Accuracy of intraoperative staging of the NO neck in squamous cell carcinoma.

Management of the neck in squamous cell carcinoma of the upper aerodigestive tract continues to be a topic of great debate. One major problem is that incorrect clinical staging is expected in approximately 20% of necks. This is true of both clinical stage NO and N+ necks, even when imaging studies are used. This prospective study of 108 necks in 79 patients examined the role of intraoperative palpation and inspection in improving the surgeon's ability to predict nodal stage. Of 62 patients with NO necks clinically on both sides, 26 were staged N+ by intraoperative node examination. Nineteen of the 26 were histologically negative (73% false-positive). Of the 36 patients staged intraoperatively as NO, 10 were histologically positive (28% false-negative). Of 108 necks judged clinically to be NO, 25 (23%) had occult metastases and 11 (10%) had extracapsular spread. Forty-one of 108 clinical NO necks were believed to have positive nodes at the time of neck dissection. Of these 41 necks, 30 (73%) were found to be histologically NO (false-positive). Of the 67 clinical NO necks that were also believed to be NO intraoperatively, occult metastases were found in 14 (21% false-negative). Therefore, intraoperative staging did not significantly improve the false-negative rate. Frozen-section biopsy obtained in the operating room was reliable in 24 (92.3%) of 26 patients. Although frozen-section biopsy was not performed in all patients, these data suggest that upstaging the neck without frozen-section biopsy is much less reliable. This study supports the use of frozen-section biopsy before converting the selective dissection to a radical or modified neck dissection in most instances.