Lymphadenectomy

Lymphadenectomy or lymph node dissection is a procedure to remove cancerous (or those at high risk of cancer) lymph nodes from a region in the body. This procedure helps stop and detect the spread of cancer, as cancer that has spread to the lymph nodes poses a higher risk of spreading further in the body.

Lymph nodes are a part of the lymphatic system of the body. 

The lymphatic system is a part of the immune system. It comprises lymph nodes, lymph fluid, lymph vessels (that run parallel to blood vessels), and organs such as the spleen and tonsils. This system returns the excess fluid from the tissues to the circulatory system and helps defend the body against pathogens and invaders like bacteria and viruses.

The lymphatic system also plays a key role in the way cancer cells travel. Cancer cells separate from the main focal tumour site (the origin of the cancer) and move in the body through the blood or lymphatic fluid to other distant locations.

Lymph nodes are small, oval organs connected by thin lymph vessels to the body tissues. Lymph nodes are present in clusters all over the body, for example, in the groin (inguinal lymph nodes), the armpits (axillary lymph nodes), the neck (cervical lymph nodes), back of the abdomen (retroperitoneal lymph nodes), and pelvis (iliac lymph nodes). They filter out cancer cells, pathogenic microbes and cellular waste from the lymph. Hence, lymph nodes are highly susceptible to the spread of cancer from nearby tissues. Cancer can also begin in lymph nodes.

Lymphadenectomy may be regional, where some lymph nodes are removed within the tumour area, or radical lymphadenectomy, where all or most of the lymph nodes in the region of the cancer are removed.

A lymphadenectomy is recommended in the following cases:

• In cancers such as melanoma, breast, head and neck, cervical, differentiated thyroid, lung, gastric, and colorectal cancer where the spread (or metastasis) occurs through lymph nodes.
• In persons with positive sentinel lymph nodes (the first lymph node that receives drainage from the tumour shows cancerous cells). A positive sentinel lymph node test means the cancer has spread to the nearest lymph node. Such a lymph node will appear swollen or feel hard or large on physical examination

There are no contraindications to lymphadenectomy per se; however, certain factors need to be considered before proceeding with surgery. These factors include:

• Age of the person (risks of any surgery increase with age)
• Consideration of other available treatment options
• Results of sentinel node biopsy (biopsy that is done to determine if a cancer from an area is spread to a nearby lymph node)
• The thickness and location of cancer, in cases of skin cancer
• Consideration of other conditions that could lead to swelling of the lymph node

The following preparations are needed before a lymphadenectomy:

• Your doctor may ask you to get blood tests done to check your general health and the functioning of your liver and kidneys. This will determine if you are otherwise healthy enough for the surgery and not at risk of complications. 
• Electrocardiogram, lung function tests, echocardiogram, and chest x-ray are some additional tests that will be performed.
• Your weight, pulse, blood pressure, and temperature will be checked.
• Inform your doctor about the medications you consume, especially diabetes medicines and blood thinners. The doctor may tell you if any medicines need to be stopped before surgery.
• Tell your doctor about any current or previous medical health conditions.
• You will be asked to sign a consent form before the surgery to allow the doctor to perform the procedure on you.

Before a lymphadenectomy is performed, a sentinel lymph node biopsy will be carried out. This biopsy is largely performed to identify and detect cancers when enlarged lymph nodes are not palpable. It is done to assess whether the tumour has spread to the sentinel lymph node, which is the first node in the cluster of lymph nodes to receive lymph fluid from the affected tissue. If the sentinel lymph nodes show the presence of cancer, then more lymph nodes in this region will be removed through lymph node dissection. This biopsy is a safe and easy procedure for breast and skin cancers.

For the biopsy, a dye or a radioactive substance will be introduced in the region of the tumour. As the substance flows through the lymph vessels and then to the lymph nodes, the lymph node that first receives the substance (usually the sentinel lymph node) is identified and removed. It is then checked under a microscope for the evidence of cancer.

Lymphadenectomy is performed under general anaesthesia (you will be asleep through the procedure) in an operation theatre. It is done by one of the following approaches:

Simple lymphadenectomy:

A simple lymphadenectomy will be performed in the following way:

• The surgeon will make an opening in your skin from where the lymph nodes have to be removed. The location of the lymph nodes determines the extent and nature of the opening.
• He/she will then excise the lymph nodes and some surrounding soft tissues and lymphatic tissues if they have become cancerous.
• A drain will be placed in the opening with a bag attached at the other end that collects the fluid drained from the surgical wound.
• Finally, the surgeon will close the incision using stitches.
• The drain will be kept in place for some weeks until no more fluid collects. This improves healing with no chance of fluid build-up.

Laparoscopic lymphadenectomy:

This procedure includes the following steps:

• The surgeon will make a small incision on your skin to access the lymph nodes.
• He/she will insert a laparoscope (camera with a tiny tube) into the opening and push it until the lymph nodes are visualised.
• The surgeon will examine the area; the images obtained on camera and received on the TV screen are a guide. Then, he/she will remove the lymph nodes with tools attached to the laparoscope.
• Finally, he/she will suture the opening.

Lymphatic tissue and lymph nodes excised during surgery will be examined in the pathological laboratory for the presence of cancer.

You may expect the following after surgery:

• The incision will be covered with gauze or bandages.
• Drainage tubes will be in place.
• You will be given pain medications and antibiotics to help you cope with the pain and prevent infections.
• Special leg pumps to prevent blood clots will be placed on your legs until the time you start walking.
• You will be discharged once you are able to drink, eat, and do not feel any discomfort.
• You will need to stay in the hospital for one to two days.

Benefits of laparoscopic lymphadenectomy:

• Quick recovery
• Minimally invasive
• Shorter hospital stay
• Less painful

The following measures should be taken during home care after discharge from the hospital:

• Your doctor will prescribe pain medications. Take them as directed. If you feel nauseous, take your painkillers with meals.
• Your surgical site may appear swollen and red, and you may also see a slightly pinkish-red discharge from it. This is normal. 
• Your doctor may advise you on taking a shower after surgery. Allow the water to flow through the wound while showering, and pat the wound dry. Secure the drains (with a robe tie) while showering to prevent them from hanging over.
• To avoid constipation caused by painkillers:
  • Eat healthy portions of fibre, fruits, and vegetables. 
  • Drink at least eight glasses of water. 
  • Take medications if required 
• Avoid lifting heavy objects that weigh more than 5 kilograms if a lymph node is removed from the arms. In cases of inguinal (groin) lymph node removal, keep the leg elevated whenever possible.
• You can resume work after two weeks.

When to see the doctor?

You should call or visit the doctor if you notice the following signs and symptoms:

• Reopening of the surgical site
• Swelling of drain sites
• Increased redness of the wound
• Excessive bleeding from the wound
• A sudden increase in pain
• Increased drainage from the site of surgery such that the collection bag needs to be emptied every one or two hours.
• Fever of 100.4^°F (38^°C) every four hours 
• Any signs of lymphoedema (swelling or inflammation) in the area of the surgery (arms, legs, or neck) such as heaviness, pain, infection, warmth, or fever.

The risks and complications associated with lymphadenectomy include:

• Lymphoedema in the area from which the lymph nodes were removed
• Skin breakdown around the surgical site
• Surgical site infection
• Collection of fluid (or seroma) at the surgical site
• Lack of sensation, pricking or soreness, pain at the surgical site

Your follow-up appointment will be scheduled within two weeks of your surgery to check if the wound is healing, to remove the drains, and discuss the results of the surgery.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.