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Clinical Oncology (2007) 19: 542e550

doi:10.1016/j.clon.2007.05.002

Original Article

An Atlas of the Pelvic Lymph Node Regions to Aid


Radiotherapy Target Volume Definition
A. Taylor*, A. G. Rockally, M. E. B. Powell*
*Department of Radiotherapy, St Bartholomew’s Hospital, London, UK; yDepartment of Radiology,
St Bartholomew’s Hospital, London, UK

ABSTRACT:
Aims: The implementation of advanced three-dimensional radiotherapy planning techniques requires accurate target
volume localisation. We have previously developed guidelines to aid definition of the pelvic lymph node regions, and the
aim of this study was to produce a CT atlas.
Materials and methods: The guidelines were applied to a CT scan of a patient to receive adjuvant radiotherapy.
Results: Reference CT images of the pelvis were generated, illustrating the nodal regions and a typical target volume for
adjuvant pelvic radiotherapy for gynaecological cancer.
Conclusion: These images can be used as an aid for target volume definition of the pelvic nodal regions. Taylor, A. et al.
(2007). Clinical Oncology 19, 542e550
ª 2007 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Key words: Clinical target volume, conformal radiotherapy, intensity-modulated radiotherapy, iron oxide particles, pelvic lymph nodes,
radiotherapy planning

Introduction for lymph nodes. Ultra-small particles of iron oxide (USPIO)


are a novel class of MRI contrast agent that make lymph
Accurate and reproducible delineation of target volumes is nodes more readily visible [7,8]. We have previously
essential for effective three-dimensional radiotherapy. reported a study with USPIO that assessed the position of
Pelvic lymph node irradiation has an important role in the the pelvic lymph nodes in relation to the blood vessels, and
management of many pelvic malignancies. Planning studies developed guidelines for outlining the lymph node regions
comparing intensity-modulated radiotherapy (IMRT) with [9]. These guidelines have been independently applied to
conventional approaches have shown significant dosimetric a further series of patients and found to be effective in
advantages in gynaecological and urological cancer [1e3]. ensuring target volume coverage for O99% of nodes [10].
However, one of the factors limiting widespread imple- The purpose of this study was to use the guidelines to
mentation of the technique has been a lack of consensus on develop a generic computed tomography atlas showing the
the target volume. position of pelvic lymph nodes that could then be applied
The probability of lymph nodes containing metastases is for three-dimensional radiotherapy planning techniques.
currently assessed using size criteria with computed
tomography or magnetic resonance imaging (MRI). A nodal Materials and Methods
maximal short axis diameter of greater than 10 mm
indicates a high risk of metastatic involvement, but the Radiotherapy planning computed tomography was used in
sensitivity of this method is only 40e70% [4e6]. Unenlarged a patient who was to receive postoperative radiotherapy to
nodes may still contain tumour deposits and it is therefore the pelvis, having previously undergone a simple abdominal
necessary to include all lymph nodes within the draining hysterectomy and bilateral salpingo-oophorectomy for uter-
regions of the tumour in the clinical target volume (CTV). ine cancer. The patient was scanned in the supine position
Most ‘normal size’ lymph nodes are too small to be directly with a full bladder, with 5 mm slice intervals from 2 cm above
visualised with standard imaging and delineation of the the aortic bifurcation to the lower limit of the inguinal
nodal CTV depends on their relationship to other pelvic region. Intravenous contrast was given to aid visualisation of
structures. the blood vessels. The images were transferred to a radio-
Anatomical studies have shown that pelvic lymph nodes therapy planning system (Eclipse v6.5, Varian).
lie adjacent to the major pelvic blood vessels. These are Using pelvic blood vessels as a surrogate target for lymph
relatively well visualised on conventional imaging and can, nodes, our guidelines for delineation were applied (Table 1).
with an appropriate margin, be used as a surrogate target First, a 7 mm margin was drawn around the pelvic blood

0936-6555/07/190542þ09 $35.00/0 ª 2007 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
PELVIC LYMPH NODE ATLAS 543

Table 1 e Summary of the guidelines for delineating nodal comprises the primary tumour, or tumour bed, structures at
regions risk of direct tumour spread, such as the parametrium, and
the draining lymph node regions. The pelvic lymph nodes,
Lymph node group Recommended margins* however, are difficult to delineate as most cannot be
visualised on computed tomography or MRI, but still may
Common iliac 7 mm margin around vessels. Extend posterior contain metastases. Because of greater conformity in all
and lateral borders to dimensions, consistent and accurate target volume defini-
psoas and vertebral body tion is particularly important with IMRT, as salvage
External iliac 7 mm margin around vessels. Extend anterior
treatment for relapsed disease due to a geographical miss
border by a further 10 mm anterolaterally
along the iliopsoas muscle to include the
is rarely successful [11].
lateral external iliac nodes With the complexity of dose pattern that can be achieved
Internal iliac 7 mm margin around vessels. Extend lateral with IMRT, it is now possible to select which nodal groups
borders to pelvic side wall need to be covered depending on tumour site and stage. The
Obturator Join external and internal iliac regions with proposed guidelines have been applied to generate an atlas
a 17 mm wide strip along the pelvic side wall of reference images defining each of the pelvic lymph node
Pre-sacral Subaortic: 10 mm strip over anterior sacrum regions and enabling standardisation of the target volumes
Mesorectal: cover entire mesorectal space for IMRT. It must be emphasised that there are no
pathologically enlarged nodes on these images, and it is still
*Also include any visible nodes. important to ensure that all visible nodes are fully encom-
passed by the CTV, as nodes with a diameter greater than
8 mm are readily identified with computed tomography.
vessels. The following modifications were then made: in the
For gynaecological cancers, the nodal CTV would
common iliac region, the contour was extended posteriorly
typically include the external iliac, internal iliac and
to the vertebral body, passing around the psoas muscle; to
obturator nodes. Treatment of the common iliac region is
encompass the obturator region, the contours around the
indicated for tumours involving the cervix, or when there is
external and internal iliac vessels were joined to create
lymphadenopathy in another pelvic region [12e15]. The
a single volume on each side of the pelvis, ensuring that
distal lateral external iliac nodes often lie distant from the
the width was at least 17 mm from the pelvic side wall;
vessels, and studies have shown that despite being missed
the upper pre-sacral region was covered with a 10 mm strip
by conventional fields in 34e45% of cases, this region is
over the anterior sacral prominence; where the margin
a rare site of recurrence [16e18]. Therefore, these nodes
passed over muscle or bone, these structures were deleted
do not need to be routinely encompassed and our practice
from the CTV; and finally, to cover the distal lateral external
would be to include them only if there is other external
iliac nodes, the volume was extended anterolaterally by
iliac nodal involvement, or if the target volume also
a further 1 cm along the line of the iliopsoas muscle. The
includes the inguinal regions. The lower pre-sacral nodes
parametria and vaginal vault were also outlined as a separate
are also included if there is tumour extension along the
structure.
uterosacral ligaments or if there is rectal involvement.
Reference images were produced showing the typical
Although the images show the CTV for gynaecological
target volume for adjuvant pelvic radiotherapy, including
cancer, it would not be unreasonable to extrapolate the
the common iliac, anterior and medial external iliac,
results to male pelvic anatomy, and to use a similar target
internal iliac, obturator and the subaortic pre-sacral lymph
volume when treating pelvic nodes for urological cancer.
node groups.
The selection of the appropriate nodal groups depends
on existing data from surgical and autopsy series, but there
Results will increasingly be more information available from
functional imaging and from sentinel lymph node studies,
The reference images produced by applying the guidelines which could help to refine or individualise the target
are shown in Fig. 1. The typical target volume for adjuvant volume. It will also be essential to collect data pro-
pelvic radiotherapy in gynaecological cancer has been spectively on the sites of pelvic recurrence in all patients
outlined, and the nodal groups are indicated. The additional treated with pelvic IMRT to assess whether future modifi-
margin required for including the distal lateral external iliac cation of the target volume is necessary.
nodes is shown in blue. The parametrium and the upper
vagina are shown in red, and the inguinal, pre-sacral and
lower para-aortic nodal regions are also indicated. Acknowledgements. This research was supported by the
X-Appeal fund, Royal College of Radiologists and the BUPA
Foundation, UK.
Discussion
Author for correspondence: A. Taylor, Department of
Conformal radiotherapy is increasingly recognised as Radiotherapy, Hammersmith Hospital, Du Cane Road, London W12
offering benefit in normal tissue sparing in whole pelvic 0HS, UK. Tel: þ44-20-8383-8132; E-mail: ataylor@hhnt.nhs.uk
irradiation. IMRT offers even greater potential for normal
tissue protection and dose escalation. The CTV usually Received 6 April 2007; accepted 2 May 2007
544 CLINICAL ONCOLOGY

Fig. 1 e The typical clinical target volume (CTV) for adjuvant pelvic radiotherapy in gynaecological cancer contoured in yellow, and
modifications shown to include lateral external iliac nodes (blue), inguino-femoral nodes (green) and the parametria and upper vagina (red).
The nodal regions indicated are para-aortic (PA), common iliac (CI), pre-sacral (PS), internal iliac (II), obturator (Obt), lateral (EIl), medial
(EIm) and anterior (EIa) external iliac, parametrial and paravaginal (Pm), and inguino-femoral (Ing) lymph nodes.
PELVIC LYMPH NODE ATLAS 545

Fig. 1 (Continued)
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Fig. 1 (Continued)
PELVIC LYMPH NODE ATLAS 547

Fig. 1 (Continued)
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Fig. 1 (Continued)
PELVIC LYMPH NODE ATLAS 549

Fig. 1 (Continued)
550 CLINICAL ONCOLOGY

References 9 Taylor A, Rockall AG, Reznek RH, et al. Mapping pelvic lymph
nodes: guidelines for delineation in intensity-modulated radio-
1 Mundt AJ, Lujan AE, Rotmensch J, et al. Intensity-modulated therapy. Int J Radiat Oncol Biol Phys 2005;63:1604e1612.
whole pelvic radiotherapy in women with gynecologic 10 Vilarino-Varela MJ, Taylor A, Rockall AG, et al. Whole pelvis
malignancies. Int J Radiat Oncol Biol Phys 2002;52: IMRT: verification of guidelines for lymph node delineation. Clin
1330e1337. Oncol 2005;17(Suppl. 1):3e4.
2 Portelance L, Chao KS, Grigsby PW, et al. Intensity-modulated 11 Hong JH, Tsai CS, Lai CH, et al. Recurrent squamous cell
radiation therapy (IMRT) reduces small bowel, rectum, and carcinoma of cervix after definitive radiotherapy. Int J Radiat
bladder doses in patients with cervical cancer receiving pelvic Oncol Biol Phys 2004;60:249e257.
and para-aortic irradiation. Int J Radiat Oncol Biol Phys 2001; 12 Benedetti-Panici P, Maneschi F, Scambia G, et al. Lymphatic
51:261e266. spread of cervical cancer: an anatomical and pathological study
3 Nutting CM, Convery DJ, Cosgrove VP, et al. Reduction of based on 225 radical hysterectomies with systematic pelvic and
small and large bowel irradiation using an optimized aortic lymphadenectomy. Gynecol Oncol 1996;62:19e24.
intensity-modulated pelvic radiotherapy technique in patients 13 Sakuragi N, Satoh C, Takeda N, et al. Incidence and distribution
with prostate cancer. Int J Radiat Oncol Biol Phys 2000;48: pattern of pelvic and paraaortic lymph node metastasis in
649e656. patients with stages IB, IIA, and IIB cervical carcinoma treated
4 Scheidler J, Hricak H, Yu KK, et al. Radiological evaluation of with radical hysterectomy. Cancer 1999;85:1547e1554.
lymph node metastases in patients with cervical cancer. A 14 Mariani A, Webb MJ, Keeney GL, et al. Routes of lymphatic
meta-analysis. JAMA 1997;278:1096e1101. spread: a study of 112 consecutive patients with endometrial
5 Williams AD, Cousins C, Soutter WP, et al. Detection of pelvic cancer. Gynecol Oncol 2001;81:100e104.
lymph node metastases in gynecologic malignancy: a comparison 15 Matsumoto K, Yoshikawa H, Yasugi T, et al. Distinct lymphatic
of CT, MR imaging, and positron emission tomography. Am J spread of endometrial carcinoma in comparison with cervical
Roentgenol 2001;177:343e348. and ovarian carcinomas. Cancer Lett 2002;180:83e89.
6 Bipat S, Glas AS, van der Velden J, et al. Computed tomography 16 Pendlebury SC, Cahill S, Crandon AJ, et al. Role of bipedal
and magnetic resonance imaging in staging of uterine cervical lymphangiogram in radiation treatment planning for cervix
carcinoma: a systematic review. Gynecol Oncol 2003;91:59e66. cancer. Int J Radiat Oncol Biol Phys 1993;27:959e962.
7 Mack MG, Balzer JO, Straub R, et al. Superparamagnetic iron 17 Bonin SR, Lanciano RM, Corn BW, et al. Bony landmarks are not
oxide-enhanced MR imaging of head and neck lymph nodes. an adequate substitute for lymphangiography in defining pelvic
Radiology 2002;222:239e244. lymph node location for the treatment of cervical cancer with
8 Rockall AG, Sohaib SA, Harisinghani MG, et al. Diagnostic radiotherapy. Int J Radiat Oncol Biol Phys 1996;34:167e172.
performance of nanoparticle-enhanced magnetic resonance 18 Greer BE, Koh WJ, Figge DC, et al. Gynecologic radiotherapy
imaging in the diagnosis of lymph node metastases in patients fields defined by intraoperative measurements. Gynecol Oncol
with endometrial and cervical cancer. J Clin Oncol 2005;23: 1990;38:421e424.
2813e2821.