Bilateral radical neck dissection with unilateral internal jugular vein reconstruction

Surgical strategy of locally advanced differentiated thyroid cancer

Approximately 20% of patients with differentiated thyroid cancer (DTC) have direct tumor extension with invasion of the surrounding tissues such as the larynx, trachea, esophagus, or recurrent laryngeal nerve. Recent progress of molecular-targeted therapy, such as the use of tyrosine kinase inhibitors, improves survival outcome in patients with advanced DTC. However, induction of tyrosine kinase inhibitors for locally-advanced DTC has presented novel fatal adverse events including fistula in patients with infiltration toward to the trachea, pharynx and esophagus, and fatal bleeding in patients with great vessel invasion. Surgery therefore still has an important role in DTC management, particularly in local control. The surgical strategy for laryngeal/tracheal invasion, which commonly occurs by DTC, is decided according to the extension (depths and area) of the tumor. The "shave procedure" is performed when the tumor has superficially invaded the larynx/trachea. However, intra-luminal extension requires resection and reconstruction of the larynx/trachea wall. Large veins, such as the internal jugular vein and the subclavian vein, are also frequently directly invaded by DTC. Three types of jugular vein reconstruction have been advocated to avoid fatal complications according to bilateral jugular vein ligation. The majority of carotid artery invasion by DTC can be managed with tumor resection of the sub-adventitial layer without reconstruction surgery using an artificial vessel. In this review article, we examine surgery for advanced DTC, showing the surgical strategy toward DTC that has invaded the laryngotracheal, recurrent laryngeal nerve, esophagus/hypopharynx, or great vessels.

Internal jugular vein reconstruction using a triple-paneled great saphenous vein graft

BACKGROUND

Donor-recipient diameter discrepancy can be problematic when using an autologous great saphenous vein graft for internal jugular vein reconstruction. A triple-paneled method of saphenous vein grafting is one solution.

CASE PRESENTATION

A 54-year-old man with a thyroid papillary carcinoma underwent total thyroidectomy and bilateral neck dissection. An 8-cm segment of the right internal jugular vein was resected. For reconstruction, a 30-cm segment of the great saphenous vein was harvested and divided into three pieces of equal length. After opening each piece longitudinally, they were sutured together in a side-by-side fashion to create a cylinder that was used to reconstruct the internal jugular vein defect. The graft was patent 10 months after the surgery.

CONCLUSION

The triple-paneled method is feasible for autologous great saphenous vein graft reconstruction of the internal jugular vein.

Bilateral radical neck dissection with immediate reconstruction of the internal jugular vein

Head and neck surgery for advanced neck disease may require ablation of critical structures, including the internal jugular vein (IJV). Although unilateral ligation of the IJV is not commonly associated with a significant increase in morbidity, bilateral sacrifice of the internal venous system may cause severe complications. We present the case of a 60-year-old man with a T4N2cM0 tumour of the left and right hypopharynx. The evolution of the disease required a bilateral modified radical neck dissection and sacrifice of both IJVs. We describe a vein grafting technique for the IJV using the external jugular vein as a donor vessel. Postoperative computed tomography imaging confirmed adequate blood perfusion. This report describes two new and accessible surgical options for immediate IJV grafting. Although this modification slightly increases the surgery time and technical difficulty, it allows immediate restoration of venous perfusion, which may improve the prognosis and patient outcomes.

[Resection of recurrent neck cancers with replacement of the carotid artery]

OBJECTIVES

The management of patients with recurrent neck cancer invading the carotid artery is controversial. The aim of this study was to evaluate the overall survival and healthy survival years (QALY) as well as the patency of carotid revascularization after enbloc tumor resection followed by complementary radiotherapy.

METHODS

From 2000 to 2016, 42 consecutive patients with recurrent neck cancer invading the carotid artery underwent resection of the tumor associated with reconstruction of the carotid artery with a PTFE prosthesis (n=31) or with a saphenous vein graft (n=11). In 11 cases, resection was associated with musculocutaneous flap coverage. The primary tumor was a squamous cell carcinoma of the larynx (20 patients) or of the pharynx (9 patients), undifferentiated carcinoma of unknown origin (10 patients) and anaplastic thyroid carcinoma (3 patients). All patients had postoperative radiotherapy (50-70Gy) supplemented in 16 of them by chemotherapy. Nine patients had metastatic dissemination at the time of reoperation with a recurrent tumor ulcerated to the skin in 5 of them.

RESULTS

The combined 30-day mortality and stroke rate was nil. Postoperative morbidity included dysphagia (n=8), vocal cord paralysis (n=6), late wound healing delay (n=2), transient mandibular claudication (n=1) and partial necrosis of the musculocutaneous flap (n=1). No infection and no thrombosis of the bypass were observed during follow-up [median: 31 months, range: 8-167 months]. Twenty-one patients (50%) died from the consequences of the spread of cancer, which had become metastatic, but without local recurrence. The 5-year survival rate was 50.9±8.3%. The median healthy survival year (QALY) was 3.38 [95% CI: 1.70-4.54] with a significant difference between patients without metastasis at the time of reoperation [n=33; QALY=4.02] and those with metastases [n=9; QALY=0.43; P=0.005]. Healthy life expectancy was also significantly longer in patients with laryngeal cancer [n=20, QALY=4.95] compared to patients with other types of tumors [n=22, QALY=1.67; P=0.032].

CONCLUSION

In the absence of metastases, enbloc resection of recurrent neck cancers invading the carotid artery improves the duration and quality of patient survival.

Resection of recurrent neck cancer with carotid artery replacement

OBJECTIVE

The management of patients with recurrent neck cancer invading the carotid artery is controversial. The purpose of this study was to evaluate overall survival rate, primary patency of vascular reconstructions, and quality-adjusted life-years (QALYs) after en bloc resection of the carotid artery and tumor with in-line polytetrafluoroethylene (PTFE) carotid grafting, followed by radiotherapy.

METHODS

From 2000 to 2014, 31 consecutive patients with recurrent neck cancer invading the carotid artery underwent en bloc resection and simultaneous carotid artery reconstruction with a PTFE graft, which was associated in 18 cases with a myocutaneous flap. The primary tumor was a squamous cell carcinoma of the larynx in 17 patients and of the hypopharynx in 7, an undifferentiated carcinoma of unknown origin in 4, and an anaplastic carcinoma of the thyroid in 3. All of the patients underwent postoperative radiotherapy (50-70 Gy), and 10 of them also underwent chemotherapy (doxorubicin and cisplatin).

RESULTS

None of the patients died or sustained a stroke during the first 30 days after the index procedure. Postoperative morbidity consisted of 6 transitory dysphagias, 3 vocal cord palsies, 2 wound dehiscences, 1 transitory mandibular claudication, and 1 partial myocutaneous flap necrosis. No graft infection occurred during follow-up. Fifteen patients (48%) died from metastatic cancer during a mean follow-up of 45.4 months (range, 8-175 months). None of the patients showed evidence of local recurrence, stroke, or thrombosis of the carotid reconstruction. The 5-year survival rate was 49 ± 10%. The overall number of QALYs was 3.12 (95% confidence interval, 1.87-4.37) with a significant difference between patients without metastasis at the time of redo surgery (n = 26; QALYs, 3.74) and those with metastasis (n = 5; QALYs, 0.56; P = .005). QALYs were also significantly improved in patients with cancer of the larynx (n = 17; QALYs, 4.69) compared to patients presenting with other types of tumors (n = 14; QALYs, 1.29; P = .032).

CONCLUSIONS

Aggressive en bloc resection of recurrent neck cancer with PTFE grafting can be curative in patients without metastases at the time of redo surgery. In this subset of patients, extensive neck surgery with carotid artery replacement can lead to excellent local control of the disease with improved quality of survival.

External-beam radiotherapy for differentiated thyroid cancer locoregional control: A statement of the American Head and Neck Society

The use of external-beam radiotherapy (EBRT) in differentiated thyroid cancer (DTC) is debated because of a lack of prospective clinical data, but recent retrospective studies have reported benefits in selected patients. The Endocrine Surgery Committee of the American Head and Neck Society provides 4 recommendations regarding EBRT for locoregional control in DTC, based on review of literature and expert opinion of the authors. (1) EBRT is recommended for patients with gross residual or unresectable locoregional disease, except for patients <45 years old with limited gross disease that is radioactive iodine (RAI)-avid. (2) EBRT should not be routinely used as adjuvant therapy after complete resection of gross disease. (3) After complete resection, EBRT may be considered in select patients >45 years old with high likelihood of microscopic residual disease and low likelihood of responding to RAI. (4) Cervical lymph node involvement alone should not be an indication for adjuvant EBRT.

Internal to external jugular vein bypass allowing for simultaneous bilateral radical neck dissection

OBJECTIVES/HYPOTHESIS

The goal of the study was to determine the role of internal jugular vein (IJV) to external jugular vein (EJV) bypass grafting in the setting of bilateral radical neck dissection with IJV sacrifice.

STUDY DESIGN

The study group consisted of eight patients who underwent bilateral radical neck dissection with IJV sacrifice. Demographic and oncologic parameters were defined for each patient, including age, gender, and pathology. Patients were monitored and evaluated for potential effects of increased intracranial pressure (ICP). Doppler ultrasonic evaluation was performed to assess patency of the site of anastamoses.

RESULTS

In all, six patients underwent unilateral bypass grafting, whereas two patients underwent bilateral bypass grafts. Average age at time of surgery was 68.2 (range 56-71). Postoperatively, no sequelae of increased ICP were noted. Follow-up ultrasonic evaluation revealed patent vessels in all patients.

CONCLUSION

We presently report on the use of EJV-to-IJV bypass grafting for all patients undergoing bilateral radical neck dissection for extensive neck disease.

LEVEL OF EVIDENCE

4.

Management of invasive well-differentiated thyroid cancer: an American Head and Neck Society consensus statement. AHNS consensus statement

BACKGROUND

Invasive differentiated thyroid cancer (DTC) is relatively frequent, yet there is a paucity of specific guidelines devoted to its management. The Endocrine Committee of the American Head and Neck Society (AHNS) convened a panel to provide clinical consensus statements based on review of the literature, synthesized with the expert opinion of the group.

METHODS

An expert panel, selected from membership of the AHNS, constructed the manuscript and recommendations for management of DTC with invasion of recurrent laryngeal nerve, trachea, esophagus, larynx, and major vessels based on current best evidence. A Modified Delphi survey was then constructed by another expert panelist utilizing 9 anchor points, 1 = strongly disagree to 9 = strongly agree. Results of the survey were utilized to determine which statements achieved consensus, near-consensus, or non-consensus.

RESULTS

After endorsement by the AHNS Endocrine Committee and Quality of Care Committee, it received final approval from the AHNS Council.

Late surgical outcomes of carotid resection and saphenous vein graft revascularization in patients with advanced head and neck squamous cell carcinoma

BACKGROUND

In head and neck squamous cell carcinoma, invasion of the carotid artery is a severe mortality predictor. We report an updated experience of 19 patients who underwent head and neck resection for squamous cell carcinoma with concomitant carotid reconstruction. This study aims to analyze overall survival rates, primary patency of the reconstructions, vascular and nonvascular complications, radiotherapy dosing as well as late follow-up and outcomes.

METHODS

From September 1997 to 2011, 19 patients with advanced squamous cell carcinoma with carotid artery invasion were submitted to resection and concomitant vascular reconstruction in a single referred oncological institution. Patient follow-up was done by means of periodic outpatient returns, where clinical and duplex scan evaluations were performed to study graft patency.

RESULTS

The average length of follow-up was 23.3 (± 34.4) months. Nonvascular complications occurred in 6 patients (31.6%). Only 1 (5.3%) vascular complication was observed, resulting from the immediate occlusion of the carotid graft. All patients were submitted to preoperative, adjuvant, or curative intent radiotherapy during the course of the oncologic treatment, with varying doses. Overall disease-free survival, primary patency, and survival with patent graft rates in 5 years are respectively 12.9%, 93.1%, and 13.0%. Three patients (15.9%) are still alive, all without tumor recurrence, and present a disease-free long-term follow-up with patent grafts 21 months, 68 months, and 151 months after surgery.

CONCLUSIONS

Aggressive surgical approach for patients with advanced squamous cell head and neck carcinoma with carotid invasion can lead to cure in a select group of patients. Saphenous vein grafts demonstrated favorable outcomes with low infection and high patency rates, suggesting a valid alternative for arterial reconstruction in these cases.

Utility of internal jugular vein reconstruction in modified radical neck dissection

The benefits to modified radical neck dissection (MRND) are established but the procedure involves substantial neck dissection with occasional resection of the internal jugular vein (IJV). Loss of the IJV is associated with morbidity including increased cerebral edema, stroke, laryngeal edema, blindness, facial fullness, and dural thrombosis. This paper discusses the morbidity associated with MRND, especially regarding venous outflow concerns and technical approaches to IJV reconstruction. Patients who have previously undergone MRND may benefit from immediate reconstruction and/or reanastomosis of the IJV. An attempt to maintain at least one major functional venous drainage point for the head and neck is indicated to minimize the significant morbidity and mortality of bilateral loss of the IJVs. The Katsuno classification system of type A, B, and C IJV reconstruction methods, and the novel type K reconstruction, are discussed as methods of maintaining venous outflow from the head and neck.

Internal jugular vein reconstruction: application of conventional type A and novel type K methods

Background:

During neck dissection, the current practice is to preserve the internal jugular vein in the majority of cases. However, sacrifice of bilateral internal jugular veins is required in rare cases. Simultaneous excision of both internal jugular veins is known to frequently cause fatal complications. Even if staged, bilateral internal jugular vein sacrifice still occasionally leads to fatal complications (in 2 per cent). We report two different methods of unilateral internal jugular vein reconstruction, in two cases requiring excision of bilateral internal jugular veins, and we review the significance of this reconstruction procedure.

Method:

The first patient underwent conventional type A reconstruction (using Katsuno's classification): end-to-end anastomosis of the internal jugular vein to the external jugular vein. For the second patient, we anastomosed the internal jugular vein to the anterior jugular vein, preserving the flow of the external jugular vein. This method, termed type K, had two main expected benefits: facial drainage via the preserved external jugular vein; and provision of a built-in safeguard in the case of occlusion (via the preserved venous networks between the internal jugular vein and the external jugular vein, e.g. the facial vein).

Results:

In both cases, the reconstructed internal jugular vein was patent and the post-operative course was uneventful, with no severe complications.

Conclusion:

The current and previous findings strongly indicate that the reconstruction of at least one internal jugular vein is highly recommended for patients requiring bilateral internal jugular vein sacrifice. Our type K method may represent a useful technique for this procedure.

Preservation of the External Jugular Venous Drainage System in Neck Dissection

OBJECTIVE: To investigate whether preserving the external jugular vein (EJV) in neck dissection reduces postoperative edema of the face and neck.

STUDY DESIGN: A prospective, randomized controlled trial.

SETTING: A tertiary hospital.

SUBJECTS AND METHODS: Thirty-eight subjects were randomly assigned to two groups: EJV preservation versus sacrifice during neck dissection after stratification according to the neck dissection extent and type, the previous treatment, the primary site, and the reconstruction type. The relative soft-tissue thickness was evaluated by follow-up computed tomography (CT) scans at one week and four to five weeks postoperatively and compared with preoperative findings. The preserved EJV patency was also determined by contrast enhancement of EJV on follow-up CT scans. In addition, the scores for pain/discomfort on the upper neck/face and laryngeal edema were recorded at each time point.

RESULTS: Relative soft-tissue thickness reached up to 160 percent of preoperative status at the hyoid and cricoid levels at one week postoperatively but resolved at four to five weeks. EJV preservation reduced the soft-tissue thickness significantly compared with EJV sacrifice ( P < 0.05) at one week postoperatively, particularly at the mandible and hyoid level. All preserved EJVs remained patent at one week, and 18 of 19 remained patent at four to five weeks. In addition, EJV preservation diminished the discomfort/pain of the upper neck/face compared with EJV sacrifice at one week ( P = 0.036). The extent of laryngeal edema did not differ between the two groups.

CONCLUSION: EJV preservation may reduce immediate postoperative neck edema and pain/discomfort related to neck dissection.

Preservation of the internal jugular vein in the radical treatment of node-positive neck--is it safe?

BACKGROUND

The aim of this study was to evaluate risk factors of neck recurrence in patients with pN+ necks submitted to a modified or a classic radical neck dissection and the safety of preserving the internal jugular vein in the treatment of a subgroup of these patients.

METHODS

The medical records of 311 untreated patients with squamous cell carcinoma of the oral cavity (106 cases), oropharynx (95 cases), larynx (49 cases), and hypopharynx (61 cases) were reviewed. Their clinical stages (CS) were CS II in 1%, CS III in 19.9%, CS IVA in 76.2%, and CS IVB in 19.6% of the cases. All patients were pN+.

RESULTS

Ipsilateral neck recurrence occurred in 18 cases (5.8%), 14 cases (4.5%) where the internal jugular vein was resected, and 4 cases (1.3%) where the internal jugular vein was preserved. Neck recurrence did not have significant correlation with tumor site (P = .852), T stage (P = .369), N stage (P = .963), adjuvant radiotherapy (P = .701), number of positive lymph nodes (P = .886), jugular vein preservation (P = .240), and extracapsular spread (P = .670). There was significant correlation between neck recurrence and the lymph node size (.040).

CONCLUSIONS

Modified radical neck dissection with internal jugular vein preservation can be performed in selected patients with lymph node metastases, with no significant increase in the risk of neck recurrence.

Severe Postextubation Laryngeal Obstruction: The Role of Prior Neck Dissection and Radiation

Aggressive treatment of advanced head and neck cancer may result in more patients undergoing surgery for unrelated illnesses. We present a case of a patient requiring emergency tracheostomy placement after a routine liver segment resection 10 yr after undergoing a bilateral modified radical neck dissection and radiation therapy. This type of patient may be at increased risk for both postoperative laryngeal edema and neuronal imbalance secondary to their preoperative condition.

Neck dissections: radical to conservative

BACKGROUND: Neck dissection is an important surgical procedure for the management of metastatic nodal disease in the neck. The gold standard of neck nodal management has been the radical neck dissection. Any modification in the neck dissection is always compared with this standard. Over the last few decades, in order to alleviate the morbidity of radical neck dissection, several modifications and conservative procedures have been advocated. These procedures retain certain lymphatic or non-lymphatic structures and have been shown not to compromise oncological safety. METHODS: A literature search of the Medline was carried out for all articles on neck dissections. The articles were systematically reviewed to analyze and trace the evolution of neck dissection. These were then categorized to address the nomenclature, management of node positive and node negative neck including those who had received chemoradiation. RESULTS: The present article discusses the neck nodal nomenclature, the radical neck dissection, its modifications and migration to more conservative procedures and possible advances in the near future. CONCLUSION: Radical neck dissection is now replaced with modified radical neck dissections in most situations. Attempts are being made to replace modified radical neck dissections with selective neck dissections for early node positivity. Sentinel node biopsy is being studied to address the issue of node negative neck. More conservative surgeries are likely to replace the 'radical' surgeries of bygone era. This process is facilitated by earlier detection of the disease and better understanding of cancer biology.

Carotid reconstruction in patients operated for malignant head and neck neoplasia

CONTEXT

Patients with malignant head and neck neoplasia may present simultaneous involvement of large vessels due to the growth of the tumoral mass. The therapeutic options are chemotherapy, radiotherapy, surgery or combined treatments.

OBJECTIVE

To analyze the result of surgical treatment with carotid reconstruction in patients with advanced malignant head and neck neoplasia.

DESIGN

Prospective.

SETTING

Hospital do Câncer A.C. Camargo, São Paulo, Brazil.

PARTICIPANTS

Eleven patients operated because of advanced malignant head and neck neoplasia that was involving the internal and/or common carotid artery.

MAIN MEASUREMENTS

By means of clinical examination, outpatient follow-up and duplex scanning, we analyzed the patency of the carotid grafts, vascular and non-vascular complications, disease recurrence and survival of the patients.

RESULTS

Six patients (54.5%) did not present any type of complication. There was one vascular complication represented by an occlusion of the carotid graft with a cerebrovascular stroke in one hemisphere. Non-vascular complications occurred in five patients (45.5%). During the follow-up, eight patients died (72.7%), of whom seven had loco-regional tumor recurrence and one had pulmonary and hepatic metastases (at an average of 9 months after the operation). Seven of these patients presented functioning grafts. The three patients still alive have no tumor recurrence and their grafts are functioning (an average of 9 months has passed since the operation).

CONCLUSIONS

Patients with advanced malignant head and neck neoplasia involving the carotid artery that are treated surgically present a prognosis with reservations. When the internal and/or common carotid artery is resected en-bloc with the tumor, arterial reconstruction must be performed. The long saphenous vein is a suitable vascular substitute.

Amaurosis: a complication of bilateral radical neck dissection

Blindness is a devastating complication of bilateral radical neck dissection. To our knowledge, it has been reported in the literature only 12 times. Although the cause is still controversial, many common factors have been identified. We present a case of blindness after bilateral neck dissection and discuss the perioperative circumstances and the possible causes. We also compare and contrast other cases described in the literature and suggest methods in which this complication can be prevented.

Venous collateral blood flow assessed by Doppler ultrasound after unilateral radical neck dissection

Removal of the internal jugular vein (IJV) in unilateral radical neck dissection (rND) necessitates redirection of cerebrovenous blood to collateral pathways. If adaptation is insufficient, neurologic sequelae develop that are due to impaired venous drainage and increased intracranial pressure. The authors studied venous hemodynamic effects of unilateral rND using Doppler and duplex ultrasound in 17 patients. Blood flow velocities (BFVs) were recorded from the distal IJV (dIJV) and the vertebral vein (VV) before and 9 to 88 days after surgery. A preoperative compression test of the dIJV was performed to identify the side of dominant drainage. The BFV increased in the contralateral dIJV after right-sided rND (n = 10) by 111% (range, 50% to 320%), and after left-sided rND (n = 7) by 34% (range, 5% to 105%). In the contralateral VV, a rise of BFV by 75% was found. Our results confirm the role of the contralateral dIJV as the predominant collateral pathway. The VVs serve as an important additional major outflow. Doppler ultrasound may help to identify patients at risk of insufficient cerebrovenous drainage after rND.