Metastatic Neck Disease

59 Metastatic Neck Disease


59.1 Triangles of the Neck


• Anterior


figure Submental


figure Submandibular


figure Carotid


figure Muscular


• Posterior


figure Occipital


figure Subclavian


59.2 Head and Neck Lymphatics


59.2.1 Waldeyer Internal Ring


• Circular collection of lymphoid tissue aggregates within pharynx at skull base


figure Adenoids


figure Tubal and lingual tonsils


figure Palatine tonsils


figure Aggregates of lymphoid tissue on posterior pharyngeal wall


59.2.2 Waldeyer External Ring


• Superficial nodal system


figure Occipital


figure Postauricular


figure Parotid


figure Preauricular


figure Buccal/facial


figure Superficial cervical


figure Submandibular


figure Submental


figure Anterior cervical


• Drains


figure Skin


figure Scalp


figure Eyelids


figure Face


figure Waldeyer internal ring


figure Sinuses


figure Oral cavity


59.2.3 Deep System (Cervical Lymph Nodes)


• Deep structures drain directly or through superficial system


figure Junctional


figure Upper cervical


figure Middle cervical


figure Lower cervical


figure Spinal accessory group


figure Nuchal


figure Visceral


figure Upper mediastinal


• Jugular trunks form from confluence of deep lymphatics


figure On right ends at junction of IJV and brachiocephalic vein or joins right lymphatic duct


figure On left joins thoracic duct


59.2.4 Drainage by Level


• I


figure Submental = lower lip, floor of mouth, lower gum


figure Submandibular = face, nose, sinuses, oral cavity, SMG


• II = oral cavity, pharynx, supraglottic larynx


• III = thyroid, larynx, hypopharynx, cervical oesophagus


• IV = intra-abdominal organs, breast, lung, oesophagus, thyroid


• V = nasopharynx, thyroid, oesophagus, lung, breast


• VI = anterior compartment (visceral) group, e.g., para- and preotracheal LNs


• VII = upper anterior mediastinum


59.2.5 Nodal Classification in Malignancy


• N1—mets in single ipsilateral node £3 cm diameter



figure

Fig. 59.1a,b


a Lymph-node metastases are solid, indolent, and fixed to the surrounding tissue.


b Exulceration of the metastases produces haemorrhagic secretion and often an inflamed reaction in the surrounding skin.


• N2—3 to 6 cm


figure N2a—single ipsilateral node


figure N2b—multiple ipsilateral nodes


figure N2c—bilateral/contralateral nodes


• N3—>6 cm diameter


59.2.6 Suspicious Imaging Features


• >1 cm diam


• Rim enhancement following IV contrast


• Central necrosis


figure Spherical shape


59.3 Features of Metastatic Neck Disease


• See Figs. 59.1 and 59.2


59.4 The N0 Neck


• Arguments for elective surgery


figure High incidence of occult metastatic disease (Table 59.1)


Table 59.1 Incidence of neck metastases
























Subsite % Risk of neck metastases
Oral cavity >20%
Glottis 0–15%
Supraglottis 8–30%
Oropharynx >50%
Hypopharynx >50%

figure Limited neck dissection has low morbidity and mortality


figure If primary lesion has to be removed from the neck, en-bloc resection is preferable


figure No clinical ability to detect conversion of N0 to N1


figure Allowing neck mets to develop increases incidence of distant mets


figure Cure rate for neck dissection decreased if gland enlargement occurs or multiple nodes appear


• Arguments against elective surgery


figure Cure rates are no lower in the N1 neck


figure Careful clinical follow-up will allow detection at earliest conversion from N0 to N1


figure Radiation is as effective as neck dissection for non-palpable disease


figure Elective neck dissection results in a large number of unnecessary surgical procedures


figure Removes barrier to spread of disease and may have detrimental immunological effect


• Indications for elective neck treatment


figure > 20 to 25% chance of subclinical disease


figure Vigilant follow-up is not possible


figure Clinical evaluation of neck is difficult


figure Surgery is being performed for access or reconstruction


figure Imaging suggests possible occult nodal spread


• Contraindications to neck dissection:


figure Primary tumour untreatable


figure Unfit for major surgery


figure Inoperable neck disease inc. carotid encasement and skull base/intracranial involvement


59.5 Radiotherapy for Metastatic Neck Disease


• Clinically negative neck (N0)


• Clinically positive neck


• Electively after surgery


figure Node-positive disease


figure Other risk factor for local recurrence inc. extracapsular spread


• Neck disease developing or recurring after initial treatment:


figure Nodal mets developing in untreated neck after initial treatment of primary tumour alone


figure Recurrence after previous surgery to neck


figure Nodal recurrence after combined treatment



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Jul 4, 2016 | Posted by in OTOLARYNGOLOGY | Comments Off on Metastatic Neck Disease

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