Oral Oncology (2005) 41, 978–983
Modified functional neck dissection: A useful technique for oral cancers Ge Minghua
, Gu Zhiyuan b, Jin Zhun b, Chun Han
Department of Head and Neck Surgery, Zhejiang Cancer Hospital, #38 Guangji St., Hangzhou, Zhejiang 310022, PR China b Department of Oral and Maxillofacial Surgery, Hospital of Stomatology, Zhejiang University, Hangzhou 310006, PR China c Department of Head and Neck Surgery, Zhejiang Cancer Hospital, Hangzhou 310022, PR China Received 22 April 2005; accepted 27 May 2005
Summary Among 60 patients with oral squamous cell carcinoma, 30 were treated by the modified functional neck dissection (preserve 8 functional tissues), 30 were treated by functional neck dissection (preserve 3 functional tissues). The recurrent rate of cervical lymph node and the sense of skin were assessed. The recurrence rates in cervical nodes was 6.67% and 10%, respectively (p > 0.05) in patients who accepted modified functional neck dissection and functional neck dissection. The sensation in skin in patients who accepted modified functional neck dissection was better than those who accepted functional neck dissection (p < 0.01). Modified functional neck dissection is helpful to decrease postoperative complications, without increasing recurrent rates of cervical lymph node. c 2005 Elsevier Ltd. All rights reserved.
Oral cancer; Functional neck dissection
The classic radical neck dissection, first described by Crile1 in the early 20th century, removes all of the ipsilateral lymph nodes, the submandibular salivary gland, sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve. This is associated with multiple functional and cosmetic * Corresponding author. Tel.: +86 571 88144401x239; fax: +86 571 88140312. E-mail address: [email protected]
deformities.2,3 The knowledge about the patterns of cervical lymph node metastases has led to various neck dissections, including the functional radical neck dissection, extended radical neck dissection, and selective neck dissection. The functional neck dissection (FND) preserves the internal jugular vein, the spinal accessory nerve, and/or the sternocleidomastoid muscle, provided that lymph nodes are not violated by cancer.4 The functional surgery is based on anatomical studies.5,6 Anatomical studies show that the whole cervical lymphatic system, wrapped by two layers
1368-8375/$ - see front matter c 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.oraloncology.2005.05.012
Modified functional neck dissection: A useful technique for oral cancers of aponeurotic fascia, is contained in the celluloadipose tissue of the neck. By stripping the aponeurotic fascia covering from the muscles, vessels and nerves, the whole lymphatic nodes and vessels can be removed.5,6 Compared with the classic radical neck dissection, the functional neck dissection is equally effective in controlling metastatic squamous cell carcinoma in patients with no clinical evidence of metastasis or with early metastasis.7–9 But after FND, patients still have sense problems, such as numb in neck. Those problems would be resolved if the supraclavicular nerve, greater auricular nerve and transverse cervical nerve were perfectly preserved. The purpose of this paper is to evaluate the necessity and possibility to preserve the supraclavicular nerve; external jugular vein, greater auricular nerve; omohyoid muscle and partial transverse cervical nerve in the neck dissection for oral cancers.
treated with radiotherapy in the neck after surgery.
Surgical procedures of MFND (1) Elevating skin and platysma from the outer fascia. The surgical field was extended from the clavicle to the mandible and mastoid and from the thyroid cartilage to the anterior border of the trapezius (incision of skin showed in Fig. 1). (2) The external jugular vein was skeletonized from the inferior parotid pole to the supraclavicle (Fig. 2). Greater auricular nerve was isolated until it enters the inferior parotid pole; transverse cervical nerve was isolated until it enters platysma and
Materials and methods Sixty untreated patients suffering from oral squamous cell carcinomas without palpable cervical nodes were treated by means of primary carcinoma dissection and neck dissection from January 1995 to May 1999 in the Department of Head and Neck Surgery of Zhejiang Cancer Center. In the 60 cases, there were 38 males and 22 females, with an average age of 50.6 years (ranged from 31 to 73 years). There were 32 tongue carcinomas, 15 buccal carcinomas, 13 gingival carcinomas, and 9 palate carcinomas. By the standard of UICC TNM classification (1992), T2N0M0 and T3N0M0 were equally 30. Among 60 cases, 30 cases were treated with primary carcinoma dissection added with FND and 30 cases were treated with primary cancer dissection added with modified functional neck dissection (MFND). FND preserved sternomastoid muscle, internal jugular vein and spinal accessory nerve (Figs. 9 and 10); MFND preserved sternomastoid muscle, internal jugular vein, spinal accessory nerve, supraclavicular nerve, external jugular vein, greater auricular nerve, omohyoid muscle, and transverse cervical nerve. Patients with T3N0M0 were treated with radiotherapy in the region of primary cancer after operation. Every patient with T2N0M0 or T3N0M0 was assigned to one cycle of cisplatin (30 mg daily, day 1–3) and fluorouracil (0.75 g daily, d1–3, continuous infusion) before operation and three cycles of cisplatin (30 mg daily, d1–3) and fluorouracil (0.75 daily, d1–3, continuous infusion) followed by surgery or by surgery and radiotherapy. None of 60 cases were
The incision of the MFND.
Figure 2 After elevated the skin and platysma from the outer fascia: (1) transverses colli nerve, (2) external jugular vein and (3) great auricular nerve.
Ge Minghua et al.
skin (Figs. 2 and 7). (3) The spinal accessory nerve was isolated throughout its course until it enters the sternomastoid and the trapezius (Figs. 3 and 7). (4) Supraclavicular nerve was isolated until it enters the supraclavicular edge (Fig. 4). The fascia covers the outer aspect of the sternomastoid muscle and omohyoid muscle was separated by means of sharp dissection (Fig. 5). (5) The internal jugular vein was skeletonized around its whole circumference. Finally, the neck dissection specimen except those preserved tissues was removed wholly in terms of the technology of FND (Fig. 6). (6) Lymph node groups of MFND were divided according to the standard of American Academy of Otolaryngology Figure 5 The fascia covers the outer aspect of the sternmastoid muscle and omohyoid muscle was arated. (1) Sternmastoid muscle and (2) omohyoid muscle.
Figure 3 The spinal accessory nerve is isolated throughout its course until it enters the sternmastoid and the trapezius. Figure 6 The neck dissection specimen was removed wholly except those preserved tissues. (1) Transverses colli nerve, (2) great auricular nerve, (3) sternmastoid muscle, (4) omohyoid muscle, (5) internal jugular vein, (6) external jugular vein, (7) supraclavicular nerve and (8) spinal accessory nerve.
Figure 4 The supraclavicular nerve is isolated until they arrive the supraclavicular edge.
Head and Neck Surgery Foundation Inc.11 (Fig. 7). Level I: submental and submandibular, level II: upper jugular, level III: mid jugular, level IV: lower jugular, level V: posterior triangle (Fig. 8). Before the study, the head of the study group made two groups of cards and put them in two boxes, respectively. Each group has 30 cards and represents patients with T2N0M0 or T3N0M0, respectively. In each group, 15 cards were marked with ‘‘multi-functional’’, the other 15 cards marked with ‘‘general’’. The head of the study group took out one card from box before patient was
Modified functional neck dissection: A useful technique for oral cancers
cal examination and the total cervical metastases rate is 41.67% (25/60). 12 cases were found in MFND (6 in T2N0M0, 6 in T3N0M0), 13 cases were found in FND (6 in T2N0M0, 7 in T3N0M0), no statistical difference was found between the two groups (p > 0.05).
Figure 7 nerve.
(1) Plexus cervicalis and (2) spinal accessory
operated, and the patient was operated according to the mark on the card. Among 60 cases, cancer cells were found in the cervical lymph nodes of 35 cases by pathologi-
Assess scales All patients were checked clinically and scanned by colored-Doppler (GE, Logiq 7, USA) every 3 months; uncertain lymph node was examined pathologically as soon as discovered. The 43 patients with MFND were examined by color Doppler scan 3 months postoperatively, to identify the blood flow of preserved external jugular vein. Skin sensation of pain and temperature on bilateral ears, neck and subclavical area was assessed by using sterilized needle and 15 °C water, respectively in all patients 3 months after surgery. Follow-up data was obtained to January 2004. The operation time was counted from skin incising to incision sewing up. All data of this study were analyzed by v2-test.
Results Incidence of neck recurrence There were 5 cases of recurrence in 60 patients (8.33%) after atleast 3 years of follow-up. Among these 5 cases of recurrence, 2 occurred in the group of MFND (6.67%), 3 in the group of FND (10%)(Table 1). However, there is no statistical significance between MFND and FND group (p > 0.05).
Blood flow of external jugular vein in MFND The blood flow of the preserved external jugular vein was identified by color Doppler Ultrasound 3 months postoperatively. The venous flow signal was identified in 30 cases with MFND (100%) and no signal was found in any case with FND.
Table 1 Neck recurrence in different group of neck dissection Operation Figure 8 The removed neck dissection specimen: (1) level II: submental and submandibular lymph nodes, (2) level III: upper jugular lymph nodes, (3) level III: mid jugular lymph nodes, (4) level IV: lower jugular lymph nodes and (5) level V: posterior triangle lymph nodes.
No. of patients
No. of patients with recurrence T2N0M0
Ge Minghua et al.
Sensation of the ipsilateral skin Irritated with needle 3 months postoperatively, 17 patients in MFND group had pain sensation in the operation area, 7 patients had pain sensation around ear, and 16 cases had pain sensation in subclavical region. There was no sensation in the operated area, ear and subclavical area of all patients in FND group after irritated with needle 3 months postoperatively. There was a significant statistical difference between two groups (p < 0.01).
Operation times The mean operation time of the FND group was 62 min and the mean operation time of the MFND group was 86 min.
Discussion The purpose of radical neck dissection is to remove as much cancer as possible (Figs. 9 and 10). But the classic radical neck dissection is associated with multiple functional and cosmetic deformities. For example, sacrificing the spinal accessory nerve (cranial nerve XI) results in impaired shoulder movement and the potential development of a painful fixed shoulder from denervating the trapezius muscle. The sequelae of radical neck dissection have aroused continual debate concerning the advantages and disadvantages of radical surgery. The FND, especially MFND, benefits patients. This study showed that most patients who underwent MFND had better skin sensation, while all patients who underwent FND felt numbness of the
Figure 9 Appearance of FND neck dissection: (1) sternmastoid muscle, (2) internal jugular vein and (3) spinal accessory nerve.
Figure 10 Appearance of FND neck dissection: (1) sternmastoid muscle, (2) internal jugular vein and (3) spinal accessory nerve.
ipsilateral skin. But we do not think we need to emphasize more on the functional and cosmetic advantages of MFND. We intend to draw the attention to better preserving the function of conserved tissues by means of improving surgical techniques. The external jugular vein is valuable for the drain of the facial region. Huan et al.10 found that the edema of face in the patients whose external jugular vein have been preserved disappeared sooner than that of the patients whose external jugular vein have not been preserved. Rouvier initially described the routes of lymphatic drainage in the head and neck in 1938 in his paper entitled ‘‘Anatomy of the human lymphatic system’’. The adequate studies of oncological safety of FND by Carlo et al.5 and Bocca et al.11 indicated that FND with the absence of fixed cervical nodes and without adherence to the sternomastoid muscle, internal jugular vein and spinal accessory nerve is reliable with comparison to radical neck dissection. The supraclavicular nerve, external jugular vein, greater auricular nerve and transverse cervical nerve locate in the superficial cervical fascia. Generally, the lymph nodes in superficial cervical fascia are not be violated unless in the last stage of the head and neck cancer. So, preservation of those nerves does not increase the risk of recurrence of cancers. Our study showed the recurrence rate after MFND is 6.67%. This confirmed the oncological radicality of MFND by comparing with FND. Of course, lower recurrence rate in the MFND group does not mean better oncological safety with MFND. It is sure that the MFND takes more time for the surgeons to preserve the supraclavicular nerve, external jugular vein, greater auricular nerve and transverse cervical nerve. It needs about 25% extra
Modified functional neck dissection: A useful technique for oral cancers time according to our experiences. But the increased operative time is bearable for the surgeons and patients. In conclusion, MFND helps to decrease the postoperative complications without increasing recurrent rate. We think that MFND should be recommended for the patients without clinical palpable cervical lymph node or with palpable mobile cervical nodes.
References 1. Crile G. Excision of cancer of the head and neck. JAMA 1906;47:1780–3. 2. Kuntz AL, Weymuller Jr EA. Impact of neck dissection on quality of life. Laryngoscope 1999;109(9):1334–8. 3. Eufinger H, Lehmbrock J. Life threatening and fatal complications of radical neck dissection. Mund Kiefer Gesichtschir 2001;5(1):193–7. 4. Suarze O. EL problema de las metastasis linfaticas y aligades del cancer de laringe y hipofaringe. Rev Otorrinolaringol(santiago) 1963;23(1):83–6.
5. Carlo V, Gianpietro T. Functional neck dissection: anatomical grounds, surgical technique, and clinical observations. Ann Otol Rhinol Larygol 1983;92(2):215–8. 6. Ferlito A, Gavilam J, Buckley JG, Shaha AR, Miodonski AJ, Rinaldo A. Functional neck dissection: fact and fiction. Head Neck 2001;23(9):804–8. 7. Kokemuller H, Brachvogel P, Eckardt A. Effectiveness of neck dissection in metastasizing mouth carcinoma. Uni- and multivariate analysis of factors of influence. Mund Kiefer Gesichtschir 2002;6(1):91–6. 8. Lassaletta L, Garcia-pallares M, Morera E, Salinas S, Bernaldez R, Patron M, et al. Functional neck dissection for the clinically negative neck: effectiveness and controversies. Ann Otol Rhinol Laryngol 2002;111(2):169–73. 9. Guney E, Yigitbasi OG, Canoz K, Ozturk M, Ersoy A. Functional neck dissection: cure and functional results. J Laryngol Otol 1998;112(12):1176–8. 10. Huang X, Li L, Wen Y. Basic research on neck dissection with external jugular vein and cervical plexus preserved (Abstr). Hua Xi Kou Qiang Yi Xue Za Zhi 2003;21(2):118–9. 11. Bocca E, Pignataro O, Oldini C, Cappac C. Functional neck dissection: an evaluation and review of 843 cases. Laryngoscope 1984;94(7):942–5.