Lymphatic drainage, tumor, Ultrasounography

Lymphatic drainage pathways in vaginal cancer depend on the localization of the tumor. The upper two thirds of the vagina usualhird drains into the inguinal and femoral nodes. Howevly drain primarily to deep pelvic nodes, the lower one-ter, some studies documented large variance of the lymph drainage. The recomended surgical approach for distal vaginal lesions involved radical resection of infiltrated vagina to achieve adequate negative margins and inguinal lymph node dissection. 72 year-old woman has been referred to University hospital of Ostrava with histologically confirmed adenocarcinoma of the vagina. Gynaecological examination revealed the exophytic tumor size of 3 × 1.5 × 1.5 centimeters involving lower posterior wall of the vagina. The distance from the vaginal entrance was 1 centimeter. Ultrasounography detected vascularised exophytic tumor of distal part of vagina with no spread to the rectal wall or lymfadenopathy in the groins and in the pelvis. Surgical treatment has been recommended. The radiolabeled technetium-99 m colloid has been injected in four quadrants around the lesion directly into the junction of tumor and normal vaginal mucosa two hours before surgery. Following lymphoscintigraphy showed no activity in the groins but detected sentinel lymph nodes in pelvis. In operating room the isosulfan blue has been injected in the same manner. Pelvic sentinel nodes were detected by gamma counter and blue dye and removed by laparoscopic approach. After systematic pelvic lymphadenectomy the radical excision of vaginal tumor with clear margin was performed. Histological findings confirmed adenocarcinoma of vagina, clear margins of excision and no involvement of lymph nodes. Conclusion The lymph drainage of the vagina has a large variance. Preoperative lymphoscintigraphy is able to identify the nodes most at risk for metastatic disease (the sentinel nodes) and helps to choose optimal surgical approach in treatment of vaginal cancer patients