Lymphodissection is one of the types of surgical treatment of oncological diseases that, depending on the stage of the tumor process, can have independent significance, and can be part of a complex therapy aimed at improving the quality of life of an oncological patient.
The concept of "lymphadenectomy" is more capacious than the concept of "lymphadenectomy", since with lymphadenectomy, not only the lymph nodes are liable to be removed, but the entire lymphatic apparatus including the lymph vessels together with the tissues of the adipose tissue adjacent to them within the fascial boxes.
There are several types of surgical interventions involving lymph node dissection. They are usually denoted by the letter D and the digital code( D1, D2, D3, D4), which indicates the volume of the structures to be deleted.
In the treatment of various cancers, the encoding principle remains the same, but under the same codes there will be completely different anatomical structures removed.
At what diseases is carried out?
Lymphodissection is used in the treatment of almost all malignant tumors( both superficial and intestinal organs): upper and lower extremities, head, neck, stomach, liver, mammary glands, thyroid, skin, genital organs.
Preparation for operation
Preparation for the operation of lymph node dissection consists of several mandatory steps:
- The patient first receives a preliminary consultation of the oncologist surgeon and agrees with him the date of the surgery.
- The next step is to undergo a comprehensive medical examination( with general clinical tests and, if there are certain indications, with a fine needle biopsy of the lymph nodes).
- Having received the results of the tests and having the specialists' conclusions, the patient goes to a consultation with the therapist in order to obtain admission to the operation.
- On the day of surgery, the patient enters the hospital, where preoperative preparation is performed.
- The obligatory moment is the consultation of an anesthesiologist. After that, the assigned operation is performed.
The course of the operation
The tactics of surgical intervention depend on many factors: on the type of malignant tumor, on the stage of the tumor process, on the presence of metastases, on the location of the cancerous tumor, etc. We will consider it as an example of the operative removal of melanoma.
- This type of operation requiring hospitalization of the patient( the duration of his stay in the clinic is set individually) is conducted under general anesthesia. Before performing the operation, the oncologist-surgeon must dedicate the patient to all the subtleties of the forthcoming intervention, and also to tell him about the possible consequences of the treatment.
- The extent and complexity of surgical intervention depends on the location of the tumor and the location of the lymph nodes to be removed. If the primary melanoma is on the leg, the inguinal lymph nodes are subjected to resection if the lymph nodes located in the armpit( on the side where the tumor is located) are on the arm-removal. If the melanoma settles on the head or on the neck - the surgeon will excise the cervical lymph nodes.
- When the operation is complete, the surgeon installs a drainage system in place of the incision, ensuring the outflow of lymph fluid through a thin tube. A few days later, the drainage is removed, and the seams or special brackets( in some cases using the bioremedial suture material) are removed after ten to fourteen days.
The huge advantage of laparoscopic operations is their minimally invasive, since the surgical intervention is performed not through impressive incisions, but through small holes.
Since laparoscopic lymph node dissections do not result in lymphatic fluid flow, the patient does not need to establish a drainage system.
Cervical lymphodiscussion
Cervical lymphodissection, which is an integral part of the surgical treatment of malignant neoplasms of the neck and head( localized in the thyroid, oral cavity or oropharynx), has several synonymous names in various medical sources: it can be called fascial-neck excision of the neck tissue, cervical dissection, lateral lymphadenectomy(there are other terms).
The goal of cervical lymph node dissection is the removal of all cervical lymph nodes that have metastatic changes.
Indication for the operation is the medical examination data, confirming the presence of metastases in the lymph nodes and adjacent tissues.
In some cases, lateral lymphadenectomy is performed prophylactically to prevent the possibility of tumor metastasis.
This is the case, for example, with patients suffering from oral cancer or tongue cancer, since metastases are often occult during this pre-operative period using computer tomography, ultrasound and magnetic resonance imaging,resonance tomography is often not possible.
Given the high probability of latent metastases, specialists of the majority of oncological clinics in such cases perform removal of the cervical tissue, immediately sending samples of the removed tissues for histological examination.
After receiving a histological report, the attending physician receives accurate information about the stage of the tumor process, as well as the presence or absence of metastases in the lymph nodes. If metastasis has begun, the affected lymph nodes are removed, and operated patients receive postoperative chemoradiotherapy or radiation therapy courses.
In the treatment of patients with thyroid cancer, diametrically opposite tactics are used. Given the extremely low probability of occult metastases, preventive cervical lymphodissection is practically not resorted to.
The type of neck lymph dissection is largely dependent on the localization of malignant neoplasm. There is an international classification, according to which the cervical lymph nodes are divided into levels.
Each such level has a different probability of defeat by an oncological tumor. For example, in patients with thyroid cancer that affects the voice of the larynx, lymph nodes located on the first level are extremely scarce, so there is no need to remove these lymph nodes.
Until recently, cervical lymphadenectomy was a category of operations involving a number of irreversible consequences: after it there was a noticeable cosmetic defect and significant impairment of shoulder function.
This happened because during the Krajl operation( in this way, in honor of the American physician George Krail, who first described it, this kind of surgical intervention is called), in addition to the affected lymph nodes, the patient was removed an additional nerve, a nerve muscle and an internal jugular vein. Because of the distant additional nerve, the patient for ever lost the opportunity to lift the upper limb high.
Today, the indication for the operation of Krajl is only a common tumor process, which does not allow to preserve the above-mentioned anatomical structures.
As a rule, in the overwhelming majority of cases, modern surgeons manage to cope with this task during the operation of a modified radical cervical lymphodissection. In Russia, this type of surgical intervention is called fascial-cervical excision of the neck fiber.
An operation is considered to be successful, during which it is possible not only to remove a malignant tumor, but also to achieve a certain cosmetic effect that makes the skin incision line almost invisible.
In some patients, the incision is performed along the natural skin folds; in others, most of it is masked, covering with loose hair. Thus, care is taken to maximize the quality of life in patients with all kinds of diseases of the neck and head.
In breast cancer
Lymphodiscussion in patients with breast cancer is designed to prevent the spread of a malignant tumor throughout the body, but if the disease still affects adjacent organs and surrounding tissues, the patient is systemically treated.
When breast cancer is carried out:
- Lymphodiscussion of watchdogs ( these are the lymph nodes that are the first to take in the lymph that comes from the mammary glands).If the lymphatic vessels are the channels of tumor spread, cancer cells will firstly be found in the guard lymph nodes.
- Axillary lymphadenectomy is an operation consisting in the removal of both sentinel and distant lymph nodes: intrathoracic, axillary, subclavian and supraclavicular. If the lesion is extensive, the minimum number of removed lymph nodes is at least ten.
The indication for axillary lymph node dissection is:
- Detection of cancer cells in tissue samples taken from lymph node biopsies.
- Lesion of three( or more) lymph nodes.
- The presence of a malignant neoplasm, the size of which exceeds five centimeters.
- Conducting a mastectomy.
After performing axillary lymphadenectomy, the patient is prescribed a course of neoadjuvant chemotherapy - drug treatment with cytostatic drugs designed to prevent further spread of the tumor process.
Inguinal lymphadenectomy
The dissection and removal of lymph nodes located in the inguinal and femoral area is an indispensable element of every surgical operation for squamous cell carcinoma, vulvar cancer and lower limb melanoma.
The standard inguinal-femoral lymphodiscussion surgery-oncologists is called the Duquesne operation.
The essence of this surgical intervention is reduced to surgical removal of cellulose and lymph nodes located in the inguinal-femoral region.
If, for example, there is a patient on the operating table who has a melanoma on his leg, during the lymphodissection he will remove all inguinal lymph nodes located on the affected side, since they are the most probable channels for the spread of the tumor process.
When is this operation expedient? If the diagnosis of melanoma has been confirmed by biopsy results, the surgeon must carefully examine the condition of the lymph nodes located in the immediate vicinity of the tumor.
Their compaction and enlarged dimensions, together with indications of excision or fine needle biopsy, confirming the presence of cancer cells in them are an indication for inguinal lymph dissection.
If the melanoma has a thickness exceeding one centimeter and the lymph nodes are of normal size, a biopsy of one of the guard lymph nodes is performed. If any signs of melanoma can not be detected in it, the probability of spreading the tumor process is considered to be very low, so lymphadenectomy is not performed.
The presence of cancer cells in the guard lymph node is an indication for full lymph node dissection - surgical removal of all lymph nodes located in the area of malignant neoplasm.
Pelvic
Pelvic lymph node dissection( consisting of excision of pelvic lymph nodes and surrounding tissues) can be performed during radical hysterectomy - a gynecological operation to remove the uterus.
Tissues of excised lymph nodes are immediately sent for histological examination.
When metastases are detected in the pelvic lymph nodes, a paraaortic lymphadenectomy is performed, during which the para-aortic lymph nodes located near the aorta are excised.
Axillary
Axillary lymphadenectomy is used to treat breast cancer, and there are different options for this operation.
In some cases, the lymphatic system( lymph nodes, vessels and fatty tissue) is removed together with the affected mammary gland during a radical mastectomy operation, in others - separate access is made during organ-saving operations - sectoral resections.
Extended
The term "preventive extended lymphadenectomy" was first used in the practice of surgical treatment of gastric malignant tumors: it was used for the operations during which the planned removal of cancer-affected organs along with the regions of regional metastasis was performed.
The first operations for monoblock removal of regional metastasis sites containing a primary lesion in patients with stomach cancer were conducted in Japan in the sixties of the last century.
From this moment on, operations of radical enlarged lymphadenectomy became an indispensable link in surgical intervention for stomach cancer.
Complications of
- The most frequent( in 70% of cases) complication of inguinal and femoral lymph node dissection is a prolonged - at least one month - ( lymphatic drainage) lymphatic process, which significantly hampers the healing of a postoperative wound. Approximately the third part of patients has its infection, which is fraught with secondary healing, formation of lymphokists and the formation of gross scars. As a result, the plan for special post-operative therapy of the patient is postponed indefinitely: in oncology this significantly worsens the prognosis of the disease.
- An extremely unpleasant and painful side effect of complete removal of lymph nodes is the development of lymphedema , a disease caused by a violation of lymph drainage. One of the functions of normally working inguinal lymph nodes is the removal of excess lymph from the lower extremities. After removal of the lymph nodes, the lymphatic fluid begins to stagnate, provoking the formation of edema, which often can not pass by itself. Strong edema can cause damage to the integrity of the skin, fraught with the development of infectious lesions.
Cost of
- The average cost of lymphadenectomy in Israeli clinics is one thousand dollars.
- In the conditions of the Moscow clinic lymphodissection will cost the patient 28 000 rubles.
Video about lymphodissection in combined treatment of breast cancer: