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Neck Dissections Flashcards

1
Q

What is the sensitivity and specificity for physical exam, CT, and combined for detecting neck disease in HN SCC.

A

Clinical Exam:
- Sensitivity 74%
- Specificity 81%
- Accuracy 77%

CT:
- Sensitivity 83%
- Specificity 83%
- Accuracy 83%

Combined:
- Sensitivity 92%

Remember sensitivities in order = 74, 83, 92 - just add 9!

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2
Q

What are ultrasound characteristics of nodal metastasis? 6

A
  1. Spherical shape
  2. Loss of fatty hilum
  3. Extracapsular spread
  4. Hypoechoic and heterogeneous
  5. Central necrosis
  6. Mixed vascularity
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3
Q

What are 6 CT signs of nodal metastasis?

What are 5 CT signs of extracapsular extension?

A

CT Signs of Nodal Metastasis:
1. Central necrosis (most accurate CT criterion)
2. Diameter >10mm in short diameter (>15mm for jugulodigastric, >8mm in retropharynx)
3. Extracapsular spread
4. Spherical shape - L/S (long axis/Short axis) Ratio < 2 (95% accuracy)
5. Nodal grouping (>3 LNs in one area)
6. Rim enhancement

Indications for extracapsular extension:
1. Indistinct nodal margin
2. Infiltration into adjacent tissue
3. Irregular nodal enhancement
4. Matted nodes (fused)
5. Central necrosis

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4
Q

What are the CT and MRI criteria for diagnosis of carotid invasion in HNSCC? 3

What is the definition of unresectable for carotid?

A

Best modality between CT or MRI or US remains controversial

Raise Suspicion:
1. Effacement of the fascial plane surrounding >25% of the vessel circumference should raise suspicion
2. Tumor involvement of 75% or more of the circumference of the carotid

CT:
- Highest accuracy (84.1%) recorded in 2 types:
- Compression/deformation of the CCA or ICA
- Partial fat or fascia deletion between tumor and the CCA or ICA

MRI:
- 100% sensitive, 94% specific
- Involvement of >270 degrees of the circumference of the carotid artery was accurate in predicting the surgeon’s inability to peel the tumor off the carotid artery in 100% of cases
- Intraluminal tumor (specific for vascular infiltration and unresectability, not very sensitive and infrequently seen)

Unresectable = >270deg involvement on MRI

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5
Q

What is the incidence of cerebral complications following common carotid occlusion?

A
  1. Abrupt ligation = 42-50%
  2. Occluded gradually over < 7 days = 30.6%
  3. Occluded gradually over ≥ 8 days (e.g. vessel compressed by tumor, or pre-op tx) = significantly decreased to 5.3%
  4. Unselected ICA interruption = 26% rate of cerebral infarction (Depends on patient age)
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6
Q

What are four tests to assess the adequacy of collateral circulation and cerebral perfusion pre-op carotid resection/carotid ligation?

A
  1. 4-vessel angiography (carotids and vertebral)
  2. Trial balloon occlusion
  3. Tomography scanning (SPECT, using Tc-99m HMPAO)
  4. Xenon-133 flow scan
  5. Other: CTA/MTA?
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7
Q

What is a preoperative intervention that may reduce cerebrovascular accident incidence over simple carotid ligation?

A

PERMANENT BALLOON OCCLUSION
- Underlying principle is that high embolization of the carotid eliminates the source of stump emboli (retrograde to ECA/ophthalmic, then intracranial)
- Angiographic placement of permanent balloons or coils (embolization) in the carotid siphon region, just proximal to the ophthalmic artery, closely monitored for 72 hours, 2 weeks prior to carotid resection
- During balloon occlusion –> test the patient every 5 minutes, consisting of motor, sensory, memory, speech, calculation, analytic capacity

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8
Q

Regarding the Xenon Cerebral Blood Flow Study, discuss:
1. Normal flow vs. failure of brain function
2. Indications
3. Results - 4
4. Management - 4

A
  • Normal Cerebral blood flow = 50mL/100g/min
  • Failure of brain function = < 20mL/100g/min

INDICATIONS:
1. En-bloc resection requiring ICA resection
2. Tumor encases ICA on imaging
3. Contour irregularities of ICA on angiography

RESULTS of Xenon-CBF study (15-minute balloon occlusion)
1. Group I: No CBF side difference
2. Group II: Mild symmetric CBF decrease
3. Group III (10-15%): Marked decrease in CBF (< 30mL/100g/min)
4. Group IV (5%): Neurologic deficit, CBF < 20mL/100g/min

2% that pass will still have symptoms post occlusion

MANAGEMENT:
1. Pre-op permanent balloon occlusion for groups I & II
2. Prophylactic or Introperative revascularization for Group III, or I & II if patient young or if contralateral disease present
3. No surgery or prophylactic revascularization for Group IV patients

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9
Q

What are the 3 pathways of referred otalgia? Discuss the anterior tongue, base of tongue, and hypopharynx, and their nerve ganglia.

A

Anterior Tongue: V3, from Gasserian ganglion (ie. Trigeminal ganglion)

Posterior Tongue: IX, from superior (jugular) or inferior (petrous) glossopharyngeal ganglion

Hypopharynx: X, from superior (jugular) ganglion and inferior (nodose) ganglion

Vancouver Pg 117

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10
Q

Describe the borders of Level Ia in the neck. 4

What does level Ia drain?

What locations are at risk for Level Ia metastasis?

A

Borders:
- Superior: Mylohyoid muscle/mandible symphysis
- Inferior: Inferior border of Hyoid bone
- Lateral: Anterior belly of digastric muscle
- Medial: Midline structure

Drains:
- Chin
- Lip
- Floor of mouth
- Tip of tongue

At risk metastasis:
- Floor of mouth
- Anterior oral tongue
- Anterior mandibular alveolar ridge
- Lower lip

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11
Q

Regarding Level Ib in the neck:
1. Borders
2. Contents
3. Drains
4. At risk metastasis
5. Structures at risk during neck dissection

A

BORDERS:
- Superior: Mylohyoid muscle/body of mandible
- Inferior: Inferior border of hyoid bone
- Posterior/Floor: Stylohyoid muscle (or vertical plane dropped from the posterior edge of the submandibular gland) and stylohyoid muscle
- Medial: Anterior belly of digastric
- Lateral: Body of mandible
- Submandibular gland is used for differentiating IB vs IIA Radiographically; clinically is the vertical plane at the posterior aspect of the submandibular gland

CONTENTS:
- Pre- and post-glandular nodes
- Pre- and post-vascular nodes
- Submandibular gland is removed with LN due to close proximity to ensure thorough exenteration of all nodes

AT RISK METASTASIS:
- Oral cavity
- Anterior nasal cavity
- Soft tissue structures of mid-face

DRAINS:
1. Lower face
2. Oral cavity
3. Nodes
4. Includes perifacial nodes (nodes of Stahr) - includes buccinator nodes, superior to mandibular body - at risk mets include buccal mucosa, anterior nasal cavity, soft tissue of cheek

AT RISK STRUCTURES:
1. Injury to marginal mandibular nerve most common

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12
Q

Regarding Level II in the neck, discuss:
1. Borders of level IIa vs IIb
2. What differentiates these two radiographically vs. intraoperatively?
3. What do they drain?
4. Contents?
5. At risk metastasis?

A

BORDERS LEVEL II:
- Superior: Skull base
- Inferior: Level of carotid bifurcation (surgical landmark) or hyoid bone (clinical/radiographic landmark)
- Lateral: Posterior border of SCM
- Medial: Lateral border of Sternohyoid muscle and Stylohyoid muscle (or radiographically, the perpendicular plane defined by the posterior aspect of the submandibular gland)

IIa vs IIb DIFFERENTATION:
1. Vertical plane defined by spinal accessory nerve (CNXI)

DRAINS:
1. Oropharynx
2. Larynx
3. Oral cavity

CONTENTS:
1. Upper third of the IJV
2. Adjacent to the spinal accessory nerve (SAN)

AT RISK METASTASIS:
1. Oral cavity
2. Nasal cavity
3. Nasopharynx
4. Oropharynx (more common IIb)
5. Hypopharynx
6. Larynx
7. Parotid gland

In absence of IIa, likely not necessary to include IIb for tumors of oral cavity/larynx - controversial

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13
Q

Regarding Level III in the neck, discuss:
1. Borders
2. Contents
3. At risk metastasis

A

BORDERS:
- Superior: Level of carotid bifurcation (surgical landmark) OR level of inferior border of hyoid bone (clinical/radiographic landmark)
- Inferior: Junction of the omohyoid muscle with the IJV (surgical landmark) OR lower border of the cricoid arch (clinical/radiographic landmark)
- Lateral: Posterior border of SCM
- Medial: Lateral border of sternohyoid muscle (surgical) OR Lateral border of the common carotid artery (clinical/rads)

CONTENTS:
- Middle third of IJV
- Jugulo-omo-hyoid node: lies immediately above the superior belly of the omohyoid muscle as it crosses the IJV

AT RISK METASTASIS:
1. Oral cavity
2. Nasopharynx
3. Oropharynx
4. Hypopharynx
5. Larynx

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14
Q

Regarding Level IV in the neck, discuss:
1. Borders
2. Contents
3. At risk metastasis

A

BORDERS:
- Superior: Omohyoid muscle (surgical landmark) OR inferior border of the cricoid arch (clinical/radiographic landmark)
- Inferior: Clavicle
- Lateral: Posterior border of SCM
- Medial: Lateral border of the sternohyoid muscle (surgical) OR lateral border of CCA (clinical/radiologic)

CONTENTS:
- Lower third of IJV

AT RISK METASTASIS:
1. Hypopharynx
2. Cervical esophagus
3. Larynx

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15
Q

Regarding Level V in the neck, discuss:
1. Borders and division between Va and Vb
2. Predominant lymphatic pathways
3. Contents
4. At risk metastasis

A

BORDERS:
- Superior: Apex formed by a convergence of the SCM and the trapezius muscles
- Inferior: Clavicle
- Lateral: Anterior border of the trapezius muscle
- Medial: Posterior border of the SCM
- Floor: Splenius capitis, levator scapulae, and scalene muscles

DIVISION BETWEEEN Va + Vb:
1. Horizontal plane marking the inferior border of the arch of the cricoid cartilage

PREDOMINANT LYMPHATIC PATHWAYS:
1. Va: Spinal accessory nodes (along the SAC)
2. Vb (worse prognosis): Transverse cervical nodes (along transverse cervical artery as it courses along the lower third of the triangle)
3. Vb (worse prognosis): Supraclavicular nodes (immediately above the clavicle)

CONTENTS:
1. Lower half of SAN
2. Transverse cervical artery
3. Sentinel Node of Virchow/Virchow’s node: Left supraclavicular node located at the terminus of the thoracic duct into the subclavian of IJV which can be enlarged in patients with abdominal cancer (gastric, ovaian, testicular, ovarian, renal)

DRAINS:
1. Nasopharynx
2. Oropharynx
3. Scalp
4. ± posterior maxillary sinus

AT RISK METASTASIS:
1. Nasopharynx (Va)
2. Oropharynx (Va)
3. Thyroid (Vb)

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16
Q

Regarding Level VI in th enext, discuss:
1. Other names for this nodal group
2. Borders
3. Contents
4. At risk metastsis

A

Other names:
1. Anterior neck / central neck compartment
2. Prelaryngeal/Delphian
3. Pretracheal
4. Paratracheal

BORDERS:
- Superior: Hyoid bone
- Inferior: Supra-Sternal notch
- Lateral: Medial border of the carotid sheath bilaterally
- Midline compartment so no “Right” or “left” (people still say which side LN were removed however)

CONTENTS:
- Pre-cricoid nodes (Delphian nodes)
- Pre- and Para-tracheal nodes
- Perithyroidal nodes (including nodes along the RLN)
- Superior component of level VI (except superior thyroid artery nodes) typically has no nodal groups

AT RISK METASTASIS:
1. Thyroid
2. Glottic and subglottic larynx
3. Apex of pyriform sinus
4. Cervical esophagus
5. Cervical trachea

17
Q

What are the borders of level VII in the neck?

A

BORDERS:
- Superior: Superior edge of manubrium
- Inferior: Superior border of arch of aorta
- Lateral: Common carotid artery on the left, innominate artery on the right

18
Q

What are the recommended levels of the neck that should be treated with neck dissection for each Head/Neck cancer?

What are the rate of pathologic metastases in each level?

A

General indications: If the reported rate of metastasis to a given level is < 20% AND that level is not involved clinically or radiographically, then that level is not dissected

Oral Cavity: I-III (“Supra-omohyoid neck dissection”); Rates of Pathologic Metastases (Hoffman 2001):
- Level I: 30.1%
- Level II: 35.7%
- Level III: 22.8%
- Level IV: 9.1%
- Level V: 2.2%
Level IV controversial in N0 neck
- Byers paper (1997) - first paper to suggest dissecting level IV
- Warshavsky (2019) - newer data suggesting that likelihood of level IV mets for oral cavity in N0 neck is 5-10%

Oropharynx: II-IV (“Lateral neck dissection”)
Rates of metastasis:
- Overall risk 30-35%
- Level I: 10.3%
- Level V: 7%
- < 5% for levels I and V if N0 neck
(Bilateral Neck drainage)

Larynx: II-IV and VI (VI ND increases risk of hypoparathyroidism)
- Supraglottis - Highest incidence of occult nodal metastasis for subsites of larynx (>30%), and >20% contralateral occult disease
- Shah 1990 rates of metastasis: Level I: 6%, Level V: 1%
- Bilateral SND recommended by most authors
- Can avoid level VI/VII if N0, but for glottis and subglottis should include VI

Hypopharynx: II-IV and VI

Nasopharynx: II-V (“Posterolateral neck dissection”)

Posterolateral neck dissection (II-V)
- Nomenclature, term may be referred to as: II-V, II-V + suboccipital group, V + suboccipital group only
- Indications:
1) Nasopharynx
2) Cutaneous malignancies: melanoma, SCC, Merkel cell carcinomas
3) Soft tissue sarcomas of the scalp and neck

19
Q

Discuss the classification of neck dissections

A

Radical Neck Dissection:
- Lymph node levels I-V (and surrounding parotid tail?)
- SCM, SAN, and IJV

Modified Radical Neck Dissection:
- LN levels I-V like radical
- Preserving at least one non-lymphatic structure (SCM, SAN, IJV)

Selective Neck Dissection: Preservation of one or more lymph node level groups relative to radical neck dissection (“selective” lymph node group)
- Reduced facial edema, improved cosmesis, and better protects carotid
- Lateral (II-IV)
- Posterolateral (II-V)
- Anterolateral (II-IV, VI)
- Supraomohyoid (I-III)

Extended Radical Neck Dissection:
- Removal of additional lymph node groups or non-lymphatic structures (muscle, blood vessel, nerve) relative to radical neck dissection.

Additional LN group examples:
- superior mediastinal, parapharyngeal, retropharyngeal, periparotid, postauricular, suboccipital, buccinators

Additional non-lymphatic structures:
- External carotid artery, hypoglossal or vagus nerves

Vancouver Page 118

20
Q

When planning a neck dissection incision, what are 4 factors that must be considered?

A
  1. Avoid trifurcations over the carotid
  2. Flap blood supply for closure
  3. Cosmesis - in RSTL (resting skin tension lines)
  4. Allow for incision extension if required
21
Q

What are four regions of invasion that make a tumor generally inoperable?

A
  1. Skull base/intracranial
  2. Encasing or invading carotid
  3. Prevertebral fascia
  4. Pterygoid plates
22
Q

On imaging, what are 4 features of perineural invasion of the skull base?

A
  1. Enhancement of the nerve with contrast (due to disruption of the blood-brain barrier, leading to leakage of contrast - happens prior to nerve enlargement) - T1 with Gad and fat suppression
  2. Enlargement of nerve diameter
  3. Denervation atrophy of the innervated muscle (e.g. masticator muscles and tongue)
  4. Enlargement/asymmetry of the skull base foramina
23
Q

Define and carotid blow out syndrome.

Describe the classification of carotid blow out syndrome

A

CAROTID BLOW OUT SYNDROME
- Involvement of the carotid artery by malignant process with compromise of vessel integrity and rupture

CLASSIFICATION:
1. Type 1: Threatened - carotid artery is exposed to the oral cavity or external environment via skin breakdown
2. Type 2: Impending - Sentinel bleed occurred but has been controlled by conservative measures
3. Type 3: Acute - Active bleeding

24
Q

What are 3 signs of an impending carotid blow out?

A
  1. Exposed carotid
  2. Sentinel bleed
  3. Fistula/infection
25
Q

Describe the management of Type 1 and Type 2 carotid blow out syndrome

A

No active bleeding

  1. CTA or angiography
  2. If no discrete source of bleeding is identified: wound management followed by surgical reconstruction of carotid and/or coverage of carotid with vascularized tissue
  3. If location of bleed identified: Perform balloon occlusion test to decide on the following two options - either (1) embolization, or (2) Covered stent followed by further surgical procedures
26
Q

Describe the management of Type 3 Carotid blow out syndrome

A

Active bleeding
1. Secure airway
2. Packing of oropharynx
3. Resuscitation
4. Notify interventional radiology (covered stent vs. embolization depending on balloon occlusion test)
5. If IR not available - surgical ligation

27
Q

What are 5 risk factors for postoperative major vessel rupture?

A
  1. Fistula/infection
  2. Exposure of the vessel
  3. Adventitia of vessel removed
  4. Recurrent tumor
  5. Radiation
28
Q

Describe the composition/components of chyle. 10
What stain can be used to recognize it? 1

A
  1. Odorless
  2. Milky appearance that separates into a cremy layer when left to stand
  3. Specific gravity > 1.012
  4. Total fat composition of 0.4-4g/L
  5. Total protein > 30g/L
  6. pH > 7.0
  7. Triglycerides >110mg/dL
  8. Sterile fluid
  9. Lipophilic globules when stained with Sudan III
  10. WBC differential of predominantly lymphocytes
  11. Failure of clearance of supernatant
29
Q

Which part of the body does the right lymphatic duct and thoracic duct drain?

A

Right lymphatic duct = right half of head/neck, right arm and upper body

Thoracic duct = Everything below hips, left half of upper body, left arm, left head/neck

See photo Vancouver notes Pg 120

30
Q

How is a chyle leak diagnosed? Discuss 3 clinical signs and 3 biochemical signs.

A

CLINICAL:
1. Sudden increase in drain output, especially if associated with eating
2. Supraclavicular erythema, lymphedema, or palpable fluid collection
3. Creamy or milky drain output

BIOCHEMICAL (drain fluid):
1. Triglycerides > 100mg/dL
2. Triglyceride > serum triglyceride level
3. Presence of chylomicrons

31
Q

What are 3 most common variations of the thoracic duct drainage?

A

Attachments to:
1. Internal jugular vein (46%)
2. Confluence of the subclavian and IJV (32%)
3. Subclavian vein (18%)
4. External jugular vein

Anatomy is extremely variable, thoracic duct can also empty as one, two, or three different small branches (see Vancouver Pg 120)

32
Q

Describe a thorough management of the chylous fistula

A

A. Ligate if seen intraoperatively

B. ACTIVITY
1. Some recommend bedrest
2. Head elevation

C. WOUND CARE
1. Closed suction drainage
2. Pressure dressing (controversial)

D. DIET
1. Non-fat or low fat, but medium-chain fatty acid diet preferred (e.g. Vivonex)
- Directly absorbed into the portal system, avoid breakdown of long-chain triglycerides into free fatty acids & glycerol, which are transported in chylomicrins
- Need to maintain essential fatty acids, fat soluble vitamins (ADEK)
2. TPN

E. MONITORING
1. Electrolytes

F. MEDICAL
1. Octreotide/somatostatin (minimized lymph fluid excreion)
2. Stool softeners
3. Minimize intrathoracic pressure/straining

G. TOPICAL SCLEROSING AGENTS
1. Might cause damage to surrounding nerves
2. Common agents: OK-432 (Picibanil, immunostimulant), Tetracycline

H. SURGERY (Neck)
1. To facilitate identification intraoperatively: (a) Trendelenburg (b) Valsalva (c) drink a fatty drink prior to OR
2. When identified: (a) ligate, (b) cover with muscle, sclerosing agents, adhesive agents, or mesh

I. INTERVENTIONAL RADIOLOGY
1. Percutaneous transabdominal cannulation of the thoracic duct at the cisterna chyli –> selective distal embolization

J. SURGERY (Chest)
1. VATS thoracic duct ligation

33
Q

What are 4 indications for early surgical intervention for chylous fistula?

A
  1. > 600mL in 24 hours
  2. Persistent > 1 week
  3. Chylothorax
  4. Cachexia
34
Q

Name 3 tumors that derive from schwann cells. What stains do they have in common? 6

A
  1. Schwannoma
  2. Neurofibroma
  3. Granular cell tumors

Stains: (true for all neuroendocrine cells)
1. Neuron-specific enolase (NSE)
2. S-100
3. Synaptophysin
4. Chromogranin
5. HMB45
6. CK20

35
Q

Regarding granular cell tumors, discuss:
1. What are they?
2. Risk of malignant transofmration?
3. Presentation?
4. Histology 1 and stains?
5. Treatment

A

GRANULAR CELL TUMORS
- Benign tumor of neural cell derivation
- 2% risk of malignant transformation (based on invasion and spread to LN)

CLINICAL PRESENTATION:
- Painless nodule on any mucosal surface (40% tongue)

HISTOLOGY:
- “Pseudoepitheliomatous hyperplasia”

Stains (as per neuroendocrine):
1. Neuron specific enolase (NSE)
2. S100
3. Synaptophysin
4. CK20
5. Chromogranin
6. HMB45

36
Q

What are 5 risk factors of osteosarcoma?

A
  1. Paget’s disease
  2. Osteochondroma
  3. Fibrous dysplasia
  4. Prior XRT
  5. Trauma

Head and Neck (15 decks)

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