Metastasis to the lymph nodes

In medical practice, the following routes of spread of malignant neoplasms are known:

• lymphogenous;
• hematogenous;
• mixed.

Lymphogenous metastasis is characterized by the penetration of tumor cells into a lymphatic vessel and then through the lymph flow to nearby or distant lymph nodes. Epithelial cancers (e.g. melanoma) are more often spread by the lymphogenous route. Tumor processes in internal organs: stomach, colon, larynx, uterus – are thus capable of creating metastases in the lymph nodes.

The hematogenous route includes the spread of tumor processes via the blood flow from the affected organ to the healthy one. Moreover, the lymphogenous route leads to regional (near the affected organ) metastases, and the hematogenous route promotes the spread of affected cells to distant organs. Lymphogenous metastasis has been well studied, which allows us to recognize most tumors at the stages of their origin and provide timely medical care.

In the neck area, the lymph nodes form a collector that accumulates lymph coming from the organs of the head, sternum, upper limbs, as well as from the peritoneum, trunk and legs. Doctors have established a pattern between the path of metastasis and the course of the lymphatic bed. In this regard, metastases in the lymph nodes located at the level of the chin and under the jaw are detected in tumor processes of the lower lip, anterior part of the tongue and oral cavity, upper jaw. Metastases of malignant neoplasms of the posterior parts of the tongue, floor of the mouth, thyroid gland, pharynx and larynx areas spread to the lymph nodes of the neck area, namely to the area of the carotid vascular-nerve bundle. Metastases in the lymph nodes of the area above the collarbone (outside the sternocleidomastoid muscle) often develop in breast or lung cancer. Malignant neoplasms of the peritoneum metastasize to the lymph nodes above the collarbone (inside the sternocleidomastoid muscle). The inguinal lymph nodes contain metastases in cancer of the lower extremities, sacrum and buttocks, and external genitalia.

Metastasis is understood as a secondary pathological lesion of cells that grows in the tissues of the human body from the site of the primary disease.

The function of the lymphatic system is to maintain metabolic processes, as well as cleansing (filtering) at the cellular level, as a supplement to the cardiovascular system. Lymph nodes are grouped according to their location in the human body and serve to produce lymphocytes - immune cells that fight harmful foreign microorganisms that enter the body.

Reasons influencing the development of metastases:

• age factor (metastases appear more often at an older age);
• development of concomitant diseases (chronic, weakening the body's defenses);
• the size and location of the initial focus of the malignant neoplasm (the presence of a large tumor increases the possibility of metastases);
• the spread of tumor cells (the growth of malignant tumors into the wall of an organ is most dangerous and more often causes metastasis than neoplasms growing into the lumen of the organ).

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Symptoms of Metastases in the Lymph Nodes

The International Classification of Malignant Tumors defines metastases in lymph nodes with the Latin letter N. The stage of the disease is described by the number of metastases, not the size of the affected tissue. N-0 indicates the absence of metastases, N-1 means a single metastasis of nodes close to the neoplasm, N-2 - a large number of metastases of regional lymph nodes. The designation N-3 means the simultaneous defeat of close and distant lymph nodes, which is inherent in the fourth stage of the tumor process.

Primary symptoms of metastases in lymph nodes are a significant increase in size, which is determined by visual examination and palpation. Most often, changes are differentiated in the cervical, supraclavicular, axillary and inguinal lymph nodes, which have a soft-elastic structure and are painless.

The growth of lymph nodes in size is often accompanied by weight loss, and the patient's condition is characterized by general weakness and anemia. Warning signs also include fever, frequent colds, neuroses, liver enlargement, migraines, and skin redness. The appearance of metastases indicates the progression of a malignant neoplasm. If you independently detect lymphadenopathy (enlargement of a lymph node), you should consult a specialist and not self-medicate.

It is important to note that often metastases in the lymph nodes are recognized earlier than the source of the problem – a malignant tumor.

Metastases in the lymph nodes of the neck

Tumors of the neck area are combined into a small, but quite diverse in clinical manifestations group. Neoplasms are observed both in the organ itself (larynx, pharynx, esophagus, thyroid gland, etc.), and in soft tissues of the neck not related to the organ.

The main lymphatic collector is located in the neck, and the formation of metastases in its nodes occurs due to damage to the lymphoreticular tissue, as a result of lymphogranulomatosis, hematosarcoma, lymphosarcoma, metastasis of malignant tumors (Virchow's metastasis).

Metastases in the lymph nodes of the neck lead to changes in the shape, size, structure and echogenicity of the nodes. Lymphogranulomatosis most often (60% of cases) occurs with metastases to the nodes of the neck. In this case, pathological processes can be observed in the axillary, inguinal, mediastinal, and retroperitoneal lymph nodes. There are cases of simultaneous damage to the thyroid gland and lymph nodes of the neck, which is clinically similar to thyroid cancer with metastasis to the cervical nodes.

Lymphogranulomatosis most often affects 20-30-year-old patients or people over 60 years old (usually males). The primary manifestation of the disease is an enlarged lymph node or group of nodes with an elastic consistency. Then, fusion of lymph nodes of varying density and size into a single conglomerate is noted. Patients complain of: general weakness, sweating, itching of the skin, fever and lack of appetite. The clinical picture varies depending on the individual course and stage of the disease, so the described symptoms may be vague or completely absent.

Metastases in lymph nodes are often detected in lymphosarcoma. The nodes are enlarged and have a dense structure, and the rate of internal changes in the affected conglomerate can cause compression of adjacent organs in just a couple of weeks. During examination, the patient may be found to have growth in the inguinal and axillary nodes.

Along with malignant tumors of the head and neck (tumor processes of the tongue, salivary glands, thyroid gland, larynx), metastases in the lymph nodes of the neck are detected in breast cancer, lung cancer or abdominal organ damage, which indicates the fourth stage of the disease.

About 30% of primary tumor processes remain undifferentiated. In order to examine a patient for cancerous formations of the neck, diagnostics under anesthesia are used. Thyroid cancer can take a latent form, manifesting itself only by metastases to the cervical lymph nodes. The palpation method and ultrasound do not always reveal dense neoplasms, therefore, puncture and excisional biopsy are widely used.

Metastases to the cervical lymph nodes

Damage to the cervical lymph nodes - metastases to the cervical lymph nodes are characterized by general symptoms:

• significant growth of nodes;
• change in shape (uneven, unclear contours);
• anechoic areas are noted.

An ultrasound examination reveals a violation of the ratio of the transverse and longitudinal sizes of the node or a difference (less than 1.5) between the long and short axes. In other words, if the lymph node acquires a round shape, then there is a high probability of its damage.

Cancerous processes in the lymph nodes increase the fluid content in them. Ultrasound scanning shows a blurred outline of the node. The capsule of the lymph node is still recognizable at an early stage of the disease. As malignant cells grow, the outlines are erased, the tumor grows into nearby tissues, and several affected lymph nodes may also fuse into a single conglomerate.

Metastases to the cervical lymph nodes are formed from lymphomas, cancers of the lungs, gastrointestinal tract, prostate or mammary gland. Most often, when metastases are detected in the lymph nodes of the neck, the localization of the primary tumor is the upper respiratory or digestive system.

Enlargement of the lymph nodes in the neck area occurs with the following oncological diseases:

• cancerous processes of the larynx, tongue, oral mucosa;
• thyroid gland damage;
• lymphogranulomatosis (Hodgkin's lymphoma).

Diagnosis is made by puncture or excisional biopsy. Treatment methods are radiation and surgical removal of the affected node.

Metastases in the lymph nodes in the groin

The lymph nodes of the inguinal zone retain and destroy pathogenic microorganisms that penetrate the lymphatic system from the pelvic organs (usually the genital area) and lower extremities. Primary malignant neoplasms or lymphomas can form in the inguinal lymph nodes themselves.

The inguinal lymph nodes are divided into deep and superficial. The latter are located in the area of the so-called "femoral triangle" and on the surface of the broad fascia of the thigh, their number varies from four to twenty. The inguinal nodes communicate with the tissues of the lower extremities, the perineal area, the anterior wall of the peritoneum below the navel. The number of deep lymph nodes in the groin ranges from one to seven. They are located under the surface of the broad fascia of the thigh. These nodes are interconnected with the lymphatic vessels located on the surface of the inguinal region and deep in the femoral area.

A painless symptom with a characteristic increase in the size of the nodes may indicate metastases in the lymph nodes in the groin. The growth of inguinal lymph nodes occurs with the following oncological diseases:

• lumbar melanoma or skin cancer of the lower extremities;
• malignant neoplasm of the rectum;
• genital cancer;
• lymphogranulomatosis (Hodgkin's lymphoma).

Cases of inguinal node lesions require a thorough examination of the skin of the legs, as well as organs located in the pelvis and abdominal cavity. For diagnostic purposes, the following are used: computed tomography (CT), colonoscopy, cystoscopy, hysteroscopy, FEGDS.

Metastases to the inguinal lymph nodes

The lymph nodes of the inguinal zone pass lymph coming from the genitals, the lower part of the rectum and the abdominal wall, the lower extremities. By location, the nodes are divided into superficial and deep.

Malignant neoplasms of the legs, sacro-gluteal zone, external genitalia form metastases in the inguinal lymph nodes. The lymph nodes take the form of rounded seals in the inguinal folds. The nodes are tightly fused with nearby tissues and are slightly mobile, which is observed when trying to move them.

Types of cancer that cause swollen lymph nodes in the groin include:

• melanoma or cancerous skin lesion of the legs (lumbar region);
• rectal oncology;
• malignant neoplasms of the genital area;
• Hodgkin's lymphoma (lymphogranulomatosis).

The initial development of lymphogranulomatosis with damage to the lymph nodes in the groin is quite rare (10%). The disease is characterized by weight loss, unexplained rise in temperature, excessive sweating at night.

During the examination, the doctor examines the lymph nodes by palpation, first along and then across the groin fold, using sliding circular movements, and moves to the area of the broad fascia of the thigh.

Metastases to the retroperitoneal lymph nodes

The retroperitoneal space is the abdominal area behind the peritoneal wall, bounded by the peritoneum, back muscles, sacrum, diaphragm, and lateral abdominal walls. The lymphatic system of the retroperitoneal space includes regional lymph nodes, vessels, and large lymph collectors, from which the thoracic lymphatic duct originates.

Localization of malignant neoplasms in the peritoneum area has the following symptoms: increased temperature, cramping pain syndrome in the abdomen (appears in attacks), bowel disorder in the form of diarrhea (less often constipation). Metastases in the retroperitoneal lymph nodes are observed in germ cell tumor processes in the testicle, kidney, cancer of the gastrointestinal tract. Enlargement of the retroperitoneal lymph nodes leads to severe back pain due to compression of the nerve roots, sometimes affecting the lumbar muscle. Gastrointestinal symptoms are common, and a sharp decrease in weight is observed.

The condition of the lymph nodes and organs of the retroperitoneal space is assessed based on the results of ultrasound examination, computed tomography and magnetic resonance imaging. Ultrasound scanning shows nodes with metastases as round or oblong, characterized by clear contours and homogeneity of structure. CT method determines metastases in lymph nodes by their round shape, soft tissue structure. Affected lymph nodes of the retroperitoneal cavity have a uniform structure and density, as well as clear contours, and can merge into large conglomerates. In cases where lymph node arrays cover the spine, aorta in the peritoneum and inferior vena cava, intravenous contrast is used for better recognition of tumor processes.

Metastases to paraaortic lymph nodes

The location of the paraaortic lymph nodes is the anterior part of the lumbar spine, along the aorta.

Metastases to para-aortic lymph nodes are observed in patients with cancer of the genital area, kidneys and adrenal glands, and gastrointestinal tract. For example, in malignant neoplasms of the stomach, affected para-aortic lymph nodes are detected in 40% of cases. Tumor processes with metastasis to para-aortic lymph nodes are classified as the third-fourth stage of the disease. Moreover, the frequency of damage to para-aortic nodes of the third degree of oncology reaches 41%, and of the fourth degree - 67%. It should be noted that, for example, metastases to para-aortic lymph nodes of ovarian cancer are resistant to chemotherapy.

The development of pancreatic cancer has its own stages of lymphogenous metastasis:

• stage one – metastases reach the head of the pancreas;
• the second stage – the retropyloric and hepatoduodenal lymph nodes are affected;
• the third stage – penetration of metastases into the celiac and superior mesenteric nodes;
• stage four – metastasis to the para-aortic lymph nodes.

Doctors note that malignant tumors of the pancreas are characterized by an aggressive course and have a poor prognosis. Cases of fatal outcome from pancreatic cancer occupy 4-5 place among all oncological diseases. High mortality is associated with recurrence of tumor processes in the postoperative period (K-ras mutations in paraaortic lymph nodes).

Metastases in the abdominal lymph nodes

A large number of lymph nodes are located in the abdominal cavity, which act as a barrier to infection and cancer cells. Peritoneal lymph nodes are divided into parietal (concentrated in the lumbar region) and intramural (arranged in rows).

The defeat of the peritoneal lymph nodes is the result of a lymphoproliferative disease (the primary tumor forms in the lymph node itself) or a consequence of metastasis. Lymphogranulomatosis and lymphosarcoma are lymphoproliferative diseases that cause compaction and growth in the size of the node without pain. Metastases in the lymph nodes of the abdominal cavity are detected in a number of cancer diseases, when tumor cells penetrate the lymph nodes from the affected organ with the flow of lymph. Thus, malignant tumors of the peritoneum (for example, the stomach) and pelvis (for example, the ovary) cause the formation of metastases in the peritoneal lymph nodes.

The main criterion confirming the presence of metastasis in the lymph nodes is an increase in the size of the node (up to 10 cm or more). CT and MRI studies of the peritoneal cavity also come to the rescue in order to obtain visualization of anatomical structures.

Melanoma metastases to lymph nodes

Melanoma is a rare malignant tumor that is more common in southern regions. It should be noted that in 70% of cases, melanoma forms on the site of an existing pigmented nevus or birthmark.

The development of melanomas occurs in two phases:

• horizontal – proliferation within the epithelial layer (lasts from 7 to 20 years);
• vertical – ingrowth of layers of the epidermis and subsequent invasion through the basement membrane into the dermis and subcutaneous fat.

The vertical stage is characterized by rapidity and the ability to metastasize. Metastases of melanoma to the lymph nodes are primarily due to the biological characteristics of the tumor. Metastasis by the lymphogenous route occurs in the skin, regional lymph nodes. The affected lymph nodes become dense in consistency and increase in size.

Diagnostic methods include aspiration biopsy of the tumor, surgical biopsy of the lymph nodes, radiography, CT and MRI of the entire body. Removal of melanoma metastases to the lymph nodes is performed by complete excision of the regional lymph collector or removal of the lymph nodes adjacent to the tumor (if the diagnosis is based on a biopsy).

Metastases to the supraclavicular lymph nodes

Metastases to the supraclavicular lymph nodes occur in:

• undifferentiated cancer (the primary tumor is located in the neck or head area);
• tumor processes in the lungs;
• cancer of the gastrointestinal tract.

The detection of Virchow's nodes (Troisier's nodes) in the left supraclavicular region indicates the presence of a malignant neoplasm of the abdominal cavity. The defeat of the supraclavicular nodes on the right side makes it possible to suspect lung or prostate cancer. Metastases in the lymph nodes of the subclavian triangle may indicate lung or breast cancer.

One of the most common tumors, stomach cancer, is diagnosed by identifying "Virchow's metastases" (usually in the left supraclavicular lymph nodes). Malignant ovarian cells sometimes penetrate through the lymphatic vessels of the diaphragm and lumbar lymph nodes, which causes lymphogenous metastasis above the diaphragm - metastasis to the supraclavicular lymph nodes.

Enlargement of the supraclavicular nodes is an alarming symptom, most often indicating tumor processes in the sternum or abdominal area. In 90% of cases, such symptoms occur in patients over 40 years of age, while younger patients account for 25% of cases. The defeat of the lymph nodes on the right corresponds to a tumor of the mediastinum, lungs, esophagus. An increase in the size of the nodes on the left in the supraclavicular zone indicates cancer of the ovaries, testicles, prostate gland, bladder, kidneys, stomach, pancreas.

Metastases in the mediastinal lymph nodes

The mediastinum is a section of the thoracic cavity, which is limited in front by the sternum, costal cartilages and retrosternal fascia, behind by the anterior zone of the thoracic spine, necks of the ribs, prevertebral fascia, and on the sides by the sheets of the mediastinal pleura. The area of the mediastinum is marked below by the diaphragm, and above by a conventional horizontal line. The thoracic lymph duct, retrosternal lymph nodes, and anterior mediastinal lymph nodes fall into the mediastinum area.

In addition to lung cancer, metastases in the mediastinal lymph nodes are formed by tumor processes of the thyroid gland and esophagus, renal hypernephroma, testicular cancer (seminoma), pigmented malignant formation (melanosarcoma), uterine cancer (chorionepithelioma) and other neoplasms. Damage to the mediastinal lymph nodes ranks third in the development of malignant processes after lymphogranulomatosis and lymphosarcoma. Cancer cells cover all groups of mediastinal lymph nodes, the paratracheal and bifurcation ones are most often affected.

Small primary tumors often produce extensive metastases in the lymph nodes of the mediastinum. A striking example of such metastasis is mediastinal lung cancer. The clinical picture describes swelling of the soft tissues of the neck and head, swelling and intertwining of veins in the front of the chest ("caput medusa"), dysphagia, hoarseness, stridor-type breathing are noted. X-ray in most cases reveals the predominance of metastases in the posterior mediastinum.

In breast cancer, the cluster of affected lymph nodes is localized in the anterior mediastinum. Mammaryography (contrast examination of the veins of the mammary glands) is used for clarification. Interruption of the venous bed, compression, and the presence of marginal defects serve as evidence of the presence of metastases that require removal or treatment by radiation.

Treatment of metastases in the lymph nodes

The main rule of oncology is to study the condition of the lymph nodes, both in the tumor area itself and in the remote ones. This allows for the most accurate diagnosis and the most effective treatment program.

Lying on the surface lymph nodes that are accessible for external examination are examined by biopsy and puncture methods. The condition of deeper lymph nodes is examined using ultrasound, CT, MRI. The most accurate method for detecting metastases in lymph nodes is considered to be positron emission tomography (PET), thanks to which it is possible to recognize the origin of malignant cells in the most difficult to access and slightly enlarged lymph nodes.

Treatment of metastases in lymph nodes is based on the same principles as the fight against primary cancer - surgical intervention, chemotherapy, radiotherapy. A combination of these methods is used individually depending on the stage of the disease (malignancy), the degree of damage to the lymphatic system.

Removal of the primary tumor is usually accompanied by the removal of all its regional lymph nodes (lymphadenectomy). Lymph nodes with affected cells located further from the cancerous tumor are treated with radiotherapy methods or a bloodless radiosurgery operation is performed using a cyber knife.

Timely diagnosis and treatment of metastases in the lymph nodes allows us to block the growth of tumor cells and prolong the patient’s life.

Prognosis of lymph node metastases

Factors influencing patient survival are conventionally divided into related ones:

• with a cancerous tumor;
• with the patient's body;
• with the treatment provided.

The most important prognostic factor is the involvement of regional lymph nodes without the presence of distant metastases. For example, the prognosis for metastases in the lymph nodes of the neck of "non-squamous cell carcinoma" remains disappointing - 10-25 months. The survival of patients with stomach cancer depends on the possibility of radical surgery. Only a small proportion of non-operated or non-radically operated patients reach the five-year mark. The average life expectancy is 3-11 months, and this figure is influenced by the presence or absence of distant metastases.

The presence of metastases in the lymph nodes in breast cancer significantly worsens the prognosis. As a rule, relapses and metastases are observed in the first five years after surgery in 35-65% of women, which indicates the activation of the process. Life expectancy after treatment is 12-24 months.

Patients with melanoma of the head, neck, and trunk have a more unfavorable prognosis than those with melanoma of the extremities, since the risk of metastasis to the lymph nodes of these tumors is 35% higher.

The criterion for successful treatment can be the five-year survival rate. The prognosis after tumor excision is determined not only by the presence or absence of metastases in regional lymph nodes, but also by the number of affected nodes.

If metastases are detected in lymph nodes without a primary tumor focus, the prognosis may be favorable. The outcome of special treatment based on the five-year survival rate for isolated metastasis to lymph nodes is: in case of axillary lymph node involvement - more than 64%, inguinal - over 63%, cervical - 48%.