Eur Arch Otorhinolaryngol (2008) 265:1535–1538 DOI 10.1007/s00405-008-0706-9
HEAD AND NECK
Early history of neck dissection Alessandra Rinaldo · AlWo Ferlito · Carl E. Silver
Received: 27 November 2007 / Accepted: 28 April 2008 / Published online: 17 May 2008 © Springer-Verlag 2008
Abstract With the exception of distant metastases, the presence of lymph node metastasis in the neck is accepted as the single most important adverse independent prognostic factor and an indicator of survival in squamous carcinoma of the head and neck. Neck dissection in its various forms is the standard surgical treatment for clinical, subclinical and subpathologic metastatic cancer to the neck. The pertinent literature from the beginning of the nineteenth century to the middle of the twentieth century was reviewed. The four giants of late nineteenth century surgery: von Langenbeck, Billroth, von Volkmann and Kocher developed and reported the early cases of diVerent types of neck dissection. Butlin, in England, conceived and developed the concept of elective neck dissection. In 1888, the Polish surgeon Jawdyjsky reported and described in detail the Wrst successful extended en bloc neck dissection. Crile, in 1905 and 1906, reported the Wrst signiWcant series of radical en bloc neck dissections, bringing this procedure to the attention of the medical world as an eVective operation with reproducible technique and results. The greatest impetus to the status of this surgical procedure came from Martin and colleagues, who published a monumental report in 1951 of 1,450 cases that established the place and technique of radical neck dissection in the modern treatment of head and neck cancer. Neck dissection, for treatment of cervical
A. Rinaldo (&) · A. Ferlito Department of Surgical Sciences, ENT Clinic, University of Udine, Policlinico Universitario, Piazzale S. Maria della Misericordia, 33100 Udine, Italy e-mail:
[email protected] C. E. Silver Departments of Surgery and Otolaryngology-Head and Neck Surgery, Albert Einstein College of Medicine, MonteWore Medical Center, Bronx, NY, USA
lymph node metastases in head and neck cancer, was conceived and attempted in the nineteenth century, with some limited success reported by the end of that era. An eVective operation was described and reported in the early twentieth century and evolved by the mid century into a fundamental tool in the management of patients with head and neck cancer. Keywords History · Neck dissection · Lymph node metastases · Head and neck cancer · Squamous carcinoma
The nineteenth century Nineteenth century surgeons were aware that spread of head and neck cancer to the cervical lymph nodes (called “glands” at the time) portended a grim prognosis. In 1847, Maximilian Joseph von Chelius (1794–1867) [1] stated “ … once the growth in the mouth has spread to the submaxillary gland, complete removal of the disease is impossible.” Prior to the early 1800s, there was little or no mention made of surgical attempts to treat metastatic cancer to the cervical nodes. By the early nineteenth century, excision of single lymph node metastases was occasionally performed, with no beneWt to the patient and often disastrous results [2–4]. In 1837, John Collins Warren (1778–1856) [5] reported two cases of attempts to locally excise metastatic cancer of the neck using an improvised technique. The unavailability of general anesthesia as well as lack of aseptic technique and other developments precluded eVective performance of all but limited surgical procedures. Lack of understanding of the cellular basis of disease and the presence of and need for excision of potential occult disease hampered even the concept of eVective treatment of neck metastases until late in the nineteenth century.
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During the mid and late nineteenth century, the four giants of European surgery: Bernhard Rudolf Konrad von Langenbeck (1810–1887), Christian Albert Theodor Billroth (1829–1894), Richard von Volkmann (1830–1889) and Theodor Kocher (1841–1917), developed and reported on various types of neck dissection [6]. The operations performed by these surgeons were usually attempts to remove entire blocks of metastatic disease, some encompassing surrounding uninvolved structures and tissue. Such operations were invariably performed in cases of advanced disease, providing essentially no opportunity to remove the metastatic cancer completely. Despite an occasional report of survival up to 3 years, the majority of patients died of their disease, if not from surgical morbidity [7]. In 1885, the concept of elective neck dissection (initially called “prophylactic”) was originated by Sir Henry Trentham Butlin (1845–1912) [8], the father of British head and neck surgery [9]. He advised the removal of cervical lymphatics through the “Kocher incision” and suggested routine elective excision of these tissues in the treatment of tongue cancer. Butlin’s ideas were the Wrst breakthrough in the development of eVective treatment for regional metastatic disease in head and neck cancer. He reported a 3-year survival rate of 42% of 70 patients submitted to his new procedure compared to 29% of 44 patients treated with local excision of the primary (tongue cancer) only. In total, 59% of patients without palpable adenopathy survived 3 years in contrast to 32% of patients who presented with palpable adenopathy [9]. In 1888, the Polish surgeon Franciszek Jawdyjski (1851–1896) [10] performed and reported on an operation which comprised an extended radical en bloc resection. The patient was discharged soon after the surgery, and the case was presented 6 weeks later at the Medical Society of Warsaw. The patient survived 7 years after the surgery [11]. Jawdyjski never reported on another similar operation, probably because of his premature death at the age of 45 [12]; and due to its publication in a Polish journal, Gazeta Lekarska, his work remained obscure. The history of neck dissection in the nineteenth century has been detailed in a recent publication [7].
The twentieth century In 1905 and in 1906, George Washington Crile (1864– 1943) [13, 14] of Cleveland, OH, published a systematic approach to neck dissection in two similar papers entitled ‘On the surgical treatment of cancer of the head and neck. With a summary of one hundred and twenty-one operations performed upon one hundred and Wve patients’ and ‘Excision of cancer of the head and neck. With special reference to the plan of dissection based on one hundred and thirty-
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two operations’, the former in Transactions of the Southern Surgical and Gynecological Association and the latter in the Journal of the American Medical Association. The Wrst paper consisted of 20 pages and the second of 9 pages. Both the papers were illustrated by, the same 12, very clear drawings and were without references. The Wrst Crile’s paper included an interesting discussion, 10 pages in length, that raised issues such as the use of less radical surgery for early cancers and for primary sites. Of note, Charles H. Mayo of Rochester, MN, in the discussion stated: “A large part of abdominal work is recreation as compared with the bulk of what might be called the heavy surgery of the neck, which Dr. Crile has so well described.” This landmark paper [13] established the basis for eVective treatment of such lesions by delineating a block resection of the cervical lymphatic-bearing tissue, to be removed either in continuity with the primary tumor or as a secondary operation for subsequent metastasis. Crile’s en bloc dissection involved the removal of all cervical lymph nodes (today called levels I–V) along the sternocleidomastoid muscle, submandibular salivary gland, tail of parotid gland, omohyoid muscle, cutaneous branches of the cervical plexus and most importantly the internal jugular vein. Such radical surgery, at the time, was fraught with diYculty because of the lack of blood transfusion, antibiotics and endotracheal anesthesia; but Crile devised several strategies for combating these obstacles [15]. Crile’s initial paper, published in a regional medical journal in 1905, did not produce much impact within the medical community. The publication, a year later, in the Journal of the American Medical Association, of essentially the same data with the addition of 11 cases, produced a widespread response and transformed radical en bloc neck dissection from a surgical curiosity into a useful, reproducible procedure that revolutionized the treatment of head and neck cancer. The paper was read before the Section of Surgery and Anatomy of the American Medical Association, at the 57th Annual Session, June, 1906. The initial 1905 publication has remained suYciently obscure that almost every source, since that time, has quoted Crile’s second paper as being the Wrst description of a systematic en bloc removal of the neck lymphatics [16–22]. Indeed, 2006 has been celebrated as the “centennial” of radical neck dissection. The 1906 paper, not readily available to the current generation of surgeons, was republished in 1987 in the Journal of the American Medical Association [23]. Crile recognized that cancer of head and neck usually recurred predominantly in the cervical lymph nodes and rarely metastasized to distant sites, and he postulated that “The collar of lymphatics of the neck forms an extraordinary barrier through which cancer rarely penetrates. Every part of this barrier is surgically accessible” [14] so that en bloc excision of cervical lymph nodes with or without the
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primary cancer was feasible. Crile [14] mentioned that, by a careful study of 4,500 cases, fewer than 1% of tumors of the head and neck, exclusive of the thyroid gland, had secondary foci in distant tissues or organs. In the 1906 series [14], only 36 of the 132 operations were radical en bloc neck dissections. The other 96 were more selective; comparable to the procedure called “supraomohyoid neck dissection” in current terminology. At 3year follow-up, the patients who underwent radical en bloc dissections had better overall survival (75% were alive at 3 years: 9 patients among 12 traced cases) than those with lesser operations (19% were alive at 3 years: 9 patients among the 48 traced cases). Thus, the radical block dissection had shown itself to be four times more eVective than the less radical surgical procedures [14]. Crile concluded that anything less than en bloc dissection was not eVective in the control of cervical lymph node metastases. He stated that “an incomplete operation disseminates and stimulates the growth, shortens life and diminishes comfort” and that “the logical technique is that of a block dissection of the regional lymphatic system as well as the primary focus on exactly the same lines as the Halstead operation for cancer of the breast. Such a dissection is indicated whether the glands are palpable or not. Palpable glands may be inXammatory and impalpable glands may be carcinomatous” [13]. The “Crile operation” has remained one of the more frequently used eponyms in oncology [12]. In 1944, Sylvestre-Benis [24] of Argentina presented an important paper regarding the treatment of cervical node metastasis in laryngeal cancer patients. He recommended neck dissection in all cases of total laryngectomy and recognized the possibility of “monoblock” extirpation of the primary lesion, the eVerent lymphatic vessels, and the receiving lymph nodes. He performed “limited” neck dissection in cases in which he felt that disease did not extend beyond the jugular chain lymph nodes. If disease extended to the supraclavicular chain, he advocated radical neck dissection. For bilateral neck dissections, he preserved one of the internal jugular veins in order to minimize cerebral edema. The greatest impetus to the development of radical neck dissection came from Hayes Martin (1892–1977) of Memorial Hospital in New York, who, with his colleagues, published a monumental paper entitled ‘Neck dissection’ in 1951 [25]. This extensive review included an analysis of 1,450 cases of neck dissection performed from 1928 to 1950, although statistics were derived from 665 operations performed in 599 patients. The authors categorically insisted that the spinal accessory nerve, internal jugular vein and the sternocleidomastoid muscle should be removed in the presence of cervical lymph node metastasis. Martin et al. [25] emphasized that “any technique that is designed to preserve the spinal accessory nerve should be
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condemned unequivocally.” The technical precepts described by Martin et al. [25] were followed by many American and international surgeons until the latter part of the twentieth century when modiWcations in technique began to again Wnd acceptance. Despite their unwavering adherence to the therapeutic radical neck dissection, the Memorial group [25] stated that “routine prophylactic neck dissection is considered illogical and unacceptable” for cancer of the oral cavity. The authors believed that radical neck dissection should not be used in the treatment of the clinically negative neck, although they advocated neck dissection if a trans-cervical approach was employed in order to perform resection of the primary tumor. They also pointed out the perils of the injudicious removal of an enlarged lymph node for diagnosis, because this invariably lessens the chance for a cure. Diagnosis should be established by discovery and biopsy of the primary tumor, and the neck dissection indicated if cervical nodes were palpable, or “clinically positive.”
Conclusions The nineteenth century surgeons appreciated the important adverse prognostic signiWcance of cervical lymph node metastasis in head and neck cancer. Early attempts were conWned to local excision of individual lymph node metastases. With the development of general anesthesia and other surgical advances during the second half of the century, more extensive extirpations were attempted, but in the absence of the concepts of block dissection and of occult disease, resections, even when extensive, were usually incomplete and unsuccessful. By the late nineteenth century some success was achieved by the employment of routine limited elective neck dissection by Butlin [8], and the performance of an en bloc complete resection of cervical nodes and surrounding normal tissues by Jawdyjski [10]. In the early twentieth century, Crile [13, 14] published his technique and results of radical neck dissection, demonstrating the eVectiveness of this procedure in controlling cervical lymph node disease. By the mid twentieth century, Martin et al. [25] had reWned the technique and published the results of a very large series of cases, establishing the basis of treatment that remains a fundamental tool in the management of patients with head and neck cancer.
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