Bilateral radical neck dissection

Bilateral

Radical

CHARLES J. STALEY, M.D.,Chicago,Illinois,

Neck

Dissection

AND EDWARD F. SCANLON, M.D., Ezranston, Illinois

From tbe Departments of Surgery, Veterans Administration Research Hospital and Northwestern University Medical School, Chicago, Illinois.

section in 1906. A number of reports appeared about this time but IittIe eIse was written for severa decades. In our opinion, it is neither logical nor desirable to compare the experiences of the early nineteen hundreds with those of recent years. In the older reports, manv of the bilateral interruptions of the jugular veins consisted of Iigation only, as for septic thrombosis foIIowing mastoiditis, leaving the collateral circulation essentiaIIy undisturbed. When bilateral cervical dissection was also accomplished, the extent of the resection was not always preciseI?; stated, but of more importance is the fact that current supportive measures \vere not then available. We certainly- would not recommend complete simultaneous bilateral neck dissection (in conjunction with resection of the primary Iesion) without the aid of a skilled anesthetist, a blood bank, antibiotics, tracheostomy, etc. It is not surprising that extensive dissections accomplished under circumstances then existent were accompaniecl by an appreciable mortality. AIthough the specific cause of death was not aIways apparent, it was usuaIIy attributed to interruption of the interna juguIar veins. The first published account in recent years appeared in rgsi when hloore and Smith [r4] reported the first one-stage bilateral neck dissection performed at the Memorial Hospital, New York. The operation \vas successfully accomplished in August 1050. Morfit [ 131 performed simuItaneous biIatera1 dissection in December 1940, and Perzik [r7] in June 1949 and December rgso although his publication was preceded by the two previously mentioned. Beahrs [4] performed the first one-stage biIateraI operation at the Mayo CIinic in June 1952. A11 patients survived and serious sequelae were not apparent. It is IikeIy that many patients have been treated since with simultaneous biIatera1 procedures,

ONVENTIONAL “ radical neck dissection ” occupies a prominent position in the surgical management of cancer of the head and neck. Although many reIativeIy insignificant technica variations exist, it is as we11 standardized as any operation and better so than most. There shouId be no doubt as to the extent of the procedure when the term radica1 neck dissection is empIoyed; preservation of the interna juguIar vein requires cIassification as modified neck dissection. In recent years this basic procedure has been extended to incIude in-continuity resection of the primary lesion. A further extension, in an attempt to salvage the patient with biIatera1 metastases, merits consideration. Opinions reIated to management may differ, but the concept that biIatera1 metastasis constitutes a contraindication to surgica1 intervention is no longer tenable. Suggested aIternatives incIude one- or two-stage bilateral neck dissection, with or without preservation of one internal jugular vein. Each method has its proponents. We are herein concerned with biIatera1 neck dissection with excision of both internal juguIar veins as a one- or two-stage procedure, depending upon the existing clinica circumstance, i.e., synchronous or metachronous biIatera1 metastasis to the cervica1 Iymph nodes. Emphasis is pIaced on the one-stage operation.

C

HISTORICAL REVIEW We shaI1 make no attempt to review completely the oIder Iiterature on biIatera1 Iigation or excision of the interna juguIar veins, aIthough it is worth mentioning that CriIe recorded a staged biIatera1 radica1 neck dis85’

American

Journal

of Surgery,

Volume

98, December,

ryio

StaIey rLi&ion

and ScanIon

L.int.jug.luppwl

of:

600 1

0’

8:30 9:00 8145

9:30

11:30 lo:151 lo:45 LO:30 Time

FIG. I. AIterations in pressure of cerebrospinal fluid in two patients simultaneous Iaryngectomy and biIateraI radica1 neck dissection.

but few, appeared.

if

any,

COLLATERAL

additiona

reports

have

CIRCULATION

Th e greatest deterrent to true biIatera1 radica1 neck dissection, either as a singIe or multiple stage procedure, has been the fear of excision of both interna jugular veins. This fear is based more on exaggerated ideas of the potential sequelae, perpetuated by repetitious quotation of exotic compIications, than on actua1 accumuIation of catastrophic experiences. BiIateraI radica1 neck dissection impIies biIatera1 sacrifice of the anterio!, .externaI and internal juguIar veins; remamrng vascuIar channels must therefore acquire a greater functiona significance. The potential adequacy of the remaining venous network may be noted by reviewing a standard text on anatomy; the reviewer is soon impressed by the number of remaining vesseIs if not by their individua1 magnitude. FolIowing biIatera1 resection of the juguIar veins the vertebra1 venous system undoubtedly pIays the most important roIe. Batson [z,~] has repeatedIy emphasized the significance of the vertebral plexus and has estimated that the cross sectiona area exceeds that of the interna juguIar veins [2]. This pIexus provides a mechanism for venous compensation foIIowing biIatera1 resection of the interna jugular veins. It is said that foIIowing death from hanging the brain appears anemic whiIe the

2.30

undergoing

face is markedly congested [r8]. This would testify to the adequacy of the vertebra1 pIexus as an outflow tract for the cerebra1 bIood. The deep cervical and occipita1 veins and the pharyngea1, pterygoid and esophagea1 pIexuses offer additiona avenues of venous return. The emissary vessels provide direct communication between the dura1 sinuses and the vesseIs outside the skuI1. These incIude the parietal, occipita1, mastoid, condyIoid, hypogIossa1, pharyngea1, ophthaImic and ethmoid veins. AIthough each is smaI1 and marked diIatation is precIuded by the course through the skuI1, their combined size is such that they shouId not be considered insignificant. Many of these vesseIs, directIy or indirectIy, are tributaries of the vertebra1 plexus; thus the system provides drainage for the extracranial as we11 as the intracrania1 structures. In the absence of some vascuIar anomaIy sufhcient channels remain ior the exit of bIood from inside the skuI1 and its subsequent return to the heart. With few insignificant exceptions there are no vaIves in the veins of the head and neck and brood may flow in either direction [J]. Many previously unmentioned venous channels, superficia1 and deep, will be directIy or indirectly interrupted during biIatera1 neck dissection, especiaIIy when associated with concomitant remova of the thyroid, cervica1 esophagus and/or Iarynx. It seems unIikeIy that excision of the superficial vesseIs is of great importance in view of the extensive coI-

Bilateral

Radical

Neck

Dissection

lateral circulation of the facia1 area, aIthough Perzik has suggested that ligation of the anterior facia1 vein blocks the return of bIood from the intracrania1 structures by way of the cavernous sinus and ophthaImic vein. Intermediate communicating channeIs certainlyprovide some compensation under these circumstances. CEREBROSPINAL

FLUID

PRESSURE

Several investigators [ zy,zg-211, have recorded alterations in the pressure of the cerehrospinal fIuid during the course of radica1 neck dissection but opinions differ regarding their significance. The pressure-eIevating effect of straining, coughing, etc. is generalIy recognized; it is less well known that ether anesthesia [2z] and turning the head to either side [20] have a similar effect. Schweizer and Leak [20] noted an eIevation to 400 to 600 mm. of water, or more, in most of their patients during uniIatera1 radica1 neck dissection; changes of similar magnitude occurred during biIatera1 dissections whether performed simultaneously or in separate stages. Within a few days of surgery the pressure of the cerebrospinal fluid was usuaIIy within normal limits. Sugarbaker and Wiley [z2] noted a normal response to the Queckenstedt maneuver on compression of the cervical musculature several weeks after the second stage of compIete bilateral neck dissection; a similar observation was made by Royster [zg], on compression of the operated side following unilateral dissection. Figure I demonstrates changes in pressure of the cerebrospinal fluid in two patients undergoing simultaneous laryngectomy and biIatera1 radical neck cIissection. It wiIl be noted that the pressure varies appreciably and assumes a not insignificant level even before the first internal jugular vein is Iigated. It wiII also be noted that there is no dramatic change following ligation of the second interna jugular vein even though the Iigations were accompIished lvithin a few minutes of each other (two surgica1 teams were working simultaneously). That the changes are usually transient has been noted by others and is demonstrated here by the decline to preoperative values within three hours. The increase in the pressure of the cerebrospinal fluid accompanying the turning of the head to the side aIso occurs after biIatera1 excision of the interna juguIar veins. Several from a strain-gauge manometer segments

4

Ligation

L .Jug .V.

Head

Had

ChwsiIlg applied 4

(upper)

mm.H.0

Head

turned

turned

tori&t

ti2’

cc

4

++

mm.H,O - 320 -280 - 240 - 200 -160 -12a -!??I ‘0

Minutee FIG. 2. Changes in pressure of the ccrebrospinal fluid (segments of strain gauge tracing) during bilateral radica1 neck dissection and Iaryngectomy.

853

StaIey

and ScanIon

tracing on a patient undergoing simultaneous bilateral neck dissection are presented in Figure 2. CHOICE

OF PROCEDURE

Bilateral metastases to the cervical Iymph nodes may be present when the patient first comes to the attention of the surgeon; or, involvement of the second side may become apparent after a uniIatera1 neck dissection has been accomplished. In the Iatter circumstance the operations wiI1 of necessity be performed in separate stages; in our opinion the second dissection should be complete, but preservation of the internal jugular vein on the second side has been recommended. There is greater conflict concerning the course to be followed when bilateral metastases are present initially. The majority of authors have indicated a preference for staging the operative intervention under these circumstances also. AIthough estimates vary as to the most desirable interva1 a period of two to six weeks is usually suggested. It is a common belief that with the longer intervaIs there wiI1 be fewer undesirable sequelae. Our experience does not support this contention. Theoretically, collateral circulation is deveIoping during this time, thereby reducing the risk of the second operation. That an expansion of the capacity of collateral venous channels actuaIIy occurs folIowing unilateral dissection has to our knowledge not been established. We have not encountered impressive evidence of such in performing neck dissections on the second side many months after the first, aIthough at times the larger vessels seem somewhat more prominent than usua1 and venous bleeding appears to be increased. (We are aware that the most important collateral channeIs would not be encountered in this dissection.) Moreover, we have seen as much facial congestion in two-stage procedures as in simultaneous dissections; in fact in our most severe instance the interval between operations was seven months. Others [1,5,9,17,21], have commented on the relatively severe congestion that may follow two-stage operations. Preservation of the internal jugular vein on the second side, instead of or in addition to staging the two dissections, has been recommended [1,6,10,13]. Without entering into a proIonged discussion of the necessity of jugular excision as a component of the conventional

radical neck dissection (a fact accepted by all when metastases are uniIateral), it would seem apparent that if such excision is essential to the first dissection it should be considered essential to the second. Preservation of the internal jugular vein during an otherwise classic radical neck dissection is technically feasible if the adenopathy is not extensive, but it is debatable that the attempt should be made even then. The anatomic and pathologic relationships are not analogous to the relationship of the axiIIary vein and radical mastectomy as suggested by some. It is obvious that in certain patients with simultaneous bilateral metastases the operation cannot be staged without vioIating the surgical held; for example, extensive metastases to the submental lymph nodes and bilateral metastases to the jugular lymph nodes from cancer of the Iip or floor of mouth, or thyroid or laryngeal cancer with biIatera1 metastasis to the cervical Iymph nodes. In these and other instances tumor-bearing tissue or potentially tumorbearing tissue would have to be transected in order to perform the resection at separate seances. If it is essential to perform neck dissection in continuity with the primary lesion when the metastases are unilateral, is it not essential also when the metastases are bilateral? Barbosa [I] and Bocca [T] have suggested that simultaneous bilateral neck dissection can be safeIy accomplished only when massive involvement of the lymph nodes has produced significant compression or actual occlusion of one or both internal jugular veins. That this is not the case is demonstrated in the small series reported herein, as the adenopathy has always been minimal on the second side and was usually not massive on either side. PRESENT

SERIES

That bilateral metastasis to the cervical lymph nodes occurs with considerable frequency is demonstrated in this series. Since the Veterans Administration Research Hospital was activated approximately five years ago, sixty-eight radical neck dissections have been performed. During this period there have been nine bilateral dissections, four one-stage, and five two-stage procedures. A considerably greater number of patients with bilateral metastases were seen whose disease was too far advanced for attempted surgical removal Martin [II] reported bilateral operations in

BiIateraI

Radical

Neck

TABLE BILATERAL

Patient and

I NECK

DISSECTION

PathoIogic Condition of the Lymph Nodes+

/ 1

Right

’

Date(s) of Surgery ~_______

Primary Site*

Age (yr.)

RADICAL

Dissection

Left

Postoperative Congestion

Postoperative Edema

Current Status*

One-Stage Procedure

I

I (62) 3008 (59) 12921 (46) 13779 (69) 2332

1Larynx ; FIoor of mouth Larynx

’

~Larynx

1169 o/40 3175 4/73

415155 6123155 1o/23/58 3/9/59

4173 ‘,‘;;;

++ ++

++

I

4171

++

+ o

/ :/ +

Living Living Living I.iving

and and and and

well, 49 mo. weIf, 47 mo. weI1, 7 mo. well, 2 mo.

Two-Stage Procedure 2422

(58)

Floor of mouth

9646 (67)

Larynx

9669 (67)

Cervical esophagus

10387 (60)

’ Tongue

11592 (66)

’ Larynx I

4/g/55 g/9/55 9117147 4/13/5S 1 l/12/57 9/18/58 11 I26157 3/4/fS q/22/58

+++

Living and well, 45 mo.

+

Living and well, 13 mo.

+

Living and welt, 8 mo.

4172

3139

2153

12137

3116

5126

I

6126

1/29

~ +

1I33

I/38

Dead, 6 mo. Living and well, 5 mo.

+++

12/18/58

-

-

-

* AI1 primary Iesions were treated surgically. t Number of positive nodes/number of nodes sectioned. * Time between last operation and May 1959.

of 5gg patients undergoing radicaI neck dissection. When patients present with biIatera1 metastasis to the cervical Iymph nodes in association with a resectable primary Iesion, simultaneous dissection is accompIished. Staged procedures are utiIized onIy when metastases deveIop on the second side following a previous radica1 neck dissection. CIinicaI evidence of biIatera1 metastases was present in a11 patients; histoIogic confirmation was obtained in a11 but one. We do not perform biIatera1 dissections prophyIacticaIIy. Aithough the prognosis may be relatively poor, the procedure is performed with intent to cure. Pertinent data referabIe to the nine biIatera1 neck dissections are presented in Table I. Al1 one-stage dissections have been carried out with two surgica1 teams operating simultaneousIy. The procedure is therefore not undulv prolonged even though the primary 1esion”is resected concomitantIv, but accurate repIacement of bIood Ioss is obviously essential. sixty-six

In our opinion, tracheostomy is mandatory, whether the dissection is performed in one or two stages. One shouId not risk respiratory embarrassment secondary to IaryngeaI and/or IinguaI edema; that it may fohow either simultaneous or staged procedures should be recognized and precautions taken. PostoperativeIy, the head of the bed is eIevated to 30 degrees or more. This position is we11 tolerated by the patient and may facilitate venous return. Activity is permitted as desired. We have not performed “therapeutic” spinal punctures in any case, although studies on the pressure of cerebrospinal fluid have been carried out during operation in a few patients. SeveraI authors [ 1f,r9,21], recommend insertion of a spinal subarachnoid catheter before biIatera1 dissection in order to make frequent checks of the pressure of the cerebrospina1 fluid and withdraw IIuid if significant eIevation occurs. We do not consider this essentia1. There have been no postoperative deaths

StaIey

and ScanIon

FIG. 4. Surgical

FIG. 3. Preoperative and postoperative appearances; biIatera1 radical neck Iaryngectomy.

(three month) dissection and

in this smaII series and

morbidity has been minimaI. Martin [12], speaking from a greater experience states, “there is no increase in postoperative mortality or disability that can be ascribed to the remova of the second internal juguIar vein.” In view of the magnitude of biIatera1 neck dissection one wouId anticipate a somewhat greater mortaIity than with uniIateraI dissection but the patient’s Iife is at risk on onIy one occasion instead of two. SEQUELAE

During the final stages or immediately foIIowing biIatera1 radical neck dissection the face may be moderateIy to markedIy discolored. If the surgeon is unaware of this possibility he ‘may view it with considerable appre-

FIG. 5. Surgical specimen. BiIateraI radica1 dissection of the neck with resection of anterior two-thirds of the tongue and horizontal rami.

specimen,

patient

seen in Figure

3.

hension as the dusky purpIish hue may be confused with cyanosis of respiratory origin. That it is due to congestion is readily demonstrated by its Iimitation to the face, an observation which may be obscured temporariIy by the surgica1 drapes. Significant facia1 cyanosis is not a constant accompaniment of biIatera1 resection of the jugular veins. It may foIIow staged operations as we11 as the simuItaneous procedure and does not necessariIy occur after either. We have noted a similar appearance many times in the past on appIication of a pressure dressing foIIowing uniIatera1 neck dissection. It is not unIikeIy that the dressing effectiveIy compressed the major venous channeIs of the side which was not operated upon and in essence had the effect of biIatera1 dissection. A considerabIe degree of facia1 edema wiI1 deveIop in the majority of patients. This occurs shortly after or even before the operation is terminated, may progress during the next few days, and gradually improves thereafter. In our experience postoperative edema has varied from aImost none to a baIIooning of the face so extensive that the eyelids couId not be separated; the patient was recognized with diffIcuIty. With the passage of time, improvement is such that the sweIIing cannot ordinariIy be considered a cosmetic IiabiIity, but slight to moderate edema of the lower portion of the face may persist indefiniteIy (Figs. 3 through 5.) Whether this is a resuIt of venous or Iymphatic deprivation is a subject of some debate. The edema is Iimited to the tissues above the transverse portion of the incision; a similar although more transient and Iess severe homoIatera1 edema of the lower part of the face not infrequentIy foIIows uni-

BilateraI

RadicaI

Neck

lateral dissection; bilateral edema of the lower part of the face may follow the so-called fGlateral upper neck dissection in which the internal juguIar veins are not disturbed; these facts indicate that the edema is of lymphatic origin. In the hope of minimizing postoperative edema \ve have applied snug compression dressings to the entire head and neck following simultaneous bilateral neck dissection, a practice avoided by some because of the possibility of venous compression. In one patient the dressing was removed on the second postoperatic-e da,v at which time very littIe edema \vas present; it was not reapplied and during the next few da!-s edema increased but was almost completely eliminated h?; the reapplication of the dressing. AI an\: patients complain of a deep-seated headache but this also occurs occasionaIIy following unilateral dissection. It is usually aggravated by the assumption of a recumbent position and may be improved or eliminated by elevating the head of the bed, sitting or standing. Within a few days or weeks marked improvement n-ill occur but a feeling of tightness about the face may persist even in the absence of significant facial edema. The exceedingly rare persistent increase in intracranial pressure associated with headache and visual disturbance as noted by Morfit and Cleveland [16] folIowing unilateral neck dissection has not occurred in this small series. hlinimal necrosis of the margins of the skin flaps has been a cause of some apprehension in view of its location near the carotid vessels but prophylactic or emergency ligation of the carotid vessels has not been necessary.

Dissection REFERENCES

I. BAKBOSA,J. F. RndicaI Iaryngectomv with bilateral neck dissection in continuity. Ar~l.1. O~olaryn~., 63: 372, 1956. 2. BATSOU, 0. V. Anatomical problems concerned in the study of cerebral blood fIow. I~derotion Proc., 3: 139. ‘944. 3. BATSON, 0. V. Discussion of Gius, .I. A. and Gricr, D. H. [(I]. 4. BEAHKS, 0. H. and JOKDAU, G. L., JK. Bilateral radical cervical dissection for malignant lesions of the head and neck. Proc. Stuff Merr. Mayo Clin . . 27: 449, 1952. 5. Bocca, E. Functional problcrns connected with biIatera1 radical neck dissection. J. Lorvng. (‘7 O!ol., 67: 567, 1953. 6. CATTEU, R. B. Neck dissection for carcinoma of the thyroid. Surg. Cl&. North America, 33: 897, 1953. 7 CKILE, G. Excision of cancer of the head and neck with special reference to the pIan of dissection based on one hundred and thirty-two operations. J. A. M. A., 47: 1780, 1906. 8. Ewruc, M. R. and ~IARTIN, FI. Disability following “radical neck dissection,” an assessment based on the postoperative evaluation of 100 patients. Cuncer, 5: 87~. ~952. 9. GJUS, J. A. and GKJER, D. 13. Venous adaptation following bilater:tI radical neck dissection with excision of the jugular veins. Surgery, 28: 305, 1950. IO. JORGE, 1I. and LAR[:FI:A, 1I. Vaciamiento biIateral de cuello en un ticmpo. Rev. A. ,If. A., 69: 436, J955. I I. MARTIN, H. et al. Neck dissection.

Cancer, 4: 44 I,

J95J. 12. MARTJK, 1-I. Surgery of Head and Neck Tumors. New York. ~ 1057. ,,, PauI B. Hoeber. Inc. 13. hlon~~r., J. Discussion of Gius, J. A. and Gricr, D. 11. 191. 14. RIOORE, 0. and SMITH, R. A case of one-stage bilateral neck dissection with recovery. Cancer, 4: ‘337, ‘95’. 15. MOR~IT, H. hl. SimuItaneous bilateral radica1 neck dissection. Total ablation of both internal and external jugular venous systems at one Sitting. Surgery, 31 : 216, 1952. 16. MORFJT, I-I. hl. and CLEVELAUD, H., JK. Permanent increased intracranial pressure folIowing unilateral radica1 neck dissection. Arch. Surp., 76: 7J3, 1958. 17. PERZIK, S. L. Simultaneous biIatcral radica1 neck dissection with recovery. Surge?>-, 31: 297, 1952. 18. PO~RIEK, P. and CHAKJ’Y, A. Traite D’Anatomie Humaine. Paris, J9J4. Masson et Cit. Cited by Gius, J. A. and Grier, D. H. [9]. 19. ROYSTEK, II. P. The relation between internal jug&r vein pressure and cerebrospinal fluid pressure in the operation of radical neck dissection. Ann. Surg., 137: 826, 1953. 20. SCHWEIZER, 0. and LEAK, G. tI. A study- of spinal fluid pressures in operations requiring removal of both internal jug&r veins. Ann. Su?g., J 36: 948, 1952. 21. SU~;ARBAKER, I:. D. and WILEI., II. M. Intracranial pressure studies incident to resection of the interna jugular veins. Cclncer, 4: 242, 1951.

SUMMARY

The management of the patient with biIatera1 metastases to the cervica1 lymph nodes has fleen discussed. Nine patients were subjected to complete bilateral radical neck dissection, four of which were performed in one stage, without operative mortality or serious postoperative morbidity. No significant complications attributable to venous engorgement or increased pressure of the cerebrospina1 fluid ha\-e been noted. Simultaneous biIatera1 radical neck dissection is a procedure of limited applicability, but is fully justified in seIected patients with potentiaIIy curable bilaterai metastases to the cervica1 Iymph nodes. 857