Journal of Cranio-Maxillo-Facial Surgery xxx (2016) 1e6

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Lymph node management in the treatment of oral cancer: Analysis of

a standardized approach
Steffen Koerdt*, 1, Jonas Ro
€ ckl 1, Niklas Rommel, Thomas Mücke, Klaus-Dietrich Wolff,
Marco R. Kesting
Department of Oral and Maxillofacial Surgery, University of Technology Munich, Ismaninger Str. 22, 81675 Munich, Germany

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: A supraomohyoid neck dissection (SOHND) is part of the surgical management of patients
Paper received 26 February 2016 with oral cancer, even in the absence of clinical or radiographic evidence of neck disease. We have
Accepted 1 August 2016 investigated a standardized approach to the management of cervical lymph nodes, in patients with a
Available online xxx
primary oral cancer. A modified surgical technique has been presented and a clinical algorithm has been
described and evaluated.
Keywords:
Materials and methods: SOHND was performed either uni- or bi-laterally. In cases of positive nodes in
Neck dissection
levels II or III, the dissection was extended in terms of a modified radical neck dissection (MRND) and a
Oral cancer
Lymphadenectomy
SOHND was performed contralaterally.
Squamous cell carcinoma Results: 112 patients were included. 42% had lymph node metastases in any level. Overall, lymph node
Mouth neoplasms metastases were found in 2.8% of all examined nodes. Most metastases (34.6%) occurred in level Ib. 12.6%
were located in level IIb. No metastases could be detected in levels IV and V. No statistically significant
difference could be shown with regard to T-stage, location, or co-factors as gender and age.
Discussion: SOHND is the gold-standard in patients with no preoperative evidence of lymph node me-
tastases. The presented algorithm is able to facilitate dissection and histological analysis and might
improve the surgical care in current treatment concepts. The extension to an MRND facilitates the
identification of patients in need of adjuvant therapy.
© 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.

1. Introduction demonstrated the importance of elective ND in comparison with

therapeutic ND. They concluded that in early-stage oral squamous-
Cervical lymphadenectomy (neck dissection, ND), which was cell cancer, elective neck dissection resulted in higher rates of
introduced by Jawdynski (1888) and further advanced by Crile at overall and disease-free survival than did therapeutic neck
the beginning of the 20th century, has become the standard dissection (D'Cruz et al., 2015).
treatment in the surgical approach to head and neck cancers (Crile, Moreover, various surgical techniques with regard to the
1906; Jawdynski, 1888). Oral squamous cell carcinoma (OSCC), approach and the extent of ND have been described in the litera-
which is the most common entity in intraoral malignancies, may be ture. Early concepts involved radical neck dissection (RND). The
accompanied with cervical lymph node metastases in advanced concept of selective neck dissection (SND) was first described in the
stages. Even amongst patients with no clinical or radiological evi- 1980s, whereby only certain groups of lymph nodes, with an
dence of lymph node metastases preoperatively, 20e30% of all increased risk for occult metastasis, were removed (Shah et al.,
specimens reveal positive nodes in pathohistological analysis 1981). Furthermore, functional neck dissections (FNDs) with the
(Crean et al., 2003; McGuirt et al., 1995; Smith et al., 2004). A recent preservation of non-lymphatic structures such as the sternoclei-
large prospective randomized controlled trial by D'Cruz et al. has domastoid muscle (SCM), the internal jugular vein (IJV), and the
spinal accessory nerve (SAN), resulting in less morbidity than RND
were first described by Suarez and coworkers in the early 1960s and
* Corresponding author. Fax: þ49 89 4140 4844. further developed as modified radical neck dissection (MRND) in
E-mail address: [Link]@[Link] (S. Koerdt). the 1970s (Ferlito et al., 2007; Suarez, 1963). Topographic-
1
The first two authors contributed equally to the manuscript.

[Link]
1010-5182/© 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

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anatomical groups of lymph nodes in the neck were defined for the Table 1
first time in 1981 by Shah, who recommended the removal of levels Scheme of systematic SOHND of levels IeIII according to the sequence of resection
defined by packages AeE (Kesting, 2014).
IeII in cases of no clinical evidence of lymph node metastases
preoperatively (Shah, 1990). Furthermore, a standardized nomen- Lymph node Level Description Bordering structure
clature for the definition of cervical levels and sublevels in NDs was package

published 2002 by the American Head and Neck Society according A IIa/III Prejugular IJV, digastric and
to the classification by Robbins et al. (2002). Shah et al. (1990) were omohyoid muscles
B IIa/III Postjugular IJV, omohyoid, SAN
able to show that most lymph node metastases from primary OSCC
C IIb Upper jugular nodes Skull base, SAN
were present in levels IeIII. The removal of levels IeIII, defined as D Ib Submental triangle Mandible and
supraomohyoid neck dissection (SOHND), has similar rates of dis- digastric muscle
ease recurrences in follow-up and is associated with a comparable E Ia Submandibular triangle Anterior bellies of digastric
morbidity as that with MRND. SOHND is now the most commonly Abbreviations: SOHND ¼ Supraomohyoid Neck Dissection; SAN ¼ Spinal Accessory
used surgical technique in the cervical lymph node management of Nerve; IJV ¼ Internal Jugular Vein.
OSCC (Dias et al., 2001; Ho et al., 1992; McGuirt et al., 1995;
Wolfensberger et al., 2001). However, in addition to the infiltra-
tion depth of the tumor, the tumor localization is a predictor for the resection of package C, which comprises of level IIb, packages A, B,
presence of lymph node metastases. The aims of an ND include and C are sent off for frozen sectioning, in order to obtain a timely
staging of the disease as well as the removal of cervical lymph histopathological statement. Packages D (level Ib) and E (level Ia)
nodes. A histologically positive node has a fundamental impact on complete the SOHND. Fig. 2 visualizes the different packages
the indication and extent of adjuvant radiation or chemoradiation. compared to the traditional levels as described by Robbins et al.
In a curatively intended ND, all preoperative suspect lymph nodes (2002). In case of matted lymph node packages, resection is per-
including additional lymph node levels are removed. This is carried formed without separation of each package intraoperatively. Mul-
out uni- or bi-laterally, depending on the preoperative staging and tiple packages together are sent in for pathological analysis. The
the tumor localization. In tumors that extend across the midline, sequential algorithm as described above is based on surgical tech-
ND of the contralateral side is necessary for oncologically sufficient nical considerations more than on anatomical topography as
surgical treatment (Bootz et al., 2008). described by Robbins et al. (2002) (Kesting, 2014). The vertical
The clinical algorithm for SND in primary OSCC of our study border of packages A and B is defined by the IJV, the horizontal
group is shown in Fig. 1. Depending on the tumor location and size, structure border is the digastric muscle. In the procedure of a ND,
bilateral SOHND is performed in tumors extending over the midline important landmarks such as the IJV and the digastric and omohyoid
or located in the ventral floor of the mouth. Furthermore, preop- muscles are able to guide the surgeon. Anatomical signposts such as
erative suspicious nodes in CT/MRI scans, evaluated by a clinical the hyoid bone are more or less arbitrary and might account for the
radiologist are managed with an initial bilateral SOHND. In all other inter-individual differences in the execution of a ND. However, not
invasive OSCC, irrespective of their size or any preoperative staging, only the sequence of resection as well as the algorithm in lymph
standardized unilateral SOHND is performed. In cases of lymph node management for oral cancers as described above, assure a
node metastasis in levels II or III, the resection is extended to levels standardized approach and make ND comparable, teachable and
IV and V ipsilaterally, in terms of a MRND and levels IeIII on the easily repeatable, guaranteeing a constant high standard.
contralateral side. A bilateral SOHND is also extended to a MRND, if Our aim in this current study has been to evaluate all stan-
positive nodes are found in frozen sectioning. dardized ND performed according to the clinical algorithm. Special
However, no clinical evidence exists for the oncological superi- attention has been paid to the occurrence of lymph node metas-
ority of an en-bloc resection (Upile et al., 2007). Splitting into lymph tases in the various levels, the topography of lymph nodes in the
node packages provides knowledge of the exact location of lymph specific packages, and the occurrence of positive nodes, especially if
node metastasis and allows tailoring of the adjuvant radiation the SOHND is extended to levels IV and V.
therapy. A definition of operative stages in standardized SND ac-
cording to the sequence of resection, which is used for all cases of all 2. Material and methods
OSCC that have not been operated on previously at the authors'
institution, is displayed in Table 1 (Kesting, 2014). Lymph node This study followed the Declaration of Helsinki concerning
packages removed at the various stages of the ND are referred to by medical protocol and ethics, and the Institutional Review Board of
the relevant letter. Package A, are all prejugular nodes bordered by the University of Technology Munich, Germany approved the study
the digastric muscle, omohyoid muscle and the IJV, followed by (No. 383/15). All participants were informed extensively and gave
package B, representing the postjugular lymph nodes. After their signed consent.

Fig. 1. Clinical algorithm in Neck Dissections (NDs) for oral squamous cell carcinomas (OSCCs with regard to the extent of the resection in cases of lymph node metastasis in an
intraoperative histopathological analysis. Abbreviations: SOHND ¼ Supraomohyoid Neck Dissection, MRND ¼ Modified Radical Neck Dissection.

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Fig. 2. Graphic scheme of a systematic supraomohyoid neck dissection (SOHND) according to the definition by Kesting in terms of a sequence based on technically surgical
landmarks such as the IJV, SAN, anterior and posterior bellies of the digastric muscle and the vertical separation of packages A and B (A) and the definition of cervical levels as
described by Robbins et al. based on topographic-anatomical structures such as the hyoid and cricoid bones and the horizontal separation of levels IIa and III (B).

Inclusion criteria were defined as follows: (i) potential patients caudal to the mastoid process, cranial to the SAN, posterior to the IJV
had to be in-patients at the Department of Oral and Maxillofacial and under the SCM muscle is resected. All packages are sent off for
Surgery, University of Technology Munich, Germany between pathological analysis of frozen sections, intraoperatively. Subse-
January 1st, 2011 and December 31st, 2014, (ii) age 18 years, (iii) quently, package D is resected from the submandibular triangle
availability of patients medical history, (iii) patients had to undergo under close monitoring of the mandibular marginal branch. Finally,
surgical procedures including a ND, (iv) histologically proven OSCC, package E is resected between the anterior bellies of both digastric
and (v) no history of a previous operative intervention to the neck. muscles, the mylohyoid muscle, and the hyoid bone. However,
All NDs were carried out by the senior author (MRK) following the packages D and E are not sent off for frozen sectioning, as any lymph
standardized surgical protocol as described above. node metastasis in these particular levels would not indicate an
Patients with preoperative radiological or clinical evidence of extension to a MRND. Nevertheless, these patients would benefit
lymph nodes metastases received primarily a MRND ipsi- and a from adjuvant postoperative radiation therapy for disease control
SOHND contra-laterally. according to the guidelines (Wolff et al., 2012).

2.3. Modified radical neck dissection (MRND)

2.1. Patients and clinical data

In cases of lymph node metastasis in packages A, B, or C, the

Preoperatively, all available patient data on relevant concomi-
SOHND is extended to levels IV and V ipsilaterally in terms of MRND
tant diseases was documented. The TNM staging, the location and
and SOHND being performed on the contralateral side in the same
histological subtype of the malignancy were obtained during
surgical intervention. For surgical access, a modified Schobinger or
recruitment of the study patients. Postoperatively, the histopath-
reversed hockey stick approach is used, which allows better access
ological reports were screened for the occurrence of lymph node
to the posterior triangle and the complete course of the SAN
metastasis and location according to the levels as described above.
(Kesting, 2014; Schobinger, 1957; Yoel and Linares, 1964). The
downward incision is placed at the anterior border of the trapezius
2.2. Supraomohyoid neck dissection (SOHND) muscle (Kesting, 2014). In patients with a short neck, the MacFee
incision is an important alternative approach to the cervical lymph
There is no evidence that an en-bloc ND is associated with a nodes. The resected fatty and lymphatic tissue of levels IV and V
significantly better outcome, compared with a separate resection of were sent off as standard pathological specimens.
particular levels and sublevels. Therefore, an SND of levels IeIII was
performed in consecutive stages with lymph node packages AeE 2.4. Statistical analysis
(Kesting, 2014). After infiltration of local anesthetic with 1:200,000
adrenaline, the incision line is placed 2 cm caudal to the mandibular All data were analyzed by using IMB®SPSS® for Mac (version
margin. After incision of the skin and subcutaneous tissue, the 22.0; IMB Corp., USA). Means and standard deviations (SD) were
platysma muscle is dissected. The contralateral anterior belly of the calculated and tests of significance were performed. The t-test was
digastric muscle builds the anterior border of the incision. The performed for normally distributed values, whereas the Man-
anterior margin of the SCM muscle is defined. Afterwards, the pla- neWhitney test was used for values not normally distributed.
tysma is reflected cranially and caudally, and the ipsilateral anterior Frequency tables of categorical data were analyzed with the chi-
belly of the digastric muscle is exposed down to the hyoid bone. The square test, with Yates' correction when the expected frequency
muscle landmarks, namely (i) posterior belly of the digastric muscle, was less than five. Statistical significance was set for a two-sided p
(ii) omohyoid muscle, and (iii) SCM muscle, are defined. The removal value of less than 0.05.
of package A is performed and exposure of the posterior belly of the
digastric muscle to the mastoid process. The anatomic area of 3. Results
package A is defined by a triangle formed by the IJV, the omohyoid
muscle, and the posterior belly of the digastric muscle. After 3.1. Patients and clinical data
cautious preparation of the SAN, the removal of package B, caudal to
the SAN, posterior of the IJV, and cranial to the crossing point of the Of the total of 112 patients enrolled in the current study, 34
omohyoid/SCM muscles is performed. Subsequently, package C, females (30.4%) and 78 male (69.6%) patients were included. The

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mean age was 61.6 ± 13.0 years (median 62, minimum 19,
maximum 87).
A unilateral SOHND of levels IeIII was performed in 34.8%
(n ¼ 39) of all study patients. In 2.7% (n ¼ 3) patients a bilateral neck
dissection was intended but had to be modified intraoperatively to
a unilateral SOHND, and the resection of level Ib contralaterally,
because of unexpected medical conditions. Moreover, 38.4%
(n ¼ 43) of all patients received a bilateral SOHND, because of the
initial tumor size, location, and/or preoperative staging. In total,
22.3% (n ¼ 25) of all patients were treated with an ipsilateral MRND
of Levels I to V and the extension to the contralateral side in terms
of a SOHND. However, 42.3% (n ¼ 11) of these patients with an
ipsilateral MRND were preoperatively planned as a unilateral
SOHND and were extended intraoperatively because of positive
nodes in the frozen sections. 1.8% (n ¼ 2) received bilateral MRNDs.
Evaluation of T-stages is displayed in Fig. 3B. Of all study pa-
tients, 26.8% (n ¼ 30) were postoperatively classified as pT1, 34.8%
(n ¼ 39) as pT2, 14.3% (n ¼ 16) as pT3, and 23.2% (n ¼ 26) as pT4a,
and one patient was classified as pT4b (0.9%).
The location of the primary tumor is shown in Fig. 3C. Tumors
within the tongue occurred in 35.7% (n ¼ 40) of all investigated
study patients. Both malignant neoplasms in the floor of the mouth
and the mandible could be observed in 25% (both n ¼ 28) of all
patients. Tumors of the maxilla (9.8%, n ¼ 11) and the soft palate
(4.5%, n ¼ 5) were less frequent.
Smoking was analyzed as a co-factor associated with cervical
lymph nodes metastases in this current study. However, no sig-
nificant difference could be observed (overall: 64.3%, n ¼ 72 vs.
35.7%, n ¼ 46; cervical metastases: 65.9%, n ¼ 31 vs. 34.1%, n ¼ 16;
p ¼ 0.445).

3.2. Incidence and location of lymph node metastases

Generally, 47 (41.9%) patients had lymph node metastases in any

level because of a carcinoma of the oral cavity. A total of 5135 lymph
nodes were analyzed histologically. Overall, lymph node metasta-
ses were found in 2.8% (n ¼ 145), 49.6% (n ¼ 72) of which showed
extracapsular spread (ECS), with 50.4% (n ¼ 73) being ECS-negative.
The localization of lymph node metastases according to the various
levels and packages is displayed in Fig. 3A. Most metastases
(n ¼ 44; 34.6%) were found in package D (level Ib). 32.3% (n ¼ 41) of
all lymph node metastases could be detected in package A (level III),
15% (n ¼ 19) in package B (level IIa), 12.6% (n ¼ 16) were found in
package C (level IIb), and 4.7% (n ¼ 6) could be identified in package
E (level Ia). However, no positive lymph nodes out of 319 examined
nodes were found in levels IV and V in cases of metastases in levels
IeIII and an intraoperative extension of the SOHND.
Beyond that, 27.3% (n ¼ 3) of patients who received an intra-
operative extension the levels IV and V ipsilaterally and to levels
IeIII contralaterally because of positive nodes ipsilaterally and with
a preoperative N0-status had contralateral lymph nodes metasta-
ses. Primary tumors of patients with contralateral metastases were
located at floor of the mouth (33.3%; n ¼ 1), buccal plane (33.3%; Fig. 3. Bar charts visualizing: (A) the number of lymph node metastases according to
n ¼ 1), and tongue edge (33.3%; n ¼ 1). the various lymph node packages; (B) the localizations of the primary tumor and the
According to the T-stages, lymph node metastases occurred observed frequency within the collective and differentiated groups according to the
occurrence of lymph node metastases; and (C) the postoperative T-stages of the pri-
most frequently in T3-tumors (Nþ: 56.3% (n ¼ 9); N: 43.7% mary tumor and the observed frequency within the collective and differentiated
(n ¼ 7)). T4-tumors, taking pT4a and pT4b together, showed posi- groups according to the occurrence of lymph node metastases.
tive nodes in 51.9% of all cases (Nþ: 51.9% (n ¼ 14); N: 48.1%
(n ¼ 13)). T1- and T2-tumors showed almost similar rates in the
occurrence of cervical lymph node metastases (T1: Nþ: 30% (n ¼ 9); Nþ and N cases could be detected (Chi-squared test c2 ¼ 15.0,
N: 70% (n ¼ 21); T2: 38.5% (n ¼ 15); N: 61.6% (n ¼ 24)). A sta- df ¼ 12, p ¼ 0.241; Fig. 3C). Tumors located in the maxilla presented
tistical analysis revealed no significant difference (Chi-squared test with lymph node metastases most commonly (Nþ: 54.5% (n ¼ 6);
c2 ¼ 8.0, df ¼ 6, p ¼ 0.238; Fig. 3B). N: 45.5% (n ¼ 5)). At least 45% of all tongue cancers showed
In terms of differentiation according to the location of the tu- positive nodes in histological analysis (Nþ: 45% (n ¼ 18); N: 55%
mor, no evidence for a statistically significant difference between (n ¼ 22)). Cancers in the floor of the mouth and the mandible

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showed similar rates of lymph node metastases (both: Nþ: 39.3% the current study had contralateral lymph node metastases,
(n ¼ 11); N: 60.7% (n ¼ 17)). Positive nodes could be detected in without preoperative clinical or radiographic evidence.
20% of all tumors located in the soft palate (Nþ: 20% (n ¼ 1); N: Taking into account the literature and the results from the cur-
80% (n ¼ 4)). rent study, the need for a prospective randomized controlled trial
Age and gender did not show a statistically significant difference (RCT) assessing the necessity of a MRND becomes obvious. How-
with respect to the incidence of lymph node metastases (p > 0.05). ever, the fact, that more than one fourth of all patients had positive
Metastases were detected in 44.1% of all female patients (15 out of nodes contralaterally, even with a cN0-neck preoperatively, em-
34) and in 41.0% of all males (32 out of 78). The mean age in all Nþ phasizes the intraoperative histological assessment by frozen
patients irrespective of the tumor size or location was 62.9 ± 10.9 sectioning and underlines the algorithm as described above.
years (median 63, minimum 34, maximum 87), and all N patients The presence and occurrence of micrometastases in oral cancers
was 60.7 ± 13.8 years old (median 60, minimum 19, maximum 87). have been subject to many studies evaluating molecular markers or
identifying sentinel nodes (Chung et al., 2015; Germani et al., 2009).
4. Discussion However, micrometastases, defined by van den Brekel et al. (1992)
as not being visible preoperatively by routine imaging, still account
SOHND has become the gold standard in the surgical manage- for almost 70% of the false-negative clinical assessments, as stated
ment of carcinomas of the oral cavity, in patients with no evidence by Woolgar (1997).
of preoperative evidence of lymph node metastases (cN0-neck). A The importance of ECS metastases has been discussed else-
rate between 27% and 40% of occult neck metastases in cN0 patients where (Ord, 2012). Ord and coworkers determine the ECS as the
has been described in the literature (Shah et al., 1990; Spiro et al., predictive parameter for lymph node metastases. This is in agree-
1988; Van den Brekel et al., 1996). The occurrence of lymph node ment with other reports from the literature (Carter et al., 1987;
metastases may be an indication for adjuvant radiation therapy Snow et al., 1982). In our current study, almost half of all exam-
with or without concomitant chemotherapy. Furthermore, the ined nodes showed ECS. This factor is of known prognostic
presence of lymph node metastases is closely associated with importance and has been defined as one of the main predictive
prognosis and disease-free survival. However, resection of cervical values in terms of disease-free survival in cancers with nodal cer-
lymph nodes in clinically inconspicuous necks has been proven to vical metastases (Woolgar, 1997).
be of oncological benefit (Kramer et al., 2001; Pitman and Dean, In a separate analysis of positive nodes according to cervical
2002). As the analysis of the metastatic patterns of carcinomas in sublevels, 5.4% (n ¼ 6) of all study patients had metastases in level
the oral cavity has shown, consistent and predictable routes of IIb. This has been controversially discussed in the literature, as
cervical lymph drainage into levels I, II, and III have been described complications such as SAN palsy have been described and a
in the literature (Shah et al., 1990). In a study with a total of 501 dissection of level IIb has just recently been recommended only in
patients with cancer of the oral cavity, J. P. Shah defined neck levels patients with multilevel neck metastases (Cheng et al., 2000; de
I, II, and III as being at greatest risk for nodal metastases from Vicente et al., 2015). Patients with positive nodes in level IIb pre-
primary OSCC (Shah, 1990). In a clinical setting, the absence of sented with malignancies in the area of the tongue (50%; n ¼ 3), the
lymph node metastases in these anatomical regions significantly mandible (33.3%; n ¼ 2), and the anterior maxilla (16.7%; n ¼ 1). In
reduces the risk of any pathologies in levels further caudally. this regard, no pattern of oral cancers according to the extent and
Therefore, SOHND is commonly performed in cases without pre- location of the tumor and the occurrence of lymph node metastases
operative evidence of lymph node metastases. The extension of the in level IIb can be proposed. Therefore, we advocate the dissection
SOHND to levels IV and V has been investigated in previous studies of level IIb, despite the possibility of any intra- or post-operative
(Crean et al., 2003; Shah et al., 1990). With regard to a clinically complications.
negative neck, up to 10% of metastatic lymph nodes have been In a comparison of this investigation with the substantial works
found in levels IV and V. of Shah (1990) and Woolgar (1997), the last two mentioned studies
Our current study aims to evaluate a standardized surgical included more patients with a similar gender correlation. However,
approach to lymph node management in OSCC. Extension of Shah et al. and Woolgar et al. only included radical neck dissections,
SOHND to levels IV and V in cases of positive nodes in levels IeIII, which were performed mostly unilaterally (>67% of all studied
a modification of the sequence in SOHND to gain intraoperative cases), whereas our study included a 39:73 ratio in terms of a uni-
pathological results and to modify and extend ND if necessary, or bi-lateral approach. Shah described a total of 62% of Nþ findings,
and the assessment of clinical staging in correlation to patho- whereas the patients of Woolgar et al. and our collective had pos-
logical analysis as described in this investigation should help to itive nodes in 47% and 42% of all cases, respectively. This might be
build a surgically orientated algorithm. A separate dissection of attributable to Shah's considerably large study including patients
levels has numerous advantages compared with an “en-bloc” from 1965 to 1986, resulting in a delayed diagnosis in a clinical
dissection, in terms of (i) a time-saving dissection rather than setting of more than five decades ago. Moreover, the number of
orientation and dissection of the specimen ex vivo, (ii) an examined nodes per ND were comparable (SOHND: 26 nodes vs.
increased accuracy of the dissection, each piece of tissue being a MRND IeIV: 21 nodes) (Woolgar, 1997). Concerning the location of
more manageable size for further processing and analysis, (iii) a lymph node metastases, our study was able to show that about 60%
better histopathological diagnosis on the topography of node of all lymph nodes were located in levels II and III. This is congruent
metastases, and (iv) a more accurate and precise adjuvant radi- with the results reported by Woolgar and Shah (Woolgar, 1997).
ation therapy (Upile et al., 2007). However, contrary to our results, both studies found lymph node
Nevertheless, our finding of no histologically evident metastases metastases in levels IV and V in up to 20% of all examined cases
in levels IV and V raises the question for the need of a MRND. Other (Shah, 1990). This might be because some of the lymph nodes in
reports from the literature, such as by Crean et al., have demon- this current study in level IV have previously been removed in a
strated that the extension of the classical SOHND to level IV can deep dissection of levels II and III. However, the dissection should
yield occult metastatic lymph nodes in a further 10% of patients always include the lymph node at the intersection of the SCM and
(Crean et al., 2003). Shah and coworkers have been able to show the omohyoid muscle. A follow-up study that will include recur-
that 6 out of 192 (3%) patients had positive lymph nodes in level IV rence rate and a five year survival will assess the value of a pro-
(Shah, 1990; Shah et al., 1990). Moreover, 27.3% of all patients from phylactic MRND.

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Please cite this article in press as: Koerdt S, et al., Lymph node management in the treatment of oral cancer: Analysis of a standardized approach,
Journal of Cranio-Maxillo-Facial Surgery (2016), [Link]