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"Whether END provides a therapeutic benefit is more controversial. Intuitively it makes sense that removing microscopic metastases at the earliest opportunity would improve patient outcome. However, there are no prospective, randomized studies that carefully compare the outcome of patients managed with END to patients who are treated with therapeutic neck dissection for metastases that occur during observation."

Jonas T. Johnson

"Self-examination by the patient and reliable follow-up are essential for watchful waiting to succeed in the management of the NO neck. Unfortunately, a significant number of the patients who do not undergo elective dissection can not be salvaged later, when they present with palpable metastases, because the disease is too far advanced."

Jesus E. Medina

"Elective treatment of lymph nodes at high risk for micrometastasis from upper aerodi-gestive tract cancers is warranted. Treatment should be undertaken when the risk for occult metastasis exceeds 10-15%. Effective treatment can be provided using either radiation therapy or surgery. Selective neck dissections are considered adequate for identifying lymph nodes with occult metastasis."

Jatin P. Shah

Management of the clinically negative neck (N0) in patients with head and neck squamous cell carcinoma (HNSCC) is controversial. In addition to the three treatment options available for the NO patient, clinicians who advocate a surgical approach must be cognizant of controversies surrounding the use of elective neck dissection (END). The focus of this chapter is to discuss the role of END for patients who are clinically NO. Head and neck surgeons continue to evaluate several issues surrounding END, which are also discussed: (1) what are the indications for END?, (2) do selective neck dissections constitute adequate procedures for staging the NO neck?, and (3) does neck dissection performed electively provide therapeutic benefit to patients with pathologic evidence of metastases?

END as a management strategy for the NO neck has evolved because the status of the cervical lymphatics is the single most important prognostic factor in HNSCC. A subset of patients without clinical evidence of regional metastases are known to harbor occult metastases. Despite intensive research efforts to identify pathologic and molecular tumor markers that reliably predict the presence of occult cervical metastases, accurate biomarkers have not been characterized. Although tumor thickness,1'2 perineural invasion,3 lymphocytic infiltration,4 and molecular tumor markers5 are associated with occult metastases, they do not provide the accuracy required for therapeutic decision making. Examination of the neck contents after END provides pathologic staging and prognostic information, and accurately guides treatment decisions.

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