Lymphatic dissemination in gynecologic malignancies: major anatomical pathways

OBJECTIVE: To propose and anatomically substantiate a 2-pathway model of lymphatic dissemination in gynecologic cancers by correlating patterns of lymphatic spread with reproducible vascular landmarks identifiable on ultrasound and confirmed by cadaveric dissection. METHODS: A descriptive anatomical study was conducted integrating schematic anatomy, targeted cadaveric dissections, and high-resolution ultrasound correlation. Lymphatic dissemination pathways were identified using reproducible vascular landmarks, which were systematically assessed on ultrasound and anatomically verified on cadaveric specimens. Representative clinical imaging cases illustrating involvement of the posterior and anterior pathways were included. RESULTS: Two principal lymphatic pathways were consistently identified. The posterior pathway, organized along major retroperitoneal vessels and their tributaries, represented the predominant route of lymphatic dissemination across gynecologic cancers, reflecting its anatomical continuity and established caudo-cranial spread from pelvic to supradiaphragmatic nodal basins. In contrast, involvement of the anterior pathway was observed mainly in association with extensive peritoneal carcinomatosis affecting the anterior abdominal wall and diaphragm. Along both pathways, lymphatic dissemination followed consistent vascular landmarks that were reproducibly identifiable on ultrasound and anatomically confirmed on cadaveric specimens. CONCLUSIONS: This study anatomically substantiates a 2-pathway model of lymphatic dissemination in gynecologic cancers through integration of cadaveric dissection and ultrasound-based imaging correlation. A posterior (retroperitoneal) lymphatic pathway was identified as the predominant route of lymphatic spread, while an anterior (parietal) lymphatic pathway was observed in association with lymphatic drainage of the anterior abdominal and thoracic walls, particularly in advanced disease with carcinomatosis and ascites. This pathway-oriented framework provides an anatomical basis for structured interpretation of lymphatic dissemination patterns and supports imaging-based lymph node assessment using reproducible vascular landmarks.