Atlas of Lymph Node Anatomy
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2 Atlas of Lymph Node Anatomy
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4 Mukesh G. Harisinghani Editor Atlas of Lymph Node Anatomy This publication was developed through an unrestricted educational grant from Siemens.
5 Editor Mukesh G. Harisinghani Massachusetts General Hospital, Department of Radiology Harvard Medical School Boston Massachusetts USA ISBN ISBN (ebook) DOI / Springer New York Heidelberg Dordrecht London Library of Congress Control Number: Springer Science+Business Media New York 2013 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, speci fi cally the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on micro fi lms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied speci fi cally for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher s location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a speci fi c statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (
6 For my wife, Alpana, and my children, Puneet and Ayesha Mukesh G. Harisinghani
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8 Preface Nodal staging is an integral part of determining therapy and prognosis in most primary tumors and the evaluation of lymph nodes involves accurate anatomical localization followed by characterization. While there is an abundance of surgical literature highlighting the distribution of regional lymph nodes in various primary tumors, a comprehensive imaging text highlighting the anatomical nodal stations and their involvement in various primary tumors is lacking. The current atlas attempts to highlight nodal anatomy by way of color illustrations and color-coded topographical depiction on cross-sectional imaging studies. We hope the content will be useful and informative to a wide range of readers fi lling in the void about nodal anatomy. Mukesh G. Harisinghani vii
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10 Acknowledgments First, I would like to acknowledge my mentors for stimulating my interest and fostering my enthusiasm during my early academic years. This project would not have been possible without their guidance and constant encouragement. I have to thank the contributors who helped me realize this atlas by providing ideas and enabling me to complete this project in a timely fashion. A special note of appreciation to my family for tolerating my time away to complete this book. Mukesh G. Harisinghani ix
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12 Contents 1 Head and Neck Lymph Node Anatomy... 1 Classification... 1 Criteria for Enlargement... 5 Level I: Submental (IA) and Submandibular (IB)... 5 Metastatic Involvement... 5 Unusual Site of Metastasis... 8 Level II... 8 Metastatic Involvement Unusual Site of Metastasis Level III Level IV Level V (A + B) Level VI References Chest Lymph Node Anatomy Mediastinal Lymph Nodes Supraclavicular Nodes Superior Mediastinal Nodes Aortic Nodes Inferior Mediastinal Nodes Hilar, Lobar, and (Sub)Segmental Nodes Malignant Causes of Enlargement Axillary Lymph Nodes Lateral or Brachial Group Anterior or Pectoral Group Posterior or Subscapular Group Central Group Apical Group Malignant Causes of Enlargement Chest Wall Nodes Internal Mammary (Internal Thoracic or Parasternal) Nodes Malignant Causes of Enlargement xi
13 xii Contents Posterior Intercostal Nodes Juxtavertebral (Pre-vertebral or Paravertebral) Nodes Diaphragmatic Nodes Anterior (Pre-pericardial or Cardiophrenic) Group Middle (Juxtaphrenic or Lateral) Group Posterior (Retrocrural) Group References Abdominal Lymph Node Anatomy Lymphatic Spread of Malignancies Liver Stomach Paraesophageal and Paracardiac Nodes Nodal Metastases in the Gastrohepatic Ligament Nodal Metastases in the Gastrosplenic Ligament Nodal Metastases in the Gastrocolic Ligament Inferior Phrenic Nodal Pathways Small Intestine Appendix Colorectal Retroperitoneal Lymph Nodes Renal, Upper Urothelial, and Adrenal Malignancies Lymphatic Spread of Malignancies Renal Tumor Urothelial Tumors Adrenal Tumors Pancreatic Cancer Lymphatic Spread and Nodal Metastasis References Pelvic Lymph Nodes Classification and Anatomical Location of Pelvic Lymph Nodes Common Iliac Nodal Group External Iliac Nodal Group Internal Iliac (Hypogastric) Nodal Group Inguinal Nodes Perivisceral Nodes Criteria for Diagnosing Abnormal Lymph Nodes Size Shape and Margin Internal Architecture Nodal Staging Gynecologic Malignancies Pattern of Lymphatic Drainage of the Female Pelvis
14 Contents xiii Lymphatic Spread of Malignancies Vulva Vagina Uterus Invasive Cervical Cancer Cancer of the Uterine Body Fallopian Tube Ovary Male Urogenital Pelvic Malignancies Superficial Inguinal Pathway Pelvic Pathways Para-aortic Pathway Modified Post-therapeutic Pathways Pathways of Nodal Spread in Urogenital Pelvic Malignancies Prostate Cancer Penile Cancer Testicular Cancer Bladder Cancer References Pitfalls and Mimics of Lymph Nodes on Imaging Structures That Can Mimic a Lymph Node on Imaging Commonly Overlooked Nodal Sites Missed Adenopathy on Imaging Common Differential Diagnosis on Nodal Morphology References Index
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