The evolution of surgery in the management of neck metastases

Abstract

In spite of advancement in science, molecular medicine and target therapies, surgical treatment of metastases using different techniques, from selective neck dissection to extended radical neck dissections, form a major part in the management of neck metastases. This is due to the fact that, so far, there is no treatment more effective for resectable neck metastases, than surgery. Since most head and neck cancer patients die due to loco-regional progression of disease, and a very large majority of them do not live long enough to develop distant metastases, the status of neck lymph nodes remains the single most important prognostic factor, in these cases. In the 100 years since George Washington Crile described Radical Neck Dissection, we now have a much better understanding of the biological and clinical behaviour of neck metastases. This has ultimately led to the conservative approaches of selective neck dissections depending on the primary site of the tumour, type of tumour and the characteristic features of the metastases themselves. A search of the literature on neck lymph nodes and neck dissections, on the internet and in old publications, not available in the electronic media, has been carried out. Using this as the basis, we arranged, in sequence, the dates of various landmarks in the treatment of head and neck cancer related to neck dissections to emphasize the overall process of evolution of neck dissection thereby showing how the field of head and neck surgery has travelled a long way from radical neck dissection to its modifications and further to selective neck dissections and sentinel node biopsies. The present understanding of the patterns of neck metastases enables us not only to adequately treat the neck metastases, but also to diagnose metastases from unknown primaries. Therefore, depending on the site of the primary tumour, it is now easy to predict the most probable route of metastatic spread and vice versa. This has enabled us to adopt modified and selective neck dissections which have ultimately led to a dramatic reduction in morbidity and almost eliminated mortality due to neck dissection. In the near future, molecular diagnostics and targeted therapies for treating metastases should be able to further reduce the burden of head and neck cancer.

Fig. 1

Gaspar Asellius (Source: Human Lymphatic system, B.N. Uskov, Medgis, Moscow, 1948).

Fig. 2

Mesenteric lymph vessels (copy of Gaspar Asellius’ work).

Fig. 3

George Washington Crile.

Fig. 4

Neck lymph node levels according to the AAO–HNS.

Fig. 5

Lymph nodes in and around the neck (Source: Human Lymphatic system, B.N. Uskov, Medgis, Moscow, 1948).