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MANAGEMENT OF N0 NECK
Souvik Adhikari
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N0 NECK: DEFINITION Non-palpable lymph nodes in the neck in the
presence of carcinoma in the drainage areas of
the nodes.
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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% whenmetastases are present).
Clinical palpation of the neck has a sensitivity andspecificity in the range of 60-70%.
Early microscopic metastases may not be detectableclinically, pathologically or radiologically.
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OCCULT NODAL METASTASES:
PREVALENCE BY SITEPiriform 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%
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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.
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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 sitesincluding the larynx.
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MANAGEMENT OF N0 NECK EXTREMELY CONTROVERSIAL:
DEBATE STILL CONTINUES!!
Challenge lies in identifying patients who areat risk of developing lymph node metastases.
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MANAGEMENT OPTIONS Conservative
Surgical therapy
Radiation therapy
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CONSERVATIVE MANAGEMENT Advocated where the likelihood of metastases
is low (
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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
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SURGICAL OPTIONS Radical Neck Dissection: historical Modified Radical Neck Dissection: preserves the
internal jugular vein, sternocleidomastoid muscle andspinal 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 oneor more groups of neck nodes.
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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: Anteriorcompartment
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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 forpatients with cancer of the oropharynx, hypopharynxand larynx (? of benefit also in oral SCC especiallybase of tongue cancers)
Posterolateral neck dissection: Levels II, III, IV andV; for malignant melanoma of the posterior scalp and
neck
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RADIATION THERAPY Lymph node dissection is advocated but the
patient refuses surgery.
Following selective node dissection if 3 ormore nodes contain metastases, ifextracapsular spread is present or if a nodal
metastases is found in 2 noncontiguous zones(skip metastases).
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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.
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FUTURE MRI spectroscopy: choline/creatine ratio high
in SCC
Photosensitizing drugs: detection of occultmetastases
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