Neck dissection: historical perspective.

Because of the proclivity of head and neck cancer to metastasize to the regional lymph nodes, a discussion of the management, regardless of the primary sites, mandates a concurrent discussion on how to treat the neck. With the exception of distant metastases the most adverse independent prognostic factor in squamous carcinoma of the head and neck is the presence of involved cervical lymph nodes. Furthermore, metastatic cancer involving the cervical lymph nodes is the most common pattern of recurrence in patients with head and neck squamous carcinoma. Such an event generally carries a fatal prognosis. The presence of a single involved lymph node reduces survival by 50 per cent. Contralateral or bilateral cervical disease reduces prognosis by an additional 50 per cent. Therefore, careful consideration must be given to treatment of the neck. Neck dissection has been used in the treatment of cervical metastases and it is generally accepted that, if the risk of lymph node metastases in the neck is greater than 20 per cent, elective treatment is required. Without diminishing the importance of the contributions by some pioneers, the Žrst systematic anatomical description of en bloc dissection of the neck was published in English by George Washington Crile, Sr, from Cleveland Clinic, Ohio, in the Transactions of the Southern Surgical and Gynecological Association in 1905. This landmark article was 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 Žve patients’ and is composed of 20 pages. His paper on this topic is accompanied by 12 drawings of great clarity and a discussion of nine pages. In particular, Charles H. Mayo of Rochester 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 publication is often not mentioned in the medical literature, however, this report represents a monumental piece of work in the treatment of the neck metastases. The operation he described has come to be known as radical neck dissection. He advocated a block resection of the cervical lymph nodebearing tissue to be removed either in continuity with the primary cancer or as a secondary operation for subsequent metastases. The surgical procedure as originally conceived by Crile is accomplished by sacriŽcing the sternocleidomastoid muscle, the internal jugular vein, the submaxillary gland and the omoyhyoid muscle. Crilementioned a study of 4500 cases with head and neck cancer made for him by Dr Hitchings in which fewer than one per cent of the tumours of the head and neck had secondary foci in distant tissue or organs (but higher rates of distant metastases have been reported in more recent studies). From this study Crile concluded that if the neck lymphatics could be removed en bloc, more cures could be accomplished. He was considered the primary proponent of this type of surgery in the United States. Crile stated that the key of dissemination of the cancer was the internal jugular vein, and therefore it was imperative to sacriŽce the vein by a block dissection. Crile practised composite block dissections with removal of a part of the mandible for lesions of the tongue and oor of the mouth. In 1906, Crile published another paper on block dissection in the Journal of the American Medical Association. This second publication is always quoted as the original approach to neck dissection and is entitled ‘Excision of cancer of the head and neck. With a special reference to the plan of dissection based on one hundred and thirty-two operations’. This paper is also accompanied by drawings of great clarity (the illustrations are the same as published in the previous paper by Crile). With these papers Crile put block dissection on a par with the Halsted operation for the treatment of breast cancer. Almost all clinicians mention the second Crile paper as the original description of neck dissection, while ignoring the Žrst publication. This error was later constantly copied in the medical literature and illustrates well the dangers of quoting historical references secondhand, particularly when the original paper was in another language. The mistake was also reported in historical landmarks in head and neck cancer surgery articles. In his second publication he reported the results of treatment of 132 head and neck cancers. Crile noted that among 48 patients who did not have a radical neck