Is Functional Neck Dissection Still Possible After Open Nodal Biopsy

In most cases, no functional approach is possible after a previous open biopsy of the neck. An open nodal biopsy usually impedes a functional approach to the neck.

The discussion about the drawbacks of open nodal biopsy started more than 50 years ago, during the time of Hayes Martin. Later studies supported that open neck biopsy was harmful in terms of increased wound necrosis, cervical recurrence, and distant metastasis. However, subsequent studies suggested that there is no detriment to survival or recurrence if definitive treatment follows the biopsy without significant delay. A significant detriment to the patient after open neck biopsy is that more structures need to be sacrificed at the time of definitive neck surgery, because a functional approach will not be possible after open nodal biopsy. At present, this is one of the most important arguments against open neck biopsy.

HOW DO YOU APPROACH A PATIENT WITH SMALL BILATERAL NODES SUITABLE FOR BILATERAL FUNCTIONAL NECK DISSECTION?

A frequent concern in bilateral neck dissection when both sides of the neck are clinically positive is whether it will be possible to preserve at least one internal jugular vein.

In some instances this may be solved by starting the dissection on the "good" side—the one with smaller nodes. This will probably ensure the preservation of the internal jugular vein on the first side, allowing a more aggressive approach on the "bad" side. However, this approach may prove impractical if the internal jugular vein is injured or must be sacrificed on the good side. In such instances the dissection of the opposite, or bad, side may be delayed approximately 3 weeks, or may be performed, accepting the risk associated with the simultaneous removal of both internal jugular veins.

WHEN BILATERAL FUNCTIONAL NECK DISSECTION IS INDICATED AND THE INTERNAL JUGULAR VEIN IS DAMAGED DURING THE DISSECTION OF THE FIRST SIDE, WILL YOU CONTINUE THE OPERATION, OR DO YOU PREFER TO STAGE THE SECOND SIDE?

The easier answer is: do not damage the internal jugular vein during surgery. However, this is not always possible and accidents do happen. On the other hand, sometimes the vein must be sacrificed on one side for oncological reasons. In such circumstances we will probably continue the operation and dissect the opposite side if the clinical situation suggests a reasonable chance of preserving the contralateral vein. The chances of accidental damage to the opposite internal jugular vein are low and there is a high probability that the operation can be completed in a single surgical time without problems.

The situation is different if radical neck dissection is planned on the opposite side or the chances to preserve the opposite internal jugular vein are low. Here the decision is more difficult. Staging the operation means not operating the side with the higher stage of disease and waiting approximately 3 weeks before definitive treatment may be accomplished. This should be regarded as potentially harmful for the patient. The alternative is to continue the operation, trying to preserve as much superficial venous drainage as possible, keeping in mind that oncological safety is much more important than venous preservation. When no superficial drainage can be preserved and both internal jugular veins are removed in the same operation, the patient must be carefully managed in the intensive care unit, and appropriate hydroelectrolytic balance should be maintained. In spite of these maneuvers, there is a high risk of severe complications. Thus, the final decision should be taken according to the patient status and clinical scenario.

WHICH IS YOUR APPROACH TO BORDERLINE INDICATIONS: FUNCTIONAL OR RADICAL?

Dealing with borderline indications requires clear concepts to avoid faulty decisions. There are two basic oncological premises that must guide the surgeon's mind when facing a borderline case:

1. Life is more important than function.

2. The first treatment is the most likely to succeed.

With this in mind the surgeon must decide the most appropriate approach for every single case. Most of the time this will probably be a more aggressive approach than desired. It must be clear to every head and neck surgeon that cancer cells cannot be ''chased'' with a knife, and technical demonstrations of surgical expertise are not good for the patient and should be limited to the dissection room.

In conclusion, when in doubt, choose the procedure that, in your own personal experience, offers the patient the highest chance for cure. Establishing priorities is one of the first things that every surgeon must learn, and for head and neck cancer surgery life is the first priority to consider.

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