petirrojo smithuis
Departamento de Radiologia do Hospital Alrijne em Leiderdorp, Holland
release date
This is an update of the 2007 article that used the Mountain-Dresler regional lymph node classification for lung cancer staging (MD-ATS maps)(1).
In 2009, the International Association for the Study of Lung Cancer (IASLC) proposed a new lung cancer lymph node map to accommodate the differences between the Naruke and MD-ATS maps and to refine border definitions. anatomy of each of them. Lymph node stations (2).
In this article, we provide illustrations and CT images for better understanding of this IASLC lymph node map.
IASLC 2009 Lymph Node Map
Regional lymph node classification for lung cancer staging adapted to the American Thoracic Society mapping scheme
supraclavicular nodules
1.Inferior cervical, supraclavicular, and sternal notch nodes
From the bottom of the cricoid to the clavicles and the top of the manubrium.
The midline of the trachea serves as the boundary between 1R and 1L.
Upper mediastinal nodules 2-4
2R.paratraquel superior
The 2R nodes extend to the left lateral border of the trachea.
From the superior border of the manubrium to the intersection of the caudal border of the innominate vein (left brachiocephalic) with the trachea.
2L.paratraquel superior
From the top of the manubrium to the top of the aortic arch.
Nodes 2L are to the left of the left lateral edge of the trachea.
3A.prevascular
These knots are not next to the trachea like the knots from station 2, but in front of the vessels.
3P.prävertebral
Nodules not next to the trachea as in station 2, but behind the prevertebral esophagus.
4R.Paratraqueal inferior
From the intersection of the caudal border of the innominate vein (left brachiocephalic) with the trachea to the inferior border of the azygos vein.
The 4R nodes extend from the right to the left lateral border of the trachea.
4L.Paratraqueal inferior
From the top of the aortic arch to the top of the left trunk of the pulmonary artery.
Aortic node 5-6
5.subaortal
These lymph nodes are located in the AP window lateral to the ligamentum arteriosum.
These lymph nodes are not located between the aorta and the pulmonary trunk, but are lateral to these vessels.
6.para-aortic
These are the ascending aorta or diaphragmatic nodes that lie anterior and lateral to the ascending aorta and aortic arch.
Lower mediastinal nodes 7-9
7.subcarinal
8.paraösophageal
Nodules under the carina.
9.lung band
Nodules found within the pulmonary ligaments.
Hilar, lobar and (sub)segmental nodes 10-14
These are all N1 nodes.
10hilar nodules
These include nodules adjacent to the main bronchus and hilar vessels.
On the right, they extend from the lower edge of the azygos vein to the interlobular region.
Left from the superior border of the pulmonary artery to the interlobular region.
Axial CT Anatomy
Click on the photograph to enlarge.
Then scroll through the axial CT images.
pictures of dr Aurelia Fairise from the Institut de Cancerologie de Lorraine in Nancy.
Specific lymph node stations
1. Nodules in the supraclavicular area
1. Nodules in the supraclavicular area
These include inferior cervical, supraclavicular, and sternal nodes.
top rail: Lower edge of the cricoid.
lower edge: clavicles and upper border of the manubrium.
The midline of the trachea serves as the boundary between 1R and 1L.
2R. Upper right paratracheal
The 2R nodes extend to the left lateral border of the trachea.
top rail: upper border of the manubrium.
lower edge: Intersection of the caudal border of the V. innomina (left brachiocephalic) with the trachea.
2L. oben links paratracheal
top rail: upper border of the manubrium.
lower edge: Upper border of the aortic arch.
On the left a 2-station knot in front of the trachea, i.e. a 2R knot.
There is also a small prevascular node, i. H. a 3A station node.
nodes 3A and 3P
3. Prevascular and prevertebral nodes
Station 3 nodes are not adjacent to the trachea like Station 2 nodes.
They are:
3A in front of vessels or similar
3B behind the prevertebral esophagus.
Station 3 nodes are not accessible with mediastinoscopy.
3P nodes can be accessible with endoscopic ultrasound (EUS).
Left node 3A in the prevascular space.
Also note the lower paratracheal nodes on the right, i.e. the 4R nodes.
4R. Lower paratracheal nodules
4R. Lower right paratracheal
top rail: Intersection of the caudal border of the V. innomina (left brachiocephalic) with the trachea.
lower edge: lower edge of the azygos vein.
The 4R nodes extend to the left lateral border of the trachea.
On the left we see the 4R paratracheal ganglia.
There is also an aortic node, the station node 6, lateral to the aortic arch.
4L Lower paratracheal nodules
4L lower left paratracheal
The 4L lymph nodes are inferior paratracheal lymph nodesto the left of the left tracheal border, between a horizontal line drawn tangent to the superior border of the aortic arch, and a line drawn tangent to the superior border of the left pulmonary artery.
These include paratracheal nodes that lie medial to the arteriosus ligament.
The nodes of station 5 (AP window) are located lateral to the ligamentum arteriosum.
Left, image just above the level of the pulmonary trunk showing the left and right inferior paratracheal lymph nodes.
There are also station nodes 3 and 5.
Left image at the level of the lower trachea just above the carina.
Left of the tracheal ganglia 4L.
Note that these 4L nodes are located between the pulmonary trunk and the aorta, but are not in the AP window as they are medial to the ligamentum arteriosum.
The node lateral to the pulmonary trunk is a station 5 node.
5. Subaortic nodules
The subaortic or aortopulmonary window nodes are lateral to the arterial ligament or aorta or left pulmonary artery and proximal to the first branch of the left pulmonary artery and lie within the mediastinal pleural lining.
6. Para-aortic nodules
The para-aortic lymph nodes (ascending or phrenic aorta) are located anterior and lateral to the ascending aorta and aortic arch, from the top to the bottom of the aortic arch.
7. Subcarinal nodules
These lymph nodes are located caudal to the carina of the trachea but are not connected to the bronchi of the lower lobe or arteries within the lungs.
On the right they extend caudally to the lower edge of the intermediate bronchus.
On the left they extend caudally to the upper edge of the lower lobe bronchus.
On the left a subcarinal node of station 7 to the right of the esophagus.
.
8 paraesophageal lymph nodes
These lymph nodes lie below the carinal lymph nodes and extend caudally to the diaphragm.
On the left a picture under the Carina.
An 8-node station to the right of the esophagus.
Left, a PET image showing the FDG uptake in a Station 8 node.
The nodule is not enlarged on the corresponding CT image (blue arrow).
The likelihood of lymph node metastasis is extremely high because the specificity of PET is greater for non-enlarged lymph nodes than for enlarged lymph nodes.
9. Pulmonary ligament nodules
Pulmonary ligament lymph nodes are located within the pulmonary ligament, including those on the posterior wall and lower portion of the inferior pulmonary vein.
The pulmonary ligament is the inferior extension of the mediastinal pleural reflexes surrounding the hila.
10 Hilusknoten
The hilar lymph nodes are proximal lobar lymph nodes, distal to the mediastinal pleural reflection and adjacent to the right intermediate bronchus.
The nodes at station 10-14 are all N1 nodes because they are not in the mediastinum.
Axial CT of the lymph nodes
Browse through the images on the left.
- Sternal notch ganglia can only be seen at this level and above this level.
- Superior paratracheal: below the clavicles and on the right above the intersection of the caudal border of the innominate vein (left brachiocephalic vein) with the trachea and on the left above the aortic arch.
- Prevascular and retrotracheal: anterior to the vessels (3A) or prevertebral (3P)
- Inferior paratracheal: below the top of the aortic arch to the level of the main bronchus
- Subaortic (A-P window): Lymph nodes lateral to the arterial ligament or lateral to the aorta or left pulmonary artery
- Paraaortic: Nodules located anterior and lateral to the ascending aorta and aortic arch below the superior border of the aortic arch.
- subcarinal
- Paraesophageal (below the carina)
- Pulmonary Ligament: Nodules found within the pulmonary ligament.
- -14: We are all N1
Mediastinoscopy and USO
conventional mediastinoscopy
The following lymph node stations can be biopsied using cervical mediastinoscopy: the left and right superior paratracheal lymph nodes (Stations 2L and 2R), the left and right inferior paratracheal lymph nodes (Stations 4L and 4R), and the subcarinal lymph nodes (Station 7).
The Ward 1 lymph nodes are located above the suprasternal notch and are not routinely reached by cervical mediastinoscopy.
Advanced mediastinoscopy
Tumors of the left upper lobe can metastasize to subaortic lymph nodes (Station 5) and para-aortic lymph nodes (Station 6).
These lymph nodes cannot be biopsied by routine cervical mediastinoscopy.
Extended mediastinoscopy is an alternative to the second anterior mediastinotomy, which is most commonly used to explore the mediastinal nodes.
This procedure is much less simple and is therefore performed less frequently than traditional mediastinoscopy.
USE-PAAF
Endoscopic ultrasonography with fine-needle aspiration can be performed on any mediastinal lymph node that can be evaluated from the esophagus.
In addition, the left adrenal gland and the left lobe of the liver can be visualized.
Specifically, EUS provides access to nodes in the lower mediastinum (stations 7, 8, and 9)
FAQs
Where is the mediastinal lymph node located? ›
Mediastinal lymph nodes are lymph nodes located in the mediastinum. The mediastinum is the area located between the lungs that contains the heart, esophagus, trachea, cardiac nerves, thymus gland, and lymph nodes of the central chest.
Does mediastinal lymph nodes mean cancer? ›We found no evidence of an association between the mediastinal lymphadenopathy location and lung cancer diagnosis (P = .
Can enlarged mediastinal lymph nodes be benign? ›Introduction: Mediastinal lymphadenopathy (ML), may be caused either by malignant or benign diseases. It usually is diagnosed by chest computed tomography and bronchoscopy with endobronchial ultrasound guided TBNA (EBUS-TBNA).
What causes swollen mediastinal lymph nodes? ›The initial clue to the presence of enlarged mediastinal lymph nodes is through thoracic imaging modalities. Malignancy (Lung cancer, lymphoma, and extrathoracic cancer) and granulomatous conditions (sarcoidosis and tuberculosis) are the most common causes.
How many mediastinal lymph nodes are there? ›As mentioned, based on lung cancer staging guidelines, the intrathoracic lymph nodes are divided into 14 stations, which are grouped into 7 zones. Stations 1–9 are located in the mediastinal pleural reflection, while stations 10–14 are distal to the mediastinal pleural reflection and within the visceral pleura.
How do you check for mediastinal lymph nodes? ›A mediastinoscopy is a procedure used to examine the mediastinum. This is the space behind the breastbone (sternum) in the middle of the chest, between the 2 lungs. It contains: Lymph nodes.
How do you treat mediastinal lymph nodes? ›Your healthcare provider may recommend surgery that involves an incision (cut) through your breastbone, called a sternotomy. Or they may recommend minimally invasive surgery to treat mediastinal tumors called video-assisted thorascopic surgery (VATS).
What are the signs that you have a cancerous lymph node? ›- Painless swelling of lymph nodes in your neck, armpits or groin.
- Persistent fatigue.
- Fever.
- Night sweats.
- Shortness of breath.
- Unexplained weight loss.
- Itchy skin.
Thymomas grow slowly and invade surrounding structures; consequently, these tumors require surgical removal with a good cure rate. A rarer but more invasive type, thymic carcinoma, is harder to manage and could require surgery, chemotherapy, and/or radiation.
What is the normal size of a mediastinal lymph node? ›The average size of these four nodes was 6.2 mm (length) x 3.5 mm (width) (range, 8 x 3 mm). In zones 2-4, all 12 patients (100%) showed lymph nodes. The average size of nodes in zone 2 was 13.3 x 9.2 mm (range, 30 x 5 mm).
How large should mediastinal lymph nodes be? ›
Of 225 lymph nodes from all zones in the CT study, 99% measured less than 16 mm in largest diameter. The average lymph node size in the four zones in the cadavers was 12.6 X 8.3 mm (length X width).
Can mediastinal lymph nodes be removed? ›VATS mediastinal lymph node dissection is essential part of lung cancer surgery and can be performed completely with appropriate surgical techniques.
What level are mediastinal lymph nodes? ›These nodes are located in the AP window lateral to the ligamentum arteriosum. These nodes are not located between the aorta and the pulmonary trunk but lateral to these vessels. These are ascending aorta or phrenic nodes lying anterior and lateral to the ascending aorta and the aortic arch.
What does lymph nodes in the mediastinum mean? ›Mediastinal lymphadenopathy generally suggests a problem related to the lungs. It is usually associated with tuberculosis and most commonly associated with lung cancer and chronic obstructive pulmonary disease (COPD).
Can you feel enlarged mediastinal lymph nodes? ›It is not possible to feel the mediastinal lymph nodes, which are deep in the chest. Other chest lymph nodes are also typically too deep to feel. Doctors usually only notice swelling in these lymph nodes on an imaging scan.