Lymph node stations on ct

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Mediastinal lymph node station classification is important for staging lung cancer. Here it is briefly dealt with

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THORACIC LYMPH NODES:

Dr. Varun Babu THORACIC LYMPH NODES

My topic:

Lymph node stations in CT D/Ds of mediastinal lymphadenopathy My topic

PowerPoint Presentation:

The general term of ‘glands’ (‘ adenes ’) Whitish and phlegmy structures, which present a wholly consistence to the touch and can be easily squeezed by the fingers Lymph glands are said to ‘attract and receive’ fluids. If the amount of moisture is moderate, there is no fluid accumulation in any part of the body because lymph glands drain off such liquid. By contrast, when glands are overfilled by humours , they become swollen and inflamed, and can transmit their disease to the rest of the body

Axillary group:

Axillary group Afferent Efferent

Axillary group:

Axillary group Lateral group Afferent Efferent

Axillary group:

Axillary group Anterior (pectoral) group Afferent Efferent

Axillary group:

Axillary group Posterior ( subcapsular ) group Afferent Efferent

Axillary group:

Axillary group Central group Afferent Efferent

Axillary group:

Axillary group Apical group Afferent Efferent

Internal mammary nodes:

Internal mammary nodes Internal thoracic or para sternal Anterior ends of intercostal spaces Anterior diaphragmatic nodes, anterosuperior portion of liver, medial part of breasts, deeper structures of anterior chest & anterior abdominal wall Right lymphatic duct, thoracic duct, inferior deep cervical nodes

Intercostal nodes:

Intercostal nodes Head and necks of posterior ribs Posterolateral intercostal spaces, posterolateral breasts, parietal pleura, vertebrae and spinal muscles One of the lymphatic trunks on the right and the thoracic duct

Diaphragmatic nodes:

On or just above the thoracic surface of diaphragm Diaphragmatic nodes Anterior (pre-pericardial / cardiophrenic ) Middle ( juxtaphrenic /lateral) Posterior ( retrocrural ) Anterior to pericardium, posterior to xiphoid , right and left cardiophrenic fat Central diaphragm, convex surface of liver on the right Behind diaphragmatic crura , anterior to spine Anterior diaphragm & its pleura, anterosuperior portion of liver Posterior diaphragm Internal mammary nodes Posterior mediastinal nodes, para -aortic nodes in upper abdomen

Visceral nodes:

>60 nodes found at autopsy 80% are in relation to trachea and bronchi – draining mainly lungs Visceral nodes

Henri Rouvière (December 23, 1876 – 1952):

Henri Rouvière ( December 23, 1876 – 1952 )

PowerPoint Presentation:

First description of systematic approach to mediastinal and hilar lymph node dissection

PowerPoint Presentation:

Japan Lung Cancer Society 1980 American Thoracic Society and Mountain- Dresler modification of the ATS map International Association for the Study of Lung Cancer

Naruke lymph node map:

Naruke lymph node map

MD-ATS:

MD-ATS

IASLC lymph node map:

IASLC lymph node map

#1 – low cervical, supraclavicular and sternal notch nodes :

#1 – low cervical, supraclavicular and sternal notch nodes Upper border: lower margin of cricoid cartilage Lower border: clavicles bilaterally and, in the midline, the upper border of the manubrium 1R designates right-sided nodes, 1L, left-sided nodes The midline of the trachea serves as the border between 1R and 1L

#1 – low cervical, supraclavicular and sternal notch nodes :

#1 – low cervical, supraclavicular and sternal notch nodes

#2 – upper paratracheal nodes :

#2 – upper paratracheal nodes 2R : Upper border: apex of the right lung and pleural space, and in the midline, the upper border of the manubrium Lower border: intersection of caudal margin of innominate vein with the trachea 2L : Upper border: apex of the left lung and pleural space, and in the midline, the upper border of the manubrium Lower border: superior border of the aortic arch

#2 – upper paratracheal nodes :

#2 – upper paratracheal nodes

#3 – prevascular and retrotracheal nodes :

#3 – prevascular and retrotracheal nodes 3a: Prevascular On the right Upper border: apex of chest Lower border: level of carina Anterior border: posterior aspect of sternum Posterior border: anterior border of superior vena cava On the left Upper border: apex of chest Lower border: level of carina Anterior border: posterior aspect of sternum Posterior border: left carotid artery 3p: Retrotracheal Upper border: apex of chest Lower border: carina

#3 – prevascular and retrotracheal nodes :

#3 – prevascular and retrotracheal nodes

#4 – lower paratracheal nodes :

#4 – lower paratracheal nodes 4R : includes right paratracheal nodes, and pretracheal nodes extending to the left lateral border of trachea Upper border: intersection of caudal margin of innominate vein with the trachea Lower border: lower border of azygos vein 4L : includes nodes to the left of the left lateral border of the trachea, medial to the ligamentum arteriosum Upper border: upper margin of the aortic arch Lower border: upper rim of the left main pulmonary artery

#4 – lower paratracheal nodes :

#4 – lower paratracheal nodes

#5 – sub aortic nodes (aortopulmonary window) :

#5 – sub aortic nodes ( aortopulmonary window) Subaortic lymph nodes lateral to the ligamentum arteriosum Upper border: the lower border of the aortic arch Lower border: upper rim of the left main pulmonary artery

#5 – sub aortic nodes (aortopulmonary window) :

#5 – sub aortic nodes ( aortopulmonary window)

#6 – para aortic nodes (ascending aortic /phrenic) :

#6 – para aortic nodes (ascending aortic / phrenic ) Lymph nodes anterior and lateral to the ascending aorta and aortic arch Upper border: a line tangential to the upper border of the aortic arch Lower border: the lower border of the aortic arch

#6 – para aortic nodes (ascending aortic /phrenic) :

#6 – para aortic nodes (ascending aortic / phrenic )

#7 – subcarinal nodes:

#7 – subcarinal nodes Upper border: the carina of the trachea Lower border: the upper border of the lower lobe bronchus on the left; the lower border of the bronchus intermedius on the right

#7 – subcarinal nodes:

#7 – subcarinal nodes

#8 – para esophageal nodes (below carina) :

#8 – para esophageal nodes (below carina) Nodes lying adjacent to the wall of the esophagus and to the right or left of the midline, excluding subcarinal nodes Upper border: the upper border of the lower lobe bronchus on the left; the lower border of the bronchus intermedius on the right Lower border: the diaphragm

#8 – para esophageal nodes (below carina) :

#8 – para esophageal nodes (below carina)

#9 – pulmonary ligament nodes:

#9 – pulmonary ligament nodes Nodes lying within the pulmonary ligament Upper border: the inferior pulmonary vein Lower border: the diaphragm

#9 – pulmonary ligament nodes:

#9 – pulmonary ligament nodes

#10 – hilar nodes:

#10 – hilar nodes Includes nodes immediately adjacent to the mainstem bronchus and hilar vessels including the proximal portions of the pulmonary veins and main pulmonary artery Upper border: the lower rim of the azygos vein on the right; upper rim of the pulmonary artery on the left Lower border: interlobar region bilaterally

#10 – hilar nodes:

#10 – hilar nodes

#11 – interlobar nodes:

#11 – interlobar nodes Between the origin of the lobar bronchi 11s : between the upper lobe bronchus and bronchus intermedius on the right 11i : between the middle and lower lobe bronchi on the right

#12 – lobar nodes:

Adjacent to the segmental bronchi #12 – lobar nodes Adjacent to the lobar bronchi #13 – segmental nodes #14 – subsegmental nodes Adjacent to the subsegmental bronchi

Anterior mediastinal group:

Anterior mediastinal group

Anterior mediastinal group:

Anterior mediastinal group Fig. a Fig. c Fig. b

Paratracheal and tracheobronchial groups:

Paratracheal and tracheobronchial groups Most of lungs and bronchi Thoracic trachea Heart Upper para esophageal nodes

PowerPoint Presentation:

Fig. a Fig. c Fig. b

Posterior mediastinal group:

Posterior mediastinal group

PowerPoint Presentation:

Fig. a Fig. b Fig. c

Lymph nodes of the lungs:

Lymph nodes of the lungs

Pathology:

Lung cancer Lymphoma Sarcoidosis Tuberculosis Castleman’s disease Metastases Pathology

Lymph node enlargement:

On radiographs: distortion of normal mediastinal contours or abnormalities of mediastinal lines, interfaces, or spaces CT round, elliptical, or triangular discrete and surrounded by mediastinal fat soft-tissue attenuation Lymph node enlargement

Quantifying enlargement:

Short axis diameter The upper limit of normal for mediastinal lymph nodes – 1 cm except subcarinal (1.5cm) Relevant clinical history Quantifying enlargement

Lung cancer:

Lung cancer Staging and reporting Defined by AJCC & UICC Size >10mm – sensitivity 49-66%; specificity 77-86% Diagnostic accuracy improved by PET-CT

Tuberculosis :

Tuberculosis Lymphadenopathy normally on the side of lung involvement Right sided adenopathy predominates – right paratracheal Low attenuating nodes (40-60 HU) with peripheral rim enhancement

Infectious granulomatous disease:

Primary TB, histoplasmosis Low attenuation lymphadenopathy with rim enhancement – suggest active disease Calcification may be seen Assess complications like broncholithiasis , middle lobe syndrome & fibrosing mediastinitis Rare infections = tularemia, plague, anthrax Anthrax – dense nodes due to hemorrhage Infectious granulomatous disease

Sarcoidosis :

Sarcoidosis Bilateral symmetrical lymph node enlargement Lymph node calcification – dense, stippled or egg shell (25 -50%) D/D –(no hilar involvement) lymphoma, metastases, granulomatous disease

Lymphoma :

Lymphoma Mediastinal involvement more frequent than hilar Tends to expand along or around rather than invade existing structures HL – involves contiguous lymph nodes, NHL involves atypical sites such as posterior mediastinal & anterior diaphragmatic nodes.

PowerPoint Presentation:

Nodal involvement Hodgkin’s Non Hodgkin’s Mediastinal nodes Almost all cases 75% Multiple node groups 85% 60% Single node group 15% 40% Superior mediastinal nodes 98% 75% Posterior mediastinal nodes 5% 20% Skips lymph node groups Uncommon Common

Castleman’s disease:

Angiofollicular mediastinal lymph node hyperplasia, angiomatous lymphoid hamartoma , giant mediastinal lymph node hyperplasia Lymph node hyperplasia of unknown etiology Rich contrast enhancement Central, dense or flocculent calcification may be seen Castleman’s disease

Castleman’s disease:

Hyaline-vascular type Plasma cell type 90% 10% Children, young adults 50-60s Localized Multicentric Benign fashion with cure after complete resection Generalized lymphadenopathy , hepatosplenomegaly 70% asymptomatic mediastinal mass Fever, anemia, infections, lymphoma, Kaposi sarcoma Difficult to treat, progressive Castleman’s disease

Metastases :

Extrathoracic malignancies <3% Breast, melanoma, head and neck, genitourinary and gastrointestinal tumors like esophageal carcinoma Asymmetric lymph node involvement Posterior mediastinum – abdominal primary Superior mediastinum – head and neck Metastases

AIDS:

Infection – tuberculous and non tuberculous mycobacterial , bacterial pneumonia, cryptococcal Malignancy – lymphoma, Kaposi sarcoma PCP – widespread lymph node calcification: cloud like or foamy appearance AIDS

Chronic infiltrative lung disease:

Idiopathic pulmonary fibrosis, collagen vascular disease (RA, scleroderma), extrinsic allergic alveolitis , cryptogenic organizing pneumonia, silicosis, asbestosis Silicosis – egg shell calcification Chronic infiltrative lung disease

Differentials:

Calcified lymph nodes Enhancing lymph nodes Low attenuation lymph nodes Differentials

Calcified lymph nodes:

Dense homogeneous, stippled, egg shell, faint/hazy Typically – prior granulomatous disease (TB, fungal infections, sarcoidosis ) Multiple nodes –seen in contiguity with hilar node calcification Dense involving all or most of abnormal node Egg shell – silicosis, coal workers’ pneumoconiosis, sarcoidosis , TB, Hodgkin’s following RT, blastomycosis , amyloidosis Rare Untreated lymphoma, metastatic carcinoma ( mucinous adenocarcinoma , thyroid carcinoma, osteogenic sarcoma). Adeno ca – stippled/faint PCP in AIDS Amyloidosis Scleroderma Castleman’s disease Calcified lymph nodes

PowerPoint Presentation:

Fig. a Fig. b Fig. c

Egg shell calcification:

Egg shell calcification 2mm thick shell like calcification in the peripheral zone of at least 2 lymph nodes May be solid or broken At least one of the lymph nodes ring should be complete Central part may show additional calcifications One of the affected lymph nodes must be at least 1cm in its greatest diameter

Calcified lymph nodes:

Complication Calcified node may erode into adjacent bronchi – broncholithiasis . Broncholith – expectorated/ atelectasis / postobstructive pneumonia/ hemoptysis D/D: lymphangiographic contrast in lymph nodes. Calcified lymph nodes

Enhancing lymph nodes:

Castleman’s disease Hypervascular metastases Melanoma, renal cell carcinoma, carcinoid , papillary thyroid cancer, Kaposi’s sarcoma Angioimmunoblastic lymphadenopathy Mild enhancement TB, fungal disease, lymphoma, metastatic lung cancer and sarcoidosis D/D – enhancing mediastinal masses Substernal thyroid & parathyroid lesions, lymphangioma , hemangioma & paraganglionoma Enhancing lymph nodes

PowerPoint Presentation:

Fig. a Fig. b Fig. c Fig. d

Low attenuation lymph nodes :

Necrosis or cystic degeneration Rim enhancement Infectious granulomatous disease TB Fungal infections – histoplasmosis Sarcoidosis (rare) Whipple’s disease Metastases Lung, testis, ovary, thyroid, gastric and lymphoma (10-20%) Low attenuation lymph nodes

PowerPoint Presentation:

Fig. a Fig. b Fig. c

Pitfalls :

Anomalous or aberrant mediastinal vessels Nodular diaphragmatic crura Para-esophageal varices , extramedullary hematopoiesis Pericardial recess fluid, mediastinal bronchogenic cysts, cysterna chyli Mediastinal paraganglionoma , intrathoracic thyroid, ectopic thyroid adenoma, parathyroid hyperplasia, hemangioma Pitfalls

References:

The Hippocratic treatise ‘On glands’: the first document on lymphoid tissue and lymph nodes Leukemia (2007) 21, 591–592 ( www.nature.com/leu ) CT Depiction of Regional Nodal Stations for Lung Cancer Staging AJR 2000;174:775–782 Regional Lymph Node Classification for Lung Cancer Staging Chest 1997;111;1718-1723 CT of thoracic lymph nodes. Part I: anatomy and drainage; The British Journal of Radiology, 79 (2006), 922–928 CT of thoracic lymph nodes. Part II: diseases and pitfalls; The British Journal of Radiology, 79 (2006), 999–1006 Imaging of Mediastinal Lymph Nodes; Radiographics 1998; 18:1061-1069 Patterns of Lymphadenopathy in Thoracic Malignancies RadioGraphics 2004; 24:419–434 The IASLC Lung Cancer Staging Project Journal of Thoracic Oncology 2009;4: 568–577 Thoracic Imaging – Webb Grainger and Allison Gray’s Anatomy Youtube and Google Images References

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