Revision surgery for cervical metastatic disease presents a difficult therapeutic challenge whose scope and potential for success depend on the extent of prior therapy. In general, revision surgery is complicated by the fact that there is usually more extensive and poorly defined disease in a debilitated patient, leading to increased technical challenges, surgical morbidity, and postoperative complications. For the purposes of this discussion, recurrent metastatic disease arising from primary squamous carcinomas of the head and neck will be considered. However, some of the principles that are elaborated may be extended to nonsquamous pathologies or to cervical metastases from infraclavicular primary sites.

Work-up

All patients with recurrent cervical metastases must have a thorough head and neck physical examination (including endoscopy of the upper aerodigestive tract). At the time of this evaluation, the primary site must be carefully investigated to rule out a recurrence, and the aerodigestive tract in general must be investigated to exclude a second primary neoplasm. The physical examination of patients with recurrent neck disease must focus specifically on the location and size of the metastasis. Additionally, the physical characteristics of the metastasis, including fixation to local structures (suggestive of direct invasion), cephalocaudad mobility overlying the carotid sheath, tethering or erosion of the overlying skin, and paresis or paralysis of cranial nerves, must be determined. The location and orientation of any prior skin incisions should also be noted. Biopsy via fine-needle aspiration (FNA) should be performed whenever possible to broadly characterize the tumor mass and potentially separate a metastatic recurrence from other pathologies.

Patients should also undergo a metastatic work-up, including chest radiographs followed by a chest computed tomography (CT) scan if any abnormalities are detected on plain radiographs. Additional imaging should include magnetic resonance imaging (MRI) with gadolinium encompassing both the initial primary site and the neck. (The soft tissue resolution provided by MRI in the setting of prior treatment, with the obliteration of tissue planes, far exceeds that of CT.) In particular, the relationship of the neck disease to the carotid artery (encasement, abutment, and invasion) needs to be visualized and the metastases investigated for any features that might suggest unresectability (see below).

Determining the resectability of cervical metastases as they relate to the carotid arterial system should include an assessment of both the anatomical and functional status of the carotid artery. Magnetic resonance angiography (MRA) and/or conventional angiography are quite valuable for the determination of arterial compression, displacement, stenosis, and flow as well as the patency of contralateral flow through the circle of Willis. This information can then be supplemented by the functional data obtained from balloon occlusion and subsequent single photon emission computed tomography (SPECT) scanning. With these data, a better sense of the likelihood of carotid resection can be ascertained and, if the carotid needs to be resected, the potential consequences better anticipated.

Finally, whole-body positron emission tomography (PET) scan imaging is frequently beneficial in the evaluation of recurrent disease, particularly when MRI findings are equivocal, a tissue confirmation of tumor recurrence is not available, or systemic metastases are suspected.

The extent and nature of the neck disease prior to a patient’s initial treatment are of critical importance (particularly when the prior treatment was rendered by a different surgeon). In particular, information regarding the size and location of the initial metastatic disease is vital. Moreover, the nature and the timing of prior therapy (to separate disease recurrence from persistence) must be ascertained. Any available surgical pathology reports should be reviewed with a particular emphasis on (1) the size and number of involved lymph nodes, (2) the presence or absence of extracapsular disease, and (3) the inclusion of any nonlymphatic structures (submandibular gland, sternomastoid muscle, and skin) within the pathologic specimen. Additionally, any prior operative reports should be obtained and carefully reviewed and, when possible, the prior treating physicians directly contacted. If radiotherapy has been employed, treatment doses, sources (including the use of nonphoton sources), ports, fractionation, and treatment duration need to be investigated. The occurrence of any significant breaks in treatment should be determined as well as reports of any chemotherapeutics administered and whether they were delivered sequentially or concomitantly.