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Wednesday, April 4, 2012

An Introduction to Brain Cancer

Significance
The brain is the center of thoughts, emotions, memory and speech.
Brain also control muscle movements and interpretation of sensory information (sight, sound, touch, taste, pain etc)
Tumors can effect any part of the brain and depending on what part(s) of the brain it affects can have a number of symptoms.
  • Seizures
  • Difficulty with language
  • Mood changes
  • Change of personality
  • Changes in vision, hearing, and sensation.
  • Difficulty with muscle movement
  • Difficulty with coordination control


Background
  • Estimated 18,400 primary malignant brain tumors will be diagnosed in 2004 —10,540 in men & 7,860 in women.
  • Approximately 12,690 people will die from these tumors in 2004.
  • Accounts for  1.4% of all cancers
  • Accounts for 2.4% of all cancer  related deaths
  • In adults over 45 years of age 90% of all brain tumors are Gliomas 
Gliomas: A general category of cancer that includes astrocytomas, oligodendrogliomas, and ependymomas

Astrocytoma
  • Astrocytes brain cells abnormally dividing causing tumors called astrocytomas.
  • Astrocytes are glial cells that help nourish neurons– they help repair damage
  • How the astroytomas are classified
o   How close the cells are together within the tumor
o   How abnormal the cells are
o   How many of the cells are proliferating
o   Whether or not there are blood vessels growing near the tumor
o   Whether or not some of the cancer cells have degenerated or not

Astrocytomas--Treatments
  • If tumors have not infiltrated normal brain tissue then surgery can be a cure
  • Low-grade Astrocytomas are not curable by surgery.  However through surgery as much of the tumor as possible is removed and then the patient usually goes through radiation treatment.
  • High-grade Astrocytomas are not curable by surgery.  After surgery has removed as much of the tumor as possible the patient can go through radiation treatment and chemotherapy.
  • Most common drug given to these patients after chemotherapy is BCN
Oligodendrogliomas
  • These tumors start in mutated oligodendrocyte brain cells
  • Oligodendrocytes make myelin which help neurons transmit signals through the axons
  • These tumors may spread through cerebrospinal fluid pathways but typically do not usually spread to locations outside of the brain or spinal cord.
Oligodendrogliomas-Treatments
  • Because these tumors infiltrate normal brain tissue these tumors are not cured through surgery.  However removal of part of the tumors can relieve some symptoms and prolong life.
  • If the tumor is causing disabilities to the patient after surgery the patient may go through chemotherapy, perhaps followed by radiation treatments.
Ependymomas
  • Mutated ependymal cells
  • Ependymal cells line the ventricles in the central area of the brain and they line part of the pathway through which the cerebrospinal fluid travels
  • Theses mutated cells may block the cerebrospinal fluid from exiting the ventricles causing the ventricles to enlarge (hydrocephalus)
Ependymomas-Treatments
  • These tumors do not usually infiltrate normal brain tissue and are therefore curable through surgery.
  • If surgery is unable to completely remove the tumors the patient may try radiation therapy.
Diagnosis
  • These tumors can be detected through a MRI, CT scan or a PET scan.
  • Once detected, depending on where the tumor is located, a biopsy officially is used to diagnosis cancer.

Risk Factors

Most brain cancers happen for reasons unknown, however some small risk factors are
  • Radiation exposure
  • Exposure to vinyl chloride
  • Immune system disorders

Prognosis
  • For people ages 15-44 five year survival rate is 55%
  • For people ages 45-64 five year survival rate is 16%
  • For people over 65 five year survival rate is 5%

Friday, October 28, 2011

Basal Cell Carcinoma Lecture note with Video

Basal cell carcinoma
  • The most common cancer affecting humans
  • Slow growing
  • At least 75% first tumours are on the face
  • Relatively ‘benign’ in most cases – but if left untreated can be disfiguring and life threatening


Aetiology and epidemiology
  • The most important risk factor is solar ultraviolet radiation
  • Type 1 skin
  • Episodes of painful sunburn in early life
  • Mechanism of injury by UV radiation is complex: direct DNA damage
  • damage to repair mechanisms
  • immune dysregulation
  • mutations in p53 suppressor genes
Types of BCC-Nodular
  • Usually begin as a small pink ‘pearly’ papule
  • Develop a depression in the centre
  • Rolled edge
  • Overlying telangiectasia
 

Types of BCC-Superficial
  • Usually found on the trunk
  • May be multiple
  • Flat red patches
  • Usually have typical beaded edge
 

Types of BCC-Morphoeic
  • White or waxy
  • Always on face
  • Presents as a spontaneous ‘scar’
  • Margins are usually much wider than what is clinically visible
 

Types of bcc -Multifocal
  • Bowenoid – usually found on lower legs of women with sun damaged skin. Diagnosis by biopsy
  • Poorly differentiated


Differential diagnosis
  1. Cyst
  2. Infected spot
  3. Sebaceous hyperplasia
  4. Naevus
  5. Molluscum contagiosum
  6. Wart
  7. Bowens disease
  8. Tinea
  9. Eczema/psoriasis
  10. Malignant melanoma
  11. Seborrhoeic keratosis
  12. Erosions and leg ulcers
Management
  • Surgical excision – with 4mm margins – complete excision of 98% tumours less than 2cm in diameter
  • Moh’s micrographic surgery – immediate histological analysis. If residual tumour – further surgery. Ensures precise and conservative tumour removal. Usually reserved for high risk lesions – eyelids, nose, lips, ears. 5 year cure rate 99%
  • Photodynamic therapy
  • Radiation therapy
  • Topical therapy – imiquimod (aldara) – immune modulator
Follow up policy
  • Overall recurrence rate for BCC is around 5%
  • Thus patients are followed up for 2 years – at least 6 monthly
  • However risk of second primary – 5 years after excision 36% patients develop a second primary and 20% develop multiple new BCCs 

 

Thursday, October 27, 2011

Mediastinal Tumors

The Mediastinum

Anterior Superior 54%  
  • Thymus Gland
  • Aortic Arch
  • SVC Superior Vena Cava
  • Lymph Node
  • Parathyroid Gland
  • Ectopic Thyroid Tissue


Middle 20%
  • Pericardium
  • Heart
  • Great Vessels
  • Trachea
  • Trachea Bifurcation
  • Main Bronchi
  • Phrenic Nerve
  • Hilar Lymph Node
Posterior 26%   

  • Esophagus
  • Vagus nerves
  • Sympathetic Chain
  • Thoracic duct
  • Thoracic desending
  • Aorta
  • Azygos
  • Hemiazygosvein
  • Paravertebral Lymphnode          
Subdivision of mediastinum
as seen on cross section
  1. anterior mediastinum (1)
  2. middle mediastinum (2)
  3. posterior mediastinum (3) 
Children
  • Posterior Mediastinum
  • Most often benign
  • 2/3 of tumors symptomatic        

Adult
  • Anterior Mediastinum
  • Often Malignant
  • Ages 30 – 50
  • 1/3 of tumors are symptomatic
Malignancy        
  • All tumors 25% Per Section        
  • Anterior Superior 59%
  • Posterior 16%
  • Middle 16%

Etiology of Tumors

Lympathic tumors
  • 45% in Children Anterior
  • Adult Second more common anterior
  • Found in mediastinum
  • Immunoblastic T-cell
  • Immunoblastic B-cell
  • Follicular center cell
  • Lymphoblastic
  • Hodgkin Lymphoma (nodular sclerosing type)-
Malignant Tumors Invasion Structure
  • Tracheobronchial tree and lungs
  • Esophagus
  • Superior Vena Cava
  • Pleura and Chest Wall
  • Intrathoracic nerves
 Primary Mediastinal Tumors
  • 10% of mediastinal masses
  • Thymic carcinoma
  • Neuroendocrine carcinoma
  • Germ-cell tumors (GCT)
  • Lymphoma
  • Neurogenic tumors
  • Parathyroid Tumors
  • Mesenchymal Tumors
 Symptoms
  • Cough  
  • Shortness of Breath
  • Chest pain
  • Fever
  • Chills
  • Night Sweats
  • Hemoptysis
  • Hoarseness
Diagnostic
  • Chest X-Rays
  • CT ( Computed Tomography)
  • MRI
  • CT guided needle biopsy
  • Mediastinoscopy with biopsy
  • Radionuclide Scanning
 Treatment
  • Varies according location of tumors
  • Common is Surgical resection
  • Thymic Cancer – Surgery follow by radiation/or chemotherapy
  • Exception
  • Lymphatic Tumors
  • Mesenchimal  Tumors (Rhabdomyosarcoma) 
Prognosis
  • Varies depending on type of tumors and resection.
  • Benign tumors – excellent prognosis
  • Malignant tumors – depends on the type
Malignant Tumors Prognosis
  • Mediastinal Lymphoma
  • Malignant Mesenchymal Tumors
  • Mediastinal Parathyroid Carcinoma
  • Intrathoracic goiter with Occult Malignancy


Friday, October 14, 2011

Small Cell Carcinoma

Introduction
Lung cancer is a malignant tumor of the lungs. There are many types of lung cancer, but most can be categorized into two basic types, "small cell" and “non-small cell.”
Small cell lung cancer is generally faster growing than non-small cell, but more likely to respond to chemotherapy.

Definition
Small cell cancer is divided into "limited stage" (generally cancer confined to the chest) and "extensive stage" (cancer that has spread outside the chest).
Lung cancer begins in cells that line the airways and often invade adjacent tissues or spread elsewhere in the body before symptoms are noticed.

Small Cell Carcinoma

Lung Cancer from Smoking

Statistics
·         About 20% of all lung cancer cases are small cell lung cancer, meaning about 30,000 patients each year are diagnosed with this disease
·         At the time of diagnosis, approximately 30% of patients with small cell carcinoma will have tumor confined to the hemithorax of origin, the mediastinum, or the supraclavicular lymph nodes. These patients are designated as having limited stage disease, and most 2-year disease-free survivors come from this group.
·         In limited stage disease, median survival of 16 to 24 months with current forms of treatment can reasonably be expected. A small proportion of patients with limited stage disease may benefit from surgery with or without chemotherapy; these patients have an even better prognosis.
·         Government surveys show that as many as 3,000 people each year develop lung cancer from second-hand smoke.

Treatments
·         The treatment depends upon the stage of the cancer.
·         For small  cell cancer, chemotherapy and radiation are usually in the limited stage disease (when the disease is confined to the chest.)
·         Studies have shown that giving chemotherapy and radiation therapy at the same time is better than giving one after the other. Chemotherapy alone is used for extensive stage disease.
·         In some cases where a patient with limited stage disease has only one small tumor, the tumor will be surgically removed, followed by chemotherapy. However, very few patients with small cell lung cancer are candidates for surgery.
·         Some patients with limited stage disease may need radiation to the entire brain after they have completed chemotherapy and radiation to the chest. This is known as prophylactic cranial irradiation (PCI).
·         Because patients with small cell lung cancer tend to develop distant metastases, localized forms of treatment, such as surgical resection or radiation therapy, rarely produce long-term survival.
·         About 10% of the total population of patients remain free of disease over 2 years from the start of therapy, the time period during which most relapses occur.
·         However, even these patients are at risk of dying from lung cancer (both small and non-small cell types). The overall survival at 5 years is 5% to 10%

Symptoms
·         Cough
·         Bloody sputum
·         Shortness of breath
·         Wheezing
·         Chest Pain
·         Loss of Appetite
·         Weight  loss
·         Weakness
·         Swallowing difficulty
·         Nail abnormalities
·         Hoarseness or changing voice
·         Fever
·         Facial Swelling

Risks
·         Most lung cancers are caused by cigarette smoking.  The more cigarettes you smoke per day and the earlier you started smoking, the greater the risk of lung cancer.
·         Second-hand smoke increases the risk.
·         High levels of pollution, radiation, and asbestos exposure may also increase risk.

Prevention
If you smoke, stop smoking. Try t avoid second-hand smoke.
There is no evidence that screening for small cell lung cancer with chest X-rays, CT scans or other means is beneficial for patients at high risk of developing small cell lung cancer, and such screening is not recommended

Diagnosis & Tests
The doctor can sometimes detect fluid that has collected around the lungs from a cancer by listening to your chest with a stethoscope. 

Additional test would include:
Chest X-ray, CAT Scan of the chest, a PET scan, a needle biopsy, and more.

Prognosis (Expectations)
·         The overall survival depends on the stage of the disease. For limited stage small cell cancer, cure rates may be as high as 25%, while cure rates for extensive stage disease are less than 5%.
·         The early the better chances of survival
·         Patients with tumors that have spread beyond the supraclavicular areas are said to have extensive stage disease and have a worse prognosis than patients with limited stage disease. Median survival of 6 to 12 months is reported with currently available therapy, but long-term disease-free survival is rare.
·         The pretreatment prognostic factors which consistently predict for prolonged survival include good performance status, female gender, and limited stage disease. Patients with involvement of the central nervous system or liver at the time of diagnosis have a significantly worse outcome.
·         In general, patients who are confined to bed tolerate aggressive forms of treatment poorly, have increased morbidity, and rarely attain 2-year disease-free survival. However, patients with poor performance status can often derive significant palliative benefit and prolongation of survival from treatment

Conclusion
Small Cell Lung Cancer Complications
Spread of disease beyond the lung
Side effects of surgery, chemotherapy, or radiation therapy.

Additional Info
There is a large variety of Small Cell Lung Cancer Support Groups online.
Call your health care provider if you have risk factors for developing lung cancer, or you develop symptoms of lung cancer (particularly if you smoke).

Small cell carcinoma

Cervical Cancer

Cervix
·         Lower part of the uterus
·         Connects the body of the uterus to the vagina (birth canal)

Cervical Cancer
·         Begins in the lining of the cervix
·         Cells change from normal to pre-cancer (dysplasia) and then to cancer

Three Types
·         Squamous cell Carcinomas
o   Cancer of flat epithelial cell
o   80% to 90%
·         Adenocarcinomas
o   Cancer arising from glandular epithelium
o   10% - 20%
·         Mixed carcinoma
o   Features both types

Statistics
·         10,520 new cases in the U.S. this year
·         3,900 will die
·         50% are diagnosed between ages 35 and 55.
·         20% at the age of 65 or over.
·         Rarely occurs in women younger than 20
·         Noninvasive is four times more common
·         74% decrease in deaths between 1955 and 1992 in the U.S.
·         Death rate continuous to decline by 2% a year

Signs and Symptoms
·         Vaginal bleeding
·         Menstrual bleeding is longer and heavier than usual
·         Bleeding after menopause or increased vaginal discharge
·         Bleeding following intercourse or pelvic exam
·         Pain during intercourse

Risk Factors
·         Human papillomavirus infection (HPV) – Primary factor
o   HPV 16, HPV 18, HPV 31, HPV 33, HPV 45
o   50% are caused by HPV 16 AND 18
·         Sexual behavior
·         Smoking
·         HIV infection
·         Chlamydia infection
·         Diet
·         Oral contraceptives
·         Multiple pregnancies
·         Low socioeconomic status
·         Diethylstilbestrol (DES)
·         Family history

Prevention
·         Avoiding the risk factors
o   Especially HPV
o   Help for low-income women (NBCCEDP)
·         Having the Pap Test
o   3 years after first vaginal intercourse or by age 21.
o   Have test annually

Diagnosis
·         Cervical Cytology (Pap Test)
·         Cells are removed from the cervix and examined under the microscope.
·         Can detect epithelial cell abnormalities
o   Atypical squamous cells
o   Squamous intraepithelial lesions
o   Squamous cell carcinoma (likely to be invasive)

Additional testing
·         Colposcopy
o   Cervix is viewed through a colposcope and the surface of the cervix can be seen close and clear.
·         Cervical Biopsies
o   Colposcopic biopsy – removal of small section of the abnormal area of the surface.
o   Endocervical curettage – removing some tissue lining from the endocervical canal.
o   Cone biopsy – cone-shaped piece of tissue is removed from the cervix

Staging
FIGO System (International Federation Of Gynecology and Obstetrics)
Has five stages – 0 to 4
  • Stage 0 Carcinoma in situ
  • Stage 1 Invaded cervix, but has not spread.
  • Stage 2 Has spread to nearby areas, not leaving pelvic area.
  • Stage 3 Cancer has spread to the lower part of the vagina.
  • Stage 4 Cancer has spread to nearby organs; metastasis. 
 Survival Rate
·         5-year survival rate is 92% for earliest stage
·         71% for all stages combined

Treatment
·         Surgery
Preinvasive cervical cancer
o   Cryosurgery
o   Laser surgery
o   Conization
Invasive cervical cancer
o   Simple hysterectomy
o   Removal of the body of the uterus and cervix.
Radical hysterectomy and pelvic lymph node dissection
Removal of entire uterus, surrounding tissue, upper part of the vagina, and lymph nodes from the cervix.
·         Radiation
·         Chemotherapy
Source: American Cancer Society

What’s new in cervical cancer research and treatment?
·         HPV test
·         HPV vaccine
·         Radical trachelectomy procedure
·         Other clinical trials

Cervical cancer

Thursday, October 13, 2011

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

Introduction
  • 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
    • 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


Classification
The RND is classified according to the Academy’s Committee for Head & Neck Surgery & Oncology into four major type:
  1. Radical Neck Dissection (RND)
  2. Modified Radical Neck Dissection (MRND)
  3. Selective Neck Dissection (SND)
    • Supraomohyoid
    • Posterolateral
    • Lateral
    • Anterior
  4. 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



Facts
General nodal metastasis produces 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 Neck Dissection
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% 

Indications

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”  

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
Summary
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

Radical neck dissection

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