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Thank you for sharing your experience with lymphoscintigraphy of the cervical pathways and bringing to our attention the possibility of lymphovenous shunting of head and neck malignancies. The lymph nodes along the internal jugular vein are usually considered to represent a downward pathway of lymphatic spread for tumor emboli and the lower jugular lymph nodes represent the inferior extent of this route. Your work with lymphoscintigraphic tracers suggests that this is not always the case and there is shunting from the upper jugular lymph nodes directly into the venous circulation.
I will attempt to respond to your question on whether the distribution of pathologic lymph nodes in the neck outlined in our previous article on the classification of neck dissection is related to preferential pathways of drainage, retrograde lymphatic spread, or early lymphovenous shunting. In the neck dissection classification article, we defined the names and surgical boundaries of six regions
Thomas Robbins K. Possible Implications of Neck Lymphovenous Shunts-Reply. Arch Otolaryngol Head Neck Surg. 1995;121(3):353. doi:10.1001/archotol.1995.01890030078015
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