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MANAGEMENT OF N0 NECK

Souvik Adhikari

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N0 NECK: DEFINITION Non-palpable lymph nodes in the neck in the

presence of carcinoma in the drainage areas of

the nodes.

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N0 NECK: IMPORTANT POINTS Squamous cell carcinoma of upper aerodigestive tract

with regional node metastases have a negative impact

on survival (survival rate decreased by 50% whenmetastases are present).

Clinical palpation of the neck has a sensitivity andspecificity in the range of 60-70%.

Early microscopic metastases may not be detectableclinically, pathologically or radiologically.

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OCCULT NODAL METASTASES:

PREVALENCE BY SITEPiriform sinus: 65% False vocal cord: 15%

Tongue: 60% Hard palate: 15%

Tongue base: 55% Alveolus: 15%

Tonsil: 36% True vocal cord: 15%

Aryepiglottic fold: 30% Epiglottis: 15%

Floor of mouth: 25%

Buccal mucosa: 20%

Retromolar trigone: 20%

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PREOPERATIVE NECK

EVALUATION Neck ultrasound

Contrast enhanced CT scan

MRI with gadolinium

PET imaging

Isosulfan blue/technetium scanning (head and

neck melanomas) Sentinel node biopsy using

lymphoscintigraphy: seems to accurately

predict the status of regional lymph nodes.

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IMPORTANCE OF HISTOLOGY OF

PRIMARY TUMOR Tumors of the oral cavity having a depth of

invasion >3 mm have a statistically significant

higher rate of occult nodal metastases (>20%).

Not significant in other head and neck sitesincluding the larynx.

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MANAGEMENT OF N0 NECK EXTREMELY CONTROVERSIAL:

DEBATE STILL CONTINUES!!

Challenge lies in identifying patients who areat risk of developing lymph node metastases.

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MANAGEMENT OPTIONS Conservative

Surgical therapy

Radiation therapy

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CONSERVATIVE MANAGEMENT Advocated where the likelihood of metastases

is low (

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SURGICAL MANAGEMENT Advocated where the likelihood of metastases

is high (>20%).

Primary tumor has aggressive characteristics:

- perineural invasion

- deep penetration (> 3mm in oral cavity)

- angiolymphatic invasion

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SURGICAL OPTIONS Radical Neck Dissection: historical Modified Radical Neck Dissection: preserves the

internal jugular vein, sternocleidomastoid muscle andspinal accessory nerve in various combination:- Type 1: preserves accessory nerve- Type 2: preserves accessory nerve + IJV

- Type 3: preserves all three structures Selective Neck Node Dissection: advocated,

preserves all the above structures in addition to oneor more groups of neck nodes.

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LEVELS OF NECK NODES Level I: Submental &

submandibular

Level II: Upper jugular Level III: Middle jugular

Level IV: Lower jugular

Level V: Posterior triangle

Level VI: Anteriorcompartment

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NECK NODE DISSECTION Supraomohyoid neck dissection: Levels I, II and III;

used for oral cavity cancers

Lateral neck dissection: Levels II, III and IV; used forpatients with cancer of the oropharynx, hypopharynxand larynx (? of benefit also in oral SCC especiallybase of tongue cancers)

Posterolateral neck dissection: Levels II, III, IV andV; for malignant melanoma of the posterior scalp and

neck

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RADIATION THERAPY Lymph node dissection is advocated but the

patient refuses surgery.

Following selective node dissection if 3 ormore nodes contain metastases, ifextracapsular spread is present or if a nodal

metastases is found in 2 noncontiguous zones(skip metastases).

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CONTRALATERAL NECK Occult lymph node involvement in the

contralateral neck occurs more commonly in:

- oral cavity SCC stage T3 and above

- tumors crossing the midline with

unilateral metastases

Elective surgery or radiotherapy is advocated.

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FUTURE MRI spectroscopy: choline/creatine ratio high

in SCC

Photosensitizing drugs: detection of occultmetastases

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