1.1 Crile and the Radical Neck Dissection

The “grandfather” of neck dissection is George Crile, Sr., of the Cleveland Clinic. In 1906, Crile portrayed the field of head-and-neck surgery as being behind the times in terms of interest and progress. Crile believed that, if the neck lymphatics could be removed in a “radical” manner and “en bloc,” more cures could be accomplished. The oncological approach to the neck proposed by Crile was strongly influenced by the oncologic principles used by Halstead for breast cancer. The concept of the “bloc” that was in vogue for the treatment of breast cancer required removal of the primary site with draining lymphatics and nodes in continuity. In breast surgery, the pectoralis muscle and the axillary vein were part of the “bloc,” as were all other structures surrounding the tumor. No oncological benefits beyond access were claimed.

Following these principles, Crile designed a similar operation to remove the lymphatic system of the neck in patients with head-and-neck tumors. Here, the sternocleidomastoid muscle and the internal jugular vein suffered the same fate as the pectoralis muscle and the axillary vein in breast cancer surgery. Crile’s procedure allowed a systematic removal of the lymphatic tissue of the neck, along with the surrounding structures. Only the carotid artery and some “lucky” nerves survived the Halstedian concept of oncological surgery. This operation received the name of “Radical Neck Dissection” and was popularized by Hayes Martin.

The work of Martin completely changed the world of neck dissection. Radical neck dissection became the standard procedure for patients requiring surgical treatment of the lymphatics of the neck in combination with removal of the primary tumor. The lymphatic tissue had to be removed from the neck and the best way to do this was by removing almost every single structure within the cervical area.

1.2 Time to Change

The analogous thinking between general surgery and head-and-neck surgery persisted until the early 1960s when general surgeons began to reconsider the usefulness of the “bigger is better” concept in breast cancer. Head-and-neck surgeons had a similar evolution. It was evident to all those involved in the management of patients with head-and-neck cancer that the radical operation was adequate for the treatment of large palpable masses. But two new issues gained importance in the field of head-and-neck cancer surgery: the need for treatment of the N0 neck, and the need for simultaneous bilateral neck dissection.

The need to treat the neck in patients without palpable disease became evident at the light of the knowledge of the biological behavior of the lymphatic metastases. Some primary tumors were associated with a high rate of false clinical and radiological N0 necks, leading to a high incidence of neck recurrences that could be prevented by neck dissection. The radical operation was considered too aggressive for these patients. The concept “elective neck dissection” became soon a matter of debate. Some authors refer to elective neck dissection as prophylactic neck dissection. This is a clear misuse of the term “prophylactic.” Prophylaxis implies prevention of something to happen. In Martin’s time, there was the subtle suggestion that a prophylactic dissection actually prevented something, but what that something was is not clear. Neck dissection does not prevent either neck relapse or anything: it either treats existing neck metastases (evident or occult) or provides valuable information about the actual absence of metastases. Nowadays, the concept of prophylactic neck dissection is clearly faulty. From an oncologic standpoint, a neck dissection is either therapeutic, when positive nodes are found in the specimen, or oncologically useless, when positive nodes are not identified in the surgical specimen. However, there are other nononcological advantages of neck dissection. Namely, prognostic information—a true N0 patient has around 50% more chances of survival than an N+ patient—and postoperative treatment planning.

Another argument in favor of less aggressive neck dissections was the possibility of bilateral neck metastasis that some head-and-neck tumors have. Multiple studies about cervical lymph flow demonstrated that head-and-neck midline structures could metastasize with similar probabilities to both sides of the neck. It was noteworthy that radical neck dissection was not practical as a simultaneous bilateral procedure. The need for less aggressive types of neck dissection became evident also in these cases.

1.3 Modified Radical Neck Dissection

From Martin’s time, surgeons recognized that the Crile operation was not always necessary and was unwarranted in some cases of head-and-neck cancer. Data assured surgeons that neck recurrence rates with pathologically negative necks and low-staged clinically positive necks were similar regardless whether the accessory nerve was sacrificed or not. The long-term functional consequences of accessory nerve sacrifice were described in the 1960s as the shoulder syndrome. Shoulder droop, diminished range of motion, shoulder abduction, and external rotation and pain led to reconsideration of routine nerve sacrifice. Modified neck dissection that preserved the accessory nerve was a logical first modification. It later became obvious that preserving the nerve, by dissecting it free, was not always followed by normal nerve function. Surgical trauma during dissection left some with variations of the shoulder syndrome. Questionnaires about shoulder function were reassuring but electromyography and careful clinical evaluation by experts documented that preserving the accessory nerve is not always enough. However, careful nerve preservation is more rational than routine sacrifice of the nerve.

The loss of contour after removal of the sternocleidomastoid muscle led also to reconsideration of that practice. The muscle does not contain lymphatics or lymph nodes, but its removal does make neck dissection easier. Routine sacrifice of the jugular vein adds no oncological safety in the clinically negative and low-stage clinically positive neck situations. For surgeons who favored elective and bilateral dissections, it was evident that the radical operation was excessive when no metastases were found in the neck.

The team at UT MD Anderson Cancer Center, including Richard H. Jesse and Alando J. Ballantyne, pioneered modified neck dissections in the United States, and they first reported their results in the American Journal of Surgery in an article titled “Radical or modified neck dissection: a therapeutic dilemma” in 1978. Soon surgeons in the United States accepted that “less than radical neck dissection” was a good option in selected patients and the terms modified, supraomohyoid, upper, midline were used to describe these lesser operations.

The nomenclature became confusing to teach and lacked standardization for reporting. The American Academy of Otolaryngology—Head and Neck Surgery convened a special task force to address the terminology problems. The group was tasked to (1) recommend terminology that adhered to the more traditional words as radical and modified radical; (2) define which lymphatic structures and other nonlymphatic structures would be removed relative to the radical dissection; (3) provide a standard nomenclature for lymph node groups and nonlymphatic structures; (4) define the boundaries for resection of lymph node groups; (5) use terms for neck dissection procedures that are basic and easy to understand; and (6) develop a classification based on the biology of cervical metastases and the principles of oncological surgery.

Some of these goals were accomplished. Terminology was fashioned, and lymph node groups were defined, as were the boundaries of the groups. Whether these accomplishments created a system, basic and easy to use, is in doubt. The Academy classification was based on the rationale that (1) radical neck dissection is the standard reference procedure; (2) when one or more nonlymphoid structures are preserved, the term modified neck dissection is preferred; (3) when one or more lymphoid groups are preserved, the term selective dissection is recommended; and (4) when a procedure removes other lymph node groups or nonlymphoid structures different from those removed in the radical neck dissection, the recommended term is extended neck dissection.

The Academy classification defined seven different neck dissections (Table 1‑1). Other classifications are cited in the literature and preferred by their authors’ institutions, so the classification issue is not unanimously agreed upon. For example, Spiro from Memorial Hospital offers a list of 11 neck dissections (Table 1‑2). Medina modified the Academy classification with eight different types of comprehensive neck dissection, seven selective operations, and one extended neck dissection (Table 1‑3). A classification published in 2011 by several renowned authors attempting a consensus proposed that the symbol “ND” be followed by the lymphatic levels removed and nonlymphatic structures resected. In our opinion, all these proposals add very little to clarifying the field of neck dissection from a practical educational standpoint.

What is not clear, on a statistically supported basis, is what dissection is appropriate for what clinical scenario. The question of whether many of the modifications make any clinical difference, in terms of survival, morbidity, or any other measure of value recognized today, has not been answered. Only empirical assumption is offered as a basis for these recommendations. It is unlikely that statistical data will be forthcoming in the immediate future because the whole issue of the type of neck dissection is being overshadowed by the questions raised about neck treatment when concomitant chemoradiotherapy programs are used as initial treatment for both the primary site and neck metastases.

Names like Robert M. Byers, Eugene N. Myers, Lawrence W. DeSanto, Jonas T. Johnson, and many others were early adapters of modified radical neck dissection and published their results in several seminal articles in the mid-1990s.

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