Personal Contribution to the History of Neck Dissection

The evolution of neck dissection in Latin countries followed a similar course to that of the United States during the first half of the 20th century. During those early years, neck dissection was not widely used in spite of the well-known work of Crile. The name of the masters of Spanish laryngology—Garcia Tapia, Ager, Sanchez Rodriguez, M. Gavilan, and others—was recognized among the world experts in the emerging field of what eventually would be called head and neck surgery. However, the surgeons of these early times still used terms such as visiting the lymphatic chains and nodal toilette when referring to lymph node surgery associated with the removal of the primary tumor. The term visiting the lymphatic chains was used to describe a shy palpation along the carotid sheath in an attempt to identify enlarged nodes suspicious of harboring metastatic cells. When the nodes were identified as potentially metastatic, a nodal toilette was performed. In reality this was no more than an elegant name for a vulgar node picking.

The work of Hayes Martin completely changed the world of neck dissection by popularizing the operation described by Crile in 1906. Radical neck dissection soon became the standard procedure for patients requiring surgical treatment of the lymphatics of the neck in combination with removal of the primary tumor. As often happens in life, the law of the pendulum proved again to be a loyal fellow of human progress. In a very short period of time neck surgery moved from a ''slight caress'' to the lymphatic tissue of the neck to an aggressive management of all neck structures. The lymphatic tissue had to be removed from the neck and the best way to do this was by removing almost every single structure within the cervical area. Only the carotid artery and some ''lucky'' nerves survived the Halsteadian concept of oncological surgery.

It soon became evident to all those involved in the management of patients with head and neck cancer that the radical operation was adequate for the treatment of large palpable masses, but excessive for patients without palpable nodes under high risk of cervical metastasis, as well as for some patients with small palpable nodes. It was also noteworthy that radical neck dissection was not practical as a simultaneous bilateral procedure. And bilateral issues were extremely important in countries with a high incidence of midline lesions (e.g., tumors of the supraglottic larynx, base of the tongue, etc.).

In 1967 I (CG) was appointed as chairman of the Department of Otolaryngology at La Paz Hospital. This was the first large hospital of a newly developed national health system in Spain and soon became the flagship of the Spanish public health system. During the first year, more than 125 new cases of cancer of the larynx were surgically treated. Radical neck dissection was used for patients with palpable nodes, but all other patients were left untreated. One year later, the new 125 laryngeal cancer patients had to share treatment with a large number of recurrent patients from the previous year. Most recurrences developed in the neck, and a significant percentage of them were inoperable at the time of diagnosis. We quickly realized that something was failing, and coined a sentence that became popular in our environment: ''Patients operated for cancer of the larynx die from nodal cancer.'' Radical neck dissection was not a solution to our problem because most patients were clinically N0 at presentation, and more than 60% of them had supraglottic tumors.

At that time there were rumors about an operation called functional neck dissection that was performed by an Argentinean named Osvaldo Suarez. The operation was designed to remove the lymphatic tissue of the neck, preserving the remaining neck structures. However, the operation was not appealing for two reasons: (1) It was less than the accepted dogma of the moment — radical neck dissection, and (2) the name suggested a dangerous approach to cancer. How can a terrible disease like cancer be treated with a mild ''functional'' operation? (Remember that Halsteadian principles were still leading the world of oncology at that time.) We had the opportunity to see a film on functional neck dissection performed in Spain. The film was of poor quality: the surgery was not systematic or didactic, the surgeon was messy, and the quality of the image was deplorable. After this experience our disapproval of the new technique was even more evident. We did not want this for our patients.

In the context of the previous paragraph it could be interesting to emphasize that a scientist's mind must have firm rules and guidelines, but should always be prepared to accept changes and innovations. In medicine there are no immutable rules—or at least there are very few of them— and one should always remain open to new concepts, techniques, or facts that can render true what initially seemed false. Scientists must be prepared to identify and respond appropriately to such information when it appears, sometimes by sheer good fortune, which is what happened in our case.

In 1968 I (CG) was invited to lecture on vestibular disorders at the Medical School of the University of Co rdoba (Argentina). Osvaldo Sua rez was among the attendants (Fig. 1-1). Although he was employed in the Department of Otolaryngology, he also worked at the Department of Anatomy under the direction of Pedro Ara. Professor Ara was known as the ''Spanish anatomist,'' and he was very popular in Argentina for having embalmed the corpse of Eva Peron. His dual projection as an anatomist and otolaryngologist conferred on Suarez a privileged position. On the one hand, as an otolaryngologist, he had a thorough knowledge of head and neck cancer— especially cancer of the larynx. On the other, as an anatomist, he was very familiar with all anatomical details concerning neck dissection.

After the course I was invited by Sua rez to watch a couple of surgical cases of cancer of the larynx with their respective functional neck dissections. The experience was striking—truly an instance of fortune knocking at our door.

The operation, as performed by Sua rez, was nothing like we had seen before. It was clean, systematic, comprehensive, and easy to understand and teach. Moreover, it looked extremely useful from an oncological standpoint. Thus, we immediately arranged for Sua rez to visit Madrid in the coming year. I asked him to remain with us at La Paz Hospital for 2 weeks. During the first week he would perform as many operations with us as possible. The second week would be devoted to a course on cancer of the larynx. He accepted our invitation.

In spite of his subsequently being diagnosed with a serious disease—which eventually killed him—he attended to his date in Madrid. In June 1969 he spent a week operating daily on head and neck cancer patients in our department, and a second week teaching a course in which he alternated lectures (Fig. 1-2) with live surgery demonstrations.

In 1970 we tried to contact him again to repeat the exciting experience of the previous year, but, unfortunately, he had died a few months earlier from the previously diagnosed illness. He left a well-trained disciple, who was also his relative, Dr. Filiberti, but he also died shortly thereafter, taking with him the knowledge and the tradition of Suarez's experience. We were among the last people directly trained by him, during the 2 weeks that he had spent in Madrid.

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