Radical Neck Dissection: RND Classification, Indication and Techniques

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
• 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
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
• 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 Academys
  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
• 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 63 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
• 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
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) 521-532 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 160 405-409 1990 Shah Cancer
July 1 109-113 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 160-167 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, Erbs
  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 1109-113 1990