Level I Sparing Radical Neck Dissections for Cutaneous Melanoma in the Lymphoscintigram Era

Abstract

Excision of regional lymph nodes (LNs) in the neck as part of the management for tumors of the head and neck dates back to the 19th century. Crile originally reported the technique of performing a radical neck block dissection in 1905, with notable modifications to the extensive dissection reported throughout the 20th century by Suarez, Ballantyne, Ariyan, and Shah among others. These modifications have aimed to reduce the morbidity encountered by performing the radical neck dissection while balancing the need to remove diseased structures in the head and neck. In this report, we evaluate the outcomes of performing a functional radical neck dissection while sparing the level I LNs as indicated by lymphoscintigraphy. The charts of patients from the Yale Melanoma Unit who underwent resection of their head and neck melanoma from January 2000 to December 2006 were reviewed. The location of the primary melanoma and clinical course was noted. Those patients who underwent neck dissections were documented and the extent of the dissections from the operative reports was noted. Demographic and outcome data were recorded, including clinical course of melanoma presentation, local recurrence, and postoperative management. Student t test and χ tests were used to determine statistical significance between groups. P values less than 0.05 were considered statistically significant. A total of 41 patients who were documented to have had a head and neck primary melanoma underwent a functional radical neck dissection. Level I dissections were deemed necessary in 39% of these cases, whereas 61% of patients received functional radical neck dissections with sparing of level I LNs. Specific recurrence of melanoma in the submandibular basin was equivocal for LN sparing dissections (n=1) as compared to excision of level I LNs (n=1) (4% vs 6.25%, P=0.488). Follow-up metastatic rates between the 2 groups were also comparable (44% vs 56%, P=0.328). Overall metastatic rate in follow-up for all patients undergoing LN dissection was 48.8%. There was no statistically significant difference between the average age of patients at diagnosis, Breslow depth, Clark level, and staging between patients who underwent functional radical neck dissections with either excision or sparing of level I LNs. Clinical and pathological presentation between patients who needed level I sparing dissections and those who did not, failed to demonstrate a statistically significant difference allowing for an adequate comparison. Our results indicate that if lymphoscintigraphy does not show drainage to level I LNs, the functional radical neck dissection can be tailored to spare level I LNs without affecting local recurrence. When not indicated by lymphoscintigram, sparing of level I nodes can be performed safely without changing clinical outcomes, while saving operating room time and minimizing potential damage to the buccal branch of facial nerve and the submandiblular gland.