriate surgical management of the regional lymphatics plays a central role in the treatment of oral cancer patients
- Two-year overall survival rates for early-stage disease treated with various treatment modalities range from 83% to 100%
- Stage III survival rate is 41%, and stage IV is 15%
Understanding the importance and purposes of removal of at-risk lymphatic basins, including identifying occult metastasis in patients.
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