How Can We Identify the Position of the Positive Nodes in the Different Pelvic Compartments by Imaging?

Chapter

Abstract

Knowledge of the normal rectal lymphatic drainage is necessary to understand the location of metastatic nodes. The lymphatic drainage of the rectum and the enveloping fat (the mesorectum) follows the venous drainage of the rectum. The drainage occurs along a superior and lateral pathway [1]. The inferior part of the rectum (the distal 3 cm) drains through the lymphatic vessels along the middle rectal artery and subsequently into the internal iliac lymph nodes in the obturator areas (Fig. 12.1 shows the internal iliac lymph node chain and obturator area at MRI) [1]. The lymphatic drainage of the superior part of the rectum follows the superior rectal artery (Fig. 12.2) in the mesorectum to the pararectal lymph nodes and then towards the mesenteric lymph nodes of the sigmoid mesentery, from which they drain along the inferior mesenteric and lumbar lymph nodes [1]. The very low rectum (or the anorectum and thus relevant when low tumours invade the anal canal) can drain into the inguinal nodes and then along the external iliac chain [1]. Reports have shown that there is some variety in the lymphatic anatomy, mostly occurring in the drainage towards the internal iliac chain [2]. Additionally, it has been postulated that lateral drainage via the middle rectal artery to the internal iliac nodes might occur when the superior drainage is blocked, e.g. when tumour is obstructing the pathway [1]. Moreover, one should keep in mind that even the presence of tumour in the rectum can lead to an increase in the number and size of nodes, even in the absence of nodal metastasis [3].

References

  1. 1.
    Bell S, Sasaki J, Sinclair G et al (2009) Understanding the anatomy of lymphatic drainage and the use of blue-dye mapping to determine the extent of lymphadenectomy in rectal cancer surgery: unresolved issues. Color Dis 11:443–449CrossRefGoogle Scholar
  2. 2.
    Blair JB, Holyoke EA, Best RR (1950) A note on the lymphatics of the middle and lower rectum and anus. Anat Rec 108:635–644CrossRefPubMedGoogle Scholar
  3. 3.
    Maas M, Lambregts DM, Berkhof M et al (2010) Does the number of lymph nodes harvested at pathology in rectal cancer depend on the surgeon and pathologist only? Eur J Surg Oncol 36:813Google Scholar
  4. 4.
    Arcangeli S, Valentini V, Nori SL et al (2003) Underlying anatomy for CTV contouring and lymphatic drainage in rectal cancer radiation therapy. Rays 28:331–336PubMedGoogle Scholar
  5. 5.
    Maas M, Beets-Tan RG, Lambregts DM et al (2011) Wait-and-see policy for clinical complete responders after chemoradiation for rectal cancer. J Clin Oncol 29:4633–4640CrossRefPubMedGoogle Scholar
  6. 6.
    Habr-Gama A, Perez RO, Nadalin W et al (2004) Operative versus nonoperative treatment for stage 0 distal rectal cancer following chemoradiation therapy: long-term results. Ann Surg 240:711–717; discussion 717–718Google Scholar
  7. 7.
    Wu ZY, Wan J, Li JH et al (2007) Prognostic value of lateral lymph node metastasis for advanced low rectal cancer. World J Gastroenterol 13:6048–6052CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Kim JS, Sohn DK, Park JW et al (2011) Prognostic significance of distribution of lymph node metastasis in advanced mid or low rectal cancer. J Surg Oncol 104:486–492CrossRefPubMedGoogle Scholar
  9. 9.
    Sprenger T, Rothe H, Becker H et al (2013) Lymph node metastases in rectal cancer after preoperative radiochemotherapy: impact of intramesorectal distribution and residual micrometastatic involvement. Am J Surg Pathol 37:1283–1289CrossRefPubMedGoogle Scholar
  10. 10.
    Leibold T, Shia J, Ruo L et al (2008) Prognostic implications of the distribution of lymph node metastases in rectal cancer after neoadjuvant chemoradiotherapy. J Clin Oncol 26:2106–2111CrossRefPubMedGoogle Scholar
  11. 11.
    Yao YF, Wang L, Liu YQ et al (2011) Lymph node distribution and pattern of metastases in the mesorectum following total mesorectal excision using the modified fat clearing technique. J Clin Pathol 64:1073–1077CrossRefPubMedGoogle Scholar
  12. 12.
    Engelen SM, Beets-Tan RG, Lahaye MJ et al (2008) Location of involved mesorectal and extramesorectal lymph nodes in patients with primary rectal cancer: preoperative assessment with MR imaging. Eur J Surg Oncol 34:776–781CrossRefPubMedGoogle Scholar
  13. 13.
    Heijnen LA, Maas M, Beets-Tan RG et al (2016) Nodal staging in rectal cancer: why is restaging after chemoradiation more accurate than primary nodal staging? Int J Color Dis 31:1157–1162CrossRefGoogle Scholar
  14. 14.
    Koh DM, Chau I, Tait D et al (2008) Evaluating mesorectal lymph nodes in rectal cancer before and after neoadjuvant chemoradiation using thin-section T2-weighted magnetic resonance imaging. Int J Radiat Oncol Biol Phys 71:456–461CrossRefPubMedGoogle Scholar
  15. 15.
    Heijnen LA, Lambregts DM, Lahaye MJ et al (2016) Good and complete responding locally advanced rectal tumors after chemoradiotherapy: where are the residual positive nodes located on restaging MRI? Abdom Radiol (NY) 41:1245–1252CrossRefGoogle Scholar
  16. 16.
    Koh DM, Brown G, Temple L et al (2005) Distribution of mesorectal lymph nodes in rectal cancer: in vivo MR imaging compared with histopathological examination. Initial observations. Eur Radiol 15:1650–1657CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2018

Authors and Affiliations

  1. 1.Department of RadiologyThe Netherlands Cancer InstituteAmsterdamThe Netherlands

Personalised recommendations