The management of regional lymph nodes in cancer

Early clinical observation in cancer patients suggested that tumours spread in a methodical, stepwise fashion from the primary site to the regional lymphatics, and only then to distant locations. Based on these observations, the regional lymphatics were believed to be mechanical barriers preventing the widespread dissemination of tumour. Despite evidence now available disputing its validity, this barrier theory has guided the surgical management of the regional lymphatics for more than a century, influencing the use of such surgical modalities as therapeutic lymph node dissection, elective lymph node dissection and most recently sentinel lymph node biopsy. No published randomized controlled trial exists that demonstrates improved overall survival for patients with cancer of any type undergoing surgery of the regional lymphatics. We believe the presence of tumour in the regional lymphatics indicates the presence of systemic disease, and therapeutic interventions should be directed accordingly.