Unilateral Radical Neck Dissection Research Articles

Level V Metastasis, a Novel Predicative Factor for Recurrence in N1b Papillary Thyroid Carcinoma.

Lymph nodal (LN) metastasis, classified as pN1b, is considered as an independent poor prognostic factor for Papillary thyroid carcinoma (PTC) patients. However, whether LN metastasis can serve as a predictive factor for recurrence or disease-free survival of N1b PTC is still plagued by controversy. The N1b PTC patients who underwent total thyroidectomy and unilateral modified radical neck dissection (MRND) by the same surgical team in Ningbo NO.2 Hospital from March, 1998 to March, 2015 were included in this study. The clinical and pathological characteristics of each patient were recorded in detail. Univariate and multivariate Cox proportional hazards regression models were performed to analyze the associations between clinicopathological characteristics with recurrence. Kaplan-Meier analysis and log-rank test were used for the analysis of overall RFS and level V metastasis. A total of 214 patients were eligible for the final analyses. Of the 214 finally included patients with N1b PTC, 39 patients were classified with recurrence and 175 without recurrence. The final univariate and multiple Cox proportional hazards analysis only suggested level V metastasis as the independent predictive factor of N1b PTC recurrence (HR: 4.11; 95% CI:1.22-11.05, P=0.028). The patients with level V metastasis showed a significantly lower 10-year RFS rate (P=0.031) as illustrated by Kaplan-Meier analysis and log-rank test. Level V metastasis is a novel indicator for tumor recurrence and 10-year RFS in patients with N1b PTC.

Intraoperative baroreflex failure following lignocaine infiltration during unilateral radical neck dissection.

Intraoperative baroreflex failure following lignocaine infiltration during unilateral radical neck dissection.

Results of Total Laryngectomy as Treatment for Locally Advanced Hypopharyngeal Cancer

Introduction and objectivesTotal laryngectomy (TL), with eventual postoperative radiotherapy, has proven to be effective in treating cases of locally advanced hypopharyngeal cancer. The aim of this study was to analyse the oncological outcomes of this procedure in patients with hypopharyngeal cancer classified T3 and T4. MethodsWe studied 59 patients (33 T3 and 26 T4a) with primary squamous cell carcinoma of the hypopharynx treated with TL from 1998 to 2012. ResultsMean age was 61 years with a male predominance (96.6%). All the patients were smokers and 96% consumed alcohol. Unilateral selective neck dissection (ND) was performed in 12 patients, unilateral radical ND in 11 patients, bilateral selective ND in 20 patients and radical ND plus selective ND in 14 patients. Sixty-six percentage of the patients received postoperative radiotherapy. Lymph node metastases occurred in 81% of the patients and extranodal invasion in 56% of them. Twenty-nine percentage of the patients had loco-regional recurrence, 17% developed distant metastases, and 25% a second primary tumour. The 5-year disease-specific survival was 46%. ConclusionsTL extended to pharynx (with eventual postoperative radiotherapy) offers good oncological results in terms of loco-regional control and survival in locally advanced hypopharyngeal cancer, so organ preservation protocols should achieve similar oncological results to those shown by TL.

Resultados de la laringectomía total en carcinomas localmente avanzados de hipofaringe

Introduction and objectivesTotal laryngectomy (TL), with eventual postoperative radiotherapy, has proven to be effective in treating cases of locally advanced hypopharyngeal cancer. The aim of this study was to analyse the oncological outcomes of this procedure in patients with hypopharyngeal cancer classified T3 and T4. MethodsWe studied 59 patients (33 T3 and 26 T4a) with primary squamous cell carcinoma of the hypopharynx treated with TL from 1998 to 2012. ResultsMean age was 61 years with a male predominance (96.6%). All the patients were smokers and 96% consumed alcohol. Unilateral selective neck dissection (ND) was performed in 12 patients, unilateral radical ND in 11 patients, bilateral selective ND in 20 patients and radical ND plus selective ND in 14 patients. 66% of the patients received postoperative radiotherapy. Lymph node metastases occurred in 81% of the patients and extranodal invasion in 56% of them. 29% of the patients had loco-regional recurrence, 17% developed distant metastases, and 25% a second primary tumour. The 5-year disease-specific survival was 46%. ConclusionsTL extended to pharynx (with eventual postoperative radiotherapy) offers good oncological results in terms of loco-regional control and survival in locally advanced hypopharyngeal cancer, so organ preservation protocols should achieve similar oncological results to those shown by TL.

Intraocular Pressure-Lowering Effect of Latanoprost Is Hampered by Defective Cervical Lymphatic Drainage.

PurposeTo evaluate whether defects in cervical lymphatic drainage influence the intraocular pressure (IOP)-lowering effect of latanoprost in patients with primary open-angle glaucoma (POAG) who have undergone unilateral radical neck dissection (uRND).MethodsWe enrolled (1) bilateral POAG patients who had started (bilateral) latanoprost (0.005%) monotherapy prior to their uRND and (2) treatment-naïve, bilateral glaucoma suspects (GSs) who had undergone the same surgery. We compared the eyes ipsilateral to the uRND with their fellow eyes in terms of the changes in IOP between the baseline (prior to the uRND) and the follow-up visits (1, 3, and 6 months after the uRND).ResultsThe study involved 22 eyes of 11 POAG patients and 14 eyes of 7 GSs. In the POAG patients, IOP had increased significantly after surgery in the eyes ipsilateral to the uRND (from 14.7±1.4mmHg to 17.1±2.2mmHg; P = 0.007). Interestingly, in the eyes contralateral to the uRND, IOP had not changed significantly after surgery (from 14.2±1.8mmHg to 14.4±2.0mmHg; P = 0.826). In GSs, the eyes ipsilateral to the uRND did not differ significantly from their fellow eyes in terms of post-operative IOP change (ipsilateral value: 0.3±0.5mmHg, fellow eyes: -0.1±0.7mmHg; P = 0.242).ConclusionIn the POAG patients, IOP had increased significantly in the eyes ipsilateral to the uRND. However, it had not changed significantly in the eyes contralateral to the surgery or in the eyes of the GSs. These findings suggest that, latanoprost works, at least in part, by enhancing outflow from the aqueous humor via the uveolymphatic pathway.

術前化学療法により扁平上皮癌から形質転換が疑われた舌紡錘細胞癌の1例

There have been few reports on cases of spindle cell squamous cell carcinoma of the oral cavity. In this paper, we report a case of spindle cell squamous carcinoma arising in the tongue. A 76-year-old male with tongue squamous cell carcinoma was referred to our hospital. After two courses of neoadjuvant chemotherapy, subtotal resection of the tongue, unilateral radical neck dissection, and reconstruction with free transverse rectus abdominis myocutaneous flap were performed. Pathological diagnosis of the surgical specimen was spindle cell squamous carcinoma （pT3N0M0, Stage Ⅲ）. Recurrence of primary tumor was detected about four months after the operation and it showed extremely rapid growth. Palliative radiotherapy （two courses with 24Gy/8 fractions and 20Gy/5fractions） effectively controlled the patient’s quality of life. It is thought that although spindle cell squamous carcinoma clinically shows a response to radiotherapy or chemotherapy, some tumor cells （low sensitivity cancer stem cells） may resist and survive. So, radical resection with wider surgical free margin may be essential.

Monitoring the visual field of a patient with secondary pseudotumour cerebri syndrome due to one-sided lymphadenectomy and internal jugular vein ligature — case report

We describe a case of a 37-year-old man who developed prolonged papilledema as a result of increased intracranial pressure following unilateral radical neck dissection due to diffuse large B-cell non-Hodgkin lymphoma. It seems that the increase in intracranial pressure was a result of insufficient collateral venous drainage of the brain. Clinical examination showed bilateral papilloedema, diplopia, and visual deterioration in the left eye. Magnetic resonance imaging and computed tomography of the brain were normal. Semi-automated kinetic perimetry was used to mo­nitor the visual function during 12 months of the follow-up. This method revealed enlargement of the blind spot in the left eye without progression. Peripheral borders of the visual field were within normal limits.

Increasing Thyroid Cancer Rate and the Extent of Thyroid Surgery in Korea

BackgroundIt is evident that the rate of thyroid cancer is increasing throughout the world. One reason is increased detection of preclinical small cancers. However, it is not clear whether the increase in thyroid cancer rate is reducing the extent of thyroid surgeries. The purpose of this study was to evaluate the thyroid cancer rate and analyze recent changes in the extent of thyroid cancer surgeries in Korea.MethodsAn observational study was conducted using data from Korea’s Health Insurance Review and Assessment Service (HIRAS) for thyroidectomy with/without neck dissection, with 228,051 registered patients between 2007 and 2011. Data were categorized by the extent of surgery: unilateral thyroidectomy without neck dissection (UT), bilateral thyroidectomy or radical thyroidectomy without neck dissection (TT), any thyroidectomy with unilateral selective neck dissection (SND), any thyroidectomy with unilateral modified radical neck dissection (MRND), any thyroidectomy with unilateral radical neck dissection (RND), and any thyroidectomy with bilateral neck dissection (BND). Annual rate difference for each surgery was analyzed with a linear by linear association.ResultsThe absolute numbers of total thyroid surgeries (UT+TT+SND+MRND+RND+BND) were increased from 28539 to 61481. The proportion of patients who underwent only thyroidectomy without neck dissection (UT+TT) decreased from 67.30% to 60.50%, whereas the proportion of patients who underwent neck dissection (SND+MRND+RND+BND) increased from 32.70% to 39.50% during the 5-year study period.ConclusionDespite the increase in rate of thyroid cancer due to earlier detection, increased rate of neck dissection was noted.

Surgical management for residual or recurrent diseases in the neck after radiotherapy in nasopharyngeal carcinoma

To investigate the surgical managements for residual or recurrent diseases in the neck after radiotherapy in nasopharyngeal carcinoma. Seventy-eight cases of neck masses (39 cases for unilateral residual diseases, 9 for bilateral residual diseases and 30 for recurrent diseases) after radiotherapy in nasopharyngeal carcinoma who were treated surgically between January 1990 and December 2005 were retrospectively analyzed. There were 56 males and 22 females. Their ages ranged from 28 to 65 years (median 41 years). There were 27 patients with skin involvement. After preoperative imaging assessment, 17 patients whose common carotid arteries or internal carotid arteries were difficult to separate routinely attained the carotid balloon occlusion test which confirmed that 15 cases of cerebral arterial circle open to compensation, however, two cases of poor compensation. Surgical procedures included expanded neck mass resection (21 cases), unilateral radical neck dissection (49 cases) and bilateral radical neck dissection (8 cases). Of them 5 patients were with unilateral internal carotid artery resection. Neck defects were repaired with pectoralis major muscle flaps (15 cases), free anterolateral femoral skin flaps (9 cases) and trapezius muscle flaps (3 cases). Of the 78 patients, 13 with microscopic positive diseases and 2 with residual diseases in internal carotid artery walls underwent postoperative radiotherapy, with the doses of 45 to 50 Gy. All patients were closely followed-up more than 5 years. Three- and five-year survival rates were 46.2% and 28.3% respectively. Neck defects were successfully repaired with skin flaps immediately after resecting diseases in 27 cases, only one patient with delayed healing. Of 51 patients without skin flap repair, neck wounds healed successfully in 45 patients and with delayed healing in 6 patients. Pathological positive rates of lymph nodes located in the level I, II, III, IV and V were 10.5%, 61.4%, 10.5%, 1.8% and 28.1% respectively. Preoperative balloon occlusion test is required to assess the function of Willis' ring before determining ligation or resection of internal carotid artery. Residual or recurrent diseases commonly exist in level II, VA and III, which should be included in neck dissection. Pectoralis major muscle flap and free anterolateral femoral skin flap are recommended for the repair of neck defect.

A case of increased intracranial pressure after unilateral modified radical neck dissection

Objective This study aimed to study case reports and review the world literature concerning increased intracranial pressure secondary to unilateral radical neck dissection. Case report A male patient presented with a painless lump in the left side of his neck. Diagnostic investigation revealed papillary thyroid carcinoma and 4 × 2-cm left cervical lymph node. Total thyroidectomy with modified radical neck dissection on the left side that included removal of the internal jugular vein was undertaken. Eleven days after the operation, the patient presented with a history of headache and diplopia. Clinical examination showed bilateral papilledema and right-sided sixth cranial nerve palsy. A computed tomographic scan and magnetic resonance image of the brain was normal. Subsequent magnetic resonance venography revealed an aplastic contralateral transverse sinus. Conclusion Based on our case, vascular anomalies should be considered in any patient who exhibits signs of increased intracranial pressure after unilateral neck dissection.

Comparison of Definitive Concurrent Chemoradiotherapy (CCRT) and Laryngectomy Followed by Adjuvant CCRT for Resectable Advanced Hypopharyngeal Cancer

This retrospective study compares the outcomes of different treatment modalities for resectable advanced hypopharyngeal cancer. (i.e., T4b, N3, T1N0, and small T2N0 were excluded.) From 2003 to 2007, a total of 46 patients with resectable advanced hypopharyngeal cancer were included in this study. According to major or minor risk factors revealed after laryngectomy and neck dissection, seventeen patients underwent adjuvant CCRT (13/17) or radiotherapy (RT) alone (4/17). Twenty-nine patients were treated with definitive CCRT, and four of them underwent unilateral radical neck dissection in advance. Thirty-two stage IVa patients were distributed in laryngectomy-CCRT arm (14/17) and CCRT arm (18/29). Intensity modulated radiation therapy (IMRT) plans treated gross tumor volume (GTV), high-risk, and low-risk areas to 70, 63, and 54 Gy, respectively, in the CCRT arm, and to high-risk and low-risk areas to 63 and 54 Gy in the laryngectomy-CCRT arm. Fractionation was 1.8 per day. Concurrent cisplatin-based chemotherapy was administered for 5 days every 3 weeks. The mean follow-up time was 15.9 months (range, 2-42 months). The mean overall survival in the laryngectomy-CCRT arm has a superior trend over CCRT arm (28.4 vs. 21.93 months, p = 0.18). In the CCRT arm, one refused to complete treatment and one died both due to severe neutropenia. The numbers of patients with complete response (CR), partial response (PR), and stable or progressive disease (SPD) in the CCRT arm were 17 (58.6%), 6 (20.7%), and 6 (20.7%), respectively. Salvage laryngectomy were performed for 2 patients who had CR and for only 2 who had PR or SPD. The CR arm had similar mean overall survival comparing to the laryngectomy-CCRT arm (32.2 vs. 28.4 months, p = 0.59) but less favorable 2-year disease-free survival (DFS) rate (66% vs. 86%, p = 0.23). Patients who required gastrostomy were correlated with poorer DFS significantly. In patients who had CR, definitive CCRT provides an overall survival equivalent to laryngectomy-CCRT, with much better functional and cosmetic results. Further investigation of a reliable molecular or clinical indicator for assessing the probability of achieving CR with CCRT will be invaluable for organ preservation purpose in patients of resectable advanced hypopharyngeal cancer.

Anterior ischemic optic neuropathy after unilateral radical neck dissection: Case report and review

Background Blindness or visual deterioration after neck dissection is a known and a rare complication of the operation. Visual impairment usually occurs immediately after bilateral radical neck dissections either performed synchronously or in a stepwise manner, resulting in permanent blindness. Hypotension and blood loss during long operations, elevated venous pressure postoperatively result in optic neuropathies, which are anterior ischemic optic neuropathy (AION) or mostly posterior ischemic optic neuropathy (PION) affecting different portions of the nerve. Methods Review of literature and case report. Results To date there are only three cases of AION after neck dissection reported in the literature, with a different visual prognosis. Conclusion Vision loss may be reversible when both internal jugular veins are preserved, but permanent when any of them are resected. Here we present the first case of anterior ischemic optic neuropathy developed after unilateral radical neck dissection, resulting in partial visual deterioration.

Extension of Intracranial Thrombosis After Unilateral Dissection of the Internal Jugular Vein

Resection of the internal jugular vein can be necessary in cases of radical neck dissection or even in cases involving benign neoplasms such as glomus tumors. According to the triad described by Virchow (ie, stasis of blood flow, damage to the endothelium, and changes in hemostasis), the development of a thrombosis in the venous vessels superior to the resected internal jugular vein seems to be possible. The aim of this study was to determine the extension of possible intracranial thrombosis after wound healing. A total of 17 patients requiring resection of the internal jugular vein were evaluated prospectively using magnetic resonance imaging and 2-dimensional (time-of-flight) magnetic resonance angiography after the surgical treatment. Preoperative magnetic resonance images were obtained in all 17 patients for staging purposes as well as to exclude preoperative thrombosis of the internal jugular vein. Sixteen patients had malignant tumors, and 1 patient had a glomus tumor. Intracranial thrombosis with thrombosis of the sigmoid sinus was found in 4 patients, and thrombosis of the transverse sinus was found in 3 patients. There were no complications such as intracranial hemorrhage or signs of increased intracranial pressure in any patients. There was no evidence of intracranial thrombosis in 10 cases. In these cases, thrombosis of the venous vessels superior to the resected vein ranged from none to complete thrombosis of the superior bulb of the internal jugular vein. After unilateral resection of the internal jugular vein, the venous blood leaves the brain mainly via the venous network of the contralateral side of the neck. Although intracranial thrombosis of the sigmoid or transverse sinus seems to occur more frequently than was previously thought, intracranial complications such as venous infarction or increased intracranial pressure appear to be very rare. After unilateral radical neck dissection, the venous blood leaves the brain mainly via the venous system of the other side of the neck and the ipsilateral collateral veins.

画像解析装置を用いた片側全頸部郭清術症例の嚥下機能評価‐舌骨位置および食道入口部開大の解析‐

画像解析装置を用いた片側全頸部郭清術症例の嚥下機能評価‐舌骨位置および食道入口部開大の解析‐

Metástases cervicais bilaterais no carcinoma epidermóide de cabeça e pescoço: tratamento cirúrgico em um ou dois tempos

OBJETIVO: Avaliar os resultados do tratamento dos pacientes com metástases cervicais bilaterais de carcinoma epidermóide das vias aerodigestivas superiores. FORMA DE ESTUDO: Série de casos retrospectiva. CASUÍSTICA E MÉTODO: Revisão dos prontuários de 855 pacientes com carcinoma epidermóide de boca, orofaringe, hipofaringe e laringe submetidos à ressecção do tumor primário e esvaziamento cervical radical entre 1977 e 1996. Foram selecionados 96 pacientes com metástases bilaterais confirmadas histologicamente, dos quais 73 foram submetidos inicialmente ao esvaziamento cervical bilateral (ECB) e 23 pacientes que se submeteram ao esvaziamento unilateral e, posteriormente, desenvolveram recidiva cervical contralateral. A evolução dos pacientes foi avaliada por meio da sobrevida livre de doença e do controle cervical. RESULTADOS: Entre os 23 pacientes submetidos ao esvaziamento unilateral (pN+) que desenvolveram recidiva contralateral, foram resgatados 18 pacientes. O controle da doença no pescoço em 2 anos foi alcançado em 46% dos pacientes. Entre os 73 pacientes submetidos ao esvaziamento bilateral (pN2c) ocorreram 12 casos de recidivas cervicais, dos quais apenas 3 foram resgatados. O controle da doença no pescoço em dois anos foi alcançado em 77% dos pacientes. A sobrevida livre de doença foi semelhante entre os 2 grupos, apesar da diferença observada na taxa de controle cervical. CONCLUSÃO: O esvaziamento bilateral em tempo único apresentou melhor controle da doença no pescoço, mas não alterou a sobrevida livre de doença neste grupo de pacientes. A despeito do controle da doença cervical ser obtido na maioria dos pacientes, apenas um terço daqueles com metástases bilaterais apresentaram doença controlada após 2 anos.

Neck dissection shoulder syndrome: quantification and three-dimensional evaluation with an optoelectronic tracking system.

Objective 3-dimensional biomechanical changes of the shoulder at rest or during arm elevation were measured by means of a new specific method using an optoelectronic detection system that was developed for computer-aided surgery. Additionally, the shoulder syndrome following neck dissection was evaluated by the recognized orthopedic shoulder Constant score. The statistical evaluation encompassed 12 patients with unilateral radical neck dissection (RND), 12 patients with unilateral modified radical neck dissection (MRND) with preservation of the accessory nerve, and 10 healthy subjects. The healthy shoulders showed normal kinematic behavior, the so-called "scapulohumeral rhythm" (SHR). After MRND, the static scapular position and SHR showed no significant 3-dimensional variations. In contrast, RND produced a highly significant scapular displacement at rest (p < .01) and a near-total abolition of SHR. The Constant scores were significantly lower after RND than after MRND (p < .01). Three-dimensional evaluation of the shoulder syndrome supports the Constant score, quantifying what can be measured objectively.

Venous Drainage Patterns in a Case of Pseudotumor Cerebri Following Unilateral Radical Neck Dissection

We report the extracranial venous ultrasound findings in a case of pseudotumor cerebri (PTC) following unilateral radical neck dissection (rND). PTC is known to be a rare complication following bilateral rND, and is caused by venous outflow obstruction. Single cases of PTC have been reported after unilateral rND, and are thought to be due to resection of the dominant internal jugular vein (IJV) in the presence of a hypoplastic or aplastic contralateral transverse sinus. Our patient developed PTC despite prominent flow in the contralateral IJV as shown by venous ultrasound. No compensatory increase in flow in the vertebral veins was observed, as confirmed by digital subtraction angiography. We conclude that the physiological collateral function of the vertebral venous system and deep neck veins was insufficient and contributed to global venous outflow obstruction in our case of unilateral rND.

Venous Drainage Patterns in a Case of Pseudotumor Cerebri Following Unilateral Radical Neck Dissection

Venous Drainage Patterns in a Case of Pseudotumor Cerebri Following Unilateral Radical Neck Dissection

片側根治的頚部郭清術後に重篤な頭蓋内静脈潅流不全を継発した１例

Intracranial perfusion failure is one of the well-documented complications of bilateral radical neck dissection, but rarely occurs after unilateral radical neck dissection. We describe a male patient who had intracranial perfusion failure after unilateral radical dissection of the right side of the neck. Three days after the dissection, he complained of severe headache and nausea and then had increased blood and intracranial pressures. Carotid angiograms showed dominant right transverse sinus drainage probably because of hypoplastic left transverse sinus drainage. Furthermore, dissection of the right internal jugular vein caused occlusion at the superior bulb of the right jugular vein, leading to intracranial perfusion failure. The patient was treated by drainage of cerebrospinal fluid and a dehydrator and became asymptomatic. In our patient radical neck dissection done on the side of the dominant transverse sinus drainage, caused intracranial perfusion failure followed by severe headache and nausea, possibly because of the hypoplastic contralateral transverse sinus drainage.

Pattern of cervical lymph node metastases from papillary carcinoma of the thyroid.

The management of cervical metastases from papillary thyroid carcinoma ranges from selective removal (berry picking) to a formal comprehensive neck dissection. Without a clear understanding of the distribution of nodes at risk, the formulation of strategies on how best to manage the clinically positive neck is difficult. This study reports on observations made in patients who underwent a therapeutic comprehensive neck dissection for metastatic papillary thyroid carcinoma by defining lymph node involvement with respect to neck level. The clinical records and pathological reports of 75 consecutive patients who underwent a neck dissection for cervical metastases from papillary thyroid carcinoma over a 10-year period were reviewed. All dissections were therapeutic in nature, being performed in patients with clinically positive neck nodes. Eighty neck dissection specimens were obtained and analyses were divided into three groups by virtue of the type of dissection performed: a bilateral comprehensive neck dissection, unilateral radical neck dissection and unilateral comprehensive neck dissection. The relative involvement of cervical nodes was analysed with reference to node levels I-V. Patients in the anterolateral group (levels II, III and IV) were at greatest risk of metastatic disease, with level III nodes consistently the most frequently involved, across all treatment groups. Only three patients exhibited level I involvement, all of whom had extensive neck disease involving all or almost all neck levels. The majority of patients present with multiple level node disease, with the anterolateral group at greatest risk. A comprehensive neck dissection is recommended for all patients with palpable cervical lymphadenopathy.