Correlation between Central and Lateral Neck Dissection in Differentiated Thyroid Carcinoma

Objective: To determine the histopathological correlation between central and lateral neck metastasis in differentiated thyroid carcinoma, and its potential therapeutic impact. Although the central neck dissection (CND) is recommended in differentiated thyroid carcinoma, the indication for lateral neck dissection (LND) remains controversial. Design: Retrospective study. Methods and Main Outcome Measures: Pathological analysis of systematic ipsilateral central neck dissection (CND) and LND performed with total thyroidectomy in differentiated thyroid carcinoma was retrospectively reviewed according to “side” and to “patient”. Results: A total of 56 sides (46 patients) were suitable for analysis. Analysis by “side” revealed that CND and LND dissection samples were both negative in 15 cases, both positive in 32, CND was positive and LND was negative for 8 cases and CND was negative and LND was positive in 1 case. The combined presence of positive LND and positive CND was therefore observed in 32/40 “sides” and 26/46 “patients”. Analysis by “side” of the impact of the treatment decision to perform ipsilateral LND only in patients with positive CND and vice versa demonstrated a sensitivity, specificity, and accuracy of 97%, 65%, and 84%, respectively. Conclusions: In most cases, the presence of positive LND was associated with positive ipsilateral CND. The very low prevalence of positive LND in patients with negative CND may justify LND as a second step procedure only in patients with positive CND, except in the case of documented lateral neck metastasis.

Neck observation versus elective neck dissection in management of clinical T1/2N0 oral squamous cell carcinoma: a retrospective study of 232 patients

Objective: The management of early-stage (cT1/2N0) oral squamous cell carcinoma (OSCC) remains a controversial issue. The aim of this study was to compare the clinical outcomes of neck observation (OBS) and elective neck dissection (END) in treating patients with cT1/2N0 OSCC. Methods: A total of 232 patients with cT1/2N0 OSCC were included in this retrospective study. Of these patients, 181 were treated with END and 51 with OBS. The survival curves of 5-year overall survival (OS), disease-specific survival (DSS), and recurrence-free survival (RFS) rates were plotted using the Kaplan-Meier method for each group, and compared using the Log-rank test. Results: There was no significant difference in 5-year OS and DSS rates between END and OBS groups (OS: 89.0% vs. 88.2%, P=0.906; DSS: 92.3% vs. 92.2%, P=0.998). However, the END group had a higher 5-year RFS rate than the OBS group (90.1% vs. 76.5%, P=0.009). Patients with occult metastases in OBS group (7/51) had similar 5-year OS rate (57.1% vs. 64.1%, P=0.839) and DSS rate (71.4% vs. 74.4%, P=0.982) to those in END group (39/181). In the regional recurrence patients, the 5-year OS rate (57.1% vs. 11.1%, P=0.011) and DSS rate (71.4% vs. 22.2%, P=0.022) in OBS group (7/51) were higher than those in END group (9/181). Conclusions: The results indicated that OBS policy could obtain the same 5-year OS and DSS as END. Under close follow-up, OBS policy may be an available treatment option for patients with clinical T1/2N0 OSCC.

Neck dissection for recurrent and persistent lymph nodes of nasopharyngeal carcinoma after radiotherapy： effect and choice

Objective： To investigate the best surgical mode for the patients of nasopharyngeal carcinoma with recurrent and persistent lymph nodes after radiotherapy. Methods： The clinical data of 88 patients of nasopharyngeal carcinoma with recurrent and persistent lymph nodes after radiotherapy were analyzed retrospectively. The levels of involved lymph nodes and the relationship among the levels were analyzed; the survival rate and recurrent rate of the surgical modes including radical neck dissection （RND）, modified radical neck dissection （MRND）, selective neck dissection （SND）, and lymph node resection （LNR） were analyzed; the role of postoperative radiotherapy was evaluated. Results： （1） The recurrent and persistent lymph nodes mainly located in level Ⅱ（55.6% and 58.6%, respectively）, next was level Ⅲ and rarely in level Ⅳ, Ⅴ, and Ⅰ, but the number of levels Ⅳ Ⅴ, and Ⅰ with cancer-bearing lymph nodes was relatively more than that of clinical measurement. （2） Patients with lymph nodes involved in level Ⅲ and Ⅳ, usually, have other levels involved simultaneously; the percentages were 63.6% and 88.9%, respectively. However, the lymph nodes in level Ⅱ and Ⅴ were mainly isolated. （3） The 5-year survival rate and recurrent rate of the whole group were 42.77% and 22.7%, respectively. （4） The 5-year survival rates of RND, MRND, SND, and LMR groups were 39.75%, 60.00%, 37.87%, and 44.10%, respectively; the differences were insignificant （Log-rank = 1.0, P = 0.8011）; the recurrent rate between the extensive and local surgery groups were insignificant （X^2 = 0.470, P = 0.493）. （5） The 5-year survival rates of the patients with and without postoperative radiotherapy were 39.06% and 45.26%, respectively; the difference was insignificant （Log-rank = 0.06, P = 0.8138）. Conclusion： The extensive surgery was recommended when the recurrent and persistent lymph nodes were more than one level involved or very large or immovable, otherwise, the SND should be performed and postoperative radiotherapy was important compensation if necessary.

THE UNILATERAL BIG HOCKEY STICK INCISION FOR NECK DISSECTION IN THYROID CARCINOMA

Objective: To investigate the feasibility and advantages of the unilateral big hockey stick incision in thyroid carcinoma. Method: Neck dissection using the unilateral big hockey stick incision was performed on 23 patients with thyroid carcinoma. Results: The big hockey stick incision results in a cosmetic scar which is barely visible and easily covered by hair or clothing, while it provides sufficient exposure of the operation field. A small area of marginal necrosis is occasionally seen at the apex of the skin flap due to preoperative radiotherapy. Conclusion: The unilateral big hockey stick incision has adequate surgical access, good healing of skin flaps, and a good cosmetic result.

UNILATERAL BIG HOCKEY STICK INCISION FOR NECK DISSECTION IN HEAD AND NECK CARCINOMA

Objective: To investigate for the feasibility and advantages performed by the unilateral big hockey stick incision (BHSI) in head and neck carcinoma. Methods: Neck dissection by using the unilateral big hockey stick incision (BHSI) was performed on 93 patients with head and neck carcinoma. Results: The big hockey stick incision has a cosmetic scar and not scar contraction and is barely visible and easily covered in hair and clothing; sufficient exposure of the operation field; a small area of marginal necrosis was occasionally seen at the apex of the skin flap due to having preoperative radiotherapy. Conclusion: The unilateral big hockey stick incision has adequate surgical access, good healing of skin flaps, and a good cosmetic result.

The launch of a special issue on “Neck Dissection in Differentiated Thyroid Carcinoma” in Gland Surgery

Given the high incidence of cervical lymph node metastasis in differentiated thyroid cancer （DTC） and the rapidly increased importance of neck dissection in DTC, the journal of Gland Surgery is launching a special issue on ＂Neck Dissection in Differentiated Thyroid Carcinoma＂ in November Issue of 2013, inviting Dr. Xinying Li from Xiangya Hospital, China, as the guest editor.

A new device for the identification of lymph nodes removed during different types of neck dissection

Meticulous mapping of the lymph node status is a general principle in present-day head and neck surgery. The removal of a certain number of lymphatic levels during neck dissection may well be therapeutic in intent, but it is also mandatory for correct tumour staging. We pre- sent a precise lymph node mapping during dif- ferent types of neck dissection in the course of major head and neck surgery by a sterile plastic tray moulded in the shape of the neck. This de- vice makes lymph node mapping simpler, safer, quicker and methodically more structured than any of the present methods. It facilitates the work of the pathologist and the flow of reliable information along the surgeon-pathologist- oncologist chain. With this device, a more stru- ctured, methodical means of lymph node removal has become possible.

Para-tracheal neck dissection-is dissection of the upper part of level Ⅵ necessary?

Papillary thyroid carcinoma(PTC)has a high propensity for regional metastases,however,the impact of such metastases on the outcome of the patients is minimal.The central compartment of the neck is considered the first and the most common echelon of metastases from thyroid carcinoma.Physical examination along with ultrasonography are the gold standard pre-operative evaluation of patients with PTC.Ultrasonography is highly sensitive in evaluating lateral neck nodes,however,its value in evaluating the central compartment is limited,resulting in a relatively high rate of occult metastases in this compartment.The main potential complications of para-tracheal neck dissection(PTND)are recurrent laryngeal nerve paralysis and hypocalcemia and these may be higher in patients undergoing PTND compared to thyroidectomy alone.New histological data is available showing no evidence of lymph nodes in the central compartment above a level parallel to the inferior border of the cricoid cartilage.These findings support withholding dissection of the upper para-tracheal region routinely as a part of PTND in patients with well-differentiated thyroid cancer.By doing that,the complications may be lower and identical to thyroidectomy alone,thus may abolish arguments against more common use of elective PTND in patients with thyroid carcinoma.

Elective neck dissection or ＂watchful waiting＂： optimal management strategy for early stage NO tongue carcinoma using decision analysis techniques

Background Although tongue cancer is a common disease of the head and neck, the choice of neck treatment between elective neck dissection and ＂watchful waiting＂ remains controversial for patients with early stage NO oral tongue carcinoma. Methods On the basis of the current state of head and neck cancers a decision analysis model was created to compare two treatment strategies for early tongue cancer. Expected value （EV） was calculated according to the literature which met the defined criteria. Sensitivity analyses were performed. Results The results showed that the decision model favored elective neck dissection （EV=0.87）, over ＂watchful waiting＂ （EV=0.77）. One-way sensitivity analyses demonstrated that the outcome was influenced by regional recurrence, threshold value of 0.28 for the elective neck dissection group and 0.17 for the ＂watchful waiting＂ group, and a salvage rate threshold value 0.73 for the ＂watchful waiting＂ group. Conclusions These results suggested that elective neck dissection strategy of the neck should be applied for early stage NO oral tongue carcinoma patients with no clinical nodal metastases. When the occult lymph node metastases rate was less than 0.17 and the salvage rate was more than 0.73, ＂watchful waiting＂ strategy would be preferable.

Clinical manifestations and managements of post-neck dissection chylothorax

Neck and head neoplasm, such as thyroid carcinoma, often has a high rate of regional lymph nodemetastasis.L Neck dissection is a conventmnal optmn m management of head and neck neoplasm with confirmed or suspected neck lymph node metastasis. Chylothorax represents a relatively rare early post-operative complication of neck dissection） We retrospectively analyzed neck dissection associated chylothorax in patients with thyroid carcinoma in our hospital. Published reports on neck dissection associated chylothorax were also summarized to describe clinical manifestations and optimal managements. METHODS Patients with primary thyroid carcinoma, who underwent surgery were retrospectively analyzed in the database of the Second Affiliated Hospital of Zhejiang University from June 1, 2009 to June 1, 2011. Clinical data were further analyzed in detail to determine if lateral neck dissections were performed and postoperative chylothorax occurred. Postoperative chylothorax was determined through both chest imaging manifestations and pleural effusion biochemical results. RESULTS A total number of 242 patients diagnosed as thyroid carcinoma with confirmed or suspected neck lymph node metastasis underwent lateral neck dissection. Five patients accompanied with postoperative chylothorax with an incidence of 2.07%. Symptoms occurred between the second to eighth post-operative day. Detailed clinical information was listed in Table 1. One patient with synchronous chylous leak and liquid collection in the surgical area underwent thoracic duct ligation and drainage tubes re-insertion under local anesthesia in cervical region on the third post-operative day. After re-operation, she underwent conservative therapeutics and finally got cured. The other four patients were successfully managed with conservative therapeutics. All five patients did not undergo any chronic complications of chylothorax during their 12-month follow-up durations.

Role of prophylactic central neck lymph node dissection for papillary thyroid carcinoma in the era of de-escalation

Thyroid cancer is the most common endocrine malignancy.While there has been no appreciable increase in the observed mortality of well-differentiated thyroid cancer,there has been an overall rise in its incidence worldwide over the last few decades.Patients with papillary thyroid carcinoma(PTC)and clinical evidence of central(cN1)and/or lateral lymph node metastases require total thyroidectomy plus central and/or lateral neck dissection as the initial surgical treatment.Nodal status in PTC patients plays a crucial role in the prognostic evaluation of the recurrence risk.The 2015 guidelines of the American Thyroid Association(ATA)have more accurately determined the indications for therapeutic central and lateral lymph node dissection.However,prophylactic central neck lymph node dissection(pCND)in negative lymph node(cN0)PTC patients is controversial,as the 2009 ATA guidelines recommended that CND“should be considered”routinely in patients who underwent total thyroidectomy for PTC.Although the current guidelines show clear indications for therapeutic CND,the role of pCND in cN0 patients with PTC is still debated.In small solitary papillary carcinoma(T1,T2),pCND is not recommended unless there are high-risk prediction factors for recurrence and diffuse nodal spread(extrathyroid extension,mutation in the BRAF gene).pCND can be considered in cN0 disease with advanced primary tumors(T3 or T4)or clinical lateral neck disease(cN1b)or for staging and treatment planning purposes.The role of the preoperative evaluation is fundamental to minimizing the possible detrimental effect of overtreatment of the types of patients who are associated with low disease-related morbidity and mortality.On the other hand,it determines the choice of appropriate treatment and determines if close monitoring of patients at a higher risk is needed.Thus,pCND is currently recommended for T3 and T4 tumors but not for T1 and T2 tumors without high-risk prediction factors of recurrence.

Elective neck dissection in oral squamous cell carcinoma of the upper maxilla:necessary?

Aim:Surgical treatment of clinically negative neck in maxillary squamous cell carcinoma(SCC)of the upper jaw is controversial.The purpose of this systematic review was to define the incidence of cervical metastasis and to assess if elective neck dissection is justified when the neck is not primarily affected.Methods:An electronic literature search was conducted in several databases,including MEDLINE,EMBASE,and Cochrane Central databases,for articles written in English.Results:Twenty-eight articles were included in the review.The overall cervical metastases rate was 33%and the total initial cervical metastases rate was 16%.Interestingly,the author found that 71%of patients with cervical metastases from maxillary SCC carcinoma were T3/T4 stage.Conclusion:This review shows the need for a change in the management of the N0 neck in SCC arising in the maxillary alveolus and hard palate.Elective neck dissection should be performed in patients with T3/T4 tumours with clinic or radiographic negative necks(N0c).

A critical readability and quality analysis of internet-based patient information on neck dissections

Objective:Patients are increasingly turning to the Internet as a source of healthcare information.Given that neck dissection is a common procedure within the field of Otolaryngology-Head and Neck Surgery,the aim of this study was to evaluate the quality and readability of online patient education materials on neck dissection.Methods:A Google search was performed using the term"neck dissection."The first 10 pages of a Google search using the term"neck dissection"were analyzed.The DISCERN instrument was used to assess quality of information.Readability was calculated using the Flesch-Reading Ease,Flesch-Kincaid Grade Level,Gunning-Fog Index,Coleman-Liau Index,and Simple Measure of Gobbledygook Index.Results:Thirty-one online patient education materials were included.Fifty-five percent(n=17)of results originated from academic institutions or hospitals.The mean Flesch-Reading Ease score was 61.2±11.9.Fifty-two percent(n=16)of patient education materials had Flesch-Reading Ease scores above the recommended score of 65.The average reading grade level was 10.5±2.1.The average total DISCERN score was 43.6±10.1.Only 26%of patient education materials(PEMs)had DISCERN scores corresponding to a"good quality"rating.There was a significant positive correlation between DISCERN scores and both Flesch-Reading Ease scores and average reading grade level.Conclusions:The majority of patient education materials were written above the recommended sixth-grade reading level and the quality of online information pertaining to neck dissections was found to be suboptimal.This research highlights the need for patient education materials regarding neck dissection that are high quality and easily understandable by patients.

Neck dissection does not add to morbidity or mortality of laryngectomy

Objectives:To examine the national rates of complications,readmission,reoperation,death and length of hospital stay after laryngectomy.To explore the risks of neck dissection with laryngectomy using outcomes.Methods:The American College of Surgeons National Quality Improvement Program(ACS-NSQIP)database was reviewed retrospectively.The database was analyzed for patients undergoing laryngectomy with and without neck dissection.Demographic,perioperative complication,reoperation,readmission,and death variables were analyzed.Results:754 patients who underwent total laryngectomy during this time were found.Demographic analysis showed average age was 63 years old,566(75.1%)were white,and 598(79.3%)were male.Of these patients,520(69.0%)included a neck dissection while 234(31.0%)did not.When comparing patients who received a neck dissection to those who did not,there were no significant differences in median length of hospital stay(12.5 days w/vs.13.3 days w/o,P=0.99),rates of complication(40%w/vs.35%w/o,P=0.23),reoperation(13.5%w/vs.14%w/o,P=0.81),readmission(14%w/vs.18%w/o,P=0.27),and death(1.3%w/vs.1.3%w/o,P>0.99).Furthermore,neck dissection did not increase the risk of complication(P=0.23),readmission(P=0.27),reoperation(P=0.81),death(P=0.94),or lengthened hospital stay(P=0.38).Conclusions:Concurrent neck dissection does not increase postoperative morbidity or mortality in patients undergoing total laryngectomies.These results may help physicians make decisions regarding concurrent neck dissection with total laryngectomy.

Contralateral neck dissection in oral squamous cell carcinoma:when it should be done?

Oral cavity squamous cell carcinoma(OSCC)has a high incidence of cervical micrometastases and sometimes metastasizes bilaterally because of the rich lymphatics in the submucosal plexus,which freely communicate across the midline.The presence of contralateral pathologic lymph nodes has been reported previously as a critical factor influencing the survival of patients.There are a few reports in the literature with regard to the rates of contralateral neck disease and the factors that may be involved in the risk with them.An elective ipsilateral neck treatment is generally recommended for initial treatment in all OSCC.However,no consensus exists whether or not to perform an elective contralateral neck dissection or radiation.In this study,a systematic review has been performed in order to evaluate the predictive value of clinical-histopathologic factors potentially related to contralateral occult lymph node metastasis in squamous cell carcinomas of the oral cavity to form a rational basis for elective contralateral neck management.

Elective neck dissection in early oral squamous cell carcinoma:necessary?

Aim:The indication of neck dissection in oral squamous cell carcinoma(OSCC)is a problem of risk-benefit evaluation between probability of neck metastases,the problem of complications associated with neck dissection and the prognostic influence of delayed diagnosis of metastasis during follow-up.There is no consensus on the elective treatment of the neck in early oral cancer patients with a clinically N0(cN0)neck.Methods:The author performed a search of PubMed articles with the words"elective neck dissection vs.observation","node negative neck"and"early stage oral squamous cell carcinoma".The author selected those articles that studied the early OSCC(T1-T2),and elective neck treatment was compared with clinical observation.Results:Many studies have compared the outcome of elective neck dissection(END)to observation of the neck in early OSCC.The results of them are described.The biologic aggressiveness of oral cavity squamous cell carcinoma,particularly in the early stages,is reflected in its ability to metastasize to regional lymph node chains.Many pretreatment imaging techniques to diminish the incidence of occult metastases haven been studied,and comparative studies have shown ultrasound guided fine needle aspiration cytology(USgFNAC)to be the most accurate.Conclusion:A few non-randomized studies have shown no advantages of END when strict USgFNAC follow-up was employed.Thus,if routine strict follow-up using USgFNAC by a well-trained ultrasonographer cannot be assured,END is the safest strategy.

A review of clinical and histological parameters associated with contralateral neck metastases in oral squamous cell carcinoma

Oral squamous cell carcinoma （OSCC） has a high incidence of cervical micrometastases and sometimes metastasizes contralaterally because of the rich lymphatic intercommunications relative to submucosal plexus of oral cavity that freely communicate across the midline, and it can facilitate the spread of neoplastic cells to any area of the neck consequently. Clinical and histopathologic factors continue to provide predictive information to contralateral neck metastases （CLNM） in OSCC, which determine prophylactic and adjuvant treatments for an individual patient. This review describes the predictive value of clinical-histopathologic factors, which relate to primary tumor and cervical lymph nodes, and surgical dissection and adjuvant treatments. In addition, the indications for elective contralateral neck dissection and adjuvant radiotherapy （aRT） and strategies for follow-up are offered, which is strongly focused by clinicians to prevent later CLNM and poor prognosis subsequently.

Vessel selection and free flap monitoring in head and neck microvascular reconstruction

Microvascular free flap surgery has become a successful and reliable method of reconstruction following head and neck cancer resection. The effectiveness of free flap reconstruction has increased with improved surgical technique as well as technological refinement in vessel selection and flap monitoring. Few papers have studied the factors that influence success or failure rates of free flap reconstructions, particularly with an eye towards the technologic advancements that have refined the procedure in the last several decades. Here we present a comprehensive review of perioperative and intraoperative considerations that influence free flap outcomes as well methods of vessel selection and flap monitoring important during microvascular reconstruction of the head and neck.

Sternocleidomastoid flap for reconstruction of tongue small cell carcinoma: A case report

BACKGROUND The management of tongue carcinoma is excision and radical neck dissection followed with reconstruction.This is a case report of a patient with tongue squamous cell carcinoma(SCC)who underwent the procedure with sternocleidomastoid(SCM)flap reconstruction.CASE SUMMARY A 52-year-old woman without smoking history complained tongue ulcer since 3 years ago.Based on the histopathological examination,the patient was diagnosed with T2N2M0 right tongue SCC and underwent wide excision of tumor;right mandibular;neck dissection and were reconstructed with SCM flap.CONCLUSION SCC of the tongue requires wide excision and dissection of the neck and mandible if infiltration into the surrounding lymph nodes has been found.The SCM flap reconstruction could be used post-surgery.