Surgical treatment of the N0 neck - indications and choice of operation

Abstract

The risk of subclinical nodal metastasis in head and neck cancer increases with increasing T stage. Forty percent of patients with early carcinoma of the tongue have subclinical cervical lymph nodes (CLN) metastases on presentation and the corresponding values for primary carcinoma of the oral cavity, hypopharynx and tongue base are 35%, 40% and 55%. These lymph nodes should be treated electively to improve survival and regional tumour control. In view of associated morbidity radical neck dissection (RND) should not be performed for NO neck because of the associated morbidity. Modified neck dissection (MND) removes all the CLN with micrometastasis and creates space for transposition of flaps. Selective neck dissection (SND) removes clinically non-palpable, yet diseased nodes, for pathological examination; postoperative radiotherapy should be given for patients with extracapsular nodal extension. In a study of RND performed in 384 patients at the Head and Neck Division of the Department of Surgery, The University of Hong Kong at Queen Mary Hospital, an association was found between the location of the primary tumour and the level of nodal metatasis. In patients with primary carcinoma of the larynx or hypopharynx, most involved CLN were in levels II, I and IV. For carcinoma of the tongue and oral cavity, the affected CLN were in levels I, H and mI and for oropharyngeal carcinoma, in levels II and III. In summary the surgical treatment of the NO neck should be MIND if space is required to accommodate a flap and SND should remove nodes in those regions that drain the primary tumour.