Neck Dissection and Staging - AHNS · 1 Neck Dissection and Staging Jesus E. Medina, MD Department...

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Neck Dissection and Staging

Jesus E. Medina, MDJesus E. Medina, MD

Department of OtolaryngologyDepartment of Otolaryngology

The University of Oklahoma The University of Oklahoma

20132013

OBJECTIVES

●● To review the current Staging SystemTo review the current Staging System

●● To define the different Neck Dissections.To define the different Neck Dissections.

●● To describe the current management of the cervical lymph To describe the current management of the cervical lymph

nodes in nodes in SCCaSCCa of the H&N in a “stage based paradigm”.of the H&N in a “stage based paradigm”.

“N” STAGE

Prognostic Significance

“N” STAGE

Prognostic Significance

0

5

10

15

20

25

30

35

40

45

50

N0 N1 N2a N2b N2c N3

5 Year Disease Free Survival

Modified from KOWALSKI et al, Head & Neck 22:307, 2000

22

“N” Staging: Regional Lymph Nodes

Oral Cavity, Oropharynx,

Hypopharynx and Larynx

N0N0 No regional lymph node metastasis

N1N1 Metastasis in a single ipsilateral lymph node, 3 cm or

less in greatest dimension

N2aN2a Metastasis in single ipsilateral lymph node more than

3 cm but not more than 6 cm in greatest dimension

N2bN2b Metastasis in multiple ipsilateral lymph nodes, none

more than 6 cm in greatest dimension

N2cN2c Metastasis in bilateral or contralateral lymph nodes,

none more than 6 cm in greatest dimension

N3N3 Metastasis in a lymph node more than 6 cm in greatest

dimension

Nasopharynx

N0 No regional lymph node metastasis

N1 Unilateral metastasis in lymph node(s), 6 cm or less in

greatest dimension, above the supraclavicular fossa*

N2Bilateral metastasis in lymph node(s), 6 cm or less in

greatest dimension, above the supraclavicular fossa*

N3a Greater than 6 cm in dimension

N3b Extension to the supraclavicular fossa

Size

Side

Location

NECK DISSECTION

CLASSIFICATION CRITERIA:CLASSIFICATION CRITERIA:

�� The lymph node regions (levels) removedThe lymph node regions (levels) removed

�� The The structures preserved (XI structures preserved (XI Nerve, IJV, SCMM) Nerve, IJV, SCMM)

NECK DISSECTION CLASSIFICATION

The lymph node

regions (levels)

of the neck

NECK DISSECTIONS: CLASSIFICATION

Lymph Node Groups

Structures Preserved

RADICAL I - VSCMM, IJV,

XIN

33

RADICAL NECK DISSECTION:

Sequelae NECK DISSECTIONS: CLASSIFICATION

Lymph Node Groups



XIN

Modified Radical (I)

I - V XI N


Lymph Node Groups



XIN

Modified Radical

(I)

I - V SSCM, IJV

Modified Radical

(III)(Functional)

I - VSCMM, IJV,

XIN


Lymph Node Groups


RADICAL I – V - - -

Modified Radical

(III)

I – V XI N

Functional(I) I – V

SCMM, IJV, XIN

44


Lymph Node Groups

Structures Removed

SELECTIVEI – III/IV

“Supraomohyoid”---


Lymph Node Groups

Structures Removed




Lymph Node Groups

Structures Removed



Lymph Node Groups

Structures Removed

SELECTIVE

I – III/IV“Supraomohyoid”

---

II – IV“Lateral”

---


Lymph Node Groups

Structures Removed

SELECTIVE

I – III/IV“Supraomohyoid”

---

II – IV“Lateral”

---

II – V, suboccipital,

retroauricular“Posterolateral”

---

55


�� RADICAL RADICAL

�� MODIFIED RADICALMODIFIED RADICAL�� With Preservation of XI NerveWith Preservation of XI Nerve

�� With Preservation of XI Nerve, With Preservation of XI Nerve,

IJV, SCMMIJV, SCMM

�� SELECTIVESELECTIVE�� I I –– III/IV (III/IV (SupraomohyoidSupraomohyoid))

�� II II –– IV (Lateral)IV (Lateral)

�� PosterolateralPosterolateral

�� EXTENDEDEXTENDED

OBJECTIVES

●● To review the current Staging SystemTo review the current Staging System

●● To define the different Neck Dissections.To define the different Neck Dissections.

●● To describe the current management of the cervical lymph To describe the current management of the cervical lymph

nodes in nodes in SCCaSCCa of the H&N in a “stage based paradigm”.of the H&N in a “stage based paradigm”.

Stage Based Treatment of the Neck Stage Based Treatment of the Neck

� Treatment modality: Primary TumorPrimary Tumor

� N Stage: N0 N0 vsvs N+ (Extent of Disease)N+ (Extent of Disease)


� Treatment modality: SURGERYSURGERY

�� Oral CavityOral Cavity

�� T1T1--2 2 SupraglotticSupraglottic larynxlarynx

�� T 1T 1--2 Oropharynx 2 Oropharynx ((TransoralTransoral resection)resection)

66

Clinical N0


� Treatment modality: SURGERYSURGERY N0 Neck:

Concern for Subclinical Metastases?

Site of Primary TumorPercentage of Necks With Node

Metastases

ORAL CAVITY T1 T2 T3 T4

Oral Tongue 14 30 47.5 76.5

Floor of the Mouth 11 29 43.5 53.5

Retromolar Trigone 11 37.5 54 67.5

Site of Primary TumorPercentage of Necks With Node

Metastases

LARYNX T1 T2 T3 T4

Glottic 11 22

Supraglottic 39 69.5 64.5 59

HYPOPHARYNX 63 69.5 79 73.5

N0 Neck:


� CT, MRI, PET scans do not detect 40 - 50%

subclinical metastases

The Neck: Subclinical Metastases?

DiNardo 98 Don et al 95

Node Size (Oral Cavity) (All sites)

< 10 mm 88% 67%

77

Tumor Thickness Cutoff Point

No of StudiesNegative Predictive Value

Falsely Predicted Negative

3 mm 4 94.7 5.3

4 mm 9 95.5 4.5

5 mm 6 83.4 16.6

6 mm 4 87.0 13.0

p = 0.007

SCCa of Oral Cavity

Tumor Thickness: Predictive Value for LN Metastases

A Meta-analysis of Reported Studies

Huang S et al. Cancer 115:1489, 2009 T1: 9mm thick

T2: 2mm thick

N0 Neck:


Clinical N0

SNB

Selective ND

Treatment of the Neck: Stage Based

Primary Treated with SURGERY

Observation

Clinical N0

SNB

Selective ND



ObservationObservation

88

5 Year DFS % N+

Observation

%Salvaged

Observation END

Kligerman et al 1994 72 49 42 27

Yuen et a 2009 87 89 31 100

N0 Neck

Elective Treatment vs. Observation

Yuen AP et al. Head & Neck 31:765, 2009

Kligerman J et al. Am J Surg 168: 391,.1994

“Modern” Prospective Randomized Studies

5 Year DFS % N+

Observation

%Salvaged

Observation END

Kligerman et al 1994 72 49 42 27

Yuen et al 2009 87 89 31 100

Cruz et al 2009 68 74 47 59

N0 Neck

Elective Treatment vs. Observation

Yuen AP et al. Head & Neck 31:765, 2009

Kligerman J et al. Am J Surg 168: 391,.1994

“Modern” Prospective Randomized Studies

Currently… most H&N Surgeons prefer to dissect the neck

electively (social/psychological make up of our patients)

In the future… increasing reliance on US for follow up may

make surgeons more comfortable with observation

Clinical N0

SNB

Selective ND



Observation

99

SELECTIVE NECK DISSECTION

(SURGERY ALONE)

NECK PATHOLOGICALLY N0

Recurrence Rate

Byers, 1986 6.9%

Spiro, et al, 1988 5.0%

Kowalski, et al, 1993 3.2%

Medina et al, 1995 3.45%

Ambrosch, 1996 4.1%

Pitman, et al, 1997 4.9%

Davidson, et al, 1997 7.0%

Pelliteri, et al, 1997 3.0%

PROSPECTIVE TRIALPROSPECTIVE TRIAL

SUPRAOMOHYOID NECK DISSECTION

vs

TYPE III MRND

Brazilian Head & Neck Cancer Study Group

Am J Surgery 176 (5):422, 1998

Overall Survival Rates According to Therapeutic Group

Am J Surgery 176 (5):422, 1998

Currently, selective neck dissection is the Currently, selective neck dissection is the preferred surgicalpreferred surgical treatment of the Ntreatment of the N0 0 neckneck

1010

In the foreseeable future:

A selective neck dissection will not be the preferred way to detect occult metastases.

In the foreseeable future:

A selective neck dissection will not be the preferred way to detect occult metastases.

Clinical N0

SNB

Selective ND



Observation

1111

Lymphoscintigraphy

Sentinel Node Excision

Serial Sectioning & IHC

Evolution of Treatment of the Neck: The N0 Neck

Selective Neck Dissection

● Average: 24 nodes

● One histologic section

Friedman et al. Laryngoscope 109:368, 1999

Sentinel Node

Biopsy

● Average : 2.4 nodes

● Serial Sectioning, IHC, molecular markers

Shoabib et al. Br J Pl Surg 58:790, 2005

Evolution of Treatment of the Neck: The N0 Neck

NSLN

detection rate

SLN pos

SLN neg NPVNPV

Literature 223 98% 30% 70% 98%98%

Conference 379 97% 29% 71% 96%96%

2nd International Conference SNB in Mucosal Head and Neck Cancer: 2005

1212

SNB: Limitations

In the future:

The likelihood of occult metastases from tongue cancer will be determined based on a panel of molecular/gene markers in the primary tumor.

Clinical N+

SND,

MRND, RND (Adequate

removal of neck disease)



Nodes pathologically negative (pN0) 54.7%

Isolated Metastasis: Level IV or V 0.0%

THE N+ NECK: Recent observations

Clinically N1 neck disease involving levels I or II

Kowalski & Carvallo. Head Neck 2002;24:921-4

1313

Selective ND

I - IV

N2aN2a

Level I

N + NECK : SELECTIVE NECK DISECTIONSELECTIVE NECK DISECTION: N+ Neck

Pathological Stage Recurrence Rate

N1 4.9%

N2 12.1%

Ambrosch et al. Otolaryngol Head Neck Surg 2001;124:180-7.

PROSPECTIVE TRIAL” BRAZILIAN HEAD AND NECK GROUPOverall Survival Rates According to Therapeutic Group

Am J Surgery 176 (5):422, 1998

SELECTIVE NECK DISSECTION IN THE CLINICALLY POSITIVE NECK

Patel, RS et al Head and Neck 30: 1231Patel, RS et al Head and Neck 30: 1231––1236, 20081236, 2008

Control in Dissected Neck Overall Survival

1414

• Multiple, large

nodes at different

levels..

Radical neck dissection

• Multiple,

matted nodes.

Radical neck dissection

Modified radical neck

dissection

Multiple small nodes in

different levels, including

Level V

Modified radical neck

dissection

1515

Clinical N0 Clinical N+

SNB

Selective ND

RND,

MRND, SND(Adequate


No further

treatment

pN0




SNB

Selective ND

RND,

MRND, SND(Adequate


Postop.

Radiation (?)

pN1



NECK DISSECTION

Oral Tongue Cancer

NECK PATHOLOGICALLY N1

Medina, et al, 20%

Byers, et al, 25%

Ambrosch, et al, 16%

Path N1 + ECS

50

With XRT: 36 Without XRT: 14

2/36 (5.6%) Regional Failure 5/14 (35.7%)2/36 (5.6%) Regional Failure 5/14 (35.7%)

Regional Failure Supraomohyoid Neck Dissection

Byers et al, 2002

1616


SNB

Selective ND

RND,

MRND, SND(Adequate


Postop. Radiation

ECS: Chemo/Radiation

pN 2-3


Primary Treated with SURGERYEvaluation of the Dose for Postoperative Radiation Therapy of H&N Cancer: Prospective Randomized Trial (MDACC)

Risk Dose (Gy)

Lower 57.6

Higher (ECS) 63.0

Peters, LJ et al. Int J Rad Oncol Biol Phys 26:3, 1993

The Treatment of the N+ Neck

Postoperative Radiation vs Concurrent Radiation

and Chemotherapy

459 Patients

334 Patients

Radiotherapy

60 – 66Gy/ 6 – 6.5 weeks

Radiotherapy

Cisplatin 100mg/msq

(D 1, 22, 43 - 44)

RANDOMIZED

RTOG. N Engl J Med 350: 1937, 2004

EORTC. N Engl J Med 350:1945, 2004

Treatment Arm

Local Regional Control

RTOG EORTC

Radiation 72% 69%

Radiation +

Chemotherapy82% 82%

p= 0.01 p= 0.007

1717

Bernier et al. Head Neck 27: 843, 2005


SNB

Selective ND

RND,

MRND, SND(Adequate


No further

treatment

pN0

Postop.

Radiation (?)

pN1

Postop. Radiation

Chemo/Radiation

pN 2-3




� Treatment modality: RADIATION RADIATION ++ CHEMOCHEMO

�� OropharynxOropharynx

�� T3 larynx, T3 larynx, hypopharynxhypopharynx


Primary Treated with RADIATION + CHEMOTHERAPY

1818

Clinical N0



Clinical N0

Radiation

No further

treatment



Clinical N0

Radiation

No further

treatment



Clinical N+

Complete

Response

Persistent

Palpable/Rad.

Abnormality

PET/CT 12 wks

Observation

NEGATIVE

Persistent Palpable or Radiological Abnormality

1919

PETPathology

PPV NPV

Positive (SUV >3) 44% 100%

Sterling R et al.. Presented AAOHN . October 2012

Utility of PET-CTManagement N+ Neck: Organ Preservation

PET/CT 12 wks

Neck Dissection Observation

POSITIVE NEGATIVE

Persistent Palpable or Radiological Abnormality

Exam q 4 wks

US/CT

Extent of Disease Extent of Disease

(RND, MRND, SND, SSND )(RND, MRND, SND, SSND )

Pre-treatment: SUV 13.6 Post-treatment: SUV 3

2020

●● Patients with clinical and Patients with clinical and radiologicallyradiologically positive nodes in positive nodes in Level II only could Level II only could benefit from benefit from SSND?SSND?

Regional Control

Overall Neck Recurrence Rate:Overall Neck Recurrence Rate: 2/50 (4%)2/50 (4%)

Planned Neck Dissection for Clinical/Radiological “Residual” Abnormality Recent trend….

Selective NeckSelective Neck

DissectionDissection

Recurrence in the Recurrence in the

NeckNeck

Stenson et al (2000)Stenson et al (2000) 5656 1 ( 2%)1 ( 2%)

Robbins T et al (2004)Robbins T et al (2004) 3333 1 ( 3%)1 ( 3%)

Stenson K et al Arch Otolaryngol 126:950, 2000

Robbins KT et al J Am Coll Surg 199:913, 2004

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OBJECTIVES

●● Understand the current Staging SystemUnderstand the current Staging System

●● Know the different neck dissections.Know the different neck dissections.

●● Working understanding of the role of staging on the current Working understanding of the role of staging on the current

management of the cervical lymph nodes in management of the cervical lymph nodes in SCCaSCCa of the H&N.of the H&N.


�� RADICAL RADICAL

�� MODIFIED RADICALMODIFIED RADICAL�� With Preservation of XI NerveWith Preservation of XI Nerve

�� With Preservation of XI Nerve, With Preservation of XI Nerve,

IJV, SCMMIJV, SCMM

�� SELECTIVESELECTIVE�� I I –– III/IV (III/IV (SupraomohyoidSupraomohyoid))

�� II II –– IV (Lateral)IV (Lateral)

�� PosterolateralPosterolateral

�� EXTENDEDEXTENDED

Neck Dissection and Staging - AHNS · 1 Neck Dissection and Staging Jesus E. Medina, MD Department...

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