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Lymph glands in chest: Swollen lymph nodes – Symptoms and causes

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Mediastinoscopy | Johns Hopkins Medicine

What is mediastinoscopy?

A mediastinoscopy is a procedure used to examine the mediastinum. This is
the space behind the breastbone (sternum) in the middle of the chest,
between the 2 lungs. It contains:

  • Lymph nodes
  • The heart and its great vessels
  • The windpipe (trachea)
  • The tube that leads down to the stomach (esophagus)
  • The thymus gland, a part of the immune system

This area can be examined with a tool called a mediastinoscope. This is a
long, thin, flexible tube that has a light and a tiny camera. It lets a
healthcare provider see the organs and structures of the mediastinum. The
images can also be sent to a computer screen and recorded.

Why might I need mediastinoscopy?

The procedure is most often done to remove lymph nodes when a person has
lung cancer. The nodes are examined to help see how far the cancer has
spread. This can help determine the best treatment choices for lung cancer.

It can also be used to find problems such as:

  • Cancer of the bronchi
  • Cancer of other structures in the mediastinum
  • Infection or inflammation
  • Cancer that starts in the lymphatic system (lymphoma), including
    Hodgkin disease
  • Sarcoidosis, a condition that causes areas of inflammation in the
    organs such as the liver, lungs, and spleen
  • A tumor of the thymus gland (thymoma)

Your healthcare provider may have other reasons to advise a
mediastinoscopy.

What are the risks of mediastinoscopy?

All procedures have some risks. The risks of this procedure may include:

  • Bleeding
  • Infection
  • Temporary or permanent paralysis of the laryngeal nerve. This may cause
    hoarseness.
  • Air in the space between the lung covering (pleural space) that causes
    the lung to collapse (pneumothorax)
  • Air trapped under the skin (subcutaneous emphysema)
  • Hole (perforation) in the esophagus, trachea, or large blood vessels of
    the heart (rare)

Your risks may vary depending on your general health and other factors. Ask
your healthcare provider which risks apply most to you. Talk with him or
her about any concerns you have.

In some cases, a person shouldn’t have a mediastinoscopy. Reasons for this
can include:

  • A previous mediastinoscopy, heart surgery, or other chest surgery
  • Previous neck or cervical spine surgery
  • Any health conditions that would prevent proper positioning of the neck
    during the procedure
  • Pregnancy
  • Blockage in the large vein that carries blood from the upper body into
    the heart (superior vena cava obstruction)
  • Severe heart disease

How do I get ready for mediastinoscopy?

Your healthcare provider will explain the procedure to you. Ask him or her
any questions you have. Surgery may be done during the procedure, if
needed. Your healthcare provider will tell you more. You may be asked to
sign a consent form that gives permission to do the procedure. Read the
form carefully. Ask questions if anything is not clear.

Tell your healthcare provider if you:

  • Are pregnant or think you may be pregnant
  • Are allergic to contrast dye or iodine
  • Are sensitive to or allergic to any medicines, latex, tape, or
    anesthetic medicines (local and general)
  • Take any medicines, including prescriptions, over-the-counter
    medicines, vitamins, and herbal supplements
  • Have had a bleeding disorder
  • Take blood-thinning medicine (anticoagulant), aspirin, or other
    medicines that affect blood clotting

Make sure to:

  • Stop taking certain medicines before the procedure, if instructed by
    your healthcare provider
  • Not eat or drink for 8 hours before the procedure, or as instructed by
    your healthcare provider
  • Plan to have someone drive you home from the hospital
  • Follow any other instructions your healthcare provider gives you

You may have blood tests or other tests or exams before the procedure. Your
healthcare provider will tell you more.

What happens during mediastinoscopy?

The way the procedure is done and how long you are in the hospital will
vary. It depends on your condition and your healthcare provider’s methods.
In most cases, the procedure will follow this process:

  1. You may be asked to remove your clothes. If so, you will be given a
    hospital gown to wear. You may be asked to remove jewelry or other
    objects.
  2. You will lie down on an operating table.
  3. An intravenous (IV) line will be put into your arm or hand.
  4. You will be given general anesthesia. This is medicine that prevents
    pain and lets you sleep through the procedure.
  5. A breathing tube will be put into your throat and hooked up to a
    breathing machine (ventilator). Your heart rate, blood pressure, and
    breathing will be watched during the procedure.
  6. Hair in the area of surgery may be trimmed. The skin in the area will
    be cleaned with an antiseptic solution.
  7. The healthcare provider will make a small cut (incision) just above
    your breastbone (sternum).
  8. He or she will use a finger to make a passageway into the mediastinum
    and examine the lymph nodes by touch.
  9. The mediastinoscope will be put through the passageway. Tissue samples
    may be taken (biopsy). This is often done from the lymph nodes.
  10. After the exam and any other procedures are done, the mediastinoscope
    will be removed.
  11. If more surgery is needed, it may be done at this time.
  12. The skin incision will be closed with stitches (sutures) or adhesive
    strips. A bandage or dressing will be put on the area.
  13. The tissue samples will be sent to a lab.
  14. The breathing tube may be taken out before you leave the operating
    room. Or it may be taken out later in the recovery room.

What happens after mediastinoscopy?

After the procedure, you will spend some time in a recovery room. You may
be sleepy and confused when you wake up from general anesthesia or
sedation. Your healthcare team will watch your vital signs, such as your
heart rate and breathing. You may have a chest X-ray after the procedure.
This is to check for bleeding or air in the pleural space.

Your incision will be checked for bleeding before you leave. Keep the
incision area clean and dry. Your healthcare provider will give you bathing
instructions. If stitches were used, they will be removed during a
follow-up appointment. If adhesive strips were used, they should be kept
dry. They will likely fall off in a few days.

You can take pain medicine as advised by your healthcare provider. Aspirin
and certain other pain medicines may increase bleeding. Make sure to take
only the medicines your healthcare provider advises.

At home, you can go back to your normal diet and activities if instructed
by your healthcare provider. You may need to not do strenuous physical
activity for a few days.

Call your healthcare provider if you have any of the below:

  • Fever of 100.4°F (38°C) or higher, or as directed by your healthcare
    provider
  • Redness or swelling of the incision
  • Blood or other fluid leaking from the incision
  • Increased pain around the incision
  • Coughing up blood
  • Chest pain
  • Any changes in voice or trouble breathing

Your healthcare provider may give you other instructions after the
procedure.

Next steps

Before you agree to the test or the procedure make sure you know:

  • The name of the test or procedure
  • The reason you are having the test or procedure
  • What results to expect and what they mean
  • The risks and benefits of the test or procedure
  • What the possible side effects or complications are
  • When and where you are to have the test or procedure
  • Who will do the test or procedure and what that person’s qualifications
    are
  • What would happen if you did not have the test or procedure
  • Any alternative tests or procedures to think about
  • When and how will you get the results
  • Who to call after the test or procedure if you have questions or
    problems
  • How much will you have to pay for the test or procedure

Lymphoma (for Parents) – Nemours Kidshealth

The body’s lymphatic system helps the immune system filter out bacteria, viruses, and other unwanted or harmful substances.  The lymphatic system includes:

  • the lymph nodes (also called lymph glands)
  • thymus
  • spleen
  • tonsils
  • adenoids
  • bone marrow

Channels — called lymphatics or lymph vessels — connect the parts of the lymphatic system.

Lymphoma is a type of cancer that begins in lymphatic tissue. There are several different types of lymphomas. Some involve lymphoid cells and are grouped under the heading of Hodgkin lymphoma. All other forms of lymphoma fall into the non-Hodgkin lymphoma grouping.

Hodgkin Lymphoma

Lymphomas that involve a type of cell called a Reed-Sternberg cell are classified as Hodgkin lymphoma. Different types of Hodgkin lymphoma are classified based on how the cancerous tissue looks under a microscope. Hodgkin lymphoma affects about 3 out of every 100,000 Americans, most commonly during early and late adulthood (between ages 15 and 40 and after age 55).

The most common first symptom of Hodgkin lymphoma is a painless enlargement of the lymph nodes (a condition known as swollen glands) in the neck, above the collarbone, in the underarm area, or in the groin.

If Hodgkin lymphoma involves the lymph nodes in the center of the chest, pressure from this swelling may cause an unexplained cough, shortness of breath, or problems in blood flow to and from the heart.

Some people have other symptoms including fatigue (tiredness), poor appetite, itching, or hives. Unexplained fever, night sweats, and weight loss are also common.

Non-Hodgkin Lymphoma (NHL)

Non-Hodgkin lymphoma (NHL) can happen at any age during childhood, but is rare before age 3. NHL is slightly more common than Hodgkin disease in kids younger than 15 years old. 

In non-Hodgkin lymphoma, there is malignant (cancerous) growth of specific types of lymphocytes (a kind of white blood cell that collects in the lymph nodes).

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Risk for Childhood Lymphoma

Both Hodgkin lymphoma and non-Hodgkin lymphoma tend to happen more often in people with certain severe immune deficiencies, including:

  • those with inherited immune defects (defects passed down by parents)
  • adults with human immunodeficiency virus (HIV) infection
  • those treated with immunosuppressive drugs after organ transplants (these strong drugs help hold back the activity of the immune system) 

Kids who have had either radiation therapy or chemotherapy for other types of cancer seem to have a higher risk of developing lymphoma later in life.

Regular pediatric checkups can sometimes spot early symptoms when lymphoma is linked to an inherited immune problem, HIV infection, treatment with immunosuppressive drugs, or prior cancer treatment.

No lifestyle factors have been definitely linked to childhood lymphomas. Usually, neither parents nor kids have control over what causes lymphomas. Most cases are due to noninherited mutations (errors) in the genes of growing blood cells.

Diagnosis

Doctors will check a child’s weight and do a physical examination to look for enlarged lymph nodes and signs of infection. Using a stethoscope, they’ll examine the chest and feel the abdomen to check for pain, organ enlargement, or fluid build-up.

In addition to the physical exam, doctors take a medical history by asking about the child’s past health, his or her family’s health, and other issues.

Sometimes, when a child has an enlarged lymph node for no apparent reason, the doctor will watch the node closely to see if it continues to grow. The doctor may prescribe antibiotics if the gland is thought to be infected by bacteria, or do blood tests for certain types of infection.

If the lymph node stays enlarged, the next step is a biopsy (removing and examining tissue, cells, or fluids from the body). Biopsies are also necessary for lymphomas that involve the bone marrow or structures in the chest or abdomen.

The biopsy may be done using a thin hollow needle (this is known as needle aspiration). Or, a small surgical incision might be made while the patient is under general anesthesia. Sometimes, a biopsy may require a surgical excision under anesthesia. This means a piece of the lymph node or the entire lymph node is removed.

In the laboratory, tissue samples from the biopsy are examined to determine the specific type of lymphoma. Besides these basic lab tests, more sophisticated tests are usually done, including genetic studies, to distinguish between specific types of lymphoma.

To identify which areas of the body are affected by lymphoma, these tests are also used:

  • blood tests, including complete blood count (CBC)
  • blood chemistry, including tests of liver and kidney function
  • bone marrow biopsy or aspiration
  • lumbar puncture (spinal tap) to check for cancer spread to the central nervous system (brain and spinal cord)
  • ultrasound
  • computed tomography (CT) of the chest and abdomen, and sometimes X-rays
  • magnetic resonance imaging (MRI)
  • bone scan, gallium scan, and/or positron emisson tomography (PET) scan (when a radioactive material is injected into the bloodstream to look for evidence of tumors throughout the body)

These tests help doctors decide which type of treatment to use.

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Treatment

Treatment of childhood lymphoma is largely determined by staging. Staging is a way to categorize or classify patients according to how extensive the disease is at the time of diagnosis.

Chemotherapy (the use of highly potent medical drugs to kill cancer cells) is the main form of treatment for all types of lymphoma. In certain cases, radiation (using high-energy rays  to kill cancer cells and keep them from growing and multiplying) may also be used.

Short-Term and Long-Term Side Effects

Chemotherapy for lymphoma affects the bone marrow, causing anemia and bleeding problems, and increases a person’s risk for serious infections.

Chemotherapy and radiation treatments have many other side effects — some short-term (such as hair loss, changes in skin color, increased infection risk, and nausea and vomiting) and some long-term (such heart and kidney damage, reproductive problems, thyroid problems, or the development of another cancer later in life).

Parents should discuss all potential side effects with their child’s care team.

Relapses

Although most kids recover from lymphoma, some with severe lymphoma will have a relapse (reappearance of the cancer). For these children, bone marrow transplants and stem cell transplants are often among the treatment options.

During a bone marrow/stem cell transplant, chemotherapy with or without radiation therapy is given to kill cancerous cells. Then, healthy bone marrow/stem cells are introduced into the body. These healthy cells can produce white blood cells that will help the child fight infections.

New Treatments

New treatments for childhood lymphomas include several different types of immune therapy, specifically using antibodies to deliver chemotherapy medicines or radioactive chemicals directly to lymphoma cells. (Antibodies are proteins made by the immune system to fight bacteria, viruses, and toxins.) This direct targeting of lymphoma cells can help a person avoid the side effects that happen when chemotherapy and radiation treatments damage normal, noncancerous body tissues.

Cancer of the Lymphatic System | Non-Hodgkin Lymphoma

Non-Hodgkin lumphoma is disease in which malignant (cancer) cells form in the lymph system. The lymph system is part of the body’s immune system. The immune system protects the body from foreign substances, infection, and diseases. The following is all part of the lymph system:

  • Lymph: Colorless, watery fluid that carries lymphocytes (type of white blood cell) through the lymph system. Lymphocytes protect the body against infection.
  • Lymph nodes: Small bean-shaped structures that filter lymph and store white blood cells that help fight infection and disease. Lymph nodes are located along lymph vessels, found throughout body. Clusters of lymph nodes are found in the neck, underarm, abdomen, pelvis and groin.
  • Spleen: An organ located on the left side of the abdomen near the stomach, that filters blood, makes lymphocytes, stores blood cells and destroys old blood cells.
  • Thymus: An organ in which lymphocytes grow and multiply. The thymus is located in the chest behind the breastbone.
  • Tonsils: Two small masses of lymph tissue at the back of the throat. The tonsils make lymphocytes.
  • Bone marrow: The soft spongy tissue in the center of the large bones. Bone marrow makes white blood cells, red blood cells and platelets.

Signs and symptoms

Depending on its location in the body, some of the signs and symptoms could be:

  • Swollen lymph nodes: Painless, near the collarbone, or in neck, chest, underarm or groin

  • If located in chest there could be cough, shortness of breath, difficulty breathing or chest pain

  • If located in the abdomen there could be pain, bloating, nausea, vomiting, constipation or diarrhea


Tests to help diagnose Non-Hodgkin Lymphoma

  • Physical exam and history: The health care provider will check general signs of health, assess for any lumps or anything else that seems unusual. They will also get history of past illnesses, health habits and any family
    history of illness or cancer.

  • CT scan: A computer assisted X-ray that shows detailed pictures inside the body, such as neck, chest, abdomen and pelvis. A dye may be injected into a vein or swallowed to help the organ and tissues show up more clearly.

  • PET scan (positron emission tomography): An X-ray that helps to show where the malignant tumor cells are in the body. A small amount of radioactive glucose (sugar) is injected into the vein. The scanner will then make pictures
    where the glucose is being used in the body. Cancer cells show up brighter in the picture because they take up more glucose than normal cells. The PET scan has three steps:

    1. Injection of radioactive glucose

    2. A waiting period of 30-60 minutes

    3. Scanning by the PET machine. 

  • Chest X-ray: An X-ray of the organs and bones inside the chest.

  • Blood tests:

    • CBC (complete blood count) checks the number of red blood cells (oxygen carriers), platelets (cells that help the blood clot properly) and white blood cells (infection fighters)

    • Sedimentation rate can help measure how much inflammation is in the body

    • Blood chemistry studies measures amounts of certain substances released into the blood by organs and tissues in the body

All these tests are usually done at time of diagnosis to rule out other diseases, and are also done throughout treatment to monitor response and to monitor for possible side effects of treatment.

A pathologist will look at the tissue under the microscope to look for cancer cells. Reed – Sternberg cells are common in classical Hodgkin lymphoma.

  • Bone marrow aspiration and biopsy: Sometimes done to help determine if the Hodgkin lymphoma cells are in the bone marrow, the blood producing factory in the body. A special needle is inserted into one of the bones (typically
    the back of the hip bone) and a small amount of marrow (liquid part) is aspirated into a syringe. The biopsy includes taking a small piece of bone and sending it to lab for review. Since the procedure is uncomfortable most patients are given
    pain medicine or sedated during procedure.

  • Lumbar puncture: This is a procedure done to collect a sample of cerebral spinal fluid from the spinal column. This procedure is typically done under sedation but can also be done awake with local anesthesia. The sample of
    cerebral spinal fluid is checked for the presence of non-Hodgkin lymphoma cells. 

  • Pleural or peritoneal fluid assessment: Sometimes non-Hodgkin lymphoma can spread to the thin membranes inside the pleural (chest) or peritoneal (abdomen) cavities, causing fluid to accumulate. Testing is done by inserting needle
    through skin into the chest or abdomen and withdrawing small amount of fluid. Most patients are sedated for this. Sometimes this test is done in place of a tumor biopsy in some situations. 

All About Adult Hodgkin Lymphoma

What are lymph nodes?

Lymph nodes are small, bean-sized glands that are found throughout the body and makeup part of the lymphatic fluid circulation system. Lymphatic fluid is a clear fluid that leaks out of blood vessels. In order for the body to keep the blood volume constant, lymphatic fluid is collected and returned to the blood via the lymphatic circulation. Lymph nodes are connected to each other by small lymph vessels that move the lymphatic fluid.

Before returning the lymphatic fluid to the blood, lymph nodes clean the fluid, looking for possible infection-causing germs (bacteria, viruses, etc.). Most people can remember having swollen “glands” under their neck when they had an infection. Those “glands” were swollen lymph nodes that were reacting to the infection. In most cancers, this network of lymph nodes is one of the first areas to which cancer can spread. However, in Hodgkin lymphoma, the cancer arises from the lymph nodes themselves.

Clusters of lymph nodes exist in certain parts of the body, like the neck, the underarm, and the groin. There are also specific organs in the body that are considered part of the lymphatic system, like the spleen and the tonsils. Small amounts of lymph tissue can also be found in almost every other organ in the body. While there are certain areas in the body where lymph nodes are often found, the arrangement and number of these lymph nodes is different from person to person.

What is Hodgkin Lymphoma?

Hodgkin lymphoma is a cancer of lymph nodes and lymphatic tissue. It is named after the pathologist who first described the disease in 1832, Dr. Thomas Hodgkin. There are about 8,110cases of Hodgkin lymphoma diagnosed yearly in the United States. Hodgkin lymphoma occurs slightly more in men and much more frequently in Caucasians and Hispanic men. Hodgkin lymphoma most commonly affects people ages 15 to 40 (especially those in their 20s) and those over the age of 55 (Pediatric Hodgkin lymphoma is discussed separately).

There are other types of lymphomas besides Hodgkin lymphoma, known as non-Hodgkin lymphomas. Although non-Hodgkin lymphomas are also a cancer of the lymph nodes, they act differently and are treated differently. Hodgkin lymphoma occurs when infection-fighting cells in the lymph nodes begin to grow out of control and compress nearby tissues or spread throughout the body via the lymphatic circulation. Hodgkin lymphoma is distinguished from the other types of lymphomas by the way it looks under a microscope and by the way it grows and spreads.

There are two main types of Hodgkin lymphoma: classical Hodgkin lymphoma and nodular lymphocyte-predominant Hodgkin disease. There are four subtypes of the classical type:

  • Nodular sclerosing (70%).
  • Mixed cellularity (20-25%).
  • Lymphocyte-depleted (5%).
  • Lymphocyte-rich (<1%).

Overall, classical Hodgkin lymphoma accounts for about 95% of all cases, while nodular lymphocyte-predominant (NLP) Hodgkin lymphoma is quite rare. The type of Hodgkin lymphoma a person has is determined by a pathologist, who tests a portion of tissue of the involved node(s). Pathologists look for a particular abnormal cell known as a Reed-Sternberg cell (also known as an “owl’s eye” cell) in order to diagnose classic Hodgkin lymphoma, or a “popcorn” cell to diagnose NLP Hodgkin lymphoma. The distinction between classical Hodgkin and NLP is important because they are treated differently.

What causes Hodgkin Lymphoma and am I at risk?

No one knows what causes Hodgkin lymphoma. Several factors have been linked with Hodgkin lymphoma. It is important to note that these factors may increase the risk of developing Hodgkin lymphoma, but that the majority of people with these conditions still do not develop Hodgkin lymphoma.

  • Epstein-Barr Virus: Infection with the Epstein-Barr virus may play a role in the development of certain types of Hodgkin lymphoma. Epstein-Barr virus also causes mononucleosis, also known as “mono” or “kissing disease.
  • Family History: It appears that the relatives of people who develop Hodgkin lymphoma at a very young age may be at increased risk of developing Hodgkin lymphoma.
  • HIV Infection: People with depressed immune function, such as patients with HIV/AIDS or those taking medications that suppress the immune system (for example, people with organ transplants or autoimmune diseases), appear to be at higher risk of developing Hodgkin lymphoma. Hodgkin lymphoma in HIV-infected patients is generally more aggressive and advanced than in non-HIV-infected patients.

How can I prevent Hodgkin lymphoma?

Because no one knows exactly what causes Hodgkin lymphoma, there are no specific steps you can take to prevent it.

What screening tests are used for Hodgkin lymphoma?

Hodgkin lymphoma is rare enough that it is not screened for in the general population with any specific blood tests or radiology studies. The best way to detect Hodgkin lymphoma early is to see your healthcare provider regularly for a thorough physical examination. Often, the patient is the first to notice a lump, and if this happens, you should see your healthcare provider for examination and further evaluation.

What are the signs of Hodgkin lymphoma?

The early stages of Hodgkin lymphoma often do not cause any symptoms. As the tumor grows in size it can produce a variety of symptoms. The most common lymph node site affected by Hodgkin lymphoma is in the neck, and neck swelling is what often brings people to the healthcare provider. However, Hodgkin lymphoma can also cause swelling of the lymph nodes in the underarm, upper chest, abdomen, or groin. These swellings are often not painful but can feel rubbery. Hodgkin lymphoma can also cause fevers, drenching night sweats, fatigue, weight loss, and even generalized itching.

If the Hodgkin lymphoma is affecting the lymph nodes in the chest, which are not typically seen or felt, the swelling can cause symptoms such as cough, shortness of breath, or chest pain. A chest x-ray can often show these swollen nodes in the chest. Some people with Hodgkin lymphoma will note pain in the lymph nodes after minimal alcohol consumption.

Many of these symptoms are non-specific, and could represent a variety of different conditions; however, your healthcare provider needs to see you if you have any of these problems.

How is Hodgkin lymphoma diagnosed?

When a patient presents with symptoms suggestive of Hodgkin lymphoma, their healthcare provider will perform a thorough history and physical examination. If there is a node that is enlarged, it will likely be surgically removed in what is called an excisional biopsy. Either part of or the entire node is removed so that a doctor, called a pathologist, can look at it under a microscope. A biopsy specimen is required to make the diagnosis of Hodgkin lymphoma. It is important that the provider use an excisional biopsy–the alternative is a core-needle biopsy, where a small needle is inserted into the swollen lymph node and a sample of the lymph node is taken. However, core-needle biopsies may not provide enough tissue to make a diagnosis.

Once the diagnosis is made, a healthcare provider will order a number of tests to get a sense of the extent and severity of the disease. A few different blood tests will probably be ordered, including blood counts, liver function tests, kidney function tests, erythrocyte sedimentation rate (ESR, a marker of inflammation), and a pregnancy test in women of childbearing age.

Your healthcare provider will also order a PET-CT scan to see the extent of the disease. A PET-CT scan combines a CT scan of the body (a 3D x-ray) with PET. The CT portion helps define the location of lymph nodes that are affected by cancer. The PET scan is a special type of scan where a sugar solution is injected through an IV. Tissues that are very active (like cancer cells) use the sugar for energy. These areas “light up” when they are scanned. The PET scan is important for two reasons: 1) It helps confirm where lymphoma is located in the body; and 2) It gives your provider the “before-treatment” picture. PET scan is used after treatment to be able to compare the “after-treatment” PET with a “before-treatment” PET. 

You may have a bone marrow aspiration and biopsy done to determine if the disease is in your bone marrow. You may have a number of other tests depending on the symptoms you are having. These tests include an echocardiogram to check your heart function, pulmonary function tests to check the function of your lungs, X-rays, CT scans, and MRIs. Your provider will determine which of these tests are necessary.

How is Hodgkin lymphoma staged?

After your full workup is complete your care team will stage your cancer. Staging is important because it classifies your cancer by how much disease you have and if/where it has spread. Staging helps guide your treatment plan. The staging system for Hodgkin lymphoma is known as the Cotswold system. It has four different stages:

  • Stage I: Also known as early stage. A single lymph node region is involved.
  • Stage II: Also known as locally advanced disease. Two or more lymph node regions involved on the same side of the diaphragm (the muscle that controls breathing and that separates the chest from the abdomen) or one lymph node region plus a nearby area or organ. If the disease involves a nearby area or organ it is classified as “E” disease or “extension.”
  • Stage III: Also known as advanced disease. Lymph nodes above and below the diaphragm are involved, or one node area and one organ on the opposite side of the diaphragm. Disease involving one node area and one organ on the opposite side of the diaphragm is “E” disease.
  • Stage IV: Also known as widespread disease. The lymphoma has spread outside the lymph nodes and spleen and into one or more other areas of the body including the bone, bone marrow, skin, and organs.

Early-stage Hodgkin lymphoma (Stage I-II) is divided further into two groups, “favorable” and “unfavorable,” to help predict which patients may benefit from more aggressive treatment. The criteria for unfavorable disease are as follows:

  • Bulky disease (tumor >10 cm in size).
  • Extension outside of lymph nodes (“extranodal” disease).
  • Involvement of three or more lymph node areas, or ESR > 50 mm. The erythrocyte sedimentation rate (ESR) is a laboratory test that measures the rate at which red blood cells sediment in a period of one hour.

Your cancer staging may also include letters. Explanations are as follows:

  • E: There is an extension of the disease affecting an organ outside of the lymph system.
  • S: The disease involves the spleen.
  • B: The patient has presented with “B” symptoms related to the disease including: loss of more than 10% of body weight over the past 6 months, fever of 100.4 F or higher or night sweats.
  • A: The patient has had no “B” symptoms.
  • X: The patient has bulky disease. Bulky disease is disease that describes tumors in the chest that are at least one third as wide as the chest.

Some other terms used when describing Hodgkin lymphoma are “resistant” or “progressive” disease. These terms are used when treatment does not make the disease go away or the disease gets worse. “Recurrent” or “relapsed” disease is the term used when the disease went away with treatment, but has returned in either the same place or in another part of the body.

How is Hodgkin lymphoma treated?

The treatment plan chosen depends on the stage of the disease and the patient’s current health status. The treatment plan should be developed by a provider who specializes in the treatment of lymphomas. The type and duration of treatment depend on the stage of Hodgkin lymphoma, whether it is favorable or unfavorable, and if it is NLP Hodgkin.

The two standards of treatment for Hodgkin lymphoma are chemotherapy and radiation. Hodgkin lymphoma can also be treated with multimodal therapy (combination of therapies), which includes chemotherapy, radiation and stem cell transplant. Other therapies may include targeted therapy or clinical trials.

Chemotherapy

Chemotherapy is the use of medications that treat cancer. Chemotherapy is known as a “systemic” treatment, which means that it goes throughout the entire body. These medications may be given through a vein (IV, intravenously) or by mouth, as pills. Chemotherapy is frequently used to treat Hodgkin lymphoma, and combinations of different chemotherapy medications are typically used to kill the tumor cells. Some chemotherapy regimens may be given prior to treatment with radiation. The most common chemotherapy regimens used are called ABVD, BEACOPP, and Stanford Five (V).

  • ABVD: adriamycin, bleomycin, vinblastine, and dacarbazine.
  • BEACOPP: bleomycin, etoposide, adriamycin, cyclophosphamide, vincristine, procarbazine, and prednisone.
  • Stanford V: doxorubicin, vinblastine, mechlorethamine, vincristine, bleomycin, etoposide, and prednisone.

You may receive one of these regimens or a combination of other medications. It is not always clear that one chemotherapy regimen is better than the others. The regimen selected may vary between providers. Your provider can explain why they recommend one particular regimen over another.

The most common targeted therapy used in the treatment of Hodgkin lymphoma, especially in the treatment of NDL, is rituximab (Rituxan®). Rituximab can be given by itself or in combination with chemotherapy and/or radiation. Brentuximab vedotin is often used for patients whose disease has returned after other treatment regimens. Other targeted therapies used in the treatment of relapsed or refractory Hodgkin lymphoma include everolimus, nivolumab, and pembrolizumab.

Because of the potential risk to fertility associated with chemotherapy medications used to treat Hodgkin lymphoma, discuss fertility preservation options with your healthcare provider before starting treatment.

Radiation Therapy

Radiation therapy uses high-energy rays (similar to x-rays), delivered from an external source, to kill cancer cells. Unlike chemotherapy, which goes everywhere in the body, radiation therapy is a local treatment. It targets small areas. There are two main types of radiation used to treat Hodgkin lymphoma: photon (traditional radiation) and proton therapy. Proton therapy is only available at a certain centers. You should discuss with your provider which type of radiation therapy is right for you.

Radiation therapy has evolved in the last few decades, as concern has grown over the long-term effects of radiation on important organs, like the heart and lungs. For this reason, when possible, radiation is avoided. In patients who need radiation, there is considerable effort made to protect the surrounding healthy tissue. Advanced radiation techniques and methods, such as IMRT, respiratory gating, breath-holding, and advanced simulation techniques (4D imaging), allow for highly conforming doses. This means the radiation beams are shaped tightly around the tumor and spare surrounding tissue as much as possible.  

In addition, the area treated has evolved over time. Many radiation oncologists now choose to treat just the lymph nodes that are involved and the surrounding areas where the tumor had spread (called involved site radiation therapy, ISRT). This has largely replaced treating an entire field around the involved lymph nodes (involved field radiation therapy). In the past, even larger fields were treated, including large areas of healthy tissue (called extended field radiation therapy). 

Radiation therapy typically requires patients to come to a radiation therapy treatment center 5 days a week, for several weeks. The radiation team will take scans and measurements to determine the number of doses needed and exactly where the radiation beams should be aimed. The treatment takes just a few minutes, and it is painless. You shouldn’t feel anything, though you may see some lights on the machines and hear them as they move around. Most radiation providers see patients weekly while they are receiving treatment to monitor for side effects and answer questions.

Stem Cell Transplant

Sometimes patients receive chemotherapy and/or radiation therapy, but the Hodgkin lymphoma is still present (also known as refractory Hodgkin lymphoma). When this happens, the provider may recommend stem cell transplantation (SCT). Stem cells are precursor cells that can develop into other cells of the body when placed in the right environment. In the case of SCT, the stem cells used are pre-destined to become blood cells (white and red blood cells or platelets).

Stem cell transplant is used along with high doses of chemotherapy. The high doses of chemotherapy are given with the intent to wipe out a person’s bone marrow. Without bone marrow, a person can’t make the components of blood and the immune system that are necessary to survive. In order to replace the patient’s bone marrow, stem cells are given. In the case of an autologous stem cell transplants, a patient’s own stem cells are harvested (collected) before the high dose chemotherapy is given. These cells are stored and then finally returned to the patient after the chemotherapy is done. Another option is an allogeneic stem cell transplant, where the stem cells are taken from a donor whose cells “match” those of the recipient. These cells are used in the same way, given to the patient after high dose chemotherapy. In both cases, bone marrow cells can re-grow from the stem cells. This enables a patient to tolerate the high doses of chemotherapy that work against Hodgkin lymphoma but have the unwanted side effect of wiping out healthy bone marrow.

Stem cell transplantation can sometimes cure patients when other treatment strategies have failed. However, stem cell transplantation is a complex and intense treatment, so it is typically reserved for patients who aren’t cured with the initial treatment regimens of chemotherapy and/or radiation therapy.

Clinical Trials

Clinical trials are extremely important in furthering our knowledge of this disease. It is through clinical trials that we know what we do today, and many exciting new therapies are currently being tested. Talk to your healthcare provider about participating in clinical trials in your area. You can also explore currently open clinical trials using the OncoLink Clinical Trials Matching Service. 

Follow-up Care and Survivorship

Once you have been treated for Hodgkin lymphoma, you will be followed closely by your care team. For the first two years after treatment, it is recommended you have a physical exam and complete blood counts every 3-6 months. After the first two years, you should see your care provider every 6-12 months until you are three years post-treatment, and annually thereafter. It is recommended you receive a CT scan of the chest, abdomen, and pelvis at 6, 12 and 24 months after completion of therapy. Survivors should also receive annual flu vaccines. If you received radiation to the spleen or had your spleen removed, you should receive pneumococcal, meningococcal, and H-flu revaccination 5-7 years after you have completed treatment.

Patients who are cured of their Hodgkin lymphoma can expect to live many decades after their treatment. However, this means that some late effects of treatments can be seen. These include:

  • Secondary cancers: Other cancers, including lung and breast cancer, non-Hodgkin lymphoma and leukemia can occur, even many years after treatment for Hodgkin lymphoma. These depend on the type of treatment received and the location where radiation therapy may have been targeted. Your treatment team will discuss cancer screening plans with you after you have completed treatment.
  • Cardiovascular disease: Patients who have received radiation to the mediastinum (chest) and certain kinds of chemotherapy may be at a higher risk for developing heart disease, sometimes 5 to 10 years after completion of treatment. Your team should monitor your blood pressure at all follow-up appointments. Your care team may also recommend a stress test or echocardiogram every 10 years after the completion of treatment.
  • Hypothyroidism: Decreased thyroid function (hypothyroidism) has been reported in 50% of Hodgkin lymphoma survivors who also received radiation to their neck or chest. Your thyroid should be examined as part of your regular exams and thyroid function tests should be performed every year after treatment.

Fear of recurrence, the financial impact of cancer treatment, employment issues, and coping strategies are common emotional and practical issues experienced by Hodgkin lymphoma survivors. Your healthcare team can identify resources for support and management of these challenges faced during and after cancer.

Cancer survivorship is a relatively new focus of oncology care. With some 15 million cancer survivors in the US alone, there is a need to help patients transition from active treatment to survivorship. What happens next, how do you get back to normal, what should you know and do to live healthy going forward? A survivorship care plan can be a first step in educating yourself about navigating life after cancer and helping you communicate knowledgeably with your healthcare providers. Create a survivorship care plan today on OncoLink.

Resources for More Information

Leukemia and Lymphoma Society

Provides disease information and support resources. www.lls.org

Lymphoma Research Foundation

Offers education and patient services, information on research, co-pay assistance and stories of hope. www.lymphoma.org

American Society of Hematology

The official website of providers who treat blood disorders including Hodgkin lymphoma. www.hematology.org/Patients/Cancers/Lymphoma.aspx

LymphomaInfo.net

Aims to bring people together around lymphoma-related issues by providing concise, up-to-date information and a meeting place for lymphoma patients and those who care about them. www.lymphomainfo.net

Lymph node removal (lymphadenectomy) | Health Information

Aftercare for lymph node removal

How long you need to stay in hospital depends on the type of lymph node removal operation you had. You might be able to go home the same day or you may need to stay longer. Ask your surgeon how long you’ll need to stay in hospital for.

If you had a local anaesthetic, you’ll need to take it easy until feeling returns to the area. Be careful not to bump the affected area. Similarly, if you had a general anaesthetic, you’ll need to rest until all the effects wear off. You might have some discomfort as this happens, but you’ll be offered pain relief.

If you had a general anaesthetic and are able to go home the same day, you’ll need to arrange for someone to drive you home. This is a good idea even if you had a local anaesthetic. Try to have a friend or relative stay with you for the first 24 hours after you get home.

Having a general anaesthetic affects everyone differently and in ways you may not expect. You might find that you’re not so coordinated or that it’s difficult to think clearly. This should pass within 24 hours. In the meantime, don’t drive, drink alcohol, operate machinery or sign anything important. Always follow your surgeon’s advice.

You’ll be given advice about caring for a surgical wound before you go home, as well as a date for a follow-up appointment.

If you have a drain from your wound, it will usually be removed after a few days. You might be able to go home with the drain in place. A practice nurse at your GP surgery or a district nurse may then visit you at home to remove it. You’ll have a dressing covering your wound. Your nurse or surgeon will tell you when you can remove this.

If your surgeon used dissolvable stitches to close your cut, these won’t need to be removed. They will dissolve completely within a week to three months depending on which type your surgeon used. If you had non-dissolvable stitches or staples, you’ll need to have these removed 10 days to two weeks after your operation.

It may take up to two weeks for the laboratory test results to come back. Results are usually sent to the doctor who requested your procedure. The results will tell your doctor if cancer cells were found in your lymph nodes. Your doctor will talk to you about your results at your follow-up appointment.

Lymphoma – Diagnosis, Evaluation and Treatment

Lymphoma is a cancer that develops in the white blood cells of the lymphatic system. Symptoms may include enlarged lymph nodes, unexplained weight loss, fatigue, night sweats and shortness of breath, cough or trouble breathing.

Your doctor will perform a physical exam and may order blood tests or lymph node biopsy to help evaluate your condition. If lymphoma is diagnosed, bone marrow aspiration and biopsy, lumbar puncture, chest x-ray, body CT, PET, bone scan, body MRI or abdominal ultrasound may be used to look for enlarged lymph nodes throughout the body and determine whether the lymphoma has spread. Treatment depends on the type and stage of the lymphoma as well as your age and overall health. Some types of lymphoma may only require monitoring while others may require chemotherapy, radiation therapy, radioimmunotherapy, biologic therapy or stem cell transplant.

What is lymphoma?

Lymphoma is a cancer that develops in the white blood cells (lymphocytes) of the lymphatic system, which is part of the body’s immune system.

The lymphatic system includes a network of small channels similar to blood vessels that circulate fluid (called lymph), lymph nodes (also called glands), bone marrow and several organs including the spleen, all of which are made up of lymphocytes.

There are two major types of lymphoma: Hodgkin (HL) and non-Hodgkin (NHL), each of which has several subtypes. Hodgkin lymphoma—also known as Hodgkin’s disease—is far less common than non-Hodgkin lymphoma.

Individual lymphomas differ in how they behave, spread and respond to treatment. The type of lymphoma is determined by examining some of the cancer cells under a microscope. When an abnormal cell called a Reed-Sternberg cell is present, the lymphoma is classified as Hodgkin. When it is not present, the cancer is classified as non-Hodgkin.

Symptoms of lymphoma may include:

  • enlarged lymph nodes in the neck, armpits or groin
  • unexplained weight loss
  • fever
  • drenching night sweats
  • generalized itching
  • fatigue
  • loss of appetite
  • coughing or trouble breathing
  • pain in the abdomen, chest or bones
  • swollen abdomen
  • feeling full after only a small amount of food
  • shortness of breath or cough

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How is lymphoma diagnosed and evaluated?

Your primary doctor will begin by asking you about your medical history and symptoms and perform a physical exam. Your doctor may also order one or more of the following tests.

Blood tests: The number of white blood cells, platelets and red blood cells may become low when lymphoma spreads to the bone marrow. Blood test results help determine how the liver and kidneys are functioning.

Lymph Node Biopsy: A procedure in which a portion of or an entire lymph node is surgically removed so it can be examined under a microscope to look for the presence of lymphoma cells. Occasionally, a needle biopsy may be sufficient to make a diagnosis. Other laboratory tests may be performed on the biopsy sample, including molecular genetic tests.

Bone marrow aspiration and biopsy: A surgical procedure in which a thin, hollow needle is inserted into the hip bone to remove a small amount of liquid bone marrow so it can be analyzed under a microscope. This procedure is typically performed after lymphoma has been diagnosed to help determine if the disease has spread to the bone marrow. See the Biopsy page for more information.

Lumbar puncture (spinal tap): A minimally invasive test that involves the removal of a small amount of cerebrospinal fluid (CSF)—the fluid that surrounds the brain and spinal cord—so it can be analyzed for the presence of lymphoma cells. This test is typically only performed for certain types of lymphoma or if the patient has symptoms that suggest the lymphoma may have reached the brain.

Chest x-ray: A chest x-ray is used to look for enlarged lymph nodes.

Body CT: A CT of the body is used to detect enlarged lymph nodes or organs and abnormalities in the abdomen, pelvis, chest, head and neck.

In some cases, CT may be used to guide a biopsy needle precisely into a suspicious area so that a tissue sample can be removed and examined under a microscope. This procedure is called a CT-guided needle biopsy.

PET scan: A PET scan, which uses a small amount of radioactive material, can help show if an enlarged lymph node is cancerous and detect cancer cells throughout the body that may not be seen on a CT scan. Some patients with lymphoma undergo PET scanning after receiving therapy to determine if the cancer is responding to treatment. A PET scan is combined with a CT or MRI scan to provide highly detailed views of the body.

Bone scan: In a bone scan, a radioactive isotope called technetium-99m is injected into a vein and travels to damaged areas of bone. This test is typically performed if the patient is having bone pain or other tests suggest lymphoma has traveled to the bone.

MRI: An MRI scan is helpful in detecting lymphoma that has spread to the spinal cord or brain. It can be helpful in other areas of the body as well, such as the head and neck area.

Abdominal ultrasound: Abdominal ultrasound may be used to examine enlarged lymph nodes, especially in the abdomen. Ultrasound is also used to image the abdominal organs and kidneys, which may be affected by enlarged lymph nodes.

Women should always inform their physician or x-ray technologist if there is any possibility that they are pregnant. For pregnant women with lymphoma, MRI and ultrasound may be used to stage the disease while protecting the fetus from harmful radiation. See the Safety page for more information about pregnancy and radiation.

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How is lymphoma treated?

Treatment options are based on the type and stage of lymphoma and the age and overall health of the patient. For some types of lymphoma, if the disease is advanced but slow-growing (indolent), a wait-and-see approach may be an option. When treatment is required for lymphoma, one or more of the following therapies may be used.

Chemotherapy: Chemotherapy, used alone or in combination with radiation therapy, is one of the main methods of treatment for lymphoma. It involves the use of cancer-killing drugs that are given by mouth or injection.

CNS prophylaxis, in which chemotherapy is injected into the spinal column through a lumbar puncture, may be used to treat certain types of non-Hodgkin lymphoma that have spread to the brain or are at high risk for such spread. In addition, steroid drugs may be used to relieve swelling and inflammation.

Radiation therapy: Radiation therapy uses high-energy radiation to shrink tumors and kill cancer cells. Patients with lymphoma may be treated with external beam therapy in which beams of high energy x-rays are generated by a machine outside the patient and directed at the tumor and cancerous lymph nodes. External beam therapy may be used alone or in combination with chemotherapy.

Monoclonal antibody therapy (also called targeted therapy): This is a treatment involving laboratory-produced molecules called monoclonal antibodies that are engineered to recognize and bind to the surface of cancer cells. Monoclonal antibodies mimic naturally produced antibodies in the body that attack invading foreign substances, such as bacteria and viruses. Monoclonal antibodies may be combined with a chemotherapy drug or radioactive material, allowing the antibody to deliver a direct dose of the cancer-killing agent to the cancer cell.

Two common monoclonal antibodies used for lymphoma are:

  • Rituximab®, a monoclonal antibody designed to seek out and lock onto the protein receptor (CD20) found on a specific type of lymphocyte (B cells), which causes the lymphoma cell to die. This treatment is used for many patients with “B-cell” lymphoma and may be combined with chemotherapy and/or radiation therapy.
  • Brentuximab vedotin (Adcetris®), which combines a chemotherapy drug with a monoclonal antibody that attaches to a specific molecule (CD30) on the surface of Hodgkin disease cells and some other types of lymphoma.

Radioimmunotherapy (also called radiolabeled monoclonal antibody therapy): This therapy pairs a monoclonal antibody with a radioactive material, such as Yttrium-90 with Ibritumomab Tiuxetan (Zevalin®). The radiolabeled monoclonal antibody travels to and binds to cancer cells, allowing a high dose of radiation to be delivered directly to the tumor.

Biologic therapy: This treatment involves natural or laboratory-made substances designed to boost, direct or restore the body’s natural defenses against cancer, or to interfere with specific biologic pathways within the lymphoma cells. Interferon is one type of biologic therapy that affects the division of cancer cells and can slow tumor growth. Lenalidomide and ibrutinib are examples of agents that interfere with metabolic pathways within the lymphoma cells.

Stem cell transplant: In this treatment, diseased bone marrow is replaced with the patient’s own healthy stem cells (called autologous) or the stem cells of a donor (called allogeneic) in order to help new bone marrow grow. A stem cell transplant may be an option if lymphoma returns after treatment. Patients undergoing a stem cell transplant may first receive whole-body external beam radiation along with high-dose chemotherapy to eliminate as many lymphoma cells as possible throughout the body.

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This page was reviewed on June, 15, 2020

Hodgkin lymphoma | UF Health, University of Florida Health

Definition

Hodgkin lymphoma is a cancer of lymph tissue. Lymph tissue is found in the lymph nodes, spleen, liver, bone marrow, and other sites.

Lymphatic system

Alternative Names

Lymphoma – Hodgkin; Hodgkin disease; Cancer – Hodgkin lymphoma

Causes

The cause of Hodgkin lymphoma is not known. Hodgkin lymphoma is most common among people 15 to 35 years old and 50 to 70 years old. Past infection with the Epstein-Barr virus (EBV) is thought to contribute to some cases. People with HIV infection are at increased risk compared to the general population.

Video: Hodgkin lymphoma

Symptoms

The first sign of Hodgkin lymphoma is often a swollen lymph node that appears without a known cause. The disease can spread to nearby lymph nodes. Later it may spread to the spleen, liver, bone marrow, or other organs.

Symptoms may include any of the following:

  • Feeling very tired all the time
  • Fever and chills that come and go
  • Itching all over the body that cannot be explained
  • Loss of appetite
  • Drenching night sweats
  • Painless swelling of the lymph nodes in the neck, armpits, or groin (swollen glands)
  • Weight loss that cannot be explained

Other symptoms that may occur with this disease:

  • Coughing, chest pains, or breathing problems if there are swollen lymph nodes in the chest
  • Excessive sweating
  • Pain or feeling of fullness below the ribs due to swollen spleen or liver
  • Pain in lymph nodes after drinking alcohol
  • Skin blushing or flushing

Symptoms caused by Hodgkin lymphoma may occur with other conditions. Talk to your health care provider about the meaning of your specific symptoms.

Exams and Tests

The provider will perform a physical exam and check body areas with lymph nodes to feel if they are swollen.

Hodgkin’s disease – liver involvement

The disease is often diagnosed after a biopsy of suspected tissue, usually a lymph node.

Lymphoma, malignant – CT scan

The following procedures will usually be done:

If tests show that you have Hodgkin lymphoma, more tests will be done to see how far the cancer has spread. This is called staging. Staging helps guide treatment and follow-up.

Treatment

Treatment depends on the following:

  • The type of Hodgkin lymphoma (there are different forms of Hodgkin lymphoma)
  • The stage (where the disease has spread)
  • Your age and other medical issues
  • Other factors, including weight loss, night sweats, and fever

You may receive chemotherapy, radiation therapy, or both. Your provider can tell you more about your specific treatment.

High-dose chemotherapy may be given when Hodgkin lymphoma returns after treatment or does not respond to the first treatment. This is followed by a stem cell transplant that uses your own stem cells.

You and your provider may need to manage other concerns during your treatment, including:

Support Groups

You can ease the stress of illness by joining a cancer support group. Sharing with others who have common experiences can help you not feel alone.

Outlook (Prognosis)

Hodgkin lymphoma is one of the most curable cancers. Cure is even more likely if it is diagnosed and treated early. Unlike other cancers, Hodgkin lymphoma is also very curable in its late stages.

You will need to have regular exams for years after your treatment. This helps your provider check for signs of the cancer returning and for any long-term treatment effects.

Possible Complications

Treatments for Hodgkin lymphoma can have complications. Long-term complications of chemotherapy or radiation therapy include:

  • Bone marrow diseases (such as leukemia)
  • Heart disease
  • Inability to have children (infertility)
  • Lung problems
  • Other cancers
  • Thyroid problems

Keep following up with a provider who knows about monitoring and preventing these complications.

When to Contact a Medical Professional

Call your provider if:

  • You have symptoms of Hodgkin lymphoma
  • You have Hodgkin lymphoma and you have side effects from the treatment

Images

References

Bartlett N, Triska G. Hodgkin lymphoma. In: Niederhuber JE, Armitage JO, Kastan MB, Doroshow JH, Tepper JE, eds. Abeloff’s Clinical Oncology. 6th ed. Philadelphia, PA: Elsevier; 2020:chap 102.

National Cancer Institute website. Adult Hodgkin lymphoma treatment (PDQ) – health professional version. www.cancer.gov/types/lymphoma/hp/adult-hodgkin-treatment-pdq. Updated January 14, 2021. Accessed February 13, 2020.

National Cancer Institute website. Childhood Hodgkin lymphoma treatment (PDQ) – health professional version. www.cancer.gov/types/lymphoma/hp/child-hodgkin-treatment-pdq. Updated February 3, 2021. Accessed June 3, 2021.

National Comprehensive Cancer Network website. NCCN clinical practice guidelines in oncology: Hodgkin lymphoma. Version 4.2021 – April 20, 2021. www.nccn.org/professionals/physician_gls/pdf/hodgkins.pdf. Accessed June 3, 2021.

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ᐈ Lymphadenectomy • Removal of lymph nodes in breast cancer

Lymphadenectomy

In the surgical treatment of patients with oncopathology, lymphadenectomy (aka lymphadenectomy) is an integral part of a competent and comprehensive approach to solving problems associated with breast cancer.

Up until the mid-1970s, extended mastectomies were a popular surgical treatment for breast cancer. In the course of such an operation, which was difficult for both the body and the patient’s psyche, in addition to the breast affected by the disease, the pectoral muscles, subclavian-axillary-subscapularis fatty tissues with lymph nodes, as well as parasternal, subclavian and even mediastinal lymph nodes were removed. These operations often led to deformation of the chest wall, stiffness in the shoulder joint and lymphostasis (swelling, soreness, thickening of the skin, etc.).of the upper limb, so, having brought enormous discomfort and traumatizing psychologically, patients often went through a difficult period of social rehabilitation from such treatment. Given the sufficient number of severe consequences following the operation of mastectomy, leading surgeons constantly worked to find the most sparing and effective methods of surgical care for breast cancer.

At present, organ-preserving operations, which are carried out in our center, have become the standard of surgical treatment of breast cancer.In the course of preliminary diagnostics, the “sentinel” lymph nodes affected by the disease and the groups of lymph nodes that are directly involved in the lymph drainage and are associated with the tumor affected area are precisely determined in each specific case. The presence of metastases in the lymphatic collector is the basis for lymph node dissection.

Thus, the purpose of the operation is not only to remove the tumor itself, but also the diseased regional lymphatic collector, which consists of lymphatic capillaries, outgoing vessels, lymphatic drainage pathways with regional and distant lymph nodes, surrounding tissue.Such operations significantly improve the quality of life of patients after the operation and help their early rehabilitation.

Types of lymph node dissection surgery that we do. Characteristic. Recovery.

Our rich experience, constant striving for professional self-improvement and scrupulous attitude to the preservation of not only health, but also the client’s psyche, motivate us to search for not typical, but the best solutions in the treatment of breast cancer. Especially if the decision comes down to surgical treatment.

If clinically necessary, we combine other surgical techniques with such types of lymphadenectomy as:

  • axillary-subscapular-subclavian-intermuscular lymphadenectomy – performed as a stage of radical mastectomy. Includes removal of the listed groups of lymph nodes;
  • axillary-subscapular-subclavian lymph node dissection – removal of the specified groups of lymph nodes. It is performed when malignant skin tumors metastasize to the axillary lymph nodes.Permissible as a sparing variant of lymphadenectomy for modified mastectomies;
  • mediastinal lymph node dissection – removal of the lymph nodes of the anterior mediastinum is now rarely performed, usually endoscopically. The indication is the metastasis of breast cancer in the specified lymphatic collector.

The principles of lymph node dissection are followed:

  • Zoning. The operation affects one anatomical area with a tumor. The patient’s postoperative period is easier;
  • Carrying case.Removal of tumor nodes within the anatomical “cases”. Thus, we reduce the risk of metastases;
  • Monoblock. Removal of tumor nodes in combination with surrounding tissues. Thus, the patient’s risk of intraoperative metastasis is reduced to zero.

Since the removal of lymph nodes causes a violation of the patency of the lymphatic pathways, leading to various complications, we approach the determination of the appropriateness of excision of a particular lymph node very carefully and scrupulously, operating really only what is needed.This approach allows us to reduce the number of postoperative complications and improve the quality of life of our patients.

Sentinel lymph node biopsy for breast cancer

In the vast majority of cases, lymph from the mammary glands flows into the axillary (axillary) lymph nodes.

In order to find the sentinel lymph node in breast cancer, a radiopharmaceutical is injected into the mammary gland (either into the tumor itself, or subcutaneously – under the nipple), which is a set of small particles the size of a cell.These particles are labeled with a radioactive isotope, which allows them to be seen with gamma detectors. The particles behave in the same way as cells detached from the tumor, which enter the intercellular space, that is, they are carried away along with the lymph and get stuck in the lymph nodes. Thus, most of these particles will be stuck in the first lymph node in the lymph outflow pathway, that is, in the sentinel lymph node.

After the introduction of a radiopharmaceutical, it is necessary to determine where the sentinel lymph node is located.This is done using a gamma camera (SPECT / CT). Thanks to this, the surgeon can determine in advance what access he needs in order to find this lymph node minimally traumatic for the patient.

During the operation, the sentinel lymph node is localized using a gamma probe through a small incision in the skin, to which the lymph node is fed. The isotopically labeled lymph node is removed and transferred for intraoperative histological examination. If no metastases are found in the lymph node, then the wound is sutured, and the removed lymph nodes are sent for an extended histological examination to the laboratory.If the lymph nodes are intact, then the patient with minimal postoperative changes (with small scars) goes home to recover. If micrometastases are still found in the lymph nodes, a decision is made on how to further treat the patient. This can be chemotherapy, radiation therapy, or extended surgery.

Currently, multicenter studies are underway, which show that even if there are micrometastases in one or two sentinel lymph nodes in breast cancer that do not grow into the capsule of the lymph node itself, then it is not necessary to do an extended lymph node dissection.In this case, radiation therapy is performed on the armpit area. The data show that the life expectancy after surgery in such patients is comparable to the life expectancy of patients who underwent lymphadenectomy, but the quality of life remains at a higher level.

What happens if sentinel lymph node biopsy is not performed for breast cancer?

At the earliest stages of the disease, when all diagnostic methods showed the absence of distant metastases, there are two options for surgical treatment of patients without sentinel lymph node biopsy:

1. Removal of the tumor and extended lymph node dissection (removal of all, or almost all of the lymph nodes).

As a result of extended lymph node dissection, many complications develop, such as edema, impaired motor function of the arm, and, as a result, disability of the patient.

Lymphedema is the most serious of all side effects after lymph node removal and can be irreversible. Lymphedema is manifested by swelling of the fingers, palms and hands, or even the entire arm, formed due to the accumulation of lymph.

2. Removal of the tumor itself while preserving the lymph nodes and further irradiation of of the axillary region, that is, chemotherapy and / or radiation therapy.

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onkoplastika-i-rekonstruktsiya

Oncoplastic and reconstructive operations in the treatment of breast cancer


Reconstruction

The main treatment for breast cancer is Madden or Patey Modified Radical Mastectomy.

With a radical mastectomy, the mammary gland, fatty tissue, which contains the lymph nodes, is removed, as well as the pectoral muscles (depending on the type of mastectomy).
Often, after such an intervention, the patient may experience psychological problems that affect the adaptation of a woman in society.
After mastectomy, 90% of patients experience a feeling of inferiority, more than 30% of patients experience problems in their sexual life, 22% have problems in personal and family relationships.
The modern approach to the treatment of oncological diseases includes not only an increase in life expectancy, but also an improvement in the patient’s quality of life. Our goal is to return the patient to the way of life that he led before the development of the disease.
Breast reconstruction is considered one of the most effective methods of rehabilitation after mastectomy.

The purpose of the reconstructive surgery is

restoration of the contours and volumes of the breast,

achieving symmetry with respect to the second,

intact breasts.

Breast reconstruction surgery is performed simultaneously or delayed relative to mastectomy. At the same time, the reconstructive stage has absolutely no effect either on the effectiveness of radical surgical treatment, or on the volume of removed tissues. Also, the reconstructive stage does not affect the further adjuvant treatment of the patient.

Numerous studies have shown that the performance of reconstructive surgery does not affect the rate of recurrence, the duration of overall survival, and the effectiveness of general anticancer treatment.

Breast reconstruction methods

Various materials are used to carry out reconstructive operations. Thus, operations can be divided into several types, depending on the materials used:

· Reconstruction with the use of endoprostheses of the mammary glands, expander-implant method;

· Breast reconstruction using only the patient’s own tissues (TRAM flap, free revascularized flap;

· Combined reconstructive surgery (thoraco-dorsal flap with implantation).

The procedure for the operation is determined by a specialist, depending on individual indications.

Expander-implant method

Most of the reconstructive operations performed in our clinic are performed using the expander-implant method.

When using this technique, reconstruction is carried out in several stages.

First step

The surgeon places an expander (tissue expander) under the pectoralis major muscle, in the area of ​​the postmastectomy defect.

After a while, using a special port, saline is injected into the expander. Due to this, the volume of the expander increases, the skin and pectoralis major muscle are stretched. If indicated, during this stage, patients undergo a course of radiation or drug therapy.

Second phase

Replacement of the expander filled with saline with a permanent endoprosthesis of the breast – an implant. Often there is a need for correction (tightening, augmentation, removal with simultaneous endoprosthetics !!!!!) of the second breast to achieve symmetry and obtain a good aesthetic result.Correction of the second breast is carried out simultaneously with the installation or replacement of the expander.

How long does it take between stages? Between the stages, it takes from 1.5 to 6 months, depending on the previous treatment, the patient’s tissues and the tasks set.

Advantages of the Expander-Implant method

The advantages of this method include a small amount of scars after surgery, low trauma, a short period of hospitalization (1-2 days).The disadvantages are several surgical procedures.

Thoraco-dorsal flap

The operation is carried out in one stage – a permanent implant is immediately installed in the postmastectomy defect area, the deficiency of skin and integumentary tissues is compensated with the help of a thoraco-dorsal flap. As with the expander-implant technique, in most cases a second breast correction is required.

The main advantages of this technique are one-stage and slight tautmatism.The disadvantages of this method include an additional scar on the back in the area of ​​removal of the mop.

Own tissue (TRAM flap)

This technique is more complicated; during the operation, the surgeon carries out the transfer of skin and subcutaneous fat from the abdominal area (hypogastric flap) on one or two rectus abdominis muscles, which provide blood supply to the flap. In this case, the reconstructed mammary gland is formed from transplanted tissues.

The advantages of this technique include the ability to form a moderately ptosized breast, in addition, when a flap is taken from the abdominal zone (hypogastric flap), abdominoplasty is performed, and after the operation, the patient gets a flat, taut abdomen.

However, breast reconstruction using a TRAM flap is a longer and more complex surgical procedure and requires a longer hospital stay.

Our clinic employs specialists with many years of experience in carrying out reconstructive surgeries.The most modern equipment, extensive experience allows us to minimize the number of postoperative complications and allows us to offer each patient an optimal method of breast reconstruction.

mammary

Diseases of the mammary glands are today the most common pathology that occurs in women. Breast cancer is the most common form of cancer among all existing among women and men, its share is 30% of all types of cancer.

Early detection of breast cancer is an important strategy for reducing breast cancer mortality.

According to the Department of Health of the Vologda Oblast, in the last 3-4 decades, the incidence of breast cancer in our country and abroad has increased significantly. Last year, 400 women in the Vologda Oblast were diagnosed with breast cancer, which is slightly more than a year earlier. The number of registered women with this disease is increasing by 3-4% per year.Every year in our country, for the first time, more than 40 thousand patients with breast cancer are registered and more than 20 thousand die from this disease.
According to statistics, about every eighth woman suffers from breast cancer, i.e. about 12.7% of all women experience this disease at least once in their lifetime

According to studies carried out in Finland, in 27% of cases, thanks to MRI, it was possible to reveal a wider prevalence of the disease than previously established by mammography.Without a preoperative MRI study, in 1 out of 5 cases, foci of cancer cells remain in the patient’s chest! It has also been proven that without the use of MRI, every tenth patient would need a second operation.

In its early stages, breast cancer usually has no symptoms. The tumor is small and difficult to palpate. Early breast cancer is usually diagnosed with MRI. In later stages, the tumor is usually palpable, especially if done by an experienced doctor.

    If the cancer was not detected in the early stages, then as it develops, the following symptoms may appear:

  • enlargement of all or part of the breast;
  • irritation or ripples on the skin of the chest;
  • 90,031 chest pain;

    90,031 nipple pain;

  • nipple is permanently retracted;
  • nipple discharge;
  • enlargement of lymph nodes in the armpit.

These symptoms are not always indicative of cancer, but rather often due to an infection or cyst in the chest, which can be identified with an MRI scan.

Modern medical diagnostics allows detecting this disease at the earliest stages, when it can be completely defeated, and here a lot depends on how a woman treats her health – from a timely visit to a doctor for a preventive examination.

Magnetic resonance imaging (MRI) is one of the methods for diagnosing breast cancer. MRI has more benefits than mammography and ultrasound.Based on the results of MRI examinations, doctors receive additional information about the size of the tumor and its extent, as well as important information for drawing up a plan of surgical treatment. Unlike mammography, magnetic resonance imaging is performed without X-rays, and the effectiveness of an MRI study does not depend on the density of breast tissue.

When conducting MRI studies, contrast agents are used, which make it possible to determine with great clarity any changes in the tumor.

Often, it is MRI that makes it possible to better distinguish pathologically altered, diseased tissue from healthy tissue than other imaging techniques such as radiography, CT or ultrasound.

The value of this method for early diagnosis and planning of treatment of neoplasms in the mammary gland can hardly be overestimated. The use of MRI mammography in addition to the usual methods of breast examination can increase the detection rate of neoplasms up to 90 percent, while X-ray mammography in combination with ultrasound only gives 45-50% of detection.

    Annual MRI is recommended:

  • Screening, that is, active examination, of women at high risk of developing breast cancer.
  • If a woman is found to have genes responsible for the development of breast cancer (BRCA1 or BRCA2).
  • Family history – If these genes are found in first-degree relatives (mother, sister, daughter). They can also be cousins ​​or aunts, including relatives with ovarian cancer.
  • If the woman has had radiation therapy to the breast area between the ages of 10 and 30.
  • Lifestyle. Excessive consumption of fatty foods and alcoholic beverages increases the risk of developing breast cancer. At the same time, studies show that cigarettes, stress and caffeine do not affect the appearance of breast cancer.
  • If you have other risk factors for breast cancer.

Modern oncologists necessarily prescribe MRI of an unaffected breast to patients with a unilateral breast tumor, in order to make sure that cancer does not develop in the other.

MRI not only provides a clear image of the delicate structures of the breast, but also allows you to assess the blood supply in the area of ​​the breast tumor of various localization, and this helps to better plan treatment measures and determine the prognosis.

MRI of the mammary glands is a new opportunity for non-invasive examination of the mammary glands, without surgery, and most importantly, without X-ray radiation. Currently, MRI of the mammary glands provides clear images of the breast, and it is much easier to distinguish between healthy and diseased tissue.

Currently, there is the possibility of MRI of the mammary glands, both with a contrast agent and without it. The procedure without contrast medium provides information about tissue density, presence of cysts, dilated milk ducts, hematoma, rupture or leakage of breast implants. MRI of the mammary glands with a contrast agent gives information about the size and location of any pathological formation, allows you to distinguish between benign and malignant formations, and identify enlarged lymph nodes.

    Benefits of breast MRI:

  • is a new opportunity for non-invasive examination of the mammary glands, without surgery, and most importantly, without X-rays.
  • The contrast material used in MRI is much less likely to cause allergic reactions than the iodine-based contrast used in conventional X-ray and CT scans.
  • The procedure does not pose a risk to the patient.
    allows you to see pathology where other imaging techniques have proven useless.
  • MRI of the mammary glands is able to reveal latent (for mammography and palpation) lesions of the breast with already established cancer of the other breast.
  • This type of MRI can be used to examine dense mammary glands in young women, as well as breast implants, which is difficult to do with conventional mammography.
  • This type of MRI has gained popularity as an alternative to conventional X-ray mammography in the diagnosis of early stages of breast cancer.
    MRI of mammary glands indications:

  • clarification of the nature of the formations detected by mammography;
  • early diagnosis of tumors and differential diagnosis of benign and malignant tumors not detected by other methods, especially in women with a predominance of glandular tissue in the mammary gland, and in women with a high risk of developing cancer;
  • determination of the integrity of breast implants;
  • Differential diagnosis between postoperative scars and recurrent breast tumors after surgery;
  • evaluation of multiple tumors before non-radical breast-conserving surgeries;
  • Determination of the spread to the chest wall of breast cancer detected by mammography or ultrasound;
  • Determination of the extent of tumor spread after breast surgery;
  • evaluating the effectiveness of chemotherapy and other treatments.

With MRI with contrast, we can speak about the characteristics and localization of the neoplasm in the mammary gland against the background of its dense and loose tissue, estimate its size (and MRI allows us to detect a formation less than 5 mm), identify and characterize nearby lymph nodes.

With the help of MRI, which is carried out without the use of contrast medium, it is possible to obtain information about the density of the gland tissues, the presence of cysts, the expansion of the milk ducts, the presence of hematomas, leakage or rupture of breast implants.Unlike other medical imaging methods (CT, X-ray, or ultrasound), MRI makes it much easier to distinguish between healthy and diseased tissue. At the same time, MRI does not use X-rays, so the study can be repeated many times without harm to the patient.

MRI allows you to detect the so-called preliminary stage of the disease, which, in comparison with “real breast cancer”, has an uncommon nature and is almost always curable, which is one of the most remarkable possibilities of contrast-enhanced MR mammography, when the neoplasm is practically “invisible” by other diagnostic methods …

90,000 ultrasound of lymph nodes in Saratov

Ultrasound of the lymph nodes is prescribed to detect abnormalities in the functioning of the lymphatic system or diseases of internal organs. The study is carried out quickly, and the results are ready almost immediately after the procedure, so the attending physician quickly receives information and can make a diagnosis.

If there are indications for an ultrasound of the lymph nodes, you can undergo such an examination at the “Alpha Health Center” in Saratov, and then contact a general practitioner or other specialist with the results.

Indications for ultrasound

It is important to examine the lymph nodes if there is a suspicion of an inflammatory process in them and nearby organs, infection or neoplasms in the body. Normally, the lymph nodes are practically not palpable, they are not felt and do not cause any discomfort. If something has changed, an ultrasound scan will help to identify the cause.

The doctor may send an ultrasound scan of the lymph nodes with symptoms such as:

  • An increase in the groin, cervical and other nodes located directly under the skin and are clearly visible;
  • Soreness of the lymph nodes when touched;
  • High temperature for a long time;
  • The presence of seals in the area of ​​the lymph nodes.

In case of discomfort and seals in the area of ​​the mammary glands, an ultrasound of the axillary lymph nodes and regional nodes of the chest is additionally done.

What the ultrasound shows

Peripheral lymph nodes are clearly visible on ultrasound: these include nodules in the armpits, groin, neck, under the elbows and knees. Peripheral nodes are close to the skin and palpable on palpation.

Ultrasound of regional lymph nodes (located close to internal organs, often at a fairly large depth) is also performed.To make it informative, the equipment is tuned to the desired frequency.

During the study, the ultrasound diagnostic doctor records:

  • The shape of regional or peripheral nodes, their compliance with normal sizes;
  • The state of each examined lymph node – how many inflamed nodules and how many healthy ones;
  • Mobility of knots;
  • The presence of infectious or neoplastic lesions.

Contraindications

Ultrasound examination of lymph nodes is absolutely safe and painless. During the procedure, the doctor moves a sensor across the skin surface, which emits safe ultrasound waves of the desired frequency. The technique has no contraindications, therefore, an ultrasound scan can be performed repeatedly to clarify the diagnosis or during treatment.

Make an ultrasound of the lymph nodes in Saratov

In the clinic “Alfa-Health Center” in Saratov, you can undergo an ultrasound scan of the lymph nodes of the neck, as well as the groin area, armpits and other areas, depending on the disturbing symptoms.The procedure is carried out on a safe General Electric LOGIQ apparatus with a minimum level of radiation and without harm to the body.

To make an appointment for an examination and have it on any convenient day without waiting and stress, call us.

Axillary lymph nodes – 24Radiology.ru

For this anatomical region, the following groups of lymph nodes are divided into 3 levels (relatively pectoralis minor):

Level I

  1. The anterior pectoral lymph nodes are located immediately below the edge of the pectoralis major muscle at the level of the III – IV ribs.The one closest to the mammary gland is most often the first lymph node where the tumor metastasizes. (sentinel limph node [SLN])
  2. The lower thoracic lymph nodes are located below, lateral to the lateral thoracic vessels; take lymph from the lower parts of the gland.
  3. The posterior thoracic (subscapular) lymph nodes are located along the subscapularis, take lymph from the upper back, scapula; rarely affected.
  4. Upper thoracic lymph nodes are located in the upper-outer part of the armpit, take lymph from the upper limb; as a rule, metastatic cancer cells are not affected.
  5. Central lymph nodes are located in the upper-inner corner of the armpit, serve as a collector for all lymphatic vessels of the upper limb, chest wall, breast.

Level II

  1. Interpectoral lymph nodes – Rotter’s lymph nodes – are located between the pectoralis major and minor; rarely affected.
  2. The subpectoral lymph nodes are located directly below the pectoralis minor muscle.Lymph is taken from the tissues of the chest wall, breast.

Level III

  1. The subclavian lymph nodes are located between the edge of the pectoralis minor and the clavicle, receiving lymph from all groups of nodes (level III).

All of the above groups of nodes are interconnected by lymphatic vessels, forming a plexus: plexus lymphaticus axillaris et subclavius.