The Laryngoscope

Lippincott Williams & Wilkins

2008 The American Laryngological,
Rhinological and Otological Society, Inc.
Is Radical Neck Dissection a Current Option
for Neck Disease?
Alfio Ferlito, MD, FRCS, FACS; Alessandra Rinaldo, MD, FACS
For many years after the first description of a suc-
cessful en bloc neck dissection by the Polish surgeon Jaw-
dyn ski
1
in 1888, this procedure was the only operation
accepted for the surgical treatment of the neck in patients
with cancer of the head and neck staged N0 or otherwise.
The operation he described has come to be known as the
radical neck dissection (RND). This surgical procedure
was strongly advocated by Crile in the early 20th centu-
ry
24
and well established by Martin et al.
5
in the 1950s.
The term RND has been accepted by the Committee for
Neck Classification of the American Head and Neck Soci-
ety.
68
The Japan Neck Dissection Study Group recently
termed this surgical treatment as total neck dissection.
9
RND includes removal of all ipsilateral cervical
lymph node groups extending from the inferior border of
the mandible above, to the clavicle below, and from the
lateral border of the sternohyoid muscle, the hyoid bone,
and the contralateral anterior belly of the digastric muscle
anteriorly, to the anterior border of the trapezius muscle
posteriorly. It includes all lymph node groups from levels
I to V (the submental group, the submandibular group, the
upper jugular group, the middle jugular group, the lower
jugular group, and the posterior triangle group). The spi-
nal accessory nerve, the internal jugular vein, the sterno-
cleidomastoid muscle, the submandibular gland, the tail
of parotid gland, and the cervical plexus nerves are all
removed. RND does not include removal of the suboccipi-
tal nodes, periparotid nodes (except intraparotid nodes
located in the posterior aspect of the submandibular tri-
angle), buccinator nodes, retropharyngeal nodes, and mid-
line visceral (anterior compartment) nodes.
7
RND there-
fore is the dissection of all the lymph node levels and
sublevels of the lateral neck.
At present, conventional RND and modified RND
(MRND) are no longer indicated for elective neck dissec-
tion. The cancers of the head and neck do not involve all
levels and sublevels of the lateral neck. In particular,
RND is an overtreatment for N0 and Ndisease. Sublevel
IA is usually not involved in advanced tumors of the
larynx, hypopharynx, oropharynx, nasopharynx, parotid
gland, submandibular gland, thyroid gland, parathyroid
gland, trachea, and cervical esophagus. There is no pri-
mary cancer of the head and neck in which there is a high
risk for involvement of sublevels IA and IB, IIA and IIB,
VA and VB, and levels III and IV. In particular, the absence
of metastases in sublevel IA and/or in sublevel VB does not
justify a comprehensive dissection including levels I to V in
patients with primary cancer of the head and neck.
A strong trend exists in support of selective neck
dissection being implemented as an oncologically safe and
effective procedure for multiple N disease while limiting
morbidity.
The classic RND has been used for advanced-stage
nodal metastases from head and neck cancer followed by
adjuvant postoperative radiation therapy combined or not
with concomitant chemotherapy. The specific indications
were patients with N3 disease, extensive soft tissue dis-
ease either appreciated clinically or demonstrated radio-
logically. In cases with N3 neck disease, RND may not be
sufficient. These patients remain at the highest risk for
the development of local recurrence and distant metasta-
ses.
10
The prognosis is usually poor. It is also important to
remember that a large number of patients with advanced
neck disease are not suitable candidates for aggressive
treatment because of their clinical status or associated
comorbidities and are, as a consequence, submitted to
radiation therapy alone.
10
Patients with advanced N stages are currently
treated initially with nonsurgical methods, usually with
concomitant combinations of chemotherapy and irradia-
tion. After the introduction of organ preservation strat-
egies, with various combinations using chemoradiother-
apy for definitive treatment of advanced locoregional
cancer of the larynx and pharynx, there is emerging trend
toward performing planned neck dissection for bulky cer-
vical lymphadenopathy. The regional disease control for
patients with persistent neck disease using selective and
superselective neck dissections for advanced N2 and N3
disease after concurrent chemoradiation is excellent.
1118
There is ample evidence in the literature that concom-
itant or concurrent radiochemotherapy can achieve
From the Department of Surgical Sciences, ENT Clinic, University
of Udine, Udine, Italy.
Editors Note: This Manuscript was accepted for publication April
24, 2008.
Send correspondence to Alfio Ferlito, MD, FRCS, FACS, Director of
the Department of Surgical Sciences, Professor and Chairman of the ENT
Clinic, University of Udine, Policlinico Universitario, Piazzale S. Maria
della Misericordia, I-33100 Udine, Italy. E-mail: a.ferlito@uniud.it
DOI: 10.1097/MLG.0b013e31817d9cd5
Laryngoscope 118: October 2008 Editorial
1717
good regional control in patients with advanced neck dis-
ease. However, the development of distant metastases
does remain a problem, despite the administration of sys-
temic therapy.
11
The technique of selective neck dissection has also
expanded to include removal of one or more of the non-
lymphatic structures routinely included in the MRND or
RND (i.e., sternocleidomastoid muscle, internal jugular
vein, spinal accessory nerve). The structures most fre-
quently sacrificed are the submandibular salivary gland
and the internal jugular vein.
19,20
Medina et al.
21
recently investigated the feasibility of
performing a single-level dissection in patients with
head and neck cancer treated with radiation therapy with
or without chemotherapy. The results confirmed the effec-
tiveness of selective neck dissection in the management of
residual disease in the neck.
The majority of patients who present squamous car-
cinoma in the neck with an unknown primary have N2 or
N3 neck disease, stage IV head and neck cancer. The
standard treatment choice has been RND followed by ra-
diation therapy; however, the current treatment is a com-
bination of chemoradiation therapy with neck dissection
reserved for salvage purposes. The usage of the RND, even
for advanced neck disease with unknown primary tumor,
is generally unnecessary because all the five neck levels
are rarely involved. At present, the use of RND has be-
come greatly limited and this surgical procedure is no
longer standard.
22
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