Overview
Lymph Node Biopsy is a crucial diagnostic procedure used to evaluate lymphadenopathy and diagnose various conditions including lymphoma, metastatic disease, and infectious processes. The procedure involves obtaining tissue from enlarged or suspicious lymph nodes for histological examination, immunohistochemistry, and molecular studies. Lymph node biopsy can be performed as an excisional biopsy (removing the entire node) or incisional biopsy (removing part of the node), depending on the clinical scenario and node size.
Lymph node biopsy is essential for diagnosing and staging various malignancies, particularly lymphoma and metastatic cancer. It provides critical information about tumor type, grade, and extent of disease, which directly impacts treatment decisions and prognosis. The procedure is also valuable for evaluating unexplained lymphadenopathy, monitoring treatment response, and detecting infectious diseases such as tuberculosis and sarcoidosis. Modern techniques allow for comprehensive evaluation including flow cytometry, cytogenetics, and molecular studies.
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Indications
Evaluation of persistent lymphadenopathy of unknown etiology
Diagnosis and classification of Hodgkin and non-Hodgkin lymphoma
Assessment of lymph node involvement by solid tumors
Evaluation of sentinel lymph nodes in cancer staging
Diagnosis of tuberculosis, sarcoidosis, and other granulomatous diseases
Assessment of treatment response in lymphoma and other malignancies
Contraindications
Absolute Contraindications
Relative Contraindications
📋 Equipment Checklist
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Pre-procedure Preparation
Patient preparation includes obtaining informed consent, reviewing coagulation parameters (platelets >50,000, INR <1.5), and ensuring adequate pain control. The patient should be positioned comfortably based on the lymph node location. Local anesthesia with lidocaine is administered, and conscious sedation may be considered for anxious patients. The skin over the target lymph node is cleaned with antiseptic solution and draped sterilely. Ultrasound guidance may be used for deep-seated or non-palpable lymph nodes.Step-by-Step Procedure
Step 1: Patient Positioning and Site Preparation
Position the patient comfortably with the target lymph node easily accessible. For cervical lymph nodes, position with the neck extended. For axillary nodes, abduct the arm. For inguinal nodes, position supine with legs slightly abducted. Clean the skin over the lymph node with antiseptic solution in a circular motion, starting from the center and moving outward. Allow the antiseptic to dry completely.
⚠️ Common Mistakes to Avoid:
- Inadequate positioning leading to difficult access
- Not allowing antiseptic to dry, which can contaminate the specimen
- Inadequate skin preparation increasing infection risk
💡 Pro Tip:
For deep-seated lymph nodes, consider using ultrasound guidance to ensure accurate targeting.
Step 2: Local Anesthesia Administration
Using a 25-gauge needle, create a skin wheal with 1% lidocaine at the planned incision site. Then, using a 22-gauge needle, infiltrate the subcutaneous tissue with 2-3 mL of 1% lidocaine. Wait 2-3 minutes for the anesthetic to take effect. Test the area with a needle prick to ensure adequate anesthesia before proceeding.
⚠️ Common Mistakes to Avoid:
- Inadequate anesthesia causing patient discomfort
- Not waiting for anesthetic to take effect
- Insufficient infiltration of the subcutaneous tissue
💡 Pro Tip:
For larger lymph nodes, consider using a longer-acting local anesthetic like bupivacaine.
Step 3: Skin Incision
Make a skin incision over the lymph node, typically 2-4 cm in length depending on the node size and location. The incision should follow natural skin lines (Langer's lines) to minimize scarring. Incise through the skin and subcutaneous tissue until you reach the superficial fascia. Use electrocautery or sharp dissection to control bleeding from small vessels.
⚠️ Common Mistakes to Avoid:
- Incision too small making the procedure difficult
- Incision not following natural skin lines causing poor cosmesis
- Inadequate hemostasis during incision
💡 Pro Tip:
For cosmetic areas like the neck, make the incision in a natural skin crease when possible.
Step 4: Lymph Node Identification and Dissection
Carefully dissect through the subcutaneous tissue to identify the lymph node. Lymph nodes are typically firm, oval structures with a smooth surface. Use blunt dissection with scissors or fingers to free the lymph node from surrounding tissue. Identify and preserve any important structures such as nerves or blood vessels. For sentinel lymph node biopsy, use blue dye or radioactive tracer to identify the target node.
⚠️ Common Mistakes to Avoid:
- Inadequate dissection causing incomplete lymph node removal
- Damage to surrounding structures during dissection
- Not identifying the correct lymph node
💡 Pro Tip:
Lymph nodes often have a characteristic "rubbery" feel that helps distinguish them from surrounding tissue.
Step 5: Lymph Node Excision
Once the lymph node is identified and freed from surrounding tissue, carefully excise it. For excisional biopsy, remove the entire lymph node. For incisional biopsy, remove a representative portion of the lymph node. Use sharp dissection to avoid crushing the specimen. Place the lymph node immediately in 10% neutral buffered formalin for fixation.
⚠️ Common Mistakes to Avoid:
- Crushing the lymph node during removal
- Incomplete removal in excisional biopsy
- Delayed fixation causing autolysis
💡 Pro Tip:
Handle the lymph node gently to preserve its architecture for accurate histological examination.
Step 6: Hemostasis and Wound Closure
Achieve hemostasis using electrocautery, suture ligation, or pressure as appropriate. Irrigate the wound with sterile saline to remove any debris. Close the subcutaneous tissue with interrupted absorbable sutures (3-0 or 4-0). Close the skin with interrupted non-absorbable sutures or staples. Apply a sterile dressing.
⚠️ Common Mistakes to Avoid:
- Inadequate hemostasis leading to hematoma formation
- Poor wound closure causing dehiscence
- Not irrigating the wound to remove debris
💡 Pro Tip:
For larger lymph nodes or deep dissections, consider placing a small drain to prevent seroma formation.
Step 7: Specimen Processing and Documentation
Document the procedure in the patient's chart including the site, size of lymph node, and any complications. Label the specimen container clearly with patient information and site. The lymph node should be processed for routine histology with H&E staining. Additional studies such as immunohistochemistry, flow cytometry, or molecular studies may be requested based on the clinical suspicion.
⚠️ Common Mistakes to Avoid:
- Inadequate documentation of the procedure
- Poor specimen labeling leading to mix-ups
- Not requesting appropriate additional studies
💡 Pro Tip:
Always correlate the lymph node appearance with the clinical history and imaging findings.
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Post-procedure Care
Post-procedure care involves applying pressure to the biopsy site for 10-15 minutes to prevent hematoma formation. Patients should be observed for 30-60 minutes for any immediate complications. Instructions include keeping the site clean and dry for 24-48 hours, avoiding strenuous activity for 24-48 hours, and watching for signs of infection or excessive bleeding. Most patients can resume normal activities within 24-48 hours, though some may experience local discomfort for several days.Complications & Management
| Complication | Incidence | Signs | Management | Prevention |
|---|---|---|---|---|
| Hematoma | 2-5% | Swelling, pain, discoloration at biopsy site | Apply ice pack, analgesics, observation for 24-48 hours | Adequate hemostasis, correct coagulation parameters |
| Infection | <1% | Erythema, warmth, purulent discharge after 24-48 hours | Antibiotics based on culture, local wound care | Strict aseptic technique, proper wound care |
| Nerve injury | <1% | Numbness, tingling, weakness in the affected area | Neurological evaluation, MRI if indicated | Careful dissection, identification of important structures |
| Lymphatic leak | 1-3% | Clear fluid drainage from the wound | Pressure dressing, observation, rarely surgical intervention | Careful dissection, ligation of lymphatic vessels |
| Seroma | 3-8% | Fluid collection under the skin | Observation, aspiration if large, pressure dressing | Adequate hemostasis, consideration of drain placement |
Clinical Pearls
Always palpate the lymph node before making the incision to confirm its location and mobility.
For sentinel lymph node biopsy, use both blue dye and radioactive tracer for optimal detection rates.
Lymph nodes in different locations have different drainage patterns - consider this when selecting the biopsy site.
Always document the lymph node size, consistency, and any unusual features for correlation with pathology.
For suspected lymphoma, consider sending fresh tissue for flow cytometry in addition to formalin-fixed tissue.
The incision should be large enough to allow adequate exposure and prevent tissue trauma during dissection.
Be aware of the location of important structures such as nerves and blood vessels to avoid injury during dissection.