Level IIb Dissection Research Articles

Assessment of level IIB lymph nodes in oral cancer - Should we spare or care?

Objectives The extent of neck dissection over the years has evolved from a radical neck dissection to a super-selective neck dissection with an attempt to achieve a balance between oncological safety and acceptable morbidity. There is an ongoing debate concerning dissection of level IIB in both node negative and positive patients, primarily due to the low incidence of metastasis in this region and possible spinal accessory nerve injury. In this study, we intended to find the rate of metastasis to level IIB nodes in patients who were treated with neck dissection for oral cancers. Material and Methods Patients with squamous cell carcinoma of the oral cavity who underwent neck dissection were analyzed. Patients with clinically node negative (cN0) disease underwent selective neck dissection (SND), whereas patients with clinically node positive (cN+) disease underwent modified radical neck dissection (MRND). Results Out of the total 34 patients, 12 patients underwent MRND and 22 patients underwent SND. In the MRND group, three patients (25%) had positive level IIB nodes. The median number of IIB nodes removed was two and the median number of positive IIB nodes was one. In the SND group, the median number of IIB nodes removed was three and none of the patients had positive level IIB node. Conclusion In oral cancer with cN+, routine dissection of level IIB nodes has both therapeutic and prognostic values. Whereas, in patients with cN0, routine dissection of level IIB nodes can be omitted. Further large volume studies are needed on cN0 disease.

Anatomic Variability of the Accessory Nerve: Implications for Dissection of Level IIB.

During neck dissection, level IIB lymphadenectomy necessitates manipulation of the spinal accessory nerve that might be avoided and might cause postoperative disability. Current literature does not describe the effect of variation in the spinal accessory nerve in the upper neck. We sought to measure the effect of the dimensions of level IIB on nodal yield in level IIB and on patient reported neck symptoms. We measured the boundaries of level IIB of 150 patients undergoing neck dissection. Level II was dissected and separated into levels IIA and IIB intraoperatively. Patient-reported symptoms were assessed in 50 patients using the Neck Dissection Impairment Inventory. We computed descriptive statistics, and sought to identify correlation with the number and proportion of level IIB nodes and the number of metastatic nodes. Level IIB dimensions were analyzed as predictors of postoperative symptoms. We measured 184 sides, with 37.7% of level II nodes found in level IIB. Mean accessory nerve length across level II was 2.5 cm. Every additional 1 cm in accessory nerve length was associated with two more level IIB nodes. At all accessory nerve lengths, meaningful numbers of nodes were present in level IIB. Accessory nerve length and other factors did not correlate with NDII scores. Longer lengths of accessory nerve across level IIB correlated with greater nodal yield. However, data did not point to an accessory nerve length cutoff below which level IIB dissection could be avoided. In addition, the dimensions of level IIB did not correlate with postoperative neck symptoms. 2 Laryngoscope, 134:154-159, 2024.

Lymph node metastasis in level IIb in oropharyngeal squamous cell carcinoma: a multicentric, longitudinal, retrospective analysis.

Nowadays, 70% of patients in Europe and the USA are affected by a p16 + , potentially HPV driven oropharyngeal squamous cell carcinoma. However, despite the improved survival rate in this group, the quality-of-life remains low in cases which neck dissection took place. In this vein, in recent years, some surgeons have considered to avoid dissection of level IIB, proposing a supra-selective non-IIb neck dissection. A retrospective, longitudinal, multicentric study was conducted, including patients with pathologically confirmed primary HPV + or HPV - OPSCC who went through surgical treatment for the primary lesion and neck dissection. 141 patients were included. Among them, 99 (70.2%) were male and 42 (29.8%) were female. The mean age was 62 ± 9years (range 36-81). The most frequent anatomical location was the tonsil in 63 (44.7%) of patients. The most common approach was the classic transoral oropharyngectomy in 51 (36.2%) patients. Immunohistochemistry for p16 was positive in 62 (44%) patients. One-hundred and five (74.5%) patients received a unilateral ND, and a 36 (25.5%) a bilateral ND. Of those, a 12.8% (18/141) of patients were level IIb LN + . According to our results, level IIb ND should be considered in patients underwent therapeutic ND with positive LN metastasis in level IIa (OR = 9.83; 95% CI 3.463-27.917) or III (OR = 6.25; 95% CI 2.158-18.143), advanced (T3/T4) oropharyngeal primary tumors (OR = 3.38; 95% CI 1.366-8.405), and patients with ENE (OR = 6.56; 95% CI 2.182-19.770), regardless of p16 status. According to our results, level IIb ND should be considered in patients who underwent therapeutic ND with positive LN metastasis in level IIa or III, advanced oropharyngeal primary tumors, and patients with ENE, independently of p16 status. Prospective data are necessary to definitively ensure the safety of omitting ipsilateral or contralateral level IIb ND in cN - patients with early stage disease.

Primary and recurrent regional metastases for lateralized oral cavity squamous cell carcinoma

ObjectivesMap regional lymph node metastases for lateralized oral cavity squamous cell carcinoma (OCSCC) and evaluate factors associated with regional metastases and recurrence. Materials and methodsRetrospective cohort study of 715 patients with lateralized OCSCC surgically treated in 1997–2011. Analysis was performed using log-rank, Kaplan-Meier, and multivariable logistic and Cox regression. ResultsRegional metastases were identified in ipsilateral levels IIA (24%), IB (18%), III (13%), V (9%), IV (7%), IA (2%) and IIB (1%) and the contralateral neck (3%). Lymphovascular invasion (LVI) (Hazard Ratio [HR] 2.2, 95% Confidence Interval [CI] 1.2–3.9) and T category (T3 vs. T1: HR 4.1, 95% CI 1.9–9.3; T4 vs. T1: HR 2.3, 95% CI 1.2–4.3) were associated with regional metastases. Most (71%) isolated regional metastatic recurrences were in undissected levels of the neck, including 58% in levels IV and V. Tumors of the hard palate (HR 4.3, 95% CI 1.2–16.1), upper alveolus (HR 3.2, 95% CI 1.0–4.7) or with LVI (HR 2.0, 95% CI 1.0–3.9) were associated with isolated regional recurrence. For upper alveolar/hard palate tumors, depth of invasion (DOI) ≥4 mm (P = .003) and LVI (P = .04) were associated with regional metastases. ConclusionsFor lateralized OCSCC, elective neck dissection of level IIB or the contralateral neck may rarely be needed, but additional surgical or radiation treatment of levels IV and V may be considered based on patient risk factors, including T category 3–4 or LVI. For upper alveolar/hard palate tumors, DOI ≥4 mm is an appropriate threshold for elective neck dissection.

Clinical comparison of superior thyroid artery perforator flap and sternocleidomastoid myocutaneous flap for intraoral reconstruction

The aim was to evaluate the techniques and outcomes of superior thyroid artery perforator flaps (STAPF) for intraoral reconstruction and to compare them with those of the sternocleidomastoid myocutaneous flap (SCMMF). The cases of 43 patients who underwent reconstruction with either a SCMMF or STAPF for the repair of a medium-sized intraoral defect, between January 2013 and December 2020, were reviewed retrospectively. Although both flaps are based on the superior thyroid artery, their specific harvesting techniques largely differ. All SCMMF (n = 23) were superiorly-based rotational flaps with myocutaneous designs. The STAPF cases (n = 20) included 18 septocutaneous flaps and two chimeric flaps. The flap size was larger in the STAPF group (P = 0.008), while incomplete level IIB dissection (oncological safety) was more frequent in the SCMMF group (P = 0.002). The flap necrosis rate was lower in the STAPF group (STAPF 15% vs SCMMF 34.8%, though this was not statistically significant). Cox multivariate analysis showed that the postoperative flap outcome (total flap necrosis vs flap survival; hazard ratio 27, 95% confidence interval 2.149–336.05; P = 0.001) and complications (excluding fistula) (hazard ratio 14, 95% confidence interval 1.314–142.767; P = 0.029) were associated with overall patient survival. Both speech (P < 0.001) and neck mobility (P < 0.001) functions were superior with STAPF reconstruction. Compared with the traditional SCMMF, the STAPF was found to have a lower necrosis rate with uncompromised oncological safety during harvesting. The STAPF is a good alternative for the repair of medium-sized head and neck defects.

Predictive modelling of level IIb lymph node metastasis in oral squamous cell carcinoma

The aim of the present study was to examine the conditions, characteristics, and risk factors of level IIb lymph node metastases in oral squamous cell carcinoma and to formulate surgical criteria for level IIb lymph node dissection. We analyzed clinical and pathological records for 541 oral squamous carcinoma patients in relation to level IIb metastasis. Univariate and multivariate analyses were performed to detect risk factors for level IIb lymph node metastasis; a predictive model was built based on multivariate analysis and tested in a validation group. Univariate and multivariate analyses using the training group indicated that level IIa metastasis and Lymphovascular permeation (LVP) were two independent risk factors for level IIb lymph node metastasis. This model was built and tested in a validation group, the area under the curve being 0.697 (P < .0.001). The model’s sensitivity was 66.7% and specificity was 77.4%. Nomogram incorporating validated variables was developed for level IIb metastasis prediction. Expected survival probabilites were analysed to specify significance of model's variable on patients’ overall survival and recurrence. Level IIb dissection should be performed in patients with level IIa metastasis and LVP. However, thorough consideration of the oncologic safety of omitting level IIb dissection is compulsory.

Level IIB dissection in early stages cT1-T2 oral squamous cell carcinomas: pros and cons

Level IIB dissection in early stages cT1-T2 oral squamous cell carcinomas: pros and cons

Relevance of level IIb neck dissection in patients with papillary thyroid carcinoma.

Cervical nodal metastasis is a key prognostic factor in patients with papillary thyroid carcinoma. The role of lymph nodes in papillary thyroid carcinoma management and prognosis remains controversial. Level IIb lymph nodes obtained from 44 patients with papillary thyroid carcinoma were histopathologically examined retrospectively. Specimens were classified as ipsilateral or contralateral. The number of dissected nodes and prevalence of level IIb metastasis were compared according to pre-operative clinical nodal stage. In the node-negative neck, the prevalence of contralateral and ipsilateral IIb nodes was 0 out of 20 and 0 out of 3, respectively. In the node-positive neck, the prevalence of contralateral and ipsilateral IIb nodes was 1 out of 13 (7.70 per cent) and 3 out of 41 (7.32 per cent), respectively. Clinically determined and pathologically confirmed level IIb node negativity were significantly associated. Thirty-four patients (77.3 per cent) developed accessory nerve complications from level IIb dissection. Level IIb neck dissection for papillary thyroid carcinoma may be required if pre-operative examination reveals multilevel, level IIa or suspicious level IIb metastasis.

Level IIb involvement in oral cavity squamous cell carcinoma

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; Cervical lymph node status is the most significant prognostic factor in the treatment of patients with OSCC. Adequate clearance of level IIb lymph nodes require traction and elevation of the spinal accessory nerve (SAN) and can lead to consequent shoulder problems.Therefore, avoiding the dissection of level IIb has been increasingly proposed to overcome this complication. The aim of this study was to determine the prevalence of level IIb metastasis in patients with oral squamous cell carcinomas (OSCCs).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;A total of 106 newly diagnosed oral cavity cancer patients requiring surgery as the primary modality were included in the study. Preoperative clinical examinations were done and tumor-node-metastasis staging was noted. Intraoperative, level IIb nodal tissue was dissected and sent separately.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;A total of 106 neck dissections were done out of which male: female ratio of 2.78:1. 49.05% patients were suffering from buccal mucosa carcinoma followed by tongue carcinoma (22.64%). 52.83% of patients had no neck involvement. Among neck positive cases, pN1 was the most common presentation. Out of these, only 8 (7.54%) neck dissections had level IIb positive.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;Dissection of the level IIb region in patients with OSCC may be required only in cases with advanced N stage, positive level IIa lymph nodes, and extra capsular spread. Further evaluation can be done among various subsites of OSCC, clinical staging of tumour, occult bilateral nodal metastasis to assess the need of resection of level IIb in OSCC.&lt;/p&gt;

Primary Tumour Characteristics Poorly Correlate with Extracapsular Spread and Cervical Sublevel IIb Metastasis in Patients with Oral Squamous Cell Carcinoma and Clinically N0 Neck: A Retrospective Study.

Introduction:Nodal metastasis reduces the survival by 50% in head-and-neck squamous cell carcinomas. The presence of nodal extension/extracapsular spread (ECS) further reduces survival. Current literature favors a selective level IIb sparing neck dissection in clinically N0 neck. Studies have evaluated the role of primary tumour size, number of lymph nodes, and depth of invasion (DOI) with the occurrence of extranodal extension (ENE).Patients and Methods:Patients were retrospectively reviewed who presented with oral cavity carcinomas and clinically N0 neck. Relationship was sought between tumour site, size, histological grading, DOI, and the occurrence of level IIb metastasis and ECS. A P < 0.05 was considered statistically significant.Results:The relationship showed insignificant correlation with P values (0.6643, 0.6704, 0.6779, and 0.6779) between site, size, grading, DOI, and level IIb and ENE.Discussion:Previous studies have shown DOI >5 mm and lymph node size 15 mm and multiple lymph nodes predict ECS. DOI and primary site with more than 20% for occult metastasis predicts elective neck treatment. However, in our study, no correlation was found between primary tumour characteristics and ECS or level IIb metastasis. Elective neck dissection is the standard surgical protocol from both diagnostic and therapeutic viewpoints. The only criterion for level IIb dissection is concomitant presence of level IIa involvement intraoperatively. Since ENE can occur early in the disease process, elective neck dissection remains the standard of care.

The necessity of level IIb dissection for clinically negative neck oral squamous cell carcinoma

AimSelective neck dissection reduces the incidence of complications associated with radical neck dissection while achieving the same oncological results, especially in clinically node-negative (cN0) cases. The most common complications associated with selective neck dissection are spinal accessory nerve dysfunction and shoulder disability, which result from level IIb dissection. The aim of the present study was to evaluate the incidence of level IIb lymph node metastasis in cN0 oral squamous cell carcinoma (OSCC) patients to determine the necessity of selective neck surgery. MethodsThe medical records of 138 consecutive OSCC cN0 patients seen from June 2012 to June 2017 were retrospectively reviewed for age, gender, tumor localization, and TNM classification. ResultsThe incidence of occult metastasis was 29.7%, but level IIb nodes were not involved in any case. DiscussionThe lack of involvement of level IIb nodes in occult metastasis, and high prevalence of shoulder dysfunction caused by injury to the spinal accessory nerve during surgery, challenge the necessity of surgical IIb node clearance in cNO OSCC; this is true for all stages and especially for early T1 stage cases, when the likelihood of occult lymph node metastasis is low (15.6%).

Review of treatment modalities and outcomes of patients with basal cell adenocarcinoma.

This study summarizes the treatment modalities of basal cell adenocarcinoma (BCAC) of the parotid gland and subsequent outcome at a single institution to better define the treatment of this rare tumor. A retrospective review of patients treated for BCAC of the parotid gland from 1/01/1996 to 08/1/2018 was performed. Patients were identified using our institution's Cancer Registry. A total of thirteen patients (46% female, median age of 56) treated for BCAC of the parotid gland were identified. Eight patients (57%) were staged as T1, four were staged as T2 (29%), and two were stage T4a (14%) due to tumor involvement of the facial nerve. None of the patients had nodal involvement or distant metastases. Three patients (21%) underwent radiation therapy ranging from 60-70Gy for positive margin or facial nerve involvement by tumor. Five patients (36%) underwent a neck dissection (ND) ranging from just a level IIb dissection up to levels IIa, IIb, and III with none of the nodes being positive for disease. The remainder of patients did not undergo a neck dissection. Follow-up was 8.1±6.2 (mean±SD) years with no local or regional recurrence at time of last follow-up in any patient cohort. Our review suggests that elective neck dissections are not necessary following resection of T1/T2N0M0 basal cell adenocarcinoma for the prevention of local or regional recurrence. No longer performing neck dissections for T1/T2N0M0 BCAC would reduce the morbidity associated with the treatment of this rare parotid tumor.

The necessity of IIb dissection in T1\u2013T2N0M0 oral squamous cell carcinoma: protocol for a randomized controlled trial

BackgroundThere is a growing debate on the relationship between health-related quality of life (HRQoL) and patient survival which has been going on for the last few decades. The greatest wish of clinicians is to extend the latter while improving the former. Following neck dissection of early-stage oral carcinoma, “shoulder syndrome” appears due to traction of the accessory nerve during removal of level IIb, which greatly affects patient quality of life. Since occult metastasis in level IIb of early-stage oral carcinoma is extremely low, some surgeons suggest that level IIb can be exempt from dissection to improve the HRQoL. However, other surgeons take the opposite view, and thus there is no consensus on the necessity of IIb dissection in T1–2N0M0 oral squamous cell carcinoma (OSCC).MethodsWe designed a parallel-group, randomized, non-inferiority trial that is supported by Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China. We will enroll 522 patients with early oral carcinoma who match the inclusion criteria, and compare differences in 3-year overall survival, progression–free survival (PFS) and HRQoL under different interventions (retention or dissection of level IIb). The primary endpoints will be tested by means of two-sided log-rank tests. Analysis of overall and progression-free survival will be performed in subgroups that were defined according to stratification factors with the use of univariate Cox analysis. In addition, we will use post-hoc subgroup analyses on the basis of histological factors that were known to have effects on survival, such as death of invasion of the primary tumor. To evaluate HRQoL, we will choose the Constant–Murley scale to measure shoulder function.DiscussionCurrently, there are no randomized controlled trials with large sample sizes on the necessity of IIB dissection in T1–T2N0M0 OSCC. We designed this noninferiority RCT that combines survival rate and HRQoL to assess the feasibility of IIb neck dissection. The result of this trial may guide clinical practice and change the criteria of how early-stage oral cancer is managed. The balance between survival and HRQoL in this trial is based on early-stage breast cancer treatment and may provide new ideas for other malignancies.Trial registrationChinese Clinical Trial Registry, ChiCTR1800019128. Registered on 26 October 2018.

Frequency of Level IIb Neck Dissections for OSCC

Introduction: Selective neck dissection (SND) is the gold standard in oncological management of the neck, it enables us to reduce the morbidity of neck dissection while maintaining the same oncological results. Spinal accessory nerve dysfunction and related shoulder disability is the commonest morbidity associated with dissection of Level IIb. This study was undertaken to ascertain the frequency of undertaking Level IIb dissection and the rate of Nodal metastasis to this level.

Cervical level IIb metastases in squamous cell carcinoma of the oral cavity: a systematic review and meta-analysis.

PurposeThe aim of this study was to clarify whether level IIb dissection should be performed or avoided in the treatment of oral squamous cell carcinoma by meta-analysis.Materials and methodsArticles that were published before June 2017 were searched electronically in four databases (Web of Science, PubMed, Ovid and China National Knowledge Infrastructure) without any date or language restrictions by two independent reviewers. s and full-text papers which investigated the cervical metastases to level IIb from primary head and neck cancers and were deemed potentially relevant were screened. Data were analyzed using RevMan 5.3.ResultsFour hundred and fifty-five abstracts and 129 full-text papers were screened, and 22 studies were included in the analysis. Among the 2001 patients included, 112 patients had level IIb metastases, the pooled frequency of which was 6% (95% confidence interval [CI]: 4.0–7.0). Among the 400 patients with tongue squamous cell carcinoma from 12 studies, 37 patients had level IIb metastases, the pooled incidence of which was 7% (95% CI: 5.0–10.0). Metastases to level IIb always went together with level IIa, and only three patients were found to have isolated level IIb metastases without involving the other levels.ConclusionDue to the low frequency of level IIb nodal metastases in oral squamous cell carcinoma patients and rare occurrence of isolated level IIb, level IIb dissection could be avoided when the primary lesions were in early stages (T1 and T2), with the exception of tongue cancer. It is recommended to dissect level IIb tongue cancers without considering the stages of primary lesions and the lymph nodes status. It is also suggested that level IIb dissection should be performed in patients preoperatively or intraoperatively found with multilevel neck metastasis, especially level IIa metastasis.

Level IIb Neck Dissection in Oral Cavity Cancers- When Should One Address it..?

Nodal metastases is the most important prognostic marker for oral cavity cancers. Nodal dissection at level IIb risks damage to the spinal accessory nerve. We aim to study positivity of level IIb lymph nodes in oral cancers. In this non-randomized prospective observational study, 65 patients of oral cavity cancers were evaluated. Appropriate surgery for primary tumour and neck dissection were undertaken. All patients underwent level II b dissection. Out of 67 neck dissections (27 elective and 40 therapeutic), 7 patients had level IIb positive for metastases (10.44%) with no isolated or contralateral metastases at level IIb and direct correlation with level IIa nodes. There was no statistical association of level IIb positivity with stage or site of primary. Level IIb dissection can be avoided in N0 necks. For therapeutic neck dissections, Level IIb should be cleared if there are positive nodes at level IIa.

Selective Neck Dissection (IIa, III): A Rational Replacement for Extended Supraomohyoid Neck Dissection in Patients with N0 Supraglottic and Glottic Squamous Cell Carcinoma.

OBJECTIVESTo evaluate the effectiveness of selective neck dissection of sublevel IIa and level III in cases of glottis and supraglottic laryngeal carcinoma in the absence of lymph node metastasis and to show if there is value in dissecting the sublevel IIb or level IV in these cases.PATIENTS AND METHODSTwenty-five patients with N0 glottic or supraglottic cancer were subjected to unilateral or bilateral selective neck dissection according to the site and the extent of the tumor, and the specimens were histopathologically examined for metastasis.RESULTSTwenty-five patients (23 males and 2 females) with mean age of 55.72 years were included in the study. Lymph node metastasis to sublevel IIa and level III was found in 6/25 (24%) cases with glottic or supraglottic carcinoma, while to sublevel IIb and level IV was found in 1/25 (4%) with P-value of 0.05, which is statistically significant.CONCLUSIONSelective neck dissection of level IIb is not required in cases of the supraglottic laryngeal cancer. Dissection of sublevel IIa and level III takes less time and is effective. Dissection of level IV is not needed in the case of supraglottic cancer.

A Prospective Study of Level IIB Nodal Metastasis (Supraretrospinal) in Clinically N0 Oral Squamous Cell Carcinoma in Indian Population.

Oral cavity carcinoma is the most common cancer in Indian population. Metastatic nodal disease is the most important prognostic factor for oral cancers. In head and neck cancers with clinically N0 neck, standard selective neck dissection is performed by protecting the spinal accessory nerve to remove level IIA & IIB lymph nodes. The purpose of this study was to analyze the significance of level IIB dissection in patients of oral cavity cancer who underwent primary surgery with functional neck dissection. Two hundred ten patients with clinically N0 neck underwent neck dissection, where level IIB lymph nodes were dissected, labelled and processed separately. Among 210 patients of clinically N0 neck, 168 patients were pathologically N0 (80%). Out of remaining 42 (20%), 36 (17.14%) were pN1 and 6 (2.86%) were pN2. Among those with pN1 (36), level IB was involved in 24 patients (66.67%) and level IIA was involved in 12 patients (33.33%). Only 2 patients had involvement of level IIB lymph nodes. Among 6 patients of pN2 disease, 4 patients had simultaneous involvement of level IB and level IIA lymph nodes. Remaining 2 patients had isolated involvement of level III lymph nodes. Thus only 2 patients (< 1%) out of 210 clinically N0 oral squamous cell carcinoma showed level IIB lymph node involvement. Thus we conclude that a frozen section of level 2a is advisable to decide the need for level 2b node dissection in clinically N0 neck as the sensitivity of clinical evaluation is extremely low.

Level IIB lymph node metastasis in laryngeal and hypopharyngeal squamous cell carcinoma: Single‐institution case series and review of the literature

To determine the incidence of level IIB lymph node metastasis in patients with laryngeal or hypopharyngeal squamous cell carcinoma and to evaluate the need for elective and therapeutic neck dissection of level IIB. Retrospective cohort study and review of the literature. Patients with laryngeal or hypopharyngeal squamous cell carcinoma (N = 65) were primarily treated with surgery at Mayo Clinic (Rochester, Minnesota) from 2004 through 2010. Neck dissection specimens were analyzed by a pathologist, and metastases to level IIB were reported. In addition, 18 previously published studies, totaling 1,114 neck dissections, were reviewed. Level IIB lymph node metastases were present in 4% and 17% of elective and therapeutic neck dissections, respectively. Ipsilateral IIB metastasis was more common than contralateral IIB metastasis in elective and therapeutic neck dissection specimens. Level IIB lymph node metastasis was not significantly associated with level IIA nodal metastasis, level III nodal metastasis, clinical primary tumor stage, clinical nodal stage, or pathologic confirmation of extracapsular spread in either laryngeal or hypopharyngeal squamous cell carcinoma. The rate of occult IIB metastasis in laryngeal and hypopharyngeal squamous cell carcinoma is exceedingly low. In a clinically node-negative case, the ipsilateral and contralateral level IIB nodal packet should not be dissected. For clinically node-positive cases, ipsilateral level IIB dissection should be performed; contralateral IIB dissection should be performed only when indicated.

Level IIB lymph node metastasis in oropharyngeal squamous cell carcinoma

To determine the incidence of level IIB lymph node metastasis in patients with oropharyngeal squamous cell carcinoma (OPSCC) and to evaluate the necessity of level IIB dissection for elective and therapeutic neck dissections. Retrospective cohort study. Patients with OPSCC (N = 348) were surgically managed at our institution from 2004 through 2010. Neck dissection specimens were reviewed by a pathologist, and level IIB metastases were analyzed with respect to clinical and pathologic data. Level IIB lymph node metastases were present in 2.5% and 25% of elective and therapeutic neck dissections, respectively. Level IIA metastasis, clinical tumor stage, clinical nodal stage, extracapsular spread, and primary tumor location in the tonsil were significantly associated with level IIB metastasis. This study uniquely demonstrated a statistically significant association between clinical tumor stage and tonsil subsite with level IIB metastasis in OPSCC. Considering the predicted incidence of nodal metastasis, we conclude that level IIB neck dissection can be omitted in early stage (T1 or T2) clinically node negative (cN0) OPSCC. In patients with a cN0 neck and advanced OPSCC (T3 or T4), primary tumor in the tonsil, or ipsilateral clinically node positive (cN(+) ) and contralateral cN0 neck, level IIB dissection should be considered. Level IIB dissection should be performed routinely in patients with cN(+) OPSCC.