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Modified neck dissection for carcinoma of the thyroid gland
Modified Neck Dissection for Carcinoma of the Thyroid Gland F. C. MARCHETTA, MD, Buffalo, New York K. SAKO, MD, Buffalo, New York H. MATSUURA, MD, Buffalo, New York
]n April 1960 a preliminary r¢,,~rt on modified neck dissection for carcinoma of the thyroid gland was presented at the meeting of the Society of Head and Neck Surgeons: The modification consisted of preservation of the sternocieidomastoid muscle, spinal accessory nerve, and internal jugular vein. The arguments presented were as follows: (1) The dissection in the visceral compartment was not an en bloc excision but excision of the thyroid gland and a dissection of the fat lymphatic tissues along the trachea, recurrent laryngeal nerve, ;rod carotid arteries; in reality, it was a node dissection. If node dissection was adequate in removing disease from the visceral compartment, it should prove adequate for removing disease in the neck. (2) Dissection of the spinal accessory nerve was similar to dissection of the recurrent laryngeal nerve. (3) The results of clearing several hundred surgical specimens from radical neck dissections demonstrated that lymph nodes were not found within the substance of t h e sternocleidomastoid muscle. (4) Lymph nodes which contained metastases from papillary follicular carcinoma of the thyroid gland were surrounded by a resilient layer of fibrous tissue and were infrequently fixed to the adjacent tissues. (5) Although tumor thrombi extending from the thyroid veins into the jugular vein have been reported, they occur only in far advanced disease. (6) Preserving the spinal accessory nerve, prevented deformity and impairment of function, preserving t h e sternocleidomastoid muscle reduced deformity and protected the carotid bulb, and preserving the vein (especially in bilateral operations) reduced swetling and edema of the face.
Material We have .had the opportunity of adding several more cases to our original series and, more important, to observe the results over a long period of time. Our present series includes thirty patients, eight of whom~underwent bilateral or a second neck dissection at. a later date, makFrom Section A, Department of Head end lqeck Surgery, Roswell Park Memorta| institute (New York State Department of Health), Buffalo, New York 14203. : Presented at the Sixteenth Annual Meeting of The Society of Head and Neck Surgeons, Rochester, IMinne$ota, April 1:2-14, 1970." 452
ing a total of thirty-eight operations which we classified as modified radical neck dissection. In each instance the operation was reserved for patients who clinically dcntonstrated palpable, presumably metastatic, nodes in the neck or in whom the presence of metastatic disease was established by biopsy of a neck node. Twenty-five of our thirty patients had undergone surgery prior to referral, Some form of thyroidectomy had been performed in thirteen patients, and excision of a neck node (which established the diagnosis) in twelve. When metastases to the cervical lymph nodes had developed, we considered total thyroidectomy and modified radical neck dissection to be the therapy of choice. When only portions of the thyroid were removed, the thyroid compartment was re-entered and totally dissected in conjunction with modified neck dissection. Thus, twenty patients underwent total thyroidectomy and modified radical neck dissection (two of whom had total thyroidectomy. and bilateral modified neck dissection), and sixteen had modified neck dissection only since total thyroidectomy had adequately been performed previously.
Operative Procedure The usual collar incision was placed over the lower part of the neck. A vertical limb was extended upward from the lateral end of the collar incision toward the angle of the jaw. In some instances the upper end of the incision was extended in Y fashion toward the mastoid and parallel to the inferior ramus of the mandible. More recently the operation has been performed through double transverse incisions, The skin flaps were developed below the IY~meof the platysma muscle. The strap muscles were transected at their origin and insertions were left attached to the thyroid. Dissection in the visceral compartment was begun on the theoretically uninvolved side. The recurrent laryngeal nerve was identified. Parathyroid glands were identified and dissected away from th~ thyroid capsule. Fat and lymphatic tissues were dissected away from the recurrent laryngeal nerve and the trachea down to the clavicle. The dissection was continued medially, baring the trachea and taking all thyroid tissue with the specimen. Dissection of the tumor-bearing side was generally more difficult. In most instances metastatic nodes The Americ~;n Joume! of Surgery
Modified Neck Dissection for Thyroid Carcinoma
were present along the recurrent laryngeal nerve and tracheal esophageal groove. It was usually difficult and even unwise to identify grossly and to preserve parathyroid tissue on this side. If tissue was identified (his, tologic sections were usually necessary to differentiate parathyroid tissue from metastatic disease), it was •thinly sliced and implanted in muscle [1]. All thyroid tissue was removed, the recurrent laryngeal nerve was dissected clean, and fat and lymphatic tissues in the tracheoesophageal groove d o w n to t h e level of the clavicle were included in the specimen, The surgic~l specimen was left attached to the carotid sheath. Attention was next directed to dissection of the neck. A linear incision extending from the mastoid process to the clavicle was made through the fascia covering the sternocleidomastoid musclc. The fascia was dissected medially and laterally, exposing the entire sternocleidomastoid muscle. T h e sternal and clavicular heads of the muscle were transccted through their tendinous insertions. The muscle w a s dissected upward out of its bed, leaving the posterior layer o f investing fascia in place. The border of t h e trapezius muscle wns dissected clean. The spinal accessory n e r v e , which courses parallel to the muscle approximately I cm from its border, was identified and dissected t o tlie point where it enfered the belly of the sternocleidomastoid muscle. The dissection was carried down to the prevertebral fascia and proceded in the usual manner, exposing the posterior musculature and the brachial plexus, continuing upward in the posterior triangle to the mastoid process. T h e dissection continued from the posterior triangle medially to e x p o s e the phrenic nerve. The cutaneous branches of the cervical plexus were transected in the usual manner, A s the dissection progressed and the sPecimen Was rotated medially, the internal jugular v6in coursing along the posterior aspect of the surgical specimen was seen throagli t h e p r e , vertebral fascia. A n incision, through this thin layer of
fascia allowed the vein to bulge forward. The vein was then dissected away from the surgical specimen a.s tile dissection progressed upward in the neck. The carotid artery, vagus nerve, and sympathetic chain were dissected in the usual manner. Care was exercised t o dissect that portion of the spinal accessory nerve as it passed from the sternocteidomastoid muscle upwards along the anterior surface Of the jugular vein t o the jugular foramen. T h e usual dissection of the submaxillary triangle was carried out. The surgical specimen from both the visceral compartment and the neck had been carried toward the carotid sheath. As the carotid sheath was dissected clean, the surgical specimen was delivered. (Figures I and 2.) The procedure with diagrammatic illustrations has previously been reported [2]. Surgical
Specimens
The gross amount of tissue removed in the surgical specimen was sizeable. (Figure 3.) The histologie diagnosis in all patients was papillary or mixed p~lpillary follicular carcinoma. Thirty surgical specimens were cleared and all lymph nodes cotinted, charted, and examined. In six instances the surgical specimens were examined grossly and representative nodes were sectioned for examination, Every neck specimen contained metastatic disease. The number of positive nodes in a single neck specimen was as high as twenty. The average number of nodes containing metastatic disease was seven.
Mctastatic disease occurred in all areas and at ~ll levels of thc ncck, Positivc nodcs wcrc found in thc visceral compartment in 81 per cent of paticnts. I n thc ncck, mctastatic discasc was found in the supraclavicular area in 32 per cent, Iowcr jugular area in 79 per cent. midjugular a r e a in 87 per c e n t , u p p e r jugular area in 1 6 per cent. submaxillary area in I I p e r c e n t , and spinal accessory area in 13 per cent. (Figure 4.)
ii
¥olume 120, October 1970
453
Marchetta, Sako, and Matsuura
TOTAL THYRO~DE~Y • MOOIFtEOPJ~DICALNECK DISSECTION
--I
TOTAL TttYROIOECTOMY I ~ " B{LATERALMOO~REDRADICALNECK DISSECTION
13~ • MODIFIEDRADIC.ALNECKDI$~'GTION
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~
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9
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SURVIVAL IN YEARS F i g u r e 3. Surgical specimen showing thyroid r i g h t a n d s u b m a × i l l a r y d i s s e c t i o n in u p p e r r i g h t .
in
lower
Blood vessel inwlsion of the thyroid specimen was specifically mentioned in twelve cases. It was presumed that a review of material with additional tissue sections and examination of the thyroid specimens held by other hospitals would yield a higher figure. Results
Although the results of surgery must necessarily include the disease status of the patient, recurrent disease in the field of neck dissection was of particular concern in evaluating a surgical procedure which deviates from a more. radical one. The follow-up period was over ten years in five patients and over three years in twenty-two patients. (Figure 5.) To date no patient has had recurrent disease in the field of neck dissection. Two patients in the series have died. The first died C A R C I N O M A OF THYROID L O C A T I O N OF METASTATIC NODES
UPPER JUGULAR MID JUGULAR LOWER ,JUGULAR SUPRAGLAVICULAR SPINAL ACCESSORY SUBMAXILLARY VISCERAL COMPARTMENT
Figure 4. thyroid. 454
Locate.on
of metastatic
nodes
16 87 79 32 13 I I 8 I
rn c a r c i n o m a
% % % % % % %
ot
Figure 5. Survival curve in modified radical neck dissection for carcinoma of the thyroid gland.
of a cerebral hemorrhage thirty-six months after surgery. At autopsy the body was free of thyroid cancer. The second patient died of disease, but in this instance death was due to extensive pulmonary metastases and tumor compression of the lower trachea. The field of neck dissection, which in this instance was bilateral, contained no tumor. Pulmonary metastases were present in five patients at the time of radical surgery. In these instances most would agree to perform total thyroidectomy to enhance the uptake.of radioactive iodine by metastatic lesions. In grossly palpable disease, as was present in all of our patients, modified neck dissection was added to reduce the amount of gross tumor, thereby, in theory. stimulating greater uptake by the pulmonary metastases. In two instances pulmonary metastases regressed completely after treatment with radioactive iodine as evidenced by x-ray examination. Metastatic disease in the lung has remained unchanged in two patients, in one for over ten years, and in another for two years. The fifth patient died of the disease. In a sixth patient lung metastases developed some time after surgery, but these recessed completely after radioactive iodine therapy. Recurrent disease over the trachea also developed in this patient. She was treated by excision followed by external radiation, and was alive and well eleven and a half years after radical surgery in the neck. Comments
Two thirds of the patients were female. The youngest patient was four and a half years old and the oldest was seventy-four. FiftY per cent of the patients were under thirty years of age. The American
Journal
of Surgery
Modified Neck Dissection for Thyroid Carcinoma In some patients the palpable nodes in the neck measured up to 3 cm in diameter. Depending on surgical judgment, it may sometimes be judicious to sacrifice one or more of the structures which we advocate preserving, such as when the nodes arc intimately attached to the internal jugular vein. Thus, the hlternal jugular vein was taken with the specimen in ten instances, the sternocleidomastoid muscle in five, and the spinal accessory nerve in one. The histologic and clinical follow-up studies of patients indicate that the operation successfully removes disease from the neck and is as cffective as radical neck dissection. Some advocate radical neck dissection even in the absence of palpable disease. If modified radical neck dissection is capable of removing metastatic nodes up to 3 cm in diameter, it should represent adequate surgery for clinically nonpalpable nodes containing metastatic disease. The deformity in radical neck dissection is produced primarily by sectioning the spinal accessory nerve which, in turn, produces a drooping of the shoulder and exaggerates the concavity of the neck. P-cserving the nerve eliminates the greater part of the cosmetic de-
Volume 120, October ][970
fortuity. The sternocleidomastoid muscle helps to fill in the defect in the operative field, but more important, it protects the carotid artery. Preserving the vein, especially in bilateral operations, prevents or minimizes chronic edema of the facial tissues which is commonly seen after bilateral radical neck dissection.
Summary 1. A modified neck operation for cm'cinoma of the thyroid gland is described in which the stcrnocleidomastoid muscle, internal jugular vein, and spinal accessory nerve are preserved. 2. Histologic studies and clinical follow-up data suggest that the operation is as effective as standard radical neck dissection. 3. T h e operation has the advantage of reducing cosmetic disfigurement and preserving function. References
1. Matsuura H, Sako K, Marchetta FC: Successful reim. plantation of autogenous parathyroid tissue. Amer J Surg 118: 779, 1969. 2. Marchetta FC, Sako K: Modified neck dissection for carcinoma of the thyroid gland. Surg Gynec Obstet 119: 551, 1964.
455
]n April 1960 a preliminary r¢,,~rt on modified neck dissection for carcinoma of the thyroid gland was presented at the meeting of the Society of Head and Neck Surgeons: The modification consisted of preservation of the sternocieidomastoid muscle, spinal accessory nerve, and internal jugular vein. The arguments presented were as follows: (1) The dissection in the visceral compartment was not an en bloc excision but excision of the thyroid gland and a dissection of the fat lymphatic tissues along the trachea, recurrent laryngeal nerve, ;rod carotid arteries; in reality, it was a node dissection. If node dissection was adequate in removing disease from the visceral compartment, it should prove adequate for removing disease in the neck. (2) Dissection of the spinal accessory nerve was similar to dissection of the recurrent laryngeal nerve. (3) The results of clearing several hundred surgical specimens from radical neck dissections demonstrated that lymph nodes were not found within the substance of t h e sternocleidomastoid muscle. (4) Lymph nodes which contained metastases from papillary follicular carcinoma of the thyroid gland were surrounded by a resilient layer of fibrous tissue and were infrequently fixed to the adjacent tissues. (5) Although tumor thrombi extending from the thyroid veins into the jugular vein have been reported, they occur only in far advanced disease. (6) Preserving the spinal accessory nerve, prevented deformity and impairment of function, preserving t h e sternocleidomastoid muscle reduced deformity and protected the carotid bulb, and preserving the vein (especially in bilateral operations) reduced swetling and edema of the face.
Material We have .had the opportunity of adding several more cases to our original series and, more important, to observe the results over a long period of time. Our present series includes thirty patients, eight of whom~underwent bilateral or a second neck dissection at. a later date, makFrom Section A, Department of Head end lqeck Surgery, Roswell Park Memorta| institute (New York State Department of Health), Buffalo, New York 14203. : Presented at the Sixteenth Annual Meeting of The Society of Head and Neck Surgeons, Rochester, IMinne$ota, April 1:2-14, 1970." 452
ing a total of thirty-eight operations which we classified as modified radical neck dissection. In each instance the operation was reserved for patients who clinically dcntonstrated palpable, presumably metastatic, nodes in the neck or in whom the presence of metastatic disease was established by biopsy of a neck node. Twenty-five of our thirty patients had undergone surgery prior to referral, Some form of thyroidectomy had been performed in thirteen patients, and excision of a neck node (which established the diagnosis) in twelve. When metastases to the cervical lymph nodes had developed, we considered total thyroidectomy and modified radical neck dissection to be the therapy of choice. When only portions of the thyroid were removed, the thyroid compartment was re-entered and totally dissected in conjunction with modified neck dissection. Thus, twenty patients underwent total thyroidectomy and modified radical neck dissection (two of whom had total thyroidectomy. and bilateral modified neck dissection), and sixteen had modified neck dissection only since total thyroidectomy had adequately been performed previously.
Operative Procedure The usual collar incision was placed over the lower part of the neck. A vertical limb was extended upward from the lateral end of the collar incision toward the angle of the jaw. In some instances the upper end of the incision was extended in Y fashion toward the mastoid and parallel to the inferior ramus of the mandible. More recently the operation has been performed through double transverse incisions, The skin flaps were developed below the IY~meof the platysma muscle. The strap muscles were transected at their origin and insertions were left attached to the thyroid. Dissection in the visceral compartment was begun on the theoretically uninvolved side. The recurrent laryngeal nerve was identified. Parathyroid glands were identified and dissected away from th~ thyroid capsule. Fat and lymphatic tissues were dissected away from the recurrent laryngeal nerve and the trachea down to the clavicle. The dissection was continued medially, baring the trachea and taking all thyroid tissue with the specimen. Dissection of the tumor-bearing side was generally more difficult. In most instances metastatic nodes The Americ~;n Joume! of Surgery
Modified Neck Dissection for Thyroid Carcinoma
were present along the recurrent laryngeal nerve and tracheal esophageal groove. It was usually difficult and even unwise to identify grossly and to preserve parathyroid tissue on this side. If tissue was identified (his, tologic sections were usually necessary to differentiate parathyroid tissue from metastatic disease), it was •thinly sliced and implanted in muscle [1]. All thyroid tissue was removed, the recurrent laryngeal nerve was dissected clean, and fat and lymphatic tissues in the tracheoesophageal groove d o w n to t h e level of the clavicle were included in the specimen, The surgic~l specimen was left attached to the carotid sheath. Attention was next directed to dissection of the neck. A linear incision extending from the mastoid process to the clavicle was made through the fascia covering the sternocleidomastoid musclc. The fascia was dissected medially and laterally, exposing the entire sternocleidomastoid muscle. T h e sternal and clavicular heads of the muscle were transccted through their tendinous insertions. The muscle w a s dissected upward out of its bed, leaving the posterior layer o f investing fascia in place. The border of t h e trapezius muscle wns dissected clean. The spinal accessory n e r v e , which courses parallel to the muscle approximately I cm from its border, was identified and dissected t o tlie point where it enfered the belly of the sternocleidomastoid muscle. The dissection was carried down to the prevertebral fascia and proceded in the usual manner, exposing the posterior musculature and the brachial plexus, continuing upward in the posterior triangle to the mastoid process. T h e dissection continued from the posterior triangle medially to e x p o s e the phrenic nerve. The cutaneous branches of the cervical plexus were transected in the usual manner, A s the dissection progressed and the sPecimen Was rotated medially, the internal jugular v6in coursing along the posterior aspect of the surgical specimen was seen throagli t h e p r e , vertebral fascia. A n incision, through this thin layer of
fascia allowed the vein to bulge forward. The vein was then dissected away from the surgical specimen a.s tile dissection progressed upward in the neck. The carotid artery, vagus nerve, and sympathetic chain were dissected in the usual manner. Care was exercised t o dissect that portion of the spinal accessory nerve as it passed from the sternocteidomastoid muscle upwards along the anterior surface Of the jugular vein t o the jugular foramen. T h e usual dissection of the submaxillary triangle was carried out. The surgical specimen from both the visceral compartment and the neck had been carried toward the carotid sheath. As the carotid sheath was dissected clean, the surgical specimen was delivered. (Figures I and 2.) The procedure with diagrammatic illustrations has previously been reported [2]. Surgical
Specimens
The gross amount of tissue removed in the surgical specimen was sizeable. (Figure 3.) The histologie diagnosis in all patients was papillary or mixed p~lpillary follicular carcinoma. Thirty surgical specimens were cleared and all lymph nodes cotinted, charted, and examined. In six instances the surgical specimens were examined grossly and representative nodes were sectioned for examination, Every neck specimen contained metastatic disease. The number of positive nodes in a single neck specimen was as high as twenty. The average number of nodes containing metastatic disease was seven.
Mctastatic disease occurred in all areas and at ~ll levels of thc ncck, Positivc nodcs wcrc found in thc visceral compartment in 81 per cent of paticnts. I n thc ncck, mctastatic discasc was found in the supraclavicular area in 32 per cent, Iowcr jugular area in 79 per cent. midjugular a r e a in 87 per c e n t , u p p e r jugular area in 1 6 per cent. submaxillary area in I I p e r c e n t , and spinal accessory area in 13 per cent. (Figure 4.)
ii
¥olume 120, October 1970
453
Marchetta, Sako, and Matsuura
TOTAL THYRO~DE~Y • MOOIFtEOPJ~DICALNECK DISSECTION
--I
TOTAL TttYROIOECTOMY I ~ " B{LATERALMOO~REDRADICALNECK DISSECTION
13~ • MODIFIEDRADIC.ALNECKDI$~'GTION
t-Z
W Z 0 (/) t;E tlJ W tE o. Ld a: CD "1" Id
i
z
~
k
S
S
r
e
9
so
SURVIVAL IN YEARS F i g u r e 3. Surgical specimen showing thyroid r i g h t a n d s u b m a × i l l a r y d i s s e c t i o n in u p p e r r i g h t .
in
lower
Blood vessel inwlsion of the thyroid specimen was specifically mentioned in twelve cases. It was presumed that a review of material with additional tissue sections and examination of the thyroid specimens held by other hospitals would yield a higher figure. Results
Although the results of surgery must necessarily include the disease status of the patient, recurrent disease in the field of neck dissection was of particular concern in evaluating a surgical procedure which deviates from a more. radical one. The follow-up period was over ten years in five patients and over three years in twenty-two patients. (Figure 5.) To date no patient has had recurrent disease in the field of neck dissection. Two patients in the series have died. The first died C A R C I N O M A OF THYROID L O C A T I O N OF METASTATIC NODES
UPPER JUGULAR MID JUGULAR LOWER ,JUGULAR SUPRAGLAVICULAR SPINAL ACCESSORY SUBMAXILLARY VISCERAL COMPARTMENT
Figure 4. thyroid. 454
Locate.on
of metastatic
nodes
16 87 79 32 13 I I 8 I
rn c a r c i n o m a
% % % % % % %
ot
Figure 5. Survival curve in modified radical neck dissection for carcinoma of the thyroid gland.
of a cerebral hemorrhage thirty-six months after surgery. At autopsy the body was free of thyroid cancer. The second patient died of disease, but in this instance death was due to extensive pulmonary metastases and tumor compression of the lower trachea. The field of neck dissection, which in this instance was bilateral, contained no tumor. Pulmonary metastases were present in five patients at the time of radical surgery. In these instances most would agree to perform total thyroidectomy to enhance the uptake.of radioactive iodine by metastatic lesions. In grossly palpable disease, as was present in all of our patients, modified neck dissection was added to reduce the amount of gross tumor, thereby, in theory. stimulating greater uptake by the pulmonary metastases. In two instances pulmonary metastases regressed completely after treatment with radioactive iodine as evidenced by x-ray examination. Metastatic disease in the lung has remained unchanged in two patients, in one for over ten years, and in another for two years. The fifth patient died of the disease. In a sixth patient lung metastases developed some time after surgery, but these recessed completely after radioactive iodine therapy. Recurrent disease over the trachea also developed in this patient. She was treated by excision followed by external radiation, and was alive and well eleven and a half years after radical surgery in the neck. Comments
Two thirds of the patients were female. The youngest patient was four and a half years old and the oldest was seventy-four. FiftY per cent of the patients were under thirty years of age. The American
Journal
of Surgery
Modified Neck Dissection for Thyroid Carcinoma In some patients the palpable nodes in the neck measured up to 3 cm in diameter. Depending on surgical judgment, it may sometimes be judicious to sacrifice one or more of the structures which we advocate preserving, such as when the nodes arc intimately attached to the internal jugular vein. Thus, the hlternal jugular vein was taken with the specimen in ten instances, the sternocleidomastoid muscle in five, and the spinal accessory nerve in one. The histologic and clinical follow-up studies of patients indicate that the operation successfully removes disease from the neck and is as cffective as radical neck dissection. Some advocate radical neck dissection even in the absence of palpable disease. If modified radical neck dissection is capable of removing metastatic nodes up to 3 cm in diameter, it should represent adequate surgery for clinically nonpalpable nodes containing metastatic disease. The deformity in radical neck dissection is produced primarily by sectioning the spinal accessory nerve which, in turn, produces a drooping of the shoulder and exaggerates the concavity of the neck. P-cserving the nerve eliminates the greater part of the cosmetic de-
Volume 120, October ][970
fortuity. The sternocleidomastoid muscle helps to fill in the defect in the operative field, but more important, it protects the carotid artery. Preserving the vein, especially in bilateral operations, prevents or minimizes chronic edema of the facial tissues which is commonly seen after bilateral radical neck dissection.
Summary 1. A modified neck operation for cm'cinoma of the thyroid gland is described in which the stcrnocleidomastoid muscle, internal jugular vein, and spinal accessory nerve are preserved. 2. Histologic studies and clinical follow-up data suggest that the operation is as effective as standard radical neck dissection. 3. T h e operation has the advantage of reducing cosmetic disfigurement and preserving function. References
1. Matsuura H, Sako K, Marchetta FC: Successful reim. plantation of autogenous parathyroid tissue. Amer J Surg 118: 779, 1969. 2. Marchetta FC, Sako K: Modified neck dissection for carcinoma of the thyroid gland. Surg Gynec Obstet 119: 551, 1964.
455