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      Neck Nodes at Level IIB in Oral Cavity Carcinoma: Can We Leave Behind Visible Nodes?


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          Oral cancer patients have a chance of metastasis to the cervical nodes. A prophylactic neck dissection is advised in clinically undetectable necks. The extent of the neck dissection has been in doubt and various levels with a low propensity are usually skipped such as level IIB. Though a routine level IIB node dissection is not suggested in patients with N0 neck, it is often confusing when visible nodes are present in this subgroup.

          Patients and methods

          A prospective analysis of consecutive oral cancer patients was conducted to see for level IIB nodes in an ipsilateral neck dissection.


          Forty-four patients underwent a neck dissection, including level IIB, retrieving 165 nodes from level IIB. Stage-wise distribution was 9, 22, 3, and 10 patients in T1, T2, T3, and T4 stages with majority in tongue cancers. An estimated 30 patients had a clinically node-positive disease, but only 18 underwent a modified or radical neck dissection. A pathologically node positive disease was seen in 12 patients, but only two had level IIB positive (0.01%), both of which had positive level IIA nodes.


          This study adds to the evidence that the majority of nodes in level IIB are reactive nodes and a metastasis to this group in isolation is unlikely.

          How to cite this article

          Babu S, Singh A, et al. Neck Nodes at Level IIB in Oral Cavity Carcinoma: Can We Leave Behind Visible Nodes? Int J Head Neck Surg 2018;9(4):117-120.

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          Most cited references14

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          Selective neck dissection (IIA, III): a rational replacement for complete functional neck dissection in patients with N0 supraglottic and glottic squamous carcinoma.

          The purpose of this paper is to determine the optimal elective treatment of the neck for patients with supraglottic and glottic squamous carcinoma. During the past century, various types of necks dissection have been employed including conventional and modified radical neck dissection (MRND), selective neck dissection (SND) and various modifications of SND. A number of studies were reviewed to compare the results of MRND and SND in regional recurrence and survival of patients with supraglottic and glottic cancers, as well as the distribution of lymph node metastases in these tumors. Data from seven prospective, multi-institutional, pathologic, and molecular analyses of neck dissection specimens, obtained from 272 patients with laryngeal squamous carcinoma and clinically negative necks, revealed only four patients (1.4%) with positive lymph nodes at sublevel IIB. Data was also collected from three prospective, multi-institutional, pathologic and molecular studies of neck dissection specimens which include 175 patients with laryngeal squamous carcinoma (only 2 with subglottic cancer) and clinically negative necks. Only six patients (3.4%) had positive nodes at level IV. SND of sublevel IIA and level III appears to be adequate for elective surgical treatment of the neck in supraglottic and glottic squamous carcinoma. Dissection of level IV lymph nodes may not be justified for elective neck dissection of stage N0 supraglottic and glottic squamous carcinoma. Bilateral neck dissection in cases of supraglottic cancer may be necessary only in patients with centrally or bilaterally located tumors.
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            Dissection of the submuscular recess (sublevel IIb) in squamous cell cancer of the upper aerodigestive tract: prospective study and systematic review of the literature.

            Selective neck dissection is commonly used to clear occult neck metastases in the N0 neck. The aim of this study was to identify the incidence of occult metastases in lymph nodes of sublevel IIb (submuscular recess; SMR) in upper aerodigestive tract squamous cell carcinoma in the setting of clinically and radiologically staged N0 necks and to perform a systematic review of the literature on the incidence of metastases in this setting. We conducted a prospective study of 50 neck dissections and systematic review of the literature. (A) Prospective study: Tissue dissected out from the SMR was sent separately for histopathologic analysis. Between 0 and 7 nodes were harvested from sublevel IIb. One patient had a metastatic node in sublevel IIb with extracapsular spread in the ipsilateral neck. No other positive nodes were detected. Sixteen necks showed occult metastases at other levels. (B) Systematic review: The review identified 14 articles with 903 necks suitable for inclusion. The overall incidence of metastatic disease at this sublevel in the context of an N0 neck from any site is 2.0% (18 of 903). The incidence of occult metastatic disease in sublevel IIb for oral cavity, oropharyngeal, and laryngeal cancer is 3.9% (11 of 279), 5.2% (5 of 96), and 0.4% (1 of 230) patients, respectively. Contralateral positive nodes (0.9%) and isolated metastases (0.3%) at this sublevel were rare. Nodal metastases are uncommon in the SMR even in the presence of positive nodes in adjacent sublevel IIa. There appears to be no advantage in performing contralateral SMR dissection in N0 necks and in laryngeal primaries.
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              Prevalence of nodal metastases in the submuscular recess (level IIb) during selective neck dissection.

              To determine the prevalence of nodal metastases in the submuscular recess (SMR) in patients undergoing selective neck dissection (SND) and to identify potential risk factors for the presence of metastatic disease in the SMR. Prospective cohort study. Academic tertiary care referral center. Consecutive patients undergoing SND for squamous cell carcinoma of the head and neck between January 5, 1998, and November 23, 2001, were prospectively analyzed. Patients with a history of neck dissection or whose pathology reports did not clearly distinguish the SMR from other nodal levels were excluded from the study. Patients underwent SND based on the primary tumor site and well established regional lymphatic drainage patterns.Main Outcome Measure Presence of histopathologically proven nodal disease in the SMR. Seventy-four patients underwent 90 SNDs, 16 of which were bilateral. The prevalence of metastases in the SMR was 1.6% (1/63) in clinically N0 necks and 11.1% (3/27) in clinically node-positive necks, with an overall incidence of 4.4% (4/90). There was a statistically significant association between SMR metastases and advanced pathologic N stage (P =.003), particularly with positive nodal disease in level IIa (P =.001). Extracapsular tumor spread was also shown to have a statistically significant association with metastases in the SMR (P =.01). No significant associations were observed between SMR metastases and primary tumor site (P =.06), clinical N stage (P =.09), a history of primary tumor recurrence (P =.52), or previous radiation therapy (P =.68). The results of the present study suggest that nodal metastases in the SMR are rare in head and neck cancer patients undergoing SND.

                Author and article information

                International Journal of Head and Neck Surgery
                Jaypee Brothers Medical Publishers
                October-December 2018
                : 9
                : 4
                : 117-120
                [1,5 ]Department of Surgical Oncology, Malabar Cancer Centre, Thalassery, Kerala, India
                [2 ]Department of Maxillofacial Surgery, Government Dental College, Shimla, Himachal Pradesh, India
                [3 ]Department of Oncopathology, Malabar Cancer Centre, Thalassery, Kerala, India
                [4 ]Department of Radiation Oncology, Malabar Cancer Centre, Thalassery, Kerala, India
                Author notes
                Sajith Babu, Department of Surgical Oncology, Malabar Cancer Centre, Thalassery, Kerala, India, Phone: +91 9496048806, e-mail: drsajith@ 123456gmail.com
                Copyright © 2018; Jaypee Brothers Medical Publishers (P) Ltd.

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