Chapter 146.

Management of the Neck

in Head and Neck Cancer
David E Eibling

Table of Contents
SUGGESTED READING .................................................................................................................... 3

Many cancers of the head and neck metastasize to the regional lymph nodes early in the course of the disease.
The impact on prognosis is dependent on primary site and stage, tumor growth characteristics, presence of distant
metastases, and extent of regional adenopathy. Some sites (oropharynx and nasopharynx) and some tumor variants
such as Epstein-Barr virus (EBV) and human papilloma virus (HPV)-related cancers demonstrate an early propensity to

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 Management of the Neck
in Head and Neck Cancer

metastasize, whereas others (i.e. glottic cancers) rarely metastasize until late in the disease course. With the exception
of thyroid and EBV-related nasopharyngeal cancers, the presence of cervical adenopathy reduces the likelihood of cure,
and the staging system reflects this negative impact. As a result, treatment strategies for head and neck cancer must
consider management of the neck, whether or not palpable adenopathy is present. Recent studies have demonstrated
significant differences in the clinical behavior of HPV-related oropharyngeal (OP) cancer, with improved survival even
in the presence of adenopathy, hence dramatic changes in treatment algorithms for HPV-related OP cancer may be
promulgated in the near future. This algorithm will address cancers of the upper aerodigestive track and nonmelanoma
skin cancer, but not thyroid, salivary gland, or melanoma.

A. The history, physical examination, and imaging will determine the clinical stage of the cancer. The presence
of palpable adenopathy indicates, for most head and neck cancers, stage III disease. The probability of occult
adenopathy in a clinically negative neck is dependent on the site and extent of the primary tumor, as well as cell type.
The presence of specific molecular markers, as currently employed in thyroid and melanoma, may be incorporated
into future treatment algorithms.

B. Imaging is typically obtained at the time the head and neck cancer is identified or suspected. The standard in many
centers is computerized tomography (CT), although ultrasound is commonly used by those experienced with its
performance. Positron-emission tomography (PET) imaging, especially combined with CT (PET-CT) is useful in
demonstrating extent of disease as well as regional and distant metastases, but will fail to detect small (<1 cm)
tumor deposits. Imaging of the chest is required for all patients with head and neck cancer, and is usually obtained
at the same time the neck and primary tumor is imaged. Malignant neck nodes with central necrosis often resemble
benign cystic masses on imaging, which can lead to delayed diagnosis. The absence of radiographic evidence of
metastatic disease does not rule out the presence of histologically positive regional nodes.

C. The presence of a neck mass in an adult suggests the presence of metastatic cancer until proven otherwise.
Concurrent with the increasing prevalence of HPV-related cancer in nonsmokers, the probability that a neck mass
in any adult represents metastatic cancer has increased. Even in the absence of a visible or palpable primary tumor,
the physician must assume that a neck mass is cancer until proven otherwise.

D. The initial step in the evaluation of a neck mass without an identifiable primary cancer should be a fine-needle
aspiration biopsy (FNAB). Unfortunately, the false-negative FNAB rate of a cystic neck mass is ~30%. Therefore, a
negative FNAB mandates a repeat FNAB, core-needle biopsy, or even eventual open biopsy to rule out malignancy.
Molecular markers for HPV should be obtained in addition to histologic examination and may impact therapeutic
decisions.

E. Biopsy-proven metastatic cancer in the absence of primary cancer mandates a search for the primary. The search
is directed by the location and histology of the positive node. If not previously performed, imaging, to include
PET-CT if available, should be obtained. Laryngopharyngoscopy under general anesthesia with focused biopsies
of likely sites is the next step. Most surgeons perform routine tonsillectomy as well as directed biopsies of the base
of tongue. More recently, many head and neck surgeons routinely perform robotic excision of the tongue base due
to the occult nature of many primary cancers. Careful histologic examination is required since large palpable nodes
are often associated with very small (2–3 mm) primary cancers.

F. If no primary tumor is found, most centers radiate the usual locations of occult primaries within Waldeyer's ring,
including the neck nodes.

G. Definitive therapy of primary and neck nodes depends on a variety of factors, including local therapeutic algorithms.
Palpable adenopathy in association with a known primary tumor requires treatment (therapeutic neck dissection). If
the primary and metastases are resectable with curative intent, the preferred modality is therapeutic neck dissection.
If unresectable, then nonoperative treatment is selected. If primary radiation therapy is selected as the treatment
modality for the primary tumor, typically the neck nodes are incorporated into the treatment plan. Larger nodes and
advanced primary cancers are managed with radiotherapy with radiosensitizing doses of chemotherapy (CRT).

H. Decisions regarding contralateral neck dissection (and type of dissection) are site specific. Bilateral therapeutic
neck dissection is the standard therapy for patients with bilateral palpable nodes, or for specific tumor sites such as
midline tongue/floor of mouth cancers, medial wall of pyriform sinus, and supraglottis.

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 Management of the Neck
in Head and Neck Cancer

I. The presence of occult adenopathy varies widely with tumor site and histology. Imaging may identify suspicious
adenopathy but has a wide margin of error. Malignant neck nodes often appear as cystic masses on imaging.
Positron-emission tomography imaging, especially when combined with CT may be beneficial, but will fail to detect
small (<1 cm) tumor deposits. The absence of radiographic findings to suggest metastatic disease does not rule out
the presence of histologically positive regional nodes.

J. In the absence of palpable or radiographic evidence of cervical metastases, decisions regarding the treatment of
the neck are based on the knowledge of the biologic behavior of the specific cancer, with specific attention to the
incidence of occult adenopathy. Although not included in the staging system, depth of invasion has been shown
to impact the likelihood of metastasis in cancers of the oral tongue. The incidence of bilateral adenopathy is very
high in supraglottic and hypopharyngeal cancers; hence, bilateral neck dissections are standard part of treatment,
even in the absence of palpable nodes. Most authorities perform sentinel node biopsies (SNBs) for intermediate-
thickness melanoma since the presence of positive nodes has a large impact on therapeutic decisions, whereas SNB
has not yet supplanted elective neck dissection in upper aerodigestive tract squamous cell cancer.

K. Treatment of the neck is not required for low-risk cancers—such as superficial (<4 mm depth) tongue cancers or
superficial small (<2 cm) skin cancers—when there is no objective evidence of adenopathy.

L. Histologic examination of the resected primary and neck specimens provides rich information regarding the biologic
behavior of the malignancy. Histologic characteristics such as extracapsular spread of cancer, or perineural or
intravascular invasion suggest a biologically aggressive tumor, information that helps drive treatment decisions.

M.Most centers use post-treatment PET-CT scanning to drive decision making following completion of therapy,
particularly CRT in which clinical follow-up is often difficult. The sensitivity of PET-CT for persistent cancer is
high; however, specificity is not. Local inflammation following therapy persists for several months, hence early
post-treatment imaging (<3 months) should be avoided. A negative PET-CT implies cure, whereas a positive scan
is of less value (specificity of 50%) in driving decision making regarding biopsy and salvage therapy.

SUGGESTED READING
RM, Byers PF, Wolf AJ. Ballantyne “Rationale for elective modified neck dissection.” Head Neck Surg. 1998;10:160–
167.

C, Lutz JT, Johnson EN, Myers et al. “Supraglottic carcinoma: patterns of recurrence.” Ann Otol Rhinol Laryngol.
1990;99:12–17.

Myers E (Ed). Operative Otolaryngology: Head and Neck Surgery, 2nd edition. Philadelphia, PA: WB Saunders; 2004.

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