Since the report of George Crile, Sr. describing the technic of radical neck dissection in 1906, this operation has been developed and standardized, and remains the most effective procedure for the management of cervical metastases from malignant tumors of the head and neck.
This report is based upon 146 radical neck dissections performed on 130 patients at Presbyterian Medical Center between January 1, 1961 and June 30, 1968. Combined resection of the primary tumor with neck dissection was done in 100 operations, and separate or staged neck dissections were performed in 46 operations. The complication rate was 39%, but few of these were of serious nature. The operative mortality was 1.5%. The dissections were "prophylactic" in 21% of the procedures, having been performed either because resection of the primary required entering the neck which might be clinically negative; or because the clinical situation justified the neck dissection because of the nature of the tumor.
Cervical metastases were porven histologically in 67.7% of all cases. The clinical accuracy for the diagnosis of cervical node involvement was 82.3%. Among patients with no palpable nodes 19.7% had histologically-proven metastasis.
Of the 130 patients in this series, 118 patients have been followed long enough to be considered determinate cases (follow-up rate 93.8%).
Analysis of these patients reveal the following:
A. The overall recurrence rate was 49.1%. However, the rate of recurrence in the dissected neck was only 18.6%, a figure lower than in most published series.
The site of recurrence in order of frequency was the primary site, followed by the dissected neck, the opposite neck, and finally, distant metastasis. Among 22 patients who developed recurrence in the dissected neck, those cases with histologically positive nodes had a recurrence rate of 23%, whereas those with histologically negative nodes had a recurrence rate of 4.6%.
B. The use of pre-operative radiation as an adjunct appears to have been effective in curtailing recurrence. Among 45 patients who had positive nodes and did not receive pre-operative radiation, the recurrence rate was 26.6% in the neck. Among 8 patients with positive nodes who received pre-operative radiation there were no recurrences in the neck.
C. The success of our efforts in controlling disease can be analyzed in terms of the disease as a whole, and in terms of the dissected neck alone. The overall success rate with the therapeutic attack was 56.8%; among those who recurred 12% could be salvaged. However, in terms of the neck dissection alone, 73.4% of the procedures were successful in controlling disease on that side of the neck.
D. The 3-year survival rate was 52.2%, and the 5-year figure was 39.4%. The salvage rate is higher in patients who did not receive adjunctive radiation due to the fact that combined surgical-radiation therapy was reserved for the more advanced cancer situations.
E. In the non-radiation group the salvage rate was 78.1%, the 3-year survival 72.2%, and the 5-year survival 46.8%. In the combined therapy group, the salvage rate was 31.5%, the 3-year survival 30.3%, and the 5-year survival 27.2%.
In summary:
1. Radical neck dissection is an effective and safe method of dealing with metastatic cancer in the neck.
2. The recurrence rate in the dissected neck, 18.6%, is lower than in most published series.
Recurrence is more apt to occur at the primary site in our experience; however, the majority of these were radiation failure.
3. Because the mortality rate of radical neck dissection is low, prophylactic neck dissection is justified when the appreach to the primary site is through the neck, and in the management of thyroid and extrinsic larynx.
4. The results may be further improved (a) by routine preoperative field radiation to the neck; and (b) by technical efforts to procure a wider margin around the primary tumor.
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