Overview of Lymph Node Dissection
Lymph node dissection, also known as lymphadenectomy, is a type of surgery where lymph nodes are removed and tested for cancer. Lymph nodes are small, bean-shaped structures that help your body fight against illness and disease. During this procedure, a piece of tissue is examined under a microscope to check for signs of cancer.
This operation is usually done when someone is treating cancerous tumors. The surgery can be either ‘regional lymphadenectomy’, where only some lymph nodes in the area of the tumor are removed, or ‘radical lymphadenectomy’, where most or all of the lymph nodes in the tumor area are taken out.
These areas can include the groin (inguinal), thigh (femoral), lower back (iliac), elbow (epitrochlear), neck (cervical), knee (popliteal), behind the intestines (retroperitoneal), or armpit (axillary). If cancer cells are found in the lymph nodes, it means there’s a higher possibility of the cancer spreading to other parts of the body. This usually signals that the cancer is more serious.
The location from where the lymph nodes are removed depends on the site of the tumor. The four most frequent sites are the armpits (for breast cancer), the groin area (for cancers of the penis, anus, and vulva), the neck (for cancers of the head, neck, and thyroid), and the area behind the intestines (for testicular and ovarian cancers).
Anatomy and Physiology of Lymph Node Dissection
The lymphatic system, sometimes called the lymphoid system, is an essential part of our body’s circulation and defense systems. Its major components include the primary and secondary lymphoid organs. The primary lymphoid organs are the thymus gland and the bone marrow, both of which play key roles in developing lymphocytes, a type of white blood cell.
Bone marrow, found within our bones, produces B and T cells, two types of lymphocytes. B cells then leave the bone marrow and go to the secondary lymphoid organs to help defend against disease-causingMicro-organisms. T cells, on the other hand, move from the bone marrow to the thymus gland for maturation.
The thymus gland, nestled behind your breastbone, helps mature T cells, ensuring they can help fight off diseases in the body. Importantly, the thymus has a process to ensure that these T cells won’t attack the body’s own cells, a form of self-defense called ‘self-tolerance’.
The secondary lymphoid organs, which includes the lymph nodes, spleen, and tissues linked to mucus membranes, also play an important role in our body’s defenses. For instance, the spleen, found in the upper left part of the abdomen, has two main parts: the red pulp and the white pulp. The red pulp stores half of the body’s monocytes (a type of white blood cell), while the white pulp is where antibodies (proteins that help fight infections) are made. The spleen also removes bacteria and blood cells coated with antibodies from circulation.
Lymph nodes and tissues linked to mucus membranes, spread across the body, especially in the digestive, urinary, and respiratory tracts, help identify and respond to harmful substances. The lymph nodes, in particular, are small, bean-shaped structures that help disease-fighting cells interact with harmful substances to neutralize them.
The lymphatic vessels form a network of tubes throughout the body, functioning like highways for the movement of lymph (a clear fluid containing white blood cells). This fluid is absorbed from body tissues and moved into larger collecting ducts before finally returning to the bloodstream via a large vein in the neck.
The lymphatic system has many crucial roles. Beyond developing and deploying disease-fighting cells, it collects and returns fluid from body tissues back to the bloodstream. It also absorbs and transport fats from the digestive system and helps the body mount a defense against harmful substances.
Why do People Need Lymph Node Dissection
Lymph nodes, which are part of your body’s immune system, are often the first places where cancer spreads. An acclaimed British surgeon, Sir Berkeley Moynihan, once stated that cancer surgery focuses not on the organs where cancer originates but on the lymphatic system – the pathway that most cancers use to spread.
Because certain types of malignant (cancerous) tumors often spread to lymph nodes at the early stages, doctors usually surgically remove and examine these lymph nodes to assess the extent of cancer’s spread. This process is known as lymph node dissection and is particularly beneficial for cancers like breast, colorectal, melanoma, thyroid, head and neck, gastric, and lung cancers that usually follow a predictable path of spread.
When and how extensively a lymph node dissection is undertaken depends on the location and type of the malignant tumor. For instance, a radical neck dissection is often used for thyroid and head and neck cancers, removal of axillary (underarm) lymph nodes is common in treating breast cancer, total mesorectal excision is used for rectal cancer, and a procedure known as D2 lymph node dissection is used for stomach cancers.
When a Person Should Avoid Lymph Node Dissection
There aren’t any firm rules against performing a lymph node dissection, which is a procedure where doctors remove lymph nodes to check for signs of disease. However, this operation is typically not done if the patient already has distant metastasis, which means the disease has spread to parts of the body further away from its origin.
Equipment used for Lymph Node Dissection
The types of surgical tools used can vary based on the specific operation being performed, in this case a lymph node removal. A surgical room with anesthesia equipment is essential. Sometimes, doctors may prefer to use a less invasive method known as laparoscopy for procedures like the removal of part of the stomach and surrounding lymph nodes (laparoscopic distal gastrectomy with D2 lymphadenectomy). In such circumstances, specific laparoscopic equipment is needed. This includes a laparoscopic tower, a device with a camera that allows the doctor to view the inside of your body on a monitor, and various laparoscopic tools such as a needle driver for stitches, trocars (thin tubes through which surgical tools are inserted), and a device to hold and manipulate the bowels.
Who is needed to perform Lymph Node Dissection?
The type of surgery you’re getting will determine who performs your operation. Usually, general surgeons or other specialized surgeons may carry out what is called a lymph node dissection. This procedure involves removing some of the lymph nodes in your body, which are small glands that make white blood cells to fight infections and diseases.
For example, breast surgeons typically carry out an operation called an ‘axillary lymphadenectomy,’ which is just a medical way of saying they’re going to remove lymph nodes in your armpit area. They often do this during breast cancer treatment.
If you have cancer in your reproductive system and need to remove your uterus, fallopian tubes, and ovaries (total abdominal hysterectomy with bilateral salpingo-oophorectomy), a type of specialist known as a ‘gynecologic oncologist’ would usually perform the operation and possibly remove lymph nodes in the lower abdomen (pelvic) and in the back section of your belly (retroperitoneal) as well.
If you are a man with testicular or penile cancer, a urologist, who specializes in conditions affecting male reproductive and urinary systems, might remove the lymph nodes in the same area.
Last but not least, if you have thyroid cancer or cancer in the head and neck, a specialist known as an ‘otorhinolaryngologist’ might perform a dissection of your cervical lymph nodes (found in your neck). This doctor specializes in conditions related to your ears, nose, and throat.
Preparing for Lymph Node Dissection
Patients are typically admitted to the hospital a day before their surgery. Standard blood tests and a chest X-ray are often part of the preparation process. Before the surgery, doctors take the time to fully explain the procedure to ensure the patient understands and agrees to it, known as giving ‘informed consent’. The steps taken to prepare for the surgery can vary depending on the specific type of operation. As an example, if a patient is undergoing a specific type of colorectal surgery known as a ‘total mesorectal excision’, they may be asked to take an enema the night before. An enema is a treatment that helps empty the bowels, which is important for the surgery.
How is Lymph Node Dissection performed
Lymphadenectomy is a procedure to remove lymph nodes, which are small, bean-shaped organs that produce and store cells that fight infection and disease. Depending on where the lymph nodes are in the body, this procedure can be done in two ways: open surgery or laparoscopic surgery.
In a radical open inguinal lymphadenectomy, done to treat penile cancer, the patient lays flat on their back with their legs slightly turned outward. The surgeon makes a horizontal cut, about four inches long, two centimeters above the groin fold. The surgeon then peels back the lower layer of skin to get to the area near the apex of the femoral triangle,10 to 12 centimeters below the initial cut. The great saphenous vein, a large vein running up the inside of our leg, is then cut and isolated.
The surgeon removes the lymph nodes between two large muscles in the thigh, the sartorius and adductor longus, along with the tissue covering these muscles. This tissue is then sent to a lab to be tested for cancer cells. To prevent a build-up of lymph fluid, the surrounding tissues are sewn together.
When treating breast cancer, an axillary lymph node dissection may be done, where the surgeon makes a two-inch incision under the patient’s arm, in the armpit. They then remove lymph nodes located beneath the lower edge of a muscle in the chest, the pectoralis minor muscle. Sometimes, a small drain is inserted to prevent any complications after surgery.
Retroperitoneal lymph node dissection is performed for testicular cancers and other cancers in the back of the abdomen. This procedure can be done through open surgery, where the abdomen is open by making a 6 to 9-inch cut. The surgeon removes certain veins and arteries as they disappear into a muscle.
The total mesorectal excision is another common surgery used to treat colorectal cancer. In this procedure, the patient is placed in a specific position, and the aim is to remove the rectal cancer and the lymph nodes located in a specific area of the rectum, while keeping the surrounding tissue intact. This surgery can be performed through open surgery, laparoscopy, or robotic surgery, all with similar results in cancer treatment.
Neck dissection is a surgery to remove cervical lymph nodes from the neck, this is usually done to treat cancer. The surgeon often makes two parallel horizontal cuts, identifies a certain muscle and continues with the dissection. Depending on the extent of the cancer, different areas are accessed and in some cases, flaps of skin are used for reconstruction.
Possible Complications of Lymph Node Dissection
Removing lymph nodes, which is often part of cancer treatment, is somehow similar to other surgeries and can result in some complications. These issues can vary based on where the surgery was performed and how many lymph nodes were removed. Common problems after lymph nodes removal include pain, numbness, and infections in the area of surgery. Patients might also experience a condition called lymphedema, where certain parts of the body, like arms or lower legs, tend to swell up and feel heavy. This happens when the body’s lymph fluid builds up in the body’s tissues.
Some complications are more related to the type of surgery and the area from where lymph nodes were removed. For example, certain types of problems might occur after removing lymph nodes during surgery for stomach cancer. These might include a pancreatic fistula (an abnormal duct connecting the pancreas and other organs), bleeding, injury to the bile duct (the tube that carries bile from the liver to the small intestine), and a chylous fistula (an abnormal connection that allows a fatty fluid called chyle seep out from the lymphatic system).
Additionally, if more than 14 lymph nodes are removed from the area behind the stomach, it could increase the chances of having blood clots in deep veins, infections beyond the surgical site, increase in lymph cells, need for another surgery, fever, and wound splitting open in women receiving surgery for a type of cancer called endometrial carcinoma.
Removing lymph nodes from the armpit area, which is typically performed in breast cancer surgeries, could lead to lymphedema, change in skin sensation, buildup of fluid (seroma), lymphatic cyst (lymphocele), blood clot outside the blood vessels (hematoma), hardening of the lymph vessels (lymphatic fibrosis), and blood clots in the axillary vein (a large vein that carries blood from the armpit to the heart).
Surgeries involving the removal of lymph nodes from the neck for thyroid cancer treatment can sometimes result in severe complications such as bleeding during and after surgery, damage to the nerves controlling facial muscles or voice box, and difficulty in breathing.
What Else Should I Know About Lymph Node Dissection?
The lymphoid system, which includes parts of your body like the lymph nodes, plays a puzzling role in human health. While it’s often seen that bigger, more serious tumors have a higher chance of spreading to your lymph nodes, it’s not always the case. There are many patients with large tumors who don’t see this kind of spread. Conversely, patients with smaller, early-stage tumors sometimes experience the disease spreading to multiple lymph nodes.
Furthermore, if the cancer has spread to the lymph nodes, it’s often an indication of how the disease might progress for the patient. For many types of cancer – such as prostate, testicular, breast, certain female reproductive cancers, cancers in the head or neck, and skin cancer (melanoma) – a procedure known as lymph node dissection is used. This procedure, which involves removing and examining the lymph nodes, provides a reliable and accurate way to assess and manage the spread of the disease.
