Neck Dissection

Thirty-eight clinics in Germany, Austria and Switzerland participated in the multi-center retrospective DÖSAK REHAB (REHABILITATION) study of tumors in the maxillofacial region. An ethics approval was performed in every participating clinic successfully. The Bochum patient questionnaire on rehabilitation containing 147 questions in nine chapters (personal data, course of disease prior to treatment, during treatment and post-treatment, coping with disease, life circumstances and lifestyle) was used. The doctor’s questionnaire attached to each patient questionnaire included questions about tumor size, localization, neck dissection and reconstruction. Tumor size was determined according to the UICC classification of malignant tumors (1987): T1 ≤ 2 cm, T2 > 2 to 4 cm, T3 > 4 cm, T4 infiltrating neighboring structures. 1761 questionnaires were returned anonymously. The data was analyzed with the SPSS program 21.0 including descriptive statistics, correlations, chi-square test and ANOVA calculations and with a step-by-step regression analysis. The questionnaires were checked for systematic and non-systematic errors to avoid bias. A five-point Likert scale was used to measure 19 impairments (Table 1) which are important from the experience of surgeons in the Department of Maxillofacial Surgery and further symptoms that arose throughout the disease and therapy (no impairment = 0, slight impairment = 1, moderate impairment = 2, severe impairment = 3, very severe impairment = 4). Quality of life was measured using a 100-point scale (from 0 = completely dissatisfied to 100 = completely satisfied).
Quality of life was measured using a 100-point scale and the patients classified in three groups (very dissatisfied, satisfied, very satisfied). High standard residues (SR) indicate the closeness of the connections between two variables. The psychological variables were measured using German versions of the following scales in their short forms: depressiveness with the Depression Scaleby vs. Zerssen D (Depression Scale 1976; published by Hogrefe) [37 (link)], fear with STAI by Laux (State-Trait Anxiety Inventory 1972; published by Hogrefe) [38 (link)], coping with the disease with the Freiburg Questionnaire on Coping with Disease by Muthny (Freiburg Questionnaire of Coping with Disease 1996; published by Beltz/Hogrefe) [39 ]. Higher figures indicate a greater mental strain. The 1652 patients from the total random sample were divided into three groups: those who had lost weight, gained weight or maintained the same weight. Besides this, the groups of patients who had lost or gained weight were sub-divided into those who had lost or gained up to 10 kilograms in weight and those who had lost or gained more than 10 kg.

The database maintained by the Department of Radiation Oncology at The University of Texas M.D. Anderson Cancer Center (MDACC) was searched to identify patients irradiated for oropharyngeal carcinoma (squamous cell, poorly differentiated or undifferentiated, or not otherwise specified) between the years 2000–2007. Our institutional review board granted permission to conduct this retrospective study.
The search identified 1162 medical records. Patients were excluded for the following reasons: distant metastases or concurrent malignancies (exclusive of a second malignancy of the oropharynx) at the time of diagnosis (16 patients), a previously treated malignancy of the head and neck or previous radiation to the head or neck (8), a history of any malignancy (excluding non-melanomatous skin cancer) within two years of diagnosis (7), or treatment with chemotherapy prior to staging at MDACC (8). In addition 69 patients who did not meet the staging criteria of interest (Stage 3- 4B), and 8 patients with poor performance statuses, staged 4B, and treated with palliative intent were excluded. One thousand forty-six patients formed the cohort for analysis.
Medical records were reviewed to assess patients’ demographic, clinical, radiologic and pathologic data. Based upon the medical history at presentation and as described previously [18 (link)] patients were classified as current smokers, former smokers, or never-smokers. Smokers were further evaluated to assess if they quit smoking, or continued to smoke during or subsequent to treatment.
Patients’ disease was staged according to the AJCC 2002 staging system [19 ]. Charts were reviewed to verify tumor size and sites of invasion. Staging variables of interest included T-category, N-category, and overall AJCC group stage. Patients staged Tx were typically those seen post-tonsillectomy and if the tumor size could not be determined after record review, these patients were staged T1 for the purpose of AJCC stage grouping in this analysis. Those staged Nx were patients in whom a solitary node was excised for diagnosis, and size could not be determined. These patients were coded as N1 for the purpose of this analysis.
Chi-squared tests were used to compare proportions between subsets. The t-test was used for comparison of means. The Kaplan-Meier method was used to calculate actuarial curves. Time of diagnosis was used as time zero. Comparisons between survival curves were made using the log-rank test. Multivariate analysis was performed using the Cox proportional model.
Our approach has been to perform neck dissection only in patients with suspected residual disease following radiation. During the years of this study reassessment principally consisted of physical examination and CT scan 6 to 8 weeks after radiation. Those patients with an obvious residual mass were operated. Patients with questionable residual disease had sonograms with aspiration performed to try to resolve whether there was viable disease. Routine use of positron-emission tomography had not become a routine practice during the years of this study. Details of our experience with regards to management of the neck in an overlapping cohort has been recently described [20 (link)]. Patients who had neck dissections performed within 6 months of radiation for suspected residual disease were not scored as having disease recurrence.

To generate the HNSCC PDX, the human HNSCC tissues were obtained without patient information from the Peking University School and Hospital of Stomatology. The tumor tissues were cut into small pieces, followed by implantation into the flanks of NOD-SCID mice (6 weeks old), according to a previously described method [8 (link)]. HNSCC specimens from 60 patients were obtained from the Peking University School and Hospital of Stomatology from September 2012 to October 2016. The inclusion criteria were as follows: 1) the tumor was in the tongue; 2) there was no distant metastasis; 3) removal of the primary carcinoma and neck dissection without preoperative radiotherapy or chemotherapy; and 4) patients who underwent postoperative follow-up for at least five years. Without conducting a pathological study, the clinical TNM staging approach was used to classify the tumor size and clinical stage for the 40 HNSCC samples among the 60 samples: 1) tumor size limited in T2 and T3; 2) clinically negative cervical lymph node (cN0); and 3) no distant metastasis (M0). Based on the histopathologic evaluation of the lymph nodes, these 40 patients were split into lymph node-negative and positive groups. These experiments were approved by the Institutional Review Board of the Peking University School and Hospital of Stomatology and all samples were obtained from patients who signed informed consent forms approving the use of their tissues for research purposes after surgery (Approval number: PKUSSIRB-2012010). The tissues were snap-frozen and placed at −80 °C until analysis.

This retrospective study included patients with SCCT who underwent surgery-based treatment at our institution between January 2013 and December 2020. Patients without clinical evidence of lymph node metastasis (N−) usually underwent selective neck dissection, whereas those with lymph node metastasis (N +) underwent modified radical neck dissection^{24 (link),25 (link)}. Clinicopathological data, including histopathology and surgical records, were retrieved from the patient’s medical records, and the follow-up time was set from the date of surgery to death, loss of visit, or May 2022. Given that the etiology and prognosis of squamous cell carcinoma in the posterior part of the tongue are different from those of the anterior part, only the anterior two-thirds of the tongue was studied in the present research. The inclusion criteria were (1) diagnosis of SCCT based on preoperative imaging and postoperative pathology; (2) no preoperative chemotherapy, radiotherapy, immunotherapy, or endocrine therapy; (3) first onset and treatment occurring during the study period; (4) no distant metastasis detected before surgery; and (5) complete clinical and pathological data. Patients were excluded from the study if they had incomplete records, were lost to follow-up, or had concomitant malignant tumors or a malignant tumor history.
This study was carried out following the Code of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans that were further updated, and the protocol was reviewed and approved by the Medical ethics committee of the Second Affiliated Hospital of Fujian Medical University(no. 274, 2022). All procedures conducted in studies involving human participants met the ethical standards of the Institutional Research Committee. Informed consent was obtained from all patients. All methods were performed in accordance with the relevant guidelines and regulations.

On day 14 after the FLIT procedure, mice were anesthetized with isoflurane in oxygen. The same neck incision and neck cervical dissection were performed as described for the FLIT procedure. After locating the foramen lacerum, the Surgifoam was removed with care. The incision was closed as described in the FLIT procedure. Recompression surgery was performed as described in the FLIT procedure.