Neck lymph node metastases to the posterior triangle apex: evaluation of clinical and histopathological risk factors

The boundary of posterior to level V region and the theoretical feasibility of irradiation dose reduction of level Va in nasopharyngeal carcinoma

The lymph node involvement in the posterior to level V (PLV) region is mainly observed in nasopharyngeal carcinoma (NPC). Recently, we have reported the distribution of metastatic lymph nodes in the PLV region and there are correlations between the neck node levels (NNL) of NPC, but what is the boundary of the PLV region and how to delineate it remains unclear, and we further to elaborate whether the bilateral level Va should be covered as intermediate-risk nodal regions (CTVn2, about 60 Gy equivalent) for all T and N categories based on these correlations. A total of 1021 consecutive NPC patients with N1-3 stage from January 2012 to December 2020 were reviewed. The lymph node metastasis level of each patient was evaluated according to the updated guidelines proposed in 2013. According to the distribution pattern of lymph node metastasis and the anatomical structure in the PLV region, the boundaries of PLV region was delineated, and whether it is appropriate to cover the bilateral level Va as CTVn2 for all the NPC patients was further discussed. The correlations of level Va with other NNL were studied using logistic regression model. The cranial boundary of PLV region is the caudal border of cricoid cartilage, the caudal boundary is the plane serratus anterior muscle begins to appear, the anterior boundary is the anterior border of trapezius, and the posterior boundary is the convergence of levator scapulae and trapezius. Laterally, the PLV region is limited by the medial edge of trapezius and medially by the lateral surface of levator scapulae. The nodal spread in level Va is based on the lymph node metastasis of level IIb in NPC. The PLV region is a missing NNL of head and neck tumors, especially in NPC. The proposed boundaries of the PLV region can provide a preliminary proposal for the further revision of NNL in head and neck tumors. It is theoretically feasible to reduce the prophylactic irradiation dose of the bilateral level Va in patients with N0 stage or with isolated metastases in level VIIa.

Cervical level IIb metastases in squamous cell carcinoma of the oral cavity: a systematic review and meta-analysis

Purpose

The aim of this study was to clarify whether level IIb dissection should be performed or avoided in the treatment of oral squamous cell carcinoma by meta-analysis.

Materials and methods

Articles that were published before June 2017 were searched electronically in four databases (Web of Science, PubMed, Ovid and China National Knowledge Infrastructure) without any date or language restrictions by two independent reviewers. Abstracts and full-text papers which investigated the cervical metastases to level IIb from primary head and neck cancers and were deemed potentially relevant were screened. Data were analyzed using RevMan 5.3.

Results

Four hundred and fifty-five abstracts and 129 full-text papers were screened, and 22 studies were included in the analysis. Among the 2001 patients included, 112 patients had level IIb metastases, the pooled frequency of which was 6% (95% confidence interval [CI]: 4.0–7.0). Among the 400 patients with tongue squamous cell carcinoma from 12 studies, 37 patients had level IIb metastases, the pooled incidence of which was 7% (95% CI: 5.0–10.0). Metastases to level IIb always went together with level IIa, and only three patients were found to have isolated level IIb metastases without involving the other levels.

Conclusion

Due to the low frequency of level IIb nodal metastases in oral squamous cell carcinoma patients and rare occurrence of isolated level IIb, level IIb dissection could be avoided when the primary lesions were in early stages (T1 and T2), with the exception of tongue cancer. It is recommended to dissect level IIb tongue cancers without considering the stages of primary lesions and the lymph nodes status. It is also suggested that level IIb dissection should be performed in patients preoperatively or intraoperatively found with multilevel neck metastasis, especially level IIa metastasis.

Is it worthy? Removal of level IIB nodes during selective neck dissection (I-III) for oral carcinomas

Aims:

The aim was to correlate the incidence of metastasis to Level IIB of neck lymph nodes (LNs) for oral cavity carcinomas with the site, size, and histological grade of tumor.

Settings and Design:

Total 30 patients of either sex, with biopsy-proven oral squamous cell carcinoma of any site, size or histologic grade, but N0/N1 were taken for selective neck dissection (SND).

Materials and Methods:

Thirty patients who underwent SND for oral carcinoma were analyzed for the relation of the site, size, and histological grade of malignancy with metastatic involvement to Level IIB nodes. Level IIB nodes were dissected separately and sent for histopathological examination.

Statistical Analysis Used:

The data were entered in custom written software in Excel (MS office 2007, Windows XP) and the data were analyzed using statistical software STATA version 10.0. The statistical test used for the analysis of the result was Chi-square test. The critical level of statistical significance chosen was P < 0.05.

Results:

Only 2 of 30 patients (6.6%) had the involvement of Level IIB neck nodes. There was no relation between the site, size, and histologic grade of primary tumor with the metastasis to Level IIB. The Level IIA nodes were positive in both the positive cases of Level IIB.

Conclusions:

For tumors in oral cavity (N0/N1), while performing elective or therapeutic SND the dissection of Level IIB nodes could be omitted as it will provide significant decrease in operative time and also less of spinal accessory nerve trauma-related complications.

Relevance of level IIb neck dissection in oral squamous cell carcinoma

Background

The purpose of this study was to determine the prevalence of level IIb metastasis in patients with oral squamous cell carcinomas (OSCCs).

Material and Methods

A prospective analysis of 56 patients with OSCC who underwent surgical treatment of the primary lesion with simultaneous neck dissection was performed. During neck dissection, level IIb lymph nodes were separately removed and processed. Neck dissection was bilateral in 26 patients (46%) and unilateral in 30 patients (54%).

Results

The mean number of nodes found in the level IIb specimens was 4.7 (range: 0-8 nodes). The prevalence of metastasis at level IIb was 0% in pN0 necks and 3.4% in pN+ necks, with an overall prevalence of 1.8%. A significant association between metastasis to level IIb and type of neck dissection was observed. There were no isolated metastases to level IIb without the involvement of other nodes in the remaining neck specimen. Four regional recurrences were observed during follow-up.

Conclusions

Based on our findings, we suggest that dissection of the level IIb region in patients with OSCC may be required only in patients with multilevel neck metastasis or if level IIa metastasis is found intraoperatively.

Key words: Oral squamous cell carcinoma, neck dissection, level IIb, metastasis, spinal accessory nerve.

Relevance of level I and IIB neck dissection in laryngeal cancer

OBJECTIVES

Dissection of neck levels I and IIB is time-consuming and can cause comorbidity. This study aimed to determine whether level I and IIB neck dissection was necessary in patients with laryngeal cancer and clinically detectable or nondetectable neck nodes.

PATIENTS AND METHODS

This was a retrospective review of 73 patients with laryngeal cancer. Essential clinical data were obtained and analysed to determine the incidence of neck node metastasis in levels I and IIB.

RESULTS

Of the 48 patients with no clinically apparent neck nodes, none had level I metastases and only one had level IIB metastases. Of the patients with clinically detectable neck nodes, three of 21 patients had level I metastases and three of 25 patients had level IIB metastases; these six patients also had additional metastases in level IIA.

CONCLUSION

Dissection of neck levels I and IIB is justifiable in laryngeal cancer patients with clinically detectable neck nodes and suspicious lymph nodes in the respective level or level IIA. However, in patients without clinically detectable neck nodes, preservation of levels I and IIB is oncologically safe, economical and reduces the risk of comorbidity.

Current management strategy of hypopharyngeal carcinoma

OBJECTIVES

Squamous cell carcinoma (SCC) of the hypopharynx represents a distinct clinical entity among other cancers of the head and neck region. Despite recent advances in chemoradiotherapy, surgery remains the preferred therapeutic option for locally advanced disease and salvage for failure after chemo-radiotherapy. In this article, several aspects of surgical and non-surgical approaches in the management of hypopharyngeal cancer are discussed.

METHODS

A search in pubmed was made for publications with regard to the management of hypopharyngeal carcinoma.

RESULTS

In early-staged hypopharyngeal cancer, the overall and disease-specific survival rates after organ-preserving radiotherapy is comparable to that after surgery. However, for advanced staged disease, the results initial surgery with post-operative adjuvant radiotherapy was superior to chemoradiotherapy alone. The incidence of occult nodal metastasis is found to be more than 20%. Selective neck dissection removing cervical lymph node level II-IV is the procedure of choice for patients with clinically N0 neck. Contralateral nodal clearance may also be considered in tumors involving the medial wall of the pyriform recess, post-crioid region or the posterior wall, and those with ipsilateral palpable nodal metastasis and clinical stage IV disease. Transoral robotic surgery (TORS) has the potential value as the minimally invasive procedure for the management of carcinoma of the hypopharynx.

CONCLUSIONS

The treatment strategy for carcinoma of the hypopharynx has been evolving with time. Organ preserving chemoradiotherapy has been the treatment of choice for early stage disease, with surgical resection and reconstruction reserved for advanced and recurrent tumors.

Focus issue: neck dissection for oropharyngeal squamous cell carcinoma

The staging and prognosis of oropharyngeal squamous cell carcinoma is intimately tied to the status of the cervical lymph nodes. Due to the high risk for occult nodal disease, most clinicians recommend treating the neck for these primary tumors. While there are many modalities available, surgical resection of nodal disease offers both a therapeutic and a diagnostic intervention. We review the relevant anatomy, nodal drainage patterns, clinical workup, surgical management and common complications associated with neck dissection for oropharyngeal squamous cell carcinoma.

The necessity of dissection of level IIb in laryngeal squamous cell carcinoma: a clinical study

OBJECTIVE

Head and neck squamous cell carcinomas readily metastasize to adjacent cervical lymph nodes. This is seen frequently in laryngeal squamous cell carcinoma (LSCC), and neck dissection may be performed in addition to excision of the primary lesion. The aim of this study was to define the frequency of level IIb metastasis to the lymph nodes in patients who underwent selective neck dissection because of LSCC.

STUDY DESIGN AND SETTING

Cross-sectional study with planned data collection in a tertiary referral hospital.

SUBJECTS AND METHODS

Eighty-one patients diagnosed with LSCC were accepted into the study. One hundred forty-eight neck dissection specimens were examined histopathologically, and those with level IIb metastasis were identified. The frequency of level IIb metastasis was evaluated in accordance with the primary tumor site, clinical N stage, central tumor presence, and T stage.

RESULTS

Forty-seven of 81 patients were clinically N-, and 34 patients were clinically N+. Level IIb metastasis was seen in 5 (6%) of 81 patients, representing 5 of 148 neck dissection specimens. Two of these 5 patients were clinically N+ (6%), and 3 were clinically N- (6%). The relationship between level IIb metastasis and clinical N stage was not statistically significant (P ≥ .05). Likewise, no statistically significant relationships between the other parameters and level IIb involvement were found.

CONCLUSION

Level IIb nodal involvement is very rare in LSCC. Therefore, the area can generally be preserved in elective neck dissection to lessen morbidity and, specifically, to avoid damaging the function of the spinal accessory nerve.

Guidelines for delineation of lymphatic clinical target volumes for high conformal radiotherapy: head and neck region

The success of radiotherapy depends on the accurate delineation of the clinical target volume. The delineation of the lymph node regions has most impact, especially for tumors in the head and neck region. The purpose of this article was the development an atlas for the delineation of the clinical target volume for patients, who should receive radiotherapy for a tumor of the head and neck region. Literature was reviewed for localisations of the adjacent lymph node regions and their lymph drain in dependence of the tumor entity. On this basis the lymph node regions were contoured on transversal CT slices. The probability for involvement was reviewed and a recommendation for the delineation of the CTV was generated.

Is it necessary to dissect levels I and IIB in hypopharyngeal cancer?

CONCLUSION

The low incidence of metastases in levels I and IIB in patients with hypopharyngeal cancer in cases of clinical N0 and N+ neck and the fact that all patients with metastases in levels I and IIB received postoperative radiotherapy justifies the preservation of levels I and IIB in patients with hypopharyngeal cancer to improve functional results and reduce the operating time.

OBJECTIVES

Neck dissection of levels I and IIB is technically demanding due to the complex local anatomy and can cause several comorbidities. Therefore the aim of the study was to analyze whether levels I and IIB have to be dissected in patients with hypopharyngeal cancer.

METHODS

This was a retrospective analysis of all patients who underwent primary surgical treatment for hypopharyngeal cancer and neck dissection, with evaluation of the incidence of metastases in levels I and IIB in cases of cN0 and cN+ neck.

RESULTS

None of the patients with cN0 neck but 2/33 patients with cN+ neck had metastases in level I. Metastases in level IIB were detected in 1/14 patients with cN0 neck and 2/36 patients with cN+ neck. All patients with metastases in levels I and IIB received postoperative radiotherapy due to the N2b and N2c status.

Metastases to level IIb in squamous cell carcinoma of the oral cavity: a systematic review and meta-analysis

BACKGROUND

In this study, a meta-analysis of level IIb metastases in squamous cell carcinoma (SCC) of the oral cavity was conducted.

METHODS

Two independent reviewers screened abstracts and full text papers deemed potentially relevant. Data were pooled using a random intercept model.

RESULTS

In this analysis, 729 abstracts and 177 full text papers were screened (Kappa statistic 0.8 and 1.0, respectively). A total of 332 patients in 9 papers were included in the analysis. Twenty patients had level IIb metastases (mean, 6%; range, 0% to 10.4%). The pooled percentage of level IIb metastases was 6.0% (95% CI: 3.5-8.6). Only 3 patients with level IIb metastases had isolated nodal disease. Eighty-five percent of those with level IIb metastases had additional nodal disease (95% CI: 64.0-94.8), with IIa being a common denominator among all.

CONCLUSION

Level IIb nodal metastases are relatively uncommon in previously untreated SCC of the oral cavity (6%). Furthermore, isolated level IIb nodal disease is uncommon. However, given the quality of evidence to date, it is recommended that dissection of level IIb remain the standard of care in oral cavity squamous cell cancer.

Accessory nerve function after level 2b-preserving selective neck dissection

BACKGROUND

The aim of this prospective study was to evaluate the relationship between accessory nerve functions and level 2b-preserving selective neck dissection.

METHODS

Forty-one necks of 30 patients with laryngeal cancer who underwent unilateral or bilateral level 2b-preserving neck dissections, between February 2003 and July 2005, were evaluated. Neck and shoulder movements and muscle strengths were examined and electroneuromyography (ENMG) was performed preoperatively at the postoperative 21st day and 6th month. Pathological anatomical findings at the postoperative 6th month were also evaluated.

RESULTS

All shoulder movements and muscle strengths were preserved. Neck extension, rotation movements, and flexion strengths were restricted. ENMG values were affected moderately in the early postoperative period and improved slightly in the late postoperative period. None of the patients developed shoulder syndrome or adhesive capsulitis.

CONCLUSION

Preserving level 2b during selective neck dissection decreases trauma to the accessory nerve and improves functional results.

Is level IIb lymph node dissection always necessary in N1b papillary thyroid carcinoma patients?

INTRODUCTION

Papillary thyroid carcinoma (PTC) patients show a high rate of cervical lymphatic metastasis. However, there are no universal binding guidelines for the extent of lateral cervical lymph node dissection (LND) in such cases. In particular, the need for LND above the spinal accessory nerve (SAN) remains controversial. The present study examined whether level IIb lymph node (LN) dissection is always necessary in PTC patients with lateral cervical LN metastasis.

MATERIALS AND METHODS

The study prospectively examined 167 PTC patients with lateral cervical LN metastasis who underwent modified radical neck dissection (MRND) in our institution from November 2005 to March 2007. The MRND was bilateral in 24 cases. All patients underwent level II, III, IV, and V LND. Levels IIa and IIb LNs were individually dissected in all cases. All LND was performed using strict leveling criteria by a single operating team. The patterns of lymphatic metastasis and potential risk factors for level IIb LN involvement were evaluated.

RESULTS

The most common site of metastasis was level III (80.6% of cases), followed by level IV (74.9%) and II (55.5%). The metastasis rates in level IIa and IIb were 55.5% and 6.8%, respectively; all level IIb LN metastasis was accompanied by level IIa metastasis (p=0.001). In addition, level IIb LN metastasis was found to be associated with the aggressiveness of lymphatic metastasis (i.e., the total number of metastatic LNs) (p<0.0001).

CONCLUSIONS

A level IIb LND should be performed when there is clinical or radiological evidence of lymphatic metastasis. In the absence of such evidence, the findings suggest that level IIb LND is not necessary in N1b PTC patients when there is no level IIa LN metastasis, or when the metastasis is not aggressive.

Dissection of the submuscular recess (sublevel IIb) in squamous cell cancer of the upper aerodigestive tract: Prospective study and systematic review of the literature

BACKGROUND

Selective neck dissection is commonly used to clear occult neck metastases in the N0 neck. The aim of this study was to identify the incidence of occult metastases in lymph nodes of sublevel IIb (submuscular recess; SMR) in upper aerodigestive tract squamous cell carcinoma in the setting of clinically and radiologically staged N0 necks and to perform a systematic review of the literature on the incidence of metastases in this setting.

METHODS

We conducted a prospective study of 50 neck dissections and systematic review of the literature.

RESULTS

(A) Prospective study: Tissue dissected out from the SMR was sent separately for histopathologic analysis. Between 0 and 7 nodes were harvested from sublevel IIb. One patient had a metastatic node in sublevel IIb with extracapsular spread in the ipsilateral neck. No other positive nodes were detected. Sixteen necks showed occult metastases at other levels. (B) Systematic review: The review identified 14 articles with 903 necks suitable for inclusion. The overall incidence of metastatic disease at this sublevel in the context of an N0 neck from any site is 2.0% (18 of 903). The incidence of occult metastatic disease in sublevel IIb for oral cavity, oropharyngeal, and laryngeal cancer is 3.9% (11 of 279), 5.2% (5 of 96), and 0.4% (1 of 230) patients, respectively. Contralateral positive nodes (0.9%) and isolated metastases (0.3%) at this sublevel were rare.

CONCLUSION

Nodal metastases are uncommon in the SMR even in the presence of positive nodes in adjacent sublevel IIa. There appears to be no advantage in performing contralateral SMR dissection in N0 necks and in laryngeal primaries.

Frequency of metastases at the area of the supraretrospinal (level IIB) lymph node in laryngeal cancer

BACKGROUND

Neck dissection is the surgical gold standard for the treatment of patients with cervical lymphatic spread. The purpose of this study was to determine the presence of metastases in the supraretrospinal (level IIB) nodal group and the necessity of routine dissection of level IIB during neck dissection, in patients with squamous cell carcinoma of the larynx.

METHODS

Over a 4-year period (between January 2000 and June 2004), the records of patients undergoing laryngectomy and neck dissection were retrospectively evaluated. The numbers of the lymph node and carcinoma metastases at level IIB were recorded. The American Joint Committee on Cancer tumor-node-metastasis classification system was used to classify the primary tumor and neck, and the Memorial Sloan-Kettering Cancer Center classification was used to classify the cervical lymphatic chain.

RESULTS

Sixty-three patients with 98 neck dissections were included in the study. Two patients (3.17%) had subglottic lesions, 19 patients (30.15%) had glottic lesions, and 42 patients (66.66%) had supraglottic lesions. In total, 673 lymph nodes were dissected from level II, and 340 were dissected from level IIB. The 11 supraretrospinal lymph nodes of the 340 dissected nodes demonstrated histologic evidence of metastases (3.23%). Six patients (9.52%; 6/63) had metastases at level IIB, and 2 of them also had synchronous metastases at the contralateral level IIB. The patients without palpable lymph nodes at the neck had no metastases at level IIB.

CONCLUSION

Our results showed that, if the level IIA shows positive metastatic changes, perioperative pathologic examination by frozen section that includes level IIb could be an alternative approach. This area may not be routinely dissected during the surgical management of laryngeal carcinoma with no palpable lymph nodes.

The spinal accessory nerve in head and neck surgery

PURPOSE OF REVIEW

To describe landmarks and tips used for minimizing surgical traumas to the spinal accessory nerve, and different options in case of its injury.

RECENT FINDINGS

Modified radical and selective neck dissections reduce the prevalence of shoulder syndrome, a sequela of radical neck dissection. Impaired shoulder mobility and pain may be present even after nerve-sparing procedures, as shown using electromyography, particularly when dissection is extended to level V. In these cases physical therapy is mandatory to prevent shoulder pain and functional limitations. The issue of spinal accessory nerve repair when macroscopically damaged or transected remains critical.

SUMMARY

Subclinical spinal accessory nerve impairment can be observed even after selective neck dissections (levels II-IV) due to routine clearance of sublevel IIB. Further studies should be performed to select patients in whom this sublevel could be left undissected without impairing oncologic radicality and to demonstrate if such a policy leads to better functional results. Early diagnosis of shoulder syndrome by questionnaires and clinical tests is recommended to appropriately plan physical therapy. Spinal accessory nerve repair is advocated to reduce the prevalence of shoulder syndrome after radical neck dissection. More data are needed to assess the superiority of newer techniques such as nerve transposition or bioresorbable nerve guides.

Level IIb lymph node metastasis in elective neck dissection of oropharyngeal squamous cell carcinoma

This study investigated the oncologic safety of preserving level IIb lymph nodes in ipsilateral and/or contralateral elective neck dissection (END) in patients with oropharyngeal squamous cell carcinoma (SCC). Fifty-one oropharyngeal SCC patients who underwent surgery as an initial treatment were reviewed. Twenty-one patients had clinically node negative necks (cN0) while 30 patients had ipsilateral clinically node positive necks (cN+). Of the cN0 patients, bilateral or ipsilateral END was performed in 15 and six patients, respectively. For the cN+ cases, ipsilateral therapeutic neck dissection with contralateral END was performed in 24 of 30 patients. In the cN0 patients, nodal metastasis to level IIb lymph nodes was not observed in any ipsilateral (21) or contralateral necks (15). Of the 24 cN+ patients who underwent contralateral END, two cases (8.3%) showed contralateral occult level IIb lymph node metastasis. Our data suggest that in cN0 oropharyngeal cancer patients, level IIb lymph nodes may be preserved in ipsilateral and contralateral neck dissection. However, caution is advised when preserving contralateral level IIb nodes in ipsilateral cN+ cases.

Level IIb lymph node metastasis in laryngeal squamous cell carcinoma

OBJECTIVES

Selective neck dissection, despite preservation of the spinal accessory nerve, can lead to some degree of postoperative shoulder dysfunction as a result of removal of level IIb lymph nodes. The aim of this study was to determine whether level IIb lymph nodes can be preserved in elective or therapeutic neck dissection as a treatment for patients with laryngeal squamous cell carcinoma (SCC).

STUDY DESIGN

This was a prospective analysis of a case series.

METHODS

A prospective analysis of 65 patients with laryngeal SCC who underwent surgical treatment of the primary lesion with simultaneous neck dissection from January 1999 to December 2002 was performed. During the neck dissection, the contents of the level IIb lymph nodes were dissected, labeled, and processed separately from the remainder of level II nodes and the main neck dissection specimen. The incidence of pathologic metastasis to level IIb lymph nodes and the regional recurrence within this area were evaluated. In addition, several potential risk factors for metastatic disease in the level IIb lymph nodes such as sex, age, cT stage, cN stage, and the presence of other positive lymph nodes were also evaluated.

RESULTS

A total of 125 neck dissections were performed in this series. Of these dissections, 102 (82%) were elective and 23 (18%) were therapeutic. The prevalence of metastases in the level IIb lymph nodes was 1% (one of 46) and 0% (zero of 56) in clinically node-negative (N0) ipsilateral and contralateral necks, respectively, and 37% (seven of 19) and 0% (zero of four) in clinically node-positive ipsilateral and contralateral necks, respectively. There was a statistically significant association between level IIb metastases and clinically positive N stage (P<.001). The presence of other positive lymph nodes was also shown to have a statistically significant association with metastasis in the level IIb lymph nodes (P=.001). Only two of 46 patients (4%) with clinically N0 necks developed a regional recurrence. However, three of eight cases (38%) with positive pathologic level IIb lymph nodes developed regional recurrence.

CONCLUSION

Level IIb lymph node pads may be preserved in elective neck dissection in patients with laryngeal SCC. However, this area should be removed thoroughly during therapeutic neck dissection in the treatment of clinically node-positive necks.

Accessory Nerve Function in Lateral Selective Neck Dissection with Undissected Level IIB

BACKGROUND

To investigate the accessory nerve function in lateral selective neck dissections (LSND) performed in laryngeal squamous cell carcinoma patients without dissection of level IIB.

METHODS

Fifteen LSND were performed in 11 N0 laryngeal carcinoma patients with preservation of level IIB. Distal latencies, compound muscle action potentials (CMAP), and electromyography findings were investigated before surgery, during the 3rd postoperative week, and 3 months thereafter to compare the effects of the procedure on the accessory nerve.

RESULTS

Distal latencies and CMAP values were significantly lower in the early and late postoperative periods when compared with preoperative values. In 8 patients, there was no motor unit potential (MUP) in the early postoperative period. However, in the late postoperative period, there was no MUP loss.

CONCLUSIONS

Only temporary functional deterioration of the accessory nerve was seen in patients in whom LSND was performed with undissected level IIB.

Selective neck dissection for clinically N0 neck in laryngeal cancer: is dissection of level IIb necessary?

The most common morbidity associated with selective neck dissection (SND; II-IV) is spinal accessory nerve dysfunction and related shoulder disability. Nerve dysfunction is usually attributed to stretching of the nerve during clearance of lymph nodes lying posterior and superior to the spinal accessory nerve (level IIb). If these lymph nodes were left in place and not removed, stretching of the spinal accessory nerve during neck dissection and postoperative shoulder disability could be avoided. 113 SNDs (II-IV) performed on clinically N0 necks of patients with laryngeal carcinoma were enrolled in this prospective study. During SND, level IIb was separately removed and processed. Mean number of lymph nodes in level IIb was 6.26 (range, 0-19). In none of the 113 SND (II-IV) specimens did level IIb contain metastases, thus providing an oncological basis that leaving these lymph nodes in place is an oncologically safe approach, probably avoiding postoperative shoulder disability.

Prevalence of lymph nodes in the apex of level V: A plea against the necessity to dissect the apex of level V in mucosal head and neck cancer

BACKGROUND

We assessed the prevalence of histologically proven normal or invaded lymph nodes in the apex of level V.

METHODS

Seventy neck dissections were performed in 41 patients with mucosal head and neck squamous cell carcinoma (SCC). Fifty-one neck dissections were performed in 30 previously untreated patients (group 1); 19 neck dissections were carried out in 11 patients previously irradiated (group 2).

RESULTS

Pathologic analysis was unable to identify any lymph node in 70% of the apex specimens. In group 1, no lymph nodes were detected in 63%, whereas one or more noninvaded lymph nodes were present in 37%; in group 2, no lymph nodes were identified in 89%, whereas one or more normal lymph nodes were found in 11% (p = .03). Metastatic lymph nodes were never identified.

CONCLUSIONS

The prevalence of lymph nodes in the apex was 30%. No invaded lymph nodes were identified. In addition to anatomic evidence, these results suggest that dissection of the apex is not necessary in mucosal head and neck SCC.