Upper jugular lymph nodes (submuscular recess) in non-squamous-cell cancerof the head and neck: surgical considerations

Cervical lymphadenectomy of level II encompasses lymph nodes associated wit h the upper internal jugular vein and the spinal accessory nerve (SAN). Rem oval of tissue superior to the SAN (submuscular recess-(SMR)) was recently shown to be unwarranted in selected cases of squamous-cell cancer. Thirty-f ive patients with non-squamous-cell cancer (SCC) of the head and neck treat ed with cervical lymphadenectomy were prospectively evaluated. Thirty-seven neck dissection specimens were histologically analysed for the number of l ymph nodes involved with cancer. At the time of surgery, level Il was separ ated into the supraspinal accessory nerve component (IIa) and the component anterior to the SAN (IIb). Neck dissections were most commonly performed for cancer of the thyroid gla nd (19) followed in frequency by the parotid gland (seven), skin: melanoma (five), basal-cell cancer (two), and other sites (four). Twenty-five neck d issections were modified-selective procedures and 12 were either radical or modified radical neck dissection. Twenty-nine necks were clinically N+ and eight NO. Histological staging was pathologically N+ in 32 neck dissection specimens. Level IIb contained an average of 12 nodes and the Ha component contained a mean of 5.0 nodes. Level II contained metastatic disease in 28 of 32 histologically node-positive specimens (87 per cent). Level Ha was i nvolved with cancer in six cases (16 per cent), five of which were pre-oper atively staged as clinically N+. All cases (100 per cent) with level IIa in volvement had level IIb positive nodes. Three of the level Ha positive case s were cancer of the parotid gland comprising 43 per cent of this sub-group of patients. Incidence of involvement of SMR in non-SCC cases is not uncommon. The addit ional time required and morbidity associated with dissection of the suprasp inal accessory nerve component of level II are probably justified when perf orming neck dissection in cancer of the thyroid gland. The SMR should be ex cised in cancer of the parotid gland. Large-scale prospective controlled st udies with long-term follow-up periods are necessary to support resection o f level IIb only.