Surgery to remove lymph nodes for melanoma skin cancer

Some people may have surgery to remove the lymph nodes close to the melanoma. This operation is called a lymph node dissection or lymphadenectomy.

What is a lymph node?

Lymph nodes are part of our lymphatic system. This is a network of thin tubes and nodes that run throughout the body and carry a fluid called lymph.

Lymph nodes filter the lymph fluid as it passes through them. They can trap bacteria, viruses and cancer cells. Lymph nodes are also called lymph glands.

We have lymph nodes almost everywhere in our body. They are usually small and can only be felt in certain areas such as:

• your neck

• under the arm (armpit)

• your groin

Checking your lymph nodes

You may have more tests after being diagnosed with melanoma. This is to find out whether it has spread anywhere else in the body. This is called staging. It helps your doctor decide which treatment is best for you.

Your doctor might find that melanoma has spread to your lymph nodes after:

• a physical examination shows your lymph nodes feel abnormally large or hard
• a scan shows that your lymph nodes appear abnormal
• a sentinel lymph node biopsy finds melanoma cells in your lymph nodes

A sentinel lymph node biopsy is where your surgeon removes the first lymph nodes the melanoma could have spread to. Your doctor may do this test if your lymph nodes look and feel normal but they want to check for small amounts of cancer cells. 

If your lymph nodes look or feel abnormal

Your doctor usually takes a sample of tissue (biopsy) from lymph nodes that feel swollen (enlarged) or appear abnormal on a scan. This is a different type of biopsy to a sentinel lymph node biopsy.  If the biopsy shows melanoma in a node or nodes, they usually offer you an operation to remove all of the lymph nodes in that area. This is called a lymph node dissection or lymphadenectomy.

If a sentinel node biopsy shows melanoma in your lymph nodes

This is called a positive sentinel lymph node biopsy. You don’t usually have a lymph node dissection if you have a positive sentinel lymph node biopsy.

You may have regular ultrasound scans to check your lymph nodes to see if the cancer grows (progresses). Or you might have treatment such as targeted cancer drugs or immunotherapy.

Some people may have a lymph node dissection if they have a positive sentinel lymph node biopsy. This is because it can be difficult for doctors to treat the lymph nodes or monitor the cancer in some people. This includes people who:

• have melanoma in the head or neck
• can’t have targeted cancer drugs or immunotherapy
• aren’t able to see their doctor regularly

What happens

The operation removes the collection of nodes nearest the melanoma. There is a collection of lymph nodes in both:

• of your armpits
• sides of your groin
• sides of your neck

Having a lymph node dissection is a large operation. You normally have it under a general anaesthetic , so you are asleep.

Your doctor will tell you more about the operation and how long you might be in hospital. They will also tell you about the possible risks. 

Before the operation

You go to the pre assessment clinic before your operation.

Pre assessment clinic

Your pre assessment appointment prepares you for your operation. This usually happens in the 2 weeks before your surgery.

At your appointment the pre assessment team may:

• ask you questions about your health and any medicines you are taking
• tell you when to stop eating and drinking before your operation
• tell you if you need to stop taking any of your medicines before surgery
• check your weight, blood pressure, pulse and temperature
• ask what help and support you have at home

The pre assessment team will tell you how to prepare for your operation. What you need to do depends on what operation you are having.

They may also give you a leaflet about breathing and leg exercises to do after your operation. This is to help prevent chest infections and blood clots.

It helps to write down any questions you have and take them with you. The more you know about what is going to happen, the less frightening it will seem. You can ask more questions when you go into hospital so don’t worry if you forget to ask some.

You normally go into hospital on the morning of your operation. Sometimes you may go in the night before. This can depend on the hospital.

During the operation

You normally have a general anaesthetic injection through a small tube (cannula) in your vein. This will make you go to sleep. Your surgeon then makes a cut (incision) over the collection of lymph nodes they are removing. They take out all the lymph nodes, the lymph node vessels and some of the tissue around them.

They send these to the laboratory.  A specialist doctor (pathologist) looks at the lymph nodes under a microscope. They will be able to tell how many of them contain cancer cells.

Your doctor normally puts 1 or 2 drains in the wound to stop any blood or lymph fluid collecting. They close the wound with either stitches or surgical clips, and put a dressing on top.

After the operation

After the operation you go to the recovery room. A nurse monitors you closely. They regularly check your blood pressure and pulse, and make sure there is no bleeding. They also check you have no pain. When you are awake and well enough you go back to the ward.

On the ward your nurses will let you know when you can eat and drink. They also encourage you to keep:

• your arm raised if you’ve had the nodes in your armpit (axilla) removed
• your leg up if you’ve had groin nodes removed
• sat up if you’ve had nodes in your neck removed

This helps to reduce swelling. Moving around also helps. You may see a physiotherapist during your stay. They help you move around and give you exercises to do.

It is important to let the nurses know if you have any pain, so they can give you painkillers. Having these will help you move around easier. 

Drains

When your doctor or nurse will remove the drains depends on what lymph nodes you have had taken out. This may be a few days after having neck nodes removed. Or up to 2 weeks after having axilla or groin nodes taken out.

Sometimes you may go home with the drains still in. Your nurse teaches you how to look after them. They will tell you what to look for and who to contact if there are any problems. You go back to the hospital for them to remove the drains.

Going home

You normally go home between 2 and 10 days after the operation. Before you leave the hospital your nurse tells you when your stitches or clips need removing. They also tell you where it’s done. This may be back at the hospital. Or you may need to make an appointment with the practice nurse at your GP surgery.

Sometimes your doctor uses stitches that dissolve. These don’t need removing. Your doctor or nurse tells you which type you have before you go home. They will also tell you:

• how to look after the dressings
• what problems to look out for
• who to contact if you have any problems
• when you can go back to your normal activities, including work and driving
• when to expect the results and a follow up appointment

Possible risks

As with any medical procedure there are possible risks or complications. Your doctor makes sure the benefit of the treatment outweighs these risks.

Lymphoedema

Having all the lymph nodes in an area removed can cause some long term problems. Lymph nodes drain fluid from your arms, legs and head. If the surgeon removes the lymph nodes, fluid can build up and cause swelling. This is called lymphoedema. Your doctor and nurses will tell you how you can reduce your chance of getting lymphoedema.

Other possible risks

The other risks of having your lymph nodes removed include:

• infection
• problems with your wound healing
• a build up of fluid at the site you had surgery (seroma )
• a collection of blood at the operation site (haematoma)
• numbness, tingling or pain in the area - this is due to nerve injury
• blood clots - more common after removal of lymph nodes in the groin area
• scarring

If you have the nodes in your axilla taken out risks can also include:

• injury to the nerve that holds your shoulder blade flat - this causes your shoulder blade to stick out (winged scapula)
• injury to the nerve that goes to the large muscle in the middle of your back - this can make moving your arm difficult

Let your doctor or specialist nurse know if you have any problems after your operation.

Follow up

At your follow up appointment, your doctor:

• gives you the results of the surgery

• examines you

• asks how you are and if you've had any problems

This is also your opportunity to ask any questions. Write down any questions you have before your appointment to help you remember what to ask. Taking someone with you can also help you to remember what the doctor says and provide support.

Between appointments, you can also contact your specialist nurse. They are called a key worker in some hospitals. So don't worry if you do forget to ask something. 

How often you have follow up appointments after this depends on the results of your surgery. Ask your doctor how often you need to see them and what will happen at the appointments.