The surgical removal of selected cervical lymph nodes is a fundamental aspect of head and neck oncology that has evolved over the last 25 years. Prior to this time, the radical neck dissection stood as the standard of care for patients undergoing surgery on the neck for cancer. Dr. Robbins has been a leader in this evolution, and the views expressed in his article are widely accepted in the field.
In his article, Dr. Robbins presents valuable insights into surgical techniques and sound conclusions regarding their use, which are supported by a thorough review of the available literature. In addition, Dr. Robbins appropriately points out that some controversy remains in the application of these techniques, especially in the treatment of patients who have enlarged lymph nodes at the time of surgery. This controversy is due to the fact that there has never been, nor is there ever likely to be, a definitive randomized clinical trial comparing the results of various newer techniques with each other or with the radical neck dissection.
Evolution of the Radical Neck Dissection
Some background regarding the radical neck dissection may enhance the reader’s understanding of the role of the selective techniques discussed by Dr. Robbins. The radical neck dissection was originally described by George Crile Sr in 1906. He advocated the “block” removal of all ipsilateral cervical lymph nodes along with the sternocleidomastoid muscle, the jugular vein, the spinal accessory nerve, and the submandibular gland. In support of the concept, he referred to the techniques of William Halstead for the surgical treatment of breast cancer. Apropos to the subject at hand, Dr. Crile’s report advised a complete block procedure for patients presenting with palpable lymph nodes, and removal of only “the regional glands that are known to drain the field of the original focus” in cases where there were no palpable nodes.
The technique of radical neck dissection was standardized by Hayes Martin, who educated many head and neck surgeons of the next generation. Dr. Martin’s opus on the subject, which, in 1951, occupied 57 pages in the journal Cancer, described his experience with 599 patients. He advised against performing “prophylactic” neck surgery when lymph nodes were not enlarged, and advocated the complete en bloc procedure for patients with palpable nodes. His influence was such that the radical neck dissection technique was zealously adhered to for many years. It is interesting to note that neither of these surgical “giants” advocated the use of radical neck dissection for patients who presented without palpable lymph nodes.
As a standard of comparison, the radical neck dissection is a thorough and reproducible surgical procedure. However, the results achieved with regard to regional cancer control are not especially good—unless radiation therapy is added either before or after surgery. In a paper published in 1969, Elliot Strong demonstrated a regional recurrence rate of 54% in 129 patients who underwent radical neck dissection, and who were found to have positive nodes in their specimen. Delivery of low-dose, preoperative radiation decreased the recurrence rate to 34% in a similar group of 104 patients treated concurrently. Delivery of a higher dose of radiation within 6 weeks following surgery was later shown to nearly eliminate regional recurrence following radical neck dissection.
In short, these studies showed that the “radical” technique sacrifices an extensive amount of useful tissue to achieve an en bloc resection of all cervical nodes, yet it does not stand alone successfully as a treatment modality for patients who need it most. At the time, it certainly made sense to explore the development of procedures aimed at conservation of tissue and function.
Rationale for Selective Neck Dissection
Dr. Robbins does an excellent job of defining the rationale for selective neck dissection and summarizing the work of the innovative surgeons who advocated this change in surgical practice. His approach of focusing on the primary site to describe the when, how, and why of selective neck dissection, rather than focusing on a specific type of selective procedure, is relatively novel and especially useful. From this discussion, it seems clear that selective neck dissection has become an accepted standard of care for surgical patients who have:
(1) no palpable nodes, but a primary tumor that is associated with a high likelihood of occult cervical node metastases;
(2) no palpable nodes, whereby the surgeon will focus on exposure to the neck to safely and effectively remove the primary tumor; or
(3) a palpable node or nodes at a single level within the neck.
In these three circumstances, sparing normal tissue that would otherwise be removed by a radical neck dissection has been a major advance for our patients. On the other hand, the efficacy of selective neck dissection has not yet been validated for surgical patients who present with bulky disease at more than one level in the neck, and for patients who undergo planned neck dissection after radiation therapy alone or in combination with chemotherapy for advanced neck disease. In these situations, it seems appropriate to offer the patient an informed choice and to err on the side of the more complete procedure for patients who prefer to trust their surgeon’s judgment.
Finally, Dr. Robbin’s excellent article provides us with a snapshot of the current status of this evolving field of surgical practice. As always, many questions remain to be answered by surgeons of today and tomorrow.