Challenges Around
Lymph Node Searches
Lymph node number is a quality metric to measure the performance of healthcare providers, due to its clear correlation with patient survival. [1][2][3]
Medical authorities, such as AJCC, NCCN, ASCO, CAP, stipulate lymph node count requirements and recommendations for different cancer types. [4]
American College of Surgeons (ACS) Commission on Cancer (CoC) has stricter requirements for lymph node counts for different cancer types. [1]
Manual palpation is the standard of care for lymph node searches in anatomic pathology.
It is one of the most laborious and inconsistent steps in anatomic pathology and even cancer care.
What do practitioners say about lymph node searching?
“Grossing a colon is easy. Lymph node search is the time-consuming, tedious and mind-numbing step.”
− Benjamin Farmer MHS, HTL(ASCP)PA
“Finding a big lymph node is like manna from heaven, because all the other ones are just going to be harder and harder to find.”
− Rhonda K. Yantiss, MD Weil Cornell Medical Center
Laborious:
“The United Kingdom Royal College of Pathologists’ Guidelines on Staffing and Workload allocates … an anticipated time spent of 31-50 min.[6] This would appear to underestimate the time required for a thorough job.”
Lymph node grossing contributes to pathology resident burnouts, according to College of American Pathologists (CAP). [7]
Inconsistent:
A Mayo Clinic Study found that one Mayo Clinic hospital was retrieving 50% fewer lymph nodes than another Mayo Clinic hospital. The reason was attributed to pathology practitioner human errors.[8]
Close to 50% lymph nodes are missed during traditional manual palpation, according to data published by Vanderbilt University.[9]
Up to 50% of the cancerous lymph nodes are less than 5 mm in size. They are the smaller lymph nodes that are easily missed in traditional manual palpation.[10-12]
The Blame Game:
Because lymph node counts are performance metrics for providers, surgeons and pathologists often get into a blame game over whose fault it is when the required number of lymph nodes are not found.[13]
The community needs a technical breakthrough to resolve the practical challenges in lymph node searches.
Dezube AR, Mazzola E, Bravo-Iñiguez CE, et al. Analysis of Lymph Node Sampling Minimums in Early Stage Non-Small-Cell Lung
Cancer.
Semin Thorac Cardiovasc Surg. 2021;33(3):834-845. doi:10.1053/j.semtcvs.2020.11.007
Raoof M, Zafar SN, Ituarte PHG, Krouse RS, Melstrom K. Using a Lymph Node Count Metric to Identify Underperforming Hospitals After Rectal Cancer Surgery.
J Surg Res. 2019;236:216-223. doi:10.1016/j.jss.2018.11.040
Divi V, Chen MM, Nussenbaum B, et al. Lymph Node Count From Neck Dissection Predicts Mortality in Head and Neck Cancer. J
Clin Oncol. 2016;34(32):3892-3897. doi:10.1200/JCO.2016.67.3863
Amin, Mahul B.; Gress, Donna M.; Meyer Vega, Laura R.; Edge, Stephen B.. AJCC Cancer Staging Manual, Eighth Edition (p. 278).
American College of Surgeons.
https://www.facs.org/quality-programs/cancer-programs/national-cancer-database/quality-of-care-measures/
Ong ML, Schofield JB. Assessment of lymph node involvement in colorectal cancer. World J Gastrointest Surg. 2016;8(3):179-192.
doi:10.4240/wjgs.v8.i3.179
https://www.cap.org/member-resources/articles/pathology-resident-burnout
Schoenleber SJ, Schnelldorfer T, Wood CM, Qin R, Sarr MG, Donohue JH. Factors influencing lymph node recovery from the operative specimen after gastrectomy for gastric adenocarcinoma. J Gastrointest Surg. 2009;13(7):1233-1237. doi:10.1007/s11605-
009-0886-7
Hamza A, Sakhi R, Khawar S, et al. Role of “Second Look” Lymph Node Search in Harvesting Optimal Number of Lymph Nodes for Staging of Colorectal Carcinoma. Gastroenterol Res Pract. 2018;2018:1985031. Published 2018 Apr 2. doi:10.1155/2018/1985031
Herrera L, Villarreal JR. Incidence of metastases from rectal adenocarcinoma in small lymph nodes detected by a clearing technique.
Dis Colon Rectum. 1992;35(8):783-788. doi:10.1007/BF02050329
Kotanagi H, Fukuoka T, Shibata Y, et al. The size of regional lymph nodes does not correlate with the presence or absence of metastasis in lymph nodes in rectal cancer.
J Surg Oncol. 1993;54(4):252-254. doi:10.1002/jso.2930540414
Rodriguez-Bigas MA, Maamoun S, Weber TK, Penetrante RB, Blumenson LE, Petrelli NJ. Clinical significance of colorectal cancer: metastases in lymph nodes < 5 mm in size.
Ann Surg Oncol. 1996;3(2):124-130. doi:10.1007/BF02305790
Jakub JW, Russell G, Tillman CL, Lariscy C. Colon Cancer and Low Lymph Node Count: Who Is to Blame?
Arch Surg. 2009;144(12):1115–1120. doi:10.1001/archsurg.2009.210
