Level IIb Lymph Node Metastasis Research Articles

Patterns of lymph node metastasis in level IIB and contralateral level VI for papillary thyroid carcinoma with pN1b and safety of low collar extended incision for neck dissection in level II

ObjectiveTo explore relevant clinical factors of level IIB and contralateral level VI lymph node metastasis and evaluate the safety of low-collar extended incision (LCEI) for lymph node dissection in level II for papillary thyroid carcinoma (PTC) with pN1b.MethodA retrospective analysis was performed on 218 patients with PTC with pN1b who were treated surgically in the Head and Neck Surgery Center of Sichuan Cancer Hospital from September 2021 to May 2022. Data on age, sex, body mass index (BMI), tumor location, maximum tumor diameter, multifocality, Braf gene, T staging, surgical incision style, and lymph node metastasis in each cervical subregion were collected. The chi-square test was used for comparative analysis of relevant factors. All statistical analyses were completed by SPSS 24 software.ResultEach subgroup on sex, age, BMI, multifocality, tumor location, extrathyroidal extension, Braf gene, and lymphatic metastasis in level III, level IV, and level V had no significant difference in the positive rate of lymph node metastasis in level IIB (P > 0.05). In contrast, patients with bilateral lateral cervical lymphatic metastasis were more likely to have level IIB lymphatic metastasis than those with unilateral lateral cervical lymphatic metastasis, with a statistically significant difference (P = 0.000). In addition, lymph node metastasis in level IIA was significantly associated with lymph node metastasis in level IIB (P = 0.001). After multivariate analysis, lymph node metastasis in level IIA was independently associated with lymph node metastasis in level IIB (P = 0.010). The LCEI group had a similar lymphatic metastasis number and lymphatic metastasis rate in both level IIA and level IIB as the L-shaped incision group (P > 0.05). There were 86 patients with ipsilateral central lymphatic metastasis (78.2%). Patients with contralateral central lymphatic metastasis accounted for 56.4%. The contralateral central lymphatic metastasis rate was not correlated with age, BMI, multifocality, tumor invasion, or ipsilateral central lymphatic metastasis, and there was no significant difference (P > 0.05). The contralateral central lymphatic metastasis in males was slightly higher than that in females, and the difference was statistically significant (68.2% vs. 48.5%, P = 0.041).ConclusionLymphatic metastasis in level IIA was an independent predictor of lymphatic metastasis in level IIB. When bilateral lateral cervical lymphatic metastasis or lymph node metastasis of level IIA is found, lymph node dissection in level IIB is strongly recommended. When unilateral lateral cervical lymphatic metastasis and lymphatic metastasis in level IIA are negative, lymph node dissection in level IIB may be performed as appropriate on the premise of no damage to the accessory nerve. LCEI is safe and effective for lymph node dissection in level II. When the tumor is located in the unilateral lobe, attention should be given to contralateral central lymph node dissection because of the high lymphatic metastasis rate.

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 lymph node metastasis characteristics and predictive factors for patients with cN1b papillary thyroid carcinoma

BackgroundThe aim of the present study was to examine the frequency, characteristics, and risk factors of level IIb lymph node metastases in papillary thyroid carcinoma. MethodsWe reviewed and collected clinical and pathological records for 954 papillary thyroid carcinoma patients with clinically positive lateral neck node 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. ResultsLevel IIb lymph node metastasis was observed in 137 of 954 patients (14.4%). Univariate and multivariate analyses using the training group indicated that gross extrathyroidal extension of the primary tumor, tumor location in the upper pole, and preoperative distant metastasis were 3 independent risk factors for level IIb lymph node metastasis. This model was built and tested in a validation group, and the area under the curve was 0.840 (P < .001). The cutoff of the IIb score was 12, which was tested in the validation group; the sensitivity was 82.1% and the specificity was 95.6%. ConclusionLevel IIb dissection should be performed in select patients with IIb scores ≥12.

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%).

Evaluation of incidence of metastatic involvement of level IIb subgroup lymph nodes in squamous cell carcinoma of the oral cavity

Background: To determine the overall incidence of level IIb lymph node metastases in N0/N+ neck and whether level IIb node removal is necessary in oral squamous cell carcinoma (OSCC) patinets. Material and methods: A prospective analysis of 182 biopsy proven OSCC patients who underwent surgical excision of the primary lesion with safe margins. Based on the site, nodal involvement etc the planned neck dissection has been performed. Resected primary lesion and different levels of removed lymph nodes was marked and sent for histopathological examination. 26 (14.3%) patients underwent bilateral neck dissection and unilateral in remaining 156 patients (85.7%). Results: 22 patients in our study specifically had metastases in level IIb, representing 22 out of 182 patients (12%) and 22 out of 208 neck dissection specimens (10.5%), combining pathologically N0 necks and clinically node-positive necks. 31 patients reported with a local recurrence at 1-year follow-up period, whereas remaining 151 patients had no loco regional residual disease at 1 year follow up. All the patients with recurrent disease were provided palliative treatment. Conclusions: Our results indicate the importance of always dissecting level IIb nodes in case of high metastatic rate of patients with clinically positive neck nodes, exclusively staged as N2b or greater. However, for a therapeutic neck dissection, level IIb clearance should always be done if there are positive lymph nodes at level IIa clinically or intra-operatively on frozen section.

Preliminary study of patterns of level IIb lymph node metastasis in papillary thyroid carcinoma

To evaluate the factors related to level IIb lymph node(LN) metastasis in papillary thyroid carcinoma (PTC). Method The medical records of 63 PTC patients were reviewed. The patients underwent neck dissection (ND) between January 2011 and December 2012, who were determined with pathologically lateral cervical LN metastasis. A total of 67 ND specimens were obtained and analyzed for LN involvement with respect to neck levels. The relation of level IIb LN metastasis with clinical factors, including age and sex of patients, tumor size, location, multifocality, extracapsular spread (ECS) and stage of primary PTC, coexistence of lymphocytic thyroiditis, distribution of metastasis LN in different levels, fusion and extracapsular invasion of LN were analyzed with univariate analysis and χ(2) test. SPSS 14.0 software was used to analyze the data. Of 63 patients, 41 patients revealed thyroid tumor maximum diameter more than 1 centimeter, 26 patients with tumor located in the upper 1/3 thyroid lobe, 39 patients with multiplicity of thyroid tumor and 54 patients with ECS, 54 patients with pathological T3/T4a stage, 15 patients with coexisting lymphocytic thyroiditis. Among the 67 ND specimens, 12 specimens (17.9%) showed level IIb LN metastasis and the incidences of LN metastasis at level IIa, III, IV, V, VI, IIa+III, III+IV, and IIa+III+IV were 56.7%, 86.6%, 68.7%, 22.4%, 86.6%, 52.2%, 55.2%, 37.3%, respectively. Of the 38 ND specimens with level IIa LN metastases, 10 were positive in level IIb(26.3%). But of 29 ND specimens without level IIa LN metastases, only 2 were positive in level IIb. A univariate analysis revealed that level IIa LN metastasis was a significant predictive factor for level IIb LN metastasis (χ(2) = 4.219, P = 0.040). The incidence of LN metastasis to level IIb is low in PTC, which is less when level IIa is not involved.

Involvement of level IIb lymph node metastasis and dissection in thyroid cancer.

Thyroid neoplasms are the most frequent neoplasm in the head and neck region. Most thyroid carcinomas are well-differentiated tumors of follicular cell origin. Thyroid papillary carcinoma (TPC) is the most common thyroid malignancy. It constitutes 60% to 90% of all the thyroid carcinomas and cervical lymph node metastases are commonly seen in these patients. Although cervical lymph node metastases are common in this cancer, the management and the prognostic role of lymph nodes in TPC remains controversial. In this paper we reviewed the currently available literature regarding the extent of lateral neck dissection in papillary thyroid carcinoma patients with lateral neck metastasis.

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.

Incidence of level IIB lymph node metastasis in supraglottic laryngeal squamous cell carcinoma with clinically negative neck—A prospective study

The purpose of this study was to determine the incidence of level IIB metastasis in patients with clinically negative (N0) necks with squamous cell carcinoma (SCC) of the supraglottic larynx and to assess whether level IIB lymph nodes may be left undissected in such patients. This was a prospective analysis of a case series. A prospective analysis of 68 patients with SCC of the supraglottic larynx and N0 neck who underwent surgical treatment of the primary lesion with simultaneous selective neck dissection (SND) of levels II and III. During neck dissection, level IIB lymph nodes were separately removed and processed. Occult metastasis at levels IIA, IIB, and III and the regional recurrence within this area were evaluated. One hundred twenty-two SND (levels II and III) procedures were performed on 68 patients in this series. The occult metastasis rate was 30.9% (21 of 68). The mean number of lymph nodes harvested in level IIB was 4.1 (range, 1-14). In none of the 122 SND specimens (levels II and III) was metastasis found in level IIB either in the ipsilateral or contralateral neck sides. Five patients developed neck recurrence, none of which was in level IIB. When SND was carried out for patients with SCC of the supraglottic larynx with N0 neck, superselective neck dissection removing lymph nodes in levels IIA and III was adequate. Level IIB lymph node pads may be left undissected so that spinal accessory nerve dysfunction is decreased and operative time reduced.

Is Routine Dissection of Level II‐B and V‐A Necessary in Patients with Papillary Thyroid Cancer Undergoing Lateral Neck Dissection for FNA‐Confirmed Metastases in Other Levels

We read with interest the article by Farrag et al. [1] published in the August 2009 issue and want to congratulate them for their highly informative effort. Spinal accessory nerve (SAN) injury been addressed by various thyroid and cancer surgeons [2], as it may lead to shoulder syndrome, which has a profound effect on the patient’s quality of life. It is also important in cases of cancers with relatively good prognosis, where other adjuvant treatment options following neck dissection for head and neck malignancies are available in the form of radioactive iodine ablation. Therefore, the risk of level IIb and Va lymph node metastasis must be weighed against the risk of SAN injury following dissection at these levels. Lee et al. [3] did the first prospective study in this regard and found that the anterolateral group were at greatest risk of lymphatic metastasis. In addition, level IIb lymph nodes metastasis was found only in association with level IIa metastasis. Similar evaluations performed retrospectively by others found similar results [4, 5]. However, we would like to gain some clarity from the authors about the exact levels of lymph nodes found positive on fine-needle aspiration cytology or peroperatively and their correlation with the level IIb lymph nodes, as the incidence of skip metastasis and multiple level disease is significantly high for papillary thyroid cancer [4, 5]. We also want to know the exact numbers, the levels of lymph nodes dissected, and the histopathologic features of the primary tumor and the metastatic lymph nodes as these data may also throw more light on the risk of involvement of level IIb lymph nodes.

Level IIb lymph node metastasis in thyroid papillary carcinoma

The objective of the study was to evaluate the incidence of level IIb lymph node metastases in neck dissections for thyroid papillary carcinoma (TPC) patients. 47 neck dissections of 33 patients with TPC were prospectively evaluated. Selective neck dissections (levels II, III, IV, and V) were performed in all cases. If level I lymph node metastasis was suspected during the procedure, level I dissection was also performed. All level IIb specimens were sent separately from the remainder of the neck dissection for the pathological examination. The number of dissected and metastatic lymph nodes in each specimen was recorded. Twenty-two of 47 neck dissections (46.8%) were positive for the lymph node metastasis. Among 47 neck dissection specimens, the incidence of lymph node metastasis at level II was 12.7% (6 of 47) and level IIb was 2.1% (1 of 47). The rate of level IIb lymph node involvement among patients with metastatic cervical lymph nodes was 4.5% (1 of 22). The specimen with metastatic lymph node at level IIb had also metastasis at levels IIa, III, IV, and V. The results of the present study suggested that lymph node metastases in level IIb are rare in patients with TPC undergoing neck dissection.

Predictive Factors of Level IIb Lymph Node Metastasis in Patients with Papillary Thyroid Carcinoma

The extent of neck dissection (ND) appropriate for necks yielding clinical evidence of metastases of papillary thyroid carcinoma (PTC) is controversial. The need for level IIb lymph node (LN) dissection is particularly uncertain in view of its association with postoperative shoulder dysfunction. In the present study, we examined the frequency, pattern, and predictive factors of level IIb LN metastases in PTC patients with clinically positive lateral neck nodes. We reviewed the medical records of 76 PTC patients who underwent therapeutic lateral ND for the treatment of clinically positive lateral neck nodes between March 2005 and July 2008. ND specimens were separately obtained for analyzing LN involvement with respect to neck level. Metastatic disease at levels II, III, IV, and V, was seen in 40 (52.6%), 55 (72.4%), 52 (68.4%), and 12 (15.8%) of the patients, respectively. The metastasis rate in level IIb was 11.8% (9 of 76). By univariate analysis, the rate of level IIb LN metastasis was significantly higher in patients with positive level IIa LNs and positive LNs in all lateral neck levels (levels IIa + III + IV) (P < .05). Multivariate analysis showed that positive LN involvement in all lateral neck levels (IIa + III + IV) was an independent predictive factor of level IIb LN metastasis (P = .044, odds ratio = 9.692). Level IIb LN dissection may be omitted in the treatment of positive neck nodes in PTC patients if multilevel involvement including level IIa involvement is absent.

Is Level IIb Lymph Node Dissection Always Necessary in N1b Papillary Thyroid Carcinoma Patients?

Papillary thyroid carcinoma (PTC) patients show a high rate of cervical lymphatic metastasis. However, there are no universal binding guidelines for the extent of lateral cervical lymph node dissection (LND) in such cases. In particular, the need for LND above the spinal accessory nerve (SAN) remains controversial. The present study examined whether level IIb lymph node (LN) dissection is always necessary in PTC patients with lateral cervical LN metastasis. The study prospectively examined 167 PTC patients with lateral cervical LN metastasis who underwent modified radical neck dissection (MRND) in our institution from November 2005 to March 2007. The MRND was bilateral in 24 cases. All patients underwent level II, III, IV, and V LND. Levels IIa and IIb LNs were individually dissected in all cases. All LND was performed using strict leveling criteria by a single operating team. The patterns of lymphatic metastasis and potential risk factors for level IIb LN involvement were evaluated. The most common site of metastasis was level III (80.6% of cases), followed by level IV (74.9%) and II (55.5%). The metastasis rates in level IIa and IIb were 55.5% and 6.8%, respectively; all level IIb LN metastasis was accompanied by level IIa metastasis (p=0.001). In addition, level IIb LN metastasis was found to be associated with the aggressiveness of lymphatic metastasis (i.e., the total number of metastatic LNs) (p<0.0001). A level IIb LND should be performed when there is clinical or radiological evidence of lymphatic metastasis. In the absence of such evidence, the findings suggest that level IIb LND is not necessary in N1b PTC patients when there is no level IIa LN metastasis, or when the metastasis is not aggressive.

Level IIb Lymph Node Metastasis in Neck Dissection for Papillary Thyroid Carcinoma

To determine the patterns of lateral cervical metastasis and the incidence of level IIb lymph node metastasis in papillary thyroid carcinoma. Retrospective medical record review. Academic medicine. From March 1, 2000, to April 30, 2006, 46 consecutive patients (38 women and 8 men) with papillary thyroid carcinoma. Patients underwent 55 modified radical neck dissections for the management of lateral cervical metastasis. All patients had preoperative evidence of a metastatic cervical lymph node. All specimens were labeled and mapped by the operating surgeon to identify their levels. Among 55 specimens, 82% (45 specimens) exhibited nodal disease at multiple levels. The incidences of metastases at level II, III, IV, and V nodes were 60% (33 specimens), 82% (45 specimens), 75% (41 specimens), and 20% (11 specimens), respectively. Skip metastases were present at a low rate (6% [3 specimens]). Among 12 specimens (22%) with metastatic lymph nodes at level IIb, 92% (11 specimens) had disease at level IIa. The rate of level IIb lymph node involvement in patients with metastatic lymph nodes at level IIa was 34% (11 of 32). Tumor involvement at multiple nodal levels usually occurs when patients have lateral cervical lymph node metastasis. Neck dissection should include the level IIb lymph node whenever level IIa lymph node metastasis is found. Level IIb dissection is probably unnecessary when level IIa lymph nodes are uninvolved because the incidence of metastasis to level IIb is low if level IIa is not involved.

Lymphatic Metastases to Level IIb in Hypopharyngeal Squamous Cell Carcinoma

To evaluate the prevalence of level IIb lymph node (LN) metastasis and to identify potential clinical risk factors when level IIb metastatic diseases are present in patients with clinically node-negative (N0) and node-positive (N+) necks with hypopharyngeal squamous cell carcinoma (HPSCC). This will provide a basis for determining whether this region can be excluded in elective or therapeutic neck dissection in patients with HPSCC. Prospective analysis of a case series. University hospital. Fifty patients with HPSCC who underwent surgical treatment for a primary lesion and simultaneous neck dissection from January 1998 to February 2004. The incidences and clinical risk factors for level IIb LN metastasis and regional recurrence according to the presence or absence of pathologic LN involvement in level IIb. A total of 93 neck dissections were analyzed in this study. Of these dissections, 59 (63%) were elective and 34 (37%) were therapeutic. Three percent (2 of 59) of all N0 necks and 32% (11 of 34) of all N+ necks had level IIb LN metastases. Level IIb nodal metastases were significantly more prevalent in N+ necks (P=.007) than in N0 necks and in the presence of other positive LNs (P=.01) than in the absence of other positive LNs. Of the 35 patients with pathologic LNs, the regional recurrence rate was significantly higher in cases with positive level IIb LNs (33% [4 of 12]) than without (4% [1 of 23]; P=.04). Level IIb LN pads may be preserved during elective neck dissection in the treatment of patients with clinically N0 necks with HPSCC. This area should be removed during therapeutic neck dissection in the treatment of clinically N+ necks.

Level IIb lymph node metastasis in elective neck dissection of oropharyngeal squamous cell carcinoma

This study investigated the oncologic safety of preserving level IIb lymph nodes in ipsilateral and/or contralateral elective neck dissection (END) in patients with oropharyngeal squamous cell carcinoma (SCC). Fifty-one oropharyngeal SCC patients who underwent surgery as an initial treatment were reviewed. Twenty-one patients had clinically node negative necks (cN0) while 30 patients had ipsilateral clinically node positive necks (cN+). Of the cN0 patients, bilateral or ipsilateral END was performed in 15 and six patients, respectively. For the cN+ cases, ipsilateral therapeutic neck dissection with contralateral END was performed in 24 of 30 patients. In the cN0 patients, nodal metastasis to level IIb lymph nodes was not observed in any ipsilateral (21) or contralateral necks (15). Of the 24 cN+ patients who underwent contralateral END, two cases (8.3%) showed contralateral occult level IIb lymph node metastasis. Our data suggest that in cN0 oropharyngeal cancer patients, level IIb lymph nodes may be preserved in ipsilateral and contralateral neck dissection. However, caution is advised when preserving contralateral level IIb nodes in ipsilateral cN+ cases.

Level IIb Lymph Nodes Metastasis in Elective Supraomohyoid Neck Dissection for Oral Cavity Squamous Cell Carcinoma: A Molecular‐Based Study

To identify the incidence of level IIb lymph nodes metastasis in elective supraomohyoid neck dissection (SOHND) as a treatment for patients with squamous cell carcinoma (SCC) of the oral cavity. Prospective analysis of a case series. Forty-eight patients with SCC of the oral cavity and with no palpable lymph nodes at the neck who underwent an elective SOHND were prospectively studied. The incidence of micrometastasis to level IIb lymph nodes after performing elective SOHND was evaluated by pathologic examination and molecular analysis. Of the 48 patients, 15 (31%) by pathologic analysis and 22 (46%) by molecular analysis had lymph nodes positive for metastatic SCC. By molecular analysis, 5 (10%) of the 48 patients had involvement of level IIb lymph nodes. All patients with metastasis to level IIb lymph nodes have their primary lesions in the tongue and constituted 22% of patients with tongue lesions. There was no instance of isolated metastasis to level IIb lymph nodes without involvement of other nodes in the SOHND specimens. In this study, level IIb lymph node metastasis was only found in association with tongue carcinoma. Although this region may be preserved in elective SOHND in patients with SCC of the oral cavity, it should be included whenever the tongue is the primary site.