1. Radical Neck Dissection: (RND) Classification, Indication and Techniques

2. Introduction
Crile in 1906 introduced RND and is followed by Martin as a the classical procedure for the management of cervical lymph node metastasis
Recently changes in classification and indication led to inconsistency
N0 in recent studies may require selective RND to reduce morbidity

3. Staging of Neck Nodes NX: N0: N1: N2:
Regional lymph nodes can not be assessed
N0:
No regional lymph node metastasis
N1:
Metastasis in a single ipsilateral lymph nodes, 3 cm or less in greatest dimension
N2:
N2a:
Metastasis in a single epsilateral lymph nodes, more than 3 cm but less than 6 cm

4. Meyers & Eugene: Operative Otolaryngology. 1997
Staging of Neck Nodes
N2b:
Metastasis in multiple ipsilateral lymph nodes, not more than 6 cm
N2c:
Metastasis in bilateral or contralateral nodes not more than 6 cm in diameter
N3:
Metastasis in lymph nodes more than 6 cm in in greatest diameter
Meyers & Eugene: Operative Otolaryngology. 1997

5. Lymph Node Regions Region I: Submental and submandibular triangle
Ia: Submental triangle:
Bounded by the anterior belly of digastric and the mylohyoid muscle deep
Ib: Submandibular triangle:
Formed by the anterior and posterior belly of the digastric muscle and the body of the mandible
Memorial Sloan-kettering Cancer center

6. Lymph Node Regions Region II – IV:
Lymph nodes are associated with the Internal Jugular Vein (IJV) within the fibroadipose tissues that extend from the posterior border of sternocledo-mastoid muscle (SCM) medial to lateral border of the sternohyoid muscle
Memorial Sloan-kettering Cancer center

7. Lymph Node Regions Region II:
Upper third including upper jugular, jugulodigastric and upper posterior cervical nodes
Bounded by the digastric muscle superiorly and the hyoid bone or carotid bifurcation inferiorly
IIa:
nodes anterior to Spinal Accessory Nerve (SAN)
IIb:
nodes posterior to Spinal Accessory Nerve (SAN)
Memorial Sloan-kettering Cancer center

8. Lymph Node Regions Region III: Region IV:
Middle third jugular nodes from the carotid bifurcation to cricothyroid notch or omohyoid muscle
Region IV:
Lower third jugular nodes from omohyoid muscle superiorly to the clavicle inferiorly
Memorial Sloan-kettering Cancer center

9. Lymph Node Regions Region V:
Lymph nodes of the posterior triangle along the lower half of the SAN and the transverse cervical artery
Bounded by the anterior border of the trapezius posteriorly, the posterior border of SCM anteriorly and the clavicle inferiorly
Memorial Sloan-kettering Cancer center

10. Lymph Node Regions Region VI:
Anterior compartment, lymph nodes surrounding the midline visceral structures that extend from the hyoid bone superiorly to the suprasternal notch inferiorly
The lateral boundary is the medial border of the carotid sheath
Perithyroid, paratracheal, and lymph nodes around the recurrent laryngeal nerve
Memorial Sloan-kettering Cancer center

11. Classification
The RND is classified according to the Academy’s Committee for Head & Neck Surgery & Oncology into four major type:
Radical Neck Dissection (RND)
Modified Radical Neck Dissection (MRND)
Selective Neck Dissection (SND)
Supraomohyoid
Posterolateral
Lateral
Anterior
Extended Radical Neck Dissection (ERND)

12. Classification Radical neck Dissection:
Removing all lymphatic tissues in regions I - V and include removal of SAN, SCM and IJV
Modified radical neck dissection:
Excision of all lymph nodes removed with RND with preservation of one or more non-lymphatic structures, SAN, SCM and/or IJV
Subtype I: Preserve SAN
Subtype II: Preserve SAN & SJV
Subtype III: preserve SAN, SJV and SCM
Known as Functional neck dissection (Bocca)

13. Classification Selective Neck dissection:
Any type of cervical lymphadenectomy with preservation of one or more lymph node groups
Four subtype:
Supraomohyoid neck dissection
Posterolateral neck dissection
Lateral neck dissection
Anterior neck dissection

14. Classification Supraomohyoid neck dissection:
Removal of lymph nodes in regions I –III
The posterior limit is the cutaneous branches of the cervical plexus and posterior border of SCM
The inferior limit is the superior belly of the omohyoid where it cross IJN
Posterolateral neck dissection
Removal of suboccipital, retroauricular, levels II – V and level V
Subtyped I – III depending on the preservation of SAN, IJV and /or SCM
Medina

15. Classification Lateral neck dissection: Anterior neck dissection:
Remove lymph nodes in levels II – IV
Anterior neck dissection:
Require the removal of the lymph nodes surrounding the visceral structure in the anterior aspect of the neck, level VI
Superior limit, hyoid bone
Inferior limit, suprasternal notch
Laterally, the carotid sheath

16. Classification Extended neck dissection:
Any previous dissection and including one or more additional lymph node groups and/or non-lymphatic tissues

17. Facts General nodal metastasis produce the following fact:
The most important factor in prognosis of SCC of the upper aero-digestive tract is the status of cervical lymph nodes
Cure rate drops 50% with involvement of the regional lymph nodes

18. Indications For ND
Radical neck dissection was believed by Martin to be the only method to control cervical lymphadenectomy
Anderson found that preservation of SAN did not change the survival or tumor control in the neck
Actual 5-year survival and neck failure rate is:
RND: % and 12 %
MRND: 71% and 12%

19. Indications Radical Neck Dissection
Multiple clinically obvious cervical lymph node metastasis particularly of posterior triangle and closely related to SAN
Large metastatic tumor mass or multiple matted in upper part of the neck
Tumor should not be dissected to preserve Structures

20. Indications Modified radical neck dissection MRND Type I:
Clinically obvious neck lymph nodes metastasis and SAN not involved by tumor
Intraoperative decision just like preservation of the facial nerve in parotid surgery

21. Indications MRND Type II: MRND Type III: Rarely planned
Intra-operative decision for tumor found adherent to SCM but away from SAN & IJV
MRND Type III:
Depend on the autopsy reports
Lymph nodes were in the fibrofatty and do not share the same adventitia with blood vessels
They are not found within the aponeurosis or glandular capsule of the submandibular “Functional neck dissection”

22. Indications MRND Type III: For treatment of N0 neck nodes
Indicated for N1 mobile nodes and not greater than 2.5 – 3.0 cm
Contra-indicated in the presence of node fixation
Result is difficult to interpret because of the use of radiation therapy

23. Indications Selective/elective neck dissection:
For treatment of N0 neck nodes
For N+ nodes when combined with radiotherapy
Adjuvant radiotherapy for patient with 2 – 4 positive nodes or extra-capsular spread
Supraomohyoid is indicated for SCC of oral cavity with N0 and N1 with palpable mobile nodes less than 3 cm and located in level I and II
Upgrade intra-operatively following positive frozen section

24. Treatment option for N0 nodes
Observe
Radiation therapy
Elective neck dissection
Low morbidity
Staging neck for possible extended surgery
Need for post-operative radiotherapy

25. Rationale for S/END
Rate of occult metastasis in clinically negative nodes is 20 – 30% using clinical and radiographic findings
Ct scan combined with physical exam decreased the rate of occult metastasis to 12%
This suggested lowering of the criteria for elective neck dissection
Friedman et al Laryngoscope 100; 54 – 59: 1990

26. Shah. Ann Surg Oncol 1(6); 521-532: 1994
Rationale for S/END
Anatomic studies showed that lymphatic drainage from the mucosal surfaces follow a constant and predictable route
Lymph flow from SA chain to the jugular chain is unilateral
Shah. Ann Surg Oncol 1(6); : 1994

27. Rationale for S/END
Shah, in his study produced a compelling evidence of predictable nodal metastasis from SCC from upper aerodigastive tract
He found a specific pattern for nodal spread by location of primary
NO in patients with oral cavity SCC:
7/1119 (3.5%) had nodal involvement outside supraomohyoid dissection
3 (1.5%) had isolated involvement outside level I - III
Friedman Laryngoscope 100; 54-59: 1990

28. Rationale for S/END N+ nodes in patients with oral SCC:
50/246 had nodal metastasis outside level IV
10/246 had metastasis in level V
He examined nodal involvement in patients with nasopharynx and other upper parts of the aerodigastive tract
Conclusion:
SCC of the oral cavity:
Level I, II and III are at risk
SCC nasopharynx and larynx
Level II, III and IV are at risk
Shah Amer J Surg 160; : 1990
Shah Cancer July 1 ; : 1990

29. Rationale for S/END
Byers stated that SND combined with postoperative radiotherapy in selected patients with oral cavity SCC was adequate treatment with similar recurrence rate as those treated with MRND III
Spiro reported 12% with supraomohyoid dissection in N1 nodes but not all of them received radiotherapy
Byers Head Neck Surg; Jan-Feb; : 1988

30. Selective/Elective Neck Dissection
A good option for N0 neck
Not a suitable option for N+ neck
Is used N+ neck when combined with radiotherapy
Intra-operative frozen section evaluation is needed to confirm in cases of intraoperative palpable nodes

31. The anatomy
Skin:
Blood supply:
Descending branches:
The facial
The submental
Occipital
Ascending branches
Transverse cervical
Suprascapular
The branches perforate the platysma muscle, anastomose to form superficial vertically-directed network of vessels
Skin incision is superiorly based apron-like incision from mastoid to mentum or to contralateral mastoid

32. The anatomy Platysma muscle: Wide, quadrangular sheet-like muscle
Run obliquely from the upper part of the chest to lower face
Skin flap is raised immediately deep to the muscle
The posterior border is over or just anterior to IJV and great auricular nerve
Does not cover the inferior part of the anterior triangle and the posterolateral neck

33. The anatomy Sternocleidomastoid muscle: SCM
Differentiated from the platysma by the direction of its fibres
Crossed by the IJV and the great auricular nerve from inferior to posterior deep to platysma
The posterior border represent the posterior boundary of nodes level II - IV

34. The anatomy Marginal Mandibular nerve: MMN
Located 1 cm in front of and below the angle of the mandible
Deep to the superficial layer of the deep cervical fascia
Superficial to adventitia of the anterior facial vein

35. The anatomy Spinal Accessory nerve: SAN
Emerge from the jugular foramen medial to the digastric and stylohyoid muscles and lateral and posterior to IJV (30% medial to the vein and in 3 -5% split the nerve)
It passes obliquely downward and backward to reach the medial surface of the SCM near the junction of its superior and middle thirds, Erb’s point

36. The anatomy Trapezius muscle:
Its anterior border is the posterior boundary of level V
Difficult to identify because of its superficial position
Dissect superficial to the fascia in order to preserve the cervical nerves

37. The anatomy Digastric Muscle; Posterior belly:
Originate from a groove in the mastoid process, digastric ridge
The marginal mandibular nerve lie superficial
The external and internal carotid artery, hypoglossal and 11th cranial nerves and the IJV lie medial

38. The anatomy Omohyoid muscle:
Made of two bellies, and is the anatomic separation of nodal levels III and IV
The posterior belly is superficial to the brachial plexus, phrenic nerve and transverse cervical artery and vein
The anterior belly is superficial to the IJV

39. The anatomy Brachial Plexus & Phrenic nerve:
The plexus exit between the anterior and middle scalene muscles, pass inferiorly deep to the clavicle under the posterior belly of the omohyoid
The phrenic nerve lie on top of the anterior scalene muscle and receive it is cervical supply from C3 – C5

40. The anatomy Thoracic duct:
Located in the lower let neck posterior to the jugular vein and anterior to phrenic nerve and transverse cervical artery
Have a very thin wall and should be handled gently to avoid avulsion or tear leading to chyle leak

41. The anatomy Exit via the hypoglossal canal near the jugular foramen
Passes deep to the IJV and over the ICA and ECA and then deep and inferior to the digastric muscle and enveloped by a venous plexus, the ranine veins
Pass deep to the fascia of the floor of the submandibular triangle before entering the tongue

42. Summary Unified classification is relatively new
Indication and the type of ND, specially for N0, is controversial
The following surgical outline was suggested:
SCC oral cavity anterior to circumvalate papilla
Supraomohyoid
SCC Oropharynx, larynx and hypopharynx
level I- IV or level II-V
SCC with N+ nodes
RND
SCC with 2-4 positive nodes or extracapsular spread
RND and adjuvant therapy
Shah Cancer July 1; : 1990