Crile and the Radical Neck Dissection

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The grandfather of neck dissection in North America is George Crile, Sr., of the Cleveland Clinic. In 1906, Crile portrayed the field of head and neck surgery as being behind the times in terms of interest and progress. Many head and neck cases were regarded as hopeless. The belief, at that time, held that cancer of the upper aerodigestive system remained localized until regional metastases developed. Regional lymph nodes were regarded as vigorous barriers to distant dissemination. Crile cited an autopsy study of 4500 patients with head and neck cancer that was initiated by himself but carried out by Dr. Hitchings. The latter claimed that less than 1% of head and neck cancers, at death, had distant metastases. Crile believed that, if the neck lymphatics could be removed in a "radical" manner and ''en bloc,'' more cures could be accomplished. The oncological premises of Crile's time were strongly influenced by Halstead. The concept of the ''bloc'' that was in vogue for the treatment of breast cancer required removal of the primary site with draining lymphatics and nodes in continuity. In breast surgery the pectoralis muscle was part of the "bloc." In the radical neck dissection the sternocleidomastoid muscle was removed to provide better access to the underlying lymphatics. No oncological benefits beyond access were claimed. In the radical breast operation the axillary vein was removed to give better clearance to lymph nodes. In the radical neck dissection the entire venous system of the lateral neck was included for the same reason. Medina observed that, in the drawings used to illustrate Crile's publication, the vein was not always removed. The analogous thinking behind head and neck and breast cancer procedures persisted for nearly a century. Following reconsideration of the basis for breast cancer surgery there was reconsideration of head and neck cancer surgery.

Crile identified several contemporary issues. He suspected a biological difference in tumor behavior and prognosis between patients who had palpable suspicious neck nodes and those who did not. He favored the radical operation for those who had palpable disease and a more limited operation for the others. The concept of a segmental or selective neck dissection is not new. Only the words used are new. Crile was not concerned about bilateral neck dissections, but he did note that staging was prudent. He believed that dissection in early cases in the absence of palpable disease was important. Increased rates of cure and decreased rates of recurrence occurred if the clinically negative neck was treated at the time of primary surgery. No statistics were cited to support his belief. Crile noted, without reference to the clinical situation (staging came much later), that among 48 patients who did not have a radical neck dissection, only nine were alive 3 years later. Of 12 other patients who underwent neck dissection 3 years after dissection, 9 were alive. From this he concluded that the radical operation was four times as effective as the less radical procedures (node picking or no neck treatment). This impression, with little supporting data, persisted for decades.

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