Lymphatics of the pelvis

Lymph Nodes Of the Pelvic region
with their use in Radiotherapy

1. Lymphatic Drainage of the Pelvis By – Dr. Abhinav Mutneja Dept. of Radiotherapy

2. Can be divided into - Parietal nodes Visceral nodes

3. LYMPHATICS OF THE PELVIS PARIETAL NODES SUPERFICIAL PARIETAL – JOINING WITH THE SUPERFICIAL INGUINAL NODES (FUNCTIONAL TERRITORY – FASCIAL SHEATH OF UROGENITAL DIAPHRAGM, DISTAL VAGINA, HYMEN AND INF. ANAL CANAL) DEEP PARIETAL - VESSELS RELAY INTO INFERIOR EPIGASTRIC, CIRCUMFLEX ILIAC AND SACRAL NODES

4. Visceral nodes JUXTA VISCERAL NODES 1.Bladder – pre lateral, post. And sub vesical nodes 2.Genital compartment – lateral to the vagina and the cervix – paravaginal and parauterine 3.Pararectal – around right and left aspects of the rectum

5. Visceral nodes Common iliac External iliac Internal iliac Obturator Pre sacral

6. Figure 2b.  (a) CT scan through the upper pelvis shows the ascending colon (ac), descending colon (dc), and small bowel loops ( sbl ) occupying the anterior portion of the pelvis.

7. Common iliac lymph nodes. 4-7 in number, grouped around CIV Lateral -1 – lateral to CIA and medial border of psoas . end – lat. Lumbar aortic Medial-2 – along inner side of CIA, just below the aortic bifurcation in front of L5 (aka subaortic group of nodes) Intermediate-3 – (3-4 nodes) posteromedial side of the artery. Located in cuneo ’ and marcille’s triangular lumbosacral fossa which is bounded medially by L5, lat by psoas

8. Common iliac lymph nodes.

9. Constitute terminal routes of the external and internal iliac chains. Some lymphatics originating from the neck of the bladder, the cervix uteri and the post. Aspect of the rectum directly enter the median group or the subaortic nodes.

10. Internal iliac lymph nodes. Named subgroups of internal iliac lymph nodes: 1 = lateral sacral , which are adjacent to lateral sacral artery (arrow); 2 = presacral ; 3 = anterior, which are anterior to anterior division of internal iliac artery (arrowhead);

11. Internal iliac lymph nodes. Often called Hypo-gastric nodes (4) , they surround the IIV and are placed near the origin of there branches, running in front of the sacro iliac joint downwards the to the lower part of the greater sciatic foramen

12. Afferent vessels – post part of the prostate, lat and lower parts of the urinary bladder, membranous and prostatic segment of the urethra, seminal vesicles, middle and lower parts of the vagina, the body of the uterus and the middle part of the rectum Superior gluteal nodes – region of the buttock Inferior gluteal nodes

13. External iliac lymph nodes. 9- 10 in number around EIV’s Lateral – 1 – interposed between medial border of the psoas and the lat. Side of the EIA Intermediate -2 – anteriorly to the EIV along the medial side of the artery Medial -3 – placed medially to the EIV against the lateral wall of the pelvic cavity above the obturator nerve

14. External iliac lymph nodes. Lateral 1 – lower node is located under the inguinal ligament aka lateral lacunar lymph node, this is closely realted to the origin of the deep inf. Epigastric and deep circumflex iliac arteries. Intermediate’s 2 – upper node is in the angle between the origins EIA and IIA aka interiliac lymph node and is covered by the iliac segment of the ureter .

15. Receive collectors from the lower limb through the superficial and deep inguinal nodes Subumbilical part of the abdominal wall and deep collecting trunks from the glans , penis/ clitoris coursing the vas in the male and the round ligament of the uterus in the female Medial chain – muscles of the medial compartment of the thigh Lateral lobes of prostate, the fundus of the urinary blaldder , the cervix uteri or the upper part of the vagina

16. Sacral nodes Internal iliac nodes External iliac nodes Common iliac nodes Lie in the hollow of the sacrum  Receive vessels from pelvic, perineal and gluteal regions Drain to the internal iliac or common iliac nodes Arranged around the internal iliac artery Receive vessels from pelvic viscera, perineum and buttock Drain to common iliac nodes Arranged around the external iliac artery Receive vessels from superficial and deep inguinal nodes, some pelvic viscera and abdominal wall below umbilicus  Drain to common iliac nodes Receive drainage from external and internal iliac nodes and sacraol nodes Drain into the lumbar group of nodes

17. Summary of pelvic viscera drainage ORGAN Node (s) Uterus Upper part of the body Lower  part of the body Cervix Region near uterine tube (along round ligament) Vagina Upper part (along uterine a.)   Lumbar External iliac,  External iliac, internal iliac, and sacral  Superficial inguinal External and internal iliac Middle part (along vaginal a.) Lower part Part below hymen (with those from vulva and skin of perineum) Internal iliac Internal iliac Sacral and common iliac Superficial inguinal Testis and epididymis (along testicular a.) Lumbar Seminal vesicle External and internal iliac Ductus deferens (pelvic portion) External iliac Prostate Internal iliac mainly; sacral and external iliac Scrotum Superficial inguinal

18. Glans external iliac Ureter (lower part) External or internal iliac Bladder Superior and inferolateral aspects Base External iliac External iliac mainly; internal iliac Neck Sacral and common iliac Urethra  Female (along internal pudendal a.) Male prostatic and membranous parts (along internal pudendal ) Spongy part   Internal iliac mainly; external iliac Internal iliac mainly; external iliac Deep inguinal mainly; external iliac Rectum Lower part   Sacral, internal iliac, and common iliac Anal canal Above pectinate line (along inferior rectal and internal pudendal ) Below pectinate line   Internal iliac

19. Main anterior pelvic pathway Mainly from anterior pelvic viscera draining into the medial external iliac nodes Clinically involved in the lymphatic spread of tumors from Fundus of urinary bladder Lateral prostatic lobes Uterine cervix and the Vaginal fornix

20. Main middle pelvic pathway Route of lymphatics from internal iliac chain Runs superiorly along the sacro -iliac joint exactly following the course of the IIV’s Clinically metastatic involvement from Prostate Bladder Uterine body Middle part of rectum

21. Main posterior pelvic pathway Clinically vessels arising from the posterior parts of the prostate, urinary bladder, uterine cervix and from the posterior aspect of the rectum This explains the skip metastasis as a primary site of lymph node involvement in the case of pelvic tumors which invade the external or internal iliac lymph nodes

22. Internal pudendal accessory pelvic pathway Pathway is connected behind the ischial spine with the middle internal iliac main pathway Clinically drains Neck of urinary bladder Apex of the prostate Lower part of the vagina

23. Gonadic ascending accessory pathway Runs along the gonadic vessels to reach the inferior group of lateral aortic nodes Located on the lateral side of the abdominal part of the ureter in front of the psoas muscle Usual route of spread of Ovarian tumors.

24. The inferior mesentric accessory pelvic pathway Only involves the drainage of the rectal pelvic compartment. (for eg . cancers of the rectal ampulla .) Accompanies the inferior mesentric vessels on the left side of the abdomen and terminates in the preaortic nodes at L3 level

25. Superficial perineal accessory pelvic pathway For cancers of the anal canal and the vulva

26. Inguinal accessory pathway Drain lymph from the uterine fundus and horns Running around round ligament of the uterus passing through the inguinal canal. Ends in the groin area.

27. Delineation of lymph node areas

28. Target Site Common iliac lymph nodes From 7mm below the L4/L5 interspace to the level of the bifurcation of the common iliac arteries into the external and internal iliac arteries.

29. Presacral lymph nodes * Lymph node region anterior to S1and S2 region.

30. External iliac lymph nodes From the level of the bifurcation of the common iliac artery into the external artery to the level of the superior aspect of the femoral head where it becomes the femoral artery.

31. Internal iliac lymph nodes From the level of the bifurcation of the common iliac artery into the internal artery, along its branches ( obturator , hypogastric ) terminating in the paravaginal tissues at the level of the vaginal cuff.

32. Upper vagina Vaginal cuff and 3 cm of vagina inferior to the cuff.

33. Parametrial / Paravaginal tissue From the vaginal cuff to the medial edge of the internal obturator muscle/ ischial ramus on each side.

34. Thank you