A.C. Kraima

Understanding Lymphatic Drainage Pathways of the Ovaries to Predict Sites for Sentinel Nodes in Ovarian Cancer

Objective In ovarian cancer, detection of sentinel nodes is an upcoming procedure. Perioperative determination of the patient’s sentinel node(s) might prevent a radical lymphadenectomy and associated morbidity. It is essential to understand the lymphatic drainage pathways of the ovaries, which are surprisingly up till now poorly investigated, to predict the anatomical regions where sentinel nodes can be found. We aimed to describe the lymphatic drainage pathways of the human ovaries including their compartmental fascia borders. Methods A series of 3 human female fetuses and tissues samples from 1 human cadaveric specimen were studied. Immunohistochemical analysis was performed on paraffin-embedded transverse sections (8 or 10 &mgr;m) using antibodies against Lyve-1, S100, and &agr;-smooth muscle actin to identify the lymphatic endothelium, Schwann, and smooth muscle cells, respectively. Three-dimensional reconstructions were created. Results Two major and 1 minor lymphatic drainage pathways from the ovaries were detected. One pathway drained via the proper ligament of the ovaries (ovarian ligament) toward the lymph nodes in the obturator fossa and the internal iliac artery. Another pathway drained the ovaries via the suspensory ligament (infundibulopelvic ligament) toward the para-aortic and paracaval lymph nodes. A third minor pathway drained the ovaries via the round ligament to the inguinal lymph nodes. Lymph vessels draining the fallopian tube all followed the lymphatic drainage pathways of the ovaries. Conclusions The lymphatic drainage pathways of the ovaries invariably run via the suspensory ligament (infundibulopelvic ligament) and the proper ligament of the ovaries (ovarian ligament), as well as through the round ligament of the uterus. Because ovarian cancer might spread lymphogenously via these routes, the sentinel node can be detected in the para-aortic and paracaval regions, obturator fossa and surrounding internal iliac arteries, and inguinal regions. These findings support the strategy of injecting tracers in both ovarian ligaments to identify sentinel nodes.

Lymphatic drainage pathways from the cervix uteri: Implications for radical hysterectomy?

OBJECTIVE Radical hysterectomy with pelvic lymphadenectomy is the treatment of choice for early-stage cervical cancer. Wertheims original technique has been often modified, mainly in the extent of parametrectomy. Okabayashis technique is considered as the most radical variant regarding removal of the ventral parametrium and paracolpal tissues. Surgical outcome concerning recurrence and survival is good, but morbidity is high due to autonomic nerve damage. While the autonomic network has been studied extensively, the lymphatic system is less understood. This study describes the lymphatic drainage pathways of the cervix uteri and specifically the presence of lymphatics in the vesico-uterine ligament (VUL). METHODS A developmental series of 10 human female fetal pelves was studied. Paraffin embedded blocks were sliced in transverse sections of 8 or 10 μm. Analysis was performed by staining with antibodies against LYVE-1 (lymphatic endothelium), S100 (Schwann cells), alpha-Smooth Muscle Actin (smooth muscle cells) and CD68 (macrophages). The results were three-dimensionally represented. RESULTS Two major pathways drained the cervix uteri: a supra-ureteral pathway, running in the cardinal ligament superior to the ureter, and a dorsal pathway, running in the utero-sacral ligament towards the rectal pillars. No lymph vessels draining the cervix uteri were detected in the VUL. In the paracolpal parametrium lymph vessels draining the upper vagina fused with those from the bladder. CONCLUSIONS The VUL does not contain lymphatics from the cervix uteri. Hence, the favorable survival outcomes of the Okabayashi technique cannot be explained by radical removal of lymphatic pathways in the ventrocaudal parametrium.

Careful Dissection of the Distal Ureter Is Highly Important in Nerve-sparing Radical Pelvic Surgery: A 3D Reconstruction and Immunohistochemical Characterization of the Vesical Plexus.

Objective Radical hysterectomy with pelvic lymphadenectomy (RHL) is the preferred treatment for early-stage cervical cancer. Although oncological outcome is good with regard to recurrence and survival rates, it is well known that RHL might result in postoperative bladder impairments due to autonomic nerve disruption. The pelvic autonomic network has been extensively studied, but the anatomy of nerve fibers branching off the inferior hypogastric plexus to innervate the bladder is less known. Besides, the pathogenesis of bladder dysfunction after RHL is multifactorial but remains unclear. We studied the 3-dimensional anatomy and neuroanatomical composition of the vesical plexus and describe implications for RHL. Materials and Methods Six female adult cadaveric pelvises were macroscopically dissected. Additionally, a series of 10 female fetal pelvises (embryonic age, 10–22 weeks) was studied. Paraffin-embedded blocks were transversely sliced in 8-μm sections. (Immuno) histological analysis was performed with hematoxylin and eosin, azan, and antibodies against S-100 (Schwann cells), tyrosine hydroxylase (postganglionic sympathetic fibers), and vasoactive intestinal peptide (postganglionic parasympathetic fibers). The results were 3-dimensionally visualized. Results The vesical plexus formed a group of nerve fibers branching off the ventral part of the inferior hypogastric plexus to innervate the bladder. In all adult and fetal specimens, the vesical plexus was closely related to the distal ureter and located in both the superficial and deep layers of the vesicouterine ligament. Efferent nerve fibers belonging to the vesical plexus predominantly expressed tyrosine hydroxylase and little vasoactive intestinal peptide. Conclusions The vesical plexus is located in both layers of the vesicouterine ligament and has a very close relationship with the distal ureter. Complete mobilization of the ureter in RHL might cause bladder dysfunction due to sympathetic and parasympathetic denervation. Hence, the distal ureter should be regarded as a risk zone in which the vesical plexus can be damaged.

What Is the Anatomical Relationship of the Nerves in the Pelvis

The pelvis is often considered to be a complex anatomical region. Due to the funnel-shaped pelvic cavity, there is a close anatomical relationship of the rectum to vital structures such as blood vessels, lymphatics and somatic and autonomic nerves. This, taken together with the relatively inaccessible location of the rectum, makes total mesorectal excision (TME) a challenging surgical procedure. The principles of TME surgery involve removal of the diseased rectum with the surrounding mesorectum as an en bloc specimen with an intact mesorectal fascia and preservation of the pelvic autonomic nerves [1]. Over the last decades, both oncological and functional outcomes of TME surgery have gained much attention. It is well known that surgical disruption of the autonomic and somatic nerves may result in postoperative urogenital and anorectal dysfunction, affecting the patient’s functional outcome [2]. If the oncological safety is not in danger, surgeons must preserve the autonomic and somatic nerves in order to warrant sufficient postoperative pelvic function.

What Is Cancer of the Rectum

Rectal cancer constitutes one-third of all colorectal cancers, representing the cancer with the second highest incidence and the second cause of cancer death in the western society [1, 2]. An estimated 100,000 new cases of rectal cancer are diagnosed each year in Europe. The incidence is increasing, mainly due to earlier detection and increasing age of the population, as the highest incidence of rectal cancer is found in the sixth and seventh decades. High incidence rates are found especially in western world populations, i.e. Western Europe, North America and Australia. This can probably be explained by a combination of factors, including dietary patterns with high amounts of red meat, obesity and smoking [3]. The United States is the only country with significantly decreasing incidence rates in both males and females in the most recent time period, which largely reflects detection and removal of precancerous lesions through colorectal cancer screening [4]. Next to dietary and life-style factors, risk factors for rectal cancer include inflammatory bowel disease and primary sclerosing cholangitis. Also genetic predisposition plays a role; however, rectal cancer most commonly occurs sporadically and is inherited in only 5% of the cases. Five-year survival rate of rectal cancer is about 60% and depends to a large extent on disease stage at diagnosis [5].

2087 The development of a 3D anatomical atlas of the pelvis: Taking the next step in enhancing surgical anatomical education and clinical guidance

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