NECK 4 CLASS 13 06102015 SECONDARIES IN NECK

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NECK 4 CLASS 13 06/10/2015

NECK 4 CLASS 13 06/10/2015

SECONDARIES IN NECK LYMPH NODES Level I—Submental (Ia) and submandibular (Ib) lymph nodes. Level

SECONDARIES IN NECK LYMPH NODES Level I—Submental (Ia) and submandibular (Ib) lymph nodes. Level II—Lymph nodes in upper deep cervical region. (It extends from base of skull to hyoid bone and from lateral margin of sternothyroid to posterior margin of sternomastoid muscle. ) Level III—Lymph nodes in middle cervical region (from hyoid bone to omohyoid muscle or cricothyroid membrane). Level IV—Lymph nodes in lower cervical region (from omohyoid muscle to clavicle).

 Level V—Lymph nodes in posterior triangle including supraclavicular region. Level VI—Lymph nodes in

Level V—Lymph nodes in posterior triangle including supraclavicular region. Level VI—Lymph nodes in the midline neck—pretracheal and prelaryngeal. Level VII—Lymph nodes in the mediastinum.

 Common sites of primary 1. Oral cavity, tongue, tonsils 2. Salivary glands 3.

Common sites of primary 1. Oral cavity, tongue, tonsils 2. Salivary glands 3. Pharynx – nasopharynx 4. Larynx 5. Oesophagus 6. Lungs 7. GIT 8. Thyroid

 It is commonly from squamous cell carcinoma, but can also be from adenocarcinoma

It is commonly from squamous cell carcinoma, but can also be from adenocarcinoma or melanoma. Squamous cell carcinoma is mainly from oral cavity, pharynx. Adenocarcinoma is usually from GIT, commonly involving left supraclavicular lymph nodes.

Features Common in elderly male Painless rapidly increasing localised swelling in the neck. Nodular

Features Common in elderly male Painless rapidly increasing localised swelling in the neck. Nodular surface and hard in consistency, often fixed when it is advanced. Secondaries from papillary carcinoma of thyroid can be soft, cystic with brownish black fluid. .

 Can infiltrate into carotids, sternomastoid, posterior vertebral muscles, spinal accessory nerve (shrugging of

Can infiltrate into carotids, sternomastoid, posterior vertebral muscles, spinal accessory nerve (shrugging of shoulder is affected), hypoglossal nerve (tongue will deviate towards the same side), cervical sympathetic chain (Horner’s syndrome). Spread into adjacent soft tissues and also to the skin causing fungation and ulceration. Skin fold prominence due to infiltration of the platysma is typical.

 Types of Secondaries in the Neck 1. Secondaries in the neck with known

Types of Secondaries in the Neck 1. Secondaries in the neck with known primary Here secondaries are present and primary has been identified clinically. Biopsy from the primary and FNAC from the secondaries are done. Primary is treated accordingly either by curative radiotherapy or by surgery (wide excision). Secondaries, when mobile are treated by radical lymph node block dissection in the neck.

2. Secondaries in the neck with clinically unidentified primary FNAC of the neck node

2. Secondaries in the neck with clinically unidentified primary FNAC of the neck node is done and secondaries is confirmed. Then search for the primary is done by various investigations. They are a. Nasopharyngoscopy. b. Laryngoscopy. c. Oesophagoscopy.

d. Bronchoscopy. e. Blind biopsies from the fossa of Rosenmuller, lateral wall of pharynx,

d. Bronchoscopy. e. Blind biopsies from the fossa of Rosenmuller, lateral wall of pharynx, pyriform fossa, larynx. f. FNAC of thyroid and suspected areas. g. CT scan. Once the biopsy confirms the primary, it is treated either by surgery or by curative radiotherapy. Secondaries in the neck is treated by radical neck dissection.

3. Secondaries in the neck with an occult primary Occult primary sites which can

3. Secondaries in the neck with an occult primary Occult primary sites which can cause secondaries in neck. Fossa of Rosenmuller Lateral wall of pharynx Posterior third of the tongue Thyroid Paranasal sinuses Bronchus Oesophagus

 Histologically -- squamous cell carcinoma or adenocarcinoma /poorly differentiated tumours (lymphoma/sarcoma/melanoma). In upper

Histologically -- squamous cell carcinoma or adenocarcinoma /poorly differentiated tumours (lymphoma/sarcoma/melanoma). In upper and mid cervical region 80% are due to squamous cell carcinomas. In lower cervical and supraclavicular region 40 % can be adenocarcinomas. Common sites of primary here (for adenocarcinoma) are thyroid, breast, gastrointestinal tract, salivary glands, lungs, prostate and kidney.

 70% of occult nodes occur in jugulodigastric group. Differential diagnosis for secondary with

70% of occult nodes occur in jugulodigastric group. Differential diagnosis for secondary with occult primary is lymphoma and primary branchiogenic carcinoma. Reasons for primary lesion being occult – Too small a primary to detect; possibility of immunological spontaneous regression of primary and inability of the present diagnostic tools to detect the primary.

 FNAC is the tool to confirm the occult secondary. If FNAC is inconclusive,

FNAC is the tool to confirm the occult secondary. If FNAC is inconclusive, only then open biopsy (incision/excision) is done to confirm. Open biopsy helps in high suspects of lymphomas or poorly differentiated carcinomas. It facilitates tissue study, immunohistochemistry, and special stains.

 Immunoperoxidase staining is the most commonly used tool. Electron microscopy Chromosomal analysis Initially

Immunoperoxidase staining is the most commonly used tool. Electron microscopy Chromosomal analysis Initially the secondaries in the neck are treated by modified radical neck dissection, then regular follow-up is done (at three monthly intervals) until the primary reveals.

 Once primary is revealed it is confirmed by biopsy and treated accordingly, either

Once primary is revealed it is confirmed by biopsy and treated accordingly, either by curative radiotherapy or by wide excision depending on location of revealed primary. This type is usually less aggressive and has got better prognosis. Nodal staging in secondaries N 0—nodes not detected N 1—single node same side < 3 cm N 2 a—single node same side 3 -6 cm N 2 b—multiple nodes same side < 6 cm N 2 c—bilateral/contralateral nodes < 6 cm N 3—node > 6 cm

 Investigations for Secondaries in Neck 1. FNAC of secondary. 2. Biopsy from primary.

Investigations for Secondaries in Neck 1. FNAC of secondary. 2. Biopsy from primary. 3. Blind biopsies from suspected areas. 4. Nasopharyngoscopy, laryngoscopy, bronchoscopy, oesophagoscopy.

5. CT scan is to see the base of skull, paranasal sinuses, nasopharynx, extension

5. CT scan is to see the base of skull, paranasal sinuses, nasopharynx, extension of primary tumour/ secondary deposits; CT scan of chest and abdomen. 6. Chest X-ray to visualise primary or secondaries in case melanomas or mediastinal nodes. 7. MRI scan or PET scan in conjunction with CT scan or MRI.

Differential Diagnosis 1. Lymphomas. 2. Tuberculous lymphadenitis. 3. Non-specific lymphadenitis. 4. HIV. 5. Chronic

Differential Diagnosis 1. Lymphomas. 2. Tuberculous lymphadenitis. 3. Non-specific lymphadenitis. 4. HIV. 5. Chronic lymphatic leukaemia.

Treatment Primary is treated depending on the site, either by wide excision (surgery) or

Treatment Primary is treated depending on the site, either by wide excision (surgery) or by curative radiotherapy. Then the secondaries are treated. Secondaries when mobile, are treated by radical neck dissection. When fixed it is inoperable.

 Palliative external radiotherapy is given to palliate pain and to prevent the anticipated

Palliative external radiotherapy is given to palliate pain and to prevent the anticipated bleeding. Sometimes initially, external radiotherapy is given to downstage the disease so that it becomes operable and later classical block dissection can be done.

Types of Block Dissection: 1. Classic radical neck dissection Mac fee incision for radical

Types of Block Dissection: 1. Classic radical neck dissection Mac fee incision for radical neck dissection.

 It is resection of Lymph nodes (level I to V), Fat, fascia, Sternomastoid

It is resection of Lymph nodes (level I to V), Fat, fascia, Sternomastoid muscle, omohyoid muscle, Internal jugular vein, external jugular vein, Accessory nerve, Submandibular salivary gland, lower part of parotid, prevertebral fascia —“en-block”(criles’ operation).

2. Conservative functional block dissection (Modified radical neck dissection—MRND) It is done only in

2. Conservative functional block dissection (Modified radical neck dissection—MRND) It is done only in selected cases where tumour is very welldifferentiated and less aggressive like in papillary carcinoma of thyroid with lymph node secondaries. Structures preserved here are sternomastoid muscle, internal jugular vein and spinal accessory nerve.

 Only spinal accessory nerve is preserved —MRND type I (most important). Accessory nerve

Only spinal accessory nerve is preserved —MRND type I (most important). Accessory nerve and sternocleidomastoid are preserved—-MRND type II. Accessory nerve, sternomastoid and internal jugular veins are preserved—MRND type III.

3. Supraomohyoid block Removal of only fat, fascia, lymph nodes, muscles, submandibular salivary gland,

3. Supraomohyoid block Removal of only fat, fascia, lymph nodes, muscles, submandibular salivary gland, with dissection above the omohyoid muscle is done. Done only in selected individuals with well-differentiated tumour and involvement of few submandibular lymph nodes. (Levels I, III are removed). Done in N 0 lesions.

4. Bilateral neck dissection Here internal jugular vein is preserved on one side. Always

4. Bilateral neck dissection Here internal jugular vein is preserved on one side. Always the side where the vein is preserved, is operated first. The patient is kept in propped-up position; antibiotics, diuretics, steroids are given, repeated CSF taps are done to control the cerebral oedema.

5. Commando operation: It is en-block removal, which includes wide excision of primary tumour

5. Commando operation: It is en-block removal, which includes wide excision of primary tumour wit hemimandibulectomy and neck block dissection, e. g. in tongue. 6. Lateral neck dissection (anterolateral/jugular/ ALND) It is done in laryngeal and pharyngeal primaries with clinically negative nodes. Levels II, IV are removed bilaterally. 7. Anterior (central) dissection Level VI (pre, paratracheal) nodes are removed.

8. Postero-lateral dissection Levels II, IV, V are removed for cutaneous malignancies, with suboccipital

8. Postero-lateral dissection Levels II, IV, V are removed for cutaneous malignancies, with suboccipital nodes. 9. Extended radical dissection Additional nodes in the mediastinum are cleared (level VII). Nodes like level VI or parapharyngeal, retropharyngeal, external carotid artery, hypoglossal nerve, parotid gland, mastoid tip—are addressed.

Complications of block dissection 1. Haemorrhage 2. Infection 3. Lymph ooze 4. Carotid blow

Complications of block dissection 1. Haemorrhage 2. Infection 3. Lymph ooze 4. Carotid blow out 5. Seroma and flap necrosis 6. Frozen shoulder is common 7. Rarely pneumothorax and chylous fistula 8. Drooping of shoulder due to paralysis of trapezius in radical neck dissection.

 CHEMOTHERAPY FOR HEAD AND NECK CANCERS Methotrexate – 40 mg/m 2 IV weekly.

CHEMOTHERAPY FOR HEAD AND NECK CANCERS Methotrexate – 40 mg/m 2 IV weekly. 5 - Fluorouracil – 10 -15 mg/m 2 IV daily for 5 days. Bleomycin – 10 -20 mg/m 2 IV weekly. Vincristine – 1 -2 mg/m 2 IV monthly.

 Cisplatin – 80 -120 mg/m 2 IV infusion once in 3 Weeks. Cyclophosphamide

Cisplatin – 80 -120 mg/m 2 IV infusion once in 3 Weeks. Cyclophosphamide – 60 -120 mg/m 2 IV for 5 days at regular 3 weeks cycles. Adriamycin – 60 -90 mg/m 2 IV. Paclitaxel and carboplatin

Mode of Administration It can be given by intra-arterial route, through external carotid artery.

Mode of Administration It can be given by intra-arterial route, through external carotid artery. Site of arterial catheter should be confirmed by Doppler or angiogram. Drug is usually administered through an arterial pump. Other method is to increase the height of the drip stand to get a pressure above the level of the systolic pressure of the patient. (i. e. more than 13 ft). Drugs can also be given intravenously or orally (methotrexate).

RULE OF 80 IN THE NECK • 80% of nonthyroid neck masses are neoplastic

RULE OF 80 IN THE NECK • 80% of nonthyroid neck masses are neoplastic • 80% of neoplastic neck masses are seen in males • 80% of neoplastic neck masses are malignant • 80% of malignant neck masses are metastatic • 80% of metastatic neck masses are from primary sites above the clavicle