Supraomohyoid Neck Dissections Research Articles

SELECTIVE NECK DISSECTION-THE SUPRAOMOHYOID, LATERAL, AND ANTEROLATERAL DISSECTION TECHNIQUES

In this article, the indications for performing the supraomohyoid, lateral, and anterolateral selective neck dissections will be discussed. Super selective neck dissections, though not included with a specific technique section, will also be briefly examined. An emphasis of the authors’ techniques will be illustrated with pertinent anatomy as well as post-operative care and complications to consider. Photographs will accompany the write-up in order to provide the reader with an anatomic operative reference.

Retroauricular Endoscope-Assisted Approach to the Neck: Early Experience in Latin America.

Introduction There has been a significant increase in concern towards improving aesthetic and functional outcomes without compromising the oncologic effectiveness in head and neck surgery. In this subset, endoscope-assisted and robotic procedures allowed the development of new approaches to the neck, including the retroauricular access, which is now routinely used, especially in Korea. Objectives This study aims to provide a descriptive analysis of our initial experience with retroauricular endoscope-assisted approach assessing feasibility, safety, and aesthetic results. Methods Prospective analysis of the first 11 eligible patients submitted to retroauricular endoscope-assisted approach for neck procedures in the Head and Neck Surgery Department at AC Camargo Cancer Center. Results A total of 18 patients were included in this study, comprising 7 supraomohyoid neck dissections, 8 submandibular gland excisions, 3 thyroid lobectomies, and one paraganglioma excision. There was no significant local complications, surgical accident, or need for conversion into conventional open procedure in this series. Conclusion Our initial experience has shown us that this approach is feasible, safe, oncologically efficient, and applicable to selected cases, with a clear cosmetic benefit.

Learning curve for robot-assisted neck dissection in head and neck cancer: a 3-year prospective case study and analysis.

Robot-assisted neck dissection (RAND) for the management of regional metastases is a recently developed technique in the field of head and neck cancer that uses a robotic surgical system. This is the first report that estimates the learning curve for RAND. To evaluate a learning curve for RAND according to the types of neck dissection and report clinical outcomes. Prospective case study of 90 patients undergoing neck dissection between May 2010 and April 2013 at a university tertiary referral center. Fifty modified radical neck dissections (MRNDs) and 40 supraomohyoid neck dissections (SONDs) were performed by a single surgeon using a robotic surgical system to treat head and neck cancer. The MRND and the SOND groups were subdivided into 5 and 4 consecutive subgroups of 10 patients each, respectively. Perioperative parameters were compared, including mean operation time, duration and amount of drainage, length of hospital stay, and postoperative complications. Significant decreases in mean operation time were observed as experience performing RAND increased in both the MRND and the SOND groups. The mean operation time for the MRND group decreased by 29% over the course of our study (initial subgroup, 298.1 minutes; last subgroup, 212.4 minutes). The mean operation time for the SOND group decreased by 53% over the course of our study (initial subgroup, 226.5 minutes; last subgroup, 106.1 minutes). There were no significant differences between subgroups for the other perioperative parameters. We explored the RAND learning curve in a single institution over a 3-year period. This study can be used as a timeline reference for institutions where the RAND procedure will be adopted as an alternative procedure.

Practicability of submandibular gland in squamous cell carcinomas of oral cavity.

Current surgical treatment for oral cancers includes wide surgical excision of the primary lesion with appropriate neck dissection. Although tumor metastasis to the gland is uncommon, submandibular glands are frequently excised as a part of neck dissection because of their proximity to the primary lesion and afferent lymph nodes. Herein, we have retrospectively investigated the rate of involvement of submandibular glands in oral cavity tumors, and discussed the feasibility about resection of the submandibular glands. 94 patients undergoing 98 supraomohyoid neck dissections for oral cavity squamous cell carcinoma from 1st May 2010 till 31st May 2014 were retrospectively evaluated. Inclusion criteria were histopathologically confirmed squamous cell carcinoma of the oral cavity and surgery as the primary treatment modality, consisting of resection of the primary lesion with additional neck dissection, including at least one submandibular gland. Among the 98 specimens involvement of submandibular gland was seen only in 3 patients (3.06%). Submandibular gland involvement was due to direct invasion of primary tumors and via the metastatic periglandular lymph nodes. Decision regarding excision of the gland should be done during the operation with the help of visual examination and frozen sections instead of preoperative planned resection. Preserving submandibular gland is both technically as well as oncologically feasible and can achieve potential benefit in preserving the submandibular salivary flow.

Supraomohyoid Neck Dissection in the Management of Oral Squamous Cell Carcinoma: Special Consideration for Skip Metastases at Level IV or V

The aim of this study was to evaluate the therapeutic safety and prognosis of supraomohyoid neck dissections for oral squamous cell carcinoma, with a special focus on the risk of skip metastases in level IV or V. A retrospective study was conducted of 637 patients with oral squamous cell carcinoma who were admitted to the department of oral and maxillofacial surgery from September 1995 through July 2010. After completing a diagnostic evaluation, all patients underwent surgery (wide primary excision with supraomohyoid neck dissection, extended supraomohyoid neck dissection, or modified radical or radical neck dissection) and were followed periodically. Levels I, II, and III were the most common sites of occult metastasis. Skip metastases alone at level IV or V and any neck recurrence at level IV or V were not found. Three-year neck recurrence-free survival and disease-specific survival were not significantly different among the patients who underwent supraomohyoid neck dissection, extended supraomohyoid neck dissection, or modified radical or radical neck dissection owing to cN0 to cN(+) disease. The rate of skip metastasis at level IV or V is very rare and is very difficult to diagnose accurately. The results of this retrospective study show that supraomohyoid neck dissection for oral squamous cell carcinoma is an appropriate treatment.

PP159: Evaluation atrophy of sternocleidomastoid muscle after neck dissection

Purpose Modified and supraomohyoid neck dissections have become common for treatment of oral cancer. In these dissections spinal accessory nerve (SAN) can be conserved. The relationship between SAN conservation and trapezius muscle function has been evaluated. However, sternocleidomastoid muscle (SCM) has not been fully evaluated. The purpose of this study is to evaluate atrophy of SCM about cosmetic and functional aspect. Materials and methods The size of SCM on cross section at the level of hyoid bone and thyroid cartilage using computed tomography (CT) images were measured from 44 (28 men and 16 women) patients who underwent unilateral neck dissection. We classified these patients into three groups, conserving SCM branch of SAN, sacrificing SCM branch and reconstructing SCM branch, including transplantation or resuture. Results Thirty-eight were conserved SCM branch, four were reconstructed and two were sacrificed. The median interval between neck dissection and postoperative CT images was 12 months. On the contralateral side, there were no significant differences between preoperative SCM size and postoperative size. On the other hand, on the ipsilateral side SCM size was decreased to 82.8% at the level of hyoid bone (HT) and to 77.4% at the level of thyroid cartilage (TC) compared to preoperative size. In conserved SCM branch group, SCM size was 86.7% at the level of HT and 79.9% at the level of TC. In reconstructed group, SCM size was 71.8% at the level of HT and 64.1% at the level of TC, whereas in sacrificed group SCM size was reduced to 34.1% at HT and 56.0% at TC. Conclusions The conservation as well as the reconstruction of SCM branch of SAN can inhibit atrophy of SCM in a similar way that the conservation of SAN can inhibit shoulder function, although there are considerable variations in the innervation.

Lower lip reconstruction with Abbe–Estlander flap modification: preserving the same side vascular pedicle

A 74-year-old man was referred to our clinic with a nonhealing crusted lower lip ulcer. On examination, an ulcerated lower lip lesion measuring 1.5 9 1.5 cm was detected at a location 1 cm from the left oral commissure approaching the midline. There was no palpable lymphadenopathy in the neck. An incisional biopsy was carried out and the lesion was reported as squamous cell carcinoma. Supra-omohyoid bilateral neck dissections were performed and the tumor was excised. Vertical full-thickness incisions were made so as to leave a safety margin of 1 cm. The defect measuring 3.5 cm was reconstructed utilizing an ipsilateral upper lip Abbe–Estlander flap, which was prepared with 3-cm length and 1.5-cm base, preserving the superior labial artery. The left upper labial artery sank deeply into the submucosal plan of the mobilized flap (Fig. 1, 2). The upper lip defect was reconstructed by primary closure. Histological examination of the specimen confirmed no metastasis in the neck, with a negative surgical margin. No complications developed in the following 6 months with satisfactory esthetic and functional results. According to the defect location and size, various lip reconstruction methods have been described. ‘’ V ‘’ or ‘’ W ‘’ shaped excision and primary closure are sufficient for smaller than 30 % lower lip defects. In 35–70 % of lower lip defects, the Karapandzic, Abbe, Estlander, McGregor or Gillies’ fan flaps, the Nakajima or Schuchardt flaps or their modifications can be used. In cases in which there is insufficient tissue in the lower lip, cheek tissue is used in Webster, Bernard and Dieffenbach advancement flaps and their various modifications. Deltopectoral or radial forearm free flaps can be options for large defects of the lip extending to the mandible [1–5]. The Abbe–Estlander flap, which is fed by the opposite superior labial artery, is a full-thickness triangular-shaped upper lip flap that creates the oral commissure and the lateral part of the lower lip. This flap begins from the medial part of the oral commissure and is approximately 1.5 9 3 cm in size. Direct rotation to the defect is completed at one stage. In our case, the lower lip was reconstructed using the modified Abbe–Estlander flap following tumor resection. We describe a method that is different from conventional methods, which protects the ipsilateral superior labial artery. It is not necessary to sacrifice the superior labial artery, which is encountered in the incision line when creating the flap. Additional dissection to expose the artery, such as that in facial arterial dissection, is not required. Therefore, no co-morbidity of the facial muscles occurs. At first, the mucosal layer of the flap is sutured to the defect area after having released a small part of the muscle. Thereafter, the flap is sutured to the defect area while preserving the artery, which is between the mucosa and the muscular layer of the flap. Protecting the ipsilateral superior labial artery does not complicate the mobility and the processing of the flap. Our modification, which goes with an intact contralateral facial artery in terms of flap feeding, may not have superiority to the classical Abbe– Estlander flap for patients who have never undergone a surgical procedure to the neck. However, in patients who This manuscript had been presented at 33rd. National Congress of Oto-Rhino-Laryngology Head and Neck Surgery, Antalya, 26–29 October 2011.

Routine removal of the carotid sheath as part of neck dissection is unnecessary if grossly uninvolved as seen intra-operatively

The aim of this research was to determine the pathologic invasion of the carotid sheath (CS) when found grossly uninvolved during surgery, in patients undergoing neck dissection for head and neck squamous cell carcinoma (HNSCC). A prospective study was undertaken in 70 consecutive patients with biopsy proven HNSCC, without prior history of any treatment, undergoing neck dissection, in whom the CS was found grossly uninvolved intra-operatively, were included. A total of 80 neck dissections were performed. Supra-omohyoid neck dissections for clinically N0 neck and appropriate modified radical neck dissections for clinically N+ neck were carried out. 129 CS were dissected separately and thoroughly examined by well trained head and neck pathologists for tumour infiltration and the presence of lymphatic tissue. On microscopic examination, 27 patients were N0 status and the remaining 43 (61.4%) had at least one metastatic lymph node (N+). None of 129 CS specimens show the presence of normal lymphatic tissue or metastatic tumour deposits. The authors think that avoiding resection of the CS in the absence of gross invasion by nodal disease is possible without jeopardising oncologic safety. A preserved CS might offer protection to the important neurovascular structures and reduce significant morbidity.

Utility of frozen section in assessment of margins and neck node metastases in patients undergoing surgery for carcinoma of the tongue

The aims of this study are to evaluate the impact of frozen section in achieving adequate surgical margin and to study the accuracy of frozen section in detection of occult metastases. This was a retrospective review of prospectively collected data of 877 patients with squamous cell carcinoma of the tongue who underwent surgery and intra-operative frozen section at our center from January 2007 to June 2010. Frozen section was found to have very high accuracy in assessment of margin as well nodal status. On frozen section, 2% of our patients had positive margins and 21% had close margins. Most of these underwent intra-operative revision and at final pathology, 1.2% patients had positive margins and 11% were close. Of the 651 supraomohyoid neck dissections performed, one third were found to have occult metastases on frozen section. Of those reported positive on frozen section, 68% got additional removal of level 4 ± 5. Interestingly, 11% of these additionally removed nodes harbored metastases at final pathology. However, 7% of the patients were wrongly declared negative on frozen section. Tumor thickness was predictor of margin positivity as well as occult metastases. Tumor volume did not correlate with occult metastases or margin status. Frozen section nearly halves the rates of positive margin and close margins which certainly translates into clinical benefits. The incidence of 11% positive nodes in the frozen section guided removal of lower levels is an important finding in our study that questions the ability of supraomohyoid neck dissection to completely eradicate the nodal burden in such patients.

Severe Cheek and Lower Eyelid Lymphedema After Resection of Oropharyngeal Tumor and Radiation

Facial lymphedema, a rare condition with poorly understood pathogenesis, is commonly associated with previous infection, radiation therapy, local tumor growth, or previous surgery in the head and neck region. Few cases of isolated facial lymphedema have been reported in the literature. Surgical excision has emerged as the mainstay of therapy in such cases, although the long-term efficacy and recurrence rate after excision remain unknown. We present a unique case of a patient with severe unilateral facial lymphedema, which manifested many years after extirpation of a floor-of-the-mouth squamous cell carcinoma, bilateral supraomohyoid neck dissections, and radiation therapy. The massive cheek and eyelid lymphedema, which extended from the patient's left lower eyelid to patient's oral commissure measured 11 x 15 cm with a thickened, brawny, lobulated, and bosselated skin surface. This mass interfered with activities of daily life, caused poor oral intake, and contributed to the patient's severe kyphosis. Because the mass did not clinically or radiologically appear to be malignant, we decided to perform a salvage procedure consisting of wide excision of the massive lymphedematous mass and immediate coverage with a split-thickness skin grafting. Temporary tarsorraphy sutures were also used to provide support to the lower eyelid. The patient tolerated the procedure well, with no complications and with full take of the skin graft. Postoperatively, he was very grateful to be relieved of his debilitating symptoms.

Radial Fasciocutaneous Free Flap “Wrap-Around” Iliac Bone Graft for Hard Palate–Premaxilla–Nasal Septum Reconstruction

Sir: A 48-year-old healthy man presented with an advanced squamous cell carcinoma at the maxillary labial sulcus, expanding into the premaxilla and palate. There was no neck or distant metastasis. Surgery was staged over 2 consecutive days. Tracheostomy and extirpation of the tumor were performed first. Excision included the premaxillary alveolus, the hard palate and the adjacent labial sulcus mucosa, the nasal septum, and the lateral nasal walls, leaving a skeletal and soft-tissue defect measuring 5 × 5 × 3 cm (Fig. 1). The next day, the patient underwent bilateral supra-omohyoid neck dissections and reconstruction of the defect.Fig. 1.: The defect after bilateral subtotal maxillectomy.An en bloc segment of the iliac crest and the adjacent gluteal surface of the ilium were harvested as a nonvascularized bone graft. The ilium was burred down to a thin sheet of cortical bone to replace the bony hard palate. The iliac crest component was to become the alveolar process. A separate bone fragment, also from the crest, was fashioned to imitate the vomer component of the septum. This new “septum” was stabilized to the new “hard palate” using metal wires. This iliac bone graft was wrapped in a radial forearm fasciocutaneous free flap and oriented so the fascia of the flap would become the nasal lining and the skin paddle would replace the oral mucosa of the palate. This composite flap-graft was inset using wires (Fig. 2). The radial artery and cephalic vein were anastomosed with the facial artery and vein using 9-0 nylon.Fig. 2.: Design of the radial fasciocutaneous free flap wrapped around the reconstructed hard palate and nasal septum.Postoperative recovery was uncomplicated (Fig. 3). The final staging was a T4N1M0 premaxillary squamous cell carcinoma. Six months postoperatively, the patient developed a recurrence and is presently undergoing palliative chemotherapy.Fig. 3.: View of the patient 3 weeks postoperatively, before radiotherapy.Palatal reconstruction is challenging. Traditionally, obturators are the mainstay of reconstruction. Autologous tissues are preferred and result in better cosmetic and functional outcomes. Local flaps and regional flaps are frequently inadequate and multistaged, and leave poor secondary defects.1 Hatoko et al. first described the use of the radial forearm free flap for palatal reconstruction.2 Other free flaps are available, but all are too bulky.3–5 We found no example of simultaneous palatal and nasal septum reconstruction in the literature. Our technique is a good option for a large premaxilla, hard palate, and nasal septum defect. The forearm skin is a reasonable oral lining. The fascia is thin, provides revascularization of the bone graft, and becomes mucosalized. The “wrap-around” technique improves the bone graft’s take. Septum reconstruction is important to prevent nasal deformity. The iliac crest has sufficient bulk to support dental prostheses or implants. The relative ease of molding and shaping of this technique provides flexibility in design. Good oral function was achieved with no early fistulas; speech was intelligible and aesthetically excellent. The disadvantages are long operative time and high personnel demand. In summary, we were able to reconstruct the premaxilla, hard palate, and nasal septum simultaneously using a radial forearm fasciocutaneous free flap wrapped around a composite nonvascularized iliac bone. We believe that this is a good option to meet the structural, functional, and aesthetic needs of this complex defect. Tam Dieu, F.R.A.C.S. Ram Silfen, M.D. Laura Chin-Lenn, M.B., B.S. Michael Schenberg, F.R.A.C.D.S., F.D.S.R.C.S. James Leong, F.R.A.C.S. Department of Plastic and Reconstructive Surgery and Hand Surgery Southern Health Melbourne, Victoria, Australia

Advantages of a new technique of neck dissection using an ultrasonic scalpel

The aim of the study was to see whether a new technique of a neck dissection applying an ultrasonic activated (harmonic) scalpel would improve patient recovery. A prospective, non-randomized study was undertaken on 40 supraomohyoid neck dissections performed using a harmonic scalpel (20 pts) or electrocoagulation (20 pts). The evaluation included: operation time, intraoperative blood loss, postoperative seroma formation and pattern of wound healing. The operative time (mean+/-SD) using a harmonic scalpel was significantly shorter (52+/-10 min vs. 86+/-22 min; p<or=0.001) and the blood loss was less (13+/-7 ml vs. 85+/-58 ml; p<or=0.001), neck drainage on the first and second postoperative days were significantly smaller after using the ultrasonic scalpel (30+/-26 ml; 44+/-23 ml vs. 77+/-65 ml; 118+/-66 ml, p<or=0.001). Wound healing complications amounted to only 5% (20% in the control group). The use of the harmonic scalpel during neck dissection led to diminished bleeding, shorter operative time, lesser seroma formation and better wound healing in the postoperative period.

Regional tumor recurrence after supraomohyoid neck dissection.

To evaluate the recurrence of lymphatic metastases in patients with squamous cell carcinoma of the oral cavity treated with supraomohyoid neck dissection with and without postoperative radiotherapy. A nonrandomized retrospective study. Department of Otolaryngology and Head and Neck, State University of Campinas, São Paulo, Brazil, a tertiary referral center. Thirty-two patients with squamous cell carcinoma of the oral cavity without previous treatment and a minimum follow-up period of 2 years were studied. There were 36 supraomohyoid neck dissections, of which 31 were elective (clinically negative nodes) and 5 therapeutic (clinically positive nodes). Resection of the primary tumor and supraomohyoid neck dissection, with or without postoperative radiotherapy. Evaluation of neck tumor recurrence according to clinical and histopathological findings in the neck and use of postoperative radiotherapy. The overall recurrence rate was 6% (2 patients). Recurrences were seen in 1 clinically negative neck (3%) and 1 clinically positive neck (20%). The presence of clinically or histopathologically positive nodes, number of positive nodes, and use of adjuvant radiotherapy did not influence the rate of neck tumor recurrence with a statistically significant difference. Neck tumor recurrence in procedures with clinically positive nodes was 6.3 times greater than in those with clinically negative nodes. There was no difference in regional recurrence of histopathologically positive node necks with or without the addition of postoperative radiotherapy. Neck tumor recurrence was not statistically influenced by clinically and histopathologically positive nodes, multiple positive nodes, and use of postoperative radiotherapy.

Supraomohyoid neck dissection in the ultrasonographically and clinically No neck in oral carcinoma

Introduction. The objective was determination of the value of supraomohyoid neck dissection in clinically and sonographically node-negative squamous cell carcinoma of the oral cavity. Methods. A retrospective analysis of the results of this operation between 1992 and 1996 was undertaken. Results. During this period, 116 supraomohyoid neck dissections were performed in 101 patients. Occult metastases were found in 25 (21.6%) neck dissections. Twelve were identified peroperatively with frozen section analysis and were converted to a modified radical neck dissection. Fourteen received postoperative radiotherapy. Six patients had no additional treatment. Median follow-up was 41 months. A locoregional recurrence was seen in three patients (3.6%) and a regional recurrence in five (4.3%). Of these seven patients, five died of disease. Five year actuarial survival was 89%. Conclusion. Occult metastatic disease in oral carcinoma has been reduced from 35%1 to 21.6% with routine ultrasonography of the neck. Awaiting further refinement of the diagnostic imaging of the neck, elective supraomohyoid neck dissection still seems to be a first-choice treatment in these patients.

Neck lymph node metastases to the posterior triangle apex: Evaluation of clinical and histopathological risk factors

Dissection of posterior triangle apex (APEX) is a surgical step in supraomohyoid and lateral neck dissections. The prevalence of lymphatic metastases at this site and the clinicohistopathologic conditions that influence their occurrence have not been established. We have evaluated the prevalence and the risk factors for cervical metastases in lymph nodes of the APEX. Sixty-two neck dissections were performed in 51 patients with squamous cell carcinoma of the oropharynx, hypopharynx, oral cavity, glottic larynx, and supraglottic larynx or with primary occult tumor. We correlated the presence of positive metastases in the APEX with the neck level involved either clinically (CLIN) or histopathologically (H/P) and with the number of CLIN- or H/P-positive neck levels with metastases. The prevalence of metastases in the APEX in elective (N0) and therapeutic (N+) neck dissections was also compared. This prevalence was also compared with that for each neck level. The histopathologic comparisons between the APEX and the neck levels were calculated for N0, N+, and all neck dissections. The primary site of tumor was correlated with the presence of H/P-positive nodes in the APEX. The overall prevalence of lymphatic metastases in the APEX was 6.5%. The prevalence in N0 neck dissections was 2.3% and in N+ neck dissections it was 16.7%. The prevalence of lymphatic metastases in the APEX for primary tumors of pharynx was 23.1%, for the oral cavity it was 3.6%, and it was 0% for other sites. Metastases in the APEX were not influenced by the neck level with CLIN or H/P metastases in N+ necks. The number of CLIN- or H/P-positive neck levels had no influence on histopathologic metastases in the APEX. Factors that influenced metastases in the APEX were positive histopathologic metastases at level II for N0 neck dissections and positive histopathologic metastases at level II or III for all neck dissections. All the comparisons were analyzed using Fisher's or Poisson's test. The prevalence of histopathologic metastases in the APEX in N+ necks is 7.3 times greater than that of N0 necks and for primary tumors of pharynx it was 6.4 times greater than for the oral cavity and significantly greater than for the larynx. Histopathologic metastases at level II for clinically N0 necks and histopathologic metastases to level II or III for all neck dissections are risk factors for metastases in the APEX. The number of positive levels did not influence the prevalence of metastases in the APEX. There are no isolated metastases in the APEX of the posterior triangle.

Quantification of lymph nodes in selective neck dissection.

Provide reference for surgeon and pathologist regarding expected yield from selective neck dissections. Quantify lymph nodes obtained from cadaver dissection based on current nodal classification and compare with clinical series. 1. Quantification of lymph nodes at levels I-V harvested from human cadavers and correlation with nodal grouping for supraomohyoid (I-III) and lateral (II-IV) neck dissections. 2. Retrospective review of operative specimens from clinical neck dissections for lymph node quantity. 1. Twenty radical neck dissection specimens, harvested from 10 fresh human cadavers without evidence of head and neck cancer, were separated by nodal level for gross and microscopic examination by a pathologist. The quantity of nodes obtained per level for each specimen was tabulated. 2. Charts of patients treated with neck dissection for squamous cell carcinoma were reviewed and tabulated for type of dissection and number of lymph nodes reported. In the 20 cadaver neck dissections, the average number of lymph nodes removed for levels I-V was 24, with 13 for levels I-III and 19 for levels II-IV. In the clinical review, 98 total neck dissections were included. In the six supraomohyoid dissections, an average of 20 lymph nodes (range, 14-26) were found, with an average of 30 (range, 15-43) in the 11 lateral compartment specimens. In 81 radical or modified radical dissections, an average of 31 nodes (range, 19-63) was reported. The number of lymph nodes removed in selective neck dissection should be comparable to that of the corresponding levels in radical neck dissection, provided that strict adherence to surgical boundaries is maintained. Dissection of normal cadavers provides a reference for the surgeon and the pathologist but may under-represent lymph node quantity in the diseased state.

Supraomohyoid neck dissection in the treatment of head and neck tumors. Survival results in 212 cases.

Elective supraomohyoid neck dissection is considered part of standard treatment of oral and oropharyngeal cancer in most institutions, but its role in the treatment of clinically positive neck cancer remains a subject of controversy. The main object of this study is to report the results of 212 consecutive patients who underwent supraomohyoid neck dissections from 1954 to 1990. Most patients had squamous cell carcinoma of the oral cavity. Eighty-six patients (40.6%) had histologically positive lymph nodes in the surgical specimen (sensitivity, 0.55; specificity, 0.53). At the study closing date there were 58.8% actuarial 10-year overall survival rates. Forty-five patients (21.2%) had 50 tumor recurrences (32 local, 13 regional, five distant), and in 40 patients (18.8%) a second primary tumor was diagnosed. A multivariate regression technique based on Cox's proportional hazards model was used, and age (65 years or younger vs older than 65 years) represented the variable with the highest predictive strength with respect to overall survival (relative risk, 2.3). Tumor site, sex, and histologically proved metastasis were also associated with overall survival rates. The same variables were also related to the risk of recurrence. In conclusion, the death rate is mainly related to the control of the primary site tumor and the occurrence of a second primary tumor rather than to neck recurrences. It confirms that supraomohyoid neck dissection is an adequate elective procedure and possibly sufficient in the treatment of a selected group of patients with lip cancer with positive nodes at level 1.

Critical assessment of supraomohyoid neck dissection

During a recent 5-year period, 115 patients had 131 supraomohyoid neck dissections. Eighty-one percent of these procedures were performed for squamous carcinoma. Seventy-nine percent of the primary tumors were located in the oral cavity and 16 percent arose in the oropharynx. Almost 80 percent of the necks dissected for primary squamous carcinoma were clinically N0, and occult nodal disease was discovered in 31 percent of these neck specimens. When the supraomohyoid neck dissection specimen showed no involvement, the overall incidence of treatment failure in the neck at 2-year follow-up was 5 percent. Almost all patients with occult squamous carcinoma in the supraomohyoid neck dissection specimen received postoperative radiotherapy, and the failure rate in the neck was 15 percent. When neck nodes were both clinically and pathologically involved, neck recurrence developed in 29 percent of the patients despite the addition of adequate postoperative radiotherapy. Among those patients with nonsquamous primary tumors and a pathologically negative supraomohyoid neck dissection specimen, there was only one subsequent treatment failure in the neck. Supraomohyoid neck dissection appears to be a valid staging procedure for clinically N0 patients with primary squamous carcinomas located in the oral cavity or oropharynx, with an appropriate yield of occult nodal disease, and infrequent treatment failure in the dissected neck when the supraomohyoid neck dissection specimen is pathologically uninvolved. When nodal disease is clinically obvious, treatment failure is more frequent, even with the addition of postoperative radiotherapy. The role of supraomohyoid neck dissection in this setting deserves further study.

Indications for neck dissection in carcinoma of the lip

In the past, neck dissections have been recommended only when nodes were clinically palpable or when they became so. A retrospective ten year study of thirty-seven patients with carcinoma of the lip and with an unusually high mortality has allowed reevaluation of indications for neck dissection. (1) Ten of thirty-seven patients died of this disease and nearly all of the ten died with and because of regional metastases. (2) Seven patients with nonpalpable nodes initially had nodal metastases later which, despite neck dissection at that later time, proved lethal. (3) Two patients who, despite nonpalpable nodes, had undergone neck dissections and were found to have occult bilateral nodal metastases were effectively cured with early neck dissection. This suggests that early bilateral supraomohyoid neck dissections for small carcinomas of the lip and ipsilateral radical neck dissections for large primaries may yield higher cure rates than currently achieved.