TheIASLCLymphNodeMap - Society of Thoracic Radiology
Transcription
TheIASLCLymphNodeMap - Society of Thoracic Radiology
The IASLC Lymph Node Map Ahmed H. El-Sherief, MD Learning Objectives After this lecture you will be able to: Ahmed H El-Sherief, MD Accurately define and label thoracic lymph nodes to conform to the new IASLC lymph node map Recognize the differences between the new IASLC lymph node map and old MD-ATS MD ATS lymph node map Recognize size criteria and pitfalls associated with each lymph node station Understand thoracic lymph node drainage patterns in lung cancer Staff, ff, Section off Thoracic Imaging g g Cleveland Clinic Evolution of Thoracic Lymph Node Maps MONDAY Th IASLC Lymph The L h Node N d Map: M Evolution of Thoracic Lymph Node Maps First lymph node map developed by Naruke in the 1960s, was widely used in North America, America Europe Europe, and Japan Therefore in the 1990s and for the first decade of the 2000s, two different thoracic lymph node maps were commonly being used: In the 1980s/1990s subsequent attempts to refine the anatomic descriptors of the N k map lled Naruke d tto th the d development l t off ttwo notable t bl N North th A American i llymph h node maps: A schema advocated byy the American Thoracic Societyy ((ATS)) A schema advocated by the American Joint Committee of Cancer (AJCC)- an adaptation of the Naruke lymph node map Naruke lymph node map MD-ATS lymph node map Important differences in the descriptors of mediastinal lymph nodes existed between the Naruke and MD-ATS MD ATS lymph node maps In 1996, the so-called Mountain-Dressler modification of the ATS-map (MD-ATS) was developed which attempted to unify the ATS and AJCC schemas into a single map Most significant discrepancy was that level 7 subcarinal lymph nodes in the MD-ATS map corresponded to levels 7 and 10 in the Naruke map As a result, some tumors staged as N2 according to the MD-ATS map, were staged N1 by the Naruke map MD-ATS was fully accepted across North America but was only sporadically used in Europe correspond to correspond to Japan continued to use the Naruke lymph node map correspond to 1960s 1980s 1990s 2000s IASLC Lymph Node Map An adaptation of the IASLC Lymph Node Map To reconcile the differences between the Naruke and MD-ATS lymph node maps, the International Association for the Study of Lung Cancer (IASLC) developed a revised lymph node map Notable changes included the following: 1. Anatomically distinct descriptions provided for all lymph node stations, with the upper and lower anatomic borders described in particular d t il detail 2. The boundary between right and left sided level 2 and level 4 nodes is reset to the left lateral wall of the trachea due to lymphatic drainage patterns 3. Supraclavicular and sternal notch lymph nodes, which are not previously considered to constitute a lymph node station station, are now categorized as level 1 nodes 4. Certain lymph nodes stations are grouped into zones for future prognostic ti analyses l and dd do nott representt currentt standard t d d nomenclature 223 IASLC Lymph Node Map Map-- Anatomic Descriptors and Numerical Levels Upper Paratracheal Lymph Nodes (Station 2) MONDAY Right Upper Paratracheal Lymph Nodes (Station 2R) Superior p extent: Upper border of the manubrium Inferior extent: Intersection of caudal margin of left innominate vein with the t h trachea Left lateral extent: Left lateral border of the trachea Left Upper Paratracheal Lymph Nodes (Station 2L) Superior p extent: Upper border of the manubrium Inferior extent: Superior border of the aortic arch Right lateral extent: L ft llateral Left t lb border d off th the ttrachea h IASLC Lymph Node Map Map-- Anatomic Descriptors and Numerical Levels Prevascular and Retrotracheal Lymph Nodes (Stations 3a and 3p) Prevascular Lymph Nodes (Station 3a) Superior extent: Upper border of the manubrium Inferior extent: Carina Anterior extent: Posterior aspect of the sternum Posterior extent: On the right: anterior border of the SVC O th On the lleft: ft lleft ft common carotid tid artery t Retrotracheal Lymph Nodes (Station 3p) Superior extent: Apex of chest Inferior extent: Carina Anterior extent: Posterior aspect of the trachea IASLC Lymph Node Map Map-- Anatomic Descriptors and Numerical Levels Subaortic Lymph Nodes (aka: AP Window) (Station 5) Lymph nodes lateral to ligamentum arteriosum Superior extent: Lower border of aortic arch Inferior extent: Upper rim of left main pulmonary artery t Paraaortic Lymph nodes (Station 6) IASLC Lymph Node Map Map-- Anatomic Descriptors and Numerical Levels Lower Paratracheal Lymph Nodes (Station 4) Right Lower Paratracheal Lymph Nodes (Station 4R) Superior p extent: Intersection of caudal margin of left innominate vein with the trachea Inferior extent: Lower border of the azygous vein L ft llateral Left t l extent: t t Left lateral border of the trachea Left Lower Paratracheal Lymph Nodes (Station 4L) Superior extent: Superior p border of the aortic arch Inferior extent: Upper rim of the left main pulmonary artery Right lateral extent: L ft llateral Left t lb border d off th the ttrachea h IASLC Lymph Node Map Map-- Anatomic Descriptors and Numerical Levels Subaortic Lymph Nodes (aka: AP Window) (Station 5) Lymph nodes lateral to ligamentum arteriosum Superior extent: Lower border of aortic arch Inferior extent: Upper rim of left main pulmonary artery t Paraaortic Lymph nodes (Station 6) Lymph nodes anterior and lateral to ascending aorta and aortic arch Superior extent: Line tangential to the upper border of the aortic arch Inferior extent: Th lower The l border b d off the th aortic ti arch h IASLC Lymph Node Map Map-- Anatomic Descriptors and Numerical Levels Subcarinal Lymph Nodes (Station 7) Superior extent: Upper border of the carina Inferior extent: On the right: lower border of the bronchus intermedius On the left: upper border of the left lower lobe bronchus Lymph nodes anterior and lateral to ascending aorta and aortic arch Superior extent: Line tangential to the upper border of the aortic arch Inferior extent: Th lower The l border b d off the th aortic ti arch h * 224 * IASLC Lymph Node Map Map-- Anatomic Descriptors and Numerical Levels Paraesophageal Lymph Nodes (Station 8) Lymph nodes lying adjacent to the wall of the esophagus, and to the right or left of the midline (excluding subcarinal lymph nodes) Pulmonary ligament Lymph Nodes (Station 9) Lymph nodes lying within the pulmonary ligament Superior extent: Inferior pulmonary vein Inferior extent: Diaphragm IASLC Lymph Node Map Map-- Anatomic Descriptors and Numerical Levels Hilar Lymph Nodes (Station 10) Includes lymph nodes immediately adjacent to the mainstem bronchus including proximal p p portions of the pulmonary p y veins and main pulmonary artery Right Hilar Lymph Nodes (Station 10R) Superior extent: Lower rim of the azygous vein Inferior extent: Interlobar region Left Hilar Lymph Nodes ((Station 10L)) Superior extent: Upper rim of the pulmonary artery Inferior extent: I t l b region Interlobar i Right Low Cervical, Supraclavicular, and Sternal Notch Lymph Nodes (Station 1R) Superior extent: Lower margin of the cricoid cartilage Inferior extent: Clavicles bilaterally Manubrium (in the midline) Left lateral margin Midline of the trachea Left Low Cervical, Supraclavicular, and Sternal Notch Lymph Nodes (Station 1L) Superior p extent: Lower margin of the cricoid cartilage Inferior extent: Clavicles bilaterally Manubrium (in the midline) Right lateral margin Midline of the trachea MONDAY Superior extent: On the right: Lower border of the bronchus intermedius On the left: Upper border of the left lower lobe bronchus Inferior extent: Diaphragm IASLC Lymph Node Map Map-- Anatomic Descriptors and Numerical Levels Low Cervical, Supraclavicular, and Sternal Notch Lymph Nodes (St ti 1) (Station IASLC Lymph Node Map Map-- Anatomic Descriptors and Numerical Levels Interlobar Lymph Nodes (Station 11) Includes lymph nodes between the origin of the lobar bronchi, on the right classified into two groups (11s and 11i) Station 11s: between the upper lobe bronchus and bronchus intermedius on the right Station 11i: between the middle and lower lobe bronchi on the right Lobar Lymph Nodes (Station 12) l d llymph h nodes d adjacent dj t tto llobar b b hi IIncludes bronchi Segmental Lymph Nodes (Station 13) Includes lymph nodes adjacent to segmental bronchi Subsegmental Lymph Nodes (Station 14) Includes lymph nodes adjacent to subsegmental bronchi IASLC Lymph Node Map Map-- Drainage of Thoracic Lymph Nodes (Pulmonary Lymph Nodes) Pulmonary Lymph Nodes Hilar (10) Intrapulmonary Interlobar (11) ( ) Lobar (12) Segmental (13) Subsegmental (14) Common d C drainage i pathway: th Lobar LNs -> Interlobar/Hilar LNs -> Subcarinal LN/or directly to Lower paratracheal LNs IASLC Lymph Node Map Map-- Drainage of Thoracic Lymph Nodes (Mediastinal Lymph Nodes) Mediastinal Lymph Nodes Paratracheal and Tracheobronchial Group Upper Paratracheal (2R, 2L) Lower Paratracheal (3R, 3L) ( ) Sub-aortic/AP Window (5) Subcarinal (7) Afferent drainage from: L Lungs/bronchi /b hi Thoracic trachea Heart Upper paraesophageal lymph nodes Common drainage pathways: paratracheal LNs -> upper pp 1. Lower p paratracheal LNs-> lower cervical LNs 2. Hilar LNs -> subcarinal -> paratracheal (R>L) (therefore, LLL tumor is the most common site f contralateral for t l t l mediastinal di ti l llymph h node d metastasis in lung cancer) 225 IASLC Lymph Node Map Map-- Drainage of Thoracic Lymph Nodes (Mediastinal Lymph Node Group) Mediastinal Lymph Nodes Mediastinal Lymph Nodes Anterior Mediastinal Group Prevascular (3A) Paraaortic(6) MONDAY IASLC Lymph Node Map Map-- Drainage of Thoracic Lymph Nodes (Mediastinal Lymph Node Group) Posterior Mediastinal Group Paraesophageal (8) Pulmonary ligament(9) Afferent drainage from: Thymus Thyroid H t/ i di Heart/pericardium Diaphragmatic/Mediastinal pleura Middle diagphragmatic lymph nodes Efferent drainage to: Right and left bronchomediastinal trunks -> right lymphatic duct, thoracic duct, independently into the jugulo-subclavian venous confluence Paraesophageal LNs Afferent drainage from: Thoracic esophagus P t i pericardium Posterior i di Diaphragm Posterior diaphragmatic lymph nodes Left hepatic lobe Pulmonary ligaments LNs Afferent drainage from: Basilar segments of the lower lobes and lower half p g of the esophagus Efferent drainage to: Tracheobronchial group (esp: subcarinal) Th Thoracic i d ductt Subdiaphragmatic para-aortic/celiac nodes IASLC Lymph Node Map Map-- Patterns of Lymph Node Involvement in Lung Cancer Lymph node metastasis according to location of primary tumor IASLC Lymph Node Map Map-- Patterns of Lymph Node Involvement in Lung Cancer Lymph node metastasis according to location of primary tumor RUL lung cancer Pulmonary lymph nodes Right Hilar (10) Right Intrapulmonary (1114) M di i l llymph Mediastinal h nodes d Right paratracheal (4) Anterior mediastinal (3) LUL lung cancer (excluding lingular segment) g t) Pulmonary lymph nodes Left Hilar (10) Left Intrapulmonary (11-14) Mediastinal lymph nodes Subaortic (5) Paraaortic (6) RML/RLL lung cancer Pulmonary lymph nodes Right Hilar (10) Right Intrapulmonary (1114) Mediastinal lymph nodes Subcarinal (7) Right paratracheal (4) IASLC Lymph Node Map Map-- Patterns of Lymph Node Involvement in Lung Cancer Lymph node metastasis according to location of primary tumor LUL lung cancer (lingular segment) Pulmonary lymph nodes Left Hilar (10) Left Intrapulmonary (11-14) Mediastinal lymph nodes Subcarinal (7) Subaortic (5) Paraaortic (6) IASLC Lymph Node Map Map-- Size Criteria and Common Pitfalls Size Criteria Lymph nodes measuring 10 10--mm or more in the short axis are considered significant in size and suspicious for metastatic disease, although the predictive accuracyy of this criterion is limited p LLL lung cancer Pulmonary lymph nodes Left Hilar (10) Left Intrapulmonary (11-14) Mediastinal lymph nodes Subcarinal (7) Left paratracheal (4) Right paratracheal (4) Lower paratracheal and subcarinal can measure up to 1111mm Upper paratracheal are generally small and measure up to 7 7--mm Right hilar LNs can measure up to 10 10--mm Left hilar LNs can measures up to 7 7--mm Paraesophageal LNs can measure up to 7 7--10 10--mm Peridiaphragmatic LNs can measure up to 55-mm No size criteria for internal mammary, retrocrural, and extrapleural nodes, and detection of these nodes should be considered abnormal Comparison studies to evaluate for new or enlarging lymph nodes (even if the lymph nodes are less than 1 cm in short axis diameter)) are helpful in evaluating for metastatic disease 226 IASLC Lymph Node Map Map-- Size Criteria and Common Pitfalls IASLC Lymph Node Map Map-- Size Criteria and Common Pitfalls Common Pitfalls Pericardial recesses/sinuses are often mistaken for lymph nodes Common Pitfalls Pericardial recesses/sinuses are often mistaken for lymph nodes * * For example: p For example: p Superior aortic recess (and its “high riding” variant): Superior aortic recess (and its “high riding” variant): Oblique sinus: Often confused for subcarinal lymph nodes Pulmonaryy venous recesses: Often confused for pulmonary lymph nodes Miscellaneous Thoracic Lymph Nodes Axillary Lymph Nodes 4 Groups Anterior group: lie deep to pectoralis major group: p lie on the lateral wall of Lateral g the axilla Posterior group: lie to the lateral edge of the subscapularis muscle on the posterior wall of the axilla A i l group: lie Apical li att th the apex off th the axilla ill immediately behind the clavicle Internal Mammary Lymph Nodes Located at the anterior ends of the intercostal spaces, along the internal mammary (internal i ) vessels l th thoracic) Posterior Intercostal Lymph Nodes * MONDAY Often confused Oft f d ffor paratracheal, t h l paraaortic, prevascular, or subaortic lymph nodes Often confused Oft f d ffor paratracheal, t h l paraaortic, prevascular, or subaortic lymph nodes * * * * * Oblique sinus: Often confused for subcarinal lymph nodes Pulmonaryy venous recesses: Often confused for pulmonary lymph nodes Miscellaneous Thoracic Lymph Nodes Diaphragmatic Lymph Nodes 3 Groups Anterior (aka: cardiophrenic) Located anterior to the pericardium,, posterior p p to the xiphoid process, and in the right and left cardiophrenic fat Middle (aka: juxtraphrenic, lateral) L Located t d llateral t l tto th the iintrathoracic t th i end of the IVC Posterior (aka: retrocrural) Located behind the diaphragmatic crura and anterior the spine Posterior Intercostal Lymph Nodes Located near the heads and necks of the posterior ribs Located near the heads and necks of the posterior ribs References Author Correspondence Information Ahmed H El-Sherief, MD [email protected] Section of Thoracic Imaging Imaging Institute Cl Cleveland l d Cli Clinic i 227