Lymphadenectomy

Lymphadenectomy, sometimes called lymph node dissection, is a surgical operation in which the lymph nodes are removed and a sample of tissue is examined under a microscope for the presence of malignancy. It's a procedure that's frequently done as part of the surgical treatment of cancerous tumors. Regional lymphadenectomy removes certain lymph nodes in the tumor area (inguinal, femoral, iliac, epitrochlear, cervical, popliteal, retroperitoneal, or axillary lymph node groups), while radical lymphadenectomy removes most or all of the lymph nodes in the tumor area. The presence of cancer cells in lymph nodes is linked to a higher chance of metastasis to other areas of the body and a worse prognosis.

The lymph node dissection site is determined by the place of involvement. Axillary lymph nodes (for breast cancer), inguinal lymph nodes (for penile, anal, and vulvar cancers), cervical lymph nodes (for head/neck malignancies and thyroid cancers), and retroperitoneal lymph nodes (for testicular and ovarian cancers) are the four most common dissection locations.

Lymphatic Anatomy and Physiology

The lymphatic system, also known as the lymphoid system, is a component of the circulatory and immunological systems. The major lymphoid organs and secondary lymphoid organs make up this system. The principal lymphoid organs are the thymus and the bone marrow. They're both engaged in lymphocyte synthesis and early clonal selection. The synthesis and maturation of B lymphocytes, as well as the development of T cells, take place in the bone marrow. In pursuit of pathogens, B cells migrate from the bone marrow to secondary lymphoid organs. T cells, on the other hand, make their way from the bone marrow to the thymus, where they mature. The thymus is the main lymphoid organ. It creates an environment in which T cells can develop and mature. Furthermore, the induction of central tolerance is one of the most critical functions of the thymus.

T cells may self-tolerate through thymic stromal cells’ function. Lymph nodes, spleen, and mucosa-associated lymphoid tissues are examples of secondary lymphoid organs. Red and white pulp make up the spleen. Half of the body's monocytes are kept in the red pulp. Antibodies, on the other hand, are made in white pulp. Antibody-coated bacteria and antibody-coated blood cells are removed from circulation by the spleen. The afferent and efferent lymph vessels, capsule, sinus, nodule, and cortex make up lymph nodes. Antigens can interact with lymphocytes in lymph nodes. Mucosa-associated lymphoid tissues are secondary lymphoid structures. These can be found on the mucosal surfaces of practically any organ, but they're most common in the digestive, genitourinary, and respiratory systems. Peyer's patches, for illustration, are small intestine mucosa-associated lymphoid tissues that sample moving antigens and bring them to underlying B and T cells.

Lymphatic vessels are thin-walled tubes that transport lymph from one part of the body to another. The lymph capillaries are in charge of absorbing extracellular fluid from the tissues. The absorbed fluid is driven into larger collecting ducts by lymph vessels before returning to the bloodstream via one of the subclavian veins.

The lymphatic system serves a variety of purposes. To begin with, it gathers and returns fluid that flows from cells and tissues to the bloodstream. Second, it absorbs fats from the digestive system: lymph delivers fats and proteins-containing fluids from the intestines back to the bloodstream, and third, it guards against foreign antigens.

Lymphadenectomy Definition

Lymphadenectomy is a surgical operation that removes the cluster of lymph nodes that are most likely to spread malignant cells throughout the body. Urogenital malignancies are most commonly seen in the kidney, bladder, or male and female reproductive systems. As a result, surgery is frequently directed at the lymph nodes closest to these organs. The inguinal and retroperitoneal regions are included.

Lymph node dissection is simply one component of a comprehensive cancer treatment plan, and the timing of surgery will vary depending on the stage and type of cancer. Surgery may help people with early-stage cancer avoid chemotherapy.

The lymphatic system includes lymph nodes. Lymph veins, lymph fluid, lymph nodes, bone marrow, and lymphatic organs (thymus, adenoid, tonsil, and spleen) make up the lymphatic system, which aids in the defense against infections.

Lymphadenectomy Types

According to the National Cancer Institute (NCI), lymphadenectomies are classified as either regional or radical.

Only some of the tumor-adjacent lymph nodes are removed during a regional lymphadenectomy. The majority, if not all, of the tumor-adjacent lymph nodes are removed during a radical lymphadenectomy.

The location and type of tumor determine whether a person needs a regional or radical lymphadenectomy.

The type of lymphadenectomy required is also determined by the surgical site. The four most prevalent lymphadenectomy procedures are:

Axillary lymph node dissection. It is a procedure that involves removing lymph nodes from the armpit and is related to breast cancer.
Inguinal lymph node dissection. This procedure removes lymph nodes from the groin and is related to malignancies of the penile, anal, and vulvar regions.
Cervical lymph node dissection. Lymph nodes from the sides and back of the neck are removed in cervical lymph node dissection, which is related to head and neck or thyroid malignancies.
Retroperitoneal lymph node dissection. Testicular and ovarian malignancies are related to retroperitoneal lymph node dissection, which removes lymph nodes from the back of the abdomen.

Lymphadenectomy Indications

Solid tumor metastases are most commonly found in lymph nodes. "The surgery of cancer is not the surgery of organs; it is the surgery of the lymphatic system," said Sir Berkeley Moynihan, a prominent British surgeon. The lymphatic system is one of the primary mechanisms by which many malignancies spread, and the neighboring lymph node is the most susceptible. Because many forms of malignant tumors have a predisposition to cause lymph node metastases early in their natural history, lymph node dissection is commonly performed. Many cancers, such as breast cancer, colon cancer, melanoma (skin cancer), thyroid cancer, head and neck cancer, stomach cancer, and lung cancer, have a consistent route of metastasis, so removing lymph nodes and investigating them microscopically for potential cancer involvement would be beneficial in the assessing cancer spread.

The need for a regional or radical lymphadenectomy is determined by the location and kind of cancer. Radical neck dissection for thyroid and head and neck cancers, axillary lymph nodes for breast cancer, whole mesorectal excision for rectal cancer, and D2 lymph node dissection for stomach malignancies are the four most common lymphadenectomy procedures.

Lymphadenectomy Equipment

The surgical equipment sets used for lymph node dissection vary depending on the technique. It is vital to have an operating room and anesthetic equipment. Surgical technique such as laparoscopic distal gastrectomy with D2 lymphadenectomy is sometimes used by surgeons. This surgical method requires a laparoscopic tower as well as laparoscopic tools (laparoscope, needle driver for sewing up, trocars, and bowel grasper).

Lymphadenectomy Personnel

General surgeons or other specialty doctors may do lymph node dissection depending on the type of procedure. Axillary lymphadenectomy is mainly performed by breast surgeons. When patients have a total abdominal hysterectomy with bilateral salpingo-oophorectomy for gynecological cancers, gynecologic oncologists are experts in pelvic and retroperitoneal lymph node dissection. For testicular malignancies, urologists do retroperitoneal lymph node dissections, whereas, for penile cancers, they undertake pelvic lymph node dissections. ENT specialists are also surgical doctors that perform cervical lymph node dissection in thyroid and head and neck cancer patients.

Lymphadenectomy Preparation

Make sure someone will drive you home. You will be unable to drive or get home on your own due to anesthesia and pain medication.
Understand the procedure, as well as the risks, advantages, and possible alternatives.
Talk with your doctor if you want to stop taking aspirin or any other blood thinner before your procedure. Make sure you comprehend all your doctor has told you. These medications raise the chances of bleeding.
Tell your doctor about all of your medications and natural health supplements. Some may raise your risk of complications during surgery. Your doctor will inform you whether and when you should stop taking any of them before the procedure.
Make a copy of your advance care plan for your surgeon and the hospital. If you don't have a copy, you should consider making one. It informs others of your healthcare preferences. It is important to it have before any operation or procedure.
Follow the recommendations for when to cease eating and drinking to the full. Your surgery may be canceled if you do not comply. If your doctor advised you to take your medications on the day before surgery, only take a sip of water with them.
Before you come in for your operation, take a bath or shower. Lotions, fragrances, deodorants, and nail polish should not be used.
You should not shave the surgery location yourself.
Remove any piercings and jewelry. Also, if you wear contact lenses, remove them.

Lymphadenectomy Procedure

Lymphadenectomy can be done either open or laparoscopically, depending on the place of the lymph nodes. The patient lies supine with legs immobilized in moderate external rotation during a radical open inguinal lymphadenectomy for penile cancer. A 10-cm horizontal skin incision is made 2 cm above the inguinal crease, using the pubic symphysis and anterior superior iliac spine as anatomical reference points. Uncovering the lower skin flap at Scarpa fascia level till 10 to 12 cm below the incision reaches the femoral triangle apex. Between ligatures, the great saphenous vein (GSV) is cut and separated. At its junction with the common femoral vein (CFV), the surgeon proceeds to dissect the GSV and its branches.

Lymphatic nodes between the sartorius and adductor longus muscles, as well as fascia surrounding these muscles, are taken from the sartorius and adductor longus muscles and then sent to the pathologist to be tested for cancer cells. All subcutaneous tissues along the medial, distal, proximal, and lateral edges are sutured to prevent lymphatic drainage.

A 2-inch incision across the patient's axilla is used to perform an axillary lymph node dissection (ALND) for breast cancer. Lymph nodes beneath the lower margin of the pectoralis minor muscle (level I) and lymph nodes directly beneath the pectoralis minor muscle (level II) are both eliminated. To avoid post-operative problems, a tiny drain may be inserted. Testicular tumors and retroperitoneal cancers are treated with retroperitoneal lymph node dissection (RPLND), which can be done open or laparoscopically. To open the abdomen, a 6 to 9-inch cut is required. To facilitate dissection, the inferior mesenteric artery (IMA) is routinely severed. The lumbar veins and arteries are ligated when they pass through the psoas muscle. The left ureter should be identified and kept in this plane of dissection.

Total mesorectal excision (TME) is a popular colorectal cancer operation that involves placing the patient in a modified lithotomy position. The goal of this technique is to remove rectal cancer in its entirety while leaving the rectal fascia intact and performing a thorough pararectal lymphadenectomy as included in the mesorectum. TME can be done open, laparoscopically, or robotically, with similar oncological outcomes. Another surgical method for colorectal cancer treatment that has received a lot of interest is transanal endoscopic total mesorectal excision (Ta-TME). The rectum is dissected through the anal canal laparoscopically in a caudal-to-cephalad plane in this procedure.

A neck dissection is a cancer treatment procedure that involves removing cervical lymph nodes from the neck. A typical incision for neck dissection is the Macfee incision, which consists of two horizontal parallel incisions. To do neck dissection, the platysma muscle is found and lifted. The extent and involvement of important structures determine the need for neck dissection. The repair is done with a pectoralis major myocutaneous flap or a temporalis flap and skin grafting.

Lymphadenectomy Postoperative Care

The length of your hospital stay will be determined by the number and location of lymph nodes excised. After your lymph node dissection, you should be discharged within a few days.

Doctors will go over recommendations for follow-up care before you leave the hospital, including painkillers or antibiotic regimen, activity limitations, and how to properly care for the incision to prevent infection. You'll probably feel some pain and discomfort in the incision site for a few days after surgery.

Within two weeks, you will be scheduled a follow-up meeting with you and your surgeon to confirm your incision is healing appropriately, remove any drains, and review the results of your pathology report, which will influence any subsequent treatment.

If one or more lymph nodes on your pathology report test positive for cancer, you may be sent to a medical oncologist or a radiation oncologist for chemotherapeutic or radiation therapies. Soft tissue sarcomas are also treated with proton therapy. Proton therapy is a more specific form of radiation therapy that permits you to have a second round of treatment.

Lymphadenectomy Complications

Although lymph node dissection is an essential component of cancer diagnosis and treatment, problems can occur as with any surgical surgery. The location and amount of the dissection determine the complications. Pain, tingling, and surgical wound infections are all common consequences. Lymphedema is swelling and edema of the arms or lower limbs caused by lymph buildup in the interstitial tissue, making the affected area feel heavy and swollen.

Other problems may arise depending on the type of procedure and lymph node dissection. Pancreatic fistula, bleeding, bile duct damage, and chylous fistula are all problems that can occur after lymph node dissection in gastric cancer surgery. In patients undergoing surgical staging for endometrial cancer, dissection of more than 15 retroperitoneal lymph nodes is also an important risk factor for postoperative complications such as deep vein thrombosis, postoperative site infections, lymphocytes, revision laparotomy, febrile morbidity, and wound dehiscence.

Lymphedema, numbness or tingling, seroma, lymphocele, hematoma, lymphatic scarring, and axillary vein thrombosis are all risks of axillary lymph node dissection. Moreover, central and lateral cervical lymph node dissection for thyroid cancer is linked to serious complications like intra- and postoperative hemorrhage, facial nerve or vagus nerve injury, and respiratory distress.

Lymphadenectomy Results

Each lymph node is removed and checked for malignancy.

There are no malignant cells in a negative lymph node.
Cancer cells can be found in a positive lymph node.

The type of malignancy, the number of lymph nodes excised, and the number of lymph nodes with cancer cells are all listed in the pathologist's report. The report may also state whether cancer has spread beyond the lymph nodes' outer layer (the capsule).

The number of positive lymph nodes is used by doctors to help stage cancer.

They use the stage, as well as other details regarding cancer's type and grade, to make therapy recommendations and prognoses.

Your doctor will determine whether you require additional testing, treatment, or follow-up care based on the results.

Lymphadenectomy Special Consideration

A lymph node dissection may be required in rare circumstances to stage or treat cancers that can spread to the lymph nodes, such as pediatric breast cancer or rhabdomyosarcoma.

Preparing children for a test or procedure might help them feel less anxious, cooperate more, and develop coping mechanisms. Explaining to children what will happen throughout the examination including what they will hear, feel, see, taste, or smell is part of the preparation process.

The age and experience of the child are factors in preparing them for a lymph node dissection.

Conclusion

Lymphadenectomies are surgical procedures that allow surgeons to see if a patient's cancer has spread to their lymphatic system.

These operations, like all surgeries, come with some hazards. Lymphadenectomies, on the other hand, can save lives and assist healthcare providers in determining a patient's treatment approach.