Extranodal extension (ENE)

Extranodal extension (ENE) is a term pathologists use when cancer cells spread outside a lymph node into the surrounding tissue. Lymph nodes are small immune organs that help filter harmful substances and are often one of the first places cancer spreads. Normally, cancer cells that travel to a lymph node stay inside the lymph node’s capsule, a thin layer of tissue that surrounds it. When cancer cells break through this capsule and invade nearby tissue, this is called extranodal extension.

ENE is an important finding in several types of cancer, including head and neck cancers, breast cancer, melanoma, and others. It is considered a sign of more aggressive disease.

Why is extranodal extension important?

Staging

The presence of extranodal extension can result in a higher cancer stage. This is because ENE indicates that the cancer is not just inside the lymph node but is also starting to spread into the surrounding area, making it harder to remove completely and more likely to continue spreading.

Prognosis

Cancers with extranodal extension are generally associated with a higher risk of recurrence and lower overall survival. ENE is considered a negative prognostic factor, meaning patients with ENE often have a worse outlook than those whose cancer is confined within the lymph node.

Treatment planning

Finding extranodal extension often leads to a more aggressive treatment plan. This may include:

• Additional surgery to remove more surrounding tissue.

• Radiation therapy targeted at the area where ENE was found.

• Chemotherapy or other systemic treatments to reduce the risk of cancer returning.

The treatment plan will depend on the type of cancer, how many lymph nodes are involved, and whether ENE is present.

How is extranodal extension detected?

Pathologists detect extranodal extension by examining lymph nodes under the microscope after they have been removed during surgery. They look for signs that tumour cells have broken through the capsule of the lymph node and have invaded the surrounding soft tissue.

ENE may be described in the pathology report using terms such as:

• Microscopic extranodal extension – only seen under the microscope.

• Gross extranodal extension – visible to the naked eye during surgery or specimen examination.

• Focal or limited ENE – small areas of extension.

• Extensive ENE – larger areas where tumour has spread outside the node.

The report may also mention how far the cancer has spread beyond the capsule, which may influence staging and treatment.

In which cancers is extranodal extension commonly reported?

Extranodal extension can occur in many types of cancer that spread to lymph nodes. It is especially important in:

• Head and neck squamous cell carcinoma.

• Breast cancer.

• Melanoma.

• Anal and cervical cancer.

• Merkel cell carcinoma.

• Prostate cancer.

In each of these cancers, the presence or absence of ENE helps doctors determine the best course of treatment.

Questions to ask your doctor

• Was extranodal extension found in any of my lymph nodes?

• How does this affect the stage of my cancer?

• Will my treatment plan change because of this finding?

• Do I need additional surgery, chemotherapy, or radiation therapy?

• What is my prognosis, and how will I be monitored going forward?