Cancer of the Neck Flashcards
Primaries causing bilateral regional mets
- Base of tongue
- Ventral tongue
- Soft palate
- Supraglottis
What if neck node FNA suggests adenocarcinoma?
For hight level nodal dz: ND with submandibulectomy and possible parotidectomy
For low level nodal dz: consider excisional bx
Initial evaluation and MAN of FNA-proven carcinoma of neck mass with unknown primary
- CXR, CT/MRI, consider PET/CT
- Complete endoscopy
- Blind biopsy: NP, tonsils, BOT, piriforms
- +/- tonsillectomy
- Consider bone scan, CT chest/abd, mammo, barium swallow, thyroid scan
Level I neck
IA: submental (b/w anterior digastrics; no left and right, just one area)
IB: submandibular triangle
Level II neck
Upper 1/3 (Base of skull to hyoid/carotid bifurcation)
- IIA (anterior to CN XI)
- IIB (posterior to CN XI)
Level III neck
Middle 1/3 (hyoid/carotid bifurcation to omohyoid/cricoid)
Level IV neck
Lower 1/3 (Omohyoid/cricoid to clavicle)
Level V neck
Posterior triangle
- VA (superior to omohyoid)
- VB (inferior to omohyoid)
Level VI neck
Central compartment (anterior neck) Between carotid sheaths
Level VII nodes
Superior mediastinum
Suprasternal notch to anterior mediastinum
When to consider an elective neck dissection in the N0 neck?
When the risk of regional mets is >15-25%:
- Supraglottis
- BOT
- Oral tongue
- Tonsils
- Advanced stage cancer
What if after w/u and blind biopsies, still have an unknown primary?
Early stage neck dz (N1):
-ND + adjuvant XRT to neck, waldeyer’s ring, NP
vs
-RT alone
Late stage neck dz (N2-3):
- ND + adjuvant XRT to neck, waldeyer’s ring, NP
- +/- chemo
Radical neck dissection
- All node levels removed
- SCM, IJ, CN XI removed
- Submandibular gland and tail of parotid removed
Modified radical neck dissection
- All node levels removed
- Type I: spares CN XI
- Type II: spares IJ and CN XI
- Type III (functional, Bocca): spares SCM, IV, CN XI
Selective neck dissection
-Not all node levels are removed
Types:
-Supraomohyoid (Anterolateral ND): Levels I-III for oral CA with N0 or some N1 dz
-Lateral ND: II-IV for supraglottic, OP, hypopharyngeal (typically b/l)
-Posterolateral ND: II-V, for select posterior scalp CA
Indications for Radical ND
- Clinically positive nodes with primary cancer that has a high risk of occult nodes
- Advanced nodal dz
- Presence of large matted nodes or posterior nodes
- Involvement of SCM, IJ, CN XI, and cervical nodes
Indications for Modified Radical ND
- Clinically positive nodes with primary cancer with a lower risk of occult nodes or the N0 neck
- No involvement of SCM, IJ, CN XI
Neck Dissection Complications
- Wound infxn
- Wound breakdown
- Flap necrosis
- Shoulder syndrome
- Injury to vagus (SLN, RLN)
- Injury to marginal mandibular (oral incompetence)
- Hematoma/seroma
- Chylous fistula
- Cerebral/facial edema (IJ sacrifice)
- Blindness
- Postop dyspnea (PTX, phrenic nerve, CHF, atelectasis)
- Carotid blowout (2/2 infected wound)
What is shoulder syndrome
Results from sacrifice of CN XI
- Loss of trapezius support
- Shoulder drop
- Winged scapula
- Pain (primary source of morbidity)
Tx:
- PT
- Early cable grafting or orthopedic recon
Chylous fistula after ND
- Typically left sided (chyLous = Left 95-97%)
- 2/2 injury of thoracic duct
- Milky drainage w/in first few days postop
- Incidence 1-2%
Tx:
- Initially conservative (pressure, elevate HOB, restrict fats, MCFA diet, manage lytes)
- Tetracycline sclerosing Rx vs surgical re-exploration if fails or output > 600 mL/day
Cerebral edema after ND
Usu from b/l IJ sacrifice
May p/w SIADH and mental status change
Address urgently with NSGY c/s, steroids, Lumbar drain, hyperventilation, hyperosmolar drugs, diuretics
