|ORIGINAL RESEARCH REPORT
|Year : 2018 | Volume
| Issue : 4 | Page : 176-182
Neck dissection: Clinicosurgical appraisal of 21 cases in a sub-Saharan African tertiary referral hospital
Abdurrazaq Olanrewaju Taiwo1, Ramat Oyebunmi Braimah2, Adebayo Aremu Ibikunle2, Olalekan Micah Gbotolorun3, Terry Godwin Ndubuizu2
1 Department of Surgery, College of Health Sciences, Usmanu Danfodiyo University, Sokoto, Nigeria
2 Department of Dental and Maxillofacial Surgery, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
3 Department of Oral and Maxillofacial Surgery, College of Medicine, University of Lagos, Lagos, Nigeria
|Date of Web Publication||3-Dec-2018|
Dr. Ramat Oyebunmi Braimah
Department of Dental and Maxillofacial Surgery, Usmanu Danfodio University Teaching Hospital, Sokoto
Source of Support: None, Conflict of Interest: None
Background: Neck dissection constitutes an essential part of overall management of cancer of the head-and-neck region. Once the tumor involves neck nodes, survival drops by almost 50%. The aim of this present study is to present our experience in neck dissections. Patients and Methods: This was a retrospective study of neck dissection carried out in the department of dental and maxillofacial surgery of a tertiary referral hospital. Information retrieved includes age, sex, diagnosis, type of primary surgery, type of neck dissection, complications, and prognosis. Data were stored and analyzed using IBM SPSS Statistics Version 20 (IBM Corp., Armonk, NY, USA). Results: A total of 21 neck dissections were carried out during the study period. The patients' age ranged from 23 to 72 years with a mean ± standard deviation of 55.1 ± 11.9. There are 12 (57%) males and 9 (42.9%) females with an M:F ratio of 1.3:1. Squamous cell carcinoma (14 [66.7%]) was the main indication for neck dissection. Modified radical neck dissection (RND) (Type 1) was the commonest type of neck dissection carried out (7 [33.3%]), while 4 (19.0%) cases and 3 (14.3%) cases of modified RND Type II and Type III, respectively, were performed. Three (14.3%) cases of selective neck dissection (SND) (Type III) and one (4.8%) case of SND (Type II) were performed. Extended neck dissections were carried out in three (14.3%) patients. Overall, 11 (52.4%) patients survived, while 7 (33.3%) were lost to follow-up and 3 (14.3%) passed away. Conclusion: Patient selection is essential in neck dissection in the overall management of oncologic head-and-neck diseases.
Keywords: Extended neck dissection, modified radical neck, rhabdomyosarcoma, selective neck dissection, squamous cell carcinoma
|How to cite this article:|
Taiwo AO, Braimah RO, Ibikunle AA, Gbotolorun OM, Ndubuizu TG. Neck dissection: Clinicosurgical appraisal of 21 cases in a sub-Saharan African tertiary referral hospital. J Clin Sci 2018;15:176-82
|How to cite this URL:|
Taiwo AO, Braimah RO, Ibikunle AA, Gbotolorun OM, Ndubuizu TG. Neck dissection: Clinicosurgical appraisal of 21 cases in a sub-Saharan African tertiary referral hospital. J Clin Sci [serial online] 2018 [cited 2019 Apr 18];15:176-82. Available from: http://www.jcsjournal.org/text.asp?2018/15/4/176/246764
| Introduction|| |
The most important prognostic factor in the management of head-and-neck cancer is the presence or absence of cervical nodal metastasis. Once the tumor involves neck nodes, survival drops by almost 50%., Thus, neck dissection constitutes an essential part of overall management of cancer of the head-and-neck region. The risk of nodal metastasis to the neck depends on: the characteristics of the primary tumor, the location of the primary tumor, the size of the primary tumor, the depth of the primary tumor, and the histological differentiation.
Metastases from squamous cell carcinoma of the head-and-neck region have a predictable pattern. Due to this predictable pattern of spread, there have been several modifications to the classic radical neck dissection (RND). These variations include the modified RND, extended RND, and selective neck dissections (SNDs), which include the supraomohyoid neck dissection, anterior compartment neck dissection, posterolateral neck dissection, and lateral neck dissection.
The classical RND removes all of the ipsilateral lymph nodes, the submandibular salivary gland, sternocleidomastoid, internal jugular vein, and spinal accessory nerve. This is associated with multiple functional and cosmetic deformities. Removal of the spinal accessory nerve (cranial nerve XI) results in impaired shoulder movement and removal of the sternocleidomastoid muscle results in flattening of the neck on the side of surgery, while internal jugular removal may lead to postoperative cerebral edema.
Modified RNDs remove all five nodal groups in one side of the neck. The three neck dissections that can be included in this category differ from each other only in the number of neural, vascular, and muscular structures that are preserved. Therefore, Medina in 1989 suggested subclassifying these neck dissections into Type I, in which only “one” structure, the spinal accessory nerve, is preserved; Type II, in which “two” structures, the spinal accessory nerve and the internal jugular vein, are preserved; and Type III, in which all the “three” structures, the spinal accessory nerve, the internal jugular vein, and the sternocleidomastoid muscle, are preserved.
To the best of our knowledge, no study has reported their experience in neck dissection in Nigeria, hence the justification for the current study. The aim of the current study, therefore, is to present our experience in neck dissection from the Usmanu Danfodiyo University Teaching Hospital (UDUTH), Sokoto, Northwest Nigeria.
| Patients and Methods|| |
This was a retrospective study of neck dissection carried out in the Department of Dental and Maxillofacial Surgery, UDUTH, Sokoto, from 2014 to 2017. UDUTH is a 1000-bed capacity tertiary regional referral center with a radiotherapy machine. It is located in the remote corner of northwestern part of Nigeria and serves a population of about 26 million from within Nigeria and the neighboring countries of Niger and Benin republic. Information retrieved includes age, sex, diagnosis, type of neck dissection, complications, and prognosis. Inclusion criteria are patients who had neck dissections with complete information, while exclusion criteria are case notes with incomplete or missing records.
Data were stored and analyzed using IBM SPSS Statistics for Windows Version 20 (IBM Corp., Armonk, NY, USA). Results were presented as simple frequencies and descriptive statistics. Statistical significance was set at P < 0.05.
| Results|| |
A total of 21 neck dissections were carried out during the study period. Patients' age ranged from 23 to 72 years with a mean ± standard deviation (SD) of 55.1 ± 11.9. There are 12 (57%) males and 9 (42.9%) females with a M:F ratio of 1.3:1 [Figure 1]. Most of the cases requiring the neck dissection in our series were secondary to squamous cell carcinoma (14 [66.7%]) and distantly followed by rhabdomyosarcoma (3 [14.3%]); other diagnoses are shown in [Table 1]. Mandibulectomy with/without disarticulation was the commonest surgery carried out (9 [42.8%]) followed by maxillectomy (total/subtotal) (7 [33.3%]). Combined maxilla and mandible (COMMAND) surgery was carried out in 2 (9.5%) cases, while no primary surgery was carried out in 1 (4.8%) case [Table 3]. Modified RND (MRND) (Type 1) was the commonest type of neck dissection carried out (7 [33.3%]), while 4 (19.0%) cases of MRND (Type II) were performed. Other types of neck dissections performed are shown in [Table 2]. In terms of complications observed, seven (33.3%) patients had no complications, while nine (42.8%) had infections. Three (14.3%) patients had severe hemorrhage during reversal of anesthesia from the slippage of suture tie on the resected internal jugular vein. One (4.8%) patient each had left hemispheric stroke and cardiac arrest intraoperatively and passed away [Table 3]. Follow-up of patients ranged from 0 to 11 months with mean ± SD of 6.3 ± 3.0. Overall, 11 (52.4%) patients survived, while 7 (33.3%) were lost to follow-up and 3 (14.3%) passed away (2 [9.5%]) within recovery/2 days postoperatively and 1 (4.8%) died 3 months after surgery due to renal shutdown from chemotherapy).
|Figure 1: Bar chart showing gender distribution according to patients' age groups|
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|Table 1: Distribution of primary diagnosis according to age group of patients|
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|Table 2: Distribution of primary surgery done and types of neck dissection performed|
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|Table 3: Distribution of types of neck dissection done and complications observed|
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| Discussion|| |
Whenever there is clinically or radiologically evident lymph nodes in head-and-neck malignancies, neck dissection procedure to control the lymph node for possible metastasis must be carried out., Furthermore, where risk of occult nodal metastasis is sufficiently high, then neck dissection must also be performed as part of the curative surgery. This is important because metastasis of tumors into the lymph nodes of the neck is one of the strongest prognostic indicators for head-and-neck cancer.,
Most of the patients fell within the age group of 41–70 years. Although most head-and-neck squamous cell carcinomas occur in the above 60 years' age group, there has been increasing percentage in younger age group in the US, various European countries, and China, since the 1970s. The lower age group in the current study may also suggest increase in the percentage of head-and-neck malignancies in the younger age group in Nigeria. Ibikunle et al. have reported modal age of presentation of orofacial malignancy in the third decade of life from the same institution. We have observed a male preponderance in the present study, which is in agreement with other reports;, however, equal gender presentation in head-and-neck malignancies has been reported.
Metastases to the neck may originate from tumors of the oral cavity, tongue, maxillary sinus nasopharynx, oropharynx, hypopharynx, and larynx, as well as the thyroid, parotid, and posterior scalp., Similarly, lung cancer or intra-abdominal malignancy can also migrate to neck nodes., In our series, most of the indications for neck dissection were secondary to squamous cell carcinoma of the oral cavity and maxillary sinus (14 [66.7%]), and none was from distant metastatic site. All were cases of clinically diagnosed neck lymph node involvement. No case of tongue squamous cell carcinoma was observed from our study, although tongue tumors have been reported to have the greatest penchant for metastasis to the neck. Mandibulectomy with/without disarticulation was the commonest primary surgery carried out (9 [42.9%]) because most of the cases of the squamous cell carcinoma involved the structures surrounding the mandible. This was followed by maxillectomy (total/subtotal) in 7 (33.3%) cases which were secondary to squamous cell carcinoma of the antrum and palate. Mandibular invasion by tumor cells has been extensively studied and has been reported to occur through the sockets in a dentate patient and dental pores of the alveolar process in an edentulous mandible.,, We opined that this was the route of spread to the mandible. Combined mandibulo-maxillary resection was performed in 2 (9.5%) patients secondary to rhabdomyosarcoma [Figure 2]a, [Figure 2]b, [Figure 2]c. Direct contiguous spread of the rhabdomyosarcoma to the neck and the maxilla from the parotid region was observed. Rhabdomyosarcoma which is more common in the pediatric age has been reported in adults by Ibikunle et al.
|Figure 2: (a) Clinical photograph of patient with rhabdomyosarcoma for COMMAND surgery and neck dissection. (b) Black vertical and horizontal arrows showing resected mandible and maxilla, respectively. (c) closure of defect following COMMAND surgery and neck dissection|
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Due to the predictable lymphatic spread in the head-and-neck region and the functional complications associated with RND, Bocca et al. and Gavilán and Gavilán. popularized conservation of nonlymphatic structures in neck dissection to yield comparable oncologic outcomes, with improved functional results. This targeted surgery was as a result of studies of lymphatic drainage together with clinical and surgical studies of the precise position of lymph node metastasis within neck dissection specimens. Experimental studies of lymphatic drainage, coupled with clinical studies of the specific location of nodal metastasis within neck dissection specimens, provided the rationale for more targeted surgery.,
MRND (Type I, in which only “one” structure, the spinal accessory nerve, is preserved) was the commonest type of neck dissection carried out in our study (7 [33.3%]). This was because the patients presented late with Stage III tumor which has involved the internal jugular vein, and the sternocleidomastoid muscle, therefore both nonlymphatic structures were sacrificed with the neck dissection [Figure 3]a, [Figure 3]b, [Figure 3]c, [Figure 3]d. MRND (Type II, in which “two” structures, the spinal accessory nerve and the internal jugular vein, are preserved) was performed in four (19.0%) patients in the current study [Figure 4]. Preservation of the internal jugular vein has been reported to prevent cerebral edema following neck dissections before opening up of collateral channels for drainage. The type III MRND (in which “three” structures, the spinal accessory nerve, the internal jugular vein, and the sternocleidomastoid muscle are preserved) also referred to as the “functional neck dissection” as popularized by Bocca et al. was carried out in three (14.3%) patients. In all our cases of MRND, lymph node levels I–IV were removed [Figure 5]. Only one case of bilateral MRND (Type I) neck dissection was performed in a patient with squamous cell carcinoma of the antrum with palatal extension and clinically visible bilateral neck metastasis [Figure 6]a, [Figure 6]b, [Figure 6]c, [Figure 6]d. His primary concern was neck swelling that he claims is making him uncomfortable.
|Figure 3: (a) Internal jugular vein being sacrificed and tied in modified radical neck dissection Type I. (b) Patient with recurrent rhabdomyosarcoma with infiltration of the sternocleidomastoid muscle. (c) Removal of sternocleidomastoid muscle with internal jugular vein in modified radical neck dissection Type I. (d) Closure of defect with pectoralis major myocutaneous flap being tunneled over the clavicle|
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|Figure 4: Black horizontal arrow showing preservation of internal jugular vein in modified radical neck dissection Type II|
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|Figure 6: (a) Intraoral photograph of patient with left antral squamous cell carcinoma. (b) Patient with antral squamous cell carcinoma and bilateral (right) neck metastasis showing fungating mass (black vertical arrow). (c) Patient with antral squamous cell carcinoma and bilateral (left) neck metastasis showing nonfungating mass (horizontal arrow). (d) Intraoperative clinical photograph of patient showing bilateral neck dissection|
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When there is preservation of any group of lymph nodes in the RND, then it is referred to as SND. These dissections consist of the selective en bloc removal of only the lymph node groups that, depending on the location of the primary tumor, are most likely to contain metastases. Literature has classified this type of neck dissection into four different groups, namely supraomohyoid neck dissection (removal of I–III groups of lymph nodes), posterolateral neck dissection (removal of suboccipital, retroauricular, levels II–IV, and level V group of lymph nodes), anterior/central neck dissection (removal of level VI group of lymph nodes), and lateral neck dissection (removal of levels II–IV).
The supraomohyoid neck dissection, which consists of the en bloc removal of nodal regions I, II, and III, is indicated in the surgical management of patients with squamous cell carcinoma of the oral cavity when the palpable node was <3 m, clearly mobile, and located in either level I or II. A total of four (19.1%) cases of SND were conducted during the study period (1 [4.8%] case of SND I and II and three [14.3%] cases of SND I–III). These patients whom we removed the nodes in Levels I–III had suspected carcinoma in pleomorphic adenoma of the submandibular gland [Figure 7]a and [Figure 7]b.
|Figure 7: (a) Clinical photograph of patient with suspicious fine-needle aspiration cytology result being prepared for submandibular gland excision and selective neck dissection Levels I–III. (b) Intraoperative photograph showing removal of submandibular gland with selective neck dissection involving lymph nodes Levels I–III|
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Three (14.3%) cases of extended neck dissections (ENDs) were carried out during the study period. Combined mandibulectomy and maxillectomy (COMMAND surgery) together with neck dissection was carried out in two (9.5%) cases [Figure 6], while in one (4.8%) case, removal of orbital floor with the COMMAND surgery was carried out. This END has been described as any neck dissection “extended” to include either lymph node groups that are not routinely removed, such as the retropharyngeal and paratracheal nodes, or structures that are not routinely removed, such as the hypoglossal nerve, the carotid artery, and the levator scapulae muscle. END is also indicated in bulky metastatic malignant tumor in the submandibular lymph nodes or submandibular salivary gland with resection of the mandible.
Three (14.3%) patients had severe hemorrhage during reversal of anesthesia from the slippage of suture tie on the resected internal jugular vein that necessitated re-induction of general anesthesia and tracing of the vein to the base of the skull and thereafter blocking internal jugular foramen with bone wax and pressure dressing. When internal jugular vein is going to be sacrificed during neck dissections, we recommend its removal to the base of the skull and blocking the internal jugular foramen with bone wax and pressure dressing to prevent this untoward effect. Alternatively, if adequate length of proximal internal jugular vein is available, we recommend placement of a minimum of two suture ligatures with nonresorbable 2/0 or 1/0 suture material. The patient with bilateral neck dissections that necessitated bilateral removal of internal jugular veins had left hemispheric stroke and eventual cardiac arrest 2 days postsurgery in the Intensive Care Unit. We opined that perhaps anesthetic care could have contributed; however, it has been documented that removal of both internal jugular veins results in significant venous edema and chronic lymph edema of the face and can be fatal in 10% of patients when performed simultaneously. Therefore, staged bilateral neck dissections with at least 2 weeks' interval between each stage would allow more collateral veins to be opened up. In addition, it has been reported that patients undergoing bilateral neck dissection can develop a syndrome of inappropriate antidiuretic hormone secretion that can lead to fluid overload and cardiac arrest. This syndrome might have also contributed to the mortality in our case. Limiting the administered fluid can help to prevent this condition.
All our patients were recommended for adjuvant chemoradiation as appropriate; however, most could not undergo this stage of management due to financial reasons and frequent breakdown of the radiotherapy machine in our institution. With all these challenges, our team was able to offer patients appropriate oncologic head-and-neck management within available limited personnel and facilities. One of the limitations of this study was that it is a retrospective study with multiple operators managing these patients. A properly designed prospective study by one single operator is recommended.
| Conclusion|| |
We have presented our clinical and surgical experience in neck dissection surgeries. Surgical excision of neck lymph nodes is mandatory in oncologic head-and-neck management, especially when there is clinically positive neck disease. This is important for molecular testing (e.g., next-generation sequencing technology) that may predict the likely benefit of treatment with novel molecularly or targeted therapies of head-and-neck malignancies.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
The authors are grateful to the Health Records Department, Usmanu Danfodiyo University Teaching Hospital, Sokoto, for assistance in data retrieval.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3]