Physical Address

304 North Cardinal St.
Dorchester Center, MA 02124

Superselective Neck Dissection


Introduction

The nodal status of the neck remains one of the most important prognostic factors for overall survival in patients with cancer of the head and neck. The lymphatic drainage of the neck is organized into anatomic compartments ( Fig. 63.1 ). The type of neck dissection depends on the nodal levels removed and the extent of nonlymphatic structures preserved ( Table 63.1 ). Over the past century, the surgical approach to regional nodal metastases has continued to evolve in an effort to lessen morbidity while preserving locoregional control and survival rates. The radical neck dissection for a clinically positive neck was described by Crile more than 100 years ago and included removal of the sternocleidomastoid (SCM) muscle, spinal accessory nerve (SAN), internal jugular vein (IJV), submandibular gland, and sensory rootlets, in addition to the lymphatic bearing fibroadipose tissue. In the 1950s Suarez found success using an approach that preserved at least one of the nonlymphatic tissue-bearing structures that would come to be known as the modified radical neck dissection, which would be popular throughout the 1950s and 1960s. In both of these procedures, the lymph node levels I–V were removed, but the postoperative morbidity was decreased with the modified radical neck dissection. In the 1960s and 1970s, Ballantyne advocated for the removal of only the nodal compartments at highest risk while leaving some nodal stations undissected and preserving all nonlymphatic structures. This type of dissection would be known as the selective neck dissection and has many variations, including the supraomohyoid and the lateral neck dissection. The concept of selective neck dissections was further popularized by the work of Lindberg and then by Shah, which showed that regional spread occurs in an orderly and predictable fashion. Many studies have shown that selective neck dissection has decreased the morbidity with surgical treatment of the neck, while preserving oncologic safety in both the N0 and N+ neck.

Fig. 63.1, Nodal compartments in the neck.

TABLE 63.1
Classic Definitions of Neck Dissections
Radical neck dissection Removal of nodal compartments I–V, IJV, SCM, and CN XI
Extended radical neck dissection Removal of nodal compartments I–V, IJV, SCM, CNXI, and a nonlymphatic structure (nerve, vessel, muscle, skin, etc.)
Modified radical neck dissection Removal of nodal compartments I–V and preservation of at one of the following: IJV, SCM, or CN XI
Selective neck dissection Removal of lymphatic bearing tissue only, leaving at least 1 nodal compartment undissected
Superselective neck dissection Removal of one or two contiguous nodal compartments and preserving all nonlymphatic tissue
IJV, Internal jugular vein; SCM, sternocleidomastoid.

Recently there has been an interest in more precisely targeting nodal levels at risk and further minimizing potential complications by using the superselective neck dissection (SSND). This technique is defined by dissection of only one or two contiguous nodal stations and preservation of all nonlymphatic bearing tissue. In this chapter we will discuss the indications, technique, and rationale for SSND.

Key Operative Learning Points

  • SSND is the removal of one or two contiguous neck levels while preserving all nonlymphatic structures.

  • SSND is appropriate for N0 necks by examination and imaging, salvage neck dissections with a single concerning node, and indeterminate lateral nodes in papillary thyroid cancer (PTC).

  • SSND performed for oral cavity primaries and N0 neck should include levels I and II.

  • SSND performed for laryngeal primaries and N0 neck should include levels II and III.

  • The goal of SSND is to minimize morbidity while maintaining regional control and survival rates.

Preoperative Period

History

  • All patients with cancer of the head and neck should have a complete basic history regarding the mass in the neck, including onset, duration, location, pain, severity, and progression.

  • All patients should be questioned about dyspnea, dysphagia, weight loss (how much over specific time period), hemoptysis, dysphonia, and otalgia.

  • All patients should be asked about previous cancer of the head and neck. If yes, how were they treated? Surgery? Radiation? Chemotherapy? Combination of modalities?

  • A full social history should be included regarding their occupation use of tobacco and alcohol, illicit drugs, and exposure to carcinogens or radiation.

  • The patient should have a good social support system and be motivated to proceed with SSND. Reliability is an important factor as well, since close surveillance and follow-up are warranted.

  • All patients should have a detailed family history performed with an emphasis on malignancies of the head and neck/thyroid.

Past Medical History

  • The history regarding bleeding and coagulation disorders must include a history of bleeding or bruising easily. Ask about a family history of bleeding easily or a history of hemophilia or von Willebrand’s disease.

  • Ask if there is a history of reactions to general anesthesia or malignant hyperthermia.

  • Ask about a history of previous neck surgery (cervical spine fusion, thyroid surgery, previous neck dissection or open biopsies, carotid endarterectomy).

  • Review the list of medications.

    • Any anticoagulants other than aspirin should be held in the perioperative period.

    • All herbal and over the counter (OTC) vitamins should be held perioperatively.

  • Ask all patients about risk factors for poor wound healing (chronic steroid use, hypothyroidism, connective tissue disorders).

Physical Examination

  • Overall appearance of the patient: Cachectic? Dehydrated? Well-nourished?

  • Primary site: Note the location of the primary cancer and whether it extends to areas that include bilateral lymphatic drainage (midline lesions such as the base of the tongue, floor of the mouth, or supraglottis). It is important to estimate the thickness of the cancer, since this has been shown to correlate with occult cervical metastases.

    • In patients who have been previously treated for the cancer, evaluate for complete response, and biopsy any suspicious areas (leukoplakia, erythema, or ulcerations).

  • Evaluate all mucosal surfaces of the oral cavity, oropharynx, larynx, and hypopharynx to rule out synchronous lesions.

  • Perform laryngoscopy to search for any mucosal lesions and vocal fold mobility.

  • Neck: Palpate for any appreciable lymphadenopathy and note the level. Is the mass freely mobile or adherent to the skin or underlying structures?

    • Evaluate mobility, including flexion and extension. Look for scars or evidence of previous surgery.

    • In patients who have previously undergone radiotherapy to the neck, note the pliability and firmness of the tissue.

  • It is important to note baseline function, especially in patients who have been previously treated.

    • Shoulder mobility, normal protrusion of the tongue, facial nerve movement, and vocal fold mobility

Imaging

  • With an overall 30% rate of occult lymph node metastases in squamous cell carcinoma (SCCa) of the head and neck, physical examination of the neck should be augmented with imaging.

  • The best imaging modality to detect nodal disease not appreciated on physical examination is controversial. While the sensitivity, specificity, and predictive values vary depending on the institution, we suggest that any of the modalities listed here are excellent options either in the pretreatment or posttreatment setting.

    • Ultrasound

    • Computed tomography (CT) scan with contrast

    • Magnetic resonance imaging (MRI) with gadolinium

    • Positron emission tomography - Computed tomography (PET-CT)

Indications

  • There are currently two clinical situations where SSND is considered:

    • Patients whose primary cancer is in the larynx or oral cavity and an N0 neck by examination and imaging

    • Patients who have been previously treated with either surgery or radiotherapy and have a persistent neck mass

  • Another proposed indication is an SSND for pathologically indeterminate lateral neck nodes but clinically suspicious for patients with malignancy. These are typically patients who have nodes that are suspicious on ultrasound or CT, but the fine-needle biopsy was indeterminate or unable to be performed due to the location of the lymph node.

Contraindications

  • Poor surgical candidate based on the patient’s medical status or comorbidities

  • Patients with distant metastatic cancer

  • In patients undergoing primary treatment, known cervical lymph node metastases are a contraindication to SSND. These patients will have a high risk of having nodal metastasis extending beyond one or two levels.

  • Any evidence of extracapsular extension that would require sacrifice of nonlymphatic tissue

Preoperative Preparation

  • All imaging should be reviewed prior to surgery. Any previous biopsies or pathology slides should be reviewed in house. We recommend a second review at the end of the case but before closing to ensure that no other suspicious areas were missed initially.

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here

Related Posts