TITLE: Neck Dissection and Sentinel Lymph Node Biopsy SOURCE: Grand Rounds Presentation, UTMB, Dept. of Otolaryngology DATE: September 20, 2006 RESIDENT PHYSICIAN: Jeffrey Buyten, MD FACULTY ADVISOR: Susan McCammon, MD SERIES EDITORS: Francis B. Quinn, Jr., MD and Matthew W. Ryan, MD ARCHIVIST: Melinda Stoner Quinn, MSICS
"This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/Head and Neck Surgery and was not intended for clinical use in its present form. It was prepared for the purpose of stimulating group discussion in a conference setting. No warranties either express or implied, are made with respect to its accuracy, completeness, or timeliness. The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion."
Aside from distant metastases, cervical nodal metastases are the worst prognostic indicator for survival in patients with head and neck carcinoma. Presence of nodal metastases decreases survival by fifty percent. Surgical therapy for cervical metastases has evolved over the past two centuries. In the early 19th century, the presence of nodal metastases indicated incurable disease. As surgical technique improved into the late 19th and early 20th century, surgeons began to advocate treatment of nodal mets. Kocher advocated wide margin lymphadenectomy and also recommended that the submandibular triangle always be dissected in patients with lingual cancer. The first published account of en bloc tumor and lymph node resection along with non- lymphatic structures was performed by Jawdynski in 1888. (1)
In 1905 and 1906 Crile’s description of en bloc lymphadenectomy became the standard operation for the majority of the 20th century. This operation removed the submandibular salivary gland, internal jugular vein, greater auricular and spinal accessory nerves, as well as the digastric, stylohyoid, and sternocleidomastoid muscles. In 1926 Bartlett and Callander advocated preservation of non-lymphatic structures (XI, internal jugular vein (IJV), sternocleidomastoid (SCM), platysma, stylohyoid, digastric), citing similar rates of recurrence when compared to more inclusive or radical procedures. Blair and Brown maintained that lymphadenectomy could not be complete without sparing the accessory nerve in 1933. In 1951, Martin et al reviewed 1450 cases of en bloc lymphadenectomy. He concluded that complete cervical lymphadenectomy was impossible without concomitant removal of the IJV, SCM and XI. Martin’s refinement of Crile’s 1906 operation became the template for the modern radical neck dissection.
As Martin advocated radical neck dissection (RND) in the US, Suarez advocated a more conservative neck dissection in Europe in 1952. He believed preservation of the SCM,