The vascular portion of the cardinal ligament: surgical significance during radical hysterectomy for cervical cancer


      The objective of the study was to analyze the histopathologic content of the vascular portion of the cardinal ligament in patients undergoing radical hysterectomy for cervical cancer.

      Study Design

      The vascular portion of the cardinal ligament was completely removed during radical hysterectomy. The maximum cervical diameter and length of the vascular ligament were measured on the fresh specimen. After inking, the pathologist separated and embedded the entire vascular segment from each side. Microscopic examination followed.


      Eighty-four patients were available for analysis. The mean cervical diameter was 3.9 cm (2-8), whereas the mean vascular segment length on the right and left sides were 4 cm (1-10) and 3.8 cm (1-7), respectively. Mean number of vascular segment lymph nodes were as follows: medial right = 0.7 (0-4), medial left = 0.6 (0-5), lateral right = 0.4 (0-3), and lateral left = 0.6 (0-6). Mean diameter of medial and lateral lymph nodes were 2 mm (0.25-8) and 3.3 mm (0.25-16), respectively. The length of the vascular segment correlated inversely with maximum cervical diameter. Thirty-one percent (26 of 84) had positive pelvic side wall lymph nodes. Fourteen patients had positive vascular segment lymph nodes (1 positive = 7, more than 1 positive = 7). Three of 7 patients had bilateral positive vascular segment lymph nodes; all 7 had microscopic disease in the paravaginal soft tissue, and all 7 had positive pelvic side wall lymph nodes (6 of 7 bilateral). Including the 14 patients, a total of 19 had nodal or nonnodal microscopic disease in the vascular segment. Of these, 7 had disease in the lateral half of the vascular ligament. Histologic sectioning revealed nerve twigs and/or scattered ganglia in the vascular segment but no large nerve trunks.


      Among a population of women with high-risk, early-stage cervical cancer, the lateral vascular segment of the cardinal ligament contained metastatic disease in a substantial number of patients. This segment contains no major nerve trunks. When radical hysterectomy is chosen as primary treatment for such patients, the vascular segment of the cardinal ligament should be completely excised.

      Key words

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        • Henriksen E.
        The lymphatic spread of carcinoma of the cervix and of the body of the uterus.
        Am J Obstet Gynecol. 1949; 58: 924-942
        • Holzaepfel J.H.
        • Ezell H.E.
        Sites of metastases of uterine carcinoma.
        Am J Obstet Gynecol. 1954; 69: 1027-1038
        • Plentl A.A.
        • Friedman E.A.
        Lymphatics of the cervix uteri.
        in: Friedman E.A. Major problems in obstetrics and gynecology. Vol 2. Saunders, Philadelphia (PA)1971: 75-115
        • Burghardt E.
        • Pickel H.
        • Haas J.
        • Lahousen M.
        Prognostic factors and operative treatment of stages 1B to 11B cervical cancer.
        Am J Obstet Gynecol. 1987; 156: 988-996
        • Girardi F.
        • Lichtenegger W.
        • Tamussino K.
        • Haas J.
        The importance of parametrial lymph nodes in the treatment of cervical cancer.
        Gynecol Oncol. 1989; 34: 206-211
        • Girardi F.
        • Pickel H.
        • Winter R.
        Pelvic and parametrial lymph nodes in the quality control of the surgical treatment of cervical cancer.
        Gynecol Oncol. 1993; 50: 330-333
        • Benedetti-Panici P.
        • Maneschi F.
        • D'Andrea G.
        • et al.
        Early cervical carcinoma.
        Cancer. 2000; 88: 2267-2274
        • Hoffman M.S.
        Extent of radical hysterectomy: Evolving emphasis.
        Gynecol Oncol. 2004; 94: 1-9
        • Hoffman M.S.
        • Cardosi R.J.
        Intraoperative measurements to determine the extent of radical hysterectomy.
        Gynecol Oncol. 2002; 87: 281-286
        • SAS Institute
        Statistical analysis software, version 9.1.
        SAS Institute, Cary (NC)2003
        • Covens A.
        • Rosen B.
        • Murphy J.
        • et al.
        How important is removal of the parametrium at surgery for carcinoma of the cervix?.
        Gynecol Oncol. 2002; 84: 145-149
        • Stegeman M.
        • Louwen M.
        • van der Velden J.
        • et al.
        The incidence of parametrial tumor involvement in select patients with early cervix cancer is too low to justify parametrectomy.
        Gynecol Oncol. 2007; 105: 475-480
        • Wright J.D.
        • Grigsby P.W.
        • Brooks R.
        • et al.
        Utility of parametrectomy for early stage cervical cancer treated with radical hysterectomy.
        Cancer. 2007; 110: 1281-1286
        • Shepherd J.
        Uterus-conserving surgery for invasive cervical cancer.
        Best Pract Res Clin Obstet Gynaecol. 2005; 19: 577-590
        • Winter R.
        • Haas J.
        • Reich O.
        • et al.
        Parametrial spread of cervical cancer in patients with negative pelvic lymph nodes.
        Gynecol Oncol. 2002; 84: 252-257
        • Hoffman M.S.
        • Cardosi R.J.
        • Roberts W.S.
        • Fiorica J.V.
        • Grendys Jr, E.C.
        • Griffin D.
        Accuracy of pelvic examination in the assessment of patients with operable cervical cancer.
        Am J Obstet Gynecol. 2004; 190: 986-993
        • American College of Obstetrics and Gynecology
        Diagnosis and treatment of cervical carcinomas.
        Obstet Gynecol. 2002; 99: 855-867
        • Alvarez R.D.
        • Soong S.-J.
        • Kinney W.K.
        • et al.
        Identification of prognostic factors and risk groups in patients found to have nodal metastasis at the time of radical hysterectomy for early-stage squamous carcinoma of the cervix.
        Gynecol Oncol. 1989; 35: 130-135
        • Inoue T.
        • Morita K.
        Long-term observation of patients treated by postoperative extended-field irradiation for nodal metastases from cervical carcinoma stages 1B, 11A, and 11B.
        Gynecol Oncol. 1995; 58: 4-10
        • Uno T.
        • Ito H.
        • Isobe K.
        • et al.
        Postoperative pelvic radiotherapy for cervical cancer patients with positive parametrial invasion.
        Gynecol Oncol. 2005; 96: 335-340
        • Hockel M.
        • Kondering M.A.
        • Heubel C.P.
        Liposuction-assisted nerve-sparing extended radical hysterectomy: Oncologic rationale, surgical anatomy, and feasibility study.
        Am J Obstet Gynecol. 1998; 178: 971-976
        • Possover M.
        • Stober S.
        • Plaul K.
        • Schneider A.
        Identification and preservation of the motoric innervation of the bladder in radical hysterectomy type 111.
        Gynecol Oncol. 2000; 79: 154-157
        • Trimbos J.B.
        • Maas C.P.
        • Deruiter M.C.
        • Peters A.A.W.
        • Kenter G.G.
        A nerve-sparing radical hysterectomy: guidelines and feasibility in Western patients.
        Int J Gynecol Cancer. 2001; 11: 180-186