Auto text: “Insert Neck Dissection” (many Levels) or “Insert Lymph Node Dissection” (one Level)

Neck Dissections are done for:

• Metastatic carcinoma to lymph nodes (N staging)
• Soft tissue tumor deposits

There are 3 types of Neck Dissections:

• Radical: Includes Levels I through V, sternocleidomastoid muscle, internal jugular vein, and spinal accessory nerve (If you receive a radical neck dissection, please contact an attending for assistance)
• Modified Radical: Includes Levels I through V, while sparing at least one of the anatomic structures in the radical dissection (SCM, IJV, CN-XI) (If you receive a modified radical neck dissection, please contact an attending for assistance)
  • Comprehensive: a variant of modified radical that includes Levels I through V while sparing ALL anatomic structures
• Selective: Includes removal of select Levels, with or without anatomic structures such as skin, IJV

Most staging dissections are Selective:

• Submandibular Gland: Level I
• Lateral Neck: Levels II-IV
• Central Neck: Level VI (pre/para-tracheal, pre-cricoid (Delphian), perithyroidal)
• Posterolateral Neck: Levels II-V

Triage

1. Most moderate-large neck dissections are best grossed after fixation, but can be done fresh if careful.
2. Measure in 3D, noting any sutures that designate Levels.
3. Fix in formalin overnight.

Gross – For soft tissue tumor deposits, any Level

1. Ink the outer surface.
2. For a large, palpable mass: serially section, measure mass in 3D, and submit representative sections (1 per cm including nearest margins).
3. Photograph a representative cut section.
4. Dissect remaining tissue for lymph nodes as follows.

Gross – Level I including Submandibular Gland

• Many neck dissections include submandibular gland (as part of a larger dissection or on its own).  The specimen may be labeled as Level I, as submandibular gland resides in the path of lymphatic drainage in Level I.

Submandibular Gland (tan-yellow lobulated) and Lymph Node Candidates (nodular, brown, at bottom)

•  Measure the gland (intact or aggregate, if fragmented).
• Serially section to evaluate for lymph nodes and tumor deposits/lesions.
• Submit all lymph nodes.
• Submit intraparenchymal lesions, if identified.
• If no gross lesions are identified, submit 1-2 representative sections of gland.
• If the neck dissection is being done for metastatic salivary-gland-type tumor and there is no known primary, then then whole gland should be submitted.

Gross – Levels II, III, IV, V, VI, VII

1. Unless otherwise designated, assume all LATERAL neck dissections include Levels II, III, and IV.
2. Separate the dissection longitudinally into THREE levels (II, III, IV), using sutures as your guidelines.
   • Level II = Upper Third
   • Level III = Middle Third
   • Level IV = Lower Third

1. Thoroughly examine each Level for lymph nodes.
2. Describe size range of nodes, grossly positive nodes, any obvious soft tissue involvement.
3. If you see anything that looks like soft tissue involvement (non-encapsulated, sclerosing, ill-defined), ink the margin adjacent to the lesion and submit sections to demonstrate mass in relation to margin.
4. If grossly negative, submit the entire node.
5. If grossly positive, submit entirely (if small) or 1 section per cm (if large).
6. If only a small amount of fat remains in each Level, submit. Make sure the block summary reflects the number of lymph node candidates you found, designating the Level.