Metastases in the lymph nodes

In medical practice, the following ways of spreading malignant neoplasms are known: 

• lymphogenous; 
• hematogenous; 
• mixed.

Lymphogenous metastasis is characterized by the penetration of tumor cells into the lymphatic vessel and then by lymph flow to nearby or distant lymph nodes. Lymphogenically, epithelial cancers are more common (eg, melanoma). Tumor processes in internal organs: the stomach, colon, larynx, uterus - are thus able to create metastases in the lymph nodes.

To the hematogenous path is the spread of tumor processes with the help of blood flow from the affected organ to a healthy one. Moreover, the lymphogenous pathway leads to regional (nearby to the affected organ) metastases, and hematogenous promotes the spread of the affected cells to distant organs. Lymphogenous metastasis is well studied, which makes it possible to recognize most of the tumors at the stages of initiation and provide timely medical care.

In the neck area, the lymph nodes form a collector, accumulating lymph coming from the organs of the head, sternum, upper limbs, as well as from the peritoneum, trunk and legs. Physicians established a regularity between the way of metastasis and the course of the lymphatic channel. In connection with this, metastases in the lymph nodes located at the level of the chin and under the jaw are revealed in the tumor processes of the lower lip, anterior part of the tongue and mouth, upper jaw. Metastases of malignant tumors of the posterior parts of the tongue, the bottom of the mouth, the thyroid gland, the pharyngeal and laryngeal zones spread to the lymph nodes of the neck zone, namely into the region of the sowing neurovascular bundle. Metastases in the lymph nodes of the area above the clavicle (outside the sternocleidomastoid muscle) often develop in breast or lung cancer. Malignant neoplasms of the peritoneal region metastasize to the lymph nodes above the clavicle (inside the sternocleidomastoid muscle). Inguinal lymph nodes contain metastases in cancer of the lower extremities, zones of the sacrum and buttocks, as well as external genital organs.

By metastasis is meant a secondary pathological lesion of cells that grows in the tissues of the human body from the focus of a primary disease.

Function of the lymphatic system - maintenance of metabolic processes, as well as purifying (filtering) at the cellular level, as an addition to the cardiovascular system. Lymph nodes are grouped in accordance with localization in the human body and serve to produce lymphocytes - immune cells that fight with harmful foreign microorganisms that enter the body.

Causes that affect the development of metastases: 

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

[1], [2], [3], [4]

Symptoms of metastases in the lymph nodes

The International Classification of Malignant Tumors determines the metastases in the lymph nodes by 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 indicates a single metastasis of the nodes adjacent to the neoplasm, N-2 - a large number of metastases of regional lymph nodes. The designation N-3 means simultaneous damage to close and distant lymph nodes, which is inherent in the fourth stage of the tumor process.

Primary symptoms of metastases in the lymph nodes - a significant increase in size, which is determined by visual examination and palpation. Most often differentiate the changes in 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, anemia. To the warning signs include temperature, frequent colds, neuroses, liver enlargement, migraine, redness of the skin. The appearance of metastases indicates the progression of malignant neoplasm. If you independently detect lymphadenopathy (enlargement of the lymph node), you should consult a specialist without self-medication.

It is important to note that often metastases in 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 region are combined into a small, but quite diverse in clinical manifestations group. Neoplasms are observed, both in the organ (larynx, pharynx, esophagus, thyroid gland, etc.), and in the soft tissues of the neck not belonging to the organ.

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

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

Lymphogranulomatosis is more likely to affect 20-30-year-old patients or persons over 60 years (more often male). The primary manifestation of the disease is an increase in the lymph node or a group of nodes with an elastic consistency. Further, splicing of lymph nodes of different density and size into a single conglomerate is noted. Patients complain: general weakness, sweating, itching of the skin, temperature and lack of appetite. The clinical picture varies depending on the individual course and stage of the disease, therefore the described symptomatology can be blurred or completely absent.

Often metastases in the lymph nodes are detected with lymphosarcoma. The nodes are enlarged and have a dense structure, and the rate of internal changes of the affected conglomerate is able to cause a compression of adjacent organs within a couple of weeks. During the examination, the patient can detect the growth of inguinal and axillary nodes.

Along with malignant formations of the head and neck (tumoral processes of the tongue, salivary glands, thyroid gland, larynx) metastases in the lymph nodes of the neck are revealed in breast cancer, lung or abdominal cavity, indicating the fourth stage of the disease.

About 30% of the situations of primary tumor processes remain non-differentiable. Diagnosis with the use of anesthesia is used to examine the patient for the presence of cancerous neck formations. Cancer of the thyroid gland can take a latent form, manifesting itself only metastases in the cervical lymph nodes. The method of palpation and ultrasound does not always reveal dense neoplasms, therefore, puncture biopsy is widely used.

Metastases in the cervical lymph nodes

The defeat of cervical lymph nodes - metastases in the cervical lymph nodes are characterized by common symptoms: 

• significant growth of nodes; 
• change in shape (contours uneven, fuzzy); 
• Anechogenous fate is noted.

Ultrasound examination reveals a violation of the ratio of transverse and longitudinal dimensions 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 rounded shape, then the probability of its destruction is high.

Cancerous processes in the lymph nodes increase the fluid content in them. The ultrasound scan shows the blurriness of the site outline. The lymph node capsule is still recognized at an early stage of the disease. As the malignant cells grow larger, the contours are erased, the tumor grows into nearby tissues, and it is also possible to connect several diseased lymph nodes into a single conglomerate.

Metastases in the cervical lymph nodes are formed from lymphomas, lung cancers, digestive tract, prostate or breast cancer. Most often, when metastases are detected in the lymph nodes of the neck, the localization of the primary tumor is the upper parts of the respiratory or digestive system.

The enlargement of the lymph nodes of the neck region occurs with the following oncological diseases: 

• cancer processes of the larynx, tongue, mucous membrane of the mouth; 
• defeat of the thyroid gland; 
• lymphogranulomatosis (Hodgkin's lymphoma).

Diagnosis is carried out by puncture or excision biopsy. The treatment methods are irradiation and surgical removal of the affected node.

Metastases in the lymph nodes in the groin

Lymph nodes in the inguinal zone hold up and destroy pathogenic microorganisms that penetrate the lymphatic system from the pelvic organs (more often the genital sphere) and lower limbs. In the inguinal lymph nodes themselves can form primary malignant neoplasms or lymphomas.

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 wide fascia of the thigh, their number varies from four to twenty pieces. Inguinal nodes communicate with the tissues of the lower extremities, the perineal zone, the anterior wall of the peritoneum below the navel. The number of deep lymph nodes in the groin is from one to seven. Their location is below the surface of the plate of the wide fascia of the thigh. These nodes are interrelated with lymphatic vessels located on the surface of the inguinal region and deep in the femoral zone.

A painless symptom with a characteristic increase in nodes in size 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 in the rectum; 
• cancer of the genital area; 
• lymphogranulomatosis (Hodgkin's lymphoma).

Cases of inguinal nodes require careful examination of the condition of the skin of the legs, as well as organs located in the small pelvis and the cavity of the peritoneum. With the diagnostic purpose apply: a computer tomography (CT), a colonoscopy, a cystoscopy, a hysteroscopy, FEGDS.

Metastases in the inguinal lymph nodes

The lymph nodes of the inguinal zone let lymph come from the genitals, the bottom of the rectum and the abdominal wall, the lower limbs. At the site nodes are divided into superficial and deep.

Malignant neoplasms of legs, sacro-gluteal zone, external genital organs form metastases in the inguinal lymph nodes. Lymph nodes take the form of rounded seals in the area of inguinal folds. The nodes are tightly welded to nearby tissues and are inactive, which is observed when trying to move them.

Types of cancer that cause an increase in lymph nodes in the groin: 

• melanoma or cancer of the skin of the legs (lumbar zone); 
• oncology of the rectum; 
• malignant formations of the genital area; 
• Hodgkin's lymphoma (lymphogranulomatosis).

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

During the examination, the doctor probes the lymph nodes first along and then across the fold of the groin, applying sliding circular motions, and passes into the zone of the wide fascia of the thigh.

Metastases in retroperitoneal lymph nodes

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

Localization of malignant neoplasms in the peritoneal zone has the following symptoms: an increase in temperature, a cramping pain in the abdomen (appears paroxysmal), a disorder of stools in the form of diarrhea (less often constipation). Metastases in retroperitoneal lymph nodes are observed in germinogenic tumor processes in the testicle, kidney, cancer of the gastrointestinal tract. An increase in retroperitoneal lymph nodes leads to severe back pain due to compression of the nerve roots, sometimes embracing the lumbar muscle. Gastrointestinal symptoms are common, a sharp decrease in weight is observed.

Evaluation of the condition of the lymph nodes and organs of the retroperitoneal space is carried out by ultrasound, computer and magnetic resonance imaging. Ultrasonic scanning shows nodes with metastases, either round or oblong, characterized by clear contours and uniformity of the structure. By CT, metastases in the lymph nodes are determined by a rounded shape, a soft-tissue structure. Affected lymph nodes of the retroperitoneal cavity have a uniform structure and density, as well as clear contours, can merge into large conglomerates. In the case where arteries of the lymph nodes cover the spine, the aorta in the peritoneum and the lower vena cava, intravenous contrast is used to better recognize the tumor processes.

Metastases in para-aortic lymph nodes

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

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

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

• the first stage - metastases reach the head of the pancreas; 
• the second stage - the retropiloric and hepatoduodenal lymph nodes are affected; 
• the third stage - the penetration of metastases into the celiac and upper mesenteric nodes; 
• The fourth stage is metastasis in para-aortic lymph nodes.

Physicians note that the malignant tumor of the pancreas is characterized by an aggressive course and has a poor prognosis. Cases of death from pancreatic cancer rank 4-5 among all oncological diseases. High mortality is associated with the recurrence of tumor processes in the postoperative period (K-ras mutations in para-aortic lymph nodes).

Metastases in the lymph nodes of the abdominal cavity

A large number of lymph nodes are located in the abdominal cavity, which represent a barrier to infection and cancer cells. Lymphonoduses of peritoneum are subdivided into parietal (concentrated in the zone of the loin) and intra-wall (located in rows).

The defeat of peritoneal lymph nodes is the result of a lymphoproliferative disease (the primary tumor is formed in the lymph node itself) or a consequence of metastasis. Lymphogranulomatosis and lymphosarcoma are related to lymphoproliferative diseases, causing compaction and growth in the size of the node without pain syndrome. Metastases in the lymph nodes of the abdominal cavity are detected in a number of cancer diseases, when tumor cells enter the lymph nodes from the affected organ with lymphatic flow. So malignant tumors of the peritoneum (for example, the stomach) and small 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 considered to increase the node in size (up to 10cm or more). To help come also CT and MRI studies of the peritoneal cavity in order to obtain visualization of anatomical structures.

Metastasis of melanoma in lymph nodes

Melanoma is a rare malignant tumor, which is more often affected by residents of southern regions. It should be noted that in 70% of cases melanoma is formed on the site of the existing pigment nevus or birthmark.

Development of melanoma occurs in two phases: 

• horizontal - proliferation within the epithelial layer (lasting from 7 to 20 years); 
• vertical - the growth of layers of the epidermis and the subsequent invasion of the basement membrane in the dermis and subcutaneous fatty tissue.

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

Diagnostic methods include aspiration biopsy of education, surgical biopsy of lymph nodes, radiography, CT and MRI of the whole organism. Removal of metastasis of melanoma in the lymph nodes is carried out by complete excision of the regional lymphocyte or removal of nearby lymph nodes (if the diagnosis is made on the basis of a biopsy).

Metastases to supraclavicular lymph nodes

Metastases in supraclavicular lymph nodes occur when: 

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

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

One of the most common tumors - gastric cancer is diagnosed by revealing "Virchow metastases" (more often 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 - metastases to the supraclavicular lymph nodes.

The increase in supraclavicular nodes is an alarming symptom, most often signifying tumor processes in the sternum or abdominal region. In 90%, this symptomatology occurs in patients older than 40, with younger cases accounting for 25% of cases. The defeat of the lymph nodes on the right corresponds to the tumor of the mediastinum, lungs, esophagus. The growth of the size of the nodes on the left in the supraclavicular zone indicates the cancer of the ovaries, testes, prostate, bladder, kidneys, stomach, pancreas.

Metastases in the lymph nodes of the mediastinum

Mediastinum is the thoracic cavity, which is bounded from the front by the sternum, costal cartilages and pozagrudinnaya fascia, from the rear - the anterior zone of the thoracic spine, the cervical ribs, the pre-invertebrate fascia, along the sides - the leaves of the mediastinal pleura. The area of mediastinum from below is indicated by a diaphragm, and from above by a conditional horizontal line. In the zone of mediastinum, thoracic lymphoprolling, chest lymph nodes, and mediastinum lymph nodes enter.

In addition to lung cancer, metastases in the mediastinal lymph nodes form tumor processes of the thyroid and esophagus, kidney hypernephroma, testicular cancer (seminoma), pigment malignant formation (melanosarcoma), uterine cancer (chorionepithelioma) and other neoplasms. The defeat of the lymph nodes of the mediastinum takes the third place in the development of malignant processes after lymphogranulomatosis and lymphosarcoma. Cancer cells cover all groups of mediastinal lymph nodes, most often affected paratracheal and bifurcation.

Primary small tumors often produce extensive metastases in the mediastinal lymph nodes. A clear example of this metastasis is lung cancer of the mediastinal form. The clinical picture describes the swelling of the soft tissues of the neck and head, the swelling and interlacing of the veins in front of the chest (the "head of the jellyfish"), dysphagia, hoarseness and breath of the stridorous type are noted. X-ray in most cases reveals the predominance of metastases in the posterior mediastinum.

In breast cancer, the accumulation of affected lymph nodes is localized in the anterior mediastinum. For the refinement method, mammariography (contrast study of the veins of the mammary glands) is used. Interruption of the venous bed, compression, the presence of edge defects serve as evidence of the presence of metastases, which require removal or treatment by irradiation.

Treatment of metastases in lymph nodes

The main rule of oncology is the study of the state of the lymph nodes, both in the tumor zone itself and in the remote zone. This allows the most accurate diagnosis and an effective treatment program.

Lying on the surface of the lymph nodes, which are accessible to external examination, are examined by methods of biopsy and puncture. The state of the deeper lymph nodes is examined with the help of ultrasound, CT, MRI. The most accurate method of detecting metastases in the lymph nodes is positron emission tomography (PET), thanks to which it is possible to recognize the nucleation of malignant cells in the most inaccessible and slightly enlarged lymph nodes.

Treatment of metastases in the lymph nodes is based on the same principles as the fight against the primary cancerous tumor - surgical intervention, chemotherapy, radiotherapy. The combination of these methods is applied individually, depending on the stage of the disease (malignancy), the degree of involvement of the lymphatic system.

The excision of the primary tumor, as a rule, is accompanied by the removal of all of its regional lymph nodes (lymphadenectomy). On the lymph nodes with the affected cells located further from the cancerous tumor, they are exposed to the methods of radiotherapy or perform a bloodless radiosurgical operation with the help of a cyber knife.

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

Prognosis of lymph node metastases

Factors affecting the survival of patients are conventionally divided into related: 

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

The most important factor in the prognosis is the defeat of regional lymph nodes without the presence of distant metastases. For example, the prognosis of metastases in the lymph nodes of the neck of "non-squamous cell cancer" remains disappointing - 10-25 months. Survival of patients with stomach cancer depends on the possibility of carrying out a radical operation. Only a small part of the patients who are not operated or operated negatively are reaching the five-year limit. The average life expectancy is 3-11 months, and the effect on this figure is exerted by the presence or absence of distant metastases.

The presence of metastasis in the lymph nodes in breast cancer significantly worsens the prognosis. As a rule, relapse and metastasis is 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 limb region, since the risk of metastasizing to the lymph nodes of these tumors is higher by 35%.

The criterion of successful treatment can serve as an indicator of five-year survival. The prognosis after excision of the tumor is determined not only by the presence or absence of metastases in regional lymph nodes, as well as the number of affected nodes.

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