Radical Neck Dissection

Radical Neck Dissection: (RND) Radical Neck Dissection: (RND) Classification, Indication and Classification, Indication and

TechniquesTechniques

IntroductionIntroduction

• Crile in 1906 introduced RND and is Crile in 1906 introduced RND and is followed by Martin as a the classical followed by Martin as a the classical procedure for the management of procedure for the management of cervical lymph node metastasiscervical lymph node metastasis

• Recently changes in classification and Recently changes in classification and indication led to inconsistencyindication led to inconsistency– NN00 in recent studies may require selective in recent studies may require selective

RND to reduce morbidityRND to reduce morbidity

Staging of Neck NodesStaging of Neck Nodes

• NNXX: : – Regional lymph nodes can not be assessedRegional lymph nodes can not be assessed

• NN00::– No regional lymph node metastasisNo regional lymph node metastasis

• NN11::– Metastasis in a single ipsilateral lymph nodes, Metastasis in a single ipsilateral lymph nodes,

3 cm or less in greatest dimension3 cm or less in greatest dimension• NN22::– NN2a2a::

• Metastasis in a single epsilateral lymph nodes, Metastasis in a single epsilateral lymph nodes, more than 3 cm but less than 6 cm more than 3 cm but less than 6 cm

Staging of Neck NodesStaging of Neck Nodes

– NN2b2b::• Metastasis in multiple ipsilateral lymph Metastasis in multiple ipsilateral lymph

nodes, not more than 6 cm nodes, not more than 6 cm

– NN2c2c::• Metastasis in bilateral or contralateral Metastasis in bilateral or contralateral

nodes not more than 6 cm in diameternodes not more than 6 cm in diameter

• NN33::– Metastasis in lymph nodes more than 6 Metastasis in lymph nodes more than 6

cm in in greatest diametercm in in greatest diameter

Meyers & Eugene: Operative Otolaryngology. 1997Meyers & Eugene: Operative Otolaryngology. 1997

Lymph Node RegionsLymph Node Regions

• Region I:Region I:– Submental and submandibular Submental and submandibular

triangletriangle• IIaa: Submental triangle:: Submental triangle:

– Bounded by the anterior belly of digastric Bounded by the anterior belly of digastric and the mylohyoid muscle deep and the mylohyoid muscle deep

• IIbb: Submandibular triangle:: Submandibular triangle:– Formed by the anterior and posterior belly Formed by the anterior and posterior belly

of the digastric muscle and the body of the of the digastric muscle and the body of the mandiblemandible

Memorial Sloan-kettering Cancer center


• Region II – IV:Region II – IV:– Lymph nodes are associated with the Lymph nodes are associated with the

Internal Jugular Vein (IJV) within the Internal Jugular Vein (IJV) within the fibroadipose tissues that extend from fibroadipose tissues that extend from the posterior border of sternocledo-the posterior border of sternocledo-mastoid muscle (SCM) medial to mastoid muscle (SCM) medial to lateral border of the sternohyoid lateral border of the sternohyoid muscle muscle



• Region II:Region II:– Upper third including upper jugular, Upper third including upper jugular,

jugulodigastric and upper posterior cervical jugulodigastric and upper posterior cervical nodesnodes

– Bounded by the digastric muscle superiorly Bounded by the digastric muscle superiorly and the hyoid bone or carotid bifurcation and the hyoid bone or carotid bifurcation inferiorlyinferiorly• IIa:IIa:

– nodes anterior to Spinal Accessory Nerve (SAN)nodes anterior to Spinal Accessory Nerve (SAN)

• IIb:IIb:– nodes posterior to Spinal Accessory Nerve (SAN)nodes posterior to Spinal Accessory Nerve (SAN)



• Region III:Region III:– Middle third jugular nodes from the Middle third jugular nodes from the

carotid bifurcation to cricothyroid carotid bifurcation to cricothyroid notch or omohyoid musclenotch or omohyoid muscle

• Region IV:Region IV:– Lower third jugular nodes from Lower third jugular nodes from

omohyoid muscle superiorly to the omohyoid muscle superiorly to the clavicle inferiorlyclavicle inferiorly



• Region V:Region V:– Lymph nodes of the posterior triangle Lymph nodes of the posterior triangle

along the lower half of the SAN and the along the lower half of the SAN and the transverse cervical arterytransverse cervical artery

– Bounded by the anterior border of the Bounded by the anterior border of the trapezius posteriorly, the posterior trapezius posteriorly, the posterior border of SCM anteriorly and the border of SCM anteriorly and the clavicle inferiorlyclavicle inferiorly



• Region VI:Region VI:– Anterior compartment, lymph nodes Anterior compartment, lymph nodes

surrounding the midline visceral structures surrounding the midline visceral structures that extend from the hyoid bone superiorly to that extend from the hyoid bone superiorly to the suprasternal notch inferiorlythe suprasternal notch inferiorly

– The lateral boundary is the medial border of The lateral boundary is the medial border of the carotid sheaththe carotid sheath

– Perithyroid, paratracheal, and lymph nodes Perithyroid, paratracheal, and lymph nodes around the recurrent laryngeal nervearound the recurrent laryngeal nerve


Classification Classification

• The RND is classified according to the The RND is classified according to the Academy’s Committee for Head & Neck Academy’s Committee for Head & Neck Surgery & Oncology into four major typeSurgery & Oncology into four major type::

1.1. Radical Neck DissectionRadical Neck Dissection (RND)(RND)2.2. Modified Radical Neck Dissection Modified Radical Neck Dissection (MRND)(MRND)3.3. Selective Neck Dissection Selective Neck Dissection (SND)(SND)

1.1. SupraomohyoidSupraomohyoid2.2. PosterolateralPosterolateral3.3. Lateral Lateral 4.4. AnteriorAnterior

4.4. Extended Radical Neck Dissection Extended Radical Neck Dissection (ERND)(ERND)

ClassificationClassification

• Radical neck Dissection:Radical neck Dissection:– Removing all lymphatic tissues in regions I - Removing all lymphatic tissues in regions I -

V and include removal of SAN, SCM and IJVV and include removal of SAN, SCM and IJV

• Modified radical neck dissection:Modified radical neck dissection:– Excision of all lymph nodes removed with Excision of all lymph nodes removed with

RND with preservation of one or more non-RND with preservation of one or more non-lymphatic structures, SAN, SCM and/or IJVlymphatic structures, SAN, SCM and/or IJV• Subtype I: Preserve SANSubtype I: Preserve SAN• Subtype II: Preserve SAN & SJVSubtype II: Preserve SAN & SJV• Subtype III: preserve SAN, SJV and SCM Subtype III: preserve SAN, SJV and SCM

– Known as Functional neck dissection (Bocca)Known as Functional neck dissection (Bocca)


• Selective Neck dissection:Selective Neck dissection:– Any type of cervical lymphadenectomy Any type of cervical lymphadenectomy

with preservation of one or more with preservation of one or more lymph node groupslymph node groups

– Four subtype:Four subtype:• Supraomohyoid neck dissectionSupraomohyoid neck dissection• Posterolateral neck dissectionPosterolateral neck dissection• Lateral neck dissectionLateral neck dissection• Anterior neck dissectionAnterior neck dissection


– Supraomohyoid neck dissection:Supraomohyoid neck dissection:• Removal of lymph nodes in regions I –III Removal of lymph nodes in regions I –III

• The posterior limit is the cutaneous branches of the The posterior limit is the cutaneous branches of the cervical plexus and posterior border of SCMcervical plexus and posterior border of SCM

• The inferior limit is the superior belly of the The inferior limit is the superior belly of the omohyoid where it cross IJN omohyoid where it cross IJN

– Posterolateral neck dissectionPosterolateral neck dissection• Removal of suboccipital, retroauricular, levels II – Removal of suboccipital, retroauricular, levels II –

V and level VV and level V

• Subtyped I – III depending on the preservation of Subtyped I – III depending on the preservation of SAN, IJV and /or SCMSAN, IJV and /or SCM Medina


– Lateral neck dissection:Lateral neck dissection:• Remove lymph nodes in levels II – IV Remove lymph nodes in levels II – IV

– Anterior neck dissection:Anterior neck dissection:• Require the removal of the lymph nodes Require the removal of the lymph nodes

surrounding the visceral structure in the surrounding the visceral structure in the anterior aspect of the neck, level VIanterior aspect of the neck, level VI

• Superior limit, hyoid boneSuperior limit, hyoid bone

• Inferior limit, suprasternal notchInferior limit, suprasternal notch

• Laterally, the carotid sheathLaterally, the carotid sheath


• Extended neck dissection:Extended neck dissection:– Any previous dissection and including Any previous dissection and including

one or more additional lymph node one or more additional lymph node groups and/or non-lymphatic tissuesgroups and/or non-lymphatic tissues

FactsFacts

• General nodal metastasis produce General nodal metastasis produce the following fact:the following fact:– The most important factor in prognosis The most important factor in prognosis

of SCC of the upper aero-digestive of SCC of the upper aero-digestive tract is the status of cervical lymph tract is the status of cervical lymph nodesnodes

– Cure rate drops 50% with involvement Cure rate drops 50% with involvement of the regional lymph nodesof the regional lymph nodes

Indications For NDIndications For ND

• Radical neck dissection was believed by Radical neck dissection was believed by Martin to be the only method to control Martin to be the only method to control cervical lymphadenectomycervical lymphadenectomy

• Anderson found that preservation of SAN Anderson found that preservation of SAN did not change the survival or tumor did not change the survival or tumor control in the neckcontrol in the neck– Actual 5-year survival and neck failure rate Actual 5-year survival and neck failure rate

is:is:• RND: 63% and 12 %RND: 63% and 12 %• MRND: 71% and 12% MRND: 71% and 12%

IndicationsIndications

• Radical Neck DissectionRadical Neck Dissection

1.1. Multiple clinically obvious cervical lymph Multiple clinically obvious cervical lymph node metastasis particularly of posterior node metastasis particularly of posterior triangle and closely related to SANtriangle and closely related to SAN

2.2. Large metastatic tumor mass or multiple Large metastatic tumor mass or multiple matted in upper part of the neckmatted in upper part of the neck• Tumor should not be dissected to preserve Tumor should not be dissected to preserve

Structures Structures


• Modified radical neck dissectionModified radical neck dissection

– MRND Type I:MRND Type I:1.1. Clinically obvious neck lymph nodes Clinically obvious neck lymph nodes

metastasis and SAN not involved by metastasis and SAN not involved by tumortumor

2.2. Intraoperative decision just like Intraoperative decision just like preservation of the facial nerve in preservation of the facial nerve in parotid surgeryparotid surgery


• MRND Type II:MRND Type II:1.1. Rarely plannedRarely planned2.2. Intra-operative decision for tumor found Intra-operative decision for tumor found

adherent to SCM but away from SAN & adherent to SCM but away from SAN & IJVIJV

• MRND Type III:MRND Type III:– Depend on the autopsy reportsDepend on the autopsy reports

1.1. Lymph nodes were in the fibrofatty and do not Lymph nodes were in the fibrofatty and do not share the same adventitia with blood vesselsshare the same adventitia with blood vessels

2.2. They are not found within the aponeurosis or They are not found within the aponeurosis or glandular capsule of the submandibular glandular capsule of the submandibular “Functional neck dissection” “Functional neck dissection”


• MRND Type III:MRND Type III:– For treatment of NFor treatment of N00 neck nodes neck nodes

– Indicated for NIndicated for N11 mobile nodes and not mobile nodes and not

greater than 2.5 – 3.0 cmgreater than 2.5 – 3.0 cm• Contra-indicated in the presence of node Contra-indicated in the presence of node

fixationfixation

• Result is difficult to interpret because of Result is difficult to interpret because of the use of radiation therapy the use of radiation therapy


• Selective/elective neck dissection:Selective/elective neck dissection:– For treatment of NFor treatment of N00 neck nodes neck nodes– For N+ nodes when combined with For N+ nodes when combined with

radiotherapyradiotherapy• Adjuvant radiotherapy for patient with 2 – 4 positive Adjuvant radiotherapy for patient with 2 – 4 positive

nodes or extra-capsular spreadnodes or extra-capsular spread– SupraomohyoidSupraomohyoid is indicated for SCC of oral is indicated for SCC of oral

cavity with Ncavity with N00 and N and N11 with palpable mobile with palpable mobile nodes less than 3 cm and located in level I and nodes less than 3 cm and located in level I and IIII

– Upgrade intra-operatively following positive Upgrade intra-operatively following positive frozen sectionfrozen section

Treatment option for NTreatment option for N00 nodes nodes

• ObserveObserve

• Radiation therapyRadiation therapy

• Elective neck dissectionElective neck dissection– Low morbidityLow morbidity– Staging neck for possible extended Staging neck for possible extended

surgerysurgery– Need for post-operative radiotherapyNeed for post-operative radiotherapy

Rationale for S/ENDRationale for S/END

• Rate of occult metastasis in clinically Rate of occult metastasis in clinically negative nodes is 20 – 30% using negative nodes is 20 – 30% using clinical and radiographic findingsclinical and radiographic findings– Ct scan combined with physical exam Ct scan combined with physical exam

decreased the rate of occult metastasis decreased the rate of occult metastasis to 12%to 12%

– This suggested lowering of the criteria This suggested lowering of the criteria for elective neck dissectionfor elective neck dissection

Friedman et al Laryngoscope 100; 54 – 59: 1990


• Anatomic studies showed that Anatomic studies showed that lymphatic drainage from the lymphatic drainage from the mucosal surfaces follow a constant mucosal surfaces follow a constant and predictable routeand predictable route

• Lymph flow from SA chain to the Lymph flow from SA chain to the jugular chain is unilateraljugular chain is unilateral

Shah. Ann Surg Oncol 1(6); 521-532: 1994


• Shah, in his study produced a compelling in his study produced a compelling evidence of predictable nodal metastasis evidence of predictable nodal metastasis from SCC from upper aerodigastive tractfrom SCC from upper aerodigastive tract– He found a specific pattern for nodal spread He found a specific pattern for nodal spread

by location of primaryby location of primary • NNOO in patients with oral cavity SCC: in patients with oral cavity SCC:

– 7/1119 (3.5%) had nodal involvement outside 7/1119 (3.5%) had nodal involvement outside supraomohyoid dissectionsupraomohyoid dissection

– 3 (1.5%) had isolated involvement outside 3 (1.5%) had isolated involvement outside level I - IIIlevel I - III

Friedman Laryngoscope 100; 54-59: 1990


– NN++ nodes in patients with oral SCC: nodes in patients with oral SCC:• 50/246 had nodal metastasis outside level IV50/246 had nodal metastasis outside level IV• 10/246 had metastasis in level V10/246 had metastasis in level V

– He examined nodal involvement in patients He examined nodal involvement in patients with nasopharynx and other upper parts of the with nasopharynx and other upper parts of the aerodigastive tractaerodigastive tract

• Conclusion:Conclusion:– SCC of the oral cavity:SCC of the oral cavity:

• Level I, II and III are at riskLevel I, II and III are at risk– SCC nasopharynx and larynxSCC nasopharynx and larynx

• Level II, III and IV are at riskLevel II, III and IV are at riskShah Amer J Surg 160; 405-409: 1990

Shah Cancer July 1 ; 109-113: 1990


• Byers stated that SND combined with Byers stated that SND combined with postoperative radiotherapy in selected postoperative radiotherapy in selected patients with oral cavity SCC was adequate patients with oral cavity SCC was adequate treatment with similar recurrence rate as treatment with similar recurrence rate as those treated with MRND IIIthose treated with MRND III

• Spiro reported 12% with supraomohyoid Spiro reported 12% with supraomohyoid dissection in N1 nodes but not all of them dissection in N1 nodes but not all of them received radiotherapyreceived radiotherapy

Byers Head Neck Surg; Jan-Feb; 160-167: 1988

Selective/Elective Neck Selective/Elective Neck DissectionDissection

• A good option for N0 neckA good option for N0 neck• Not a suitable option for N+ neckNot a suitable option for N+ neck• Is used N+ neck when combined Is used N+ neck when combined

with radiotherapywith radiotherapy• Intra-operative frozen section Intra-operative frozen section

evaluation is needed to confirm in evaluation is needed to confirm in cases of intraoperative palpable cases of intraoperative palpable nodesnodes

The anatomyThe anatomy

• Skin:Skin:– Blood supply:Blood supply:

• Descending branches: Descending branches: – The facial The facial – The submentalThe submental– OccipitalOccipital

• Ascending branchesAscending branches– Transverse cervicalTransverse cervical– SuprascapularSuprascapular

– The branches perforate the platysma muscle, anastomose The branches perforate the platysma muscle, anastomose to form superficial vertically-directed network of vesselsto form superficial vertically-directed network of vessels

• Skin incision is superiorly based apron-like incision from mastoid to mentum or to contralateral mastoid


• Platysma muscle:Platysma muscle:– Wide, quadrangular sheet-like muscleWide, quadrangular sheet-like muscle– Run obliquely from the upper part of the Run obliquely from the upper part of the

chest to lower facechest to lower face– Skin flap is raised immediately deep to the Skin flap is raised immediately deep to the

musclemuscle– The posterior border is over or just anterior The posterior border is over or just anterior

to IJV and great auricular nerveto IJV and great auricular nerve– Does not cover the inferior part of the Does not cover the inferior part of the

anterior triangle and the posterolateral neck anterior triangle and the posterolateral neck


• Sternocleidomastoid muscle:Sternocleidomastoid muscle: SCM SCM– Differentiated from the platysma by the Differentiated from the platysma by the

direction of its fibresdirection of its fibres– Crossed by the IJV and the great Crossed by the IJV and the great

auricular nerve from inferior to auricular nerve from inferior to posterior deep to platysmaposterior deep to platysma

– The posterior border represent the The posterior border represent the posterior boundary of nodes level II - IVposterior boundary of nodes level II - IV


• Marginal Mandibular nerve:Marginal Mandibular nerve: MMN MMN– Located 1 cm in front of and below Located 1 cm in front of and below

the angle of the mandiblethe angle of the mandible– Deep to the superficial layer of the Deep to the superficial layer of the

deep cervical fascia deep cervical fascia – Superficial to adventitia of the anterior Superficial to adventitia of the anterior

facial vein facial vein


• Spinal Accessory nerve: SANSpinal Accessory nerve: SAN– Emerge from the jugular foramen medial to Emerge from the jugular foramen medial to

the digastric and stylohyoid muscles and the digastric and stylohyoid muscles and lateral and posterior to IJV (30% medial to lateral and posterior to IJV (30% medial to the vein and in 3 -5% split the nerve)the vein and in 3 -5% split the nerve)

– It passes obliquely downward and backward It passes obliquely downward and backward to reach the medial surface of the SCM near to reach the medial surface of the SCM near the junction of its superior and middle thirds, the junction of its superior and middle thirds, Erb’s pointErb’s point


• Trapezius muscle:– Its anterior border is the posterior Its anterior border is the posterior

boundary of level Vboundary of level V– Difficult to identify because of its Difficult to identify because of its

superficial positionsuperficial position– Dissect superficial to the fascia in order Dissect superficial to the fascia in order

to preserve the cervical nerves to preserve the cervical nerves


• Digastric Muscle; Posterior belly:; Posterior belly:– Originate from a groove in the mastoid Originate from a groove in the mastoid

process, digastric ridgeprocess, digastric ridge– The marginal mandibular nerve lie The marginal mandibular nerve lie

superficial superficial – The external and internal carotid The external and internal carotid

artery, hypoglossal and 11artery, hypoglossal and 11thth cranial cranial nerves and the IJV lie medial nerves and the IJV lie medial


• Omohyoid muscle:– Made of two bellies, and is the Made of two bellies, and is the

anatomic separation of nodal levels III anatomic separation of nodal levels III and IVand IV

– The posterior belly is superficial to the The posterior belly is superficial to the brachial plexus, phrenic nerve and brachial plexus, phrenic nerve and transverse cervical artery and veintransverse cervical artery and vein

– The anterior belly is superficial to the The anterior belly is superficial to the IJVIJV


• Brachial Plexus & Phrenic nerve:– The plexus exit between the anterior The plexus exit between the anterior

and middle scalene muscles, pass and middle scalene muscles, pass inferiorly deep to the clavicle under the inferiorly deep to the clavicle under the posterior belly of the omohyoidposterior belly of the omohyoid

– The phrenic nerve lie on top of the The phrenic nerve lie on top of the anterior scalene muscle and receive it anterior scalene muscle and receive it is cervical supply from C3 – C5 is cervical supply from C3 – C5


• Thoracic duct:– Located in the lower let neck posterior Located in the lower let neck posterior

to the jugular vein and anterior to to the jugular vein and anterior to phrenic nerve and transverse cervical phrenic nerve and transverse cervical arteryartery

– Have a very thin wall and should be Have a very thin wall and should be handled gently to avoid avulsion or handled gently to avoid avulsion or tear leading to chyle leaktear leading to chyle leak


• Exit via the hypoglossal canal near the Exit via the hypoglossal canal near the jugular foramenjugular foramen

• Passes deep to the IJV and over the ICA Passes deep to the IJV and over the ICA and ECA and then deep and inferior to and ECA and then deep and inferior to the digastric muscle and enveloped by a the digastric muscle and enveloped by a venous plexus, the ranine veinsvenous plexus, the ranine veins

• Pass deep to the fascia of the floor of the Pass deep to the fascia of the floor of the submandibular triangle before entering submandibular triangle before entering the tonguethe tongue

SummarySummary

• Unified classification is relatively newUnified classification is relatively new• Indication and the type of ND, specially for N0, Indication and the type of ND, specially for N0,

is controversialis controversial• The following surgical outline was suggested:The following surgical outline was suggested:

– SCC oral cavity anterior to circumvalate papillaSCC oral cavity anterior to circumvalate papilla• SupraomohyoidSupraomohyoid

– SCC Oropharynx, larynx and hypopharynxSCC Oropharynx, larynx and hypopharynx• level I- IV or level II-Vlevel I- IV or level II-V

– SCC with N+ nodes SCC with N+ nodes • RND RND

– SCC with 2-4 positive nodes or extracapsular spreadSCC with 2-4 positive nodes or extracapsular spread• RND and adjuvant therapyRND and adjuvant therapy

Shah Cancer July 1;109-113: 1990

Radical Neck Dissection

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