A Brief History of Cervical Lymphadenectomy

Abstract

Head and neck cancer is an aggressive disease with substantial morbidity associated with local invasion and regional lymphatic spread. Local spread through lymphatic channels is the most common course of disease progression; and nodal disease is often regarded as the most important prognostic factor in malignancy of the head and neck. [Ferlito 2006, Shah] It has been estimated that the presence of lymphatic metastases indicates a 50% decrease in survival; with contralateral nodal disease indicating another 50% decrease. [Leemans 1993, 1994] Neck dissection describes a procedure involving the en bloc removal of some or all of the lymphatic organs of the head and neck. In current practice the procedure is often performed simultaneously with resection of a primary tumor of the head and neck. The scope of the resection is quite variable and, throughout history, has been a source of some debate. In 1988 the American Head and Neck Society formed a task group to synthesize a standard nomenclature regarding neck dissection, their recommendations have gained near universal acceptance throughout North America and internationally as well. [Robbins 1991, 2002, 2008] Currently the American Head and Neck Society classifies cervical lympadenectomy into 4 categories: 1. Radical neck dissection 2. Modified radical neck dissection 3. Selective neck dissection 4. Extended neck dissection A radical neck dissection is defined as en bloc excision of lymph node levels I-V (Figure 1) along with the internal jugular vein (IJV), sternocleidomastoid muscle (SCM), and spinal accessory nerve (SAN). A modified radical neck dissection also involves the complete removal of levels I-V but with sparing of one or more of the nonlymphatic structures (IJV, SCM, SAN). A selective neck dissection is defined as a procedure that removes anything other than levels I-V. The nomenclature of selective neck dissection assumes that IJV, SCM, and SAN are all preserved unless otherwise noted. The specific levels removed are listed in parentheses (ie. SND [I-III]). Finally, an extended neck dissection is any procedure that removes additional structures beyond those involved in a radical neck dissection, for example superior mediastinal lymph nodes, or the external carotid artery. Very complete and specific recommendations regarding classification and terminology are clearly laid out in publications by Robbins et al. [Robbins 1991, 2002, 2008]