Pathways of Lymphatic Spread in Gynecologic Malignancies

Abstract

Precise radiologic evaluation of regional adenopathic involvement in pelvic gynecologic tumors is fundamental to clinical practice because of its prognostic and therapeutic significance. Likewise, the identification of metastatic adenopathies at posttreatment imaging is essential for assessing response and detecting recurrence. Similar to urologic neoplasms, gynecologic neoplasms most often spread regionally to the pelvic and retroperitoneal lymph nodes, following the normal drainage pathways of the pelvic organs. Familiarity with routes of dissemination, treatment options, and means of analyzing lymph node characteristics is crucial to determine the extent of disease. Two staging systems can be used in characterizing gynecologic malignancies: the FIGO (International Federation of Gynecology and Obstetrics) system, which is the most commonly and universally used, and the TNM (tumor, node, metastasis) system, which is based on clinical and/or pathologic classification. Anatomic assessment with multidetector computed tomography (CT) and magnetic resonance (MR) imaging is still the most commonly used technique for the detection of lymph node spread, which is mainly based on morphologic criteria, the most important of which is nodal size. However, size has limited diagnostic specificity. Consequently, functional imaging techniques such as diffusion-weighted MR imaging, positron emission tomography combined with CT, lymphoscintigraphy, and sentinel lymph node mapping, which are based on molecular and physiologic activity and allow more precise evaluation, are often incorporated into diagnostic imaging protocols for staging of gynecologic malignancies.

Evaluating a preoperative protocol that includes magnetic resonance imaging for lymph node metastasis in the Cholangiocarcinoma Screening and Care Program (CASCAP) in Thailand

“…The determination of LNM by MRI was made by a consensus between two board-certified radiologists using the following morphological criteria: nodal size greater than 10 mm in short axis diameter, central necrosis, and inhomogeneous enhancement following intravenous contrast medium injection [ 22 – 24 ]. In equivocal cases, a gastrointestinal radiologist was also consulted.…”

Current recommendations and recent progress in endometrial cancer

“…Assessment of para‐aortic nodes remains another controversial area of management in endometrial cancer. Because the drainage pattern from the uterus is often to the pelvic lymph nodes and then the para‐aortic beds, and it is usually the case that metastatic disease is found in the pelvic nodes before the para‐aortic ones, some have advocated for the omission of para‐aortic lymphadenectomy in patients with low‐risk to moderate‐risk disease . Para‐aortic lymphadenectomy can be particularly challenging in the morbidly obese patient, and injury to the inferior vena cava during para‐aortic dissection can be life‐threatening.…”

“…Because the drainage pattern from the uterus is often to the pelvic lymph nodes and then the para-aortic beds, and it is usually the case that metastatic disease is found in the pelvic nodes before the para-aortic ones, some have advocated for the omission of para-aortic lymphadenectomy in patients with low-risk to moderate-risk disease. 45 Para-aortic lymphadenectomy can be particularly challenging in the morbidly obese patient, and injury to the inferior vena cava during para-aortic dissection can be life-threatening. Patients with node-positive disease in any basin will often receive adjuvant chemotherapy, which may eradiate microscopic disease in other nodal basins that may not be known based on surgical findings.…”

Pathological Characterization of Ovarian Cancer Patients Who Underwent Debulking Surgery in Combination With Diaphragmatic Surgery

“…In addition, the lymphatic spread of ovarian cancer is thought to occur mainly via pelvic and para-aortic pathways in an antegrade manner. 36 It is interesting to note that metastasis to the 326B (abdominal para-aortic) lymph node was significantly associated with metastasis to the diaphragmatic peritoneum ( P = 0.006). Lymphogenous metastasis appears to contradict the concept of normal lymphatic flow.…”