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Pelvic Lymphadenectomy in Gynecologic Oncology—Significance of Anatomical Variations

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Pelvic Lymphadenectomy in Gynecologic Oncology—Significance of Anatomical Variations diagnostics Review Pelvic Lymphadenectomy in Gynecologic Oncology—Significance of Anatomical Variations Stoyan Kostov 1 , Yavor Kornovski 1, Stanislav Slavchev 1 , Yonka Ivanova 1, Deyan Dzhenkov 2 , Nikolay Dimitrov 3 and Angel Yordanov 4,* 1 Department of Gynecology, Medical University Varna “Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; [email protected] (S.K.); [email protected] (Y.K.); [email protected] (S.S.); [email protected] (Y.I.) 2 Department of General and Clinical Pathology, Forensic Medicine and Deontology, Division of General and Clinical Pathology, Faculty of Medicine, Medical University Varna “Prof. Dr. Paraskev Stoyanov”, 9002 Varna, Bulgaria; [email protected] 3 Department of Anatomy, Faculty of Medicine, Trakia University, 6000 Stara Zagora, Bulgaria; [email protected] 4 Department of Gynecologic Oncology, Medical University Pleven, 5800 Pleven, Bulgaria * Correspondence: [email protected] Abstract: Pelvic lymphadenectomy is a common surgical procedure in gynecologic oncology. Pelvic lymph node dissection is performed for all types of gynecological malignancies to evaluate the extent of a disease and facilitate further treatment planning. Most studies examine the lymphatic spread, the prognostic, and therapeutic significance of the lymph nodes. However, there are very few studies describing the possible surgical approaches and the anatomical variations. Moreover, a correlation between anatomical variations and lymphadenectomy in the pelvic region has never been discussed in medical literature. The present article aims to expand the limited knowledge of the anatomical variations in the pelvis. Anatomical variations of the ureters, pelvic vessels, and nerves and their significance to pelvic lymphadenectomy are summarized, explained, and illustrated. Surgeons should Citation: Kostov, S.; Kornovski, Y.; be familiar with pelvic anatomy and its variations to safely perform a pelvic lymphadenectomy. Slavchev, S.; Ivanova, Y.; Dzhenkov, Learning the proper lymphadenectomy technique relating to anatomical landmarks and variations D.; Dimitrov, N.; Yordanov, A. Pelvic may decrease morbidity and mortality. Furthermore, accurate description and analysis of the majority Lymphadenectomy in Gynecologic Oncology—Significance of of pelvic anatomical variations may impact not only gynecological surgery, but also spinal surgery, Anatomical Variations. Diagnostics urology, and orthopedics. 2021, 11, 89. https://doi.org/ 10.3390/diagnostics11010089 Keywords: anatomical landmarks; anatomical variations; pelvic lymph nodes; gynecologic oncology; pelvic lymphadenectomy Received: 28 November 2020 Accepted: 5 January 2021 Published: 7 January 2021 1. Introduction Publisher’s Note: MDPI stays neu- Pelvic lymph node dissection (PLND) is a common surgical procedure in gynecologic tral with regard to jurisdictional clai- oncology [1]. The lymphatic system is the primary dissemination pathway for gynecologi- ms in published maps and institutio- cal malignancies. PLND is applied for cancer staging, prognosis, surgical, and postoper- nal affiliations. ative management [2,3]. PLND is performed for all types of gynecological malignancies to evaluate the extent of a disease and facilitate further treatment planning. Additionally, PLND is beneficial in cases where removing metastatic lymph nodes improves overall Copyright: © 2021 by the authors. Li- survival and disease-free survival [4]. Most studies examine the lymphatic spread, the censee MDPI, Basel, Switzerland. prognostic, and therapeutic significance of pelvic lymph nodes. However, there are very This article is an open access article few studies describing the possible surgical approach, dissection techniques and anatomi- distributed under the terms and con- cal variations [5]. There is limited information and disagreement on lymph nodes location, ditions of the Creative Commons At- groups, and overall number [6]. tribution (CC BY) license (https:// Moreover, a correlation between anatomical variations and PLND in the pelvic region creativecommons.org/licenses/by/ has never been discussed in medical literature. Surgeons should be familiar with pelvic 4.0/). Diagnostics 2021, 11, 89. https://doi.org/10.3390/diagnostics11010089 https://www.mdpi.com/journal/diagnostics Diagnostics 2021, 11, x FOR PEER REVIEW 2 of 27 pelvic anatomy and its variations to safely perform PLND. Learning the proper lymphad- enectomy technique relating to anatomical landmarks and variations may decrease mor- Diagnostics 2021, 11, 89 bidity and mortality [7]. The present article aims to define, detail,2 of 27 and summarize the an- atomic landmarks during PLND in gynecologic oncology. Furthermore, a summary of the anatomymost common and its variations anatomical to safely perform variations PLND. Learning (of nerves, the proper vessels, lymphadenectomy ureters) and potential complica- techniquetions related relating toto anatomical PLND in landmarks the pelvic and variations region mayare decreaseclearly morbidity defined. and mortality [7]. The present article aims to define, detail, and summarize the anatomic landmarks during PLND in gynecologic oncology. Furthermore, a summary of the most common2. Pelvic anatomical Lymph variations Nodes (of and nerves, Regions vessels, ureters) and potential complications related to PLND in the pelvic region are clearly defined. Knowledge of the anatomical localization of lymph node groups in the pelvis is es- 2.sential Pelvic Lymph for the Nodes effectiveness and Regions and safety of lymphadenectomy [8]. The pelvic lymph nodes Knowledge of the anatomical localization of lymph node groups in the pelvis is essentialand the for connecting the effectiveness lymphatic and safety of channels lymphadenectomy commu [8].nicate The pelvic with lymph the venous system; the lym- nodesphatic and system the connecting embryologically lymphatic channels develops communicate from with vascular the venous system;plexuses, the arising from the venous lymphatic system embryologically develops from vascular plexuses, arising from the venoussystem system [3]. [ 3].The The anatomical anatomical localization localization of the major of groupsthe major and sub-groups groups of and sub-groups of pelvic pelviclymph lymph nodes nodes is summarizedsummarized in Figures in Figures1–3[2,6,8–15 1–3]. [2,6,8–15]. FigureFigure 1. Common 1. Common iliac lymph iliac nodes lymph classification nodes (open classification surgery). 1. Lateral—between (open surgery). lateral part1. Lateral—between lateral part ofof CIV CIV and medialand partmedial of psoas part major of muscle, psoas2. medial—medial major muscle, to CIV 2. and medial—medial CIA, 3. middle—located to CIV and CIA, 3. middle— in the lumbosacral fossa, 4. subaortic—below aortic bifurcation, 5. promontory—at the promontory. AA—abdominallocated in the aorta, lumbosacral IVC—inferior vena fossa, cava, RV—right4. subaortic—below renal vein, PMM—psoas aortic major bifurcation, muscle, 5. promontory—at the CIA—commonpromontory. iliac AA—abdominal artery, CIV—common iliac aorta, vein, Cr—cranial,IVC—inferior Ca—caudal, vena L—Left, cava, R—right. RV—right renal vein, PMM—psoas major muscle, CIA—common iliac artery, CIV—common iliac vein, Cr—cranial, Ca—caudal, L— Left, R—right. Diagnostics 2021 11 Diagnostics 2021,, 11,, x 89 FOR PEER REVIEW 3 of 27 3 of 27 Diagnostics 2021, 11, x FOR PEER REVIEW 3 of 27 Figure 2. External iliac lymph nodes classification (embalmed cadaver). 1. Lateral—lateral to exter- Figure 2. External iliac lymph nodes classification (embalmed cadaver). 1. Lateral—lateral to external iliacnal artery,iliac artery,2. middle—medial 2. middle—medial to the EIA toand the lateralEIA and to the lateral EIV, 3.tomedial—medial the EIV, 3. medial—medial to both external to both ex- Figureternal 2. iliac External vessels, iliac lymph 4. obturator—around nodes classification (embalmedthe obturator cadaver). nerve 1. Lateral—lateral and vessels, to5. exter- interiliac—at the level iliacnal iliac vessels, artery,4. 2.obturator—around middle—medial to the the EIA obturator and lateral nerve to the and EIV, vessels, 3. medial—medial5. interiliac—at to both ex- the level of CIAternalof CIA bifurcation, iliac bifurcation, vessels, between 4. obturator—around between the EIA the and EIA the IIA. and obtu PMM—psoas IIA.rator PMM—nerve and majorpsoas vessels, muscle, major 5. interiliac—at muscle, EIA—external EIA—external the level iliac artery, iliac artery, EIV—externalofEIV—external CIA bifurcation, iliac iliac between vein, vein, IIA—internal the IIA—internal EIA and IIA. iliac PMM— artery, iliacpsoas arte Ur—ureter,ry, major Ur—ureter, muscle, U—uterus, EIA—external U—uterus, B—bladder, iliac B—bladder, artery, SRA—superior SRA—supe- EIV—external iliac vein, IIA—internal iliac artery, Ur—ureter, U—uterus, B—bladder, SRA—supe- rectalrior rectal artery, artery, Pr—promontorium, Pr—promontorium, R—rectum, R—rect L—left,um, r—right, L—left, Cr—cranial, r—right, Ca—caudal.Cr—cranial, Ca—caudal. rior rectal artery, Pr—promontorium, R—rectum, L—left, r—right, Cr—cranial, Ca—caudal. Figure 3. Internal iliac lymph nodes classification (embalmed cadaver—left hemipelvis). 1. Ante- Figure 3. Internal iliac lymph nodes classification (embalmed cadaver—left hemipelvis). 1. Anterior— rior—anterior to anterior division of internal iliac artery, 2. lateral sacral—close to the paired lateral anteriorsacral arteries, to anterior 3. gluteal—between division of internal superior iliac gluteal artery, and2. internallateral iliac sacral—close
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