Lymphatics of the pelvis

•Lymphatic Drainage of the Pelvis

By – Dr. Abhinav Mutneja Dept. of Radiotherapy

Can be divided into -

• Parietal nodes • Visceral nodes

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

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

Visceral nodes

• Common iliac• External iliac• Internal iliac• Obturator• Pre sacral

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.

Common iliac lymph nodes.

4-7 in number, grouped around CIV Lateral -1 – lateral to CIA and medial border of psoas. end – lat. Lumbar aorticMedial-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

Common iliac lymph nodes.

• 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.

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);

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

• 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

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 EIAIntermediate -2 – anteriorly to the EIV along the medial side of the arteryMedial -3 – placed medially to the EIV against the lateral wall of the pelvic cavity above the obturator nerve

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.

• 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

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

Summary of pelvic viscera drainage

ORGAN Node (s)

UterusUpper part of the bodyLower  part of the bodyCervixRegion near uterine tube (along round ligament)VaginaUpper part (along uterine a.)

 LumbarExternal iliac, External iliac, internal iliac, and sacral Superficial inguinalExternal and internal iliac

Middle part (along vaginal a.)Lower partPart below hymen (with those from vulva and skin of perineum)

Internal iliacInternal iliacSacral and common iliacSuperficial inguinal

Testis and epididymis (along testicular a.)

Lumbar

Seminal vesicle External and internal iliacDuctus deferens (pelvic portion) External iliac

Prostate Internal iliac mainly; sacral and external iliac

Scrotum Superficial inguinal

Glans external iliac

Ureter (lower part) External or internal iliacBladderSuperior and inferolateral aspectsBase

External iliacExternal iliac mainly; internal iliac

Neck Sacral and common iliacUrethra Female (along internal pudendal a.)Male prostatic and membranous parts (along internal pudendal)Spongy part

 Internal iliac mainly; external iliacInternal iliac mainly; external iliacDeep inguinal mainly; external iliac

Rectum

Lower part

Sacral, internal iliac, and common iliac

Anal canalAbove pectinate line (along inferior rectal and internal pudendal)Below pectinate line

 Internal iliac

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

1. Fundus of urinary bladder2. Lateral prostatic lobes3. Uterine cervix and the4. Vaginal fornix

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 from1. Prostate2. Bladder 3. Uterine body 4. Middle part of rectum

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

Follows the pre-sacral chain (regularly curved course)

Above the levator Ani along the lateral walls of the rectal compartment

In front of the sacral concavity

Reaches the lateral or less frequently the median sacral nodes

Some of the above organs terminate in the sub aortic nodes.

Internal pudendal accessory pelvic pathway

• Pathway is connected behind the ischial spine with the middle internal iliac main pathway

• Clinically drains 1. Neck of urinary bladder 2. Apex of the prostate3. Lower part of the vagina

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.

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

Superficial perineal accessory pelvic pathway

Pathway end in the superficial inguinal nodes

Follows upto the deep inguinal nodes

And then connectes to the external and common pelvic iliac chains

For cancers of the anal canal and the vulva

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.

Prostrate may involve 4 alternative pathways for the spread of metastasis

•External iliac•Internal iliac•Presacral•Internal pudendal

Rectum •Internal iliac •Presacral •Inferior mesentric •Superficial perineal routes

Uterine carcinoma6 possible pathways of

mets

•Internal iliac•External iliac•Presacral•Internal pudendal•Gonadic •Inguinal chains

Delineation of lymph node areas

Target SiteCommon 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.

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

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.

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.

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

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

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