Pathway of Nodal Metastases from Carcinoma of the Transverse Colon

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After the paracolic nodes, lymphatic spread from carcinoma of the transverse colon may follow along the branches of the middle colic vessels in the transverse mesocolon toward the root of the mesocolon (Figs. 617 through 6-20). From the hepatic flexure, the spread would follow the right colic vessels or right middle colic vessels to the nodal group at the gastrocolic trunk where it drains into the SMV anterior to the head of the pancreas. From the splenic flexure, the lymphatic drainage would follow along the left middle colic vessels toward

Table 6-5. Intermediate and Principal Nodes of Various Segments of the Colon intermediate nodes Principa) nodes

Table 6-5. Intermediate and Principal Nodes of Various Segments of the Colon intermediate nodes Principa) nodes

Cecum

Ileocolic mesentery

Root of SMA

Ascending colon

Right colic vessels

Root of SMA

Ascending mesocolon

Ileocolic mesentery

Right transverse colon

Transverse mesocolon

Pancreatic head

Middle colic vessels

Root of SMA

Left transverse colon

Transverse mesocolon

Pancreatic body

Left middle colic vessels

Root of SMA

Descending colon

Descending mesocolon

Left paraduodenal space

Left colic vessels, IMV

Root of IMA

Sigmoid colon

Sigmoid mesocolon

Root of IMA

Sigmoidal vessels

Imv Drainage Into Splenic Vein
Fig. 6—13. Pathways of lymphatic drainage of the colon. (This figure also appears in the color insert.)

the IMV just caudal to the body and tail of the pancreas. On occasion, lymphatic spread may follow the left middle colic vein to the confluence of the IMV and the junction of the splenic vein and the SMV. Since the root of the transverse mesocolon is covering over the head of the pancreas and it is inserted caudal to the body and tail of the pancreas, progression of nodal metastasis or recurrent disease could involve the pancreas and not infrequently be mistaken as a pancreatic mass.

Pathway of Nodal Metastasis from Carcinoma of the Descending Colon and Sigmoid Colon

Lymphatic drainage of the descending colon and the sigmoid mesocolon follows along the vessels such as the sigmoidal vessels, the superior hemorrhoidal vessels, and the left ascending colic vessels in the mesocolon toward text continues on page 306

Ileocolic Vessels

Fig. 6—14. Carcinoma of cecum with metastatic nodes along ileocolic vessels in the ascending mesocolon at base of the mesentery.

(a) CT at level of cecum shows primary tumor (T) with metastatic nodes (N) at paracolic nodal group. Nodes are posterior to distal ileum.

(b) CT at level 3 cm cephalad to a shows metastatic nodes (N) along ileocolic vessel (arrow) at base of mesentery.

Fig. 6—14. Carcinoma of cecum with metastatic nodes along ileocolic vessels in the ascending mesocolon at base of the mesentery.

(a) CT at level of cecum shows primary tumor (T) with metastatic nodes (N) at paracolic nodal group. Nodes are posterior to distal ileum.

(b) CT at level 3 cm cephalad to a shows metastatic nodes (N) along ileocolic vessel (arrow) at base of mesentery.

Metastatic Carcinoid Tumor RadiologyLymfoma Ceakum Radiology

Fig. 6—15. Lymphoma of redundant cecum that is suspended in the pelvis.

(a) CT shows primary tumor (T) in cecum in pelvis.

(b) Enlarged nodes (N) can be identified along ileo-colic vessels (arrow) at base of mesentery that is attached to right iliac fossa.

Ileum Lymphatic Vessel

Fig. 6—16. Carcinoid of terminal ileum.

(a) The primary tumor (T) is evident.

(b) Metastatic node (N) at base of mesentery along ileocolic vessels (arrow).

Fig. 6—16. Carcinoid of terminal ileum.

(a) The primary tumor (T) is evident.

(b) Metastatic node (N) at base of mesentery along ileocolic vessels (arrow).

Primary Hepatic CarcinomaCecal Carcinoid Images Primary Hepatic Carcinoma

Fig. 6—17. Carcinoma of ascending colon and hepatic flexure with lymph node metastases in ascending mesocolon and root of transverse mesocolon.

(a) Primary tumor (T) in hepatic flexure.

(b) Cluster of nodes (arrows) in root of transverse mesocolon anterior to head of pancreas (P). T = tumor in ascending colon.

(c) Metastatic node (N) in ascending mesocolon anterior to duodenum (D).

Transverse Mesocolon

Fig. 6—18. Carcinoma of hepatic flexure of transverse colon with metastatic nodes in mesocolon and nodes at gastrocolic trunk.

(a) Primary tumor (T) at hepatic flexure. Note metastatic nodes (arrow) at paracolic nodal group.

(b) Note metastatic nodes (N) where right middle colic vein (arrow) drains into SMV (open arrow) anterior to head of pancreas (P).

Fig. 6—18. Carcinoma of hepatic flexure of transverse colon with metastatic nodes in mesocolon and nodes at gastrocolic trunk.

(a) Primary tumor (T) at hepatic flexure. Note metastatic nodes (arrow) at paracolic nodal group.

(b) Note metastatic nodes (N) where right middle colic vein (arrow) drains into SMV (open arrow) anterior to head of pancreas (P).

Transverse Colon Radiology

Fig. 6—19. Carcinoma of mid transverse colon with metastatic node in transverse mesocolon.

(a) Primary tumor (T) at midtransverse colon (TC). Note transverse colon suspended inferiorly to level of umbilicus.

(b) Because transverse colon is hanging down to lower abdomen, transverse mesocolon can be traced in cephalad direction toward the pancreas and, in this case, a metastatic node (N) can be identified along middle colic vein (arrow) behind the stomach (S), before the middle colic vein drains into SMV (open arrow).

Fig. 6—19. Carcinoma of mid transverse colon with metastatic node in transverse mesocolon.

(a) Primary tumor (T) at midtransverse colon (TC). Note transverse colon suspended inferiorly to level of umbilicus.

(b) Because transverse colon is hanging down to lower abdomen, transverse mesocolon can be traced in cephalad direction toward the pancreas and, in this case, a metastatic node (N) can be identified along middle colic vein (arrow) behind the stomach (S), before the middle colic vein drains into SMV (open arrow).

Transverse Colon Radiology

Fig. 6—20. Carcinoma of left transverse colon with metastatic nodes in left transverse mesocolon.

(a) Primary tumor (T) at left transverse mesocolon near surgical splenic flexure. Note metastatic paracolic nodes (arrow) along marginal vessels.

(b) Note nodes (long arrows) in transverse mesocolon along branches of left middle colic vessels (short arrow). Pancreas (P) is vertically oriented because of the absence of the left kidney.

the principal nodes at the origin of the IMA1819 (Figs. 6-21 and 6-22). Progression of nodal metastasis at the root of the sigmoid mesocolon, particularly the one that crosses the left ureter, may cause hydronephrosis of the left kidney. On rare occasion, metastasis may be observed along the IMV at the left duodenomesocolic fold lateral to the fourth portion of the duodenum because there are lymphoid aggregates along the IMV (Fig. 6-

Adenocarcinoma Sigmoid Colon
Fig. 6—21. Metastatic adenopathy (arrow) in sigmoid mesocolon, shown in (a) from primary tumor (T) in sigmoid colon shown in (b). Also note enlarged paracolic node (N) in (b).

VJp a

Transeverse Colon Mri

Fig. 6—22. Metastatic adenopathy in left colic node from primary tumor in sigmoid colon.

(a) Left colic node (small arrow) is shown between inferior mesenteric artery (medium arrow) and inferior mesenteric vein (long arrow).

(b) Nodes (arrows) in sigmoid mesocolon.

(c) Primary tumor (T) in sigmoid colon.

Fig. 6—23. Recurrent adenopathy (M) at left paraduodenal space with involvement of pancreas simulating pancreatic cancer. Patient had primary tumor in sigmoid colon resected. Recurrent disease was confirmed by aspiration biopsy.

Fig. 6—23. Recurrent adenopathy (M) at left paraduodenal space with involvement of pancreas simulating pancreatic cancer. Patient had primary tumor in sigmoid colon resected. Recurrent disease was confirmed by aspiration biopsy.

Paraduodenal Area And Picture

23). Metastasis to this area may involve the pancreas and simulate the pancreatic mass.21

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