When LND is indicated, neck dissection of at least levels II, III and IV [12] is required, as metastatic disease Of the 22 patients who underwent a therapeutic level V ND, 12 (54.5%) were males and 10 (45.5%) were females, with a mean age of 44.9 ± 21.2 years (median: 41.4, IQR [26.9-58.9], range: 16.5-81.6 years). Continuous variables were evaluated for normal distribution using a histogram and Q-Q plot. Interestingly, symptoms of dysphagia, intraoperative characteristics of a macroscopic ETE, and histopathological findings of microscopic perineural invasion (P = .037) were all found to be significant risk factors for disease recurrence (HR: 2.75, 3.69, and 2.49, respectively; Table 2). In elective neck dissections for most HNSCC primary sites, level IIB nodes can be left intact, thus minimizing risk of damage to the SAN. ..... read more.. Ultrasound Otoscopes For Aiding Diagnosis Of Middle Ear Infections, Role of Balloon dilatation in chronic rhinosinusitis – Clinical consensus statement 2018, Revised Bethesda system for thyroid malignancies, TNM Staging of Nasopharyngeal Carcinoma (AJCC 8). Inclusion criteria were PTC diagnosis with local neck metastasis upon initial presentation, a total or a subsequent completion thyroidectomy including ND, and a follow-up duration longer than 3 months at the otolaryngology and/or endocrinology departments at the TLVMC. Of the 133 patients who underwent a selective therapeutic II to VI compartment ND without therapeutic level V dissection, 51 (38.4%) were males and 82 (61.6%) were females, with a mean age of 46.97 ± 17.4 years (median: 47 [33.7-61.75], range 13.1-84.7 years). Of these, levels I to V are included in a comprehensive lateral neck dissection, while levels VI and VII make up a central neck dissection. For tumors of the parotid or skin of the lateral face and scalp, level IIB dissection should be performed routinely. Categorical variables are presented as numbers and percentages. We performed an additional multivariate analysis in order to detect the prognostic implications of a therapeutic level V ND and it showed that a therapeutic level V ND (P = .422) was not a predictor for worse outcome. Most moderate-large neck dissections are best grossed after fixation, but can be done fresh if careful. Interestingly, the rate of recurrence to level V was also relatively low in the study by Xu et al, with only 4.8% (n = 5) of their patients having experienced a level V recurrence. Figure 3. The neck dissections are grouped into four broad categories of radical neck dissection, modified radical neck dissection, selective neck dissection (this group is subclassified according to which node levels are removed) and extended neck dissection. Results: A total of 489 modified radical neck dissection (MRND) (levels II–V) and 289 internal jugular node dissection (IJND) (levels II–IV) were performed in 778 patients. Selective neck dissection (SND) is done for N0 necks (no clinical evidence of neck nodes) or for very limited cervical metastases. Materials and Methods: Video demonstration of a comprehensive levels 2a, 3, 4, and 5b lateral neck dissection for thyroid cancer. These were all independent predictive factors for recurrence at level V among patients who underwent ND that included levels II to V. The clinical implication of an elective level V ND in terms of decreasing recurrence rate is rarely discussed. However, following surgery and radioactive iodine therapy, many patients will still have detectable serum thyroglobulin levels with cervical adenopathy detected on sonography . By: Kayci Reyer Posted: Friday, December 11, 2020. The rate of positive findings in lateral neck dissection was 18.6% (26 of the 140 PLND). Lean Library can solve it. Surgeons use different terms to describe neck dissections. Neck dissection (ND) is a complex surgical operation involving the removal of potential or proven metastases to cervical lymph nodes. When primary tumor arises in parotid gland or in the pharynx (may need retropharyngeal node clearance dissection). Data on initial preoperative presentation, including demographic data, clinical and physical examination findings, preoperative imaging (ultrasound [US], fine-needle aspiration [FNA], computed tomography [CT], magnetic resonance imaging [MRI], positron emission tomography [PET]), as well as intraoperative findings, postoperative final histopathology reports, adjuvant treatments, and long-term follow-up, were extracted. 8.3). Disease recurrence occurred in 5 (22.7%) of the 22 patients who required a therapeutic level V ND, and 4 (18.2%) of them had a structural recurrence. The compression of categorical variables between the 2 groups was by the χ2 testor Fisher exact test. • Lateral Neck Dissection—Includes Level IIA or Levels IIA & IIB, Level III, and Level IV (Figure 8). The radical neck dissection involves removal of all ipsilateral cervical lymph nodes from levels I through V, as well as the submandibular gland. Skin Cancer (squamous cell carcinoma and melanoma) posterior to line of tragus. Other classifications of neck dissections are Medina Classification and Spiros Classification. Though the purpose of this article is not to debate the risk-benefit aspects of dissecting selected lymph node regions, a quick wrap up of these arguments in favor and against elective neck dissection are listed below-, Based on the levels of neck nodes removed, elective neck dissection can be further classified into. Go to: Discussion. Simpson, WJ, McKinney, SE, Carruthers, JS. Selective modified radical neck dissection for papillary thyroid cancer – is level I, II and V dissection always necessary? Management and outcome of recurrent well-differentiated thyroid carcinoma, Level V clearance in neck dissection for papillary thyroid carcinoma: a need for homogeneous studies, Regional metastatic pattern of papillary thyroid carcinoma, Preoperative detection and predictors of level V lymph node metastasis in patients with papillary thyroid carcinoma, Occult lymph node metastases in neck level V in papillary thyroid carcinoma, Patterns of regional recurrence in papillary thyroid cancer patients with lateral neck metastases undergoing neck dissection, Pattern of neck recurrence after lateral neck dissection for cervical metastases in papillary thyroid cancer, Lateral Neck Dissection for Well-Differentiated Thyroid Carcinoma: Is Prophylactic Level V Neck Dissection Necessary? The nerve has lots of lymph glands lying very close to it and so it is often bruised during a neck dissection. Dear Cynthia. Our study has several limitations worth mentioning. Spriano, G, Ruscito, P, Pellini, R, Appetecchia, M, Roselli, R. Popovski, V, Benedetti, A, Popovic-Monevska, D. Battoo, AJ, Sheikh, ZA, Thankappan, K, Mir, AW, Haji, AG. In order to tailor an optimal personalized treatment, several studies sought possible predictors for level V involvement. One might aim to assess the extent of selective II to IV ND to level V via utilizing “off-label” the ATA risk-stratification scheme, claiming that evidence of lateral neck metastasis is considered to be a disease recurrence predictor. SPSS software was used for all statistical analyses (IBM SPSS Statistics for Windows, version 25). When the malignant primary is untreatable. lateral neck dissections can be as high as 50%, with a 3.6% incidence of chyle leak and an 11% or greater incidence of chronicneckpainandnumbness(19).Somestudiesshowthat the addition of a lateral neck dissection to central neck com-partment surgery (thyroidectomy or central neck dissection) doubles the risk of transient postoperative hypoparathyroid-ism (19,20). Keywords Papillary thyroid carcinoma Lateral neck dissection Recurrence of papillary thyroid carcinoma Lymph node metastases Reoperative lateral neck dissection Introduction Lateral neck lymph node involvement is quite common in patients with papillary thyroid carcinoma (PTC) either at the initial diagnosis either during follow-up [1, 2]. For cutaneous malignancies arising on the anterior and lateral face, the elective neck dissection of choice is SND (parotid and facial nodes, levels IA, IB, II, and III). The limited size of the entire cohort restricted the number of patients who sustained a recurrence. Selective therapeutic II to V ND extent was documented according to the current ATA guidelines at the time of surgery and based on the anatomical description as recorded on the operative report. This was termed a modified radical neck dissection and was recommended by Bocca and Pignataro 13,14 as entirely sufficient for control of cancer. • Origin – digastric fossa of the mandible (at the symphyseal border• Insertion –1) hyoid bone via the intermediate tendon2) mastoid process• Function –1) elevate the hyoid bone2) depress the mandible (assists lateral pterygoid) 21. Xu et al26 did not find any significant difference in the rate of recurrence between patients who underwent a level V ND and those who did not (8% vs 9% of recurrence). 5 The lateral neck dissection removes lymph tissue in levels II-IV. Cox Regression and Multivariate Analysis: Predictors (Clinical, Preoperative Evaluation, Intraoperative Findings, and Histopathological Findings) for Risk of Recurrence (N = 155). Following are the absolute indications for RND. The prognostic benefit of a level V prophylactic ND in patients with PTC continues to be a matter of controversy. Radical neck dissection. Of 44 patients in whom the nerve was not intentionally sacrificed, … This procedure was described by Crile in 1906 and later popularized by Hayes Martin in 1957. measurements of thyroglobulin levels, and neck sonography (6) . Log In or Register to continue The cure rate for neck dissection is decreased when the neck becomes N+. Selective neck dissection (SND) is done for N 0 necks (no clinical evidence of neck nodes) or for very limited cervical metasta-ses (Figure 2). Elective level VI neck dissection during thyroidectomy and lateral neck dissection (LND) for the treatment of PTC with lateral compartment lymph node metastases is controversial because of the uncertain benefit in clinical outcomes and increased risks of surgical morbidity. However, no specific contribution was found to be a robust predictor of level V involvement. The high incidence of occult metastasis in tumors of oral cavity, pharynx and to a lesser extent supraglottic laryngeal cancers, forms the basis of selective neck dissection. Selective neck dissections are generally performed on an elective basis. END is indicated when the risk of having occult cervical nodal metastases exceeds 15-20%. Selective lateral neck dissection is a recently-introduced surgical procedure for the treatment of cervical lymph nodes believed to be at risk of metastasis from primary malignant neoplasms of the upper respiratory and digestive tracts. Sign in here to access free tools such as favourites and alerts, or to access personal subscriptions, If you have access to journal content via a university, library or employer, sign in here, Research off-campus without worrying about access issues. Radical neck dissection Radical neck dissection is the historical standard by which subsequent approaches are compared and defined. However, the system is referring only to LNs size and number, while the involved nodes’ location does not play any clear role.5. Elective level V ND should not be done routinely when lateral ND is indicated but should rather be considered after careful evaluation in high-risk patients. Modified Radical Neck Dissection (MRND) – removal of all lymph node groups routinely removed in a RND, but with preservation of one or more nonlymphatic structures (SAN, SCM and IJV). Results. The recurrence rate to level V was very low throughout follow-up and did not differ between those who did and did not undergo a therapeutic level V ND. 2011Apr;90(4):186-9. Its value in the management of the clinically negative neck in cancer of the larynx is discussed. Objective:The presence of clinically detectable papillary thyroid carcinoma (PTC) metastases in the lateral neck is an indication for neck dissection (ND) … We did not find any reports on parameters that can be used as predictive factors for level V disease recurrence and thus may mandate a more extensive dissection. This study assessed the rate of recurrence in level V among patients undergoing a therapeutic selective II to IV ND with a therapeutic level V ND and patients undergoing a therapeutic selective II to IV ND without a level V ND. Radiation to the neck is as effective as neck dissection for N0. For transglottic and subglottic carcinoma larynx, carcinoma esophagus, carcinoma thyroid, etc, where it is necessary to remove paratracheal, pretracheal and anterior compartment nodes. This site uses cookies. XI may be difficult to preserve If N0, consider level I-III and Va if high grade histology (e.g. A total of 249 patients were diagnosed as having locoregional neck metastatic PTC upon initial presentation, for which they underwent total thyroidectomy with ND, and 189 of those patients met study inclusion criteria. He admonished that, “radicality must be conceived against the cancer, and not against the neck.” Definition of the compartments or levels of the lateral neck are included in the Table. [1] Cancer of the oropharynx has a propensity to metastasize to both sides of the neck. METHODS: Fifteen LSND were performed in 11 N0 laryngeal carcinoma patients with preservation of level IIB. Pattern of spread to the lateral neck in metastatic well-differentiated thyroid cancer: a systematic review and meta-analysis, Predictors of level V metastasis in well-differentiated thyroid cancer, Is routine dissection of level II-B and V-A necessary in patients with papillary thyroid cancer undergoing lateral neck dissection for FNA-confirmed metastases in other levels, Pattern of regional metastases and prognostic factors in differentiated thyroid carcinoma, Risk factors for level V lymph node metastases in solitary papillary thyroid carcinoma with clinically lateral lymph node metastases, Preservazione del nervo accessorio spinale nelle dissezioni del collo: outcomes chirurgici e funzionali, American Thyroid Association consensus review and statement regarding the anatomy, terminology, and rationale for lateral neck dissection in differentiated thyroid cancer, Nomogram for predicting level V lymph node metastases in papillary thyroid carcinoma with clinically lateral lymph node metastases: a large retrospective cohort study of 1037 patients from FDUSCC, Patterns, predictive factors and prognostic impact of multilevel metastasis in N1b papillary thyroid carcinoma. In 2012, the ATA guidelines17 specified level Vb elective dissection alone, corresponding to the findings by Kupferman et al.12 Interestingly, the 2015 ATA guidelines recommend therapeutic dissection to level V without a clear recommendation regarding the extent of the routine selective NDs of levels II to VI.5. Depending on the detection method employed, He is the founder and Editor in Chief of e4ent.com, which he began in January 2017. None of the recurrences involved level V. Recurrences to level V were sustained by 4 (3%) of the 133 patients who underwent a selective II to IV ND without a level V ND. Non-lymphatic structures include mandible, parotid gland, part of the mastoid tip, prevertebral fascia and musculature, hypoglossal nerve, external carotid artery, vagus nerve, paraspinal muscles, and skin. Background: The optimal extent of therapeutic lateral neck dissection (LND) in the management of N1b papillary thyroid microcarcinoma (PTMC) is still under debate in clinical practice. He used the term radical neck dissection when 4 or 5 levels are resected, which included conventional radical neck dissection, modified radical neck dissection and extended radical neck dissection. Differentiated and medullary thyroid cancers, Significant operable metastatic neck disease with tumor bulk near to or directly involving SAN and/or IJV. Group differences in when comparing the initial presentation and demographic characteristics, gender holds a level of significance, with 54.5% of patients who underwent a level II to IV selective therapeutic ND, with a level V ND being males compared to 38.35% of the patients who did not require a therapeutic level V ND (P = .034). Neck Dissection for Thyroid Cancer. The distribution of OLNM is reported in table 2. The main aim of this study is to assess the recurrence rate to level V among patients who underwent therapeutic levels II to IV ND, without prophylactic level V dissection. Figure 2. e4ENT is a rapidly growing, otorhinolarynology forum for ear, nose and throat (ENT) specialists and other health professionals from across the globe for Allowing neck metastasis to develop increases the incidence of distant metastasis. This is. A selective neck dissection preserves one or more lymph node levels. The mean follow-up period was 5.1 ± 3 years (median: 4.65 [2.625-7.335], range 0.33-13.04 years; Table 1). Ferlito A, Robbins KT, Shah JP, et al. Wang et al18 reported additional predictors and proposed a normogram for assessing the necessity of elective ND. Anderson Cancer Center, Texas, USA (53%)12 and Johns Hopkins University School of Medicine, Maryland, USA (40%)13 claimed that a comprehensive elective level V ND is routinely necessary. Kupferman, ME, Weinstock, YE, Santillan, AA. Timing of removal of neck drains following head and neck surgery. The cervical rootlets are skeletonized as the fat and fascia are … END results in a large number of unnecessary surgical procedures associated with inevitable morbidity. The study included a total of 405 lateral neck dissections performed in 352 patients; 197 women (56%) and 155 men (44%). Proposal for a rational classification of neck dissections. There were no significant group differences in the rates of intraoperatively detected extrathyroidal macroscopic extension (Table 1). • Any neck dissection that preserves one or more groups or levels of lymphnodes Selective neck dissection (SND) • Extended radical neck dissection (ERND) removal of additional lymphnode groups or non lymphatic structures relative to the RND. Most of the problems associated with neck dissection are the result of damage to one of two nerves: Accessory nerve – this is a nerve which runs from the top to the bottom of the neck and helps you to move your shoulder. He is passionate about teaching and has an interest in education, in particular free and open access medical education (FOAMed) and e-learning. Doctors will give their patients specific instructions regarding what to do before surgery. Systematic LN dissection of both lateral neck compartments (levels 2–5 32), saving the internal jugular vein, all nerves, and muscles (functional lateral neck dissection, FLND) without initial transsternal mediastinal dissection, was performed in all patients until the end of 2001 17. Data with normal and near-normal distributions are presented as mean ± SD, and those with non-normal distributions as median and interquartile range (IQR). The Kaplan-Meier curve showed no significant difference between them in overall disease recurrence rates (Figure 1) and biochemical and structural recurrences (Figures 2 and 3). Die einzelnen Lymphknotengruppen des Halses werden in sechs (nach Robbins 1991; modifiziert nach Robbins 2001) verschiedene Prior to reading about the classification of neck dissections, knowledge about the levels of head and neck lymphatics, the drainage pattern of head and neck malignancies, etc is recommended. While code 38700 is properly used to code the very limited SHND involving level I only, all other SNDs are reported with CPT code 38724, Cervical lymphadenectomy . A Retrospective Cohort Study, https://doi.org/10.1177/01455613211003805, https://creativecommons.org/licenses/by-nc/4.0/, https://us.sagepub.com/en-us/nam/open-access-at-sage. Being a radical procedure associated with extensive morbidities, RND should be performed only in patients with malignant tumors of head and neck. Results: A systematic step-wise approach to a standard comprehensive lateral neck dissection for thyroid cancer, inclusive of levels 2a, 3, 4, and 5b, is demonstrated. With a lateral neck dissection, Level IV is dissected by applying traction to the fibrofatty tissue deep to the omohyoid muscle in a cephalad direction and to the omohyoid muscle in a caudal direction, while dissecting the fibrofatty tissue from Level IV. Patient with significant bilateral disease – at least one IJV needs to be preserved. Triage. END can be performed during the primary surgery. I have read and accept the terms and conditions, View permissions information for this article. Yü, ce, I, Cağ, li, S, Bayram, A, Karasu, F, Gü, ney, E. View or download all content the institution has subscribed to. [5] Therefore, unless postoperative radiation therapy is part of the treatment regimen, both sides of the neck should be dissected. There were no significant associations between level V dissection and risk for recurrence. Medical records were examined for biopsy or pathologically proven lateral neck recurrence. It is retrospective in design, and it was conducted in a single institution. Another limitation is that a minority of the patients (N = 13) had a follow-up period of less than 1 year. Radical Neck Dissection (RND) – removal of all ipsilateral cervical lymph node groups from levels I through V, together with SAN, SCM and IJV.
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