Selective neck dissection (i iii) for node /certified fixed orthodontic courses by Indian dental academy

SELECTIVE NECK DISSECTION
(I-III) FOR NODE NEG AND
NODE POSITIVE NECKS

INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


INTRODUCTION
 Oral cancer accounts for 10.7% of all the solid tumors
in males & 5.4% in females in Mumbai.
 Unlike the western world gingivobuccal complex is the
commonest oral subsite involved in our study group
because of the use of smokeless tobacco
 These tumours show early bone invasion and the
cervical node metastasis takes place late.
 Even in T3 & T4 tumors less than half the tumors have
nodal metastasis ,The nodal metastasis in the oral
cancer follows a fairly predictable pattern with levels I
II III being most commonly involved.

PATIENTS & METHODS
 The study was performed on 398pts,297
males & 101 females (3:1).In 24-83yrs age
range (mean52.6yrs).
 Pts were called for follow up examination at
3month interval for 2yrs ,at 6months
interval for 3yrs and yearly thereafter.
 Any regional failure was documented in
terms of its location and salvage treatment.

RESULTS
SITE

NO (%)

Buccal mucosa

229 (58%)

Lower alveolus

84 (21%)

Tongue

61 (15%)

Retromolar trigone

15 (4%)

Floor of the mouth

9 (2%)

Total

398 (100%)

 GB complex was commenest site of primary tumor in
79% .
 SOHND was performed for clinically node –ve neck in
259 (65%) pts and rest had palpable nodes .
 Clinically 118 (30%) had N1 and 21 (5%) had N2
disease.
 However histologically only52 (13%) showed +ve
nodes.In 11 %(28/259) which are clinically No was
upstaged as node +ve and only17% (24/139) of
clinically +ve necks were actually histologically +ve.


 As expected in GB cancer level I was the
most commonest site 38 (9.5%) followed by
level II 23 (6%) ,level III 6 (1.3%).
 Isolated level I involvement was seen in
54% of node +ve neck. Skip metastasis to
Level II,III was seen only in 12 (3%) cases.
 Of all node +ve cases ,extracapsular spread
of the disease is seen in 19 (5%).
 132 (33%) had well differentiated
tumour,228(57%) moderately diff,38 (10%)
had poorly diff.


 Out of 52,42(81%) had radiation .In addition 12(3%)
pts had received prior radiotherapy and 7(2%) had
prior chemotherapy before their first visit.
 During follow-up 114 recurrences were observed in 93
(23%)pts and 7 (2%) pts had a secondary primary
tumor.
 Of 114 recurrences 80(70%) were local site failures ,
23(20%) neck failure and 2 (2%) distant mets. to lungs
and skeleton.
 At the time of last follow-up 316(80%) were disease
free,69(17%) were alive with unsalvageable disease
and 13 (3%) were dead because of unrelated cause.

 Two yr and five yr disease free survival rates were 80%
& 69%

REGIONAL FAILURE
 Of 23 pure regional recurrences 19( 83%) were
ipsilateral and 4 (17%) were contra lateral .
 Of 19,16 (84%) were with in the field of dissection at
the ipsilateral levels I II III, of these 4.8% were
identified at 2yrs and 5.8% at 5 yrs. Another 5pts
failed in neck after successful salvage of a prior local
recurrence
 Thus overall neck failure were seen in 5% at 2yrs and
8% at 5yrs.Neck failure rates were similar for node
+ve (5.8%) and node –ve neck (5.5%).


 However, node positivity and presence of and extra
capsular spread of nodal disease did not have
significant impact on the regional failure, possibly
because of the use of adjuvant radiotherapy in all these
pts.
 7/167 (4.2%) pts who received radiation failed in neck
as compared to 15/231 (6.5%) of those who did not
receive it.
 These failure pts were treated with neck dissections,
radiation and chemotherapy .
 At the time of last follow only 4pts who developed
regional failure were alive and free of disease following
salvage treatment.

DISCUSSION


Gingivobuccal sulcus being the most common SCC had
nodal mets. Only in 46% of cases even in T3 & T4 stages.



Comprehensive neck dissection has been a standard
treatment for metastatic neck nodes but various studies
have shown its morbidity to be significantly higher than that
of selective neck dissection.



Pinoselle et all found considerable shoulder dysfunction in
radical (51%) ,functional (34%),SOND 7%.



Pts undergoing MRND are reported to have significantly
worse shoulder dysfunction than the pts with SND.



SOHND is a recommended procedure for node –ve neck and
for selected node +ve neck with limited nodal disease.



Medina et all reported 5% failure in node –ve neck,10% in
single node with out extra capsular spread ,24% in multiple
nodes or nodes with extra capsular spread without
postoperative radiotherapy and 15% with post operative
radiotherapy.



In this study there was no significant difference in the regional
failures in path. Node +ve (5.8%) and node –ve (5.5%)



Adjuvant radiotherapy has been shown to have significant
influence in reducing neck failure.



In this study the diff in neck failures between radiotherapy
treated and untreated was not significant (4.2% & 6.5%), this
difference was not significant even on subset analysis in both
n0 and n+ groups.



This suggests that SND (I-III) is adequate treatment for nodeve and even selected node +ve pts in in judicious combination
with radiotherapy.


 In GB cancers the incidence of pure regional failure (
primary controlled) were reported from this institution
as 3% with RND ,12% with suprahyoid and 5% with
SOHND in pts with N-O necks
 In N +ve category RND 18% supra hyoid 34% and
SOHND 19% .
 Recurrence after SOHND can be either in the field of
dissection or out of the field.carvalho et al found 57.1%
of them inside the limits of dissection .in this study it is
70%
 These guys found out the grade of tumor differentiation
to be the most significant predictor of nodal failure,
site of the primary tumor seemed to be an independent
factor influencing neck failure .


 At the end of 5yr followup the GB
cancer had 6.5% regional failure as
compared to 12.3% for tongue
cancers. This trend Reiterates the
observation that oral cancers per se
are a diverse group of tumors and
individual subsides behave differently
from one another.


CONCLUSION
 SND (I II III ) is an oncologically
sound procedure for node –ve and a
for a select group of low volume node
+ve. Oral cancer in general and GB
cancer in particular.
 It meets the combined goal of
optimal neck treatment with minimal
morbidity.

Thank you
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Selective neck dissection (i iii) for node /certified fixed orthodontic courses by Indian dental academy

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