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

7. 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.

8. 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

9. Common iliac lymph nodes.

10. • 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.

11. 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);

12. 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

13. • 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

14. 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

15. 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.

16. • 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

17. Sacral nodes
Internal iliac nodes
•Lie in the hollow of the
sacrum
•Arranged around the internal
iliac artery
•Receive vessels from pelvic,
perineal and gluteal regions
•Receive vessels from pelvic
viscera, perineum and buttock
•Drain to the internal iliac or
common iliac nodes
External iliac nodes
•Drain to common iliac nodes
Common iliac nodes
•Receive drainage
from external and
internal iliac nodes
and sacraol nodes
•Drain into the lumbar
group of 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

18. Summary of pelvic viscera drainage
ORGAN
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.)
Middle part (along vaginal a.)
Lower part
Part below hymen (with those from
vulva and skin of perineum)
Node (s)
Lumbar
External iliac,
External iliac, internal iliac, and sacral
Superficial inguinal
External and internal iliac
Internal iliac
Internal iliac
Sacral and common iliac
Superficial inguinal
Testis and epididymis (along
testicular a.)
Seminal vesicle
Ductus deferens (pelvic portion)
Lumbar
Prostate
Internal iliac mainly; sacral and external iliac
Scrotum
Superficial inguinal
External and internal iliac
External iliac

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

20. Lymphatic drainage pathways – 8
Sharing same main terminal route
Comprise 3 lateral, intermediate and medial
chains
Pass to lacunar, external iliac and common
iliac nodes
Lateral Aortic and Lumbar trunks
Entering the cisterna chyli

21. 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 bladder
2. Lateral prostatic lobes
3. Uterine cervix and the
4. Vaginal fornix

22. 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
1. Prostate
2. Bladder
3. Uterine body
4. Middle part of rectum

23. 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.

24. 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 prostate
3. Lower part of the vagina

25. 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.

26. 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

27. Superficial
perineal accessory
pelvic pathway
For cancers of the anal
canal and the vulva
Pathway end in
the superficial
inguinal nodes
Follows upto the
deep inguinal nodes
And then connectes
to the external and
common pelvic iliac
chains

28. 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.

29. Prostrate may involve 4
alternative pathways for
the spread of metastasis
Uterine carcinoma
Rectum
• External iliac
• Internal iliac
• Presacral
• Internal pudendal
• Internal iliac
• Presacral
• Inferior mesentric
• Superficial perineal
routes
6 possible pathways of
mets
• Internal iliac
• External iliac
• Presacral
• Internal pudendal
• Gonadic
• Inguinal chains

30. Delineation of lymph node areas

31. 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.

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

34. 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.

35. 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.

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

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

38. Thank you