Lymphadenectomy

PROCEDURE OF THE DAY

Lymphadenectomy

Lymphadenectomy consists of the surgical removal of one or more groups of lymph nodes. It is almost always performed as part of the surgical management of cancer.

This is usually done because many types of cancer have a marked tendency to produce lymph node metastasis early on in their natural history. This is particularly true of melanoma, head and neck cancer, differentiated thyroid cancer, breast cancer, lung cancer, gastric cancer and colorectal cancer. Famed British surgeon Sir Berkeley Moynihan once remarked that "the surgery of cancer is not the surgery of organs; it is the surgery of the lymphatic system".

The better known examples of lymphadenectomy are axillary lymph node dissection for breast cancer; radical neck dissection for head and neck cancer and thyroid cancer; D2 lymphadenectomy for gastric cancer; and total mesorectal excision for rectal cancer.

More recently, the concept of sentinel lymph node mapping has been popularized by Dr. Donald Morton and others. Cancer with various primary sites, breast, melanoma, colorectal, etc, often metastasize early to the first drainage lymphatic basin. This process is predictable anatomically according to the primary site in the organ and the lymphatic channels. The first nodes (sentinel nodes) can be identified by particulate markers such as lymphazurin, methylene blue, india ink and radio-labelled colloid protein particles injected near the tumor site. The draining sentinel node can then be found by the surgeon and excised for verification by the pathologist if tumor cells are present, and often these tumor cells are few and only easily recognized by careful examination or by using techniques such as special stains, i.e. immunohistochemical. When the sentinel node is free of tumor cells, this is highly predictive of freedom from metastasis in the entire lymphatic basin, thus leading to futility of a full node dissection.

The practice of sentinel lymph node mapping has changed the surgical approach in many cancer systems, sparing a formal lymph node dissection for patients with sentinel lymph node negative for tumor and directing a full node dissection for patients with sentinel lymph node positive for tumor metastases. For example in stage II breast carcinoma, using the sentinel lymph node technique, 65% of patients could be spared from a formal node dissection.

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