Recu le :

24 septembre 2008
Accepte le :
18 janvier 2010
Disponible en ligne
6 mars 2010

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Original article

Effectiveness of modified radical neck

dissection and postoperative radiotherapy
Efficacite dun evidement cervical radical modifie en
association avec la radiotherapie postoperatoire
N. Zwetyengaa*, J.-C. Fricaina, H. Demeauxb, C. Deminie`rec, F. Siberchicota
a

Department of Maxillofacial and Plastic Surgery, University hospital of Bordeaux,

place Amelie-Raba-Leon, 33076 Bordeaux cedex, France
b
Department of Radiotherapy, University hospital of Bordeaux, hopital Saint-Andre,
1, rue Jean- Burguet, 33076 Bordeaux cedex, France
c
Department of Anatomy, University hospital of Bordeaux, place Amelie-Raba-Leon,
33076 Bordeaux cedex, France

Summary

Resume

Background and objective. The aim of this study was to evaluate

the effectiveness of a modified radical neck dissection with preservation of non-lymphatic structures usually removed in advancedstage head and neck epidermoid carcinoma associated with postoperative radiotherapy (PORT).
Methods. We analyzed retrospectively the files of 109 patients, presenting with epidermoid carcinoma of the upper digestive/respiratory
tract staged N2 or N3, over a 6-year period. The rates of regional control,
mortality, and recurrence were analyzed and linked to the kind of
neck-dissection (usual radical neck dissection [RND], modified radical
neck dissection [MRND], selective neck-dissection [SND]) performed.
Results. Forty-three neck dissections were RND, 92 were MRND,
and 21 were SND. PORT was used in all cases. The mean follow-up was
57.3 months. The overall rate of regional control was 93.6% (97.7% for
RND and 93.5% for MRND; p = 0.35). Patients having undergone
MRND had a better prognosis and less recurrence then patients having
undergone RND (respectively p = 0.007, and p = 0.0004).
Discussion. MRND in association with PORT is an effective treatment in patients with advanced head and neck epidermoid carcinoma
staged N2 and N3.
2010 Elsevier Masson SAS. All rights reserved.

Introduction. Le but de cette etude etait devaluer lefficacite dun

evidement cervical radical modifie preservant les structures non
lymphatiques habituellement resequees dans les stades cervicaux
avances des carcinomes epidermodes des voies aerodigestives
superieures en association avec la radiotherapie postoperatoire.
Patients et methodes. Les dossiers de 109 patients pris en charge
pour un carcinome epidermode des voies aerodigestives superieures sur une periode de six ans et classes N2 ou N3 ont ete analyses de
manie`re retrospective. Le taux de remission regional, la mortalite et
le taux de recidive ont ete analyses et rapportes au type devidement
cervical (evidement cervical radical classique [ECR], evidement
cervical radical modifie [ECRM], evidement cervical selectif
[ECS]).
Resultats. Qurante-trois evidements etaient des ECR, 92 etaient
des ECRM et 21 etaient des ECS. La radiotherapie postoperatoire a
ete systematique. Le suivi moyen etait de 57,3 mois. Le pourcentage
global de remission cervicale a ete de 93,6 % (97,7 % pour lECR et
93,5 % pour lECRM ; p = 0,35). Les patients ayant beneficie dun
ECRM avaient un meilleur pronostic vital et moins de recidives
compares aux patients ayant beneficie dun ECR classique (respectivement p = 0,007 et p = 0,0004).
Discussion. LECRM associe a` la radiotherapie postoperatoire est
un traitement efficace des carcinomes epidermodes des voies aerodigestives superieures chez les patients classes N2 et N3.
2010 Elsevier Masson SAS. Tous droits reserves.

Keywords : Epidermoid carcinoma, Head and neck cancer, Neck

dissection, Radiotherapy

Mots cles : Carcinome epidermode, Cancer de la tete et du cou,

Evidement cervical, Radiotherapie
* Corresponding author.
e-mail : nzwetyenga@gmail.com (N. Zwetyenga).
0035-1768/$ - see front matter 2010 Elsevier Masson SAS. All rights reserved.
10.1016/j.stomax.2010.01.001 Rev Stomatol Chir Maxillofac 2010;111:59-62

59

N. Zwetyenga et al.

Rev Stomatol Chir Maxillofac 2010;111:59-62

Introduction

patients presenting with oral cavity tumors. Bilateral neck

dissections were performed whenever the primary tumor site
was on the median line or overlapped it, in cases of stage N2c,
and systematically for the apex and the base of the tongue. A
total of 156 neck dissections were performed: 43 RND, 92
MRND, and 21 SND. The neck dissection was bilateral in 47
patients (43.1%). All patients underwent PORT (mean dose:
59.4 Gy) since all of them were N+. The tumoral site and
bilateral neck were irradiated at 50 Gy. A boost up to 65 Gy
was used in neck areas with extra-capsular spread and in
incomplete resection tumor site. PORT was initiated within 4
weeks after surgery even in case of incomplete healing.
For each cervical specimen, the number of nodes, number and
location of positive nodes, and number and location of extracapsular spreads were recorded.
All patient data was recorded on a computer file (MEDLOGTM). Survival and recurrence probability were analyzed
with the Statistical Package for the Social Sciences (SPSSTM,
Chicago) according to neck stage (N2 or N3), histological
findings, and surgical procedure (RND or MRND). Neck recurrence was defined as a lymph node metastasis histologically
identical to the primary tumor, without any new head and
neck tumor, and at least 6 months after the first treatment.
The probability of survival or non-recurrence was estimated
by the Kaplan-Meier method considering the period between
the first and the last consultation, or death. The log-rank test
and Fisher exact test were used to assess statistical significance and considered significant if p was inferior or equal to
0.05.

Supraomohyoid neck dissection is an efficient and safe

method for patients presenting with carcinoma of the upper
digestive tract staged N0 according to UICC. [1,2]. Most
patients with head and neck squamous cell carcinoma present
with neck metastases. Cervical node involvement is the most
significant prognostic factor in those patients [3]. This emphasizes the exceptional importance of neck dissection. It has
been clearly established that postoperative radiotherapy
(PORT) improves both neck control and survival in such
patients [4,5]. The rational use of modified radical neck dissection (MRND) in conjunction with PORT seems to be an
effective neck treatment regardless of the primary site and
stage of the disease [6,7]. In advanced-stage cervical diseases,
classical radical neck dissection (RND) usually spares the
spinal accessory nerve (SAN) only [8,9]. Removing the sternocleidomastoid muscle (SCM) induces esthetic and functional
sequels. Exeresis of the internal jugular vein (IJV) prevents
microsurgical reconstruction.
In 1988, we decided to operate advanced head and neck
epidermoid carcinoma by MRND, whenever it was technically
feasible, with preservation of non-lymphatic structures (SAN,
SCM, and IJV) associated to PORT.
The aim of our study was to confirm the effectiveness of this
treatment in a homogeneous group of patients undergoing
the same protocol.

Patients and method

The files of 1076 patients were analyzed retrospectively. The
patients were all treated in our institution, between January
1999 and December 2005, for histologically proven squamous
cell carcinoma of the oral cavity, oropharynx, hypopharynx,
and larynx. One hundred and nine patients were staged N2 or
N3 and underwent RND or MRND. Unidentified primary
tumors, previous treatment, pre-operative chemotherapy or
radiotherapy, and incomplete PORT were exclusion criteria.
Ninety-eight male patients (89.9%) and 11 female patients
(10.1%) were included. The mean age was 57.4 years, ranging
from 17 to 87 years. The primary cancer sites were the oral
cavity in 31 cases (28.4%), the oropharynx in 43 cases (39.5%),
the hypopharynx in 24 cases (22%), and the larynx in 11 cases
(10.1%). Tumors were retrospectively staged according to
UICC. (table I). Seventy-nine patients were staged N2
(72.5%) and 30 staged N3 (27.5%). No patient presented with
metastases at the first consultation.
RND consisted in a complete lymphadenectomy with removal
of the SAN, the IJV, and the SCM. MRND consisted in a
complete lymphadenectomy with preservation of the SAN,
the IJV, and SCM. Selective neck dissection (SND) consisted in
the removal of node levels I, II, and III. The submental (level IA)
and submandibular triangle (level IB) were also removed in all

60

Results
The mean number of nodes removed per side was 27.3 (1446)
in RND and 26.2 (1245) in MNRD. Eighty-three patients (76.1%)
had extracapsular spread.
At the time of the study, 50 patients were still alive (45.9%), 48
of these were free of recurrence, 57 had died (52.3%), and two
were lost to follow-up (1.8%). The overall 2- and 5-year survival
rates were 57.9% and 39.4% respectively. The site of recurrences was local in 12 cases (11.0%), local with metastases in
three cases (2.8%), neck in four cases (3.7%), neck and metastases in three cases (2.8%), and metastases in 27 cases (24.8%).

Table I
Tumor staging according to the TNM system.
N\T

Tx

T1

T2

T3

T4

Total

N2a
N2b
N2c
N3

1
1

4
5

8
5
3
7

13
11
4
9

10
5
9
6

36
27
16
30

Total

16

23

37

30

109

TNM: Tumour node metastasis.

Effectiveness of modified radical neck dissection and postoperative radiotherapy

Figure 1. Probability of survival according to the type of neck dissection (p = 0.007).

The probability for 2- and 5-year non-recurrence was 50.5%

and 41.0% respectively. The mean delay for recurrence was
10.5 months.
Patients who underwent MRND had a more favorable
prognosis than those who had RND, at 5 years (respectively
48% and 39% of probability of survival; p = 0.007) (fig. 1).
Patients who had MRND had less recurrence than those who
had RND, at 5 years (respectively 57% and 22% of probabilities
of non-recurrence; p = 0.0004) (fig. 2). The site and nodal
status had no impact on survival and treatment failure.

At the end of the study, seven patients (6.4%) presented with

cervical lymph node metastases with no evidence of tumor
recurrence (table II). 97.7% of patients having undergone RND
(42/43) and 93.5% MRND (86/92) did not present with cervical
lymph node metastases (Fisher exact test; p = 0.35).
The overall rate of patients without cervical lymph node
metastases was 94.5% if the patient presenting with a
contralateral neck recurrence without neck dissection in this
area was included.
The mean follow-up was 57.3 months (minimum: 2 years).

Figure 2. Probability of non-recurrence according to the type of neck dissection (p = 0.0004).

61

N. Zwetyenga et al.

Rev Stomatol Chir Maxillofac 2010;111:59-62

Table II
Data for patients with cervical recurrence.
Number of Clinical
patients
TNM

Tumor site

Type of neck
dissection

Nodes
histological
status

Dose of Time of
recurrence
PORT
(Grays) (months)

Site of
recurrence

Metastases Status Follow-up

(in months)

1
2
3
4
5
6
7

Floor of mouth
Base of tongue
Inferior gum
Base of tongue
Oral mucosa
Oral tongue
Tonsillar pillar

RND/SND
MRND/MRND
MRND/MRND
MRND/SND
MRND
MRND
MRND

11C /3C+
29C /7C+
12C /4C+
8C /3C+
8C /2C+
14C /2C+
9C /2C+

65
65
65
65
65
66
65

Ipsilateral
Ipsilateral
Ipsilateral
Bilateral
Ipsilateral
Controlateral
Ipsilateral

Pulmonary

T3N3
T3N2c
T4N2c
T4N2a
T3N2b
T3N3
T2N2c

7
7
8
8
9
9
12

Cutaneous
Pulmonary

DFD - 12
DFD - 23
DFD - 21
DFD - 9
AWD - 28
DFD - 12
DFD - 16

PORT: postoperative radiotherapy; C+: positive nodes with extracapsular spread; DFD: died from the disease; AWD: alive without disease.

Discussion

[2]

This study confirmed the effectiveness of MRND in advanced

neck disease.
The standard surgical treatment of lymph node cervical
metastases in head and neck epidermoid carcinoma is RND.
It was first described by Crile and popularized by Martin et al.
[10,11]. Removing the SAN and SCM induces significant esthetic and functional morbidity. PORT decreases morbidity in
neck dissection and offers acceptable control of the disease.
Sparing a non-lymphatic structure, especially the SAN, is
advised [8,9]. Removal of the IJV prevents any microsurgical
reconstruction. MRND is acceptable when feasible, for
patients staged N2, even N2+, or N3 [12]. MRND does not
compromise oncologic safety, and may be converted to RND if
necessary.
The 2 and 5 year survival rate is satisfactory for patients
staged IV (TNM) with extra-capsular node spread in 76.1%.
MRND decreases the pejorative aspect of extra-capsular
spread in terms of survival and recurrence; it also allows
for a better quality of life.

[3]

[4]

[5]

[6]

[7]

[8]

[9]

Conflict of interest statement

The authors have not declared any conflict of interest.

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[11]
[12]

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