Surgical management of cervical lymph node metastases.

Abstract

Every case of malignant neoplasm about the head and neck must be evaluated in regard to possible metastasis to cervical lymph nodes. Since clinical diagnosis of early metastatic involvement is inaccurate, estimation of the probability of the presence of metastases must be based in part upon the characteristics of the primary tumor. In addition to the known behavior of the particular neoplasm in regard to node metastasis, characteristics apparently associated with the likelihood of its occurrence are location, size, duration, grade of malignancy, gross type of growth, and previous unsuccessful attempts to achieve control of the primary lesion. When these factors are evaluated, a fairly successful estimation can be made of the probable presence of metastases, even when node involvement is not clinically obvious. The fallibility of depending upon the clinical estimate of lymph node metastasis is illustrated in Table I, demonstrating the size of cervical lymph nodes in relation to actual metastatic involvement secondary to carcinoma of the lip. Obviously a small percentage of cases of cancer of the lip harbor metastases even when they cannot be detected clinically, and the larger the lymph nodes, the greater is the likelihood of metastasis. Even some large nodes, however, may be due to simple hyperplasia and inflammation. Table II illustrates the relationship of the characteristics of the primary carcinoma of the lip to the occurrence of metastases. Similar studies of carcinoma in other sites show equivalent results. In some regions, as for example the tongue and floor of the mouth, due to a rich lymphatic plexus and the muscular activity of the part, the over-all propensity of tumors to form metastases is much greater than with lesions of the lip. Conversely, carcinomas situated over bony surfaces, as the hard palate and the gingiva, where they are not subjected to muscular activity, have a lessened likelihood of lymph node metastasis. The problem of treatment must be divided into two parts, that of the primary carcinoma and that of the node metastases. Before treatment of the nodes is undertaken, the primary carcinoma must have been controlled, or must be obviously controllable. If the primary lesion is uncontrollable, only palliative measures are indicated. Following control of the primary carcinoma, the decision must be made whether any treatment is necessary to the regional lymph node areas. This will depend upon the presence of obvious metastases or the probability of the development of metastases. A policy of watchful waiting may be justified if obvious metastases are not present, and if there is not much likelihood of the later development of metastases, provided very careful follow-up observations can be carried out. It should be realized, however, that delay involved in waiting for obvious metastasis may diminish the chance for cure, although it reduces the number of “unnecessary” operations.