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Lymph node nomenclature in gynecologic oncology
GYNECOLOGIC
ONCOLOGY
23, 222-226 (1986)
Lymph Node Nomenclature In Gynecologlc Oncology CHARLES E MANGAN, M D , STEPHEN C RUBIN, RABIN, M D , AND JOHN J MIKUTA, Dwwon
of Gynecologrc
Oncology,
Hosprtal of the Umvermty Pennsylvanra 19104
M D ,l DOUGLAS S M D
of Pennsylvanra,
Phdadelphza,
Received Mdy 15, 1985 The nomenclature of the lymph node groups drammg the pelvic organs has been poorly standardized This has lmpalred understandmg of the natural hlstory of gynecologlc mahgnancles and led to dlfficultles m commumcatlon among specmhsts treating those diseases In order to assess the extent of this problem, members of the Society of Gynecologlc Oncologists and other physlcmns treatmg pelvic malignancy were asked to label a diagram of the pelvic lymph nodes The lack of umformlty m the answers confirms the need for a simple, chmcally relevant system of nomenclature Such a system IS proposed 0 1986 Academic
Press
Inc
INTRODUCTION The lymphatic system constitutes a pnmary avenue of dlssemmatlon for many mahgnancles, and 1s of mcreasmgly recognized importance m the management of gynecologlc cancers For many such cancers, evaluation of the reglonal lymph nodes by nomnvaslve and mvaslve techniques offers important dlagnostlc, prognostic, and therapeutic mformatlon In surveying the clmlcal literature, it 1s evident that among speclahsts there 1s a wide variety and substantial discrepancy m the nomenclature of various lymph node groups Perusal of several standard reference texts also shows a confusmg array of names being applied to the genital lymph nodes [ 1,2], and many anatomy texts, m fact, pay scant attention to these nodes [3-51 These dlscrepancles m termmology could at best lead to dtificulty m commumcatlon among gynecologlc oncologists, radiation therapists, and pathologists, and at worst to serious errors in patient management MATERIALS AND METHODS To assess the extent of this problem with nomenclature, a diagram of the pelvic lymph nodes, modified from dlustratlons m Plenty1 and Fnedman [ 11, was sent to members of the Society of Gynecologc Oncolo@sts and to a representative group of academically affiliated radiation theraplsts and pathologists ’ Current address Dlvlslon of Gynecology, Memonal Sloan-Kettermg Avenue, New York, N Y 10021 222 0090-8258186 $1 50 Copyright AU n&s
0 1986 by Academic Press Inc of reproductmn m any form reserved
Cancer Center, 1275 York
LYMPH
FIG
1
NODE
NOMENCLATURE
223
The nme maJor groups of lymph nodes that prowde dramage for the pelwc organs
The diagram (Fig 1) indicates by number mne major groups of nodes that provide lymph dramage for the pelvic organs and that may be involved with the spread of pelvic malignancy Each speclahst was asked to name the designated node groups with or without the aid of reference material Of the 175 diagrams sent, 163 were returned, a 93% response The names listed for each numbered nodal group were tabulated and broken down according to the specialty of the respondent-gynecologc oncologM, ra&olo@st, patholopst In some cases names were grouped that had smular spellmgs, or used the adjectives “right” or “left,” or had other minor modlficatlons or vanatlons The responses for each nodal group are listed m Table 1 RESULTS Nodal Group No 1 What one presumes ts a tughly identifiable group of nodes, as well as one of major importance m staging and therapy, ehclted seven different names from our respondents The terms “paraaortlc” and “penaortlc” were most common, with only 16% of gynecologlc oncologists using the term “aortlc” as preferred by Plenty1 and Friedman [l] Nodal Group No 2 This group showed the most umformlty among the three respondent categories, as well as the best mtragroup consistency, with all but 4 of the 163 physicians agreeing with the designation of “common iliac ”
224
MANGAN
ET
AL
TABLE 1 PERCENTAGEOF RESFQNSES FROMPHYSICIANS“ Nodal groupb
GYN (%I
PATH wo)
1 62 18 16 4
74 13 6 7
22 11 33 34
Common iliac Other
97 3
100 0
89 11
External dlac External Iliac lateral group Other
80 19 1
81 16 3
56 34 10
External lhac (or variation) External tiac med group Intenhac Other
56 20 14 10
65 24 6 5
33 26 13 28
Obturator Hypogastnc Other
76 11 13
73 0 27
67 0 33
Gluteal (or vanatlon) Hypogastnc Obturator Other
37 14 10 39
21 29 6 44
28 0 14 58
Hypogastnc Internal Iliac Other
55
29 16
35 62 3
60 30 10
Presacral (or vanatlon) Sacral (or vanatlon) Other
66 27 7
44 47 9
10 70 20
Presacral (or vanation) Sacral (or variation) Subaortlc
54 18 15
27 33 12
10 40 10
ParaaOrtlC
Penaortic Aortlc Other 2 3
4
5
6
7
8
9
Note Abbrewatlons used, GYN, gynecologlc oncologists, patholog&s a All responses by ~10% of gynecologlc oncologists hsted b Numbers refer to nodal groups m Fig 1
RT, radlatlon
theraplsts, PATH,
Nodal Group No 3
Our respondents showed relative mtra- and intergroup consistency m naming this chain Eighty percent of gynecologlc oncologists used the term “external llac” and the maJonty of the remainder quahfied these as “external Iliac lateral group ”
LYMPH
Nodal
Group No
NODE
NOMENCLATURE
225
4
There was somewhat less agreement for this group, with the term “external iliac” being most common among the gynecologlc oncologists (56%) Much of the discrepancy m this group results from the use of a more specific name, 1 e , “external lhac medial group ” Of note IS that only 14% of the gynecologlc oncologists used Plenty1 and Friedman’s term “mtenhac ” Nodal
Group No
5
Most of the gynecolo@c oncolo@sts as well as the tiotheraplsts and pathologsts chose to call these “obturator” nodes, with the remainder preferrmg the term “hypogastnc ” This group of nodes ehclted 20 different names from our respondents, with none mcludmg these nodes with the “mtenhac” group as do Plenty1 and Friedman [l] Nodal
Group No
6
This group of nodes was poorly ldentlfied by our respondents, with only 12% of gynecologlc oncologists using Plenty1 and Fnedman’s term “mfenor gluteal” [I] Another 25% identified these only as “gluteal ” Sixty-three percent of gynecologlc oncologists surveyed used other names for these nodes, mcludmg 24% who identified these as “hypogastnc” or “obturator ” Radlotheraplsts and pathologlsts also did poorly m ldentlficatlon of this group, with only 21 and 28%, respectively, using “gluteal” or its variations Nodal
Group No
7
Thts group ehclted a relatively consistent response from our three groups of respondents, with most preferring the terms “hypogastnc” or “internal dlac,” which are commonly used as symptoms Only 7 out of the entire group of 163 used Plenty1 and Fnedman’s term “superior gluteal” [l] Nodal
Group No
8
Fourteen different terms were suggested for this group, with most of being variations of “pre-sacral” and “sacral” with quahfymg adJectlves adJectives applied would for the most part represent a source of confusion disagreement rather than clanficatlon, smce mfenor, lateral, deep, middle, superior, and median (m order of frequency) were all listed Nodal
Group No
them The and low,
9
This group demonstrated poor inter- and mtraspeclalty umformlty, as well as the most lmagmatlve names not correspondmg to Plenty1 and Fnedman [I] Most of the vanatlons clustered around “presacral” (supenor, upper, high, medd, precaval, preaortlc) and “sacral” (middle, high, mfenor, median, lumbo, lumbar, lateral, promontory) A total of 14% ldentlfied these nodes as “subaortlc,” the third most common answer DISCUSSION
Lymphatic disagreement
anatomy and nomenclature has been a SubJect of dlscusslon and for hundreds of years, and our survey confirms that termmology
226
MANGAN
TABLE PROWSED
Nodal group”
CLINICAL
ET
AL
2
NOMENCLATURE LYMPH NODES
OF PELVIC
Name Paraaortlc Common iliac External Iliac, lateral group External lhac, medial group Obturator Infenor gluteal Hypogastnc Presacral Subaortlc
a Numbers refer to nodal groups m Fig 1
IS still far from standardized This lmpau-s commumcatlon and interpretation of written reports, and hampers our understandmg of the natural history and manr agement of pelvic malignancies We found that there was a general umformlty among gynecologlc oncologists, radlatlon theraplsts, and pathologists m both nammg and mlsnammg the pelvic lymph nodes with certain groups bemg readily ldentlfied and other groups ehcltmg a wide vanety of often confllctmg deslgnatlons For all nodal groups, there were major dlscrepancles from the nomenclature system used by Plenty1 and Friedman [I], a standard and widely quoted reference We are aware that there are substantial vanatlons m nodal anatomy from patient to patient, and that our two-dlmenslonal diagram of nodal anatomy may have been difficult for some to interpret It 1s hkely that some local centers have good uniformity among then speclahsts, but this does not negate the problem of commumcatmg with other groups We also recogmze that not all the lymph nodes dlagrammed are routinely exammed by, or chmcally Important to, the pelvic cancer physlclan However, even among nodal groups that are commonly exammed and often involved there was poor agreement on nomenclature, and It IS clear that there 1s a need for a straightforward and descnptlve system for ldentlfymg these lymph nodes Such a system, proposed m Table 2, 1s a slmphficatlon of the termmology used by both Relffenstuhl [2] and Plenty1 and Friedman [l] and favors clmlcal relevance over anatomic minutia REFERENCES 1 Plentyl, A A , and Fnedman, E A Lymphahc system of the female gemtaba, Saunders, Phlladelphla (1971) 2 Reflenstuhl, G The fymphatxs of the female gemtal organs, Llppmcott, Phdadelphla (1964) 3 Grant, J C B , An atlas of anntomy, 8th ed , Wdhams & Wdkms, Baltunore (1983) 4 Ham&on, W J (Ed ) Textbook of human anatomy, 2nd ed , Mosby, St Louis (1976) 5 Gray H Anatomy of the human body, 30th Amencan ed , Lea & Feblger, Phdadelphla (1985)
ONCOLOGY
23, 222-226 (1986)
Lymph Node Nomenclature In Gynecologlc Oncology CHARLES E MANGAN, M D , STEPHEN C RUBIN, RABIN, M D , AND JOHN J MIKUTA, Dwwon
of Gynecologrc
Oncology,
Hosprtal of the Umvermty Pennsylvanra 19104
M D ,l DOUGLAS S M D
of Pennsylvanra,
Phdadelphza,
Received Mdy 15, 1985 The nomenclature of the lymph node groups drammg the pelvic organs has been poorly standardized This has lmpalred understandmg of the natural hlstory of gynecologlc mahgnancles and led to dlfficultles m commumcatlon among specmhsts treating those diseases In order to assess the extent of this problem, members of the Society of Gynecologlc Oncologists and other physlcmns treatmg pelvic malignancy were asked to label a diagram of the pelvic lymph nodes The lack of umformlty m the answers confirms the need for a simple, chmcally relevant system of nomenclature Such a system IS proposed 0 1986 Academic
Press
Inc
INTRODUCTION The lymphatic system constitutes a pnmary avenue of dlssemmatlon for many mahgnancles, and 1s of mcreasmgly recognized importance m the management of gynecologlc cancers For many such cancers, evaluation of the reglonal lymph nodes by nomnvaslve and mvaslve techniques offers important dlagnostlc, prognostic, and therapeutic mformatlon In surveying the clmlcal literature, it 1s evident that among speclahsts there 1s a wide variety and substantial discrepancy m the nomenclature of various lymph node groups Perusal of several standard reference texts also shows a confusmg array of names being applied to the genital lymph nodes [ 1,2], and many anatomy texts, m fact, pay scant attention to these nodes [3-51 These dlscrepancles m termmology could at best lead to dtificulty m commumcatlon among gynecologlc oncologists, radiation therapists, and pathologists, and at worst to serious errors in patient management MATERIALS AND METHODS To assess the extent of this problem with nomenclature, a diagram of the pelvic lymph nodes, modified from dlustratlons m Plenty1 and Fnedman [ 11, was sent to members of the Society of Gynecologc Oncolo@sts and to a representative group of academically affiliated radiation theraplsts and pathologists ’ Current address Dlvlslon of Gynecology, Memonal Sloan-Kettermg Avenue, New York, N Y 10021 222 0090-8258186 $1 50 Copyright AU n&s
0 1986 by Academic Press Inc of reproductmn m any form reserved
Cancer Center, 1275 York
LYMPH
FIG
1
NODE
NOMENCLATURE
223
The nme maJor groups of lymph nodes that prowde dramage for the pelwc organs
The diagram (Fig 1) indicates by number mne major groups of nodes that provide lymph dramage for the pelvic organs and that may be involved with the spread of pelvic malignancy Each speclahst was asked to name the designated node groups with or without the aid of reference material Of the 175 diagrams sent, 163 were returned, a 93% response The names listed for each numbered nodal group were tabulated and broken down according to the specialty of the respondent-gynecologc oncologM, ra&olo@st, patholopst In some cases names were grouped that had smular spellmgs, or used the adjectives “right” or “left,” or had other minor modlficatlons or vanatlons The responses for each nodal group are listed m Table 1 RESULTS Nodal Group No 1 What one presumes ts a tughly identifiable group of nodes, as well as one of major importance m staging and therapy, ehclted seven different names from our respondents The terms “paraaortlc” and “penaortlc” were most common, with only 16% of gynecologlc oncologists using the term “aortlc” as preferred by Plenty1 and Friedman [l] Nodal Group No 2 This group showed the most umformlty among the three respondent categories, as well as the best mtragroup consistency, with all but 4 of the 163 physicians agreeing with the designation of “common iliac ”
224
MANGAN
ET
AL
TABLE 1 PERCENTAGEOF RESFQNSES FROMPHYSICIANS“ Nodal groupb
GYN (%I
PATH wo)
1 62 18 16 4
74 13 6 7
22 11 33 34
Common iliac Other
97 3
100 0
89 11
External dlac External Iliac lateral group Other
80 19 1
81 16 3
56 34 10
External lhac (or variation) External tiac med group Intenhac Other
56 20 14 10
65 24 6 5
33 26 13 28
Obturator Hypogastnc Other
76 11 13
73 0 27
67 0 33
Gluteal (or vanatlon) Hypogastnc Obturator Other
37 14 10 39
21 29 6 44
28 0 14 58
Hypogastnc Internal Iliac Other
55
29 16
35 62 3
60 30 10
Presacral (or vanatlon) Sacral (or vanatlon) Other
66 27 7
44 47 9
10 70 20
Presacral (or vanation) Sacral (or variation) Subaortlc
54 18 15
27 33 12
10 40 10
ParaaOrtlC
Penaortic Aortlc Other 2 3
4
5
6
7
8
9
Note Abbrewatlons used, GYN, gynecologlc oncologists, patholog&s a All responses by ~10% of gynecologlc oncologists hsted b Numbers refer to nodal groups m Fig 1
RT, radlatlon
theraplsts, PATH,
Nodal Group No 3
Our respondents showed relative mtra- and intergroup consistency m naming this chain Eighty percent of gynecologlc oncologists used the term “external llac” and the maJonty of the remainder quahfied these as “external Iliac lateral group ”
LYMPH
Nodal
Group No
NODE
NOMENCLATURE
225
4
There was somewhat less agreement for this group, with the term “external iliac” being most common among the gynecologlc oncologists (56%) Much of the discrepancy m this group results from the use of a more specific name, 1 e , “external lhac medial group ” Of note IS that only 14% of the gynecologlc oncologists used Plenty1 and Friedman’s term “mtenhac ” Nodal
Group No
5
Most of the gynecolo@c oncolo@sts as well as the tiotheraplsts and pathologsts chose to call these “obturator” nodes, with the remainder preferrmg the term “hypogastnc ” This group of nodes ehclted 20 different names from our respondents, with none mcludmg these nodes with the “mtenhac” group as do Plenty1 and Friedman [l] Nodal
Group No
6
This group of nodes was poorly ldentlfied by our respondents, with only 12% of gynecologlc oncologists using Plenty1 and Fnedman’s term “mfenor gluteal” [I] Another 25% identified these only as “gluteal ” Sixty-three percent of gynecologlc oncologists surveyed used other names for these nodes, mcludmg 24% who identified these as “hypogastnc” or “obturator ” Radlotheraplsts and pathologlsts also did poorly m ldentlficatlon of this group, with only 21 and 28%, respectively, using “gluteal” or its variations Nodal
Group No
7
Thts group ehclted a relatively consistent response from our three groups of respondents, with most preferring the terms “hypogastnc” or “internal dlac,” which are commonly used as symptoms Only 7 out of the entire group of 163 used Plenty1 and Fnedman’s term “superior gluteal” [l] Nodal
Group No
8
Fourteen different terms were suggested for this group, with most of being variations of “pre-sacral” and “sacral” with quahfymg adJectlves adJectives applied would for the most part represent a source of confusion disagreement rather than clanficatlon, smce mfenor, lateral, deep, middle, superior, and median (m order of frequency) were all listed Nodal
Group No
them The and low,
9
This group demonstrated poor inter- and mtraspeclalty umformlty, as well as the most lmagmatlve names not correspondmg to Plenty1 and Fnedman [I] Most of the vanatlons clustered around “presacral” (supenor, upper, high, medd, precaval, preaortlc) and “sacral” (middle, high, mfenor, median, lumbo, lumbar, lateral, promontory) A total of 14% ldentlfied these nodes as “subaortlc,” the third most common answer DISCUSSION
Lymphatic disagreement
anatomy and nomenclature has been a SubJect of dlscusslon and for hundreds of years, and our survey confirms that termmology
226
MANGAN
TABLE PROWSED
Nodal group”
CLINICAL
ET
AL
2
NOMENCLATURE LYMPH NODES
OF PELVIC
Name Paraaortlc Common iliac External Iliac, lateral group External lhac, medial group Obturator Infenor gluteal Hypogastnc Presacral Subaortlc
a Numbers refer to nodal groups m Fig 1
IS still far from standardized This lmpau-s commumcatlon and interpretation of written reports, and hampers our understandmg of the natural history and manr agement of pelvic malignancies We found that there was a general umformlty among gynecologlc oncologists, radlatlon theraplsts, and pathologists m both nammg and mlsnammg the pelvic lymph nodes with certain groups bemg readily ldentlfied and other groups ehcltmg a wide vanety of often confllctmg deslgnatlons For all nodal groups, there were major dlscrepancles from the nomenclature system used by Plenty1 and Friedman [I], a standard and widely quoted reference We are aware that there are substantial vanatlons m nodal anatomy from patient to patient, and that our two-dlmenslonal diagram of nodal anatomy may have been difficult for some to interpret It 1s hkely that some local centers have good uniformity among then speclahsts, but this does not negate the problem of commumcatmg with other groups We also recogmze that not all the lymph nodes dlagrammed are routinely exammed by, or chmcally Important to, the pelvic cancer physlclan However, even among nodal groups that are commonly exammed and often involved there was poor agreement on nomenclature, and It IS clear that there 1s a need for a straightforward and descnptlve system for ldentlfymg these lymph nodes Such a system, proposed m Table 2, 1s a slmphficatlon of the termmology used by both Relffenstuhl [2] and Plenty1 and Friedman [l] and favors clmlcal relevance over anatomic minutia REFERENCES 1 Plentyl, A A , and Fnedman, E A Lymphahc system of the female gemtaba, Saunders, Phlladelphla (1971) 2 Reflenstuhl, G The fymphatxs of the female gemtal organs, Llppmcott, Phdadelphla (1964) 3 Grant, J C B , An atlas of anntomy, 8th ed , Wdhams & Wdkms, Baltunore (1983) 4 Ham&on, W J (Ed ) Textbook of human anatomy, 2nd ed , Mosby, St Louis (1976) 5 Gray H Anatomy of the human body, 30th Amencan ed , Lea & Feblger, Phdadelphla (1985)