Abdominal Radiology

, Volume 44, Issue 11, pp 3527–3535 | Cite as

Nodal drainage pathways in primary rectal cancer: anatomy of regional and distant nodal spread

  • Harmeet KaurEmail author
  • Randy D. Ernst
  • Gaiane M. Rauch
  • Mukesh Harisinghani
Special Section: Rectal Cancer


Nodal involvement is a significant prognostic factor in rectal cancer and difficult to assess preoperatively. An understanding of the patterns of nodal spread from different regions of the rectum can assist in this process and is essential for the purposes of surgical planning. In this article we define patterns of spread to mesenteric and pelvic sidewall nodal subgroups and discuss the importance of accurate anatomic localization of nodes for the purposes of staging and surgical planning.


Rectal cancer Rectal adenocarcinoma Lymph node MRI CT 



We would like to acknowledge our mentors Evelyne Loyer MD and the late Chulsip Charnsangavej MD whose approach to the imaging of cancer informs the content of this paper.


  1. 1.
    Heald RJ, Moran BJ. Embryology and anatomy of the rectum. Semin Surg Oncol. 1998 Sep;15(2):66-71. PubMed PMID: 9730411. Epub 1998/09/08.Google Scholar
  2. 2.
    General rules for clinical and pathological studies on cancer of the colon, rectum and anus. Part I. Clinical classification. Japanese Research Society for Cancer of the Colon and Rectum. Jpn J Surg. 1983 Nov;13(6):557-573. PubMed PMID: 6672390. Epub 1983/11/01.Google Scholar
  3. 3.
    Monson JR, Weiser MR, Buie WD, Chang GJ, Rafferty JF, Buie WD, et al. Practice parameters for the management of rectal cancer (revised). Dis Colon Rectum. 2013 May;56(5):535-550. PubMed PMID: 23575392. Epub 2013/04/12.Google Scholar
  4. 4.
    Sauer I, Bacon HE. Influence of lateral spread of cancer of the rectum on radicability of operation and prognosis. Am J Surg. 1951 Jan;81(1):111-120. PubMed PMID: 14799702. Epub 1951/01/01.Google Scholar
  5. 5.
    Gollub MJ, Maas M, Weiser M, Beets GL, Goodman K, Berkers L, et al. Recognition of the anterior peritoneal reflection at rectal MRI. AJR Am J Roentgenol. 2013 Jan;200(1):97-101. PubMed PMID: 23255747. Epub 2012/12/21.Google Scholar
  6. 6.
    Steup WH, Moriya Y, van de Velde CJ. Patterns of lymphatic spread in rectal cancer. A topographical analysis on lymph node metastases. Eur J Cancer. 2002 May;38(7):911-918. PubMed PMID: 11978516. Epub 2002/04/30.Google Scholar
  7. 7.
    Hojo K, Koyama Y, Moriya Y. Lymphatic spread and its prognostic value in patients with rectal cancer. Am J Surg. 1982 Sep;144(3):350-354. PubMed PMID: 7114377. Epub 1982/09/01.Google Scholar
  8. 8.
    Charnsangavej C, Dubrow RA, Varma DG, Herron DH, Robinson TJ, Whitley NO. CT of the mesocolon. Part 2. Pathologic considerations. Radiographics. 1993 Nov;13(6):1309-1322. PubMed PMID: 8290726. Epub 1993/11/01.Google Scholar
  9. 9.
    Morikawa E, Yasutomi M, Shindou K, Matsuda T, Mori N, Hida J, et al. Distribution of metastatic lymph nodes in colorectal cancer by the modified clearing method. Dis Colon Rectum. 1994 Mar;37(3):219-223. PubMed PMID: 8137667. Epub 1994/03/01.Google Scholar
  10. 10.
    Park JM, Charnsangavej C, Yoshimitsu K, Herron DH, Robinson TJ, Wallace S. Pathways of nodal metastasis from pelvic tumors: CT demonstration. Radiographics. 1994 Nov;14(6):1309-1321. PubMed PMID: 7855343. Epub 1994/11/01.Google Scholar
  11. 11.
    Y M. Importance of Lymphatic Spread. In: Soreide O, Norstein J In: Rectal Cancer Surgery: Optimisation S, Documentation, editor. Optimisation, Standardisation, Documentation; New York, NY: Springer-Verlag Berlin Heidelberg; 1997. p. 153-164.
  12. 12.
    McMahon CJ, Rofsky NM, Pedrosa I. Lymphatic metastases from pelvic tumors: anatomic classification, characterization, and staging. Radiology. 2010 Jan;254(1):31-46. PubMed PMID: 20032141. Epub 2009/12/25.Google Scholar
  13. 13.
    AJCC Cancer Staging Manual. 8th ed. Switzerland: Springe; 2017.Google Scholar
  14. 14.
    Akpinar E, Turkbey B, Karcaaltincaba M, Karaosmanoglu D, Akata D. MDCT of inferior mesenteric vein: normal anatomy and pathology. Clin Radiol. 2008 Jul;63(7):819-823. PubMed PMID: 18555041. Epub 2008/06/17.Google Scholar
  15. 15.
    Ogura A, Konishi T, Cunningham C, Garcia-Aguilar J, Iversen H, Toda S, et al. Neoadjuvant (Chemo)radiotherapy With Total Mesorectal Excision Only Is Not Sufficient to Prevent Lateral Local Recurrence in Enlarged Nodes: Results of the Multicenter Lateral Node Study of Patients With Low cT3/4 Rectal Cancer. J Clin Oncol. 2019 Jan 1;37(1):33-43. PubMed PMID: 30403572. Pubmed Central PMCID: PMC6366816. Epub 2018/11/08.Google Scholar
  16. 16.
    Ueno M, Oya M, Azekura K, Yamaguchi T, Muto T. Incidence and prognostic significance of lateral lymph node metastasis in patients with advanced low rectal cancer. Br J Surg. 2005 Jun;92(6):756-763. PubMed PMID: 15838895. Epub 2005/04/20.Google Scholar
  17. 17.
    Liu Y, Wang R, Ding Y, Tu S, Liu Y, Qian Y, et al. A predictive nomogram improved diagnostic accuracy and interobserver agreement of perirectal lymph nodes metastases in rectal cancer. Oncotarget. 2016 Mar 22;7(12):14755-14764. PubMed PMID: 26910373. Pubmed Central PMCID: PMC4924749. Epub 2016/02/26.Google Scholar

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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Diagnostic ImagingUniversity of Texas MD Anderson Cancer CenterHoustonUSA
  2. 2.Division of Abdominal Imaging, Department of RadiologyMassachusetts General Hospital, Harvard Medical SchoolBostonUSA

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