Lymph node biopsy

In order to understand the causes of enlarged lymph nodes, it is necessary to conduct a number of diagnostic tests. The most informative and widespread method of diagnosis is currently considered a lymph node biopsy. This is a procedure in which a piece of biomaterial is taken out for further study.

In the human body, lymph nodes play the role of a kind of filtering stations that attract and neutralize pathogens. When pathogens get into the node, its increase occurs, which is also characteristic of inflammatory reactions or malignant processes. To understand exactly what pathology occurs in the lymphatic link, and perform such a procedure as a biopsy. [1]

What is the difference between an LP and a lymph node biopsy?

Histological analysis is prescribed for the diagnosis of many pathologies, as it successfully helps to determine the type of disease process, identify its phase, differentiate the tumor, etc. Often it is this study that allows to accurately establish the diagnosis and prescribe the correct treatment.

Lymph nodes represent the main links of the body's immune system. They are "warehouses" of specific tissue that ensures the maturation of T and B-lymphocytes, forms plasma cells that produce antibodies, and cleanses the lymph. Bacteria and foreign particles with the flow of lymph are filtered in the lymph nodes. In their excess, the body's defense mechanism is activated, immunoglobulins are produced, and cellular memory is formed. All these reactions are an integral part of immunity, elimination of infectious and malignant agents.

Such a defense in the norm always works, and the person himself may not even suspect that there are such reactions in his body. Only with a massive attack or a drop in immunity, the nodes can increase, and pain may appear. However, in most patients, everything goes back to normal after a few days.

If several groups of lymph nodes are enlarged at once, the patient's well-being deteriorates sharply, fever rises, other painful signs appear, then in such a situation a diagnosis is required, including biopsy or puncture of the lymph node. Often these concepts are taken as synonyms, but this is not quite so.

The term "puncture" is usually used when referring to a puncture that involves the collection of a fluid secretion with cells for further cytologic examination. A biopsy is referred to when a large portion of biomaterial is removed for subsequent histologic analysis.

A puncture is a minimally invasive fine-needle procedure that is virtually painless. A lymph node biopsy requires a more traumatic intervention, often using a scalpel. However, there is also the concept of a "puncture biopsy," in which the node is pierced with a thicker needle-like device that allows the necessary amount of tissue to be sampled.

Indications for the procedure

When diagnosing lymphoproliferative and malignant pathologies, it is important not only to confirm the diagnosis morphologically, but also to detail it by cytology and histology. Such information can be obtained by puncture and biopsy of the lymph node.

Puncture is used as an indicative diagnostic manipulation. To determine lymphoproliferative pathology, puncture is not suitable: a biopsy (either excisional or puncture) with further cytologic and histologic examination of the biopsy specimen is required.

Indications for puncture may include:

• Enlarged single lymph node, without formed conglomerates and without signs of lymphoproliferative pathology;
• Ultrasound signs of a fluid mass;
• The need to withdraw biomaterial for ancillary examination after a biopsy has been performed.

A lymph node biopsy is a surgical procedure performed using local or general anesthesia. As a result of the procedure, a particle of the lymph node, or the entire node, is obtained for further examination. Microscopic analysis is the key to accurate and correct diagnosis.

The basic indications for biopsy are:

• High risks of tumorigenesis according to clinical information;
• Lymphadenopathy of unclear origin (all diagnostic methods involved did not help in making the diagnosis);
• Lack of effectiveness of the therapy performed.

It is impossible to say exactly at what size a lymph node biopsy is mandatory. However, most specialists believe that a lymph node that is larger than 30 mm and that is not associated with an infectious process requires a biopsy.

Sometimes a single biopsy is not enough: the patient is scheduled for repeat procedures. This is possible if multiple histologic changes were found in a previous biopsy:

• Lymph node necrosis;
• Sinus histiocytosis;
• Sclerosis;
• Paracortical response with the presence of a large number of macrophages and plasma cells.

Preparation

The preparatory stage before lymph node biopsy may include consultation with a general practitioner, surgeon, endocrinologist, anesthesiologist, oncologist and hematologist. It is obligatory to perform a general and biochemical blood test, a study of the blood coagulation system.

Ultrasound examination is prescribed in order to clarify the location of the pathologic focus.

The physician has a discussion with the patient beforehand:

• Clarifies allergy status;
• Gets information about the medications you take;
• In women, it clarifies the phase of the menstrual cycle and excludes the possibility of pregnancy.

If the patient is taking blood thinners, they are discontinued 7-10 days before the biopsy.

If the procedure will be performed using general anesthesia, the preparation is more thorough:

• Food and water intake is prohibited on the day of the intervention;
• The dinner the night before should be as light as possible, with a predominantly plant-based, easily digestible diet;
• 2-3 days before the intervention should not take alcohol, it is undesirable to smoke;
• The morning before going for the biopsy procedure, the patient should take a shower without the use of lotions or body creams.

Technique of the lymph node biopsy

Biopsies of shallow lymph nodes are usually short in duration - for many patients, the procedure is completed in about 20 minutes. Local anesthesia is usually used, although the puncture is generally considered painless. If ultrasound control is used, then the doctor with the help of an ultrasound sensor specifies the location of the painful structure, puts a special mark, which is reflected on the monitor. The skin in the puncture zone is treated with an antiseptic and then an anesthetic, or make an injection of an anesthetic drug. The patient lies on the couch horizontally, or is in a sitting position. If the biopsy is performed in the neck area, it is fixed in a special way, and the patient is explained about the need to temporarily not make swallowing movements. The patient must remain completely immobile during the biopsy.

After taking the required amount of biological material, the puncture area is treated with antiseptic. It may be recommended to apply a cold dry compress for half an hour.

There is no need for a prolonged stay in the clinic or for the patient to be hospitalized: he or she can go home on his or her own if there is no other reason to keep him or her there. It is important to avoid physical activity for the first time after the procedure.

If it is necessary to take a biopsy from a deep node, general anesthesia may be required. In such a situation, the patient does not go home after the diagnosis, but stays in the clinic - from several hours to 1-2 days.

Open biopsy requires a special set of tools: in addition to a scalpel, these are clamps, a coagulation device, and suture materials. Such an intervention lasts up to 60 minutes. The doctor chooses the necessary lymph node for biopsy, fixes it with his fingers, then performs a 4-6 cm skin incision. Dissects the subcutaneous fat layer, pulls apart muscle fibers, the network of nerves and vessels. If it is necessary to remove one or more nodes in the course of biopsy, the surgeon preliminarily ligates the vessels, in order to exclude bleeding, lymph flow, as well as the spread of tumor cells (if it is a malignant process). After removing the lymph nodes, the doctor sends them for examination, once again conducts a revision of the wound, sutures the incisions. In some cases, a drainage device is left, which is removed after 24-48 hours. Sutures are removed within a week.

How is a lymph node biopsy performed?

Taking a biopsy in one or another lymph node may have its own peculiarities, which depends on the localization, depth of the structure, as well as the presence of vital organs and large vessels near the damaged link.

• Neck lymph node biopsy may be ordered for otolaryngologic, dental problems - the most common causes of lymphadenopathy. If the lymphadenopathy is of unclear origin, an ultrasound is ordered first, and only then, if necessary, a biopsy. Lymph nodes are enlarged in malignant tumors, because cancer cells penetrate into the lymph vessels that drain the individual area. Subsequently, these cells settle in the filtering nodes as metastases and begin to develop. Often with oncology, the lesion of lymph nodes occurs "in a chain", which is perfectly determined by palpation. Neck biopsy can be performed as a needle puncture with material removal, and surgical access with complete removal of the link for histologic analysis.
• A sentinel lymph node biopsy for melanoma is performed similarly to a biopsy for breast cancer. If there is information about metastasis to distant organs and lymph nodes, biopsy is considered useless. In the absence of metastasis, sentinel node biopsy is justified. It is usually performed after removal of the melanoma itself. It is possible to visualize the lymph node using various radiological methods.
• Axillary lymph node biopsy is performed with the patient sitting in a sitting position, raising the arm upwards and withdrawing it slightly backwards. Most often such a procedure is performed when the breast is affected: lymph flows through the vessels to the nodes located in the axilla on the same side. These lymph nodes form a kind of axillary-node chain. Its lesion plays an important role in planning the treatment regimen for breast pathology. The study is also appropriate in melanoma or squamous cell cancer of the upper extremity, in lymphogranulomatosis.
• Biopsy of inguinal lymph nodes is performed from the position of the patient lying on the couch, with the leg (right or left, depending on the side of the lesion) turned aside. Such a study is most often prescribed when tumor processes are suspected (testicular, external genital, cervical, prostate, bladder, rectum), or if the cause of lymphadenopathy cannot be determined by other methods (for example, in lymphogranulomatosis or HIV infection).
• Biopsy of the supraclavicular lymph node is always caused by suspicion of quite serious pathologies: in many cases, these are tumors - metastases of cancer or lymphoma located in the chest or abdominal cavity. The supraclavicular lymph node on the right side can make itself known with tumor processes of the mediastinum, esophagus, lung. To the lymph node on the left side approaches lymph from intrathoracic organs and the abdominal cavity. Inflammatory diseases can also cause supraclavicular lymphadenopathy, but it happens much less often.
• Mediastinal lymph node biopsy is performed in the area of projection of the upper third of the intrathoracic tracheal section, from the upper edge of the subclavian artery or pulmonary apex to the point of intersection of the upper border of the left brachial vein and the middle tracheal line. The most frequent indications for mediastinal lymph node biopsy are lymphoproliferative neoplasms, tuberculosis, sarcoidosis.
• Lymph node biopsy in the lung is a common procedure in cancer, tuberculosis, sarcoidosis. Often lymphadenopathy becomes the only sign of pathology, since many lung diseases are asymptomatic. In any case, before establishing a definitive diagnosis, the doctor must perform a biopsy and obtain histologic information.
• Biopsy of abdominal lymph nodes is prescribed in case of suspected tumor processes in the gastrointestinal tract, female and male reproductive organs, urinary system. Often enlarged abdominal lymph nodes are noted in hepatosplenomegaly. Biopsy is done for both basic and differential diagnosis. A large number of lymph nodes of the abdominal cavity are located wall-to-wall along the course of the peritoneum, along the vessels, in the mesentery and along the intestine, at the omentum. Their enlargement is possible when the stomach, liver, intestines, pancreas, uterus, appendages, prostate gland, bladder are affected.
• A submandibular lymph node biopsy may be ordered in pathologies of the teeth, gums, cheeks, laryngeal region and pharynx, if the cause of lymphadenopathy cannot be detected, as well as in suspected metastases of a cancerous process or lymphoma.
• Biopsy for lymph node cancer is performed in the absence of metastases to distant organs and lymph nodes. Otherwise, the procedure is considered pointless for the patient. If there is no distant metastasis, the first lymph node in the chain, the "sentinel" lymph node, is examined first of all.
• A retroperitoneal lymph node biopsy is appropriate in malignant processes of the male and female genitalia. Approximately 30% of patients already in the first stage of cancer have microscopic metastases in the lymph nodes that cannot be detected by CT or markers. Biopsies are usually taken from the side where the primary tumor site was located. The procedure is usually performed as part of a retroperitoneal lymphadenectomy.
• Biopsy of intrathoracic lymph nodes is a mandatory examination when lung, esophageal, thymus, breast, lymphoma and lymphogranulomatosis cancer is suspected. Metastases from the abdomen, pelvis, retroperitoneum (kidneys, adrenal glands) may also spread to the mediastinal nodes in advanced stages.
• Paratracheal lymph node biopsy is often performed in patients with cancerous lesions in the lung. Paratracheal lymph nodes are located between the upper mediastinal and tracheobronchial nodes. In the absence of a primary tumor on the same side, they are defined as ipsilateral, and in the absence of a primary tumor, as contralateral.

Lymphatic fluid flows through the corresponding vessels. If cancer cells get into it, they end up first in the first lymph node of the chain. This first node is called the sentinel or signaling node. If no cancer cells are found in the sentinel lymph node, the subsequent nodes should, in theory, be healthy.

Types of biopsies

There are several types of lymph node biopsy, depending on the technique of biomaterial extraction. Some types of procedures are performed in stages: first, a needle puncture is performed, and then an open intervention is performed if the puncture was insufficient for diagnosis. An open biopsy is mandatory if the cytology result is uncertain, doubtful, or approximate.

• An open lymph node biopsy is the most complex and invasive option for this type of diagnosis. During the procedure, a scalpel is used, and the entire node is taken for examination, not just a part of it. Such an intervention is often the only correct one when malignant processes are suspected.
• Percutaneous lymph node biopsy is a relatively gentle and painless procedure that does not cause any discomfort to patients. In the course of diagnostics, a mandrel, which plays the role of a stylet, is used. With the help of a mandrel, the necessary amount of biomaterial is cut off and captured. Puncture biopsy involves the use of local anesthesia, does not require the patient to be hospitalized.
• Excisional lymph node biopsy is a term that is often applied to an open biopsy using general anesthesia. It involves removing the affected node through an incision.
• Trepan lymph node biopsy involves the use of a special large needle with notches that allow you to remove a piece of tissue of the required size.
• Fine-needle biopsy of a lymph node is called aspiration biopsy: it involves the use of a thin, hollow needle device. The node is usually palpated and punctured: if this is not possible, ultrasound is used. As a rule, fine-needle biopsy is prescribed when it is necessary to examine submandibular or supraclavicular lymph nodes, when metastases of lymphoid structures are detected.

Biopsy of lymph nodes under ultrasound control

The most acceptable technique for lymph node biopsy is currently considered by experts to be the targeted puncture procedure, or so-called "biopsy under visual ultrasound control".

This is the process of biomaterial sample extraction, which is performed under ultrasound supervision: as a result, the positioning and insertion of the puncture needle is more precise and safer. This is extremely important for the doctor, because often a suspicious lymph node is located in deep tissue near vital organs or is small in size, which makes the procedure much more difficult.

Ultrasound monitoring helps to insert the instrument clearly in the right place, without the risk of damaging nearby tissues and organs. As a result, the risk of complications is minimized.

The doctor determines which method is used to visualize the desired area. An additional advantage of the technique is not only safety, but also its low cost: no ultramodern and expensive equipment is needed.

Biopsy with ultrasound is especially recommended if it is necessary to examine not only the affected structure, but also to find out the peculiarities of blood circulation near it. This approach will avoid traumatization of vessels, exclude the escape of blood into the tissues.

Special needles with end sensors are used for the procedure. This simple device helps to clearly monitor the position of the needle and its progress.

The recovery period after such an intervention is faster and more comfortable for the patient. [2]

Contraindications to the procedure

Before referring a patient for a lymph node biopsy, the doctor will prescribe a number of studies and tests that are necessary to exclude contraindications to this procedure. The basic preliminary diagnosis is a general blood test and assessment of the quality of coagulation. Biopsy is not carried out if there is a tendency to bleeding - for example, patients suffering from hemophilia, since vessels may be traumatized during the intervention.

Lymph node biopsy is contraindicated in case of purulent processes in the area of puncture. It is undesirable to perform the procedure in pregnant or lactating women, as well as during menstrual bleeding.

In general, experts distinguish such a list of contraindications:

• Disorders of the blood coagulation system (congenital disorders, acquired, or temporary - that is, associated with taking appropriate blood thinning medications);
• Platelet count below 60,000 per μL;
• Hemoglobin level is less than 90 g/liter;
• INR greater than 1.5;
• Prothrombin time, which is 5 seconds above normal;
• Infectious and inflammatory processes in the area of biopsy;
• Menstrual bleeding in women on the day of the procedure;
• Decompensated chronic pathologies;
• Treatment with non-steroidal anti-inflammatory drugs during the last week.

Normal performance

Microscopic examination of the patient's lymph node biopsy is considered the most important in the diagnostic aspect of oncologic pathologies, helps to assess the quality of drug therapy.

Lymph node histology is a minor surgical intervention, during which a small particle of tissue is taken away for further study. With the help of lymph node biopsy, specialists can study the peculiarities of its structure, detect painful abnormalities, and notice signs of inflammatory reaction.

The lymph node is the basic link of the defense system in the body, which is the connecting element between the lymph vessels. The lymph nodes help to defeat infectious invasion by producing white blood cells, which are specific blood cells. The node catches microbial and viral infection and malignant cells.

Lymph node biopsy helps to detect the presence of atypical cells, determine the specificity of infectious inflammatory process, benign tumors, purulent pathologies. Biopsy is most often performed in the inguinal, axillary, mandibular and behind-the-ear region.

Biopsy is prescribed for patients who need to find out the type of tumor process - especially if malignant pathology is suspected. Often the diagnosis is prescribed to determine infectious diseases.

The results of the lymph node biopsy

After examining the biopsy (material obtained by biopsy of the lymph node) and detecting particles of pathology, specialists begin counting cellular structures and derive a lymphadenogram. For this purpose, an immersion method of microscopic observation is used, which allows to differentiate at least half a thousand cells and calculate their percentage presence.

Lymphadenogram data are essential and valuable in diagnosing the nonspecific form of lymphadenitis.

The norm of lymphadenogram results:

Content of relevant cell types	Percentage
Lymphoblasts	0.1 to 0.9
Prolymphocytes	5.3 to 16.4
Lymphocytes	67.8 to 90
Reticular cells	0 to 2.6
Plasmocytes	0 to 5.3
Monocytes	0.2 to 5.8
Mast cells	0 to 0.5
Neutrophilic granulocytes	0 to 0.5
Eosinophilic granulocytes.	0 to 0.3
Basophilic granulocytes	0 to 0.2

The biological material taken during a lymph node biopsy contains predominantly mature lymphocytes with prolymphocytes. Their total number can be from 95 to 98% of all cellular structures.

Reactive lymphadenitis is manifested by an increase in the number of reticular cells, detection of macrophages and immunoblasts.

In acute lymphadenitis, there is an increase in the number of macrophages and neutrophils.

Complications after the procedure

Diagnostic lymph node biopsy usually goes without any difficulties. Only in some cases complications develop:

• Bleeding on the background of accidental trauma to the vessels when performing biopsy;
• Lymph drainage from the wound;
• Paresthesias, sensory disturbance of the intervention area;
• Infection due to the entry of an infectious agent - in particular during the procedure;
• Trophic disorders associated with mechanical trauma to nerve structures.

Some patients may experience impaired consciousness, dizziness, weakness. The condition should normalize within 1-2 days.

Dangerous symptoms that require urgent medical intervention:

• Elevated temperature, fever;
• The appearance of severe, throbbing, increasing pain in the area of the lymph node biopsy;
• The discharge of blood or pus from the wound;
• Redness, swelling of the biopsy site.

Consequences after the procedure

Lymph node biopsy is not performed if the patient has any contraindications. Otherwise, it is possible to develop adverse effects. For example, if a person suffers from disorders of the blood coagulation system, even a conventional puncture biopsy may end up with bleeding.

To avoid post-procedural problems, lymph node biopsy should be performed by a specialist, in compliance with all the required conditions, rules of asepsis and antisepsis.

In some cases, it is possible for these nuisances to occur:

• Infection;
• Bleeding wounds;
• Nerve damage.

Nevertheless, the percentage of adverse effects is relatively low. However, the information obtained during the biopsy is of great value to the doctor, allowing him to make a correct diagnosis and prescribe an appropriate and effective treatment.

Care after the procedure

Usually the procedure of lymph node biopsy is not complicated and is quite well tolerated by patients. After removal of the biomaterial by aspiration or puncture, only the puncture site remains on the skin, which is treated with antiseptic solution and sealed with a plaster. If an open biopsy was performed, then the wound is sutured and bandaged. The stitches are removed within a week.

The wound after a lymph node biopsy should not be wet. It is necessary to treat with antiseptic solutions to prevent infection. If suddenly the body temperature rises, the site of intervention swells, bleeds or bothers in any other way, it is necessary to urgently visit the doctor.

Occurrence of brief, mild pain after the procedure is allowed.

What you should not do after a lymph node biopsy:

• Take a bath;
• Swimming in swimming pools, open water bodies;
• To go to a sauna or bathhouse;
• Practicing vigorous physical activity.

Such restrictions apply for about 2 weeks after the procedure, which depends on the type and extent of the intervention such as a lymph node biopsy.