The lymphatic pathway is an important route of metastasis in gynecological malignancy. Therefore, the examination of lymph nodes is an essential part of the ultrasound evaluation in patients with known or suspected gynecological malignancy. The lymph nodes most frequently involved in gynecological malignancy (apart from vulvar cancer) are parietal (retroperitoneal) and visceral abdominopelvic lymph nodes. In advanced disease, more distant lymph-node regions, such as the inguinal, axillary and supraclavicular lymph nodes, can also be involved. The standardized description of lymph nodes has been published previously by the Vulvar International Tumor Analysis (VITA) collaborative group. Herein, a collaborative group of gynecologists and gynecological oncologists with extensive ultrasound experience presents a systematic methodology for ultrasonographic lymph-node assessment performed as part of the locoregional and distant work-up to assess the extent of gynecological malignancy. The aim of this consensus opinion is also to describe the anatomical classification and drainage pathways of the lymphatic system as relevant to the gynecological organs. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Department of Biomedical Science for Health University of Milan Milan Italy

Department of Clinical Surgical Diagnostic and Pediatric Sciences Unit of Obstetrics and Gynaecology University of Pavia IRCCS San Matteo Hospital Foundation Pavia Italy

Department of Gynaecological Oncology KK Women's and Children's Hospital Singapore

Department of Gynecologic Oncology ARNAS Civico Di Cristina Benfratelli University of Palermo Palermo Italy

Department of Gynecology Obstetrics and Neonatology 1st Faculty of Medicine Charles University and General University Hospital Prague Prague Czech Republic

Department of Obstetrics and Gynaecology Faculty of Medicine Semmelweis University Budapest Hungary

Department of Radiology 1st Faculty of Medicine Charles University and General University Hospital Prague Prague Czech Republic

Department of Woman and Child Health and Public Health Fondazione Policlinico Universitario Agostino Gemelli IRCCS Università Cattolica del Sacro Cuore Rome Italy

Gemelli Woman Health Center for Digital and Personalized Medicine Dipartimento Scienze della Vita e Sanità Pubblica Università Cattolica del Sacro Cuore Rome Italy

Institute of Anatomy 1st Faculty of Medicine Charles University Prague Czech Republic

Obstetrics and Gynaecology Department University Hospital Waterford Waterford Ireland

Unità Operativa di Chirurgia degli Organi Genitali Esterni Femminili Divisione di Ginecologia Oncologica Dipartimento Scienze della Salute della Donna del Bambino e di Sanità Pubblica Fondazione Policlinico Universitario A Gemelli IRCCS Rome Italy

Zobrazit více v PubMed

Guo J, Qian H, Ma F, Zhang Y, Cui X, Duan H. The characteristics of isolated para‐aortic lymph node metastases in endometrial cancer and their prognostic significance. Ther Adv Med Oncol. 2020;12:1758835920933036. PubMed PMC

Loukas M, Wartmann CT, Louis RG Jr, et al. Cisterna chyli: a detailed anatomic investigation. Clin Anat. 2007;20:683‐688. PubMed

Pinto P, Valentin L, Borcinova M, et al. Patient satisfaction with ultrasound, whole‐body CT and whole‐body diffusion‐weighted MRI for pre‐operative ovarian cancer staging: a multicenter prospective cross‐sectional survey. Int J Gynecol Cancer. 2024;34:871‐878. PubMed

Saini S, Seltzer SE, Bramson RT, et al. Technical cost of radiologic examinations: analysis across imaging modalities. Radiology. 2000;216:269‐272. PubMed

Fischerova D, Garganese G, Reina H, et al. Terms, definitions and measurements to describe sonographic features of lymph nodes: consensus opinion from the Vulvar International Tumor Analysis (VITA) group. Ultrasound Obstet Gynecol. 2021;57:861‐879. PubMed

Fischerova D, Smet C, Scovazzi U, Sousa DN, Hundarova K, Haldorsen IS. Staging by imaging in gynecologic cancer and the role of ultrasound: an update of European joint consensus statements. Int J Gynecol Cancer. 2024;34:363‐378. PubMed PMC

FIPAT . Terminologia Anatomica. 2nd ed. Federative International Programme for Anatomical Terminology; 2019. FIPAT.library.dal.ca.

Dabi Y, Bendifallah S, Kolanska K, et al. Anatomical basis of lymph node detection in gynecologic cancers: a review from a surgical perspective. Chin Clin Oncol. 2021;10:15. PubMed

Lengele B, Scalliet P. Anatomical bases for the radiological delineation of lymph node areas. Part III: pelvis and lower limbs. Radiother Oncol. 2009;92:22‐33. PubMed

Lengele B, Nyssen‐Behets C, Scalliet P. Anatomical bases for the radiological delineation of lymph node areas. Upper limbs, chest and abdomen. Radiother Oncol. 2007;84:335‐347. PubMed

Standring S, Gray HG. Anatomy: The Anatomical Basis of Clinical Practice. 42nd ed. Elsevier; 2020.

Fischerova D, Culcasi C, Gatti E, Ng Z, Burgetova A, Szabò G. Ultrasound assessment of the pelvic sidewall: methodological consensus opinion. Ultrasound Obstet Gynecol. 2025;65(1):94‐105. PubMed PMC

Gallotta V, Fanfani F, Fagotti A, et al. Mesenteric lymph node involvement in advanced ovarian cancer patients undergoing rectosigmoid resection: prognostic role and clinical considerations. Ann Surg Oncol. 2014;21:2369‐2375. PubMed

Fischerova D. Ultrasound scanning of the pelvis and abdomen for staging of gynecological tumors: a review. Ultrasound Obstet Gynecol. 2011;38:246‐266. PubMed

Daseler EH, Anson BJ, Reimann AF. Radical excision of the inguinal and iliac lymph glands; a study based upon 450 anatomical dissections and upon supportive clinical observations. Surg Gynecol Obstet. 1948;87:679‐694. PubMed

Abu‐Hijleh MF, Habbal OA, Moqattash ST. The role of the diaphragm in lymphatic absorption from the peritoneal cavity. J Anat. 1995;186(Pt 3):453‐467. PubMed PMC

Thomakos N, Diakosavvas M, Machairiotis N, Fasoulakis Z, Zarogoulidis P, Rodolakis A. Rare distant metastatic disease of ovarian and peritoneal carcinomatosis: a review of the literature. Cancers (Basel). 2019;11:1044. PubMed PMC

Agusti N, Bonaldo G, Kahn RM, et al. Cardiophrenic lymph nodes in advanced ovarian cancer. Int J Gynecol Cancer. 2023;34:150‐158. PubMed

Parungo CP, Soybel DI, Colson YL, et al. Lymphatic drainage of the peritoneal space: a pattern dependent on bowel lymphatics. Ann Surg Oncol. 2007;14:286‐298. PubMed PMC

Mert I, Kumar A, Sheedy SP, et al. Clinical significance of enlarged cardiophrenic lymph nodes in advanced ovarian cancer: implications for survival. Gynecol Oncol. 2018;148:68‐73. PubMed

Acs M, Piso P, Prader S. Current status of metastatic cardiophrenic lymph nodes (CPLNs) in patients with ovarian cancer: a review. Anticancer Res. 2022;42:13‐24. PubMed

Feragalli B, Mantini C, Civitareale N, Polverosi R, Tartaro A, Cotroneo AR. Extrapleural and cardiophrenic lymph nodes: prevalence, clinical significance and diagnostic value. Radiol Med. 2014;119:20‐26. PubMed

Im HJ, Kim YI, Paeng JC, Chung JK, Kang SB, Lee DS. Retrocrural lymph node metastasis disclosed by (18)F‐FDG PET/CT: a predictor of supra‐diaphragmatic spread in ovarian cancer. Nucl Med Mol Imaging. 2012;46:41‐47. PubMed PMC

Aldridge T, Kusanale A, Colbert S, Brennan PA. Supraclavicular metastases from distant primaries: what is the role of the head and neck surgeon? Br J Oral Maxillofac Surg. 2013;51:288‐293. PubMed

Mizutani M, Nawata S, Hirai I, Murakami G, Kimura W. Anatomy and histology of Virchow's node. Anat Sci Int. 2005;80:193‐198. PubMed

Tanaka T, Ohmichi M. Recurrent ovarian cancer presenting in the right supraclavicular lymph node with isolated metastasis: a case report. J Med Case Rep. 2012;6:176. PubMed PMC

Lengele B, Hamoir M, Scalliet P, Gregoire V. Anatomical bases for the radiological delineation of lymph node areas. Major collecting trunks, head and neck. Radiother Oncol. 2007;85:146‐155. PubMed

Ying M, Bhatia KSS, Lee YP, Yuen HY, Ahuja AT. Review of ultrasonography of malignant neck nodes: greyscale, Doppler, contrast enhancement and elastography. Cancer Imaging. 2014;13:658‐669. PubMed PMC

El Asmar A, Veys I, Larsimont D, Donckier V, Liberale G. Inferior epigastric artery lymph nodes: a pathway for systemic dissemination from peritoneal carcinomatosis? J Surg Oncol. 2021;123:311‐314. PubMed

Hasdemir PS, Aras F, Solmaz U, Guvenal T. Vulvar cancer with bilateral axillary lymph node metastasis. J Obstet Gynaecol. 2016;36:265‐266. PubMed

Kay S. Evaluation of Rotter's lymph nodes in radical mastectomy specimens as a guide to prognosis. Cancer. 1965;18:1441‐1444. PubMed

Ecanow JS, Abe H, Newstead GM, Ecanow DB, Jeske JM. Axillary staging of breast cancer: what the radiologist should know. Radiographics. 2013;33:1589‐1612. PubMed

Berg JW. The significance of axillary node levels in the study of breast carcinoma. Cancer. 1955;8:776‐778. PubMed

Dialani V, James DF, Slanetz PJ. A practical approach to imaging the axilla. Insights Imaging. 2015;6:217‐229. PubMed PMC

Harris SR. Ovarian cancer metastases to internal mammary nodes. Breast J. 2019;25:351‐352. PubMed

Barros AC, Mori LJ, Nishimura D, Jacomo AL. Surgical anatomy of the internal thoracic lymph nodes in fresh human cadavers: basis for sentinel node biopsy. World J Surg Oncol. 2016;14:135. PubMed PMC

Urano M, Denewar FA, Murai T, et al. Internal mammary lymph node metastases in breast cancer: what should radiologists know? Jpn J Radiol. 2018;36:629‐640. PubMed