When Should the Neck Be Treated Electively

The decision to recommend elective treatment of the neck nodes depends mainly on the location and stage of the primary tumor and on a few other potential factors.


Elective treatment of the neck is indicated in patients with T2, T3, and T4 cancers of the oral cavity, regardless of the site of origin. Possible exceptions are T2 tumors of the buccal mucosa, in which the associated rate of lymph node metastases is low,13 and T1 tumors of the oral tongue, because some surgeons believe, as we do, that elective neck dissection is desirable in these patients,14'15 particularly when the lesion is thicker than 1.5 to 2 mm.16,17 An increasing number of clinical, histologic, biochemical, and genetic factors are under study as potential predictors of the propensity of a tumor to metastasize to the lymph nodes. Their role remains sufficiently unclear to recommend their use in routine treatment planning.


Tumors of the oropharynx have a high propensity to metasta-size to the regional lymph nodes even in early stages. Therefore, the regional lymph nodes should be treated electively, regardless of the stage of the primary tumor. With the exception of early, well-lateralized tumors, tumors of the oropharynx have a tendency to metastasize to both sides of the neck, often indicating treatment of both sides of the neck. Dissection of the retropharyngeal nodes should be considered particularly for tumors extending onto the pharyngeal walls, as retropharyngeal nodal metastasis occurred historically in up to 44% of cases.18


For glottic tumors staged T1 and T2, elective treatment of the neck is generally not indicated because the incidence of metastases is low. There are possibly two exceptions: (1) when tumor is found in a delphian node during the course of a partial laryngectomy, as the reported rate of lateral neck metastases in such cases is about 40%19; and (2) when treating recurrent T1-T2 tumors, because of the reported risk of occult metastases is about 20%. The need to dissect the neck in patients with T3 glottic tumors remains controversial. However, because lymph node metastases have been observed in 17 to 22% of cases, we believe that elective treatment of the neck is appropriate.20,21 Elective dissection of the neck is clearly indicated in patients with T4 tumors.22


Elective treatment is warranted in all stages of supraglottic cancer. A possible exception may be T1 tumors of the suprahyoid epiglottis. Furthermore, treatment of the neck should include the lymph nodes at risk on both sides of the neck, with as many as 75% of the recurrences in the neck occuring in the "undis-sected" contralateral side.23


Elective treatment of the lateral compartments of the neck does not seem warranted in patients with subglottic cancer. The reported incidence of metastases to these nodes is only 10%.24,25 By contrast, the paratracheal lymph nodes are involved more frequently and should be treated bilaterally.26,27

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