Lymphatic Mapping with Sentinel Node Biopsy

This information explains your lymphatic mapping with sentinel node biopsy procedure at Memorial Sloan Kettering (MSK).

You might have this procedure if you have breast cancer or melanoma. It will help your doctor see if cancer cells have spread to your lymph nodes.

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About Your Lymphatic System

Your lymphatic system has 2 main jobs:

• It helps fight infection.
• It helps drain fluid from areas of your body.

Your lymphatic system is made up of lymph nodes, lymphatic vessels, and lymphatic fluid (see Figures 1 and 2).

Figure 1. Your lymphatic system in your breast

• Lymph nodes are small bean-shaped structures located along your lymphatic vessels. They filter your lymphatic fluid, taking out bacteria, viruses, cancer cells, and other waste products. A sentinel lymph node (often called a sentinel node) is the first lymph node that cancer cells might spread to.
• Lymphatic vessels are tiny tubes (like blood vessels) that carry lymphatic fluid to and from your lymph nodes.
• Lymphatic fluid is the clear fluid that travels through your lymphatic system. It carries cells that help fight infections and other diseases.

Figure 2. Your lymphatic system in other areas of your body

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Lymphatic Mapping

Lymphatic mapping is the first step in your sentinel node biopsy. It’s done to find the sentinel node. Lymphatic mapping can be done the day before or the day of your sentinel node biopsy.

Check your appointment reminder for where to go for your lymphatic mapping procedure.

During your mapping procedure

During your procedure, you will lie on a reclining chair for about 20 minutes. While you’re in the reclining chair, a doctor or nurse will inject a small amount of a radioactive liquid under your skin below the areola of your affected breast. You might feel stinging or burning during the injection.

After the injection, you will massage the area of the injection site for 10 minutes. This will help the radioactive liquid travel to the sentinel node(s). Then, a technologist will measure the radioactivity in your breast, axilla (armpit), and thigh on your affected side to see how much of the liquid was absorbed. There are 2 ways they can do this:

• Your technologist might use a small handheld device called a Neoprobe.
• You might have a full-body imaging scan done using a larger machine that you lie down on.

Both ways work equally well. Your doctor or nurse will tell you what to expect.

After your mapping procedure

If you’re having your sentinel node biopsy the same day as your mapping procedure, you will be brought to the area where you’re having your biopsy.

If you’re not having your biopsy on the same day as your mapping procedure, you will go home after your mapping procedure.

Breastfeeding

Stop breastfeeding for 24 hours after your lymphatic mapping. You can keep pumping your milk, but don’t feed it to your baby. You can either throw the milk away or store it for 24 hours.

After 24 hours, you can start breastfeeding again, feed your stored milk to your baby, or both.

If you have any questions, speak with your nuclear medicine doctor.

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Sentinel Node Biopsy

Before your biopsy procedure

A sentinel node biopsy is a surgical procedure. Many people have their sentinel node biopsy during their breast or melanoma surgery.

If you’re having your sentinel node biopsy as a separate surgery, read the resource Getting Ready for Surgery. It explains how to get ready for your biopsy. Your nurse will give you this resource during your appointment. You can also find it online.

During your biopsy procedure

You will get anesthesia (medication to make you sleep) before your procedure.

Once you’re asleep, your surgeon will inject a small amount of blue dye near the site of your cancer. This dye will travel through your lymphatic vessels to the sentinel node(s). It will stain your sentinel node(s) blue.

Next, your surgeon will use a Neoprobe (small handheld device) to measure the radioactivity from the liquid that was injected during your lymphatic mapping procedure. Once they find the area where your sentinel node(s) are, they will make an incision (surgical cut). They will look for the blue sentinel node(s) and remove them. They will send the node(s) to the Pathology Department to see if they contain cancer cells.

If the sentinel node(s) do contain cancer cells, you might need to have more lymph nodes removed. This is called an axillary lymph node dissection. Your surgeon will discuss this with you in more detail, if needed.

After your biopsy procedure

You might go home the same day as your biopsy, or you may need to stay in the hospital. This depends on how many other surgeries you had. Your doctor or nurse will tell you what to expect.

Read the resource Caring for Yourself After Your Sentinel Lymph Node Biopsy for information about what to expect after your procedure.

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Location In Body, Purpose, Common Problems

Lymph nodes are your immune system’s first line of defense, protecting you from things like bacteria or viruses that could make you sick.

You have hundreds of the small, round, or bean-shaped glands all over your body. Most are spread out, but some are found in groups in a few major places, like your neck, under your arm, and in your chest, belly, and groin. You might be able to feel some of the clusters in those areas as little bumps, but typically, you don’t feel them or even know they are three.

Your lymph nodes are part of your lymphatic system. Along with your spleen, tonsils, and adenoids, they help you fight off illness and infections.

How Do They Work?

Your lymph nodes are connected to one another by lymph vessels (tubes that run through your body like veins). They carry lymph fluid — a clear, watery liquid that passes through the nodes.

As the fluid flows through, cells called lymphocytes help protect you from harmful germs.

There are two kinds of lymphocytes — B-lymphocytes (or B-cells) and T-lymphocytes (or T-cells).

• B-cells make antibodies that attach to germs and let your immune system know they need to be killed off.
• T-cells have a couple of jobs. Some destroy germs, while others keep track of immune cells. They let your body know when to make more of certain kinds and less of others. Memory T cells are T-cells that remain dormant after an infection and become active again when they are faced with the same infection.

Lymph fluid also carries protein, waste, cellular debris (what’s left after a cell dies), bacteria, viruses, and excess fat that are filtered by the lymphatic system before it’s dumped back into the bloodstream.

Swollen Lymph Nodes

When there’s a problem in your body, like an illness or an infection, your lymph nodes can swell. (This usually happens only in one area at a time.) It’s a sign that more lymphocytes are in action than usual, trying to kill off germs.

You may notice this most often in the glands in your neck. That’s why your doctor feels the area under your jawbone. They’re checking to see if those glands are bigger than usual or tender.

Many things can make your lymph nodes swell. Any infection can trigger it, including a cold or the flu, an ear infection, STDs (usually inguinal), shingles, tuberculosis, or an abscessed tooth. Rarely a vaccine can cause swollen lymph nodes on the side of the vaccination.  Much less often, it can be a sign of something more serious, like cancer.

Sometimes medicines like phenytoin (taken for seizures), or drugs that prevent malaria can cause swollen lymph nodes, too.

The Radiology Assistant : Mediastinum Lymph Node Map

The lymphatic system and cancer

This page tells you about the lymphatic system and how cancer may affect it. There is information about

What the lymphatic system is

The lymphatic system is a system of thin tubes and lymph nodes that run throughout the body. These tubes are called lymph vessels or lymphatic vessels. The lymph system is an important part of our immune system. It plays a role in:

• fighting bacteria and other infections
• destroying old or abnormal cells, such as cancer cells

This video is about the lymphatic system, it lasts for 1 minute and 59 seconds.

Read a transcript of this video.

You can read detailed information about the immune system and cancer.

The lymphatic system

The diagram shows the lymph vessels, lymph nodes and the other organs that make up the lymphatic system.

How it works

The lymphatic system is similar to the blood circulation. The lymph vessels branch through all parts of the body like the arteries and veins that carry blood. But the lymphatic system tubes are much finer and carry a colourless liquid called lymph.

The lymph contains a high number of a type of white blood cells called lymphocytes. These cells fight infection and destroy damaged or abnormal cells.

As the blood circulates around the body, fluid leaks out from the blood vessels into the body tissues. This fluid carries food to the cells and bathes the body tissues to form tissue fluid. The fluid then collects waste products, bacteria, and damaged cells. It also collects any cancer cells if these are present. This fluid then drains into the lymph vessels.

The lymph then flows through the lymph vessels into the lymph glands, which filter out any bacteria and damaged cells.

From the lymph glands, the lymph moves into larger lymphatic vessels that join up. These eventually reach a very large lymph vessel at the base of the neck called the thoracic duct. The thoracic duct then empties the lymph back into the blood circulation.

Lymph nodes (lymph glands)

The lymph glands are small bean shaped structures, also called lymph nodes.

There are lymph nodes in many parts of the body including:

• under your arms, in your armpits
• in each groin (at the top of your legs)
• in your neck
• in your tummy (abdomen), pelvis and chest

You may be able to feel some of them, such as the lymph nodes in your neck.

The lymph nodes filter the lymph fluid as it passes through them. White blood cells, such as B cells and T cells, attack any bacteria or viruses they find in the lymph.

When cancer cells break away from a tumour, they may become stuck in one or more of the nearest lymph nodes. So doctors check the lymph nodes first when they are working out how far a cancer has grown or spread.

When the lymph nodes are swollen, doctors call it lymphadenopathy. The most common cause is infection but lymph nodes can also become swollen because of cancer.

Other lymphatic system organs

The lymphatic system includes other organs, such as the spleen, thymus, tonsils and adenoids.

The spleen

The spleen is under your ribs, on the left side of your body. It has 2 main different types of tissue, red pulp and white pulp.

The red pulp filters worn out and damaged red blood cells from the blood and recycles them.

The white pulp contains many B lymphocytes and T lymphocytes. These are white blood cells that are very important for fighting infection. As blood passes through the spleen, these blood cells pick up on any sign of infection or illness and begin to fight it.

The thymus

The thymus is a small gland under your breast bone. It helps to produce white blood cells to fight infection. It is usually most active in teenagers and shrinks in adulthood.

The tonsils and adenoids

The tonsils are 2 glands in the back of your throat.

The adenoids are glands at the back of your nose, where it meets the back of your throat. The adenoids are also called the nasopharyngeal tonsils.

The tonsils and adenoids help to protect the entrance to the digestive system and the lungs from bacteria and viruses.

Related information

You might like to read our information about how cancer starts. We also have information about how cancer can spread.  

For information about how cancer can affect the immune system, look at our page about the immune system and cancer.

Reduced expression of innate immunity-related genes in lymph node metastases of luminal breast cancer patients

2.

Brown, M. et al. Lymph node blood vessels provide exit routes for metastatic tumor cell dissemination in mice. Science 359, 1408–1411 (2018).

ADS 
CAS 
PubMed 
Article 

Google Scholar 

9.

Mowers, E. E., Sharifi, M. N. & Macleod, K. F. Autophagy in cancer metastasis. Oncogene 36, 1619–1630 (2017).

CAS 
PubMed 
Article 
PubMed Central 

Google Scholar 

13.

Yen, M.-C. et al. S100B expression in breast cancer as a predictive marker for cancer metastasis. Int. J. Oncol. 52, 433–440 (2018).

CAS 
PubMed 

Google Scholar 

17.

Zhang, R., Liu, Q., Li, T., Liao, Q. & Zhao, Y. Role of the complement system in the tumor microenvironment. Cancer Cell Int. 19, 300 (2019).

PubMed 
PubMed Central 
Article 

Google Scholar 

21.

Reis, E. S., Mastellos, D. C., Ricklin, D., Mantovani, A. & Lambris, J. D. Complement in cancer: Untangling an intricate relationship. Nat. Rev. Immunol. 18, 5 (2018).

CAS 
PubMed 
Article 
PubMed Central 

Google Scholar 

28.

Okroj, M. et al. Local expression of complement factor I in breast cancer cells correlates with poor survival and recurrence. Cancer Immunol. Immunother. 64, 467–478 (2015).

CAS 
PubMed 
Article 

Google Scholar 

35.

Bondar, G. et al. Comparing NGS and NanoString platforms in peripheral blood mononuclear cell transcriptome profiling for advanced heart failure biomarker development. J. Biol. Methods 7, 66 (2020).

Article 

Google Scholar 

42.

Popeda, M. et al. NF-kappa B signaling-related signatures are connected with the mesenchymal phenotype of circulating tumor cells in non-metastatic breast cancer. Cancers 11, 1961 (2019).

CAS 
PubMed Central 
Article 

Google Scholar 

An Animal Model for Investigation of Postoperative Lymphatic Alterations

Abstract

Background

Lymph node dissection is often performed as a part of surgical treatment for breast cancer and malignant melanoma to prevent malignant cells from traveling via the lymphatic system. Currently little is known about postoperative lymphatic drainage pattern alterations. This knowledge may be useful for management of recurrent cancer and prevention of breast cancer related lymphedema. We mapped the complete superficial lymphatic system of a dog and used this canine model to perform preliminary studies of lymphatic architectural changes in postoperative condition.

Methods

Lymphatic territories (lymphosomes) were mapped with 4 female mongrel carcasses using an indocyanine green (ICG) fluorescent lymphography and a radiographic microinjection technique. Two live dogs were then subjected to unilateral lymph node dissection of lymph basins of the forelimb, and ICG lymphography and lymphangiogram were performed 6 months after the surgery to investigate lymphatic changes. Lymphatic patterns in the carcass were then compared with postoperative lymphatic patterns in the live dogs.

Results

Ten lymphosomes were identified, corresponding with ten lymphatic basins. Postoperative fluorescent lymphographic images and lymphangiograms in the live dogs revealed small caliber lymphatic network fulfilling gaps in the surgical area and collateral lymphatic vessels arising from the network connecting to lymph nodes in the contralateral and ipsilateral neck in one dog and the ipsilateral subclavicular vein in another dog.

Conclusion

Our canine lymphosome map allowed us to observe lymphatic collateral formations after lymph node dissection in live dogs. This canine model may help clarify our understanding of postoperative lymphatic changes in humans in future studies.

Citation: Suami H, Yamashita S, Soto-Miranda MA, Chang DW (2013) Lymphatic Territories (Lymphosomes) in a Canine: An Animal Model for Investigation of Postoperative Lymphatic Alterations. PLoS ONE 8(7):
e69222.

https://doi.org/10.1371/journal.pone.0069222

Editor: Cephas Tagumirwa Musabayane, University of KwaZulu-Natal, South Africa

Received: April 24, 2013; Accepted: June 6, 2013; Published: July 24, 2013

Copyright: © 2013 Suami et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: The Kyte Plastic Surgery Research Fund and an Institutional Research Grant of The University of Texas MD Anderson Cancer Center provided financial support for this project. The University of Texas MD Anderson Cancer Center is supported in part by a Cancer Center Support Grant (CA016672) from the National Institutes of Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Breast cancer and malignant melanoma cells are well known to travel via the lymphatic system and migrate to regional lymph nodes. Thus, removal of regional lymph nodes has been a part of the surgical strategy for treatment of these cancers since Moore proposed axillary node dissection for the treatment of breast cancer in 1867 [1]. Sappey described the lymphatic system in the torso as being divided into 4 territories by the central midline and a horizontal line at the umbilical level, and he found that each lymph quadrant drained into the ipsilateral axillary or inguinal nodes in 1874 [2]. His anatomic findings have become the guiding principle in selecting which lymph basin needs to be removed in the treatment of a primary tumor [3].

Lymph node dissection can cause secondary lymphedema, which is a debilitating iatrogenic surgical complication. Radiation therapy increases the risk of developing lymphedema [4]–[5]. Little is known about the pathophysiology of lymphedema, and no standard of care has been established. The consensus among physicians is that obstruction of lymphatic pathways provokes lymph stasis in the affected limb and retention of protein-rich lymph fluid gradually induces fibrosis in the interstitial tissue [6]–[7]. However, there are no good explanations as to why some patients suffer from postoperative lymphedema and others do not.

Sentinel node biopsy has become a standard procedure used, when possible, to avoid the morbidity of radical lymph node dissection, including lymphedema, in the treatment of primary tumors [8]–[10]. Lymphatic preference dye and/or radioactive tracer are injected in the vicinity of the primary tumor to identify the first tier of lymph nodes. However, sentinel node biopsy cannot be used for the management of cancer metastasis caused by a locally recurrent tumor because previous treatment for the primary tumor and regional lymph node/s distorts the primary lymphatic drainage pattern.

Normal lymphatic pathways can be shown using lymphoscintigraphic examination during sentinel node biopsy. However, little information is available about postoperative lymphatic alterations. Such information, which could improve understanding of secondary cancer metastasis and of how to prevent lymphedema, would first require a comprehensive reference map of the lymphatic system at baseline to permit determination of where changes have occurred. Animal experiments are thought to be an essential element for this investigation, but, to the best of our knowledge, no standard, complete animal model of the lymphatic drainage system currently exists [11]–[12]. According to our previous research, the lymphatic system of a dog demonstrated remarkable similarities to the human lymphatic system in number, size, and distribution of the lymphatic vessels [13]–[14]. Thus, the aim of this study was to map the complete canine lymphatic system and demonstrate how this map can be used to better understand lymphatic architectural changes that occur after lymph node dissection.

Materials and Methods

The animal protocol for this study was reviewed and approved by The University of Texas MD Anderson Cancer Center Institutional Animal Care and Use Committee, which is accredited by the Association for Assessment and Accreditation of Laboratory Animal Care International (Permit Number: 02-09-01972, 10-10-08371). All surgery was performed under isofulrane anesthesia, and all efforts were made to minimize suffering.

Mapping Lymphosomes in Canine Carcasses

Four female mongrel hound carcasses weighing 23–30 kg were used for mapping lymphatic territories (lymphosomes). After the animals were euthanized, the carcasses were eviscerated and frozen at −30°C. Three bodies were cut into head and neck, forequarters, and hindquarters and the sections were investigated with radiographic microinjection technique. The remaining body was kept intact during the mapping and later cut in half lengthwise for comparison with postoperative images from a live dog that had undergone lymph node dissection.

We used an indocyanine green (ICG) fluorescent lymphography system (PDE; Hamamatsu Photonics K.K., Hamamatsu, Japan) to locate lymphatic vessels in the whole-body carcass. First, 0.1 ml of ICG aqueous solution (IC-Green, 0.5 mg/ml; Akorn, Lake Forest, IL) was injected into the skin in multiple sites in the dorsal and ventral midline of the head and neck, torso, interdigital webspaces, and tail. The body was massaged gently to facilitate travel of the ICG inside lumen of the lymphatic vessel and then scanned with the ICG fluorescent lymphography system, and images were video-recorded. Finally, shiny lines visible on the monitor screen were traced on the skin with a marker (Fig. 1). These markings traced on the skin facilitated identification of the lymphatic vessels (Fig. 2).

Figure 1. Indocyanine green (ICG) fluorescent lymphographic image of the medial side of the left forelimb in a dog carcass (left).

Tracing of the lymphatic vessels visualized using ICG lymphography (right).

https://doi.org/10.1371/journal.pone.0069222.g001

Figure 2. Marked lymphatic vessels near the dorsal midline in the torso (indocyanine green injection sites are shown as green dots) (top).

A magnified photo shows that ICG was specifically taken into the lymph vessel (arrow) (bottom).

https://doi.org/10.1371/journal.pone.0069222.g002

We used a radiographic microinjection technique that we had previously developed [15]–[16]. to investigate the canine lymphatic system in both the carcass sections and the whole body carcass following ICG lymphography. In brief, 3% hydrogen peroxide with 1% dye (Prussian Blue Professional Acrylic Ink; Liquitex Artists Materials, Piscataway, NJ) was injected into the skin in the search area. Fine oxygen bubbles produced from the hydrogen peroxide inflated the lymphatic vessel and forced the pigment into the lumen. A small incision was made 2. 5 cm proximally from the injection site, and inflated lymphatic vessels were identified using a surgical microscope. A 30G 1-inch needle set with a micromanipulator (MN-153; Narishige International USA, Inc., East Meadow, NY) was then inserted into the lymphatic vessel, and an aqueous radiocontrast mixture (lead tetroxide; ScienceLab.com, Houston, TX) was injected manually using a 1-ml syringe. After injections to all lymphatic vessels were complete, the specimens were meticulously dissected until each lymphatic vessel connected to its corresponding lymph node (sentinel lymph node; Fig. 3). The specimen was radiographed in a digital format (FCR Go portable x-ray system; Fujifilm Medical Systems U.S.A., Inc., Stamford, CT).

Sections of the radiograph were composed in a montage using graphic software (Adobe Photoshop CS 5.5; Adobe Systems, Inc., San Jose, CA), and lymphatic vessels were traced (Fig 4). Each lymph node was color-coded in accordance with its regional lymphatic basin, and then each lymphatic vessel was color-coded retrogradely from its lymph node. Thus lymphatic territories (lymphosomes) were defined to reveal which area of the skin drained to which lymphatic basin.

Lymph Node Dissection in a Dog

Two female dogs weighing 18 and 25 kg were used to investigate postoperative lymphatic changes after unilateral lymph node dissection. On the basis of our previous findings, the lymphatic system in the canine forelimb included 3 pathways: the dominant pathway to the ventral cervical node, the residual superficial pathway to the axillary node, and the deep pathway to the same axillary node approached from the cranial aspect [13]. The surgery attempted to disrupt all 3 pathways.

After the dog was anesthetized with isoflurane, ICG fluorescent lymphography was used to demonstrate normal lymphatic pathways and accurately identify the locations of the lymph nodes prior to surgery (Fig 5). The ICG injection sites were either in interdigital webspaces in the forefoot – for locating the ventral cervical node – or on the medial side around the elbow joint, for locating the axillary lymph node. A skin incision of 10 cm was made above each lymph node. Isosulfan blue (Lymphozurin; Covidien, Mansfield, MA) was injected into the same sites as those used for ICG to stain the lymphatic vessels. Skin flaps were undermined with a very superficial layer because some lymphatic vessels ran immediately beneath the skin. Subcutaneous fat tissue, including the lymphatic vessels, was excised together with the underlying deep fascia and lymph node. Stamps of both the afferent and efferent lymphatic vessels were ligated or clipped. The skin incisions were closed with dermal and skin stitches, and penrose drains were inserted into the wound. Circumferential measurements of the operated forelimb at the paw, wrist, middle of the forearm, and elbow were recorded every other day for 3 weeks.

Figure 5. Montage of indocyanine green (ICG) lymphographic images of the left forelimb of the live dog prior to lymph node dissection.

The ventral superficial lymph node (arrow) was identified using injections of ICG at interdigital webspaces.

https://doi.org/10.1371/journal.pone.0069222.g005

ICG lymphography and lymphangiography were performed 6 month after the surgery. After the dogs were anesthetized, ICG lymphography was performed as described in the previous section. For lymphangiography, isosulfan blue was injected into interdigital webspaces, a 4-cm incision in the dorsal paw was made, and a small cannula (Micro Cannulation System; Fine Science Tools Inc., Foster City, CA) was inserted into a stained lymphatic vessel and secured with 8–0 nylon. An oil-based radiocontrast agent (Lipiodol Ultra-Fuide; Guerbet, Cedex, France) was injected at a rate of 6 ml per hour using a syringe pump, and the forelimb and upper body were scanned with a C-Arm (Mobile C-Arm Series 9800; OEC Medical Systems, Inc., Salt Lake City, UT) and radiographed at 30-second intervals. These images were compared with the lymphosomes mapped on the carcasses to determine where the lymphatic system had changed.

Histological study was performed after sacrificing the dog with intravenous injection of Beuthanasia (1 ml/4. 5 kg). The small cannula was inserted into a lymphatic vessel in the dorsal paw in the same manner as in lymphangiogram described above. Saline with 10% dye (Prussian Blue Professional Acrylic Ink; Liquitex Artists Materials, Piscataway, NJ) was injected manually with a 1 ml syringe. Resistance in the syringe signaled the end of injection. Several blocks of tissues including the skin, soft tissue, and superficial muscle were harvested from the stained area, fixed in 10 % formalin, and stained with hematoxylin and eosin (HE).

Results

Lymphosomes in a canine

We found that ICG fluorescent lymphography could detect lymphatic vessels even though the specimens had been frozen and thawed, and that ICG could actively travel through the vessels in the absence of live smooth muscle. Although the ICG traveled only halfway to each lymph node from the injection site, it was specifically taken into the lymph vessels, which allowed us to identify them using markings on the skin, thus facilitating microinjection of the radiocontrast mixture to verify the locations of the vessels. Imaging in the canine carcasses showed that the lymph vessels emerged 3–5 cm from the dorsal and ventral midline. Only lymph capillaries in the dermis were observed near the midline area; no lymphatic vessels were found to cross the midline in either the ventral or dorsal aspects.

Ten lymphatic basins were identified in the canine body: submandibular, parotid, dorsal superficial cervical, axillary, medial iliac, lateral sacral, hypogastric, popliteal, superficial inguinal, and ventral superficial cervical (Fig. 6). The anatomic locations of the lymphatic basins were consistent among the specimens; however, the number of lymph nodes in each basin varied from 1 to 3. No overlapping of the superficial lymphatic vessels was observed except in the head region. In the head region, the vessels ran in 2 different layers, which were above and below the facial muscles. The lymphatic vessels were interconnected within the same nodal basin but not with the neighboring territory. Therefore, one lateral half of the dog skin could be divided into 10 lymphosomes.

Figure 6. Color-coded diagram of the lymphatic territories (lymphosomes) with lymphatic vessels shown distally from their corresponding lymph nodes: 1, submandibular; 2, parotid; 3, dorsal superficial cervical; 4, axillary; 5, medial iliac; 6, lateral sacral; 7, hypogastric; 8, popliteal; 9, superficial inguinal; 10, ventral superficial cervical.

https://doi.org/10.1371/journal.pone.0069222.g006

Changes in the Lymphatic System after Lymph Node Dissection

After the initial surgery in both dogs, the skin flap in the cervical area developed wound dehiscence with marginal necrosis, which required revision on postoperative day 3 and 7 in each dog after specification of demarcation line. There were no further complications, and the dog was maintained in stable condition thereafter. The forelimbs on the operated side gradually swelled starting on the third day after the initial surgery, and this swelling reached peaks around 10 days; the circumferential measurements at the elbow were 18. 1% and 14.5 % larger than the preoperative elbow measurements. The swelling in the forelimbs gradually subsided and completely disappeared 3 weeks after the initial surgeries.

The postoperative ICG lymphographic images showed a wide, spotty blight area where the surgery took place (Figure 7, top row, Video S1). In the first dog, two unusual lymphatic pathways were found proximal to the area in which the surgery took place. The first pathway ran toward the ventral superficial cervical lymph node, and the other pathway crossed the ventral midline and connected to the contralateral ventral superficial cervical node. In the second dog, we could not chase any lymphatic vessels from the blight area.

Figure 7. A montage of indocyanine green lymphographic images of the left forelimbs of 2 live dogs 6 months after lymph node dissection (top).

Bright spots were seen in the area in which the surgery took place (black arrow). Locations of lymph nodes are marked (white arrows). Lymphangiograms from the same dogs from lateral (left) and antero-posterior (right) views showing capillary-like network (black arrows) and bypassed lymph nodes (white arrows) (middle). Diagrams show changes of lymphatic pathways (bottom).

https://doi.org/10.1371/journal.pone.0069222.g007

Lymphangiograms revealed similar findings, along with precise, high-resolution chronological information about radiocontrast media movement. The lymphatic vessels looked normal from the dorsal side of the forelimb to the area in which the surgery took place, but they then diverged and formed a capillary-like network. These tiny vessels gradually converged to form a few lymphatic vessels that connected to the adjacent lymph basins in the first dog and to the subclavicular vein in the second dog. (Figure 7, middle and bottom rows, Video S2). These vessels were functioning as collateral drainage pathways from the affected forelimb after obstruction of the normal pathways.

Histological image demonstrated that pigments of the injected dye remained in the lumen of the capillary-like network, and thus enabled lymphatics to be distinguished. (Fig. 8). Cross section revealed that these lymphatic capillaries were situated extensively inside fibrous tissue within the surgical scar.

Figure 8. Histological image with hematoxylin and eosin staining of a cross section of a skin in the capillary-like network (scale bar: 5 mm) (left).

Small lymphatics lined with pigment is found in the entire fibrous scar tissue (scale bar: 2 mm) (right: white square field of the left).

https://doi.org/10.1371/journal.pone.0069222.g008

Discussion

Our radiographic microinjection technique allowed us to create a comprehensive lymphatic topography in a dog carcass, and we found that the canine lymphatic system contained 10 lymphatic territories (lymphosomes). We were then able to use this information to show how the structure of lymphatic vessels changed in live dogs after forelimb lymph node dissection.

Knowledge of the anatomy of the lymphatic system, both in animals and in humans, is very limited [16]–[18]. Baum and Ellenberger investigated and described the lymphatic system in domestic animals, including the horse, cow, pig, dog, and chicken [19]–[22]. Their findings for the dog were precise and similar to ours, but no photographic or imaging data from their study are available for comparison. Mapping of lymphosomes – dividing the body into territories showing each lymph node basin, as we have done in this study – is a new concept that we recently introduced [13]. Lymphosomes can be used to determine which lymph basins should be dissected on the basis of the primary tumor location, and they can also be used as a control for analysis of postoperative lymphatic changes.

Using previously published information about human anatomy in the superficial lymphatic system [2], [23]–[28], as well as information from our own dissections [29]–[32] and from lymphoscintigraphic examinations in clinical settings [33]–[36], we created a tentative human lymphosome map (Fig. 9). The sizes of each territory were discordant with those of the canine lymphosomes, but otherwise the 2 diagrams demonstrated remarkable similarities. Thus, a canine model such as the one used in the present study may be a good animal model for human lymphatic studies. This human lymphosome map is preliminary and will need to be refined by further anatomic investigation, but it may provide a prospective blueprint for cancer management.

Figure 9. Human lymphosomes, similar to the canine lymphosomes.

1, Frontal cervical; 2, parotid; 3, posterior cervical; 4, axillary; 5, retroperitoneal; 6, popliteal; 7, superficial inguinal; 8, subclavicular.

https://doi.org/10.1371/journal.pone.0069222.g009

The postoperative ICG lymphographic images and lymphangiograms of the live dogs in our study showed that lymphatic vessels in the obstructed territory connected to the lymph nodes in adjacent territories and spontaneous lymphaticovenous shunt. These collaterals are thought to act as bypasses to prevent manifestation of lymphedema and new metastatic pathways of residual cancer. The timing of the collateral formation in our study was uncertain, but the reduction of limb size suggests that this process occurred within 3 weeks after the surgical obstruction of the vessels. The capillary-like network played a key role to form the collaterals and this may develop together with scar formation.

A lymph vessel crossing the midline, as we observed in the live dog after lymph node dissection, has not been observed in previous examinations of the canine lymphatic system [13]–[14], [21], nor did we observe it in our examination of canine carcasses in this study; the collateral vessels went in the opposite directions until passing the sternum. The rerouted vessels in the live dog are reminiscent of the process of vascular remodeling in flap surgeries, in which choke vessels are dilated and then linked to adjacent territories to compensate for the lost vascular supply in the source territory [37]–[38]. However, unlike in the vascular system, the collecting lymphatic vessel contains bicuspid valves in its lumen at very short intervals. Therefore, it is unlikely that the collateral vessels found in this study were an altered form of pre-existing lymphatic vessels with incompetent valves. We hypothesize that lymph fluid was rerouted superficially toward the lymph capillary network in the dermis when the collecting lymphatic vessel became obstructed by surgery. Lymph retention in the capillary may stimulate lymphangiogenesis, and new lymphatic collector vessels may be created from the dilated capillary. These collateral vessels sprout from the capillary network and grow toward the nearest escape route.

A study did report this phenomenon in a human patient. In the article describing lymphangiographic findings in patients who had undergone mastectomy and lymph node dissection, radiocontrast media injected into the arm nearest to where the dissection had occurred reached the ipsilateral axillary lymph node via a network structure in the ipsilateral axillary region and via the collecting lymphatic vessel, which crossed the front midline (Fig. 10) [39]. This image is similar to the postoperative lymphangiogram of the first live dog. Aboul-Enein et al. reported that spontaneous lymphovenous shunt was observed in non-edematous arm by lymphangiogram in 2 patients out of 20 who underwent radical mastectomy and axillary node dissection [40].

Figure 10. Postoperative lymphangiogram of a patient who underwent right breast mastectomy and axillary node dissection.

Injected radiocontrast from the affected hand reached the contralateral axillary and ipsilateral supraclavicular nodes. Compare with the lymphangiogram of the live dog in Fig. 7. (Reprinted with permission from Bobbio P, Peracchia G, Pellegrino F. (1962) Connessioni linfatiche presternali fra le regioni mammarie dei due lati. Ateneo Parmensa, 33(supp.): 95–109).

https://doi.org/10.1371/journal.pone.0069222.g010

Sentinel node biopsy in patients undergoing postoperative axillary surgery has been described in several articles [41]–[45]. In 11 (8%) of 135 patients who underwent reoperative sentinel node biopsy with successful mapping, the sentinel node was the contralateral axillary lymph node, and in 6 patients (4%), the ipsilateral clavicular node was the sentinel node. These reports speculate that collateral lymphatics were formed in patients after the axillary surgery and lymphatic pathways altered its course to adjacent lymphatic territories similar to our live dog study.

A better understanding of postoperative lymphatic changes may help physicians predict secondary cancer metastasis and improve their understanding of the pathophysiology of postoperative lymphedema. It remains unclear, for example, why some patients suffer from lymphedema after axillary node dissection and others do not. We believe that a canine model and the lymphosomes concept can help lead to new insights into the lymphatic system.

Conclusions

We have successfully mapped canine lymphosomes and showed how this map can be applied to determine lymphatic changes following lymph node dissection. Because many similarities have been identified between lymphosomes in dogs and humans, this canine model may be of use in future studies of the human lymphatic system, particularly in determining postoperative lymphatic alterations. Postoperative fluorescent lymphographic images and lymphangiograms of the live dog showed collateral lymph formation. These preliminary findings may provide useful information for future studies aimed at developing methods to predict secondary cancer metastasis and prevent secondary lymphedema.

Acknowledgments

We thank the Department of Veterinary Medicine and Surgery at The University of Texas MD Anderson Cancer Center for technical assistance. We also thank Ms. Katherine Dixon of Dunn’s Laboratory in Imaging Physics at MD Anderson for operating the C-Arm and Ms. Erica Goodoff for assistance with scientific editing.

Author Contributions

Conceived and designed the experiments: HS. Performed the experiments: HS SY MASM. Analyzed the data: HS. Wrote the paper: HS DWC. Literature review: HS.

References

1. 1.
   Moore CH (1867) On the influence of inadequate operations on the theory of cancer. Med Chir Trans 50: 245–280.
2. 2.
   Sappey MPC (1874) Anatomie, physiologie, pathologie des vaisseaux lymphatiques consideres chez l’homme at les vertebres. Paris: A. Delahaye and E. Lecrosnier.
3. 3.
   Sugarbaker EV, McBride CM (1976) Melanoma of the trunk: the results of surgical excision and anatomic guidelines for predicting nodal metastasis. Surgery 80: 22–30.
4. 4.
   Herd-Smith A, Russo A, Muraca MG, Del Turco MR, Cardona G (2001) Prognostic factors for lymphedema after primary treatment of breast carcinoma. Cancer 92: 1783–1787.
5. 5.
   Lee TS, Kilbreath SL, Refshauge KM, Herbert RD, Beith JM (2008) Prognosis of the upper limb following surgery and radiation for breast cancer. Breast Cancer Res Treat 110: 19–37.
6. 6.
   Rockson SG (2001) Lymphedema. Am J Med 110: 288–295.
7. 7.
   Szuba A, Rockson SG (1997) Lymphedema: anatomy, physiology and pathogenesis. Vasc Med 2: 321–326.
8. 8.
   Cabanas RM (1977) An approach for the treatment of penile carcinoma. Cancer 39: 456–466.
9. 9.
   Morton DL, Wen DR, Wong JH, Economou JS, Cagle LA, et al. (1992) Technical details of intraoperative lymphatic mapping for early stage melanoma. Arch Surg 127: 392–399.
10. 10.
    Alex JC, Weaver DL, Fairbank JT, Rankin BS, Krag DN (1993) Gamma-probe-guided lymph node localization in malignant melanoma. Surg Oncol 2: 303–308.
11. 11.
    Shin WS, Szuba A, Rockson SG (2003) Animal models for the study of lymphatic insufficiency. Lymphat Res Biol 1: 159–169.
12. 12.
    Hadamitzky C, Pabst R (2008) Acquired lymphedema: an urgent need for adequate animal models. Cancer Res 68: 343–345.
13. 13.
    Suami H, Shin D, Chang DW (2012) Mapping of lymphosomes in the canine forelimb: comparative anatomy between canines and humans. Plast Reconstr Surg 129: 612–620.
14. 14.
    Suami H, O’Neill JK, Pan WR, Taylor GI (2008) Perforating lymph vessels in the canine torso: direct lymph pathway from skin to the deep lymphatics. Plast Reconstr Surg 121: 31–36.
15. 15.
    Suami H, Taylor GI, Pan WR (2005) A new radiographic cadaver injection technique for investigating the lymphatic system. Plast Reconstr Surg 115: 2007–2013.
16. 16.
    Suami H, Taylor GI, O’Neill J, Pan WR (2007) Refinements of the radiographic cadaver injection technique for investigating minute lymphatic vessels. Plast Reconstr Surg 120: 61–67.
17. 17.
    Shin WS, Szuba A, Rockson SG (2003) Animal models for the study of lymphatic insufficiency. Lymphat Res Biol 1: 159–169.
18. 18.
    Hadamitzky C, Pabst R (2008) Acquired lymphedema: an urgent need for adequate animal models. Cancer Res 68: 343–345.
19. 19.
    Ellenberger W, Baum H (1926) Handbuch der vergleichenden anatomie desr haustiere. Berlin: Verlag von Julius Springer.
20. 20.
    Baum H (1912) Das lymphgefässsystem den rindes. Berlin: Verlag von August Hirschwald.
21. 21.
    Baum H (1918) Das lymphgefässsystem den hundes. Berlin: Verlag von August Hirschwald.
22. 22.
    Baum H (1938) Das lymphgefässsystem den schweines. Berlin: P. Parey.
23. 23.
    Mascagni P (1787) Vasorum lymphaticorum corporis humani historia et ichnographia. Siene: P. Carli.
24. 24.
    Delamere G, Poirier P, Cunéo B (1904) The lymphatics. (Translated and edited by Leaf CH.) Chicago: W.T. Keener & Co.
25. 25.
    Bartels P (1909) Das lymphgefässsystem. Jena: Verlag von Gustav Ficher.
26. 26.
    Jossifow GM (1930) Das lymphgefäßsystem des Menschen. (Translated by Avtokratow JW.) Jena: Verlag von Gustav Fischer.
27. 27.
    Földi M, Földi E (2006) Földi’s textbook of lymphology for physicians and lymphedema therapists. 2^nd ed. Munich: Urban & Fischer.
28. 28.
    Rouvière H (1938) Anatomy of the human lymphatic system. (Translated by Tobias MJ.) Ann Arbor: Edwards Bros. Inc.
29. 29.
    Suami H, Taylor GI, Pan WR (2007) The lymphatic territories of the upper limb: anatomical study and clinical implications. Plast Reconstr Surg 119: 1813–1822.
30. 30.
    Suami H, Pan WR, Mann GB, Taylor GI (2008) The lymphatic anatomy of the breast and its implications for sentinel lymph node biopsy: a human cadaver study. Ann Surg Oncol 15: 863–871.
31. 31.
    Suami H, O’Neill JK, Pan WR, Taylor GI (2008) Superficial lymphatic system of the upper torso: preliminary radiographic results in human cadavers. Plast Reconstr Surg 121: 1231–1239.
32. 32.
    Pan WR, Suami H, Taylor GI (2008) Lymphatic drainage of the superficial tissues of the head and neck: anatomical study and clinical implications. Plast Reconstr Surg 121: 1614–1624; discussion 1625–1616.
33. 33.
    Uren RF, Hoefnagel CA (2004) Lymphoscintigraphy. In: Thompson JF, Morton DL, Kroon BBR, editors. Textbook of melanoma. London and New York: Taylor & Francis. 339–372.
34. 34.
    Uren RF, Howman-Giles R, Thompson JF (1998) Lymphatic drainage from the skin of the back to retroperitoneal and paravertebral lymph nodes in melanoma patients. Ann Surg Oncol 5: 384–387.
35. 35.
    Uren RF (2004) Lymphatic drainage of the skin. Ann Surg Oncol 11: 179S–185S.
36. 36.
    Reynolds HM, Dunbar PR, Uren RF, Blackett SA, Thompson JF, et al. (2007) Three-dimensional visualisation of lymphatic drainage patterns in patients with cutaneous melanoma. Lancet Oncol 8: 806–812.
37. 37.
    Dhar SC, Taylor GI (1999) The delay phenomenon: the story unfolds. Plast Reconstr Surg 104: 2079–2091.
38. 38.
    Taylor GI, Corlett RJ, Dhar SC, Ashton MW (2011) The anatomical (angiosome) and clinical territories of cutaneous perforating arteries: development of the concept and designing safe flaps. Plast Reconstr Surg 127: 1447–1459.
39. 39.
    Bobbio P, Peracchia G, Pellegrino F (1962) Connessioni linfatiche presternali fra le regioni mammarie dei due lati. Ateneo Parmensa 33(supp.): 95–109.
40. 40.
    Aboul-Enein A, Eshmawy I, Arafa S, Abboud A (1984) The role of lymphovenous communication in the development of postmastectomy lymphedema. Surgery 95: 562–566.
41. 41.
    Dinan D, Nagle CE, Pettinga J (2005) Lymphatic mapping and sentinel node biopsy in women with an ipsilateral second breast carcinoma and a history of breast and axillary surgery. Am J Surg 190: 614–617.
42. 42.
    Port ER, Garcia-Etienne CA, Park J, Fey J, Borgen PI, et al. (2007) Reoperative sentinel lymph node biopsy: a new frontier in the management of ipsilateral breast tumor recurrence. Ann Surg Oncol 14: 2209–2214.
43. 43.
    Schrenk P, Tausch C, Wayand W (2008) Lymphatic mapping in patients with primary or recurrent breast cancer following previous axillary surgery. Eur J Surg Oncol 34: 851–856.
44. 44.
    Axelsson CK, Jonsson PE (2008) Sentinel lymph node biopsy in operations for recurrent breast cancer. Eur J Surg Oncol 34: 626–630.
45. 45.
    Kaur P, Kiluk JV, Meade T, Ramos D, Koeppel W, et al. (2011) Sentinel lymph node biopsy in patients with previous ipsilateral complete axillary lymph node dissection. Ann Surg Oncol 18: 727–732.

Lymph Nodes: Anatomy & Location – Video & Lesson Transcript

Anatomy

From the outside, a lymph node looks like a fat lima bean: it is oval in shape, and has a small indentation called the hilum on one side. The lymph node is covered by a tough capsule, which is penetrated in multiple places by lymphatic vessels.

The lymphatic vessels carry lymph, a clear liquid containing white blood cells, proteins, salts, and water, into and out of the lymph node. Lymphatic vessels have one-way valves along their inner walls to help move lymph in the right direction. As lymph moves past a valve, the valve closes like a door and prevents the lymph from moving backward.

The inside of a lymph node is divided into several chambers by wall-like structures called trabeculae. Stretched between the trabeculae is a meshwork of thinner walls called reticular fibers. Together, the trabeculae and reticular fibers form a support network for immune cells that are packed in like grapes. Throughout the lymph node’s interior are a series of street-like channels called sinuses that help guide the flow of lymph.

Lymph Node Function

Lymph is formed from fluid that leaks from your blood vessels. Your body re-captures this fluid in lymphatic vessels, channels it through your lymph nodes, and eventually returns it to your bloodstream. The lymph flowing in a lymph node carries with it the bacteria, viruses, cancer cells, debris, and other potentially dangerous agents that have filtered into the lymphatic vessels from your bloodstream and tissues.

Lymph enters a lymph node through an afferent lymphatic vessel and exits through an efferent lymphatic vessel. Think of the e in exit and the e in efferent to remember which is which. As the lymph filters through the node, any infectious organisms or cancerous cells within the lymph are trapped by the reticular fibers, where they can be detected by the node’s immune cells. Since there are fewer efferent, exit lymphatic vessels than afferent, enter, vessels, the flow of lymph is slowed within the lymph node. This gives the immune cells time to accomplish their protective functions.

The white blood cells within the lymph node have several functions. Some produce antibodies that destroy infectious organisms; others eliminate abnormal cells, such as cancer cells, and mature lymphocytes act as ‘teachers’ for immature lymphocytes. When the lymph finally leaves the node, through an efferent lymphatic vessel it carries antibodies and other immune molecules, as well as other educated immune cells that can mobilize an immune response throughout your body.

Where are Lymph Nodes?

Prominent chains, or groups, of lymph nodes, are found in specific regions where large blood vessels meet or where your body is particularly susceptible to invasion by infectious organisms. From the head down, lymph node chains can be found around your ears, in your neck, along your collar bones, in your armpits, near your elbows, along your windpipe, around the large blood vessels in your abdomen and pelvis, along your intestines, in your groin, and behind your knees.

Lymph Node Activation

So, why do lymph nodes swell? When a lymph node traps a potentially threatening agent, its immune cells become activated. They start producing antibodies and inflammatory chemicals, and rapidly begin dividing. This causes the lymph node to swell. In healthy people, only the lymph node chains in the neck, armpits, and groin can be felt. For example, the lymph nodes near your inner elbow usually can’t be detected; however, if you develop an infection in your hand, these nodes may grow swollen and tender, as they are activated by the bacteria in the lymph draining from your hand. Eventually as the lymph moves upward, the nodes in your armpit may also become active, and you might even see pink streaks along your arm where the lymphatic vessels become inflamed. Swollen lymph nodes are occasionally an indication of cancer. Cancer cells that are carried to a lymph node sometimes multiply within the node itself and cause it to enlarge. When cancer cells are found in lymph nodes that are some distance from the original tumor, this indicates the cancer has spread. In such cases, doctor’s use lymph nodes to stage the cancer. Stage one indicates a less advanced cancer has spread than stage four.

Lesson Summary

Lymph nodes are complex filtration and processing units for your immune system. Lymph drained from a given region of your body enters a lymph node through an afferent lymphatic vessel, travels along sinuses that guide it through and eventually exits through an efferent lymphatic vessel.

The immune cells in a lymph node react to bacteria, viruses, cancer cells, and other potentially dangerous agents brought to the node by the lymph. Antibodies within a reactive lymph node travel with the lymph to other nodes, thus allowing your immune response to spread quickly from one body region to another.

Chains of lymph nodes can be found in specific body regions where blood vessels meet or where your body is particularly susceptible to invasion by infectious organisms.

90,000 Enlargement of lymph nodes – causes of appearance, in what diseases it occurs, diagnosis and methods of treatment

IMPORTANT!

The information in this section cannot be used for self-diagnosis and self-medication. In case of pain or other exacerbation of the disease, only the attending physician should prescribe diagnostic tests. For a diagnosis and correct treatment, you should contact your doctor.

Enlargement of lymph nodes – the reasons for the appearance, for what diseases it occurs, the diagnosis and methods of treatment.

Lymph nodes are small biological filters related to the lymphatic system. Their main function is to protect the body. Lymph nodes let the flow of lymph through themselves and in their structures trap pathogens, which are destroyed by protective cells – lymphocytes.

The lymph nodes target bacteria, tumor cells and toxic substances.

What are lymph nodes? These are small accumulations of lymphoid tissue located on the connective tissue frame.

Lymphoid tissue is a pool of cells that are involved in the destruction of damaged and tumor cells and microorganisms.

Swollen lymph nodes can be a symptom of both a mild infectious disease and a serious pathology that can lead to a serious outcome. Therefore, in all cases of enlarged lymph nodes, you should consult a doctor for diagnostics and finding out the cause.

Classification

Depending on the localization, the following groups of lymph nodes are distinguished:

• occipital;
• cervical;

90,026 submandibular;

90,026 chin;

• supraclavicular and subclavian;
• axillary;
• elbows;
• inguinal;
• popliteal.

During the examination, the doctor palpates (feels) the lymph nodes and determines their size, structure, soreness, changes in the skin over the lymph node.

Causes of swollen lymph nodes

An increase in lymph nodes indicates a pathological process. Isolated lymph node enlargement, or generalized lymphadenopathy, directly depends on the underlying cause of the disease.

Most cases of swollen lymph nodes are temporary.

The reasons for the increase in lymph nodes are:

• infectious processes;
• autoimmune diseases;
• tumor pathologies;
• storage diseases (a group of diseases accompanied by metabolic disorders).

Lymph nodes are involved in the formation of immunity, and during any infectious process, the division of cells that protect the body is activated in them.

So, with brucellosis, tuberculosis, syphilis, diphtheria, bacteria can settle in the lymph nodes, causing their inflammation. In this case, the lymph nodes increase in size due to the increased flow of lymph and blood.

Most often, lymph nodes enlarge in acute upper respiratory tract infections. Among them, the largest size of the lymph nodes is acquired with tonsillitis (angina).

Painful swollen lymph nodes can be a symptom of cat scratch disease (from the name it is clear that the disease occurs in persons scratched by a cat).The cause of the inflammatory process is the bacterium Bartonella henselae.

One of the striking examples of a viral disease accompanied by a significant increase in lymph nodes is infectious mononucleosis . The disease is caused by the Epstein-Barr virus and cytomegalovirus.

Infectious mononucleosis is more common in childhood and young age. In addition to enlarged lymph nodes, it is characterized by an increase in body temperature, weakness and sore throat.

In children, generalized lymphadenopathy occurs in childhood infectious diseases , such as measles, rubella, mumps, chickenpox.

Among other viral diseases accompanied by lymphadenopathy, it is worth noting HIV infection .

Lymphadenopathy in HIV infection is accompanied by a number of symptoms: weight loss, unexplained fever, night sweats, fatigue, and later infectious diseases (herpes, cytomegalovirus infection, candidiasis).

Systemic (autoimmune) connective tissue diseases , such as rheumatoid arthritis, systemic lupus erythematosus, may be accompanied by swollen lymph nodes. In these conditions, there is a violation of the recognition of “foreign” and “own” proteins, as a result of which the body begins to attack its cells. If the process is active, then the lymph nodes increase in size due to the increasing load.

Often autoimmune diseases are accompanied by an enlarged spleen and additional symptoms.

With systemic lupus erythematosus, the skin, kidneys and serous membranes of internal organs are affected (lupus pleurisy, serositis occur). In rheumatoid arthritis, the articular cartilage is predominantly affected.

Swollen lymph nodes can be a symptom of progression of the tumor process in the body. Atypical (tumor) cells migrate to the lymph nodes, get stuck in them, multiply and stretch the node with their mass.

Separately, it is worth highlighting the group of malignant neoplasms that directly affect the lymphatic system.

• Hodgkin’s lymphoma , or lymphogranulomatosis proceeds with the formation of conglomerates of affected immature lymphocytes in the lymph nodes and spleen.
• Non-Hodgkin’s lymphomas – a group of lymphoproliferative diseases.

Swollen lymph nodes can be a symptom of storage disease : as a result of metabolic disturbances, some substance accumulates in organs and tissues, including lymph nodes.Among these diseases: hemochromatosis (iron accumulation), Wilson-Konovalov disease (copper accumulation) and other hereditary metabolic disorders.

Allergic reactions sometimes lead to swollen lymph nodes. Hypersensitivity to some drugs leads to generalized lymphadenopathy.

Among endocrinological diseases , hyperthyroidism can be characterized by lymphadenopathy, enlarged spleen and increased lymphocyte count in the blood.During treatment, all indicators return to normal.

It is worth remembering that all the lymph flowing from the organs passes through the lymph nodes, and if a person is engaged in heavy physical labor, then the elbow and popliteal lymph nodes can be enlarged due to the heavy load .

Also, lymph nodes in rare cases enlarge after vaccination on the corresponding side.

Which doctor should i contact if my lymph nodes are swollen?

An adult should turn to
a therapist, and examines a child and a teenager
pediatrician.Depending on the accompanying symptoms, the following specialists may need to be consulted:

Diagnostics and examination with enlarged lymph nodes

• Clinical blood test;

90,000 ultrasound of lymph nodes in the groin, prices for ultrasound of inguinal lymph nodes

Lymph nodes are some kind of biological filters of the body. They prevent foreign particles, viruses and bacteria from entering the bloodstream. The accumulation of lymph nodes in the groin is considered one of the largest.An increase in them indicates an inflammatory process that arose as a result of a cold or upon contact with an infection.

Indications for ultrasound of lymph nodes in the groin

In the ONMED medical center, ultrasound is used to determine the state of the inguinal lymph nodes and the iliac artery. An examination is recommended when you have the following symptoms:

• the presence of painful lumps in the groin area;
• the presence of pain in the lower abdomen;
• swelling of the legs;
• Fever or malaise.

Completely different reasons can provoke damage to the lymph nodes. Often these are sexually transmitted infections, as well as benign or malignant tumors. Inflammation can be caused by immune diseases, such as:

• tuberculosis;
• lupus;
• rheumatoid arthritis;
• toxoplasmosis.

A similar problem in men may indicate testicular cancer. With the help of an ultrasound of the lymph nodes in the groin, these and other diseases can be detected at an early stage and surgical treatment can be carried out.

Carrying out a study at the ONMED medical center

Specialists of our medical center perform ultrasound of the inguinal lymph nodes using high-precision equipment at the most affordable price in the capital. We are investigating:

• localization;
• size;
• number;
• form;
• structure;
• relationship with the surrounding soft tissues, organs and blood vessels of the affected area.

By contacting us, you are guaranteed to receive highly accurate results of ultrasound of the lymph nodes in the groin.We are located not far from the Izmailovskaya, Shchelkovskaya, Pervomayskaya metro stations on the 7th Parkovaya street, 19. You can sign up for an ultrasound scan at ONMED by phone on the website.

In addition, one of our services is an ultrasound of the abdominal lymph nodes.

Reviews about the ultrasound of the inguinal lymph nodes in our center

04/18/14

I had my first and so far the last acquaintance with the ultrasound machine at the Onmed Medical Center, so there is nothing to compare with, but I did not have any complaints or complaints.An ultrasound examination of the inguinal lymph nodes was prescribed to me after I stretched the muscles in this area and the constant pain began. In this center, the onset of an inflammatory process in the lymph nodes was found on time, and I was able to avoid disastrous consequences. And all thanks to the accurate results of ultrasound and the experience of doctors in Onmed. Arseny.

01/15/14

I recommend all women to undergo an ultrasound examination of the inguinal lymph nodes at the ONMED medical center. They helped me a lot here when, with special attention and without unreasonable intimidation, the uzist doctor discussed inflammation with me.It was the early and accurate diagnosis using an ultrasound machine at the ONMED center that told me about the infection! Here, all the comments are reasoned, the doctors are all experienced, and they explain everything clearly. Therefore, I recently brought my friend to an ultrasound scan, as I can confidently recommend the center. Patient Nadia.

Lymphatic Drainage Massage / Massage / Services / A-Media Family Clinic

The lymphatic system is one of the most complex structures of our body. Unfortunately, she is also the most vulnerable.For example, in the cardiovascular system, blood circulation is provided by the heart, which acts as a pump.

And the lymphatic pump does not have such a pump – the movement of the lymph occurs independently, nothing helps it in this. In addition, it is very dependent on external factors: “wrong” food, lack of physical activity, stress, illness, bad habits and a lack of water in the body, so it often fails in its work.

Disruption of the functioning of the lymphatic system leads to detrimental consequences for health (fatigue, headaches, insomnia) and a person’s appearance (swelling, obesity and cellulite).

What is lymphatic drainage massage?

In order to normalize and improve the functioning of the lymphatic system, a lymphatic drainage massage technique has been developed. Its purpose is to increase the tone of the lymphatic vessels and increase the flow of lymph.

Massage is performed by stroking and pressing on problem areas, taking into account the location of the lymph nodes and the direction of the lymph flow.

Indications

Lymphatic drainage is indicated for people with the following problems:

• swelling of the face, legs and arms
• weakened immunity
• varicose veins
• overweight
• scars, stretch marks, cellulite
• chronic fatigue
• metabolic disorders etc.

The procedure is absolutely painless and comfortable, well tolerated and has no side effects. But despite this, not everyone can have such a massage.

Contraindications

Massage should be postponed in the presence of the following conditions:

• inflammation of the lymph nodes
• menstruation
• psoriasis, eczema
• disorders of the heart, thyroid gland
• oncological diseases
• mental disorders
• acute infectious diseases
• thrombosis
• fever.

Contraindications should not be neglected, as you can harm the body and provoke complications of existing diseases.

Types of lymphatic drainage massage

The technique of performing massage can be hardware or manual.

Manual massage looks very similar to the usual one, but in fact, all movements are done along certain lines with different force of influence, on which the result of the procedure depends.

• Superficial – stimulates metabolic processes
• Deep – affects the vessels, which improves the outflow of lymphatic fluid
• Internal – affects the lymph nodes.

Only a specialist who knows how to “feel” the muscles, knows the anatomy of the body and acts only in the direction of lymph flow should conduct the session. A properly done massage will give the necessary medical and cosmetic effect, but a non-professional can cause significant harm to health.

The procedure of hardware lymphatic drainage massage is carried out using special devices that work on the basis of microcurrents, differential pressure, creating a vacuum or ultrasound.These methods include pressotherapy, microcurrent drainage, vacuum massage, and electroionophoresis.

Results

Any lymphatic drainage massage has a positive effect:

• reduces swelling, increases skin turgor
• accelerates the movement of lymph
• removes intercellular fluid, reducing the appearance of cellulite
• reduces weight by accelerating metabolism
• improves the functioning of the whole body …

A persistent and pronounced result appears after a course of procedures.On average, these are 10-12 sessions, which are done 2-3 times a week. The duration of one treatment will depend on the type of massage.

Lymphatic drainage massage is very popular, because it is a simple, painless and safe physiological procedure for rejuvenation and healing of the whole body.

Carrying out computed tomography | Medical and sanitary part No. 9

Computed tomography (CT) is a painless, non-invasive, high-precision diagnostic method that allows you to obtain a detailed image of internal organs and structures using X-rays.

Computed tomography in the medical unit No. 9 is carried out on a modern multislice computed tomography Somatom Definition AS Siemens (64-slice).

Advantages of 64-slice multislice CT method

• High resolution that allows even small changes to be viewed in detail.
• Fast Exam – With one breath hold, you can perform a whole body exam. It takes no more than 20 seconds.
• The method is good for patients who are unable to remain immobile for a long time and are in critical condition. Unlimited possibilities for research of patients in serious condition who need constant contact with a doctor.
• Ability to build two-dimensional and three-dimensional images, allowing you to get the most complete information about the organs under study. No noise during scanning due to the ability of the device to complete the process in one revolution.
• You can perform the study of the heart and blood vessels.
• Enables early detection of coronary atherosclerosis.
• The radiation dose has been reduced.

In what cases is the study carried out

Due to its high information content and safety in comparison with other X-ray methods, CT has become widespread. It is of the greatest importance for traumatology and neurosurgery, when it is necessary to determine the presence of damage and its nature, and in oncology it is used to determine the extent of the tumor process, as well as to plan radiation treatment (in order to affect the tumor with ionizing radiation, its exact coordinates are required).With the help of CT, many pathological conditions can be detected: injuries and their consequences, tumors, damage to the lymph nodes, vasodilatation (aneurysms), inflammatory, including purulent processes (pneumonia, abscesses), malformations, dystrophic processes, etc.

It should be noted that the radiation exposure with computed tomography is significantly lower than with conventional X-ray examination. This allows us to speak about the higher safety of the method compared to other studies using X-rays.When examining pregnant women and young children, it is necessary to carefully weigh the need for CT in each case.

Preparation for examination

The examination is painless and safe for the patient, but requires some preparation. If there is an allergy or an early reaction to the administration of a contrast agent, it is imperative to inform the doctor about this before conducting the study. You should also report pregnancy, lactation, claustrophobia, bleeding tendencies.If the results of previous examinations are available, they must be presented to the doctor.

On the day of the examination, you can take all the drugs used earlier. Diabetics should take insulin and eat at the appropriate time, and take something to eat and drink with them for the study. In case of examination of the abdominal cavity, it is recommended to take a drug that inhibits intestinal peristalsis in advance.

Before the examination, the patient must remove all metal jewelry (for example, earrings, brooches, necklaces, watches, pens, keys).You should also put aside your mobile phone, briefcase. There is no need to undress – you only need to take off those clothes that have metal elements, for example, belt buckles, metal buttons, hooks.

How CT is performed

In some CT examinations, contrast material is used to obtain more detailed tomograms of the studied areas of the body. Patients who are allergic to contrast media, as well as patients who have had kidney disease or have renal failure, should inform their doctor before starting the study.

The radiologist will place you on a movable table in the supine, side or stomach position. Straps and pillows can be used to help you maintain and maintain correct posture during a CT scan.

The table will move rapidly through the scanner to determine the correct starting position for the examination. Then, as the table begins to slowly move through the scanner, a CT scan is performed.

When the CT scan is complete, you will be asked to wait while the radiologist has checked the quality of the images.

Research results can be recorded on an electronic carrier.

90,000 memo on HIV-associated lymph node tuberculosis

PERIPHERAL LYMPH NODE TUBERCULOSIS ASSOCIATED WITH HIV

/ memo for general practitioners, surgeons, oncologists, hematologists, phthisiatricians /

Tuberculosis of peripheral lymph nodes is one of the most common extrapulmonary localizations of tuberculosis.

The clinical picture of the disease and the course of tuberculosis in patients with HIV infection depend on the stage of HIV infection and are determined by the depth of T-cell immunodeficiency. More often, an acute course of the inflammatory process in the lymph nodes with a tendency to chronicity is characteristic.

Complaints

A specific feature of the clinical course of tuberculosis of peripheral lymph nodes is a pronounced intoxication syndrome: febrile body temperature, weakness, malaise, decreased appetite, enlarged lymph nodes of a certain localization.

Examination of the patient

There is a rapid progression of inflammatory changes in the peripheral lymph nodes: their uneven, asymmetric increase. Cervical, submandibular lymph nodes are more often affected. Less common is tuberculosis of the supra- and subclavian, axillary and inguinal lymph nodes. Their single lesion is rare, usually, increasing and merging with each other, groups of lymph nodes form conglomerates, followed by abscess formation and the formation of fistulas.

Differential diagnosis tuberculosis of peripheral lymph nodes is carried out with lymphadenitis of nonspecific etiology, with cysts, with lymphoproliferative diseases: myeloma, lymphosarcoma, etc.

Diagnosis of tuberculosis of peripheral lymph nodes.

• Carefully collected anamnesis
• X-ray of the neck and other areas to identify calcified lymph nodes
• Ultrasound of soft tissues corresponding to the affected area
• Tuberculin tests (including DST)
• Bacteriological and cytological examination of fistula discharge
• Histological examination of a removed lymph node

The “risk group” includes patients who have consulted doctors (oncologists, surgeons, otolaryngologists) for recurrent lymphadenitis: cervical, submandibular, parotid, axillary and inguinal regions, tumor-like formations, non-healing ulcers and fistulas in soft tissues.

All patients with suspected tuberculosis of peripheral lymph nodes are referred to a district phthisiatrician with a clinical minimum of examination: a general blood test, a general urine test, tuberculin tests, ultrasound of soft tissues, FGL (film), the result of a study of the discharge from the fistula for secondary flora.

Compiled by: specialists of the advisory department for patients with extrapulmonary tuberculosis No. 4

GBUZ PK “PKD” Phthisiopulmonology “

© Ministry of Health of the Perm Territory

GBUZ PK “PKD” Phthisiopulmonology “, Perm, 2015

Notes for professionals and the public can be found in this section.

For reports, orders and treatment protocols, see the phthisiatrician’s library.

90,000 ultrasound of the lymph nodes of the neck, groin and axillary in Dnipro

Lymph nodes play an essential role in the human body. They act as a filter for lymph, support immunity, and participate in the metabolic process. In a healthy person, the lymph nodes can hardly be felt by palpation. However, with the development of inflammatory or other pathological processes, the node increases in size and becomes more noticeable.An ultrasound of the lymph nodes will help to understand the cause of the development of pathology. This procedure allows you to determine the state of both nodes and adjacent organs.

What groups of lymph nodes are examined during the study

Lymph nodes are located throughout the human body. However, due to the specific location, during ultrasound diagnostics it is possible to examine the condition of only some of them:

• cervical;
• ear;
• occipital;

90,467 submandibular;

90,467 axillary;

• peritoneal;
• popliteal;
• in the groin.

What parameters are determined by ultrasound of lymph nodes

Ultrasound examination of lymph nodes is used in combination with other diagnostic measures, because in itself cannot identify a specific disease that led to the development of the inflammatory process. However, it is ultrasound that can detect inflammation at the earliest stage, which allows you to prescribe effective treatment and solve the problem in the least radical way.

During the procedure, a specialist sonologist is able to examine the following parameters of the lymph nodes:

1. Dimensions.It is necessary to determine if there are enlarged nodes.
2. Structure and form. The uniformity and clarity of the contours are checked.
3. Location relative to each other and to surrounding tissues.
4. In the presence of pathological changes, their uniformity and symmetry are studied.

What can be detected by ultrasound examination of lymph nodes

Ultrasound of the lymph nodes of the neck, abdominal cavity, armpits and others allows you to determine pathological changes even before the first symptoms appear.Among such pathologies:

• metabolic disorders in the body;
• infectious diseases;
• diseases of the endocrine system;
• lymphadenitis;
• sexually transmitted diseases;
• lymphogranulomatosis;
• Oncology, including cancer cell metastases.

The location of the affected node helps to identify the disease of certain organs. So, with inflammation of the lymph nodes in the groin, diseases of the pelvic organs (inflammation, infections and oncology) can be detected.

If a patient suspects leukemia, the submandibular lymph nodes are examined first.

Axillary lymph nodes are examined for the purpose of detecting oncological diseases, neoplasms of a different nature in the area of ​​the mammary glands, chest, manifestations of the human immunodeficiency virus (HIV).

Ultrasound examination of cervical nodes is used to diagnose tuberculosis, lipoma, lymphosarcoma, Sesari’s disease, syphilis, actinomycosis.

A change in the size of the lymph nodes does not always indicate the presence of a serious disease.That is why this type of diagnosis is prescribed in the complex. A general practitioner can direct you for diagnostics; in some cases, an oncologist’s consultation may be required.

The Daily Medical Medical Center invites you to undergo examination of peripheral and regional lymph nodes using modern equipment. Diagnostics is performed by a doctor of ultrasound diagnostics of the first category, Ekaterina Anatolyevna Sinenkaya. You can get a transcript of the results from our specialists.You can sign up for an ultrasound of the inguinal lymph nodes, abdominal nodes and others, as well as for a consultation with specialists, online on the website, as well as by phone numbers that you will find in Contacts.

COST of lymph node ultrasound

GBUZ “Buryat Republican Clinical Oncological Dispensary”

Modern approach to the treatment of cancer of the body of the uterus.

Cancer of the body of the uterus accounts for approximately 5% of all types of malignant neoplasms, being the sixth most common neoplastic process in women in the world. In Russia, malignant neoplasms of the reproductive system organs have the largest share in the structure of oncological morbidity in women – 39.2% of all cases. At the same time, cancer of the body of the uterus ranks first among tumors of the genital organs and accounts for 7.8% of all malignant neoplasms in women.

Surgical treatment is the main treatment for uterine cancer.An important criterion for the prognosis and treatment tactics of patients with the first stage of RTM is the presence or absence of lesions of regional lymph nodes. However, routine lymph node dissection in these patients is associated with a high risk of postoperative complications and a low risk of lymph node metastases. Currently available non-invasive research methods (ultrasound, MSCT and MRI, radionuclide research methods) cannot give a clear answer about the presence or absence of metastases in the lymph nodes.

Metastases can be diagnosed only by morphological or molecular biological methods, which requires tumor tissue that could be examined under a microscope. The most modern method of obtaining tissue is the concept of determining the status of a “sentinel” lymph node. This concept is gaining increasing recognition and introduced for many tumor localizations into the standards of surgical treatment by the European Organization for the Study and Treatment of Cancer, the American Society of Clinical Oncology and the Russian Society of Clinical Oncology.

The technique was tested in the conditions of the Research Institute of Oncology of the Tomsk NIMTs.

On the territory of the Far East, the detection of sentinel lymph nodes is carried out only in the Buryat Oncological Dispensary using the radionuclide method.

The technique consists in the preoperative introduction of an innovative Russian RFP. Particles containing a radioactive marker, penetrating the lymphatic system, are retained in metastases, indicating the places of their presence.The main node where the markers are concentrated is called the “sentinel” lymph node. The oncologist, having removed the tumor, immediately determines the presence of the remaining metastases using the Gamma Finder II. The device immediately reacts to the radioactive marker and shows on the screen the numerical value of the zone of the remaining metastasis, signaling with a sound.

At the moment, more than 10 such operations have been performed in the BRKOD, which made it possible to personalize the treatment in this group of patients.

Gamma-finder II gamma scanner received within the framework of the regional project “Fight against oncological diseases”.

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