Radical Neck Dissection: (RND) Classification, Indication and Techniques

August 10, 2011 | By | Reply More

Radical Neck Dissection: (RND) Classification, Indication and Techniques

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Radical Neck Dissection: (RND) Classification, Indication and Techniques


•      Crile in 1906 introduced RND and is followed by Martin as a the classical procedure for the management of cervical lymph node metastasis

•      Recently changes in classification and indication led to inconsistency

–   N0 in recent studies may require selective RND to reduce morbidity

Staging of Neck Nodes

•      NX:

–    Regional lymph nodes can not be assessed

•      N0:

–    No regional lymph node metastasis

•      N1:

–    Metastasis in a single ipsilateral lymph nodes, 3 cm or less in greatest dimension

•      N2:

–    N2a:

•    Metastasis in a single epsilateral lymph nodes, more than 3 cm but less than 6 cm

Staging of Neck Nodes

–   N2b:

•   Metastasis in multiple ipsilateral lymph nodes, not more than 6 cm

–   N2c:

•   Metastasis in bilateral or contralateral nodes not more than 6 cm in diameter

•      N3:

–   Metastasis in lymph nodes more than 6 cm in in greatest diameter

Lymph Node Regions

•      Region I:

–   Submental and submandibular triangle

•   Ia: Submental triangle:

–   Bounded by the anterior belly of digastric    and the mylohyoid muscle deep

•   Ib: Submandibular triangle:

–   Formed by the anterior and posterior belly     of the digastric muscle and the body of the mandible

•      Region II – IV:

–   Lymph nodes are associated with the Internal Jugular Vein (IJV) within the fibroadipose tissues that extend from the posterior border of sternocledo-mastoid muscle (SCM) medial to lateral border of the sternohyoid muscle

•      Region II:

–    Upper third including upper jugular, jugulodigastric and upper posterior cervical nodes

–    Bounded by the digastric muscle superiorly and the hyoid bone or carotid bifurcation inferiorly

•    IIa:

–   nodes anterior to Spinal Accessory Nerve (SAN)

•    IIb:

–   nodes posterior to Spinal Accessory Nerve (SAN)

•      Region III:

–   Middle third jugular nodes from the carotid bifurcation to cricothyroid notch or omohyoid muscle

•      Region IV:

–   Lower third jugular nodes from omohyoid muscle superiorly to the clavicle inferiorly

•      Region V:

–   Lymph nodes of the posterior triangle along the lower half of the SAN and the transverse cervical artery

–   Bounded by the anterior border of the trapezius posteriorly, the posterior border of SCM anteriorly and the clavicle inferiorly

•      Region VI:

–    Anterior compartment, lymph nodes surrounding the midline visceral structures that extend from the hyoid bone superiorly to the suprasternal notch inferiorly

–    The lateral boundary is the medial border of the carotid sheath

–    Perithyroid, paratracheal, and lymph nodes around the recurrent laryngeal nerve


•             The RND is classified according to the Academy’s Committee for Head & Neck Surgery & Oncology into four major type:

–          Radical Neck Dissection    (RND)

–          Modified Radical Neck Dissection (MRND)

–          Selective Neck Dissection (SND)

–         Supraomohyoid

–         Posterolateral

–         Lateral

–         Anterior

–          Extended Radical Neck Dissection (ERND)

•      Radical neck Dissection:

–    Removing all lymphatic tissues in regions I – V and include removal of SAN, SCM and IJV

•      Modified radical neck dissection:

–    Excision of all lymph nodes removed with RND with preservation of one or more non-lymphatic structures, SAN, SCM and/or IJV

•    Subtype I: Preserve SAN

•    Subtype II: Preserve SAN & SJV

•    Subtype III: preserve SAN, SJV and SCM

–   Known as Functional neck dissection (Bocca)

•      Selective Neck dissection:

–   Any type of cervical lymphadenectomy with preservation of one or more lymph node groups

–   Four subtype:

•   Supraomohyoid neck dissection

•   Posterolateral neck dissection

•   Lateral neck dissection

•   Anterior neck dissection

–    Supraomohyoid neck dissection:

•    Removal of lymph nodes in regions I –III

•    The posterior limit is the cutaneous branches of the cervical plexus and posterior border of SCM

•    The inferior limit is the superior belly of the omohyoid where it cross IJN

–    Posterolateral neck dissection

•    Removal of suboccipital, retroauricular, levels II – V and level V

•    Subtyped I – III depending on the preservation of SAN, IJV and /or SCM

Lateral neck dissection:

•   Remove lymph nodes in levels II – IV

–   Anterior neck dissection:

•   Require the removal of the lymph nodes surrounding the visceral structure in the anterior aspect of the neck, level VI

•   Superior limit, hyoid bone

•   Inferior limit, suprasternal notch

•   Laterally, the carotid sheath

•      Extended neck dissection:

–   Any previous dissection and including one or more additional lymph node groups and/or non-lymphatic tissues


•      General nodal metastasis produce the following fact:

–   The most important factor in prognosis of SCC of the upper aero-digestive tract is the status of cervical lymph nodes

–   Cure rate drops 50% with involvement of the regional lymph nodes

Indications For ND

•      Radical neck dissection was believed by Martin to be the only method to control cervical lymphadenectomy

•      Anderson found that preservation of SAN did not change the survival or tumor control in the neck

–    Actual 5-year survival and neck failure rate is:

•    RND:     63% and 12 %

•    MRND: 71% and 12%

•             Radical Neck Dissection

•           Multiple clinically obvious cervical lymph node metastasis particularly of posterior triangle and closely related to SAN

•           Large metastatic tumor mass or multiple matted in upper part of the neck

•          Tumor should not be dissected to preserve  Structures

•             Modified radical neck dissection


–         MRND Type I:

•         Clinically obvious neck lymph nodes metastasis and SAN not involved by tumor

•         Intraoperative decision just like preservation of the facial nerve in parotid surgery

•             MRND Type II:

–          Rarely planned

•           Intra-operative decision for tumor found adherent to SCM but away from SAN & IJV

•             MRND Type III:

–          Depend on the autopsy reports

•          Lymph nodes were in the fibrofatty and do not share the same adventitia with blood vessels

•          They are not found within the aponeurosis or glandular capsule of the submandibular “Functional neck dissection”

•      MRND Type III:

–   For treatment of N0 neck nodes

–   Indicated for N1 mobile nodes and not greater than 2.5 – 3.0 cm

•   Contra-indicated in the presence of node fixation

•   Result is difficult to interpret because of the use of radiation therapy

•      Selective/elective neck dissection:

–    For treatment of N0 neck nodes

–    For N+ nodes when combined with radiotherapy

•    Adjuvant radiotherapy for patient with 2 – 4 positive nodes or extra-capsular spread

–    Supraomohyoid is indicated for SCC of oral cavity with N0 and N1 with palpable mobile nodes less than 3 cm and located in level I and II

–    Upgrade intra-operatively following positive frozen section

Treatment option for N0 nodes

•      Observe

•      Radiation therapy

•      Elective neck dissection

–   Low morbidity

–   Staging neck for possible extended surgery

–   Need for post-operative radiotherapy

Rationale for S/END

•      Rate of occult metastasis in clinically negative nodes is 20 – 30% using clinical and radiographic findings

–   Ct scan combined with physical exam decreased the rate of occult metastasis to 12%

–   This suggested lowering of the criteria for elective neck dissection

                                Friedman et al Laryngoscope 100; 54 – 59: 1990

•      Anatomic studies showed that lymphatic drainage from the mucosal surfaces follow a constant and predictable route

•      Lymph flow from SA chain to the jugular chain is unilateral

•      Shah, in his study produced a compelling evidence of predictable nodal metastasis from SCC from upper aerodigastive tract

–    He found a specific pattern for nodal spread by location of primary

•   NO in patients with oral cavity SCC:

–    7/1119 (3.5%) had nodal involvement outside supraomohyoid dissection

–   3 (1.5%) had isolated involvement outside level I – III

–    N+ nodes in patients with oral SCC:

•    50/246 had nodal metastasis outside level IV

•    10/246 had metastasis in level V

–    He examined nodal involvement in patients with nasopharynx and other upper parts of the aerodigastive tract

•      Conclusion:

–    SCC of the oral cavity:

•    Level I, II and III are at risk

–    SCC nasopharynx and larynx

•    Level II, III and IV are at risk

•      Byers stated that SND combined with postoperative radiotherapy in selected patients with oral cavity SCC was adequate treatment with similar recurrence rate as those treated with MRND III

•      Spiro reported 12% with supraomohyoid dissection in N1 nodes but not all of them received radiotherapy

Selective/Elective Neck Dissection

•      A good option for N0 neck

•      Not a suitable option for N+ neck

•      Is used N+ neck when combined with radiotherapy

•      Intra-operative frozen section evaluation is needed to confirm in cases of intraoperative palpable nodes

The anatomy

•      Skin:

–    Blood supply:

•    Descending branches:

–   The facial

–   The submental

–   Occipital

•    Ascending branches

–   Transverse cervical

–   Suprascapular

–    The branches perforate the platysma muscle, anastomose to form superficial vertically-directed network of vessels

•      Skin incision is superiorly based apron-like incision from mastoid to mentum or to contralateral mastoid

•      Platysma muscle:

–    Wide, quadrangular sheet-like muscle

–    Run obliquely from the upper part of the chest to lower face

–    Skin flap is raised immediately deep to the muscle

–    The posterior border is over or just anterior to IJV and great auricular nerve

–    Does not cover the inferior part of the anterior triangle and the posterolateral neck

•      Sternocleidomastoid muscle: SCM

–   Differentiated from the platysma by the direction of its fibres

–   Crossed by the IJV and the great auricular nerve from inferior to posterior deep to platysma

–   The posterior border represent the posterior boundary of nodes level II – IV

•      Marginal Mandibular nerve: MMN

–   Located 1 cm in front of and below   the angle of the mandible

–   Deep to the superficial layer of the deep cervical fascia

–   Superficial to adventitia of the anterior facial vein

•      Spinal Accessory nerve: SAN

–    Emerge from the jugular foramen medial to the digastric and stylohyoid muscles and lateral and posterior to IJV (30% medial to the vein and in 3 -5% split the nerve)

–    It passes obliquely downward and backward to reach the medial surface of the SCM near the junction of its superior and middle thirds, Erb’s point

•      Trapezius muscle:

–   Its anterior border is the posterior boundary of level V

–   Difficult to identify because of its superficial position

–   Dissect superficial to the fascia in order to preserve the cervical nerves

•      Digastric Muscle; Posterior belly:

–   Originate from a groove in the mastoid process, digastric ridge

–   The marginal mandibular nerve lie superficial

–   The external and internal carotid artery, hypoglossal and 11th cranial nerves and the IJV lie medial

•      Omohyoid muscle:

–   Made of two bellies, and is the anatomic separation of nodal levels III and IV

–   The posterior belly is superficial to the brachial plexus, phrenic nerve and transverse cervical artery and vein

–   The anterior belly is superficial to the IJV

•      Brachial Plexus & Phrenic nerve:

–   The plexus exit between the anterior and middle scalene muscles, pass inferiorly deep to the clavicle under the posterior belly of the omohyoid

–   The phrenic nerve lie on top of the anterior scalene muscle and receive it is cervical supply from C3 – C5

•      Thoracic duct:

–   Located in the lower let neck posterior to the jugular vein and anterior to phrenic nerve and transverse cervical artery

–   Have a very thin wall and should be handled gently to avoid avulsion or tear leading to chyle leak

•      Exit via the hypoglossal canal near the jugular foramen

•      Passes deep to the IJV and over the ICA and ECA and then deep and inferior to the digastric muscle and enveloped by a venous plexus, the ranine veins

•      Pass deep to the fascia of the floor of the submandibular triangle before entering  the tongue


•      Unified classification is relatively new

•      Indication and the type of ND, specially for N0, is controversial

•      The following surgical outline was suggested:

–    SCC oral cavity anterior to circumvalate papilla

•    Supraomohyoid

–    SCC Oropharynx, larynx and hypopharynx

•    level I- IV or level II-V

–    SCC with N+ nodes

•    RND

–    SCC with 2-4 positive nodes or extracapsular spread

•    RND and adjuvant therapy

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