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Difference between revisions of "Lymph node metastasis"
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| Caption = Lymph node metastasis (colorectal carcinoma). [[H&E stain]]. | | Caption = Lymph node metastasis (colorectal carcinoma). [[H&E stain]]. | ||
| Synonyms = | | Synonyms = | ||
| Micro = malignant cells foreign to the lymph node - dependent on specific cancer | | Micro = malignant cells foreign to the lymph node - typically subcapsular sinus; morphology dependent on specific cancer | ||
| Subtypes = micrometastasis, | | Subtypes = dependent on primary tumour - macrometastasis, micrometastasis, isolated tumour cells | ||
| LMDDx = [[endometriosis]], ectopic [[decidua]], [[endosalpingiosis]], melanocytic nevus, [[dermatopathic lymphadenopathy]], [[sinus histiocytosis]], [[tumour deposit]] (dependent on site), | | LMDDx = [[endometriosis]], ectopic [[decidua]], [[endosalpingiosis]], [[nodal nevus|nodal (melanocytic) nevus]], [[dermatopathic lymphadenopathy]], [[sinus histiocytosis]], [[tumour deposit]] (dependent on site), pathology of the lymph node - see ''[[lymph node pathology]]'' and ''[[lymphoma]]'' | ||
| Stains = dependent on tumour | | Stains = dependent on tumour | ||
| IHC = dependent on tumour | | IHC = dependent on tumour | ||
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| Molecular = | | Molecular = | ||
| IF = | | IF = | ||
| Gross = enlarged lymph node, esp. spherical, white mass | | Gross = enlarged lymph node, esp. spherical, white mass with an irregular border +/-extension into surround adipose tissue | ||
| Grossing = | | Grossing = | ||
| Site = [[lymph node]] - see ''[[lymph node pathology]]'' | | Site = [[lymph node]] - see ''[[lymph node pathology]]'' | ||
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| Syndromes = | | Syndromes = | ||
| Clinicalhx = +/-suspicion of cancer | | Clinicalhx = +/-suspicion of cancer | ||
| Signs = +/- | | Signs = +/-large lymph node/mass | ||
| Symptoms = | | Symptoms = | ||
| Prevalence = | | Prevalence = common - esp. in advanced cancer | ||
| Bloodwork = | | Bloodwork = | ||
| Rads = | | Rads = | ||
| Endoscopy = | | Endoscopy = | ||
| Prognosis = dependent on specific type of cancer | | Prognosis = dependent on specific type of cancer, +/-number of nodes affected | ||
| Other = | | Other = | ||
| ClinDDx = reactive | | ClinDDx = reactive lymphadenopathy, [[lymphoma]], other benign causes of lymphadenopathy - see ''[[lymph node pathology]]'' | ||
| Tx = dependent on underlying cancer | | Tx = dependent on underlying cancer (type and [[cancer staging|stage]]) | ||
}} | }} | ||
'''Lymph node metastasis''' is [[cancer]] that has spread to a [[lymph node]]. | '''Lymph node metastasis''' is [[cancer]] that has spread to a [[lymph node]]. | ||
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==Gross== | ==Gross== | ||
*Outside: | *Outside/surface of lymph node: | ||
**"Large" - size varies by site. | **"Large" - size varies by site.‡ | ||
***Neck >10 mm.<ref name=pmid18337039>{{Cite journal | last1 = Mack | first1 = MG. | last2 = Rieger | first2 = J. | last3 = Baghi | first3 = M. | last4 = Bisdas | first4 = S. | last5 = Vogl | first5 = TJ. | title = Cervical lymph nodes. | journal = Eur J Radiol | volume = 66 | issue = 3 | pages = 493-500 | month = Jun | year = 2008 | doi = 10.1016/j.ejrad.2008.01.019 | PMID = 18337039 }}</ref> | ***Neck >10 mm.<ref name=pmid18337039>{{Cite journal | last1 = Mack | first1 = MG. | last2 = Rieger | first2 = J. | last3 = Baghi | first3 = M. | last4 = Bisdas | first4 = S. | last5 = Vogl | first5 = TJ. | title = Cervical lymph nodes. | journal = Eur J Radiol | volume = 66 | issue = 3 | pages = 493-500 | month = Jun | year = 2008 | doi = 10.1016/j.ejrad.2008.01.019 | PMID = 18337039 }}</ref> | ||
**Shape - round more suspicious than oval. | **Shape - round more suspicious than oval. | ||
*Sectioned: | *Sectioned lymph node: | ||
**White firm lesion with irregular border - classic appearance. | **White firm lesion with irregular border - classic appearance. | ||
**Non-fatty hilum.<ref name=pmid18337039/> | **Non-fatty hilum.<ref name=pmid18337039/> | ||
Note: | |||
*‡ Small lymph nodes (<3 mm) infrequently affect the stage - at least in [[colorectal adenocarcinoma]].<ref name=pmid24676735>{{Cite journal | last1 = Sloothaak | first1 = DA. | last2 = Grewal | first2 = S. | last3 = Doornewaard | first3 = H. | last4 = van Duijvendijk | first4 = P. | last5 = Tanis | first5 = PJ. | last6 = Bemelman | first6 = WA. | last7 = van der Zaag | first7 = ES. | last8 = Buskens | first8 = CJ. | title = Lymph node size as a predictor of lymphatic staging in colonic cancer. | journal = Br J Surg | volume = 101 | issue = 6 | pages = 701-6 | month = May | year = 2014 | doi = 10.1002/bjs.9451 | PMID = 24676735 }}</ref> | |||
==Microscopic== | ==Microscopic== | ||
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#[[Soft_tissue_lesions#Lymph_node_metastases_in_sarcomas|Lymph node metastases in sarcomas]] are uncommon; they are seen in <3% of cases.<ref name=pmid8424704>{{Cite journal | last1 = Fong | first1 = Y. | last2 = Coit | first2 = DG. | last3 = Woodruff | first3 = JM. | last4 = Brennan | first4 = MF. | title = Lymph node metastasis from soft tissue sarcoma in adults. Analysis of data from a prospective database of 1772 sarcoma patients. | journal = Ann Surg | volume = 217 | issue = 1 | pages = 72-7 | month = Jan | year = 1993 | doi = | PMID = 8424704 | PMC = 1242736}}</ref> | #[[Soft_tissue_lesions#Lymph_node_metastases_in_sarcomas|Lymph node metastases in sarcomas]] are uncommon; they are seen in <3% of cases.<ref name=pmid8424704>{{Cite journal | last1 = Fong | first1 = Y. | last2 = Coit | first2 = DG. | last3 = Woodruff | first3 = JM. | last4 = Brennan | first4 = MF. | title = Lymph node metastasis from soft tissue sarcoma in adults. Analysis of data from a prospective database of 1772 sarcoma patients. | journal = Ann Surg | volume = 217 | issue = 1 | pages = 72-7 | month = Jan | year = 1993 | doi = | PMID = 8424704 | PMC = 1242736}}</ref> | ||
#Fatty lymph nodes (esp. fatty hilus<ref name=pmid18337039>{{Cite journal | last1 = Mack | first1 = MG. | last2 = Rieger | first2 = J. | last3 = Baghi | first3 = M. | last4 = Bisdas | first4 = S. | last5 = Vogl | first5 = TJ. | title = Cervical lymph nodes. | journal = Eur J Radiol | volume = 66 | issue = 3 | pages = 493-500 | month = Jun | year = 2008 | doi = 10.1016/j.ejrad.2008.01.019 | PMID = 18337039 }}</ref>) are less likely to harbor metastases.<ref name=pmid21972135>{{Cite journal | last1 = Korteweg | first1 = MA. | last2 = Veldhuis | first2 = WB. | last3 = Mali | first3 = WP. | last4 = Diepstraten | first4 = SC. | last5 = Luijten | first5 = PR. | last6 = van den Bosch | first6 = MA. | last7 = Eijkemans | first7 = RM. | last8 = van Diest | first8 = PJ. | last9 = Klomp | first9 = DW. | title = Investigation of lipid composition of dissected sentinel lymph nodes of breast cancer patients by 7T proton MR spectroscopy. | journal = J Magn Reson Imaging | volume = 35 | issue = 2 | pages = 387-92 | month = Feb | year = 2012 | doi = 10.1002/jmri.22820 | PMID = 21972135 }}</ref> | #Fatty lymph nodes (esp. fatty hilus<ref name=pmid18337039>{{Cite journal | last1 = Mack | first1 = MG. | last2 = Rieger | first2 = J. | last3 = Baghi | first3 = M. | last4 = Bisdas | first4 = S. | last5 = Vogl | first5 = TJ. | title = Cervical lymph nodes. | journal = Eur J Radiol | volume = 66 | issue = 3 | pages = 493-500 | month = Jun | year = 2008 | doi = 10.1016/j.ejrad.2008.01.019 | PMID = 18337039 }}</ref>) are less likely to harbor metastases.<ref name=pmid21972135>{{Cite journal | last1 = Korteweg | first1 = MA. | last2 = Veldhuis | first2 = WB. | last3 = Mali | first3 = WP. | last4 = Diepstraten | first4 = SC. | last5 = Luijten | first5 = PR. | last6 = van den Bosch | first6 = MA. | last7 = Eijkemans | first7 = RM. | last8 = van Diest | first8 = PJ. | last9 = Klomp | first9 = DW. | title = Investigation of lipid composition of dissected sentinel lymph nodes of breast cancer patients by 7T proton MR spectroscopy. | journal = J Magn Reson Imaging | volume = 35 | issue = 2 | pages = 387-92 | month = Feb | year = 2012 | doi = 10.1002/jmri.22820 | PMID = 21972135 }}</ref> | ||
# Cancer within adipose tissue may be classified as a ''lymph node metastasis''. | |||
#* In the context of breast cancer: breast cancer in axillary adipose tissue in the absence of normal breast tissue, absence of in situ breast carcinoma and absence of residual lymphoid tissue is classified as a lymph node metastasis/micrometastasis/isolated tumour cells in lymph node.<ref name=cap_breast_inv_ver4p5p0p0>College of American Pathologists. Cancer Protocol Templates - Breast Invasive, Resection. Version 4.5.0.0. Available at: [https://documents.cap.org/protocols/Breast.Invasive_4.5.0.0.REL_CAPCP.docx https://documents.cap.org/protocols/Breast.Invasive_4.5.0.0.REL_CAPCP.docx]. Accessed on: August 8, 2021.</ref> | |||
DDx - mimics of metastatic disease: | DDx - mimics of metastatic disease: | ||
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*Ectopic [[decidua]].<ref name=pmid15859655>{{Cite journal | last1 = Wu | first1 = DC. | last2 = Hirschowitz | first2 = S. | last3 = Natarajan | first3 = S. | title = Ectopic decidua of pelvic lymph nodes: a potential diagnostic pitfall. | journal = Arch Pathol Lab Med | volume = 129 | issue = 5 | pages = e117-20 | month = May | year = 2005 | doi = 10.1043/1543-2165(2005)129e117:EDOPLN2.0.CO;2 | PMID = 15859655 }}</ref> | *Ectopic [[decidua]].<ref name=pmid15859655>{{Cite journal | last1 = Wu | first1 = DC. | last2 = Hirschowitz | first2 = S. | last3 = Natarajan | first3 = S. | title = Ectopic decidua of pelvic lymph nodes: a potential diagnostic pitfall. | journal = Arch Pathol Lab Med | volume = 129 | issue = 5 | pages = e117-20 | month = May | year = 2005 | doi = 10.1043/1543-2165(2005)129e117:EDOPLN2.0.CO;2 | PMID = 15859655 }}</ref> | ||
*[[Endosalpingiosis]].<ref name=pmid20631604>{{Cite journal | last1 = Corben | first1 = AD. | last2 = Nehhozina | first2 = T. | last3 = Garg | first3 = K. | last4 = Vallejo | first4 = CE. | last5 = Brogi | first5 = E. | title = Endosalpingiosis in axillary lymph nodes: a possible pitfall in the staging of patients with breast carcinoma. | journal = Am J Surg Pathol | volume = 34 | issue = 8 | pages = 1211-6 | month = Aug | year = 2010 | doi = 10.1097/PAS.0b013e3181e5e03e | PMID = 20631604 }}</ref> | *[[Endosalpingiosis]].<ref name=pmid20631604>{{Cite journal | last1 = Corben | first1 = AD. | last2 = Nehhozina | first2 = T. | last3 = Garg | first3 = K. | last4 = Vallejo | first4 = CE. | last5 = Brogi | first5 = E. | title = Endosalpingiosis in axillary lymph nodes: a possible pitfall in the staging of patients with breast carcinoma. | journal = Am J Surg Pathol | volume = 34 | issue = 8 | pages = 1211-6 | month = Aug | year = 2010 | doi = 10.1097/PAS.0b013e3181e5e03e | PMID = 20631604 }}</ref> | ||
* | *[[Nodal nevus|Nodal (melanocytic) nevus]] - intracapsular or within the trabeculae.<ref name=pmid12717252>{{Cite journal | last1 = Biddle | first1 = DA. | last2 = Evans | first2 = HL. | last3 = Kemp | first3 = BL. | last4 = El-Naggar | first4 = AK. | last5 = Harvell | first5 = JD. | last6 = White | first6 = WL. | last7 = Iskandar | first7 = SS. | last8 = Prieto | first8 = VG. | title = Intraparenchymal nevus cell aggregates in lymph nodes: a possible diagnostic pitfall with malignant melanoma and carcinoma. | journal = Am J Surg Pathol | volume = 27 | issue = 5 | pages = 673-81 | month = May | year = 2003 | doi = | PMID = 12717252 }}</ref> | ||
**Incidence estimated at ~ 0.5% in axillary lymph nodes.<ref name=pmid8037154>{{cite journal |author=Bautista NC, Cohen S, Anders KH |title=Benign melanocytic nevus cells in axillary lymph nodes. A prospective incidence and immunohistochemical study with literature review |journal=Am. J. Clin. Pathol. |volume=102 |issue=1 |pages=102–8 |year=1994 |month=July |pmid=8037154 |doi= |url=}}</ref> | |||
*[[Dermatopathic lymphadenopathy]].{{fact}} | *[[Dermatopathic lymphadenopathy]].{{fact}} | ||
*[[Sinus histiocytosis]] - especially for the junior resident. | *[[Sinus histiocytosis]] - especially for the junior resident. | ||
*[[Tumour deposit]] (discoutinuous extramural extension) - definition dependent on primary tumour | *[[Tumour deposit]] (discoutinuous extramural extension) - definition dependent on primary tumour. | ||
**In the head & neck they are generally considered tumour replaced lymph nodes - though this appears to be evolving.<ref name=pmid25546631>{{Cite journal | last1 = Sarioglu | first1 = S. | last2 = Akbulut | first2 = N. | last3 = Iplikci | first3 = S. | last4 = Aydin | first4 = B. | last5 = Dogan | first5 = E. | last6 = Unlu | first6 = M. | last7 = Ellidokuz | first7 = H. | last8 = Ada | first8 = E. | last9 = Akman | first9 = F. | title = Tumor deposits in head and neck carcinomas. | journal = Head Neck | volume = 38 Suppl 1 | issue = | pages = E256-60 | month = Apr | year = 2016 | doi = 10.1002/hed.23981 | PMID = 25546631 }}</ref> | |||
**In the colon and rectum tumour deposits are considered separately and not counted as lymph nodes. | |||
*Benign thyroid inclusion - somewhat controversial, see ''[[aberrant thyroid tissue]]''.<ref name=pmid15744160 >{{Cite journal | last1 = León | first1 = X. | last2 = Sancho | first2 = FJ. | last3 = García | first3 = J. | last4 = Sañudo | first4 = JR. | last5 = Orús | first5 = C. | last6 = Quer | first6 = M. | title = Incidence and significance of clinically unsuspected thyroid tissue in lymph nodes found during neck dissection in head and neck carcinoma patients. | journal = Laryngoscope | volume = 115 | issue = 3 | pages = 470-4 | month = Mar | year = 2005 | doi = 10.1097/01.mlg.0000157841.63283.87 | PMID = 15744160 }}</ref> | |||
===Images=== | ===Images=== | ||
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Image:Endosalpingiosis_in_lymph_node_-_very_high_mag.jpg | Endosalpingiosis in a LN - very high mag. (WC) | Image:Endosalpingiosis_in_lymph_node_-_very_high_mag.jpg | Endosalpingiosis in a LN - very high mag. (WC) | ||
</gallery> | </gallery> | ||
==Staging== | |||
It is customary to record: | |||
# The size of the largest lymph node metastasis. ‡ | |||
#* It is a dictum of the ''Association of Directors of Anatomic and Surgical pathology''<ref name=pmid11007046>{{Cite journal | title = Recommendations for the reporting of specimens containing oral cavity and oropharynx neoplasms. | journal = Mod Pathol | volume = 13 | issue = 9 | pages = 1038-41 | month = Sep | year = 2000 | doi = 10.1038/modpathol.3880188 | PMID = 11007046 }}</ref> that masses >3 cm are matted lymph nodes/confluent lymph nodes ''or'' a tumour mass. | |||
# The presence/absence of extranodal extension. | |||
#* Tumour grows into the surrounding fat ''or'' extends beyond the contour of the lymph node in association with [[desmoplasia]]. | |||
Note: | |||
*‡ Large size is considered significant at some anatomical [[site]]s, e.g. pharynx. It may change the N stage. | |||
===Number of lymph nodes=== | |||
*The number of lymph nodes is important for [[staging]], as a small number may lead to stage migration (Will Rogers phenomenon);<ref name=pmid24744586>{{Cite journal | last1 = Deng | first1 = JY. | last2 = Liang | first2 = H. | title = Clinical significance of lymph node metastasis in gastric cancer. | journal = World J Gastroenterol | volume = 20 | issue = 14 | pages = 3967-75 | month = Apr | year = 2014 | doi = 10.3748/wjg.v20.i14.3967 | PMID = 24744586 }}</ref> thus, the number of lymph nodes is often used as a [[quality]] measure. | |||
Selected cancers and standard (minimum number of lymph nodes): | |||
*Stomach cancer - 16 lymph nodes.<ref name=pmid24744586/> | |||
*Colorectal cancer - 12 lymph nodes. | |||
*Esophageal cancer - no minimum as per UICC/AJCC staging - based on Li ''et al.''<ref name=pmid23124992>{{Cite journal | last1 = Li | first1 = Q. | last2 = Wu | first2 = SG. | last3 = Gao | first3 = JM. | last4 = Xu | first4 = JJ. | last5 = Hu | first5 = LY. | last6 = Xu | first6 = T. | title = Impact of esophageal cancer staging on overall survival and disease-free survival based on the 2010 AJCC classification by lymph nodes. | journal = J Radiat Res | volume = 54 | issue = 2 | pages = 307-14 | month = Mar | year = 2013 | doi = 10.1093/jrr/rrs096 | PMID = 23124992 }}</ref> - several studies give different numbers (18 lymph nodes Greenstein ''et al.'',<ref name=pmid18224663>{{Cite journal | last1 = Greenstein | first1 = AJ. | last2 = Litle | first2 = VR. | last3 = Swanson | first3 = SJ. | last4 = Divino | first4 = CM. | last5 = Packer | first5 = S. | last6 = Wisnivesky | first6 = JP. | title = Effect of the number of lymph nodes sampled on postoperative survival of lymph node-negative esophageal cancer. | journal = Cancer | volume = 112 | issue = 6 | pages = 1239-46 | month = Mar | year = 2008 | doi = 10.1002/cncr.23309 | PMID = 18224663 }}</ref> 23 lymph nodes Peyre ''et al.''<ref name=pmid18936567>{{Cite journal | last1 = Peyre | first1 = CG. | last2 = Hagen | first2 = JA. | last3 = DeMeester | first3 = SR. | last4 = Altorki | first4 = NK. | last5 = Ancona | first5 = E. | last6 = Griffin | first6 = SM. | last7 = Hölscher | first7 = A. | last8 = Lerut | first8 = T. | last9 = Law | first9 = S. | title = The number of lymph nodes removed predicts survival in esophageal cancer: an international study on the impact of extent of surgical resection. | journal = Ann Surg | volume = 248 | issue = 4 | pages = 549-56 | month = Oct | year = 2008 | doi = 10.1097/SLA.0b013e318188c474 | PMID = 18936567 }}</ref>). | |||
====Counting lymph nodes==== | |||
The number of lymph nodes is usually based on: | |||
#Number of possible lymph nodes at the time of gross or [[cut-up]]. | |||
#Number of tissue fragments with definite lymph node. | |||
#*Lymph node = lymphoid tissue + capsule. | |||
#Whether tumour nodules without lymphoid tissue are classified as lymph nodes or [[tumour deposits]] - dependent somewhat on the anatomical [[site]]. | |||
Notes: | |||
*Generally, the number of lymph nodes in a block should not exceed the number of possible lymph nodes seen at gross. | |||
==Sign out== | |||
<pre> | |||
Lymph Nodes, Left Axilla, Radical Lymph Node Dissection: | |||
- Three lymph nodes with METASTATIC MALIGNANT MELANOMA | |||
of twenty lymph nodes (3/20). | |||
-- Largest focus of melanoma: 2.1 cm. | |||
-- Extranodal extension: ABSENT. | |||
- Benign skin. | |||
</pre> | |||
===Matted lymph nodes - comment=== | |||
<pre> | |||
Comment: | |||
The size of the largest lymph node metastasis is indeterminate, as the large tumour mass (6.5 cm maximal dimension) consists of matted nodes. Clinical and radiologic correlation is suggested. | |||
</pre> | |||
==See also== | ==See also== | ||
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*[[Cancer]]. | *[[Cancer]]. | ||
*[[Cancer staging]]. | *[[Cancer staging]]. | ||
*[[Lateral aberrant thyroid tissue]]. | |||
*[[Sentinel lymph node]]. | |||
*[[Extranodal extension]]. | |||
==References== | ==References== | ||
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[[Category:Lymph node pathology]] | [[Category:Lymph node pathology]] | ||
[[Category:Cancer staging]] | |||