Shoulder function after neck dissection with level IIb preservation: a prospective observational study.

BACKGROUND: Shoulder syndrome can be reduced by preserving the spinal accessory nerve (SAN). However, it is unclear whether performing level IIb preservation will decrease the risk of SAN injury and shoulder syndrome. AIMS/OBJECTIVES: We investigated whether neck dissection with level IIb preservation can reduce shoulder dysfunction and postoperative quality of life (QOL) in head and neck cancer patients. MATERIAL AND METHODS: This prospective observational study enrolled patients who underwent neck dissection from 2011 to 2014. Patients were divided into three groups (level IIb preservation group [group 1], IIb dissection group [group 2], and IIb and V dissection group [group 3]). Postoperative shoulder function and QOL were evaluated among the three groups. RESULTS: There were a total of 35 neck sides in three groups, with nine neck sides in group 1, 16 neck sides in group 2, and 10 neck sides in group 3. Although the results showed less shoulder dysfunction in group 1 at early postoperative period. The QOL in group 1 was preserved in the early postoperative period. CONCLUSIONS AND SIGNIFICANCE: Neck dissection with level IIb preservation may help reduce shoulder syndrome and maintain QOL in the early postoperative period.

Post-operative progress of arm abduction function and rate of lymph node metastasis around the region of the accessory nerve: a multicentre prospective observational study.

OBJECTIVE: Although neck dissection is an essential technique in the surgical treatment of head and neck carcinoma, arm abduction disorders occurring after neck dissection reduce the patient's quality of life. METHODS: We prospectively evaluated the rate of lymph node metastasis in Levels IIB and V in head and neck cancer patients who underwent neck dissection at eight centres in Japan. In addition, post-operative arm abduction disability was classified according to functional assessment values at 1 month post-operatively, and the rate of maintained function at 6 and 12 months was evaluated. RESULTS: Lymph node metastasis occurred in Level IIB in 12 of 242 cases (4.9%) and in Level V in 5 cases (2.1%) during the 12-month post-operative course. In patients with preservation of the ipsilateral accessory nerve, arm abduction function was maintained in 142 of 209 patients (67.9%) at 12 months after surgery. Post-operative radiotherapy and Level V dissection had no statistically significant effect on the recovery of arm abduction function. Level V dissection caused a temporary loss of abduction function post-operatively. A higher arm abduction test score at 1 month post-operatively was associated with a higher rate of subsequent ability to maintain arm abduction function. CONCLUSIONS: In patients classified as cN0, metastatic rate at Levels IIB and V was low. In this cohort, omitting Level V dissection may be an option in strategies aimed at maintaining arm abduction function.

Rational surgical neck management in total laryngectomy for advanced stage laryngeal squamous cell carcinomas.

PURPOSE: Controversies exist in regard to surgical neck management in total laryngectomies (TL). International guidelines do not sufficiently discriminate neck sides and sublevels, or minimal neck-dissection nodal yield (NY). METHODS: Thirty-seven consecutive primary TL cases from 2009 to 2019 were retrospectively analyzed in terms of local tumor growth using a previously established imaging scheme, metastatic neck involvement, and NY impact on survival. RESULTS: There was no case of level IIB involvement on any side. For type A and B tumor midline involvement, no positive contralateral lymph nodes were found. Craniocaudal tumor extension correlated with contralateral neck involvement (OR: 1.098, p = 0.0493) and showed increased involvement when extending 33 mm (p = 0.0134). Using a bilateral NY of ≥ 24 for 5-year overall survival (OS) and ≥ 26 for 5-year disease-free survival (DFS) gave significantly increased rate advantages of 64 and 56%, respectively (both p < 0.0001). CONCLUSIONS: This work sheds light on regional metastatic distribution pattern and its influence on TL cases. An NY of n ≥ 26 can be considered a desirable benchmark for bilateral selective neck dissections as it leads to improved OS and DFS. Therefore, an omission of distinct neck levels cannot be promoted at this time.

Recommendation regarding the cranial upper border of level IIb in delineating clinical target volumes (CTV) for nasopharyngeal carcinoma.

PURPOSE: To recommend a cranial border for level IIb in delineating clinical target volumes (CTV) for nasopharyngeal carcinoma (NPC) patients receiving intensity-modulated radiotherapy and to help reach a consensus on contouring level IIb in CTV. METHODS: From 2012 to 2016, 331 nonmetastatic NPC patients treated with IMRT were retrospectively enrolled. Based on the AJCC 8th staging system of NPC, there were 15 stage I, 76 stage II, 103 stage III, and 137 stage IV patients. The distribution of cervical lymph nodes in NPC was assessed based on imaging. Comparisons of the safety and parotid dose parameters between patients with and without a reduction in the size of level IIb were conducted using SPSS 25.0 and R 2.14.2 software. RESULTS: Metastasis rates in the most commonly involved lymph nodes, the lateral retropharyngeal and IIb nodes, were 82.8% and 64.0%, respectively. Among patients with level IIb involvement, the upper borders of the metastatic nodes were beyond the caudal edge of C1 in 13.7% of cases. The parotid gland D50 and V26 values were significantly reduced after modifying the upper bound of level IIb used to delineate the CTV (P = 0.000). CONCLUSION: In principle, the upper bound of level IIb should reach the lateral skull base during delineation of the cervical CTV for NPC. To protect the parotid glands, however, individualized reduction of the upper bound of level IIb is recommended for patients who meet certain criteria.

The necessity of level IIb dissection for clinically negative neck oral squamous cell carcinoma.

AIM: Selective neck dissection reduces the incidence of complications associated with radical neck dissection while achieving the same oncological results, especially in clinically node-negative (cN0) cases. The most common complications associated with selective neck dissection are spinal accessory nerve dysfunction and shoulder disability, which result from level IIb dissection. The aim of the present study was to evaluate the incidence of level IIb lymph node metastasis in cN0 oral squamous cell carcinoma (OSCC) patients to determine the necessity of selective neck surgery. METHODS: The medical records of 138 consecutive OSCC cN0 patients seen from June 2012 to June 2017 were retrospectively reviewed for age, gender, tumor localization, and TNM classification. RESULTS: The incidence of occult metastasis was 29.7%, but level IIb nodes were not involved in any case. DISCUSSION: The lack of involvement of level IIb nodes in occult metastasis, and high prevalence of shoulder dysfunction caused by injury to the spinal accessory nerve during surgery, challenge the necessity of surgical IIb node clearance in cNO OSCC; this is true for all stages and especially for early T1 stage cases, when the likelihood of occult lymph node metastasis is low (15.6%).

Preservation of level IIb lymph nodes during supraomohyoid neck dissection for clinically node-negative oral squamous cell carcinoma.

PURPOSE: To identify the significance of level IIb neck dissection for patients with clinically node-negative oral squamous cell carcinoma (OSCC). METHODS: A retrospective study was conducted with 203 patients with OSCC with no palpable lymph nodes in neck admitted to the Department of Oral Maxillofacial-Head and Neck Oncology from January 2012 through December 2014. After the diagnostic evaluations, all patients underwent wide local dissection and periodic supraomohyoid neck dissection (SOHND). In total, 115 patients underwent SOHND with IIb lymph node dissection, and 88 patients underwent elective SOHND without IIb lymph node dissection. The incidence of level IIb lymph node metastasis was evaluated by pathological and immunohistological analyses. The results were analyzed with independent sample t-tests. The incidence of complications (mainly scapular syndrome) and IIb lymph node metastasis rate (mainly for the preserving IIb group) were analyzed. RESULTS: In total, 7 (6.09%) of the 115 patients who underwent SOHND had level IIb lymph nodes involvement. After 3 years of follow-up, 83 (72.17%) patients who underwent SOHND had different degrees of scapular syndrome, and 27 (32.53%) patients who underwent SOHND improved through rehabilitation training but did not fully recover. Four (4.55%) patients who underwent elective SOHND (preserving IIb) developed scapular syndrome and recovered through rehabilitation after surgery. The 3-year overall survival rate of the 115 patients was 86.09%, and the 3-year overall survival rate of the 88 patients who underwent elective SOHND (preserving IIb) was 84.09%. There were no significant differences between the two groups (P > 0.05). CONCLUSION: Patients with clinically N0 OSCC have a low rate of level IIb lymph node metastasis. Level IIb lymph nodes resection are not necessary during SOHND, which thereby protects the accessory nerve and its branches from damage and improves patient quality of life.

The necessity of IIb dissection in T1-T2N0M0 oral squamous cell carcinoma: protocol for a randomized controlled trial.

BACKGROUND: There is a growing debate on the relationship between health-related quality of life (HRQoL) and patient survival which has been going on for the last few decades. The greatest wish of clinicians is to extend the latter while improving the former. Following neck dissection of early-stage oral carcinoma, "shoulder syndrome" appears due to traction of the accessory nerve during removal of level IIb, which greatly affects patient quality of life. Since occult metastasis in level IIb of early-stage oral carcinoma is extremely low, some surgeons suggest that level IIb can be exempt from dissection to improve the HRQoL. However, other surgeons take the opposite view, and thus there is no consensus on the necessity of IIb dissection in T1-2N0M0 oral squamous cell carcinoma (OSCC). METHODS: We designed a parallel-group, randomized, non-inferiority trial that is supported by Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China. We will enroll 522 patients with early oral carcinoma who match the inclusion criteria, and compare differences in 3-year overall survival, progression-free survival (PFS) and HRQoL under different interventions (retention or dissection of level IIb). The primary endpoints will be tested by means of two-sided log-rank tests. Analysis of overall and progression-free survival will be performed in subgroups that were defined according to stratification factors with the use of univariate Cox analysis. In addition, we will use post-hoc subgroup analyses on the basis of histological factors that were known to have effects on survival, such as death of invasion of the primary tumor. To evaluate HRQoL, we will choose the Constant-Murley scale to measure shoulder function. DISCUSSION: Currently, there are no randomized controlled trials with large sample sizes on the necessity of IIB dissection in T1-T2N0M0 OSCC. We designed this noninferiority RCT that combines survival rate and HRQoL to assess the feasibility of IIb neck dissection. The result of this trial may guide clinical practice and change the criteria of how early-stage oral cancer is managed. The balance between survival and HRQoL in this trial is based on early-stage breast cancer treatment and may provide new ideas for other malignancies. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR1800019128 . Registered on 26 October 2018.

Metastatic involvement of level IIb nodal station in oral squamous cell carcinoma: A clinicopathological study.

BACKGROUND: The purpose of this study was to determine the prevalence of Level IIb metastasis in patients with oral squamous cell carcinomas (OSCCs). MATERIALS AND METHODS: A total of 110 newly diagnosed oral cavity cancer patients requiring surgery as the primary modality were included in the study. Preoperative clinical examinations were done and tumor-node-metastasis staging was noted. Intraoperatively, Level IIb nodal tissue was dissected and sent separately. RESULTS: A total of 129 neck dissections (58 SOHD, 67 modified neck dissections, and 4 radical neck dissections) were carried out in 110 patients (males = 80 and females = 30), 91 patients required unilateral neck dissection, and 19 patients required bilateral neck dissection. Out of these 129 neck dissections, only 4 (3.2%) neck dissections (in a total of 3 patients out of 110 patients) had Level IIb positive (with bilateral Level IIb involvement in one patient). CONCLUSIONS: Dissection of the Level IIb region in patients with OSCC may be required only in cases with advanced N stage, positive Level IIa lymph nodes, and extracapsular spread. Furthermore, in tongue cancers (high propensity of isolated Level II involvement), retromolar trigone, and floor of mouth cancers, routine Level IIb clearance should be considered.

Cervical level IIb metastases in squamous cell carcinoma of the oral cavity: a systematic review and meta-analysis.

PURPOSE: The aim of this study was to clarify whether level IIb dissection should be performed or avoided in the treatment of oral squamous cell carcinoma by meta-analysis. MATERIALS AND METHODS: Articles that were published before June 2017 were searched electronically in four databases (Web of Science, PubMed, Ovid and China National Knowledge Infrastructure) without any date or language restrictions by two independent reviewers. Abstracts and full-text papers which investigated the cervical metastases to level IIb from primary head and neck cancers and were deemed potentially relevant were screened. Data were analyzed using RevMan 5.3. RESULTS: Four hundred and fifty-five abstracts and 129 full-text papers were screened, and 22 studies were included in the analysis. Among the 2001 patients included, 112 patients had level IIb metastases, the pooled frequency of which was 6% (95% confidence interval [CI]: 4.0-7.0). Among the 400 patients with tongue squamous cell carcinoma from 12 studies, 37 patients had level IIb metastases, the pooled incidence of which was 7% (95% CI: 5.0-10.0). Metastases to level IIb always went together with level IIa, and only three patients were found to have isolated level IIb metastases without involving the other levels. CONCLUSION: Due to the low frequency of level IIb nodal metastases in oral squamous cell carcinoma patients and rare occurrence of isolated level IIb, level IIb dissection could be avoided when the primary lesions were in early stages (T1 and T2), with the exception of tongue cancer. It is recommended to dissect level IIb tongue cancers without considering the stages of primary lesions and the lymph nodes status. It is also suggested that level IIb dissection should be performed in patients preoperatively or intraoperatively found with multilevel neck metastasis, especially level IIa metastasis.

A Prospective Study of Level IIB Nodal Metastasis (Supraretrospinal) in Clinically N0 Oral Squamous Cell Carcinoma in Indian Population.

Oral cavity carcinoma is the most common cancer in Indian population. Metastatic nodal disease is the most important prognostic factor for oral cancers. In head and neck cancers with clinically N0 neck, standard selective neck dissection is performed by protecting the spinal accessory nerve to remove level IIA & IIB lymph nodes. The purpose of this study was to analyze the significance of level IIB dissection in patients of oral cavity cancer who underwent primary surgery with functional neck dissection. Two hundred ten patients with clinically N0 neck underwent neck dissection, where level IIB lymph nodes were dissected, labelled and processed separately. Among 210 patients of clinically N0 neck, 168 patients were pathologically N0 (80 %). Out of remaining 42 (20 %), 36 (17.14 %) were pN1 and 6 (2.86 %) were pN2. Among those with pN1 (36), level IB was involved in 24 patients (66.67 %) and level IIA was involved in 12 patients (33.33 %). Only 2 patients had involvement of level IIB lymph nodes. Among 6 patients of pN2 disease, 4 patients had simultaneous involvement of level IB and level IIA lymph nodes. Remaining 2 patients had isolated involvement of level III lymph nodes. Thus only 2 patients (< 1 %) out of 210 clinically N0 oral squamous cell carcinoma showed level IIB lymph node involvement. Thus we conclude that a frozen section of level 2a is advisable to decide the need for level 2b node dissection in clinically N0 neck as the sensitivity of clinical evaluation is extremely low.

Level IIb Neck Dissection in Oral Cavity Cancers- When Should One Address it..?

Nodal metastases is the most important prognostic marker for oral cavity cancers. Nodal dissection at level IIb risks damage to the spinal accessory nerve. We aim to study positivity of level IIb lymph nodes in oral cancers. In this non-randomized prospective observational study, 65 patients of oral cavity cancers were evaluated. Appropriate surgery for primary tumour and neck dissection were undertaken. All patients underwent level II b dissection. Out of 67 neck dissections (27 elective and 40 therapeutic), 7 patients had level IIb positive for metastases (10.44 %) with no isolated or contralateral metastases at level IIb and direct correlation with level IIa nodes. There was no statistical association of level IIb positivity with stage or site of primary. Level IIb dissection can be avoided in N0 necks. For therapeutic neck dissections, Level IIb should be cleared if there are positive nodes at level IIa.

Electrophysiologic analysis of injury to cranial nerve XI during neck dissection.

BACKGROUND: Despite preservation of the accessory nerve, a considerable number of patients report partial nerve damage after modified radical neck dissection (MRND) and selective neck dissection. METHODS: Accessory nerve branches for the trapezius muscle were stimulated during neck dissection, and the M wave amplitude was measured during distinct surgical phases. RESULTS: The accessory nerve was mapped in 20 patients. The M wave recordings indicated that major nerve damage occurred during dissection at levels IIa and IIb in the most proximal segment of the nerve. The M waves evoked from this nerve segment decreased significantly during surgery (analysis of variance; p = .001). CONCLUSION: The most significant intraoperative injury to the accessory nerve during neck dissection occurs at anatomic nerve levels IIa and IIb. © 2015 Wiley Periodicals, Inc. Head Neck 38: E372-E376, 2016.

Is it worthy? Removal of level IIB nodes during selective neck dissection (I-III) for oral carcinomas.

AIMS: The aim was to correlate the incidence of metastasis to Level IIB of neck lymph nodes (LNs) for oral cavity carcinomas with the site, size, and histological grade of tumor. SETTINGS AND DESIGN: Total 30 patients of either sex, with biopsy-proven oral squamous cell carcinoma of any site, size or histologic grade, but N0/N1 were taken for selective neck dissection (SND). MATERIALS AND METHODS: Thirty patients who underwent SND for oral carcinoma were analyzed for the relation of the site, size, and histological grade of malignancy with metastatic involvement to Level IIB nodes. Level IIB nodes were dissected separately and sent for histopathological examination. STATISTICAL ANALYSIS USED: The data were entered in custom written software in Excel (MS office 2007, Windows XP) and the data were analyzed using statistical software STATA version 10.0. The statistical test used for the analysis of the result was Chi-square test. The critical level of statistical significance chosen was P < 0.05. RESULTS: Only 2 of 30 patients (6.6%) had the involvement of Level IIB neck nodes. There was no relation between the site, size, and histologic grade of primary tumor with the metastasis to Level IIB. The Level IIA nodes were positive in both the positive cases of Level IIB. CONCLUSIONS: For tumors in oral cavity (N0/N1), while performing elective or therapeutic SND the dissection of Level IIB nodes could be omitted as it will provide significant decrease in operative time and also less of spinal accessory nerve trauma-related complications.

Level IIB lymph node metastasis in oropharyngeal squamous cell carcinoma.

OBJECTIVES/HYPOTHESIS: To determine the incidence of level IIB lymph node metastasis in patients with oropharyngeal squamous cell carcinoma (OPSCC) and to evaluate the necessity of level IIB dissection for elective and therapeutic neck dissections. STUDY DESIGN: Retrospective cohort study. METHODS: Patients with OPSCC (N = 348) were surgically managed at our institution from 2004 through 2010. Neck dissection specimens were reviewed by a pathologist, and level IIB metastases were analyzed with respect to clinical and pathologic data. RESULTS: Level IIB lymph node metastases were present in 2.5% and 25% of elective and therapeutic neck dissections, respectively. Level IIA metastasis, clinical tumor stage, clinical nodal stage, extracapsular spread, and primary tumor location in the tonsil were significantly associated with level IIB metastasis. CONCLUSIONS: This study uniquely demonstrated a statistically significant association between clinical tumor stage and tonsil subsite with level IIB metastasis in OPSCC. Considering the predicted incidence of nodal metastasis, we conclude that level IIB neck dissection can be omitted in early stage (T1 or T2) clinically node negative (cN0) OPSCC. In patients with a cN0 neck and advanced OPSCC (T3 or T4), primary tumor in the tonsil, or ipsilateral clinically node positive (cN(+) ) and contralateral cN0 neck, level IIB dissection should be considered. Level IIB dissection should be performed routinely in patients with cN(+) OPSCC.

Level IIB lymph node metastasis in laryngeal and hypopharyngeal squamous cell carcinoma: single-institution case series and review of the literature.

OBJECTIVES/HYPOTHESIS: To determine the incidence of level IIB lymph node metastasis in patients with laryngeal or hypopharyngeal squamous cell carcinoma and to evaluate the need for elective and therapeutic neck dissection of level IIB. STUDY DESIGN: Retrospective cohort study and review of the literature. METHODS: Patients with laryngeal or hypopharyngeal squamous cell carcinoma (N = 65) were primarily treated with surgery at Mayo Clinic (Rochester, Minnesota) from 2004 through 2010. Neck dissection specimens were analyzed by a pathologist, and metastases to level IIB were reported. In addition, 18 previously published studies, totaling 1,114 neck dissections, were reviewed. RESULTS: Level IIB lymph node metastases were present in 4% and 17% of elective and therapeutic neck dissections, respectively. Ipsilateral IIB metastasis was more common than contralateral IIB metastasis in elective and therapeutic neck dissection specimens. Level IIB lymph node metastasis was not significantly associated with level IIA nodal metastasis, level III nodal metastasis, clinical primary tumor stage, clinical nodal stage, or pathologic confirmation of extracapsular spread in either laryngeal or hypopharyngeal squamous cell carcinoma. CONCLUSIONS: The rate of occult IIB metastasis in laryngeal and hypopharyngeal squamous cell carcinoma is exceedingly low. In a clinically node-negative case, the ipsilateral and contralateral level IIB nodal packet should not be dissected. For clinically node-positive cases, ipsilateral level IIB dissection should be performed; contralateral IIB dissection should be performed only when indicated.

Evaluating the significance of level IIb neck dissection for hypopharyngeal cancer.

BACKGROUND: This study evaluated cervical lymph node metastases at level IIb in cases of hypopharyngeal cancer and analyzed the possibility of preservation of level IIb during neck dissection. METHODS: In total, 34 patients (51 neck sides) with hypopharyngeal cancer that underwent neck dissection from April 2008 to April 2011 were retrospectively analyzed. We evaluated the distribution of metastatic lymph nodes at various levels (particularly level IIb) in cases treated with therapeutic neck dissection and elective neck dissection. RESULTS: The incidence of metastases in level IIb was 13.3% (4 of 30 patients) for therapeutic neck dissection and 0% (0 of 21 patients) for elective neck dissection. All the level IIb metastases were found on the ipsilateral side in the cases treated with therapeutic neck dissection. CONCLUSIONS: The results suggest that preservation of level IIb during neck dissection was possible in N0 cases of hypopharyngeal cancer.

Involvement of level IIb lymph node metastasis and dissection in thyroid cancer.

Thyroid neoplasms are the most frequent neoplasm in the head and neck region. Most thyroid carcinomas are well-differentiated tumors of follicular cell origin. Thyroid papillary carcinoma (TPC) is the most common thyroid malignancy. It constitutes 60% to 90% of all the thyroid carcinomas and cervical lymph node metastases are commonly seen in these patients. Although cervical lymph node metastases are common in this cancer, the management and the prognostic role of lymph nodes in TPC remains controversial. In this paper we reviewed the currently available literature regarding the extent of lateral neck dissection in papillary thyroid carcinoma patients with lateral neck metastasis.

Status of level IIb lymph nodes of the neck in squamous cell carcinoma of the oral tongue in patients who underwent modified radical neck dissection and lymph node sentinel biopsy.

Status of lymph nodes of level IIb was examined to identify the incidence of nodal metastasis and the lymphatic drainage in squamous cell carcinoma of the oral tongue in patients undergoing modified radical neck dissection (MRND) and sentinel node biopsy (SNB). Overall, 72 patients were divided into two groups; 38 patients (Group A) of any T and N+ or T3-T4- N0 stage underwent MRND. The surgical specimens were sent to the Pathology Department, divided into specific levels (I, IIa, IIb, III, IV, V) and labelled. The remaining 34 patients (Group B) T1-T2 -N0 stage were submitted to SNB. The histological examination of the specimens of the two groups was performed by staining with haematoxylin and eosin several sections from each node at different levels and then using a molecular marker such as cytokeratin and Epithelial Membrane Antigen (EMA). In Group A: In N0 there were no occult metastases at level IIb; in N+ neck, 8 cases (33.3%) showed metastasis at level IIb (P = 0.04). Metastases at level IIb were observed only in combination with other levels (P = 0.03). In Group B, direct lymphatic drainage was found in 2 patients (5.9%) at level IIb. There were no occult metastases at level IIb. Out of the 54 sentinel nodes harvested, 4 lymph nodes (7.4%) were found to be metastatic; these 4 sentinel nodes were found respectively in 4 patients, 1 at level III, 3 at level II a with an occult metastasis rate of 11.7%. In conclusion, SNB has prospected a new concept of lymphatic drainage that is variable and individual. SNB has demonstrated that direct lymphatic drainage is possible to level II b. In our experience with early cancer of the tongue (T1-T2 NO ), SNB aided with lympho-scintigraphy seems to be a good technique for staging the neck with minimal morbidity.