Lymph Nodes

The range of reported lymphedema in patient who undergo pelvic lymph node dissection is between 5-30%. However, it is important to note that the range varies widely based on several factors such as the tools to measure lymphedema or the medical comorbidities of the patient such as obesity, diabetes, hypertension, and cardiovascular disease. The range of reported lymphedema in patient who undergo pelvic lymph node dissection is between 5-30%. However, it is important to note that the range varies widely based on several factors such as the tools to measure lymphedema or the medical comorbidities of the patient such as obesity, diabetes, hypertension, and cardiovascular disease.

In 1992 I was told I would be bedridden for the rest of my life. I had my lymph nodes removed during a malignant melanoma surgery. My leg was as wide as my waist when I woke up from the surgery. I was told not to exercise for a full year. (I waited 9 months and just HAD to start exercising again!) The swelling went down very slowly. Twenty years later, I still deal with lymphedema on a daily basis. I maintain it well... sleep with my leg elevated, wear compression stocking, and I know which exercises reduce or increase the swelling. I recently published a book on my experience as a cancer patient and the twenty years since. Sentinel lymph node biopsy has revolutionized melanoma surgery, staging, prognosis, and aids in the decision for adjuvant therapy after definitive surgery. However, like all things there is some down side including pain and restriction of motion (usually limited to post operative period), numbness/paraesthesias (which can be permanent) and most problematic - lymphedema. The cause of post sentinel lymph node biopsy lymphedema is poorly understood but does not appear to be related to the number of lymph nodes removed (average sentinel node biopsy has 2-3 nodes). Complicating the issue further is the actual method of deciding if lymphedema is present. The methods vary from circumferential measurements above and below the elbow/knee at specified distances, perometry (measuring shadow size of each extremity), water displacement (volumetric analysis) and bioeimpedence (as extracellular fluid increases the ability to transmit electrical charge through the limb decreases). With all of those caveats, the risk of lymphedema after sentinel lymph node biopsy is ~5-10%; after a full lymphatic dissection, it is ~15-60% (and above that if the nodal area is radiated).

The chance of the sentinel node(s) having melanoma that has spread from the skin varies by the thickness of the primary melanoma (and other factors such as ulceration, mitotic rate, vertical growth phase). For melanomas <1 mm, it is ~5-7%; for 1-4 mm, it is 12-24%; and >4mm, it is ~25-40%. However the vast majority of time the sentinel node only has a microscopic deposit of melanoma so it is unusual to discover this at the time of sentinel lymph node biopsy. Therefore, I never (rarely) do a complete dissection at the time of sentinel lymph node biopsy, waiting instead for the final pathology report. If there is a 'positive' sentinel lymph node, then the standard of care is to remove the rest of the lymph nodes in that basin (neck, axilla, groin). These basins are defined by anatomic landmarks (not absolute number of nodes) and all tissue within those boundaries is removed. The number of lymph nodes removed will vary by patient with some patients having just a few and some patients having a lot (like most things in medicine the number of lymph nodes in a basin is a bell shaped curve). There is a large international study going on (Multicenter Selective Lymphadenectomy Trial- II) that is trying to determine if we need to do a complete dissection for those patients with a positive sentinel node. The study is a randomized (meaning a computerized coin toss) trial comparing the standard of care (complete lymphatic dissection) vs no further lymphatic surgery (with ultrasound examination of the lymph node basin every 3 months to look for metastatic lymph nodes). The patient can choose to be in the study but cannot 'pick' their therapy (surgery vs observation of their lymph nodes). If you want further information on this trial please email me at beitsch@aol.com The chance of the sentinel node(s) having melanoma that has spread from the skin varies by the thickness of the primary melanoma (and other factors such as ulceration, mitotic rate, vertical growth phase). For melanomas <1 mm, it is ~5-7%; for 1-4 mm, it is 12-24%; and >4mm, it is ~25-40%. However the vast majority of time the sentinel node only has a microscopic deposit of melanoma so it is unusual to discover this at the time of sentinel lymph node biopsy. Therefore, I never (rarely) do a complete dissection at the time of sentinel lymph node biopsy, waiting instead for the final pathology report. If there is a 'positive' sentinel lymph node, then the standard of care is to remove the rest of the lymph nodes in that basin (neck, axilla, groin). These basins are defined by anatomic landmarks (not absolute number of nodes) and all tissue within those boundaries is removed. The number of lymph nodes removed will vary by patient with some patients having just a few and some patients having a lot (like most things in medicine the number of lymph nodes in a basin is a bell shaped curve). There is a large international study going on (Multicenter Selective Lymphadenectomy Trial- II) that is trying to determine if we need to do a complete dissection for those patients with a positive sentinel node. The study is a randomized (meaning a computerized coin toss) trial comparing the standard of care (complete lymphatic dissection) vs no further lymphatic surgery (with ultrasound examination of the lymph node basin every 3 months to look for metastatic lymph nodes). The patient can choose to be in the study but cannot 'pick' their therapy (surgery vs observation of their lymph nodes). If you want further information on this trial please email me at beitsch@aol.com

Lymph nodes involved with melanoma can have such extensive growth of that metastasis that it grows beyond the capsule (edge) of the lymph node. This denotes an aggressive melanoma and often leads to additional treatment of that nodal basin (axilla, groin, or neck) with radiation therapy. Lymph nodes involved with melanoma can have such extensive growth of that metastasis that it grows beyond the capsule (edge) of the lymph node. This denotes an aggressive melanoma and often leads to additional treatment of that nodal basin (axilla, groin, or neck) with radiation therapy.

Melanoma does have a predilection to spread to the lymph nodes. Rarely the lymph nodes can have a large amount of melanoma in them and they can be felt (palpable lymph nodes). More typically the lymph nodes feel normal (and appear normal on ultrasound) but may have a microscopic deposit of melanoma in them. To determine whether there is a small deposit in the regional lymph nodes (neck, axilla, or inguinal areas), surgeons will 'map' the skin to determine which lymph nodes 'drain' the patch of skin where the melanoma was located. The skin is 'mapped' by injecting a small amount of radioactive fluid in the skin at the site of the melanoma. This fluid drains just like the melanoma COULD drain and makes a regional lymph node slightly radioactive. The patient then goes to the operating room where the surgeon then uses a small geiger counter to find the lymph nodes. These lymph nodes are called the Sentinel Lymph Nodes and are the ones that drain the patch of skin where the melanoma was. A small incision is made over these lymph nodes and they are physically removed and given to the pathologist to look at under the microscope. Even just a few cells of melanoma in the sentinel lymph node are significant although the bigger the deposit of melanoma the more likely the melanoma is to spread throughout the body. Melanoma does have a predilection to spread to the lymph nodes. Rarely the lymph nodes can have a large amount of melanoma in them and they can be felt (palpable lymph nodes). More typically the lymph nodes feel normal (and appear normal on ultrasound) but may have a microscopic deposit of melanoma in them. To determine whether there is a small deposit in the regional lymph nodes (neck, axilla, or inguinal areas), surgeons will 'map' the skin to determine which lymph nodes 'drain' the patch of skin where the melanoma was located. The skin is 'mapped' by injecting a small amount of radioactive fluid in the skin at the site of the melanoma. This fluid drains just like the melanoma COULD drain and makes a regional lymph node slightly radioactive. The patient then goes to the operating room where the surgeon then uses a small geiger counter to find the lymph nodes. These lymph nodes are called the Sentinel Lymph Nodes and are the ones that drain the patch of skin where the melanoma was. A small incision is made over these lymph nodes and they are physically removed and given to the pathologist to look at under the microscope. Even just a few cells of melanoma in the sentinel lymph node are significant although the bigger the deposit of melanoma the more likely the melanoma is to spread throughout the body.

There is nothing better to assess axillary lymph node status than sentinel lymph node biopsy. PET scanning has been tried. This involves radioactive glucose injected into the patient's venous system. This radioactive glucose is taken up by cancer more readily than non-cancerous tissue and therefore becomes slightly radioactive. This radioactivity can then be detected by scanning the axilla or the entire patient. However PET scanning cannot detect small amounts of cancer in the lymph node (anything <5 mm).

However, a better question might be - Why do we need to know the status of the axillary lymph nodes in breast cancer? Removing the lymph nodes in breast cancer has always been thought of as prognostic (helping determine how well a patient will do and how much chemotherapy to give) but not therapeutic (helping to improve survival). We are now able to determine the prognosis of the patient by looking at the biology of their cancer with newer advanced pathologic tests such as MammaPrint, OncotypeDX, MammaStrat and others. I believe we will stop doing sentinel node biopsy and axillary surgery in general (outside of removing bulky lymph nodes) in the very near future. There is nothing better to assess axillary lymph node status than sentinel lymph node biopsy. PET scanning has been tried. This involves radioactive glucose injected into the patient's venous system. This radioactive glucose is taken up by cancer more readily than non-cancerous tissue and therefore becomes slightly radioactive. This radioactivity can then be detected by scanning the axilla or the entire patient. However PET scanning cannot detect small amounts of cancer in the lymph node (anything <5 mm).

However, a better question might be - Why do we need to know the status of the axillary lymph nodes in breast cancer? Removing the lymph nodes in breast cancer has always been thought of as prognostic (helping determine how well a patient will do and how much chemotherapy to give) but not therapeutic (helping to improve survival). We are now able to determine the prognosis of the patient by looking at the biology of their cancer with newer advanced pathologic tests such as MammaPrint, OncotypeDX, MammaStrat and others. I believe we will stop doing sentinel node biopsy and axillary surgery in general (outside of removing bulky lymph nodes) in the very near future.

Lymph nodes are part of a large network called the lymphatic system. This network moves fluid (called lymph) and cells around the body. Lymphatic vessels (pipe-like structures) are present throughout the body. When cancer cells migrate away (metastasize) from a tumor to neighboring or distant parts of the body, they can travel in one of three main ways. 1) they can just move to nearby tissues and spread by contact with neighboring organs, 2) they can enter a blood vessel and move through the circulatory system to a new location, or 3) they can invade a lymphatic vessel and travel in the lymphatic system to a new location.

As described in more detail in another answer, the lymphatic system is a network of vessels that drain fluid from our tissues. The fluid from any particular area gets drained into specific collection sites, or lymph nodes. When cancer is removed, surgeons will frequently remove some (or all) of the lymph nodes that are likely to have collected fluid from the area of the tumor. They can then look at the lymph nodes to see if any cancer cells have migrated to there. If they find cancer cells in the lymph nodes it means that the cancer MAY have also gone to other places in the body. It does not mean that the cancer has spread, but it does make it more likely. The information is used to design treatment plans and make sure that any cancer cells that may have left the original area are also treated.

Learn more about the lymphatic system and watch a video on lymph node biopsy: http://www.cancerquest.org/lymphedema-introduction Lymph nodes are part of a large network called the lymphatic system. This network moves fluid (called lymph) and cells around the body. Lymphatic vessels (pipe-like structures) are present throughout the body. When cancer cells migrate away (metastasize) from a tumor to neighboring or distant parts of the body, they can travel in one of three main ways. 1) they can just move to nearby tissues and spread by contact with neighboring organs, 2) they can enter a blood vessel and move through the circulatory system to a new location, or 3) they can invade a lymphatic vessel and travel in the lymphatic system to a new location.

As described in more detail in another answer, the lymphatic system is a network of vessels that drain fluid from our tissues. The fluid from any particular area gets drained into specific collection sites, or lymph nodes. When cancer is removed, surgeons will frequently remove some (or all) of the lymph nodes that are likely to have collected fluid from the area of the tumor. They can then look at the lymph nodes to see if any cancer cells have migrated to there. If they find cancer cells in the lymph nodes it means that the cancer MAY have also gone to other places in the body. It does not mean that the cancer has spread, but it does make it more likely. The information is used to design treatment plans and make sure that any cancer cells that may have left the original area are also treated.

Learn more about the lymphatic system and watch a video on lymph node biopsy: http://www.cancerquest.org/lymphedema-introduction

Lymph nodes are part of the lymphatic system, a complex network of tubes (vessels) and grape-like clusters of lymph nodes. Fluid that leaks out of blood vessels is collected into the lymphatic system. The fluid (called lymph) flows from smaller vessels into larger ones and passes through lymph nodes before being returned to the blood circulation.

Lymph nodes have several functions. Some of our immune cells develop and can multiply in lymph nodes. Cells that spend much of their time in the lymphatic system are called lymphocytes (cyte=cell). There are two major kinds of lymphocytes and they are commonly called T lymphocytes (T cells) and B lymphocytes (B cells). They both work to fight infection and can also fight cancer. Foreign objects like bacteria and viruses enter the lymphatic system where they encounter lymphocytes. This triggers a response in the T and B cells, causing them to become active and reproduce.

In cancer diagnosis, lymph nodes are often important for a different reason. The lymphatic system is found nearly everywhere in the body. When cancer cells move (metastasize) from one location to another, they can use the lymphatic system as a type of highway to migrate around the body. When a tumor is detected, nearby lymph nodes are frequently removed and examined for the presence of cancer cells. IF they are are there, it means that the cancer has been able to spread to that location and MAY be in other locations (it does NOT mean that the cancer MUST be in other locations). Also, only a small number of lymph nodes are examined. The test is not perfect (no medical test is).

Learn more about the lymphatic system. http://www.cancerquest.org/lymphatic-system-introduction
Learn more about the immune system and cancer. http://www.cancerquest.org/immune-system-cancer
Learn more about sentinel lymph node biopsy. http://www.cancerquest.org/sentinel-lymph-node-biopsy Lymph nodes are part of the lymphatic system, a complex network of tubes (vessels) and grape-like clusters of lymph nodes. Fluid that leaks out of blood vessels is collected into the lymphatic system. The fluid (called lymph) flows from smaller vessels into larger ones and passes through lymph nodes before being returned to the blood circulation.

Lymph nodes have several functions. Some of our immune cells develop and can multiply in lymph nodes. Cells that spend much of their time in the lymphatic system are called lymphocytes (cyte=cell). There are two major kinds of lymphocytes and they are commonly called T lymphocytes (T cells) and B lymphocytes (B cells). They both work to fight infection and can also fight cancer. Foreign objects like bacteria and viruses enter the lymphatic system where they encounter lymphocytes. This triggers a response in the T and B cells, causing them to become active and reproduce.

In cancer diagnosis, lymph nodes are often important for a different reason. The lymphatic system is found nearly everywhere in the body. When cancer cells move (metastasize) from one location to another, they can use the lymphatic system as a type of highway to migrate around the body. When a tumor is detected, nearby lymph nodes are frequently removed and examined for the presence of cancer cells. IF they are are there, it means that the cancer has been able to spread to that location and MAY be in other locations (it does NOT mean that the cancer MUST be in other locations). Also, only a small number of lymph nodes are examined. The test is not perfect (no medical test is).

Learn more about the lymphatic system. http://www.cancerquest.org/lymphatic-system-introduction
Learn more about the immune system and cancer. http://www.cancerquest.org/immune-system-cancer
Learn more about sentinel lymph node biopsy. http://www.cancerquest.org/sentinel-lymph-node-biopsy

i think this new research is very exciting and potentially practice changing. normally the tradition has been that if a woman has a positive sentinel lymph node, a full dissection of more nodes needs to be performed. however new data suggest that if a woman with a breast cancer up to 5cm in size and who is having a lumpectomy and radiation, has only one or two positive sentinel lymph nodes, she might not need a complete node dissection. the thought is that she will obviously be getting chemo and that the chemo above all will take care of any other nodes that have cancer. with 6 years of follow-up the two groups of women did equally well. sloan kettering has already begun this for these select women.
p.s. i think sloan kettering was involved but this research was a multi-center trial, headed by dr.giuliano at the john wayne cancer center in LA (the breast surgeon who really started the practice of sentinel node biopsy in the first place) i think this new research is very exciting and potentially practice changing. normally the tradition has been that if a woman has a positive sentinel lymph node, a full dissection of more nodes needs to be performed. however new data suggest that if a woman with a breast cancer up to 5cm in size and who is having a lumpectomy and radiation, has only one or two positive sentinel lymph nodes, she might not need a complete node dissection. the thought is that she will obviously be getting chemo and that the chemo above all will take care of any other nodes that have cancer. with 6 years of follow-up the two groups of women did equally well. sloan kettering has already begun this for these select women.
p.s. i think sloan kettering was involved but this research was a multi-center trial, headed by dr.giuliano at the john wayne cancer center in LA (the breast surgeon who really started the practice of sentinel node biopsy in the first place)