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Metastatic Lymphadenopathy

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Lymph nodes consist a center of defense for the organism. When in some part of the body there is a neoplastic or inflammatory site, the lymph glands of the certain area receive the neoplastic or inflammatory cells and try to obliterate them. In this effort of theirs, the lymph glands swell. When, therefore, we identify a malignant neoplasia in some part of the body, we have to always look for any swollen regional lymph glands, indicative of a lymphatic spread of the lesion. And the opposite, when we identify a swollen lymph node, we have to try to search for the primary, potentially neoplastic, site.

From surgical anatomy we know that, as far as the neck is concerned, lymph nodes are located inside the fat tissue of the neck. A significant number of them are in close contact with some rather important anatomic elements, blood vessels and nerves, which may need to be sacrificed in an attempt for a radical removal of the glands. We also know that, depending on the location of the malignant tumor, certain lymph glands swell initially. Thus, we have separated neck lymph glands into areas.

Let us suppose that we detect a lesion with malignant characteristics. Before we proceed with any therapeutic treatment, we should look for possible lymph swellings in the neck. The lymphatic spread of the disease may be already clinically detectable, we will be able, in other words to palpate swollen lymph glands in the neck. It is, however, possible the lymphatic spread to be subclinical. Some neoplastic cells may, that is, have passed into lymph glands without, however, having caused such a large swelling yet as to be identifiable by palpation. In this case, an analytical ultrasound of the neck is enough to identify even the smallest abnormal swelling of a lymph gland. If the swellings are so large that we consider their removal impossible, then a CT or an MRI may be necessary, in order for us to analytically study the relation between the cervical masses and the large blood vessels of the neck, the muscles of the spine etc.

The lymphatic spread is possible to be microscopic and the lymph glands to appear normal either in the ultrasound, the CT or the MRI. In these cases, the head and neck surgeon knows that the malignant disease in some area is characterized by a strong possibility of lymphatic spreading and he/she also includes the lymph nodes in the treatment, surgical or other, even if they appear normal.

Another possibility is to identify palpable lymph glands in the neck, but their swelling not to caused by a neoplastic but rather an inflammatory process. A malignant lesion may be infected and develop lymphadenopathy of an inflammatory origin. It is logical, that before a decision is made for an extensive neck node dissection, the doctor must have proof, or at least, sufficient indications that the lymphadenopathy is of a metastatic origin. The character of the cervical masses, their constitution and mobility, and if they are painful or not when felt, are often indicative of whether they are of metastatic or inflammatory origin. Nevertheless, the best method is the FNA and the cytological test. Open biopsy must be avoided, because it may lead to spreading of the tumor. In any case, when someone deals with a malignant disease, one had better be aggressive.

We said above that, when a malignant lesion is identified in some area of the head or the neck, we should look for metastatic lymph glands. On the other hand, when a cervical bulge is identified which after the diagnosis is proved to correspond to a lymph gland of metastatic origin, we should look for the primary site before we decide on any therapeutic attempt. The diagnostic procedure is what we practice in every cervical mass and it includes the taking of the history, the clinical examination including nasal, nasopharyngeal and laryngeal endoscopy in the doctors office, the imaging control, and the cytological examination. Again, open biopsy should be avoided and we should resort to it only if we have exhausted all the above.

When, therefore, we diagnose a lymph gland of metastatic origin, we should look for the primary site. We have already done most of the tests in our attempt to find the identity of the cervical mass. It would be useful, however, to repeat the tests, or re-evaluate them, given the known identity of the cervical mass. One additional test, which may help in finding the primary site, is the PET-CT. The combination, that is, of the CT and the scintigraphy. In addition, the patient should be subjected, under general anesthesia, to the so called panendoscopy. We will examine, by feeling and scanning, all the areas from the nasopharynx to the esophagus and we will take biopsies from different areas.

With the primary site known or even unknown, the metastatic lymphadenopathy has to be therapeutically treated. The method for the treatment of the lymphatic disease is, basically, the same as the one prescribed for the primary site. In order of importance for the head and neck, and generally speaking, are the surgical removal, the radiotherapy and the chemotherapy.

The removal of the lymph nodes is one of the major operations we perform on the neck. It may be therapeutic in the case of clinical lymphadenopathy or preventive when there are strong indications of microscopic lymphatic spreading. Total, when important blood vessels and neck nerves are removed as well, or functional, when only fat tissue containing the lymph glands is removed. Finally, it may concern all or some specific parts of the neck. The operation is rather safe and requires two or three days of hospitalization only.