Roentgen anatomy of the ilio-pelvic-aortic lymphatic system.

Abstract

Lymphography allows complete and systematic anatomical study of the ilio-pelvic-aortic lymphatic system in the living patient. The entire network of lymphatic channels and nodes is shown in its continuity and interrelationships. The first echelon of lymphatic drainage of all the pelvic organs is demonstrated by this procedure. In the past thirty years anatomical studies of the ilio-pelvic lymphatic system have been outnumbered by surgical and pathological investigations using surgical landmarks and specific disease entities. Nodal groups have been named according to their presumed importance. This tendency has not only led to a total confusion in terminology, but also to a distortion of the understanding of the basic anatomy. The object of this study is to show the consistency and completeness of the lymphatic anatomy as demonstrated in lymphograms. Patient Material One hundred and fifty patients were studied by our group. All were adult; the majority were females. In most instances lymphography was done because of the possibility of pathologic changes in the lymphatic system. Twenty patients were selected from the larger group for the present investigation because clinically, radiographically, and pathologically their lymphatic systems were normal. Lymphographic Technic In all cases studied a superficial lymphatic vessel on the medial aspect of the dorsum of the foot was cannulated (Kinmonth, 9–14). The contrast material was Ethiodol, the ethyl ester of iodized fatty acids of poppyseed oil, containing 37 per cent iodine (6, 22, 23). Usually 9 c.c. was injected on each side over a period of one to two hours. Roentgenograms taken immediately after injection demonstrated the lymphatic vessels, and at twenty-four to forty-eight hours the lymph nodes were visualized. Pelvic arteriograms and venograms were obtained following the lymphograms, for better topographical evaluation. Anatomical Review Our primary anatomical reference is the classical description and classification of the ilio-pelvic nodes by Cunéo and Marcille (4, 5). Though the lymphatic system, consisting of lymph channels and nodes, is continuous, without demarcation, for the convenience of description the nodes of the ilio-pelvic-aortic region are arbitrarily divided into several groups (18–21) : 1. The External Iliac Group (Fig. 1): The nodes of the external iliac group are situated around the external iliac vessels in a fairly constant arrangement, forming three chains: (a) the external chain, consisting of three or four nodes, situated laterally to the external iliac artery; (b) the middle chain, comprising two or three nodes, on the anterior surface of the external iliac vein; (c) the internal chain, formed by three or four nodes situated below the external iliac vein against the lateral pelvic wall. Though the internal chain is prolapsed into the pelvis, it is continuous with the deep inguinal lymphatic system.