Neck Dissection Slides 060920

Neck DissectionNeck Dissection

Jeffrey Buyten, MDJeffrey Buyten, MD

Susan McCammon, MDSusan McCammon, MD

Francis B. Quinn, MDFrancis B. Quinn, MD

University of Texas Medical BranchUniversity of Texas Medical Branch

Department of OtolaryngologyDepartment of OtolaryngologyGrand Rounds PresentationGrand Rounds Presentation

September 2006September 2006

OutlineOutline

HistoryHistory AnatomyAnatomy

– Nodal levelsNodal levels– Common nodal drainage patternsCommon nodal drainage patterns

StagingStaging ClassificationClassification Sentinel Lymph NodeSentinel Lymph Node

HistoryHistory

Metastatic cervical lymph nodesMetastatic cervical lymph nodes– Early 19Early 19thth Century Century incurable disease incurable disease– 2020thth Century Century improved treatment of improved treatment of

neck diseaseneck disease– 2121stst Century Century second worst prognostic second worst prognostic

indicator for head and neck SCCAindicator for head and neck SCCA

1919thth Century Century 1880 1880 Kocher advocates wide margin Kocher advocates wide margin

lymphadenectomylymphadenectomy

1881 1881 Kocher and Packard recommend Kocher and Packard recommend dissection of submandibular dissection of submandibular

triangle triangle for lingual cancerfor lingual cancer

1885 1885 Butlin questions RND for oral N Butlin questions RND for oral N00 diseasedisease

1888 1888 Jawdynski describes en bloc Jawdynski describes en bloc resection with resection of resection with resection of

carotid, carotid, IJV, SCM.IJV, SCM.

Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.

2020thth Century Century 1901 1901 Solis-Cohen advocate Solis-Cohen advocate

lymphadenectomy for Nlymphadenectomy for N00 laryngeal laryngeal CACA

1905 -1906 1905 -1906 Crile describes en Crile describes en bloc resection in JAMAbloc resection in JAMA

1926 1926 Bartlett and Callander Bartlett and Callander advocate preservation of XI, IJV, advocate preservation of XI, IJV, SCM, platysma, stylohyoid, digastricSCM, platysma, stylohyoid, digastric

1933 1933 Blair and Brown advocate Blair and Brown advocate removal of removal of XI.XI.

Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.

2020thth Century Century 1951 1951 Martin advocates Radical Neck Dissection after anaysis of Martin advocates Radical Neck Dissection after anaysis of

1450 cases1450 cases– Advocated RND for all cases.Advocated RND for all cases.– Standardized the Radical Neck DissectionStandardized the Radical Neck Dissection

1952 – Suarez describes a functional neck dissection1952 – Suarez describes a functional neck dissection– Preservation of SCM, omohyoid, submandibular gland, IJV, XI.Preservation of SCM, omohyoid, submandibular gland, IJV, XI.– Enables protection of carotid.Enables protection of carotid.

1960’s – MD Anderson advocate selective ND of highest risk nodal 1960’s – MD Anderson advocate selective ND of highest risk nodal basinsbasins

1967 - Bocca and Pignataro describe the “functional neck 1967 - Bocca and Pignataro describe the “functional neck dissection”dissection”

1975 – Bocca establishes oncologic safety of the FND compared to 1975 – Bocca establishes oncologic safety of the FND compared to the RNDthe RND

Ferlito, A et al. Neck Dissection: past, present and future? J. Laryngol Otol. 2005 (1) 1-6.

AnatomyAnatomy

Lymph Node LevelsLymph Node Levels– Sloan Kettering nomenclatureSloan Kettering nomenclature– SubgroupsSubgroups

Common Nodal Drainage PatternsCommon Nodal Drainage Patterns

Level ILevel I

Submental triangle Submental triangle (Ia)(Ia)– Anterior digastricAnterior digastric– HyoidHyoid– MylohyoidMylohyoid

Submandibular Submandibular triangle (Ib)triangle (Ib)– Anterior and Anterior and

posterior digastricposterior digastric– Mandible.Mandible.

Marginal Mandibular NerveMarginal Mandibular Nerve Most commonly injury Most commonly injury

dissection level Ibdissection level Ib Landmarks:Landmarks:

– 1cm anterior and inferior 1cm anterior and inferior to angle of mandibleto angle of mandible

– Mandibular notchMandibular notch SubplatysmalSubplatysmal Deep to fascia of the Deep to fascia of the

submandibular glandsubmandibular gland Superficial to facial veinSuperficial to facial vein

Marginal Mandibular NerveMarginal Mandibular Nerve

Hypoglossal nerveHypoglossal nerve Lies deep to the IJV, Lies deep to the IJV,

ICA, CN IX, X, and XIICA, CN IX, X, and XI Curves 90 degrees Curves 90 degrees

and passes between and passes between the IJV and ICAthe IJV and ICA

Ranine veinsRanine veins Lateral to hyoglossusLateral to hyoglossus Deep to mylohyoidDeep to mylohyoid

Level ILevel I IaIa

– ChinChin– Lower lipLower lip– Anterior floor of mouthAnterior floor of mouth– Mandibular incisorsMandibular incisors– Tip of tongueTip of tongue

IbIb– Oral CavityOral Cavity– Floor of mouthFloor of mouth– Oral tongueOral tongue– Nasal cavity (anterior)Nasal cavity (anterior)– FaceFace

Level IILevel II Upper Jugular NodesUpper Jugular Nodes

Anterior Anterior Lateral border Lateral border of sternohyoid, posterior of sternohyoid, posterior digastric and stylohyoiddigastric and stylohyoid

Posterior Posterior Posterior Posterior border of SCMborder of SCM

Skull baseSkull base Hyoid bone (clinical Hyoid bone (clinical

landmark)landmark) Carotid bifurcation Carotid bifurcation

(surgical landmark)(surgical landmark)

Level IIa anterior to XILevel IIa anterior to XI Level IIb posterior to XILevel IIb posterior to XI

– Submuscular recessSubmuscular recess– Oropharynx > oral cavity Oropharynx > oral cavity

and laryngeal metsand laryngeal mets

Spinal Accessory NerveSpinal Accessory Nerve

CN XI – Relationship with the IJVCN XI – Relationship with the IJV

Level IILevel II

Oral CavityOral Cavity Nasal CavityNasal Cavity NasopharynxNasopharynx OropharynxOropharynx LarynxLarynx HypopharynxHypopharynx ParotidParotid

Level IIILevel III

Middle jugular nodesMiddle jugular nodes– Anterior Anterior Lateral border of Lateral border of

sternohyoidsternohyoid– Posterior Posterior Posterior border Posterior border

of SCM of SCM – Inferior border of level IIInferior border of level II– Cricoid cartilage lower Cricoid cartilage lower

border (clinical landmark) border (clinical landmark) – Omohyoid muscle (surgical Omohyoid muscle (surgical

landmark)landmark) Junction with IJVJunction with IJV

Level IIILevel III

Oral cavityOral cavity NasopharynxNasopharynx OropharynxOropharynx HypopharynxHypopharynx LarynxLarynx

Level IVLevel IV

Lower jugular nodes Lower jugular nodes – Anterior Anterior Lateral border Lateral border

of sternohyoidof sternohyoid– Posterior Posterior Posterior Posterior

border of SCMborder of SCM– Cricoid cartilage lower Cricoid cartilage lower

border (clinical landmark)border (clinical landmark)– Omohyoid muscle Omohyoid muscle

(surgical landmark)(surgical landmark) Junction with IJVJunction with IJV

– ClavicleClavicle

Phrenic NervePhrenic Nerve

Sole nerve supply Sole nerve supply to the diaphragmto the diaphragm

C3-5 C3-5 Anterior surface of Anterior surface of

anterior scaleneanterior scalene Under prevertebral Under prevertebral

fasciafascia Posterolateral to Posterolateral to

carotid sheathcarotid sheath

Thoracic ductThoracic duct Conveys lymph from the Conveys lymph from the

entire body back to the blood entire body back to the blood – Exceptions:Exceptions:

Right side of head and neck, Right side of head and neck, RUE, right lung right heart RUE, right lung right heart and portion of the liverand portion of the liver

– Begins at the cisterna chyliBegins at the cisterna chyli– Enters posterior mediastinum Enters posterior mediastinum

between the azygous vein between the azygous vein and thoracic aortaand thoracic aorta

– Courses to the left into the Courses to the left into the neck anterior to the vertebral neck anterior to the vertebral artery and veinartery and vein

– Enters the junction of the left Enters the junction of the left subclavian and the IJVsubclavian and the IJV

Thoracic DuctThoracic Duct

Level IVLevel IV

HypopharynxHypopharynx LarynxLarynx ThyroidThyroid Cervical esophagusCervical esophagus

Level VLevel V

Posterior triangle of neck Posterior triangle of neck – Posterior border of SCMPosterior border of SCM– ClavicleClavicle– Anterior border of Anterior border of

trapeziustrapezius– VaVa Spinal accessory Spinal accessory

nodesnodes– Vb Vb Transverse cervical Transverse cervical

artery nodesartery nodes Radiologic landmarkRadiologic landmark

– Inferior border of CricoidInferior border of Cricoid

– Supraclavicular nodesSupraclavicular nodes

Spinal Accessory NerveSpinal Accessory Nerve

Penetrates deep surface of Penetrates deep surface of the SCMthe SCM

Exits posterior surface of Exits posterior surface of SCM deep to Erb’s pointSCM deep to Erb’s point

Traverses the posterior Traverses the posterior triangle on the levator triangle on the levator scapulaescapulae

Enters the trapezius about Enters the trapezius about 5 cm above the clavicle5 cm above the clavicle

Level VLevel V

NasopharynxNasopharynx OropharynxOropharynx Posterior neck and scalpPosterior neck and scalp

Level VILevel VI

Anterior compartmentAnterior compartment– HyoidHyoid– Suprasternal notchSuprasternal notch– Medial border of carotid Medial border of carotid

sheathsheath– Perithyroidal lymph nodesPerithyroidal lymph nodes– Paratracheal lymph nodesParatracheal lymph nodes– Precricoid (Delphian) Precricoid (Delphian)

lymph node lymph node

Level VILevel VI

ThyroidThyroid Larynx (glottic and subglottic)Larynx (glottic and subglottic) Pyriform sinus apexPyriform sinus apex Cervical esophagusCervical esophagus

SubgroupsSubgroups IaIa SubmentalSubmental IbIb SubmandibularSubmandibular

IIaIIa Upper jugular (Anterior to XI)Upper jugular (Anterior to XI) IIb IIb Upper jugular (Posterior to XI)Upper jugular (Posterior to XI)

IIIIII Middle jugularMiddle jugular

IVaIVa Lower jugular (Clavicular)Lower jugular (Clavicular) IVbIVb Lower jugular (Sternal)Lower jugular (Sternal)

VaVa Posterior triangle (XI)Posterior triangle (XI) VbVb Posterior triangle (Transverse Posterior triangle (Transverse

cervical)cervical)

VIVI Central compartmentCentral compartment

Face and Scalp Anterior Facial, Ib

  Lateral Parotid

  Posterior Occipital, V

Eyelids Medial Ib

  Lateral Parotid, II

Chin   Ia, Ib, II

External Ear Anterior Parotid, II

  Posterior Post auricular, II, V

Middle Ear   Parotid, II

Floor of mouth Anterior Ia, Ib, IIa > IIb

  Lower incisors Ia, Ib, IIa > IIb

  Lateral Ib, IIa > IIb, III

  Teeth except incisors Ib, IIa > IIb, III

Nasal Cavity Anterior Ib

  Posterior Retropharyngeal, II, V

Common Nodal Drainage PatternsCommon Nodal Drainage Patterns

Nasal Cavity Posterior Retropharyngeal, II, V

Nasopharynx   Retropharyngeal, II, III, V

Oropharynx   IIb > IIa, III, IV, V

Larynx Supraglottic IIa > IIb, III, IV

  Subglottic VI, IV

Cervical esophagus   IV, VI

Thyroid   VI, IV, V, Mediastinal

Tongue Tip Ia, Ib, IIa > IIb, III, IV

  Lateral Ib, IIa > IIb, III, IV

Common Nodal Drainage PatternsCommon Nodal Drainage Patterns

StagingStaging Nx: Regional lymph nodes cannot be Nx: Regional lymph nodes cannot be

assessed.assessed.

N0: No regional lymph node metastases.N0: No regional lymph node metastases.

N1: Single ipsilateral lymph node, N1: Single ipsilateral lymph node, << 3 cm 3 cm

StagingStaging

N2a: Single ipsilateral lymph node 3 to N2a: Single ipsilateral lymph node 3 to 6 cm6 cm

N2b: Multiple ipsilateral lymph nodes N2b: Multiple ipsilateral lymph nodes << 6 cm 6 cm

N2c: Bilateral or contralateral nodes N2c: Bilateral or contralateral nodes << 6cm6cm

N3: Metastases > 6 cmN3: Metastases > 6 cm

StagingStaging

Nasopharyngeal CarcinomaNasopharyngeal Carcinoma– N1 – Unilateral < 6cmN1 – Unilateral < 6cm– N2 – Bilateral < 6 cmN2 – Bilateral < 6 cm– N3a > 6 cmN3a > 6 cm– N3b – Extension to N3b – Extension to

supraclavicular fossasupraclavicular fossa

ThyroidThyroid– N1 – Regional node metsN1 – Regional node mets

N1a - IpsilateralN1a - Ipsilateral N1b - Bilateral, midline, N1b - Bilateral, midline,

contralateral cervical or contralateral cervical or mediastinal LNmediastinal LN

ClassificationClassification

RadicalRadical– Gold standard operationGold standard operation

Modified radicalModified radical– Preservation of non lymphatic structuresPreservation of non lymphatic structures

SelectiveSelective– Preservation of lymph node groupsPreservation of lymph node groups

ExtendedExtended– Removal of additional lymph node Removal of additional lymph node

groups or non lymphatic structuresgroups or non lymphatic structures

Radical Neck DissectionRadical Neck Dissection

Removes Removes – Nodal groups I-VNodal groups I-V– SCM, IJV, XISCM, IJV, XI– Submandibular gland, Submandibular gland,

tail of parotidtail of parotid PreservesPreserves

– Posterior auricularPosterior auricular– SuboccipitalSuboccipital– RetropharyngealRetropharyngeal– PeriparotidPeriparotid– PerifacialPerifacial– Paratracheal nodesParatracheal nodes

RemovesRemoves– Nodal groups I-VNodal groups I-V

PreservesPreserves– SCM, IJV, XI (any SCM, IJV, XI (any

combination)combination)

Notate according to Notate according to which structures are which structures are preservedpreserved

Modified Radical Neck DissectionModified Radical Neck Dissection

Selective Neck DissectionSelective Neck Dissection

Remove high risk lymph node groups Remove high risk lymph node groups based on tumor site.based on tumor site.

SupraomohyoidSupraomohyoid– Levels I-IIILevels I-III

LateralLateral– Levels II-IVLevels II-IV

Selective Neck DissectionSelective Neck Dissection

PosterolateralPosterolateral– Levels II-VLevels II-V– Postauricular nodesPostauricular nodes– Suboccipital nodesSuboccipital nodes

Selective Neck DissectionSelective Neck Dissection

AnteriorAnterior– Level VILevel VI– RLN injuryRLN injury– HyperparathyroidismHyperparathyroidism

Extended Neck DissectionExtended Neck Dissection

Removal of any structures that are Removal of any structures that are routinely preserved in a neck routinely preserved in a neck dissection.dissection.

Notated by naming the structure(s) Notated by naming the structure(s) removed.removed.

Sentinel Lymph NodeSentinel Lymph Node

OverviewOverview NN0 0 NeckNeck TechniquesTechniques ResultsResults

Sentinel Lymph Node HistorySentinel Lymph Node History

1955 First echelon node 1960 “Sentinel node” 1977 Demonstrated in penile

cancer 1992 Morton reintroduced concept

in N0 melanoma Currently widely used in melanoma

and breast cancer therapy.

Sentinel lymph node conceptSentinel lymph node concept

Tumor spreads via lymphatics to a Tumor spreads via lymphatics to a primary node.primary node.

Examination of primary echelon Examination of primary echelon nodes for tumor direct the need for nodes for tumor direct the need for surgical management of the nodal surgical management of the nodal basins.basins.

Sentinel lymph node conceptSentinel lymph node concept Difficulties of lymphatic mapping in head Difficulties of lymphatic mapping in head

and neck (O’Brien).and neck (O’Brien).

1.1. It is difficult to visualize lymphatic channels It is difficult to visualize lymphatic channels using lymphoscintigraphy because of using lymphoscintigraphy because of proximity to the injection site.proximity to the injection site.

2.2. The radiotracer travels fast in the lymphatic The radiotracer travels fast in the lymphatic vessels.vessels.

3.3. If more than one node is visible, it can be If more than one node is visible, it can be difficult to distinguish first echelon nodes from difficult to distinguish first echelon nodes from second-echelon nodes.second-echelon nodes.

4.4. The SLN may be small and not easily The SLN may be small and not easily accessible (eg, in the parotid gland).accessible (eg, in the parotid gland).

NN0 0 NeckNeck

Occult neck diseaseOccult neck disease– Head and neck cancer Head and neck cancer 30% 30%– Oral cavity CA Oral cavity CA 20% to 45% 20% to 45%

Factors that indicate > 20% chance Factors that indicate > 20% chance of subclinical metastasesof subclinical metastases– Tumor thickness > 4mmTumor thickness > 4mm– Size > 2 cmSize > 2 cm– Anatomic locationAnatomic location

Sensitivity Sensitivity % (range)% (range)

Specificity Specificity % (range)% (range)

PalpationPalpation 35 (30-40)35 (30-40) 35 (27-42)35 (27-42)

CTCT 45 (17-86)45 (17-86) 11 (3-21)11 (3-21)

USUS 46 (42-50)46 (42-50) 21 (11-33)21 (11-33)

MRIMRI 42 (20-70)42 (20-70) 14 (5-26)14 (5-26)

US FNACUS FNAC 42 (27-50)42 (27-50) 00

Accuracy of diagnostic methods in detecting occult Accuracy of diagnostic methods in detecting occult cervical metastases.cervical metastases.

A new approach to pre-treatment assessment of the N0 neck in oral squamous cell carcinoma: the role of A new approach to pre-treatment assessment of the N0 neck in oral squamous cell carcinoma: the role of sentinel node biopsy and positron emission tomographysentinel node biopsy and positron emission tomography

NN0 0 Neck TreatmentNeck Treatment

T1/T2 N0 oral SCCAT1/T2 N0 oral SCCA– Better 10-year survival in pts who had Better 10-year survival in pts who had

elective neck dissection.elective neck dissection.

T1/T2 N0 tongue SCCAT1/T2 N0 tongue SCCA– 5-year actuarial benefit for elective neck 5-year actuarial benefit for elective neck

managementmanagement

Sentinel Lymph Node Biopsy and Sentinel Lymph Node Biopsy and NN0 0 Oral Cavity SCCAOral Cavity SCCA

Multiple small case series display the Multiple small case series display the feasibility of SLNB in oral SCCAfeasibility of SLNB in oral SCCA

Majority of lesions T1/T2Majority of lesions T1/T2

No standardized techniquesNo standardized techniques

All series compare All series compare – Pre op lymphoscintigraphyPre op lymphoscintigraphy– Intra-op localizationIntra-op localization– Post op pathologyPost op pathology

Pre op TechniquePre op Technique TechnetiumTechnetium

– Day before surgeryDay before surgery– Submucosal injectionsSubmucosal injections– 10-30 MBq Tc 99m per 10-30 MBq Tc 99m per

quadrantquadrant– +/- local anesthesia+/- local anesthesia– Avoid spillageAvoid spillage– Rinse mouthRinse mouth

Dosage does not correlate Dosage does not correlate with ability to identify with ability to identify nodesnodes

Pre op TechniquePre op Technique LymphoscintigraphyLymphoscintigraphy

– DynamicDynamic 45 -60 minutes45 -60 minutes Necessary to clearly identify Necessary to clearly identify

sentinel nodessentinel nodes SLNs seen within 15 minutesSLNs seen within 15 minutes

– StaticStatic Confirms dynamic imagesConfirms dynamic images AP / Lateral / ObliqueAP / Lateral / Oblique Delayed images for non Delayed images for non

revealing dynamic studiesrevealing dynamic studies– Cobalt pencilCobalt pencil

Labels anatomical points Labels anatomical points – Left / right mandibleLeft / right mandible– ChinChin– Cricoid cartilageCricoid cartilage– Sternal notchSternal notch

Oral Cancer: Correlation of Sentinel Lymph Node Biopsy and Selective Neck Dissection HistopathologyOral Cancer: Correlation of Sentinel Lymph Node Biopsy and Selective Neck Dissection Histopathology

Oral Cancer: Correlation of Sentinel Lymph Node Biopsy and Selective Neck Dissection Histopathology Oral Cancer: Correlation of Sentinel Lymph Node Biopsy and Selective Neck Dissection Histopathology

Pre op TechniquePre op Technique

Blue DyeBlue Dye– Submucosal injection Submucosal injection – 2.5% Patent Blue dye 2.5% Patent Blue dye – No more than 20 min No more than 20 min

pre incisionpre incision

Oral Cancer: Correlation of Sentinel Lymph Node Biopsy and Selective Neck Dissection HistopathologyOral Cancer: Correlation of Sentinel Lymph Node Biopsy and Selective Neck Dissection Histopathology

Operative TechniqueOperative Technique

Limited incision guided by Limited incision guided by lymphoscintigraphy and gamma lymphoscintigraphy and gamma probeprobe

Frozen section analysisFrozen section analysis

Operative TechniqueOperative Technique

Gamma probeGamma probe– Examine operative Examine operative

bed for increased bed for increased signalsignal

– Tumor extirpationTumor extirpation– Lead shieldLead shield– Removal of high Removal of high

signal nodessignal nodes– Examine removed Examine removed

node and compare node and compare to operative bedto operative bed

ComplicationsComplications

Reported complication rates < 1%Reported complication rates < 1%– Cutaneous malignancy casesCutaneous malignancy cases

Injury of VII, XI due to limited Injury of VII, XI due to limited exposureexposure

ResultsResults

Sentinel nodes found in > 90% of Sentinel nodes found in > 90% of cases.cases.– Experience mattersExperience matters– Surgeons with less than 10 cases Surgeons with less than 10 cases 56% 56%

success in SLNBsuccess in SLNB Lymphoscintigraphy revealed Lymphoscintigraphy revealed

unexpected bilateral or contralateral unexpected bilateral or contralateral disease in about 14% of ptsdisease in about 14% of pts

About 2-3 SLN per patientAbout 2-3 SLN per patient

ResultsResults

Up to 46% of SLN harbor metastasesUp to 46% of SLN harbor metastases– Fine section frozen analysisFine section frozen analysis

Increases sensitivity to about 95%Increases sensitivity to about 95%

– Immunohistochemical stainingImmunohistochemical staining False negative ratesFalse negative rates

– 10%10%– Grossly involved nodes less likely to take up Grossly involved nodes less likely to take up

tracertracer Better sensitivity for T1/T2 lesionsBetter sensitivity for T1/T2 lesions

– Most false negative results associated with Most false negative results associated with larger T3 lesionslarger T3 lesions

BibliographyBibliography1.1. Lymphatic Mapping and Sentinel Lymphadenectomy for 106 Lymphatic Mapping and Sentinel Lymphadenectomy for 106

Head and Neck Lesions: Contrasts Between Oral Cavity and Head and Neck Lesions: Contrasts Between Oral Cavity and Cutaneous Malignancy Laryngoscope, 116(Suppl. 109):1–15, Cutaneous Malignancy Laryngoscope, 116(Suppl. 109):1–15, 20062006

2.2. Oral Cancer: Correlation of Sentinel Lymph Node Biopsy and Oral Cancer: Correlation of Sentinel Lymph Node Biopsy and Selective Neck Dissection Histopathology Selective Neck Dissection Histopathology

3.3. The value of frozen section analysis of the sentinel lymph node The value of frozen section analysis of the sentinel lymph node in clinically N0 squamous cell carcinoma of the oralin clinically N0 squamous cell carcinoma of the oralcavity and oropharynx LAURENT TSCHOPP, MD, MICHEL cavity and oropharynx LAURENT TSCHOPP, MD, MICHEL NUYENS, MD, EDOUARD STAUFFER, MD, THOMAS KRAUSE, MD, NUYENS, MD, EDOUARD STAUFFER, MD, THOMAS KRAUSE, MD, and PETER ZBÄREN, MD, Bern, Switzerland Otolaryngol Head and PETER ZBÄREN, MD, Bern, Switzerland Otolaryngol Head Neck Surg 2005;132:99-102.Neck Surg 2005;132:99-102.

4.4. A new approach to pre-treatment assessment of the N0 neck in A new approach to pre-treatment assessment of the N0 neck in oral squamous cell carcinoma: the role of sentinel node biopsy oral squamous cell carcinoma: the role of sentinel node biopsy and positron emission tomography N.C. Hydea,*, E. Prvulovichb, and positron emission tomography N.C. Hydea,*, E. Prvulovichb, L. Newmanc, W.A. Waddingtonb, D. Visvikisb, P. Ellb Oral L. Newmanc, W.A. Waddingtonb, D. Visvikisb, P. Ellb Oral Oncology 39 (2003) 350–360Oncology 39 (2003) 350–360

5.5. The Accuracy of Head and Neck Carcinoma Sentinel Lymph The Accuracy of Head and Neck Carcinoma Sentinel Lymph Node Biopsy in the Clinically N0 Neck Taimur Shoaib1 CANCER Node Biopsy in the Clinically N0 Neck Taimur Shoaib1 CANCER June 1, 2001 / Volume 91 / Number 11June 1, 2001 / Volume 91 / Number 11