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Title: Intraoperative validation of CT-based lymph nodal levels, sublevels IIa and IIb: Is it of clinical relevance in selective radiation therapy?

Abstract

Purpose: The objectives of this study are to discuss the intraoperative validation of CT-based boundaries of lymph nodal levels in the neck, and in particular the clinical relevance of the delineation of sublevels IIa and IIb in case of selective radiation therapy (RT). Methods and Materials: To validate the radiologically defined level contours, clips were positioned intraoperatively at the level boundaries defined by surgical anatomy. In 10 consecutive patients, clips were placed, at the time of a neck dissection being performed, at the most cranial border of the neck. Anterior-posterior and lateral X-ray films were obtained intraoperatively. Next, in 3 patients, neck levels were contoured on preoperative contrast-enhanced CT scans according to the international consensus guidelines. From each of these 3 patients, an intraoperative CT scan was also obtained, with clips placed at the surgical-anatomy-based level boundaries. The preoperative (CT-based) and intraoperative (surgery-defined) CT scans were matched. Results: Clips placed at the most cranial part of the neck lined up at the caudal part of the transverse process of the cervical vertebra C-I. The posterior border of surgical level IIa (spinal accessory nerve [SAN]) did not match with the posterior border of CT-based level IIa (internal jugular vein [IJV]). Othermore » surgical boundaries and CT-based contours were in good agreement. Conclusions: The cranial border of the neck, i.e., the cranial border of level IIa/IIb, corresponds to the caudal edge of the lateral process of C-I. Except for the posterior border between level IIa and level IIb, a perfect match was observed between the other surgical-clip-identified levels II-V boundaries (surgical-anatomy) and the CT-based delineation contours. It is argued that (1) because of the parotid gland overlapping part of level II, and (2) the frequent infestation of occult metastatic cells in the lymph channels around the IJV, the division of level II into radiologic sublevels IIa and IIb may not be relevant. Sparing of, for example, the ipsilateral parotid gland in selective RT can even be a treacherous undertaking with respect to regional tumor control. In contrast, the surgeon's reasoning for preserving the surgical sublevel IIb is that the morbidity associated with dissection of the supraspinal accessory nerve compartment of level II is reduced, whereas there is evidence from the surgical literature that no extra risk for regional tumor control is observed. Therefore, in selective neck dissections, the division into surgical sublevels IIa/IIb makes sense.« less

Authors:
 [1];  [2];  [3];  [1];  [1];  [1];  [4]
  1. Department of Radiation Oncology, Erasmus Medical Center-Daniel den Hoed Cancer Center, Rotterdam (Netherlands)
  2. Department of Radiation Oncology, St-Luc University Hospital, Brussels (Belgium)
  3. Department of ENT Surgery, St-Luc University Hospital, Brussels (Belgium)
  4. Department of ENT Surgery, Erasmus Medical Center-Daniel den Hoed Cancer Center, Rotterdam (Netherlands)
Publication Date:
OSTI Identifier:
20698566
Resource Type:
Journal Article
Journal Name:
International Journal of Radiation Oncology, Biology and Physics
Additional Journal Information:
Journal Volume: 62; Journal Issue: 3; Other Information: DOI: 10.1016/j.ijrobp.2004.12.006; PII: S0360-3016(04)03011-1; Copyright (c) 2005 Elsevier Science B.V., Amsterdam, Netherlands, All rights reserved; Country of input: International Atomic Energy Agency (IAEA); Journal ID: ISSN 0360-3016
Country of Publication:
United States
Language:
English
Subject:
62 RADIOLOGY AND NUCLEAR MEDICINE; ANATOMY; CARCINOMAS; COMPUTERIZED TOMOGRAPHY; GLANDS; IMAGES; LYMPH; METASTASES; NECK; NEUTRON DIFFRACTION; PATIENTS; RADIOTHERAPY; RECOMMENDATIONS; SMALL ANGLE SCATTERING; SURGERY; VALIDATION; VEINS; VERTEBRAE

Citation Formats

Levendag, Peter, Gregoire, Vincent, Hamoir, Marc, Voet, Peter, Est, Henrie van der, Heijmen, Ben, and Kerrebijn, Jeroen. Intraoperative validation of CT-based lymph nodal levels, sublevels IIa and IIb: Is it of clinical relevance in selective radiation therapy?. United States: N. p., 2005. Web. doi:10.1016/j.ijrobp.2004.12.006.
Levendag, Peter, Gregoire, Vincent, Hamoir, Marc, Voet, Peter, Est, Henrie van der, Heijmen, Ben, & Kerrebijn, Jeroen. Intraoperative validation of CT-based lymph nodal levels, sublevels IIa and IIb: Is it of clinical relevance in selective radiation therapy?. United States. https://doi.org/10.1016/j.ijrobp.2004.12.006
Levendag, Peter, Gregoire, Vincent, Hamoir, Marc, Voet, Peter, Est, Henrie van der, Heijmen, Ben, and Kerrebijn, Jeroen. 2005. "Intraoperative validation of CT-based lymph nodal levels, sublevels IIa and IIb: Is it of clinical relevance in selective radiation therapy?". United States. https://doi.org/10.1016/j.ijrobp.2004.12.006.
@article{osti_20698566,
title = {Intraoperative validation of CT-based lymph nodal levels, sublevels IIa and IIb: Is it of clinical relevance in selective radiation therapy?},
author = {Levendag, Peter and Gregoire, Vincent and Hamoir, Marc and Voet, Peter and Est, Henrie van der and Heijmen, Ben and Kerrebijn, Jeroen},
abstractNote = {Purpose: The objectives of this study are to discuss the intraoperative validation of CT-based boundaries of lymph nodal levels in the neck, and in particular the clinical relevance of the delineation of sublevels IIa and IIb in case of selective radiation therapy (RT). Methods and Materials: To validate the radiologically defined level contours, clips were positioned intraoperatively at the level boundaries defined by surgical anatomy. In 10 consecutive patients, clips were placed, at the time of a neck dissection being performed, at the most cranial border of the neck. Anterior-posterior and lateral X-ray films were obtained intraoperatively. Next, in 3 patients, neck levels were contoured on preoperative contrast-enhanced CT scans according to the international consensus guidelines. From each of these 3 patients, an intraoperative CT scan was also obtained, with clips placed at the surgical-anatomy-based level boundaries. The preoperative (CT-based) and intraoperative (surgery-defined) CT scans were matched. Results: Clips placed at the most cranial part of the neck lined up at the caudal part of the transverse process of the cervical vertebra C-I. The posterior border of surgical level IIa (spinal accessory nerve [SAN]) did not match with the posterior border of CT-based level IIa (internal jugular vein [IJV]). Other surgical boundaries and CT-based contours were in good agreement. Conclusions: The cranial border of the neck, i.e., the cranial border of level IIa/IIb, corresponds to the caudal edge of the lateral process of C-I. Except for the posterior border between level IIa and level IIb, a perfect match was observed between the other surgical-clip-identified levels II-V boundaries (surgical-anatomy) and the CT-based delineation contours. It is argued that (1) because of the parotid gland overlapping part of level II, and (2) the frequent infestation of occult metastatic cells in the lymph channels around the IJV, the division of level II into radiologic sublevels IIa and IIb may not be relevant. Sparing of, for example, the ipsilateral parotid gland in selective RT can even be a treacherous undertaking with respect to regional tumor control. In contrast, the surgeon's reasoning for preserving the surgical sublevel IIb is that the morbidity associated with dissection of the supraspinal accessory nerve compartment of level II is reduced, whereas there is evidence from the surgical literature that no extra risk for regional tumor control is observed. Therefore, in selective neck dissections, the division into surgical sublevels IIa/IIb makes sense.},
doi = {10.1016/j.ijrobp.2004.12.006},
url = {https://www.osti.gov/biblio/20698566}, journal = {International Journal of Radiation Oncology, Biology and Physics},
issn = {0360-3016},
number = 3,
volume = 62,
place = {United States},
year = {Fri Jul 01 00:00:00 EDT 2005},
month = {Fri Jul 01 00:00:00 EDT 2005}
}