Classical Radical Neck Dissection Research Articles

Clinical pathological correlation between lymph node in patients with head and neck cancer

Objective: To correlate the clinical lymph node classification with the pathological result of neck dissections performed in patients with head and neck cancer at the Otorhinolaryngology Department of the Hospital Universitario de Caracas from January 1, 2011 to December 31, 2016. Method: Descriptive, quantitative and retrospective study, which evaluated 27 patients, who underwent classical radical, modified radical and selective neck dissection. Results: average age 56 years, 77.8% male. The most frequent histological type was squamous carcinoma 81.5%. The most used type of dissection was selective 53.3%, followed by the classical radical 26.7% and the modified radical 20.0%, of these 36% presented local or cervical recurrence. Of the 16 patients with positive lymph nodes, 13 had patology confirmation, and all the negative nodes also had negative patology confirmation; regarding cervical recurrence, of the 7 cases where it was present, all positive nodes, and in the 11 patients negative nodes, all negative cervical recurrence. Conclusion: The relationship between the pathological and clinical classification, as well as the presence of positive lymph nodes in cervical recurrences are statistically significant and are related to the decrease in survival. Neck palpation continues to be a useful tool in therapeutic decision making, which has shown higher than average sensitivity and specificity.

Straightforward Method for Coverage of Major Vessels After Modified Radical Neck Dissection

A new method for covering the internal jugular vein and carotid artery after exposure of the cervical vascular axis subsequent to neck dissection is presented. To cover the most caudal part of the vascular axis, a platysma coli muscle flap is harvested from its most medial and inferior part of the neck in a caudally based fashion and is slightly rotated posteriorly up to 45°. In addition, a superiorly based sternocleidomastoid muscle flap involving the posterior half of the muscle after detachment of the clavicle head is harvested and rotated 45° anteriorly to cover the upper two thirds of the vascular axis. This technique seems to be a good alternative to the pectoralis major myocutaneous flap for covering cervical major vessels, if no classical radical neck dissection is performed, especially in those oncologic malnourished patients who will undergo adjuvant radiotherapy after surgical treatment.

Prognostic significance of residual or recurrent lymph nodes in the neck for patients with nasopharyngeal carcinoma after radiotherapy.

Nasopharyngeal carcinoma is the most frequently diagnosed primary tumor originating from the nasopharynx, and the preferred treatment modality is radiotherapy. To identify nasopharyngeal carcinoma prognostic factors in patients with residual or recurrent cervical lymph node metastases after radiotherapy. The clinicopathologic characteristics and prognoses of 67 nasopharyngeal carcinoma patients with residual or recurrent cervical lymph node metastases who were diagnosed and treated were analyzed retrospectively. The Chi-squared test and Cox proportional hazard regression model were used to investigate associations between survival and clinicopathological features. Cumulative survival plots were obtained using the Kaplan-Meier method. Data analysis using the Cox proportional hazard regression model revealed that the size of residual or recurrent lymph node metastases, level V lymph node involvement, number of involved levels, surgical procedure performed, and distant metastases were significantly associated with overall survival. Chi-squared analysis only determined a significant correlation between distant metastases and patient survival. Furthermore, the Kaplan-Meier analysis demonstrated that the 1-, 3-, and 5-year survival rates for patients were 86.6%, 52.2%, and 38.6%, respectively. Radical neck dissection resulted in substantially longer overall survival than modified neck dissection. The size of residual or recurrent lymph node metastases, level V lymph node involvement, number of involved levels, surgical procedure performed, and presence of distant metastases were prognostic factors for nasopharyngeal carcinoma patients with residual or recurrent cervical lymph node metastases after radiotherapy, with distant metastases being the most important determinant. Classical radical neck dissection is recommended for treating recurrent nodal disease in nasopharyngeal carcinoma.

К вопросу о селективных шейных лимфодиссекциях в терапии рака слизистой оболочки полости рта

Background. Incidence of oral cancer in Russia is 4.52 and mortality - 2.44. Head and neck cancer is characterized by the high risk of development of metastases in regional lymph nodes (LN). LN status exerts influence on the treatment plan and appears to be the major predictive factor. Regional metastases result into two-fold decrease of five-year survival. Treatment of metastatic LN is of prime importance.Objective. The aim of this manuscript was to illustrate and summarize publications devoted to selective neck dissections in patients with squamous cell carcinoma of the oral cavity (OC).Results. Classic radical neck dissection is the gold standard of surgical treatment of OC cancer, characterized by regional metastases. However, metastases in neck LN of the IV- and V-th level are rarely present in patients with oral cancer. Therefore, efficiency of less extensive neck surgery is of great interest of up-to-date investigations. It was established, that selective neck dissection increases disease-free survival among patients with cT1-4N0M0 oral cancer in comparison with watchful waiting. Comparison of preventive selective neck dissections with preventive and curative modified neck dissections also indicates, that these methods of surgical treatment have equal efficacy.Conclusion. Selective neck dissection is feasible treatment method of сT1-4N0M0 oral cancer. Nevertheless, comparison studies of preventive selective and modified neck dissections, were characterized by disparate design and high probability of systematic errors. Moreover, another aspect, that must be solved, is the number of LN levels to be dissected during selective neck dissection. Thus, conception of selective neck dissection in patients with clinically negative LN is changing and requires further investigation.

Squamous cell carcinoma of cervical lymph nodes from an unknown primary site: The impact of neck dissection.

To investigate the treatment strategies of squamous cell carcinoma of cervical lymph nodes from an unknown primary site (SCCUP) and the value of neck dissection (ND). The study included 133 patients referred to the Zhejiang Cancer Hospital from 2001 to 2012, with 109 males and 24 females. Distribution of patients by N status was as follows: N1 - 14 cases; N2a - 21 cases; N2b - 78 cases; N2c - 7 cases; and N3 - 13 cases. 104 patients underwent surgeries of ND while 29 patients underwent nonsurgical treatment. Among 104 patients, 24 underwent classic radical ND, 16 modified ND, 53 selective ND, and 11 extended ND. The selection of surgical strategy was determined by the extent and location of disease. According to the range of ND, 50 patients underwent ND for Levels I-V, 46 for Levels II-V, 4 for Levels I-III, 3 for Levels II-VI, and 1 for Levels I-VI. The data were analyzed with SPSS version 16.0. The differences between groups were calculated by χ2 tests. The actual overall survival (OS) rates were calculated by the Kaplan-Meier method. Different factors affecting the OS were determined by the log-rank test on univariate analysis. Cox regression was used to evaluate the multivariate analysis. The 5-year OS rate of the whole cohort was 67.1%; and the median survival time was 70.0 months. The 5-year OS of ND group and of the non-ND group were 71.3% and 53.2%, respectively (P = 0.061). Cox analysis indicated that N stage (P = 0.000), bilateral neck metastasis (P = 0.001), extracapsular spread (ES) (P = 0.016), and ND (P = 0.028) were independent prognostic factors for the OS of SCCUP. 25 patients (18.8%) had neck recurrence or residue. The locoregional failure rate of ND group and of the non-ND group were 13.5% and 37.9%, respectively (P = 0.003). Logistic regression analysis indicated that higher N stage was the main risk factor for locoregional failure (P = 0.015). N stage, bilateral neck metastasis, ES, and ND were the main factors for the survival rate of SCCUP. N3 stage was the independent risk factor for locoregional failure. ND could significantly increase the locoregional control and may benefit the survival rate.

Squamous cell carcinoma of cervical lymph nodes from an unknown primary site: a retrospective analysis of treatment strategies and prognosis

To analyze the treatment strategies and prognosis of squamous cell carcinoma of cervical lymph nodes from an unknown primary site (SCCUP). A total of 125 cases with SCCUP was retrospectively analyzed from January 2001 to December 2011. Ninety-seven of the cases were treated with neck dissection (ND), including 24 with classic radical ND, 62 with modified ND and 11 with extended radical ND. Of 125 cases with SCCUP, 72 cases were supplemented with radiotherapy and 52 cases with chemotherapy. Radiotherapy was applied with extensive field in 36 cases, bilateral neck in 15 cases, and ipsilateral neck in 21 cases. The patients were followed up and the Kaplan-Meier method was used to calculate survival curves. Cox's analysis and logistic regression were used to evaluate the prognosis factors for SCCUP. The 5-year overall survival rate and disease free survival rate of the cohort were 66.2% and 60.0%, respectively. The median survival time was 70 months. Cox's analysis showed N-stage, extracapsular spread, bilateral neck metastasis and ND were independent prognostic factors for SCCUP. Logistic regression suggested that N-stage was the main factor for nodal recurrence or uncontrolled. The primary tumor sites emerged in 27 patients (21.6%) within 3 - 96 months after treatment (median time was 15 months), but only 4 patients (11.1%) existed in 36 cases underwent radiotherapy with extensive field. N-stage and extracapsular spread are two major factors influencing the prognosis of SCCUP. ND may improve the locoregional control and long-term survival.

Radical neck dissection: is it still indicated?

The presence of lymph node metastases in the neck remains a significant prognostic factor affecting patients with head and neck squamous cell carcinoma (HNSCC). Thus, treatment of regional disease remains a critical issue in the management of many patients. The ‘‘classical’’ radical neck dissection (RND), consisting of removal of all the lymphatic and non-lymphatic structures from the mandible to the clavicle, with the exception of the carotid artery, hypoglossal, lingual, vagus and phrenic nerves, and brachial plexus, was developed in the late nineteenth and early twentieth century [1‐4]. The procedure did not achieve widespread use in the medical community until the work of Martin et al. [5] when midcentury advances such as antibiotics, blood transfusion and modern anesthesia permitted safe and efficacious operation in a large series of patients. The classic RND has been and is still considered the ‘‘gold standard’’ for the surgical management of lymph node metastases of cancers of the head and neck.

Radical neck dissection: Preserving the distal spinal accessory nerve based on its cervical plexus contribution

In an effort to overcome shoulder morbidity from the classical radical neck dissection, modifications preserving the entire spinal accessory nerve, were described. When there are metastatic upper jugular nodes with potential extracapsular spread, modifications that preserve the entire XI nerve may be oncologically unsafe. We describe a technique wherein the XI nerve is preserved based on the contribution from the cervical plexus, while allowing resection of the proximal part of the nerve en bloc with the specimen. This modification may preserve useful trapezius function without compromising oncological safety.

Preservation of the Internal Jugular Vein in the Radical Treatment of Node-Positive Neck—Is It Safe?

The aim of this study was to evaluate risk factors of neck recurrence in patients with pN+ necks submitted to a modified or a classic radical neck dissection and the safety of preserving the internal jugular vein in the treatment of a subgroup of these patients. The medical records of 311 untreated patients with squamous cell carcinoma of the oral cavity (106 cases), oropharynx (95 cases), larynx (49 cases), and hypopharynx (61 cases) were reviewed. Their clinical stages (CS) were CS II in 1%, CS III in 19.9%, CS IVA in 76.2%, and CS IVB in 19.6% of the cases. All patients were pN+. Ipsilateral neck recurrence occurred in 18 cases (5.8%), 14 cases (4.5%) where the internal jugular vein was resected, and 4 cases (1.3%) where the internal jugular vein was preserved. Neck recurrence did not have significant correlation with tumor site (P = .852), T stage (P = .369), N stage (P = .963), adjuvant radiotherapy (P = .701), number of positive lymph nodes (P = .886), jugular vein preservation (P = .240), and extracapsular spread (P = .670). There was significant correlation between neck recurrence and the lymph node size (.040). Modified radical neck dissection with internal jugular vein preservation can be performed in selected patients with lymph node metastases, with no significant increase in the risk of neck recurrence.

Effect analysis of modified radical surgery in tongue cancer at early stages

To evaluate the oncologic efficacy, surgical safety, postoperative beauty, and morbidity of an ideal procedure of modified radical surgery in tongue cancer at early stages. Six patients with early stage squamous cell carcinoma of tongue underwent a procedure of modified radical surgery, in which an inconspicuous incision was used, the external jugular vein, sternocleidomastoid muscle, spino-accessory nerve, and greater auricular nerve were preserved, half of glosso and mouth floor were excised, and the defect was repaired instantly. Recurrence of glosso, mouth floor and neck, regional edema, shoulder dysfunction, auricle sensibility, oral cavity function and beautiful outlook on the face and neck were evaluated clinically. Compared with classic radical neck dissection, this procedure of modified radical surgery showed an inconspicuous incision and pretty appearance, minor edema on face and neck, better shoulder function, and sensation of auricular skin. No recurred to the glosso, mouth floor, and neck was found during follow-up. The patients showed better oncological safety, pretty appearance of tongue, and better oral function of speech, swallow and mastication. This ideal procedure of modified radical surgery in tongue cancer at early stages lessens or avoids destruction of face and neck, shoulder malfunction, numbness of auricular skin, and oral dysfunction of speech, swallow and mastication without impairment on the oncologic safety of the radical surgery, and improves the quality of life of the patients.

A new shoulder orthosis for paralysis of the trapezius muscle after radical neck dissection: a preliminary report

Despite recent advances using more conservative approaches, standard classical radical neck dissection is still one of the most frequently performed procedures in head and neck cancer patients who have advanced metastatic neck disease. The trapezius muscle paralysis following division of the spinal accessory nerve results in severe pain and cosmetic disturbance related to malalignment of the shoulder joint. The objective of this study is to report our results with a newly developed orthosis to prevent and correct shoulder dysfunction following standard radical neck dissection. Thirty-four patients who underwent standard radical neck dissection as a part of their surgical treatment from 1997-2002 were rehabilitated by the shoulder orthosis. Beginning 2 weeks after surgery, the patients were allowed to use their orthosis. By using a standard questionnaire, the pain and activity scores were recorded at the 1st, 3rd, 6th and 12th months postoperatively. Six patients were excluded from the study, of whom two succumbed to their disease and four discontinued the use of the orthosis. Of 28 patients included in the study, 20 (72%) were completely pain free within 3 months following the surgery. Four patients (14%) noted their pain level as tolerable, and four patients (14%) reported no considerable gain in the pain threshold and/or physical activity levels. Despite the fact that the active abduction range increased only 5 to 20 degrees , the relief of pain and improved malalignment of the scapula and consequently clavicle and humerus led to functional gains, which increased the patients' endurance. At the end of the study, 23 patients (82%) were able to return to their previous jobs or activity levels. Current preliminary reports suggest that this orthosis can be recommended to prevent significant disability in patients with trapezius palsy due to ablative cancer surgery or other reasons.

Is Selective Neck Dissection Adequate Treatment for Node-Positive Disease?

Selective neck dissection, or the selective removal of nodal groups at risk for harboring cervical metastases, is an extension of the concept of the functional neck dissection first introduced in the 1960s. Until 1963, radical neck dissection (RND) was the standard surgical treatment of the cervical lymphatic nodes. In 1963 Suarez proposed a conservative, functional approach to neck dissection that was popularized by Bocca et al. These authors described the removal of cervical lymph nodes from levels I through V with their enveloping fascial sheath while sparing nonlymphatic anatomic structures adjacent to, but not containing, lymph nodes, such as the accessory nerve, internal jugular vein, and sternocleidomastoid muscle. The resulting modified RND (MRND) has been shown to avoid the cosmetic and functional morbidity associated with the classic RND without compromising oncologic safety or efficacy as a staging and therapeutic procedure. Various modifications of the functional or MRND have been proposed for the elective treatment of the clinically negative neck (cN0) when surgical treatment of the primary tumor is planned and the risk of occult metastases is greater than 20%. Selective neck dissections are based on the observation that tumors of the upper aerodigestive tract drain to predictable nodal levels according to the site of the primary tumor, and that a comprehensive neck dissection encompassing all 5 nodal levels may therefore be unwarranted. The incidence of occult metastases in the cN0 neck exceeds 20% for tumors arising from the oral cavity, oropharynx, hypopharynx, and supraglottic larynx. The presence of cervical metastases is associated with a poorer prognosis. Accurate detection of occult metastases is difficult, as approximatively 50% of occult metastases are less than 5 mm and missed on physical and radiologic examination. Extracapsular spread may be present in as many as 50% of patients with occult metastases. If neck dissection is performed therapeutically when neck disease becomes clinically apparent, survival and surgical salvage rates are significantly decreased. An appropriately selected SND, which removes lymph nodes only at the levels likely to harbor metastatic disease, provides important prognostic information and, in some circumstances, may be therapeutic. In a review of 1119 RNDs performed electively for cN0 neck disease and therapeutically for clinically node-positive neck disease, Shah found that occult metastases were present in 33% of elective neck dissections and that level V was never involved in the absence of involvement of other nodal levels. Levels I, II, and III were at greatest risk for nodal metastases from squamous cell carcinoma of the oral cavity, and levels II, III, and IV were at greatest risk for metastases from carcinomas of the oropharynx, hypopharynx, and larynx. These findings support the use of supraomohyoid neck dissection (removing lymph nodes from levels I through III) for patients with cN0 oral cavity tumors in cN0 patients and anterolateral neck dissection (removing lymph nodes from levels II through IV) in patients with cN0 tumors of the oropharynx, hypopharynx, and larynx. Byers et al have shown that “skip metastases” to level IV occur in 16% of patients with squamous cell carcinoma of the oral tongue and advocate removal of level IV nodes as part of SND for oral tongue cancer. The regional recurrence rate following SND alone in patients with histologically negative nodes (pN0) is approximately 5%, which compares favorably with the rate in patients undergoing MRND for clinically and histologically negative nodal disease. It is generally accepted that SND is as effective as comprehensive neck dissection in staging the cN0 neck and is adequate treatment for the pN0 neck. The therapeutic efficacy of SND in patients with pathologic node-positive neck disease, however, is more controversial. Data Christine G. Gourin, MD

The use and misuse of neck dissection for head and neck cancer

Management of the Carotid Artery in Neck Dissection Neck dissection, or cervical lymphadenectomy, is a time-honored procedure used to treat metastastic carcinoma to the neck. Under most circumstances, the site of origin lies within the upper aerodigestive tract, thyroid gland, salivary glands, or the surrounding cutaneous structures. Contemporary approaches to neck surgery have included modifications of the classical radical neck dissection involving preservation of certain lymphatic regions, sparing nonlymphatic structures, or in some situations, removal of additional structures. As other modalities are proving to be effective treatment strategies for metastatic neck cancer, there is also a pressing need to define the role of neck dissection as part of a multimodality approach. Given this evolving role of neck dissection, this article is intended to outline the use and, in some situations, the misuse of these procedures in the management of patients with head and neck carcinoma. We served as panelists when this topic was presented at the annual meeting of the American College of Surgeons, October 2000.

Controlling advanced neck disease: efficacy of neck dissection and radiotherapy.

Neck dissection remains the standard method of treating cervical metastasis from head and neck squamous cell carcinoma. In light of recent trends to modify the classic radical neck dissection (RND) for early neck disease, we reviewed our experience with radical and modified RND (MRND) plus radiotherapy as treatment for N2/N3 neck disease in head and neck squamous cell carcinoma. We retrospectively reviewed our clinical records from July 1989 to June 1996 to identify 43 neck dissections in 39 patients who were found to have pathologically N2 or N3 neck disease treated primarily by neck dissection and postoperative radiotherapy. All patients had head and neck squamous cell carcinoma with a minimum follow-up of 24 months. Nine percent (4/43) of the dissected necks were pathologically N2a, 72% (31/43) were N2b, 7% (3/43) were N2c, and 12% (5/43) were N3. Of these, 28% (12/43) underwent a RND and 72% (31/43) underwent a MRND. The most common modification of RND was preservation of the spinal accessory nerve. All patients underwent postoperative radiotherapy with a mean dose of 55 Gy. Only 4 of 43 dissected necks had isolated treatment failure, for a regional control rate of 91%. The combination of RND or MRND and radiotherapy is highly effective in controlling neck disease in the absence of persistent or recurrent local disease. Also, in our experience, MRND appears to be as effective as RND in controlling even advanced neck disease, which supports preservation of the spinal accessory nerve whenever oncologically feasible.

The pattern of nodal recurrence following definitive radiotherapy for nasopharyngeal carcinoma.

The pattern of nodal metastasis in previously untreated nasopharyngeal carcinoma (NPC) has been studied and reported. In order to analyse the pattern of recurrent nodal disease in previously treated NPC, a retrospective study on 68 patients who underwent radical neck dissection for regionally recurrent NPC was conducted. Seventy-four neck dissections were performed on 68 patients who developed nodal recurrence after a mean disease-free interval of 39.2 months. None of the patients had evidence of local or systemic disease at the time of surgery. Histopathological reports of the 74 neck dissections were analysed with regard to the number of positive nodes as well as the number of involved nodal levels. Of the 65 neck dissection specimens with analysable data, 31 showed metastatic disease at a single nodal level with a mean number of positive nodes of 1.2, while 34 showed metastatic disease at multiple levels with a mean number of positive nodes of 6.6. Nodal recurrence occurred at level II with the greatest frequency (78.5%). Of the 31 specimens with single level nodal involvement, 21 (67.7%) occurred at level II. Isolated involvement at the other levels did occur, but was uncommon (range 3-16%). Of the 34 specimens with multiple level nodal involvement, 30 (88.2%) showed involvement at level II. Once more than one level was involved, the frequency of involvement at any given level was at least 30%. The predominant involvement at level II and the high frequencies of involvement at all levels support the use of a classical radical neck dissection in treating recurrent nodal disease in NPC.

The making of a specialty

The making of a specialty

Stress fracture of the clavicle after selective neck dissection

Neck dissection is a valuable method to treat cervical metastasis from cancer of the head and neck. One of the most common complications of neck dissection is injury to the spinal accessory nerve (SAN). Injury of the SAN results in atrophy of the trapezius muscle and shoulder-drop syndrome. Selective neck dissection has been reported to cause much less SAN injury than modified radical neck dissection and classic radical neck dissection. 1,2 However, even procedures that involve minimal dissection of the SAN can result in its injury. 3 Herein, we report an unusual case of stress fracture of clavicle after total laryngectomy and bilateral selective (lateral) neck dissection. Long-term follow-up suggested that this is a mechanical fracture rather than a pathologic fracture.

QT interval changes following neck dissection. A stratified prospective study.

Studies from Europe have suggested that neck dissection, especially right radical neck dissection, causes a dangerous prolongation of the QT interval. Sudden cardiac arrest due to QT prolongation has been reported following right radical neck dissection. We investigated the prevalence of QT interval prolongation following neck dissection. Electrocardiogram tracings from 45 patients who underwent different combinations of neck dissection were studied. Preoperative and postoperative tracings were interpreted by a cardiologist blinded to the patient identification of each tracing. There were 28 unilateral neck dissection patients and 17 bilateral neck dissection patients eligible for analysis. There were 7 patients in the classic right radical neck dissection group, and only 3 of these had no neck dissection on the left. Comparisons of preoperative versus postoperative corrected QT interval for all subjects did not indicate a significant change. Stratification by neck dissection type (radical, modified or selective, and carotid artery resection) or by side dissected (left, right, or both) also showed no significant differences. No malignant arrhythmias were encountered. Thus, in contrast to the European experience, our findings show no significant predictable change in the QT interval after any of the combinations of neck dissection. Head and neck surgeons should be aware of the possibility of postoperative QT interval prolongation following neck dissection, although in the absence of other risk factors it appears to be a rare occurrence.

Regional Metastases in Patients With Advanced Laryngeal Cancer

To determine patterns of regional metastases in patients with advanced squamous cell carcinoma of the larynx and the effect of these patterns on regional and distant tumor recurrence and disease-free and overall survival. One hundred fifty-nine patients treated with conventional surgery and radiation in the Veterans Affairs Cooperative Study were studied. Ninety-three of the patients underwent modified or classic radical neck dissection. Median follow-up was 5 years. Patient data collected included age, gender, alcohol consumption, tobacco use, and performance status. Tumor variables evaluated included TNM classification, tumor site, surface area, presence of ulceration and invasion, and histologic growth pattern. Histologically positive regional lymph nodes were examined for level, number, site, and extracapsular spread. Outcome variables included time and location of recurrence, distant metastases, and survival. Regional metastases were more common in supraglottic than glottic or subglottic tumors (P < .001) and in tumors with larger surface dimensions (P = .004). Cervical metastases were associated with decreased disease-free interval (P < .001) and survival (P = .001) and increased distant metastases (P < .001). Presence of 3 or more positive nodes predicted distant recurrence (P < .001) and decreased survival (P < .001, multivariate analysis). An analysis of lymph node involvement (levels I-V) indicated that level 1 and 5 involvement was a significant prognostic factor. Age, sex, race, and tobacco or alcohol use were not associated with number or extent of regional metastases. These findings confirm the prognostic importance of number and level of lymph nodes in advanced laryngeal cancer. The association of distant metastases with number and level of regional nodes indicates a use for these variables in considering adjuvant chemotherapy.

Classification of neck dissection: Variations on a new theme

Commencing in 1984, we initiated a head and neck service surgical database that included a classification system for neck dissection. The aim was to reduce the confusion in terminology resulting from growing interest in modifications of conventional radical neck dissection. We considered a neck dissection as radical when four or five lymph node levels were excised; this included patients who had an otherwise classical neck dissection for supraglottic larynx or hypopharyngeal cancer sparing level 1. Lymph-node levels removed, nonlymphatic structures preserved, and excised nonlymphatic structures not ordinarily included in a classical radical neck dissection were all specified by the operating surgeon. We defined as a selective neck dissection any lymphadenectomy that encompassed no more than three nodal levels, usually supraomohyoid (levels 1, 2, 3), or jugular (levels 2, 3, 4). We defined as a limited neck dissection any lymphadenectomy that involved removal of no more than two nodal levels. At the 10-year mark, this database of 10,650 patients now includes 2,635 lymphadenectomies in 2,426 patients, the precise extent of which is accurately described in each patient. The current classification of neck dissection does not cover all possibilities. If we define as radical those lymphadenectomies that resect four or five nodal levels and specify structures preserved or additional nonlymphatic structures sacrificed, we allow for the possibility that some procedures may be both modified and extended. Selective would describe the standard, three-level dissections (eg, supraomohyoid or jugular node dissections), and the term limited would be introduced to indicate a neck dissection that involves removal of no more than two nodal levels. Such a three-tiered classification would more accurately reflect the time and effort involved and provide a more equitable basis for reimbursement.