Is Modified Radical Neck Dissection Only

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Is Modified Radical Neck Dissection OnlyA Staging Procedure?

CHRISTOPHER J. O'BRIEN, FRACS," SENGJAW SOONG, PHD,t MARSHALL M. URIST, MD.+AND WILLIAM A. MADDOX, MD$

This retrospective study evaluates the clinical benefit of modified radical neck dissection among patientswith squamous carcinoma of the upper aerodigestive tract. Ninety-eight modified neck dissections wereperformed in 86 patients over a 5-year period. The procedure entailed removal of the submaxillary andjugular chain nodes while the posterior triangle was not dissected. Thirty-two patients received postoperativeradiotherapy. Lymph nodes were histologically positive in 55 of 98 dissections (56%).Among 72 determinatepatients, recurrence in the dissected neck occurred in 8 of 38 with positive nodes and none of 34 withnegative nodes (P c 0.05). These recurrences occurred in patients who had clinically palpable nodespreoperatively. Postoperative radiotherapy did not significantly alter the overall recurrence rate or survivalof patients with positive nodes. Cumulative disease-free survival at 5 years was 70%overall. It is concludedthat the modified neck dissect ion described is appropriate in th e clinically negative neck or when regionaldisease is early (k , 1) and located in the submandibular triangle. Postoperative radiotherapy shouldbe given if more than one node is involved histologically or if extracapsular spread is present.

Cancer 59:994-999, 1987.

ODIFIED RADICAL NECK DISSECTIONS (MRND) areM ow widely performed and although techniquesvary in name and detail, they share fundamental similar-ities. In each procedure the aim is to remove the lym-phatics of the neck while attempting to limit morbidityby sparing certain anatomical structures. These are, prin-cipally, the sternocleidomastoid muscle (SCM), the spinalaccessory nerve (SAN), and the internal ugular vein (IJV).Modified radical neck dissection is especially usefulwhen carried out as an elective procedure in the clinicallynegative neck because it is associated with less cosmeticand functional disability than classical radical neck dis-section. However, the oncologic effectiveness of MRNDin patients with epidermoid carcinoma of the upper aero-digestive tract is not yet clear. Authors are divided in theiropinions as to when a modified procedure should be car-

From the Section of Surgical Oncology, Department of Surgery andthe Section of Biostatistics, Comprehensive Cancer Center, Universityof Alabama in Birmingham, Birmingham, Alabama.Supported by grants from the NCI CA382 15.* Fellow in Head and Neck Oncology, Section of Surgical Oncology.t Chief, Section of Biostatistin, ComprehensiveCancer Center.$Chief, Section of Surgical Oncology, Department of Surgery.Q Clinical Professor, Section of Surgical Oncology, Department of

Address for reprints: Marshall M. Urist, MD, University Station, 320The authors thankMs. udy Smith and Ms. Judy Warren for assistingAccepted for publication October 1, 1986.

Surgery.Kracke Building, Birmingham, AL 35294.with this study and Ms. Michelle Dunn for typing the manuscript.

ried out in the clinically positive neck and when post-operative radiation therapy should be used. In an attemptto more clearly define the role and efficacy of MRND,the experience of two of the authors (W.A.M and M.M.U)has been reviewed.

Patients and MethodsModified radical neck dissection was first carried outat the University of Alabama Hospitals in 1979, and by

December 1984, a total of 98 operations had been per-formed in 86 patients. These procedures were unilateralin 74 patients and synchronous bilateral operations in 12 .In general, patients undergoing MRND had either (1 )clinically normal necks and at least a 30%risk of occultnodal metastases based on the T-stage and histologiccharacteristics, or (2) clinically positive cervical nodes thatwere not in proximity to the course of the spinal accessorynerve. The operative technique, which was developed byone of the authors (W.A.M), has been described else-where.' The procedure consists of dissection of the sub-mandibular triangle and upper, middle, and lower jugularchains, sparing the SCM, SAN, and cervical plexus (CP)but removing the IJV. The posterior triangle is not dis-sected. When synchronous bilateral procedures were per-formed, the IJV on the side opposite the primary (or theclinically less involved side) was spared. Postoperative ra-diation therapy was given to 32 patients. This was com-menced within 4 to 6 weeks of surgery. Treatment doses

994


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No. 5 MODIFIED ADICALNECKDISSECTION O'Brien et al . 995ranged from 5000 to 6000 rad given over 5 to 6 weeks.Initially, radiation fields encompassed the primary siteand the ipsilateral neck but more recently the contralateralneck has been included in the treatment schedule.

Seventy-two of the 86 patients were determinate be-cause they had been followed up for a minimum of 2years or developed recurrence of their disease. Three pa-tients who were followed for less than 2 years and l l whodied of other causes within 2 years of MRND were re-garded as being indeterminate. Differences in recurrencerates in the ipsilateral neck, with disease controlled at theprimary site, were analyzed using a x2 est with Yates'correction factor. Disease-free survival was calculated bythe method of Kaplan and Meier and patients alive withdisease were counted as deaths. Differences between sur-vival rates were compared by a generalized Wilcoxon test.

ResultsAmong the 86 patients, there were 65 men and 21

women with ages ranging from 33 to 87 years (median,58 years). The age/sex distribution is shown in Figure 1.Table 1 shows the sites of primary tumors involved alongwith clinical node status for tumors at each site. This table,therefore, reflects the indications for MRND. For ex-ample, 10 of the 11 MRNDs for lip carcinoma were ther-apeutic procedures. Neck dissections were elective in 52of 86 patients (60%) and therapeutic in 34 (40%). Table2 shows the clinical stage of patients before MRND, ac-cording to the guidelines of the American Joint Com-mittee on Cancer (1983). The T 1NO primaries were bothhypopharyngeal cancers. Patients who had treatment forrecurrent disease at the primary site along with MRND,were staged Tx for the primary. Those with previouslytreated primaries and no evidence of recurrence at theprimary site but with clinical disease in the neck werestagedTO. One patient with an unknown primary site wasalso staged TO.Histologic Node Involvement

At the time of pathologic analysis, the total yield oflymph nodes from neck dissection specimens and thenumbers of involved nodes were noted. This informationis represented in Figures 2 and 3. Lymph nodes were his-tologically positive in 55 of 98 neck dissections (56%).Table 3 shows the correlation of the clinical and histologicfindings. The false negative rate of clinical evaluation ofthe neck was 37% (22 of 60) and the false positive ratewas 13%(5 of 38).Recurrences

Table 4 shows the recurrence data of patientssubgrouped according to the number of histologically

35No.Patients 301, 27 , 2,5

"30 40 50 60 70 80 90Age( years)

FemalesMales 0

FIG. 1. Age/sex distributionof 86 patients undergoing MR ND .

positive nodes found. The designated site of recurrencewas the most proximal site at which disease recurred.Therefore the ipsilateral neck was called the recurrencesite only when disease was controlled at the primary site.Among the 12 patients who had synchronous bilateralMRNDs, 7 had bilateral disease proven histologically andthey form a separate group; 3 had no histologic diseaseand are included among the 38 patients with no positivenodes; and 2 with unilateral disease histologically wereincluded with other patients according to the number oflymph nodes involved.

TABLE . Site of Primary Tumor and Clinical Node Statusof 86 Patients Having MRN D

Site Nodes +VE Nodes - E TotalLipOral cavityTongueFloor of mouthBuccal mucosaRetromolar trigoneAlveolar ridgeOropharynxTonsilBase of tongueSoft palate

SupraglottisGlottisHypopharynxUnknown primaryTotal

Larynx

10

24506101

1211

34

1

61 1

141022062I0

52

1 1

8156416321

I481

86+ V E positive;- V E negative; MR ND: modified radical neck d issec-tion.


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996 CANCERMarch 1 1987 VOl. 59TABLE . TNM Stage for 86 Primary Tumors at the Tim e of M RN D

NO N1 N2 N3 TotalTX 1 2 0 0 3TO 0 1 1 3 1 15T1 2 2 0 1 5T2 36 4 2 1 43T3 13 4 1 0 18T4 0 0 0 2 2Total 52 23 6 5 86

MRN D: modified radical neck dissec tion.

Where lymph nodes were histologically negative 4 of34 determinate patients (12%) developed recurrence butin no instance did this involve the ipsilateral neck. Wherenodes were histologically positive, recurrence developedin 15 of 38 patients (39%)and this involved the ipsilateralneck in 8 patients (21%). The presence of histologicallypositive nodes was associated with a significantly ncreasedrecurrence rate at all sites (P


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No. 5 MODIFIED ADICAL NECKDISSECTION OBrien et al . 997

No. ofNeck

Dissect ons

TABLE . Correlation of Clinical and Histologic Examinationfor 98 M R N D sClinically Clinically40 positive negative Total

2015

1 26 , 23 22 4 4r y y Mlr 55Histologically positive 33Histologically negative 5 38 43Total 38 60 98MRNDs: modified radical neck dissections.nif an elective neck dissection is planned, there appears tobe little justification for carrying out a radical operation.Judicious modified radical neck dissection could identify

0 1 2-4 >4 patients with occult metastases, with low morbidity, andobviate unnecessary radical neck dissection or elective ir-

50 U

NO. Nodes Involved radiation in many cases.FIG. 3. Frequency histogram showing number of histologically positivenodes in each neck dissection.

hemidiaphragmatic paresis from inadvertent division ofthe left phrenic nerve.

DiscussionThe management of the neck in patients with squamous

carcinomas of the upper aerodigestive tract varies ac-cording to the clinical circumstances. Clinically palpablenodes are usually treated by classical radical neck dissec-tion, and radiation therapy often is added in an attemptto prevent subsequent recurrence in the neck. Recentlyhowever, patients with clinically positive neck nodes havebeen treated by modified radical dissection, but the placeof this operation has not been fully defined. Managementof the clinically negative neck is even more controversial.Opinion is divided as to whether the best treatment iselective irradiation, elective neck dissection, or observa-tion with subsequent therapeutic neck dissection whenclinical metastases appear. In fact, any of these optionsmay be appropriate in an individual patient, dependingon the site and stage of the primary tumor. At this time,

In this retrospective study, modified neck dissectionshave been carried out as both therapeutic and electiveprocedures. Elective removal of occult nodal metastaseswas associated with a significantly better survival at 2 yearsthan when nodes were clinically positive. However, thedifference in survival of the two groups had all but dis-appeared by 5 years. The implication is that removal ofinvolved lymph nodes before they became clinically ev-ident has little effect on ultimate survival and this is theargument advanced by antagonists of elective neck dis-section. However, in this nonrandomized series no definiteconclusions can be made about the potential survivalbenefit from elective MRND.Bocca et al . recently reported their series of 1500functional neck dissections of which 1200 were electiveprocedures.* However, 87% of their patients had carci-noma of the larynx and neither the distribution of cancerswithin the larynx nor the incidence of histologicallypos-itive nodes in these clinically negative necks were stated.Since glottic carcinoma accounts for 50% to 75% of la-ryngeal cancers and rarely metastasizes to the neck unlessa d ~ a n c e d , ~ - ~t is not clear just how many patients neededor benefited from elective neck dissection. In the sameseries, 171 patients with clinical N 1 or N2 disease had a

TABLE . Initial Site of Recurrence According to Num ber of Nodes InvolvedSite of recurrencesTotal DeterminateNodes positive patients patients Primary Ipsilat neck Contralat neck Distant Total

0 38 34 3 0 I 0 4 (12%)1 18 12 0 1 0 0 1 ( 8 % )2-4 18 16 3 1 0 1 5 (31%)> 4 5 4 0 4 0 0 4 100%)Bilateral nodes 7 6 2 2 0 1 5 (83%)

Total 86 12 8 8 1 2 19 (26%)Ipsilat: ipsilateral; contralat: contralateral.


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998 CANCERMarch 1 1987 Vol. 59

6 900 80C 70.g 600v)c 400 30

20

c.

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No . 5 MODIFIED ADICAL NECKDISSECTION O'Brien et al. 999Thus when postoperative radiation therapy is to be addedto the modified neck dissection described in this series, itshould encompass the entire ipsilateral neck to decreasethe risk of recurrence in the posterior triangle.

It appears, therefore, that modified radical neck dis-section is primarily a staging procedure. When carriedout electively, the morbidity is low and patients with occultmetastatic disease can be identified. In this series, 38% ofnecks clinically judged to be negative contained occultdisease. If the yield of positive lymph nodes is none orone, without extracapsular spread, then no further treat-ment to the neck is necessary since recurrence is unlikelyto occur. If, however, more than one node is positive orextracapsular spread is present, then postoperative radia-tion therapy should be added to the modified neck dis-section. Although our results failed to show any definitebenefit from postoperative radiation therapy, its advan-tages in improving regional control have beenrep~rted '~- '~nd we continue to adhere to this principle.Modified neck dissection alone can effectively controldisease in the neck only in patients with minimal histo-logic metastatic disease. Otherwise, its efficacy is depen-dent upon its combination with planned postoperativeradiotherapy. Nonetheless this procedure has distinct ad-vantages over classical radical neck dissection as anelective operation and also may prevent a number of pa-tients undergoing unnecessary elective neck irradiation.Whether or not MRND can be used effectively instead ofradical neck dissection among more patients with palpablenodes can only be determined by a randomized clinicaltrial in which both procedures are combined with adjuvantradiotherapy according to the pathologic findings.

1.1 N o d e I n = l 8 )

201 0

1 vs. 2 p = o . 1 82 v s . 3 p = 0 . 6 21 vs. 3 ~ ( 0 . 0 5

1.2.3 vs . 4 p

Is Modified Radical Neck Dissection Only

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