Management Of Cervical Nodes Research Articles

Ratio of Metastatic Lymph Nodes: A Significant Prognostic Factor in Patients with Oral Squamous Cell Carcinoma

Background: One of the significant prognostic factors for survival in squamous cell carcinoma of the oral cavity is the presence or absence of cervical metastasis. Thus, management of cervical lymph nodes becomes a vital component of the overall treatment strategy for patients with cancers of the head and neck. The aim of this study was to investigate the prognostic value of the ratio of metastatic lymph nodes in patients with oral squamous cell carcinoma. Methods: A retrospective analysis of 225 biopsy-proven oral squamous cell carcinoma (OSCC) patients with T1-T4a status of the primary tumor was done. All cases had a history of surgical excision of the primary lesion and neck dissection with a follow-up period of two years. Primary tumor sites include viz buccal mucosa, tongue, alveolus, gingivo-buccal sulcus and retromolar trigone. Patients with loco-regionally advanced disease and a history of any previous surgery or radio-therapeutic treatment of the head and neck were excluded from the study. Locoregional recurrence, disease-free survival, and the associations between clinicopathological features and recurrence were analysed using univariate and multivariate analysis. p-value ≤ 0.001 was found to be significant. Survival curves were plotted using the Kaplan-Meier method for 5-year disease-free survival. Results: The patients with positive lymph nodes were divided into high- or low-risk groups using the best nodal parameter cut-off values (0.06). Our univariate analysis showed a significant correlation between locoregional recurrence and type of neck dissection, pN classification, staging, extranodal extension, perineural invasion, and ratio of metastatic lymph nodes (RML). However, on multivariate analysis, RML showed an independent prognostic predictor (p= 0.04) for locoregional recurrence. Conclusion: The findings of our study suggest that RML is a strong independent predictor of prognosis in patients with oral squamous cell carcinoma.

Role of elective neck dissection in prognosis of N0M0 maxillary sinus squamous cell carcinoma: Insights from SEER database analysis

BackgroundThe optimal management of cervical lymph nodes in N0M0 maxillary sinus squamous cell carcinoma (MSSCC) remains a subject of debate. This study aimed to investigate the impact of elective neck dissection (END) on the prognosis of N0M0 MSSCC patients and explore potential prognostic factors. MethodsA retrospective analysis was conducted using the Surveillance, Epidemiology, and End Results (SEER) database. Propensity score matching (PSM) was employed to minimize bias between the END and non-END groups. Cox regression analysis was performed to identify prognostic factors, and subgroup analyses were conducted based on patient characteristics. Furthermore, the optimal number of lymph nodes in END was determined using maximally selected test statistics. ResultsA total of 777 N0M0 MSSCC patients were included in the study. After PSM, patients who underwent END demonstrated significantly improved overall survival (OS) and cancer-specific survival (CSS) compared to those who did not undergo END (p < 0.05). Subgroup analyses revealed a favorable prognosis for patients receiving radiotherapy and END, with a hazard ratio of 0.729 (95% CI: 0.549–0.967; p = 0.029) for OS. Furthermore, patients with a lymph node count greater than 5 in END had significantly better OS and CSS compared to those with 5 or fewer lymph nodes (p = 0.013, p = 0.018, respectively). ConclusionOur findings suggest that END provides a survival benefit for N0M0 MSSCC patients. Additionally, a lymph node count greater than 5 in END is associated with improved staging accuracy and better prognosis. Prospective research is needed to validate these findings and inform clinical decision-making for N0M0 MSSCC patients.

The utility of sentinel Lymph node biopsy in the lateral neck in papillary thyroid carcinoma.

BackgroundRegional lymph node metastases (LNMs) are very common in papillary thyroid carcinoma (PTC) and associate with locoregional recurrence. The appropriate management of cervical lymph nodes is very important. Therefore, this study evaluated the application of sentinel lymph node biopsy (SLNB) in the lateral neck in PTC patients.MethodsThis prospective study was conducted from 1 November 2015 to 31 December 2017 and recruited 78 PTC patients treated with SLNB in the lateral neck and prophylactic lateral neck dissection (compartments II–IV) followed by thyroidectomy or lobectomy and central neck dissection.ResultsThere were 78 PTC patients enrolled and sentinel lymph nodes (SLNs) were detected among 77 patients. A total of 30 patients were diagnosed with SLN metastases (SLNMs). The remaining 47 patients were pathologically negative of SLN, whereas 4 patients were found with metastases in the non-SLN samples. The detection rate, sensitivity, specificity, and accuracy rate of SLNB in the lateral neck were 98.7%, 87.1%, 98.7%, and 93.6%, respectively. However, the values varied greatly in each specific compartment of the lateral neck, and all of them were no more than 80%. These 34 PTC patients diagnosed with lateral compartment LNM (LLNM) were more likely to be younger (41.38 vs. 48.95 years old, p = 0.002) and exhibit extrathyroidal extension (56.8% vs. 31.7%, p = 0.026) and central compartment LNM (66.7% vs. 12.1%, p < 0.001). Tumors located in the upper third of the thyroid lobe also had a significantly higher probability of LLNM compared with those in middle or inferior location (66.7% vs. 35.3% vs. 34.8%, p = 0.044). At last, age (OR=0.912, p = 0.026), tumor location (upper vs inferior, OR=17.478, p = 0.011), and central compartment LNM (OR=25.364, p < 0.001) were independently predictive of LLNM.ConclusionsSLNB can help surgeons to identify some PTC patients who may benefit from therapeutic lateral neck dissection and protect some patients from prophylactic lateral neck dissection. However, it cannot accurately indicate specific lateral compartment-oriented neck dissection. Meanwhile, LLNM is more likely to occur in PTC patients with younger age or upper pole tumors or central compartment LNM.

Correlation between histological grading, LVI and PNI of carcinoma oral tongue to lymph node metastasis

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Squamous cell carcinoma (SCC) of oral tongue has a higher predisposition to lymph node metastasis which reduces survival by 50%. In clinical practice, TNM classification is used for treatment planning which does not provide information on the biological characteristics of the tumor.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This prospective cross sectional observational study included 30 patients with T1 to T3, N0/+ oral tongue SCC from 1&lt;sup&gt;st&lt;/sup&gt; March 2014 to 30&lt;sup&gt;th&lt;/sup&gt; April 2015. Incisional biopsy was taken from the primary tumour, pathological evaluation for differentiation of the tumour and assessment of lymphovascular (LVI) and perineural invasion(PNI) was carried out. Post operative histopathological examination included differentiation, LVI and PNI. The pathological findings were correlated using chi square test. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Majority presented with T2 stage. 27% had nodal metastasis. There was higher incidence of lymph node metastasis in moderately differentiated (MD) and poorly differentiated (PD) SCC which was not statistically significant. Significant correlation was seen between LVI and PNI to lymph node metastasis (p≤0.001).&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; There is a higher incidence of lymph node metastasis seen in moderately and poorly differentiated SCC of oral tongue, which can be assessed on the preoperative biopsy, guiding us to be more aggressive in the management of cervical nodes in early tongue cancer.&lt;strong&gt; &lt;/strong&gt;LVI and PNI are good predictors of nodal metastasis, help in assessing aggressiveness and prognosis of the disease, and are soft indicators for considering adjuvant / concurrent RT.&lt;/p&gt;

Evaluation of fine needle aspiration cytology in the diagnosis of cervical lymph node lymphomas

PurposeSurgical biopsy examination is the gold standard for the diagnosis of lymph node lymphomas. Fine-needle aspiration cytology (FNAC) is a quick and safe method in the management of cervical lymph nodes. Its value in confirming recurrent or residual lymphoma is well established. However, its role in the primary diagnosis of lymph node lymphoma remains controversial. The aim of this study was to assess, in our experience, the reliability of FNAC in the diagnosis of cervical lymph node lymphomas. Materials and methodsThis was a retrospective study carried out over a 6-year period (January 2011 to December 2016) and conducted at the Cytology Unit in our Pathology Department (Charles Nicolle Hospital, Tunisia). The measures of diagnostic accuracy of FNAC in the diagnosis of cervical lymph node lymphomas were calculated taking histopathology as the gold standard. ResultsA total of 937 FNA samples were obtained from 851 patients. The diagnosis of lymphoma was obtained in 65 cases (6.9%). Cytological diagnoses of lymphoma were as follows: 28 (44%) Hodgkin lymphoma, 17 (25%) high-grade lymphoma, 15 (23%) low-grade lymphoma, and 5 (8%) “suggestive of lymphoma.” FNAC of cervical lymph nodes had a sensitivity of 95.5%, specificity of 98.7%, positive predictive value (PPV) of 97.7%, and negative predictive value (NPP) of 97.5%. ConclusionThe present study demonstrated that cytology is capable to detect nodes suspicious for the presence of lymphoma precisely, in terms of low- or high-grade lymphoma, which is a relevant and very achievable first step in the management of patients with cervical lymph node lymphoma.

Differentiated and Medullary Thyroid Cancer: Surgical Management of Cervical Lymph Nodes

Thyroid cancer metastasises to the central and lateral compartments of the neck frequently and early. The impact of nodal metastases on outcome is affected by the histological subtype of the primary tumour and the patient's age, as well as the size, number and location of those metastases. The impact of extranodal extension has recently been highlighted as an important prognosticating factor. Although clinically evident nodal disease in the lateral neck compartments has a significant impact on both survival and recurrence, microscopic metastases to the central or the lateral neck in well-differentiated thyroid cancer do not significantly affect outcome. Here we discuss the surgical management of neck metastases in well-differentiated and medullary thyroid carcinoma.

ACR appropriateness criteria® nasal cavity and paranasal sinus cancers.

The American College of Radiology (ACR) Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. Here, we present the Appropriateness Criteria for cancers arising in the nasal cavity and paranasal sinuses (maxillary, sphenoid, and ethmoid sinuses). This includes clinical presentation, prognostic factors, principles of management, and treatment outcomes. Controversies regarding management of cervical lymph nodes are discussed. Rare and unusual nasal cavity cancers, such as esthesioneuroblastoma and sinonasal undifferentiated carcinomas, are included. © 2016 American College of Radiology. Head Neck, 2016 © 2016 Wiley Periodicals, Inc. Head Neck 39: 407-418, 2017.

Lymph node management in the treatment of oral cancer: Analysis of a standardized approach.

A supraomohyoid neck dissection (SOHND) is part of the surgical management of patients with oral cancer, even in the absence of clinical or radiographic evidence of neck disease. We have investigated a standardized approach to the management of cervical lymph nodes, in patients with a primary oral cancer. A modified surgical technique has been presented and a clinical algorithm has been described and evaluated. SOHND was performed either uni- or bi-laterally. In cases of positive nodes in levels II or III, the dissection was extended in terms of a modified radical neck dissection (MRND) and a SOHND was performed contralaterally. 112 patients were included. 42% had lymph node metastases in any level. Overall, lymph node metastases were found in 2.8% of all examined nodes. Most metastases (34.6%) occurred in level Ib. 12.6% were located in level IIb. No metastases could be detected in levels IV and V. No statistically significant difference could be shown with regard to T-stage, location, or co-factors as gender and age. SOHND is the gold-standard in patients with no preoperative evidence of lymph node metastases. The presented algorithm is able to facilitate dissection and histological analysis and might improve the surgical care in current treatment concepts. The extension to an MRND facilitates the identification of patients in need of adjuvant therapy.

Management of cervical lymph nodes for cN0 advanced glottic laryngeal carcinoma and its long-term results

Conclusions: Cervical lymph node metastatic rates tend to increase by T stage in cN0 glottic laryngeal carcinoma (GLC). Moreover, cervical lymph node metastasis (LNM) shows a sequential pattern according to the regions involved and LNM affects the prognosis. Objectives: To investigate factors that contribute to LNM of N0 (cN0) T2–T4 GLC and their effect on prognosis. Methods: A total of 212 GLC patients who had been admitted between December 2002 and January 2013 were retrospectively analyzed. They included 202 men and 10 women, median age 58.6 years (range 29–85 years), whose identified tumor stages included T2 (n = 81), T3 (n = 67), and T4 (n = 64). Relevant factors of cervical LNM were analyzed; multivariate analyses and receiver operating characteristic (ROC) curve were carried out to predict the metastasis and prognosis. Results: The overall metastatic rate of N0 GLC was 14.6%. T staging and pathological classification were the risk factors for LNM. Metastatic rates for levels II, III, and IV were 10.2%, 14.6%, and 2.5%, respectively. Approximate 4.2% of patients experienced LNM with no recurrence of laryngeal cancer. Overall 3- and 5-year survival rates were 85% and 80%, respectively, compared with 66% and 57%, respectively, among patients with LNM. The inter-group survival curve comparison was statistically significant (p = 0.012).

Detection and management of cervical lymph nodes in papillary thyroid cancer

Lymph node metastases in papillary thyroid cancer are a common occurrence; however, the management of clinically negative cervical lymph nodes remains controversial. Preoperative neck ultrasound mapping is crucial, and complete dissection of a nodal compartment is recommended for any metastatic lymph nodes. The role of prophylactic central neck dissection remains controversial. The BRAF V600E mutation is a common mutation in papillary thyroid cancer, and has been associated with more aggressive tumor behavior. Evaluating the BRAF status of tumors may have implications for treatment and surveillance. New areas of research continue to focus on risk stratification and identifying which patients benefit from a more aggressive treatment, such as prophylactic central lymphadenectomy and radioiodine ablation and more intense surveillance strategies.

The Management of Cervical Lymph Nodes in Patients with Cutaneous Melanoma

The aim of this study was to review the management of cervical lymph nodes in patients with cutaneous melanoma and to analyze factors influencing prognosis. This was a retrospective cohort study of patients who had cervical node surgery at the Sydney Melanoma Unit from 1990 to 2004. Of 716 patients who met the study criteria, 339 had a sentinel node biopsy (SNB) and 396 had a neck dissection. Locoregional recurrence occurred in 27.6% of those undergoing therapeutic neck dissection and 60% eventually developed distant metastases. Radiotherapy was given as adjuvant treatment in 110 of the patients who had a therapeutic neck dissection (41%), but this was not associated with improved regional control (p=.322). Multivariate analysis showed that nodal positivity (p<.001) and primary tumor ulceration (p=<.027) were the most important predictors of locoregional recurrence and that primary tumor Breslow thickness (p=.009) and node positivity (p=.046) were the most important factors predicting survival. SNB-positive patients who underwent immediate completion lymphadenectomy had a 5-year survival advantage over those who had a therapeutic neck dissection for macroscopic disease (54% vs 47%, p=.028). Nodal status was the most important factor predicting disease-free and overall survival in patients with melanoma of the head and neck. Adjuvant radiotherapy was not associated with better locoregional control in the non-randomized cohorts of patients in this study.

Vascular Endothelial Growth Factor A and Proliferation Marker in Prediction of Lymph Node Metastasis in Oral and Pharyngeal Squamous Cell Carcinoma

To explore the effect of Ki-67 and vascular endothelial growth factor A (VEGF-A) expression on the risks of advanced T category (T3,4) and positive lymph node involvement (N+) in oral and pharyngeal squamous cell carcinoma (SCC) compared with laryngeal SCC. Immunohistochemical analysis of prospectively recruited patients. University-affiliated hospital. A total of 147 previously untreated patients with different stages of SCC in the oral cavity, pharynx, and larynx. Relative risks of T3,4 tumor and N+, a risk ratio comparing risks under high vs low marker expression. A significant association of Ki-67 and VEGF-A expression with tumor T category was observed for oral and pharyngeal SCC and for laryngeal SCC (P < or = .006). Regarding nodal status, Ki-67 expression was a significant risk factor for N+ in all tumors (P < or = .009), whereas VEGF-A expression was related to N+ in oral and pharyngeal SCC only (P < .03). Analytically, Ki-67 expression alone in oral and pharyngeal SCC was associated with a relative risk of N+ of 3.83 (95% confidence interval, 1.22-11.99; P = .009), and additional expression of VEGF-A raised the value to 6.12 (2.09-17.93; P < .001). Moreover, the combined expression of both markers was 3.25 times more effective in predicting N+ for T1,2 tumor compared with T3,4 tumor. Proliferative status was a common risk factor for N+ in all of the tumors in this series. Exploitation of VEGF-A in lymph node metastasis in addition to proliferation by oral and pharyngeal SCC but not by laryngeal SCC explains the clinical aggressiveness of oral and pharyngeal SCC, especially the early lymphatic invasion. In the management of cervical lymph nodes, combined expression of Ki-67 and VEGF-A may help identify patients at risk for occult metastases. This study suggests anti-VEGF-A therapy, an additional intervention to the classic antiproliferative regimen, for preventing lymphatic progression of oral and pharyngeal SCC.

Role of Lymph Node Dissection in Primary Surgery for Thyroid Cancer

The preoperative evaluation of the clinically N0 neck and the operative management of cervical lymph nodes in patients with papillary and medullary thyroid cancer remains controversial. The appreciation that even patients with low-risk disease have a significant risk for recurrence has generated interest in a more comprehensive preoperative evaluation of the neck and has renewed debate on the extent of lymphadenectomy at the time of thyroidectomy. The authors recommend using preoperative ultrasound before thyroidectomy for all patients with thyroid cancer and before any subsequent surgeries for recurrent disease to identify the extent of lymph node metastases and thereby facilitate complete surgical removal of all gross disease in the neck. The optimal surgical procedure for removing cervical lymphadenopathy is compartment-oriented neck dissection based on the findings from preoperative ultrasound.

Neck Management in Patients Undergoing Postradiotherapy Salvage Laryngeal Surgery for Recurrent/Persistent Laryngeal Cancer

To determine a plan for the management of cervical lymph nodes in patients undergoing salvage laryngeal surgery (SLS) for recurrent/persistent laryngeal cancer after primary radiotherapy (RT). : Retrospective chart review. Charts of 51 consecutive patients who had salvage total or supracricoid laryngectomy with or without neck dissection for recurrent/persistent laryngeal squamous cell carcinoma after primary RT from 1988 to 2005 in our institution were reviewed. No patients received concomitant or neo-adjuvant chemotherapy. Thirty-four patients underwent SLS along with unilateral or bilateral neck dissection, whereas 17 patients underwent the SLS without neck dissection. Reports of preRT and preSLS staging of the primary tumor and the neck, recorded using the TNM system, were reviewed. Reports of the final histopathologic examination for the excised laryngeal cancer and cervical lymph nodes were reviewed. Thirty-four patients underwent SLS with unilateral or bilateral neck dissection. The preRT staging of the primary tumor for those 34 patients showed that 32 (94%) were staged T-1 (14) and T-2 (18), whereas the preSLS staging of the primary tumor for those 34 patients showed that 29 (85%) were staged T-3 and T-4. The postSLS final histopathologic examination of the excised lymph nodes in those 34 patients demonstrated that 30 (88%) did not have any evidence of nodal metastasis. On comparing patients with and without nodal metastasis (on their postSLS final histopathology), we found that the preSLS neck staging, based on computed tomographic (CT) scanning of the neck, was significantly associated with the negative/positive postSLS status of nodal metastasis (P = .006). Of 29 patients staged preSLS as N-0, 28 (97%) patients did not have nodal metastasis on their postSLS final pathology (negative predictive value = 97%, confidence interval, 82.2-99.9). PreRT neck staging, preRT and preSLS staging of the primary tumor, along with laryngeal subsite involvement (supraglottis, glottis, subglottis) did not significantly correlate with the status of neck metastasis on final postSLS histopathology (P = .68, 0.78, 0.49, and 0.42, respectively). None of the 34 patients had any neck tumor recurrence in the postSLS follow-up period (median, 3 yr). In addition, all 17 patients who underwent SLS without neck dissection were staged N-0 both before RT as well as preSLS, and none developed neck disease in the postSLS follow-up period (median, 2.5 yr). Management of the neck in patients undergoing salvage total or supracricoid laryngectomy for laryngeal cancer recurrence/persistence after primary RT should be based on the preSLS CT staging of the neck. Patients staged N-0 preSLS are not likely to harbor occult nodal metastasis and therefore may not require elective neck dissection.

Sentinel Lymph Node Biopsy May Be Used to Support the Decision to Perform Modified Radical Neck Dissection in Differentiated Thyroid Carcinoma

The prognostic significance of lymph node metastases (LNM) in follicle cell-derived differentiated thyroid carcinoma (DTC) is still controversial. The management of cervical lymph nodes varies from "berry picking" to modified radical neck dissection (MRND). The incidence of LNM in papillary thyroid carcinoma varies from 27% to 80%. The importance of sentinel lymph node (SLN) biopsy for decisions about the surgical management of lymph nodes in DTC has been the subject of several previous studies. In 40 patients with DTC methylene blue dye was applied peritumorally. Both SLN and non-SLN in the lower third of the jugulo-carotid chain were dissected prior to total thyroidectomy and routine dissection of the central neck compartment and examined by frozen-section and standard histology. MRND was performed in 9 cases of LNM in the lateral neck compartment. The SLN identification rate was 92.5%. Metastases in SLNs were revealed by frozen-section histology in 7 cases, leading to immediate MRND. The findings were confirmed on standard HE examination. In 2 false-negative cases SLN metastases were revealed on standard histology and MRND was performed 1 week later. The specificity of the method was 100%, sensitivity 77.7%, negative predictive value 94%, positive predictive value 100%, with overall accuracy of 95%. Our results seem to imply that SLN biopsy in the jugulo-carotid chain using methylene blue dye mapping may be a feasible and valuable method for estimating lymph node status in the lateral neck compartment. It may be helpful in the detection of true-positive but nonpalpable lymph nodes, and in such cases may support the decision to perform MRND in patients with DTC.

Endocrine surgery committee: Update on management of differentiated thyroid cancers

Management of differentiated thyroid cancers continues to be an everchanging field. Controversies continue to exist regarding the extent of surgery, the role of radioactive iodine treatment and methods of tumor surveillance. This purpose of this miniseminar is to provide an update on some of the new modalities available for management of differentiated thyroid cancers as well as some of the controversial issues. The topics covered will be: (1) the role of thyrogen stimulated I131 scans and thyroglobulin measurements; (2) new imaging modalities for cancer surveillance; (3) management of cervical lymph nodes; (4) management of recurrent laryngeal nerve and the role of nerve monitoring; (5) molecular tumor markers for diagnosis and predicting behavior.

Identification of sentinel lymph nodes in thyroid carcinoma

Sentinel lymph node (SLN) was defined as the first lymph node that the tumor would drain to, within that tumors regional lymphatic basin. In 1998, Kelemen and coworkers have published the first results on SLN lymphonodectomy in thyroid carcinomas. Different methods have been used in a goal of lymphatic mapping (application of vital blue dye and/or radiocolloid). In a period from 2001 to 2003 we have performed SLN biopsy in 64 patients with thyroid tumors. There were 12 cases of thyroid carcinoma. SLN identification rate was 73.44%. We found no false positive or negative results on definitive histopathology. The impact of lymph node metastases in differentiated thyroid carcinoma is still controversial. The management of cervical lymph nodes varies from berry picking to modified radical neck dissection. There is a significant disproportion in percentage of pre and intraoperatively enlarged lymph nodes (27-45%) and histologically confirmed lymph node metastases (80-90%) in papillary thyroid carcinoma. In the current literature the average rate of SLN identification is 91% (66-100%) and when identified, the SLN accurately predicts the disease status of the neck in most patients (80-100%). The SLN biopsy for thyroid carcinoma is good and feasible technique for estimating the cervical lymph node status.

Is the Standard Radical Neck Dissection no Longer Standard?

The presence of lymph node metastasis from a head and neck cancer signie cantly reduces the probability of regional control and consequently patient survival. Therefore, management of the regional lymph nodes is an integral part of the overall management of cancer of the head and neck in patients with advanced tumors. During recent years, there has been a signiecant evolution in the philosophy of surgical management of cervical lymph nodes for squamous and non-squamous carcinoma of the head and neck (1‐3). Lymphatic metastases do not occur randomly but in a predictable and well-documented pattern, in accordance with the site and subsite of the primary tumor (4‐7), and follow the pre-existing lymphatic anatomy. These pathways may be altered by lymphatic obstruction caused by previous surgical or radiation treatment. Knowledge of the lymphatic anatomy contained within the fascial system of the neck, as well as improved understanding of lymph node drainage patterns, has led to surgical procedures which spare anatomical structures while removing the nodes at risk of metastasis. Application of this concept has signie cantly decreased the morbidity associated with the more radical procedures. Consequently, pressure to increase the frequency and indications for the less radical procedures is justie ed. If the destructive effect of a radical neck dissection is well known, is there any appropriate indication for its use? First, some preoperative factors must be considered prior to recommending this procedure, as improved information may modify the indications for such surgery. A thorough knowledge of the patient’s history, an understanding of the extent of the primary tumor and the clinically relevant neck disease, histological data regarding the phenotype, radiologic imaging of the disease locally, regionally and systematically and the presence or absence of a second primary cancer must be assessed. In addition, the status of any intercurrent disease (comorbidity), alternative modalities of treatment for the index cancer and quality-of-life issues affected by the possible therapeutic options must be assessed. After analyzing all of these factors, a rational decision can be made as to the usefulness of a radical neck dissection in the treatment of a patient with cancer of the head and neck.

Management of cervical lymph nodes in squamous carcinomas of the head and neck.

Due to the overwhelming prognostic significance of regional metastases, proper management of cervical lymph nodes in cases of squamous cell carcinoma of the head and neck is essential for an optimal outcome. Better understanding of the predictability of incidence and patterns of metastases of these tumors in recent years has led us away from the radical neck dissection as the only surgical therapeutic or staging procedure done on the neck. Recent studies suggest that selective removal of lymph node groups at risk in clinically negative necks, or modified neck dissections that save important structures, like the jugular vein, XI nerve, and sternocleidomastoid muscle, in clinically positive necks, are appropriate in many patients. Careful selection of the type of neck dissection and judicious use of postoperative radiation therapy can optimize cure rates as well as functional and cosmetic results.

Surgical management of cervical lymph nodes in patients with oral and oropharyngeal cancer.

The incidence of neck metastases in oral cancer is approximately 50%, whereas cancers arising in the oropharynx have a metastatic rate of well over 50%. In general, it holds true that the more advanced the primary tumour, the higher the incidence of cervical metastases. The distribution of lymphatic metastases is, for the most part, explicable in mechanical and anatomical terms (Lindberg 1972; Shah 1990; Shah et al. 1990; Candela et al. 1990). The filter and barrier function of lymph nodes appears to be effective in the initial stage, as lymphatic spread is generally limited initially to the first echelon of lymph nodes.