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1
Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270,
Rama VI Road, Rajthevi, Bangkok 10400, Thailand and 2Mallinckrodt Institute of Radiology,
Washington University School of Medicine, 510 South Kingshighway Blvd, Campus Box 8131, Saint
Louis, Missouri 63110, USA
CT is the primary non-invasive technique for the pectoral muscles excluding their medial portions, pari-
diagnostic evaluation of thoracic lymph nodes. Lymph etal pleura, and skin and muscles of the trunk above the
node abnormalities are depicted by CT as an increase in umbilicus and iliac crest [1, 2]. The lymph flow is
nodal size and/or number or change in attenuation. directed toward the terminal nodal group in the axillary
Although these findings are non-specific, patterns of apices. The efferent vessels from this group unite as the
thoracic lymph node involvement can provide important subclavian trunk, which finally drains directly or indi-
clues in the diagnosis of many pulmonary and extra- rectly into the jugulo-subclavian venous confluence [1, 2,
pulmonary diseases. Part I of this pictorial review 6]. A few efferents usually reach the supraclavicular
illustrates the anatomic location and drainage of thoracic nodes, a well-recognized route for the spread of breast
lymph nodes in the chest wall, mediastinum and lungs cancer [1, 2, 6].
through examples of pathologic involvement. Part II The internal mammary (internal thoracic or paraster-
focuses on CT patterns of lymph node involvement in nal) nodes (Figure 4) lie at the anterior ends of the
various pulmonary and extrapulmonary diseases. intercostal spaces, along the internal mammary (internal
thoracic) vessels. They receive lymphatic drainage from
the anterior diaphragmatic nodes, anterosuperior por-
Classification of thoracic lymph nodes tion of the liver, medial part of the breasts, and deeper
As in other parts of the body, thoracic lymph nodes are structures of the anterior chest and upper anterior
named using descriptive terminology according to the abdominal wall [2]. Their efferent channels may empty
blood vessels or visceral structures to which they are into the right lymphatic duct, the thoracic duct, or the
most closely related, or by their general anatomic inferior deep cervical nodes [3, 6].
location. Although there are slight differences in the The posterior intercostal nodes (Figures 5 and 6),
classification of the thoracic nodes [1–5], they can be located near the heads and necks of the posterior ribs,
divided into those of the chest wall and those of the receive lymphatic drainage from the posterolateral
intrathoracic contents. To facilitate accurate pathologic intercostal spaces, posterolateral breasts, parietal pleura,
staging and analysis of treatment outcomes in lung vertebrae and spinal muscles [2–4]. The efferent vessels
cancer, a classification scheme for mediastinal and from the upper intercostal spaces end in the thoracic
pulmonary lymph nodes (Figure 1) has been devised duct on the left, and in one of the lymphatic trunks on
by the American Joint Committee on Cancer (AJCC) and the right [2–4]. Those from the lower four to seven
the Union Internationale Contre le Cancer (UICC) [5], intercostal spaces unite to form a common trunk, which
based on surgically recognizable anatomic landmarks. empties into the thoracic duct or cisterna chyli [2–4]. The
juxtavertebral (pre-vertebral or paravertebral) nodes lie
along the anterior and lateral aspects of the vertebral
Chest wall nodes bodies, most numerous from T8 to T12 (Figures 5 and 6)
The axillary nodes (Figures 2 and 3) receive superficial [3, 4]. They communicate with posterior mediastinal
lymphatic drainage from the upper limbs, breasts and lymph nodes [3] and the posterior intercostal nodes, and
similarly drain to the right lymphatic duct or thoracic
Address correspondence to: D S Gierada. duct [3, 4].
(a) (b)
Figure 1. Revised American Joint Committee on Cancer (AJCC) and the Union Internationale Contre le Cancer (UICC) regional
nodal stations for lung cancer staging. (From Mountain CF, Dresler CM. Regional lymph node classification for lung cancer
staging. Chest 1997;111:1718–23 [5]. Reprinted with permission). (a) Drawing illustrates mediastinum lymph node stations in the
frontal projection. Ao 5 aortic arch, PA 5 main pulmonary artery, 1 (red) 5 highest mediastinal nodes, 2R and 2L (dark blue) 5
right and left upper paratracheal nodes, 4R and 4L (orange) 5 right and left lower paratracheal nodes, 7 (blue) 5 subcarinal
nodes, 8 (grey) 5 para-oesophageal nodes, 9 (brown) 5 pulmonary ligament nodes, 10R and 10L (yellow) 5 right and left hilar
nodes, 11R and 11L (green) 5 right and left interlobar nodes, 12R and 12L (pink) 5 right and left lobar nodes, 13R and 13L (pink)
5 right and left segmental nodes, 14R and 14L (pink) 5 right and left subsegmental nodes. (b) Illustration of mediastinum lymph
node stations in the left anterior oblique projection. Ao 5 aortic arch, PA 5 main pulmonary artery, 3 (pink) 5 pre-vascular and
retrotracheal nodes, 5 (black) 5 subaortic nodes, 6 (red) 5 para-aortic nodes.
The diaphragmatic nodes are located on or just above Mediastinal lymph nodes
the thoracic surface of the diaphragm and are divided
into three groups [2–4, 7]. The anterior (pre-pericardial or Anterior mediastinal group
cardiophrenic) group (Figure 6) is located anterior to the This group includes the highest mediastinal (station 1,
pericardium, posterior to the xiphoid process, and in the Figures 1 and 3a), pre-vascular (station 3A, Figures 1
right and left cardiophrenic fat. This node group receives and 3b), and para-aortic (station 6, Figures 1 and 9)
afferent drainage from the anterior part of the diaphragm
and its pleura, and the anterosuperior portion of the
liver. They drain to the internal mammary nodes
alongside the xiphoid and can provide a route for
retrograde spread of breast cancer to the liver, via
lymphatics of the rectus abdominis muscle when the
upper internal thoracic trunks are blocked [4]. The
middle (juxtaphrenic or lateral) (Figure 7) group receives
lymph from the central diaphragm and from the convex
surface of the liver on the right [2]. The posterior
(retrocrural) group (Figure 8), lying behind the dia-
phragmatic crura and anterior to the spine, receives
lymph from the posterior part of the diaphragm and
communicates with the posterior mediastinal nodes and
para-aortic nodes in the upper abdomen [2, 4]. When
diaphragmatic nodes are enlarged, widespread disease Figure 2. Enhanced CT scan in a 66-year-old woman with
in other locations is usually present, so biopsy of these lymphoma showing multiple enlarged bilateral axillary
sites is uncommon [7]. lymph nodes (arrows).
(a) (b)
Figure 3. A 65-year-old man with chronic lymphocytic leukaemia. (a) Enhanced CT scan demonstrates enlarged right axillary
nodes (arrowheads) and right interpectoral (Rotter) node (black arrow) lying between pectoralis major (M) and minor (m)
muscles. Nodes in the subpectoral and interpectoral regions are included in the axillary nodal group. Also seen are enlarged
highest mediastinal nodes (station 1; white arrows) defined by their location cranial to the superior margin of the left
brachiocephalic vein, behind and to the right and left sides of the trachea. (b) Enhanced CT scan at the lower level shows
bilaterally enlarged axillary nodes (arrowheads), including left subpectoral nodes (open arrow) underneath the left pectoralis
minor muscle (m). There are enlarged pre-vascular nodes (station 3A; white arrows), which lie between the superior margin of
the left brachiocephalic vein (V) and the superior margin of the aortic arch, and anterior to its large arterial branches; enlarged
retrotracheal node (station 3P; black arrow), which lies behind the trachea and above the inferior aspect of azygos vein arch;
and enlarged right upper paratracheal nodes (station 2R; wavy arrow), which are located above the superior margin of the
aortic arch.
Thus, the left lower lobe is the most common primary Figure 16. Axial CT scan with lung-window setting in a 59-
site for contralateral mediastinal lymph node metastasis year-old man with myocardial infarction showing a 1 cm,
in lung cancer. indeterminate, solitary pulmonary nodule containing an
eccentric calcific focus in the right middle lobe (arrow).
Wedge resection revealed a subsegmental lymph node
Posterior mediastinal group (station 14R) with calcified granuloma.
The posterior mediastinal nodes are comprised of the
para-oesophageal (station 8, Figures 1 and 12) and
the left hepatic lobe, and are more numerous on the left
pulmonary ligament (station 9, Figures 1 and 13) nodes
[2]. The pulmonary ligament nodes receive drainage
[4, 5]. The para-oesophageal nodes receive afferent
from the basilar segments of the lower lobes and lower
vessels from the thoracic oesophagus, posterior pericar-
half of the oesophagus [4]. The efferents from the
dium, diaphragm, posterior diaphragmatic nodes and
posterior mediastinal nodes communicate with the
tracheobronchial group, particularly subcarinal nodes,
and drain chiefly into the thoracic duct, but also drain to
the subdiaphragmatic para-aortic or coeliac nodes [3, 4].
(a) (b)
Figure 17. A 58-year-old man with bronchioloalveolar carcinoma of the left upper lobe (not shown). (a) CT scan with lung-
window setting demonstrates a tiny, subpleural nodule in the lingular segment (arrow). (b) Histological examination reveals a
normal lymph node (arrows), surrounded by alveolar tissue. It had capsule with visible germinal centres and contains histiocytes
and carbon pigment (haematoxylin and eosin 640).
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