Chest Lymph Node Anatomy

Transcription

1 Chest Lymph Node Antomy 2 Medistinl Lymph Nodes In 2009, new lung cncer lymph node mp ws proposed y the Interntionl Assocition for the Study of Lung Cncer (IASLC) to reconcile the difference etween the Nruke [ 1 ] nd the Mountin Dresler Americn Thorcic Society (ATS) [2 ] mps nd rede fi ne the de fi nitions of the ntomicl oundries of ech lymph node sttion [ 3 ]. Suprclviculr Nodes 1 1R nd 1L. Low cervicl, suprclviculr, nd sternl notch nodes (see Figs ). Upper order: Lower mrgin of cricoid crtilge. Lower order: Clvicles ilterlly nd, in the midline, the upper order of the mnurium; 1R designtes right-sided nodes; 1L designtes left-sided nodes in this region. For lymph node sttion 1, the midline of the trche serves s the order etween 1R nd 1L. Fig. 2.1 (, ) Axil CT scn through the lung pices shows enlrged left suprclviculr lymph node ( lue ) M.G. Hrisinghni (ed.), Atls of Lymph Node Antomy, DOI / _2, Springer Science+Business Medi New York

2 32 2 Chest Lymph Node Antomy Fig. 2.2 (, ) Axil CT scn through the lung pices shows enlrged left suprclviculr lymph node ( lue ) Fig. 2.3 (, ) Axil CT scn through the lung pices shows enlrged left suprclviculr lymph node ( lue ) Fig. 2.4 (, ) Axil CT scn through the lung pices shows enlrged left suprclviculr lymph node ( lue ) Fig. 2.5 Schemtic digrm showing the ntomic loctions of the low cervicl, suprclviculr nd sternl notch node sttions, which together comprise the suprclviculr lymph nodes

3 Medistinl Lymph Nodes 33 Superior Medistinl Nodes 2 4 2R. Upper prtrchel. Includes nodes extending to the left lterl order of the trche. Upper order: Apex of the right lung nd pleurl spce nd in the midline, the upper order of the mnurium. Lower order: Intersection of cudl mrgin of innominte vein with the trche. 2L. Upper prtrchel. Upper order: Apex of the left lung nd pleurl spce nd in the midline, the upper order of the mnurium. Lower order: Superior order of the ortic rch ( see Figs. 2.6 nd 2.7 ). Fig. 2.6 (, ) Axil CT scn showing n enlrged right upper prtrchel lymph node ( green ) Fig. 2.7 Schemtic illustrtion showing ntomic loctions for prtrchel lymph nodes

4 34 2 Chest Lymph Node Antomy 3A. Prevsculr (see Figs ). On the right: Upper order: Apex of chest. Lower order: Level of crin. Anterior order: Posterior spect of sternum. Posterior order: Anterior order of superior ven cv. On the left: Upper order: Apex of chest. Lower order: Level of crin. Anterior order: Posterior spect of sternum. Posterior order: Left crotid rtery. Fig. 2.8 (, ) Contrst-enhnced xil CT scn shows n enlrged lymph node in the prevsculr spce on the left side, nterior to the rch of ort ( red ) Fig. 2.9 (, ) Contrst-enhnced xil CT scn shows n enlrged lymph node in the prevsculr re on the left side, nterior to the descending ort ( red )

5 Medistinl Lymph Nodes 35 Fig Schemtic illustrtion shows the ntomic loction of prevsculr group of lymph nodes 3P. Retrotrchel (see Fig ). Upper order: Apex of chest. Lower order: Crin. 4R. Lower prtrchel. Includes right prtrchel nodes, nd pretrchel nodes extending to the left lterl order of trche ( see Figs ). Upper order: Intersection of cudl mrgin of innominte veins with the trche. Lower order: Lower order of zygos vein. 4L. Lower prtrchel. Includes nodes to the left of the left lterl order of the trche, medil to the ligmentum rteriosum. Upper order: Upper mrgins of the ortic rch. Lower order: Upper rim of the left min pulmonry rtery.

6 36 2 Chest Lymph Node Antomy Fig Schemtic illustrtion shows the ntomic loction nd distriution of retrotrchel group of lymph nodes ( drk red )

7 Medistinl Lymph Nodes 37 Fig (, ) Axil contrst-enhnced CT imge through the upper thorx shows n enlrged right-sided lower pretrchel lymph node ( green ) Fig (, ) Coronl reformtted CT scn imge of the sme ptient shows enlrged right lower pretrchel lymph node ( green )

8 38 2 Chest Lymph Node Antomy Fig (, ) Axil contrst-enhnced CT scn through upper thorx shows n enlrged left lower prtrchel lymph node utting the left lterl wll of the trche ( green ) Aortic Nodes Suortic. Lymph nodes lterl to the ligmentum rteriosum ( see Fig ). Upper order: The lower order of the ortic rch. Lower order: Upper rim of the left min pulmonry rtery. 6. Pr-ortic. Lymph nodes nterior nd lterl to the scending ort nd ortic rch ( see Figs nd 2.17 ). Upper order: A line tngentil to the upper order of the ortic rch. Lower order: The lower order of the ortic rch. Inferior Medistinl Nodes Sucrinl (see Fig ). Upper order: The crin of the trche. Lower order: The upper order of the lower loe ronchus on the left; the lower order of the ronchus intermedius on the right. 8. Presophgel. Lymph nodes djcent to the wll of the esophgus nd to the right or left of the midline, excluding sucrinl nodes ( see Figs ). Upper order: The upper order of the lower loe ronchus on the left; the lower order of the ronchus intermedius on the right. Lower order: The diphrgm. 9. Pulmonry ligment. Lymph nodes lying within the pulmonry ligment ( see Fig ). Upper order: The inferior pulmonry vein. Lower order: The diphrgm.

9 Medistinl Lymph Nodes 39 Fig ( ) Schemtic illustrtion shows the ntomic loction of suortic lymph nodes. (, c ) Axil contrst-enhnced CT scn imge of the thorx shows n enlrged suortic lymph node ( purple ) c Fig Schemtic illustrtion shows the ntomic loction for prortic group of lymph nodes

10 40 2 Chest Lymph Node Antomy Fig Schemtic illustrtion shows the ntomic loctions of the pr-ortic nd retroortic group of lymph nodes using color coding scheme Fig (, ) Axil contrst-enhnced CT scn of the thorx shows enlrged sucrinl group of lymph nodes ( green ) Fig (, ) Axil contrst-enhnced CT scn of the thorx shows enlrged presophgel group of lymph nodes ( purple )

11 Medistinl Lymph Nodes 41 Fig (, ) Axil contrst-enhnced CT scn of the thorx shows enlrged presophgel group of lymph nodes ( purple ) Fig (, ) Axil contrst-enhnced CT scn of the thorx shows enlrged presophgel group of lymph nodes ( purple )

12 42 2 Chest Lymph Node Antomy Fig Schemtic illustrtion shows the ntomic loction nd distriution of the presophgel group of lymph nodes using color-coding scheme

13 Medistinl Lymph Nodes 43 c Fig ( ) Schemtic illustrtion shows the ntomic loction nd distriution of lymph nodes lying within the pulmonry ligment ( green ). These re seen interspersed etween the presophgel group of lymph nodes ( violet ). (, c ) Axil contrst-enhnced CT scn of the thorx shows n enlrged right-sided pulmonry ligment lymph ( green )

14 44 2 Chest Lymph Node Antomy Hilr, Lor, nd (Su)Segmentl Nodes These re ll N1 nodes: 10. Hilr. Includes lymph nodes immeditely djcent to the minstem ronchus nd hilr vessels, including the proximl portions of the pulmonry veins nd the min pulmonry rtery ( see Fig ). Upper order: The lower rim of the zygos vein on the right; upper rim of the pulmonry rtery on the left. Lower order: Interlor region ilterlly. 11. Interlor. Between the origin of the lor ronchi ( see Fig ). 11s: Between the upper loe ronchus nd ronchus intermedius on the right. 11i: Between the middle nd lower loe ronchus on the right. 12. Lor. Adjcent to the lor ronchi ( see Fig ). 13. Segmentl. Adjcent to the segmentl ronchi. 14. Susegmentl. Adjcent to the susegmentl ronchi. c d Fig (, ) Axil contrst-enhnced CT scn of the thorx shows enlrged right hilr group of lymph nodes ( ornge ). (c, d ) Axil contrst-enhnced CT scn of the thorx shows enlrged left hilr group of lymph nodes ( ornge )

15 Medistinl Lymph Nodes 45 c Fig ( ) Schemtic illustrtion shows the ntomic loction nd distriution of the hilr nd interlor group of lymph node. (, c ) An xil CT scn imge of the thorx shows n enlrged right interlor lymph node ( ornge ) c d e Fig ( ) Schemtic illustrtion shows the ntomic loction nd distriution of the lor, segmentl, nd susegmentl group of lymph nodes using color-coding scheme. (, c ) Axil CT scn of the thorx shows n enlrged right segmentl lymph node ( lue ). (d, e ) Axil CT scn of the thorx shows enlrged right susegmentl lymph node ( lue )

16 46 2 Chest Lymph Node Antomy Mlignnt Cuses of Enlrgement A study ws performed to look t the ppernce of the lymph node t CT to improve speci fi city for detecting mlignnt nodes in ronchogenic crcinom. The four prmeters evluted were (1) node loction, (2) homogenicity, (3) order delinetion, nd (4) delinetion y ft. Of 54 crcinom ptients, nodes were pthologiclly mlignnt in 21. CT showed enlrged lymph nodes (>1 cm) in 20 of these (true-positive rte, 96 %), ut lso in 13 of the 33 ptients with pthologiclly enign lymph nodes (flse-positive rte, 39 %). A comintion of ll four CT prmeters reduced the flse-positive rte from 39 to 21 % nd decresed the true-positive rte from 96 to 86 % [ 4 ]. The most common cuse of mlignnt lymph node enlrgement in the medistinum is lung cncer. It hs een reported tht % of clinicl stge I disese hve medistinl lymph node disese [ 5 7 ]. In ptients with esophgel cncer, loction of medistinl lymph nodes depend on the loction of the primry tumor. Thorcic medistinl lymph nodes were involved in % of ptients with upper thorcic esophgel crcinom; in 34.7 % of ptients with middle thorcic esophgel crcinoms; nd in 34.1 % of ptients with lower thorcic esophgel crcinom [ 8 ]. Another cuse of thorcic lymphdenopthy is lymphom, in which medistinl lymph node involvement is more frequent thn hilr, which is usully symmetricl nd ccompnied y medistinl involvement [ 9 ] (see Figs ). Fig (, ) Axil positron emission tomogrphy (PET) scn of the thorx shows fl uorodeoxy-glucose (FDG) vid uptke y medistinl lymph nodes in cse of lymphom ( green ) Fig (, ) Axil PET scn of the thorx shows FDG vid uptke y medistinl lymph nodes in cse of lymphom ( green )

17 Medistinl Lymph Nodes 47 Lymphom tends to expnd long or round rther thn invde existing structures. In Hodgkin s disese, upwrds of 85 % of ptients hve intrthorcic involvement on CT, compred with pproximtely 50 % with non-hodgkin s lymphom [ 9, 10 ]. Hodgkin s disese tends to spred contiguously etween lymph node groups, while non-hodgkin s lymphom more frequently involves typicl lymph node sites, such s posterior medistinl nd nterior diphrgmtic nodes [ 9, 10 ]. Fig (, ) Axil PET scn of the thorx shows FDG vid uptke y medistinl lymph nodes in cse of lymphom ( green ) Fig (, ) Axil PET scn of the thorx shows FDG vid uptke y medistinl lymph nodes in cse of lymphom ( green ) Fig (, ) Axil PET scn of the thorx shows FDG vid uptke y medistinl lymph nodes in cse of lymphom ( purple )

18 48 2 Chest Lymph Node Antomy Fig (, ) Axil PET scn of the thorx shows FDG vid uptke y medistinl lymph nodes in cse of lymphom ( purple ) Intrthorcic lymph node metstses from extrthorcic crcinoms re infrequent. They were detected on chest rdiogrph in 25 of 1,071 ptients (2.3 %) y McLoud nd collegues [ 11 ]. The primry mlignncies included eight tumors of the hed nd neck, 12 genitourinry mlignncies, three crcinoms of the rest, nd two mlignnt lymphoms. The most frequently detected lymph node group ws the right prtrchel 4R nd 2R (60 %). Mon nd Lishitz [ 12 ] nlyzed 50 medistinl metstses of infrdiphrgmtic mlignncies on computed tomodensitogrphy, technique llowing etter visuliztion of ll nodl groups in the medistinum. Severl lymph node sttions were commonly involved, nd only one single sttion ws involved in only 6 %. Besides mjority of genitourinry mlignncies (kidney, 25; testis, 7; prostte, 4; ovry, 3; ldder, 2), they lso oserved metstses from crcinom of the colon or rectum in 6 nd stomch in 3. Lison nd collegues [ 13 ] reported 12 cses of medistinl metstses in 19,994 ptients (1 %) with crcinoms of the stomch, pncres, colon, nd rectum. In recent study on the role of surgery in intrthorcic lymph node metstses from extrthorcic crcinom [ 14 ], 26 of 565 ptients with medistinl lymph node enlrgement hd history of extrthorcic crcinom (rest, 7; kidney, 5; testis, 3; prostte, 2; ldder, 1; hed nd neck, 3; thyroid glnd, 2; rectum, 1; intestine, 1; melnom, 1). Axillry Lymph Nodes Axillry lymph nodes re divided into fi ve groups ccording to their fferent vessels nd respective reltionships with the vsculr structures of the xill [ 15 ] ( see Figs ).

19 Axillry Lymph Nodes 49 Fig (, ) Axil contrst-enhnced CT scn of the thorx shows enlrged xillry group of lymph nodes ( yellow ) Fig Schemtic illustrtion shows different sugroups of the xillry lymph nodes using color-coding scheme Fig Schemtic illustrtion shows different sugroups of the xillry lymph nodes using color-coding scheme

20 50 2 Chest Lymph Node Antomy Lterl or Brchil Group Nodes situted to the inferomedil side of the xillry vein. Afferent vessels: Drin the lymph from the super fi cil nd deep comprtments of upper lymph, except for the super fi cil vessels of the rm tht run long the cephlic vein. Efferent vessels: Most terminte in the centrl or picl groups, wheres others pss into the suprclviculr nodes. Anterior or Pectorl Group Nodes locted ehind the pectorlis mjor muscle nd long the lower order of the pectorlis minor, forming chin long nd ehind the lterl thorcic vessels. Afferent vessels: From the skin nd muscles of the nterior nd lterl wlls of the trunk ove the umilicus, nd the lterl prts of the rest. Efferent vessels: Extend to the centrl nd picl groups of xillry nodes. Posterior or Suscpulr Group Nodes rrnged in chin tht follows the suscpulr vessels in the groove tht seprtes the teres minor nd suscpulris muscles. Afferent vessels: Collect the lymph nodes rising from the muscles nd skin of the ck nd from the scpulr re down to the ilic crest. Efferent vessels: Drin into the centrl nd picl lymph nodes Centrl Group Locted in the centrl prt of the dipose tissue of the xill etween the preceding chins tht progressively converge towrd them. Efferent vessels: Extend into the picl group. Apicl Group Nodes tht occupy the pex of the xill, ehind the upper portion of the pectorlis minor nd prtly ove this muscle. The mjority of these nodes rest on the inferomedil side of the proximl prt of the xillry vein, in close contct with the upper digittions of serrtus nterior. Afferent vessels: From ll other xillry nodes; they lso drin some super fi cil vessels running long the cephlic vein. Efferent vessels: The efferent vessels of this group unite to form the suclvin trunk, which fi nlly opens into the right lymphtic duct on the right side or into the thorcic duct on the left side.

21 Chest Wll Nodes 51 The inferior order of the pectorlis mjor nd the inferolterl nd superomedil edges of the pectorlis minor cn e used s ntomicl lndmrks to seprte the inferior (I), middle (II), nd superior (III) levels of the xillry spce. Nrrowing progressively, these levels contin the nterior (pectorl), lterl (rchil), posterior (suscpulr), nd centrl groups of nodes (level I), nd then the centrl nd picl groups (levels II nd III). Mlignnt Cuses of Enlrgement The most common cuse of mlignnt xillry lymph node enlrgement is rest cncer. The reltionship etween the tumor dimeter nd the proility of nodl involvement in ll tumor sizes ppers liner. For ptients with cncer 5 cm or greter, 71.1 % re expected to hve t lest one node involved [ 16 ]. Other common cuses include lymphom nd mlignnt melnom. Rre cuses would include sl cell crcinom [ 17 ] nd ovrin cncer [18 ]. Chest Wll Nodes Internl Mmmry (Internl Thorcic or Prsternl) Nodes These nodes lie t the nterior ends of the intercostl spces, long the internl mmmry (internl thorcic) vessels ( see Figs nd 2.37 ). Afferent vessels: These nodes receive lymphtic dringe from the nterior diphrgmtic nodes, nterosuperior portions of the liver, medil prt of the rests, nd deeper structures of the nterior chest nd upper nterior dominl wll. Efferent vessels: My empty into the right lymphtic duct, the thorcic duct, or the inferior deep cervicl nodes [ 19 ]. Mlignnt Cuses of Enlrgement One of the commonest cuses of internl mmmry lymph node enlrgement is rest cncer. In study on ptients undergoing free fl p rest reconstruction, 43 ptients hd internl mmmry lymph node smpling nd six ptients hd positive lymph nodes [ 20 ]. Posterior Intercostl Nodes These nodes re locted ner the heds nd necks of the posterior ris. Afferent vessels: They receive lymphtic dringe from the posterolterl intercostl spces, posterolterl rests, prietl pleur, vertere, nd spinl muscles. Efferent vessels: From the upper intercostl spces end in the thorcic duct on the left, nd in one of the lymphtic ducts on the right. Those from the lower four to seven intercostl spces unite to form common trunk, which empties into the thorcic duct or cistern chyli [ 19 ].

22 52 2 Chest Lymph Node Antomy Fig (, ) Axil contrst-enhnced CT scn of the thorx shows enlrged left internl mmmry lymph nodes ( pink ) Fig (, ) Axil contrst-enhnced CT scn of the thorx shows enlrged left internl mmmry lymph nodes ( pink ) Juxtverterl (Pre-verterl or Prverterl) Nodes These lie long the nterior nd lterl spects of the verterl odies, most common from T8 to T12. They communicte with posterior medistinl lymph nodes nd the posterior intercostl nodes, nd similrly drin to the right lymphtic duct or thorcic duct [ 19 ]. Diphrgmtic Nodes They re locted on or just ove the thorcic surfce of the diphrgm nd re divided into three groups [ 21 ].

23 Chest Wll Nodes 53 Anterior (Pre-pericrdil or Crdiophrenic) Group These re locted nterior to the pericrdium, posterior to the xiphoid process, nd in the right nd left crdiophrenic ft ( see Figs ). Afferent vessels: From the nterior prt of the diphrgm nd its pleur, nd the nterosuperior portion of the liver. Efferent vessels: They drin to the internl mmmry nodes longside the xiphoid nd cn provide route for retrogrde spred of rest cncer to the liver vi lymphtics of the rectus dominis muscle when the upper internl thorcic trunks re locked. Middle (Juxtphrenic or Lterl) Group This group receives lymph from the centrl diphrgm nd from the convex surfce of the liver on the right. Posterior (Retrocrurl) Group These nodes lie ehind diphrgmtic crur nd nterior to the spine. Afferent vessels: Lymph from the posterior prt of the diphrgm. Efferent vessels: They communicte with the posterior medistinl nd prortic nodes in the upper domen. Figure 2.42 represents the schemtic illustrtion of ll mjor groups of lymph nodes in the chest using color-coding scheme. The color coding is lso depicted on Fig Fig (, ) Axil contrst-enhnced CT scn of the thorx shows enlrged pericrdil lymph node in cse of heptocellulr crcinom ( green )

24 54 2 Chest Lymph Node Antomy Fig (, ) Sgittl reformtted CT scn of the thorx nd upper domen shows enlrged pericrdil lymph node in cse of heptocellulr crcinom ( green ) Fig (, ) Axil contrst-enhnced CT scn of the thorx shows enlrged nterior diphrgmtic lymph node ( ornge ) Fig (, ) Axil contrst-enhnced CT scn of the thorx shows enlrged nterior diphrgmtic lymph node in cse of srcoidosis ( ornge )

25 Chest Wll Nodes 55 Fig Schemtic illustrtion shows ll mjor groups of lymph nodes in the chest using colorcoding scheme

26 56 2 Chest Lymph Node Antomy Fig Digrm showing the color-coding scheme used to identify vrious groups of lymph nodes in the chest References 1. Nruke T, Suemsu K, Ishikw S. Lymph node mpping nd curility t vrious levels of metstsis in resected lung cncer. J Thorc Crdiovsc Surg. 1978;76: Mountin CF, Dresler CM. Regionl lymph node clssi fi ction for lung cncer stging. Chest. 1997;111: Rusch VW, Asmur H, Wtne H, et l. The IASLC lung cncer stging project: proposl for new interntionl lymph node mp in the forthcoming seventh edition of the TNM clssi fi ction for lung cncer. J Thorc Oncol. 2009;4: Feigin DS, Friedmn PJ, Liston SE, et l. Improving speci fi city of computed tomogrphy in dignosis of mlignnt medistinl lymph nodes. J Comput Tomogr. 1985;9: Seely JM, Myo JR, Miller RR, Muller NL. T1 lung cncer: prevlence of medistinl nodl metstses nd dignostic ccurcy of CT. Rdiology. 1993;186:

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