Frequently Asked Questions

Every time that we lecture about functional neck dissection, there are a number of questions that systematically appear in the discussion. In this chapter we would like to answer these questions following the basic guidelines presented in the previous pages.

DOES THE SITE OF THE PRIMARY TUMOR INFLUENCE THE TYPE OF DISSECTION (I.E., FUNCTIONAL VS. RADICAL)?

This question was frequently asked in the early days of functional neck dissection when the operation was not considered safe from the oncological standpoint. At that time, more aggressive neck treatment was advised for tumor sites behaving more aggressively (floor of the mouth, tongue, hypopharynx). Thus, radical neck dissection was preferred to a functional approach as a means to improve the outcome.

Nowadays we have learned to separate primary and neck. We are aware that some tumor locations do more poorly than others. Hypopharynx cancer has a worse prognosis than tumors of the larynx, but this will not be modified by using a more aggressive neck treatment than is required by the clinical scenario. In other words, for an N0 neck on a patient with a piriform sinus tumor, radical neck dissection is not safer than functional neck dissection.

In head and neck cancer patients the neck must be treated according to its own status. The primary should not be used as a criterion for deciding the approach to the neck. The decision whether to use radical or functional neck dissection should be based only on the characteristics of the neck. However, once a functional approach has been selected, the type and extent of the dissection (complete or selective) should be determined by the location of the primary and the experience of the surgeon, as we have repeatedly emphasized in the previous pages.

This is another controversial issue concerning functional neck dissection. Again, most doubts in this respect come from the early days when functional neck dissection was considered insufficient.

Although not unanimously recognized, the number of positive nodes in the neck dissection specimen may harbor prognostic information. However, the exact number of nodes defining the chances for a poor outcome vary in different studies. On the other hand, in some series, the number of nodes is not considered to be important from the prognostic standpoint. In any case, selection of the surgical approach to the neck should not be indicated by the number of nodes, but by the characteristics of every single node that has been detected in the patient’s neck.

Functional neck dissection can be performed in patients with nonpalpable and small palpable mobile nodes (usually smaller than 2.5 cm), the size being just a merely orientating factor. The operation is totally safe in patients with multiple nodes, as long as all nodes fulfill these criteria. In these cases, radical neck dissection will not be safer than a functional approach. Thus, it is not the number of nodes that is important, but their clinical characteristics.

DO YOU ALWAYS USE POSTOPERATIVE RADIATION THERAPY AFTER FUNCTIONAL NECK DISSECTION IN PN⁺ PATIENTS?

We would very much like to have a conclusive answer to the question of postoperative radiotherapy for positive nodes, but unfortunately this is not the case. In fact, nobody has the answer to this question.

Postoperative radiotherapy has been recommended in a large variety of situations: for all patients with positive nodes; only for patients with more than a certain number of positive nodes—the number being as variable as the authors that propose this approach; only for patients with positive nodes showing extracapsular extension; and also, for some combinations of the above.