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OBJECTIVES: Perimarginal nodes (PMN) lie in close relationship with marginal mandibular nerve (MMN), in the lymphatic drainage pathway of gingivo-buccal cancers (GBC), above the lower border of mandible and remain unaddressed in conventional neck dissection. We have aimed to define the boundaries of perimarginal node dissection, explore incidence of PMN metastasis and its correlation with histopathological characteristics. MATERIALS AND METHODS: A prospective study was conducted on 112 consecutive patients of GB carcinoma. PMN dissection was performed in an anatomically defined quadrangle. Prospective clinical characteristics included subsite, tumor and nodal stage, location of primary and clinical skin involvement. Histopathological characteristics analyzed included grade, size, pathological tumor, nodal stage, skin and/or bone involvement, depth of invasion, Brandwein Gensler histological risk score and lympho-vascular emboli. MMN function was graded at 3 and 6 months post-operatively. RESULTS: The PMN were identified histologically in 75.89 % patients. 15.2 % patients harboured metastasis in PMN. 16.7 % patients had clinically occult metastasis with 11.7 % having isolated PMN metastasis. None of the pre-operative clinical factors was found to be significant in predicting incidence of metastasis. Higher nodal burden (p = 0.01) and pathological skin involvement (p = 0.03) were found statistically significant on multivariable analysis. At 6 months follow-up, none of the patients had any MMN functional deformity at rest. CONCLUSION: There is a high incidence of occult PMN metastasis from gingivo-buccal complex cancer. High nodal stage and pathological skin involvement are independent predictors for PMN metastasis. PMN dissection must be performed in all cases of GB cancer.

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Among the various anatomical landmarks during neck dissection, digastric muscle is one of the most important. It is well known that all important blood vessels in neck lies deep to digastric. Thus, it acts as a safety landmark during neck dissection. In this article we describe a variation in vascular anatomy with relation to posterior belly of digastric that has not been reported so far during live surgery. Surgeon performing neck dissection should have a detailed knowledge of anatomy and infrequent anatomical variation. The knowledge of current anatomical variation will avoid torrential bleed during neck dissection and preserve the artery for vascular related procedures.

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BACKGROUND: The incidental finding of thyroid inclusions in lymph nodes of neck dissections of non-thyroid cancer patients is an unusual event. It is still controversial for pathologists about whether this represents benign inclusions or metastatic papillary thyroid carcinoma (PTC). This study is to analyze clinicopathological features of such cases in an attempt to explore their clinical implications. METHODS: Pathological data were searched for incidentally detected PTC of cervical lymph nodes in non-thyroid cancer cases. Clinicopathological characteristics were reevaluated and recorded. BRAF V600E protein expression and sequencing analysis was then performed in cases with sufficient tissues. RESULTS: 31 patients had an incidental finding of PTC in lymph nodes of patients with non-thyroid cancer. BRAF immunohistochemical staining were performed in 17 metastatic lymph nodes with sufficient tumor tissues, and 6 were positive. BRAF V600E point mutation was detected in 5 of 6 BRAF V600E positive cases. Subsequent imaging examinations of the thyroid showed no nodules or calcifications/benign nodules in 20 patients, and suspected malignant nodules in 5 patients. 12 patients underwent total thyroidectomy or ipsilateral lobectomy, and 6 showed PTC in postoperative pathological examinations. The remaining 19 patients without surgery were kept under active surveillance, and no one had recurrence of PTC. CONCLUSION: Incidentally discovered PTC in lymph nodes has usually interpreted as metastasis from a clinical occult thyroid primary cancer, but primary PTC was not always detected. This suggests it could be double occult lesions. With regards to concurrence with highly malignant tumor, most patients could keep regular surveillance.

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Apart from complete surgical clearance of the malignancy, reducing morbidity and improving quality of life of the patient is also considered. One of the morbidities linked with neck dissections is shoulder dysfunction. The aim of our study is to analyse the functional outcomes in patients operated for various neck dissections with preservation of the Spinal accessory nerve. A single centre prospective observational study was conducted in a total of 45 patients with oral cancers. These patients underwent Wide local excision of the primary tumour along with neck dissection. Tests for assessing spinal accessory nerve function was elicited in all these patients preoperatively and postoperatively. Patients were examined for shoulder pain and shoulder disability using Arm abduction test. All 45 patients underwent spinal accessory nerve preserving neck dissection. On post operative day 10, 89% of patients showed arm abduction test score of 1 and 47% of patients had a pain score of 6 whereas 13% had a pain score of 8. After 6 months of rehabilitation and regular follow up, 62% of the patients had improved arm abduction test score of 4 and above and all 45 patients had pain score improved to score of 4 and less. Variable amount of shoulder dysfunction is seen even in spinal accessory nerve preserving neck dissections. But active rehabilitation and regular follow up of these patients reduces the morbidity associated with shoulder syndrome.

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Introduction Squamous cell Carcinoma of the Head and Neck (HNSCC) is the most common tumor entity of malignant processes in the head and neck area. Due to the metastasizing behavior of these tumors, the staging is indispensable for the treatment planning and requires imaging techniques, which are sensitive, specific, and as far as possible cost-effective, to benefit ultimately the patient and to ensure optimal care. Objectives The aim of the present study is to compare the clinical examination including palpation, ultrasound and computed tomography (CT)/magnetic resonance imaging (MRI) for the diagnosis of neck metastases to make the correct indication for a neck dissection. Methods Data from 286 patients with HNSCC were analyzed for neck metastases to determine which diagnostic tool is the best to answer the question if a neck dissection is necessary or not. Each study method was examined retrospectively by comparing sensitivity, specificity, the positive/negative predictive value, the positive likelihood ratio and the diagnostic accuracy. Results The ultrasound showed a sensitivity of 91.52%, a specificity of 61.67%, a positive/negative predictive value of 76.65%/84.09%, a positive likelihood ratio of 2.39 and a diagnostic accuracy of 78.95%. The clinical examination showed a sensitivity of 75.76%, a specificity of 66.12%, a positive/negative predictive value of 75.30%/66.67%, a positive likelihood ratio of 2.24 and a diagnostic accuracy of 71.68%. The CT/MRI showed a sensitivity of 78.66%, a specificity of 62.50%, a positive/negative predictive value of 74.14%/68.18%, a positive likelihood ratio of 2.10 and a diagnostic accuracy of 71.83%. Radiographically, ultrasound, as well as the clinical examination, could be judged to be free from radiation load and side effects from the contrast medium. The high dependence on the investigator when using ultrasound made reproducibility of the results difficult. Conclusions It could be shown that ultrasound was the diagnostic tool with the highest sensitivity, positive/negative predictive value, positive likelihood ratio and diagnostic accuracy by detecting and interpreting metastases in the head and neck region correctly. Whether a neck dissection should be performed depends to a large extent on the ultrasound findings.

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Abstract Introduction Squamous cell Carcinoma of the Head and Neck (HNSCC) is the most common tumor entity of malignant processes in the head and neck area. Due to the metastasizing behavior of these tumors, the staging is indispensable for the treatment planning and requires imaging techniques, which are sensitive, specific, and as far as possible cost-effective, to benefit ultimately the patient and to ensure optimal care. Objectives The aim of the present study is to compare the clinical examination including palpation, ultrasound and computed tomography (CT)/magnetic resonance imaging (MRI) for the diagnosis of neck metastases to make the correct indication for a neck dissection. Methods Data from 286 patients with HNSCC were analyzed for neck metastases to determine which diagnostic tool is the best to answer the question if a neck dissection is necessary or not. Each study method was examined retrospectively by comparing sensitivity, specificity, the positive/negative predictive value, the positive likelihood ratio and the diagnostic accuracy. Results The ultrasound showed a sensitivity of 91.52%, a specificity of 61.67%, a positive/negative predictive value of 76.65%/84.09%, a positive likelihood ratio of 2.39 and a diagnostic accuracy of 78.95%. The clinical examination showed a sensitivity of 75.76%, a specificity of 66.12%, a positive/negative predictive value of 75.30%/66.67%, a positive likelihood ratio of 2.24 and a diagnostic accuracy of 71.68%. The CT/MRI showed a sensitivity of 78.66%, a specificity of 62.50%, a positive/negative predictive value of 74.14%/68.18%, a positive likelihood ratio of 2.10 and a diagnostic accuracy of 71.83%. Radiographically, ultrasound, as well as the clinical examination, could be judged to be free from radiation load and side effects from the contrast medium. The high dependence on the investigator when using ultrasound made reproducibility of the results difficult. Conclusions It could be shown that ultrasound was the diagnostic tool with the highest sensitivity, positive/negative predictive value, positive likelihood ratio and diagnostic accuracy by detecting and interpreting metastases in the head and neck region correctly. Whether a neck dissection should be performed depends to a large extent on the ultrasound findings.

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BACKGROUND: Regional metastasis sometimes occurs in anatomies that are not included in traditional neck dissections. The purpose of this study was to evaluate the treatment outcomes of squamous cell carcinoma of oral cavity (SCCOC) patients with unconventional metastatic lymph nodes (UMLNs) in sublingual, buccinator, and parotid anatomies. METHODS: This retrospective multi-institutional analysis of squamous cell carcinoma of oral cavity patients with unconventional metastatic lymph nodes was performed from January 2008 to December 2015. All the included patients received surgical treatment for unconventional metastatic lymph nodes. The end point of the study was to determine the factors influencing these patients' survival and the corresponding solutions to improve survival. Pathological grade, contralateral metastasis, extranodal extension, and other factors were collected and analyzed by logistic regression and the Cox model. RESULTS: A total of 89 patients were identified. Among these patients, 25 (28.1%) received primary treatment, 28 (31.5%) received staged (therapeutic) neck dissections, and 36 (40.4%) had recurrent or residual diseases. Altogether, 45 patients (51%) had buccinator node metastases, 31 (35%) had sublingual metastases, 12 (14%) had parotid metastases, and 1 had both buccinator and parotid metastases. Regarding regional metastases, 31 patients (34.8%) had isolated unconventional metastatic lymph nodes. Adjuvant therapies were administered to 72 (80.9%) patients, 25 (28.1%) of whom were treated with radio-chemotherapies. The overall survival rate was 38.2%. Multivariate analysis found that the subsites of unconventional metastatic lymph nodes (P = 0.029), extranodal extension in both unconventional metastatic lymph nodes (P = 0.025) and cervical lymph nodes (P = 0.015), sites of primary or recurrent squamous cell carcinoma of oral cavity (P = 0.035), and types of neck dissections (P = 0.025) were significantly associated with overall survival. CONCLUSIONS: Unconventional metastatic lymph nodes are uncommon, yet awareness of potential unconventional metastatic lymph nodes should be heightened. Early surgical interventions are warranted in patients with sublingual or buccinator metastases, while caution should be given to those with parotid metastases. Aggressive en bloc (in-continuity) resections may be mandatory in advanced oral cancer cases for close anatomic locations with possible buccal or sublingual metastases.

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OBJECTIVE: To investigate the efficacy of extracorporeal shockwave therapy (ESWT) on cervical myofascial pain following neck dissection in reducing pain and improving cervical range of motion (ROM). METHODS: Forty-six patients with cervical myofascial pain following neck dissection surgery were recruited and subdivided at random into two equal groups. The ESWT group received ESWT once a week for 4 weeks (0.25 mL/mm2, 1,000 shocks) and a topical non-steroidal anti-inflammatory drug (3 times/day for 4 weeks). The control group received only topical NSAID. The pain assessment was done by using the visual analog scale (VAS) and pressure algometry. A cervical ROM device was used for the assessment of the lateral flexion and rotation of the neck ROM on both sides. All measurements were collected at baseline, 2 weeks, and 4 weeks. RESULTS: The ESWT group revealed a significant improvement in all parameters at post I and post II than did the control group (p>0.001), that revealed a statistical decrease only in the VAS score at post I without any statistical difference in the pain threshold and neck ROM. However, there were statistical differences in all parameters at post II compared to those at pre-treatment and post I (p<0.001). CONCLUSION: As a confirmation of the efficacy of ESWT in cervical myofascial pain control following neck dissection, we observed better results with no side effects in the ESWT group (Clinical Trial Registry No. PACTR202002648274347).

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INTRODUCTION AND OBJECTIVES: Lymph node density or lymph node ratio (LNR), defined as the quotient between the total number of positive lymph nodes and the total number of dissected lymph nodes, has demonstrated a prognostic capacity in several tumour models, including patients with head and neck squamous cell carcinomas (HNSCC). The aim of the present study is to analyse the prognostic value of LNR in a wide cohort of patients with HNSCC. METHODS: We carried out a retrospective study of a cohort of 1,311 patients with HNSCC treated with unilateral or bilateral neck dissections. Of the patients included in the study, 55.0% had lymph node metastases (pN+). We proceeded to calculate the value of the LNR, and its categorization through a recursive partition analysis considering specific survival as the dependent variable. RESULTS: Three categories were defined according to the value of the LNR with a cut-off point at the values < of .025 and .118. The 5-year specific survival for patients with an LNR less than .025 (n=654, 49.8%) was 87.2%, for patients with a LNR .025-.118 (n=394, 30.1%) it was 51.6%, and for patients with a LNR greater than .188 (n=263, 20.1%) it was 27.3% (P=.0001). According to the results of a multivariate analysis, the LNR significantly related to specific survival. CONCLUSION: The LNR can be a prognostic variable to be considered in the pathological staging of the lymph nodes.

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The spinal accessory nerve (SAN) exhibits variant anatomy in its relation to the internal jugular vein (IJV) as well as the sternocleidomastoid muscle (SCM). These variations are important in locating the nerve during surgical neck procedures to avoid its inadvertent injury. These variations, however, are not conserved among different populations and data from the Kenyan setting are partly elucidated. This study, therefore, aims to determine the variant anatomical relationship of the SAN to the SCM and IJV in a select Kenyan population. Forty cadaveric necks were studied bilaterally during routine dissection and the data collected were analyzed using SPSS version 21. Means and modes were calculated for the point of entry of the SAN into the posterior triangle of the neck as well as for its relation to the SCM. Side variations for both of these were analyzed using Student's t -test. Data relating the SAN to the IJV were represented in percentages and side variations were analyzed using the chi-square test. The SAN point of entry into the posterior triangle of the neck was 5.38 cm (3.501-8.008 cm) on the left side and 5.637 cm (3.504-9.173 cm) on the right side ( p = 0.785) from the mastoid process. The nerve perforated the SCM in four cases (10%) on the left side and in eight cases (20%) on the right ( p = 0.253). The SAN lay predominantly medial to the IJV on both sides of the neck, 87.5% on the left side of the neck versus 82.5% on the right ( p = 0.831). In conclusion, the variant relation of the SAN to the IJV and SCM as observed in this setting is an important consideration during radical neck procedures and node biopsies.

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Lateral neck metastasis is an independent risk factor of the loco-regional recurrence in papillary thyroid carcinoma (PTC). Ultrasonography (US) and computed tomography are frequently performed to diagnose the lymph node (LN) metastasis. However, some metastatic LNs can remain after initial treatment and can present as regional recurrences. A 19-year-old woman was diagnosed as having 1.99 cm PTC. No abnormal LNs was detected on preoperative CT and US. She underwent operation and radioactive iodine (RAI) therapy: seven months after RAI therapy, thyroglobulin level was elevated. However, no metastatic LNs were detected on neck CT, US and positron emission tomography-CT. Neck exploration was performed and metastatic PTC was diagnosed in bilateral level III and IV. A radiologist retrospectively reviewed the neck CTs taken before the first surgery and the second surgery. There was no significant difference in the LN appearances of two CTs. On both CT scans, all LNs were very small, homogenously enhanced, without calcification or cystic changes.

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Introducción: el desarrollo acelerado de la oncología ha condicionado recientes modificaciones terapéuticas que pudieran incluir la preservación de la glándula submandibular en las disecciones de cuello. Objetivos: identificar los criterios para preservar quirúrgicamente la glándula submandibular y exponer los fundamentos científico-teóricos que permitan plantear una modificación actual a la técnica de disección de cuello para conservar esta glándula. Métodos: se realizó una búsqueda exhaustiva retrospectiva de artículos publicados en las bases de datos electrónicas Pubmed, Medline, Cochrane e Hinari desde enero de 2009 hasta julio de 2014, en las revistas Head and Neck, Otolaryngology and Head and Neck Surgery y The Laryngoscope con los términos: preservación glándula submandibular, criterios oncológicos conservar glándula submandibular, modificaciones disecciones linfonodulares cervicales, sin restricciones idiomáticas. Se incluyeron solo los artículos publicados durante los últimos cinco años, cuyo material y método reflejara: estudios poblacionales, disecciones de cuello como tratamiento oncoespecífico y confirmación anatomo-patológica para concluir el diagnóstico. Análisis e integración de la información: de 3 estudios que conformaron una metapoblación de 829 pacientes, donde se preservó la glándula submandibular en un grupo de pacientes con tumores de cavidad bucal y orofaringe y disecciones de cuello simultáneas, se evidenció que no hubo diferencias en cuanto a recaída local, regional, a distancia ni sobrevida al compararlos con otro grupo de pacientes donde la disección de cuello no incluyó este proceder. Conclusión: los estudios coinciden en el bajo riesgo de metástasis ocultas a la glándula por carcinomas escamosos de cabeza y cuello, xerostomía posquirúrgica y factibilidad de la técnica quirúrgica como fundamentos para preservar la submandibular, de igual manera en que la ausencia de terapia oncoespecífica anterior, linfonódulos positivos en el subnivel IB y relación entre el tumor primario y la glándula son criterios necesarios en la selección de candidatos para realizar este proceder(AU)

Introduction: as a result of the swift development of oncology, some therapeutic modifications have recently been considered, among them the potential preservation of the submandibular gland in neck dissections. Objectives: identify the criteria to surgically preserve the submandibular gland and expound the theoretical scientific foundations allowing to set forth a modification to neck dissection technique with a view to preserving this gland. Methods: an exhaustive retrospective search was conducted of papers published in the databases Pubmed, Medline, Cochrane and Hinari from January 2009 to July 2014. The journals surveyed were Head and Neck, Otolaryngology and Head and Neck Surgery, and The Laryngoscope. The search terms used were submandibular gland preservation, oncological criteria preserve submandibular gland, modifications cervical lymph node dissections, without any language restrictions. Only papers published in the last five years were included. On the other hand, their materials and methods section should make reference to population studies, neck dissection as an onco-specific treatment, and anatomopathological confirmation of the diagnosis. Data analysis and integration: three studies with a metapopulation of 829 patients referred to a group of patients with oral and oropharyngeal tumors and simultaneous neck dissections whose submandibular gland had been preserved. These studies do not report any difference as to local, regional or distant relapse or survival when compared with another group of patients in whom neck dissection did not include such a procedure. Conclusion: all studies referred to the following aspects: the low risk of occult metastasis to the gland from head and neck squamous cell carcinomas, postsurgical xerostomia, and the feasibility of the surgical technique as foundations for the preservation of the submandibular gland. They also referred to the fact that absence of prior onco-specific therapy, positive lymph nodes in sublevel IB, and the relationship between the primary tumor and the gland are all required criteria for the selection of candidates for the procedure(AU)

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OBJECTIVE: The aim of this study was to evaluate the oncologic outcomes after a selective neck dissection (SND), both in elective and therapeutic settings, with particular regard to regional recurrence rate. METHODS: Retrospective analysis of 827 patients with head and neck primary tumors submitted to SND from 1999 to 2011 in two large hospital centers of northern Italy. RESULTS: A total of 40 neck recurrences were found in the whole series, with the same incidence after primary or salvage surgery (4.4% and 5.2%, respectively), but only 22 neck recurrences occurred in the same side of the dissected neck (3.0%). Factors predicting an increase of ipsilateral neck relapse were pathologically positive nodes, number of positive nodes, and nodal ratio (ratio between positive nodes and total nodal removed), but the risk of regional relapse did not exceed 5.0% in any subgroups. A total of 320 patients (39%) had postoperative radiotherapy (52.0% and 22.0% after primary and salvage surgery, respectively). Considering the primary surgery group alone, postoperative radiotherapy produced only a light reduction of homolateral neck recurrence rate in patients with pathological positive nodes (2.4% vs. 5.0%), but it impacted significantly disease-specific survival, both in pathological classification of nodes (pN)1 and pN2-3 patients. CONCLUSION: The SND can be considered a safe and sound procedure both in primary surgery and in salvage setting. Postoperative radiotherapy adds minor advantage to regional control only in node-positive patients but may impact survival. LEVEL OF EVIDENCE: 4.

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BACKGROUND: Although existing literature provides surgical recommendations for treating occult disease (cN0) in early-stage oral cavity squamous cell carcinoma (SCC), a focus on late-stage oral cavity SCC is less pervasive. METHODS: The medical records of 162 patients with late-stage oral cavity SCC pN0 who underwent primary neck dissections were reviewed. Lymph node yield as a prognosticator was examined. RESULTS: Despite being staged pN0, patients that had a higher lymph node yield had an improved regional/distant control rates, disease-free survival (DFS), disease-specific survival (DSS), and overall survival (OS). Lymph node yield consistently outperformed all other standard variables as being the single best prognostic factor with a tight risk ratio range (RR = 0.95-0.98) even when correcting for the number of lymph nodes examined. CONCLUSION: The results of this study showed that lower regional recurrence rates and improved survival outcomes were seen as lymph node yield increased for advanced T classification oral cavity SCC pN0. This suggests that increasing lymph node yield with an extended cervical lymphadenectomy may result in lower recurrence rates and improved survival outcomes for this advanced stage group.

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BACKGROUND AND OBJECTIVES: To compare shoulder function with respect to pain and disability in patients who have undergone nerve sparing neck dissection i.e. selective neck dissection (levels I, II, III) and functional neck dissection as a part of their treatment modality for carcinoma tongue on a follow up of minimum six months. MATERIAL AND METHODS: A total of 100 patients were selected for this study. 50 patients who had undergone selective neck dissection (levels I, II, III) and 50 who underwent functional neck dissection as a part of their treatment modality for squamous cell carcinoma of the tongue from January 2005 to January 2007 were asked to participate in this study. A standardized questionnaire was used to assess pain and disability. Pain and disability scores were then compared between the two nerve sparing dissections. RESULTS: 100% of the patients in Selective Neck Dissection (SND) (levels I, II, III) group and in Functional Neck Dissection (FND) groups complained of pain. Though there is pain present in both the treatment groups, no significant difference in the pain values was found between FND and SND (levels I, II, III) in any of the pain parameters. Disability was present in both the treatment groups. However patients who have undergone FND had significantly higher severity of disability when compared to SND (levels I, II, III) especially during activities which involve shoulder abduction like dressing, doing heavy household work, hair wash and washing clothes/dishes (5.18, 5.22, 5.5, 4.88 in FND and 2.26, 4.08, 4.58, 2.2 in SND (levels I, II, III) respectively. Disability perceived during other activities like doing heavy household and facial care was 2.08 and 1.84 in both the treatment groups respectively. INTERPRETATION AND CONCLUSION: Degree of shoulder morbidity is much higher in patients who have undergone FND as compared to SND (levels I, II, III) as a treatment modality for carcinoma tongue, even though both the treatment options are nerve preserving.