MANAGEMENT OF N0 NECK

Souvik Adhikari

N0 NECK: DEFINITION
Non-palpable lymph nodes in the neck in the presence of carcinoma in the drainage areas of the nodes.

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% when metastases are present). Clinical palpation of the neck has a sensitivity and specificity in the range of 60-70%. Early microscopic metastases may not be detectable clinically, pathologically or radiologically.

OCCULT NODAL METASTASES: PREVALENCE BY SITE

Piriform 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%

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.

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 sites including the larynx.

MANAGEMENT OF N0 NECK
EXTREMELY CONTROVERSIAL: DEBATE STILL CONTINUES!! Challenge lies in identifying patients who are at risk of developing lymph node metastases.

MANAGEMENT OPTIONS
Conservative Surgical therapy Radiation therapy

CONSERVATIVE MANAGEMENT
Advocated where the likelihood of metastases is low (<20%). Primary tumor is not aggressive. A period of watchful waiting is advocated.

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

SURGICAL OPTIONS
Radical Neck Dissection: historical Modified Radical Neck Dissection: preserves the internal jugular vein, sternocleidomastoid muscle and spinal 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 one or more groups of neck nodes.

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: Anterior compartment

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 for patients with cancer of the oropharynx, hypopharynx and larynx (? of benefit also in oral SCC especially base of tongue cancers) Posterolateral neck dissection: Levels II, III, IV and V; for malignant melanoma of the posterior scalp and neck

RADIATION THERAPY
Lymph node dissection is advocated but the patient refuses surgery. Following selective node dissection if 3 or more nodes contain metastases, if extracapsular spread is present or if a nodal metastases is found in 2 noncontiguous zones (skip metastases).

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.

FUTURE
MRI spectroscopy: choline/creatine ratio high in SCC Photosensitizing drugs: detection of occult metastases