CT OF THORACIC LYMPH

NODES. PART I: ANATOMY

AND DRAINAGE
Journal Reading : The British Journal of Radiology, November 2006
Preceptor : dr. Yanto Budiman, Sp.Rad., M.Kes.

Department of Radiology
School of Medicine Atma Jaya Catholic University of Indonesia
Jakarta 2016

By :
Jessy Claudia

2014 061 061

Swastiko Wiweka Adi

2014 061 063

Jesica Tatang

2015 061 019

Vincentius Henry Sundah

2015 061 023

Eldaa Prisca Refianti Sutanto

2015 061 024

Jemmy Gunawan

2015 061 026

Primary non-invasive technique

for the diagnostic evaluation

Lymph node abnormalities are

depicted by CT as an increase
in nodal size and/or number or
change in attenuation

CT of Thoracic Lymph Node

Non-specific, but patterns of

thoracic lymph node clues in
diagnosis of many pulmonary &
extra-pulmonary disease

Aim of study: illustrates the

anatomic location & drainage
of thoracic lymph node in the
chest wall, mediastinum &
lungs

Classification of Thoracic Lymph

Nodes
Terminology blood vessels or visceral structures closely related / general anatomic
location

Divided by : chest wall and intrathoracic

Classification scheme for mediastinal and pulmonary lymph nodes based on surgically
recognizable anatomic landmarks to facilitate accurate pathologic staging and
analysis of treatment outcomes in lung cancer :
American Joint Committee on Cancer (AJCC)

Union Internationale Contre le Cancer (UICC)

Figure 1(a). 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;111:171823. Reprinted with permission).
Drawing illustrates mediastinum lymph node stations in the frontal
projection.
Ao = aortic arch,
PA = main pulmonary artery,
1 (red) = highest mediastinal nodes,
2R and 2L (dark blue) = right and left upper paratracheal nodes,
4R and 4L (orange) = right and left lower paratracheal nodes,
7 (blue) = subcarinal nodes,
8 (grey) = para-oesophageal nodes,
9 (brown) = pulmonary ligament nodes,
10R and 10L (yellow) = right and left hilar nodes,
11R and 11L (green) = right and left interlobar nodes,
12R and 12L (pink) = right and left lobar nodes,
13R and 13L (pink) = right and left segmetal nodes,
14R and 14L (pink) = right and left subsegmental nodes.

Figure 1(b). 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;111:171823. Reprinted with permission).

Illustration of mediastinum lymph node

stations in the left anterior oblique
projection.
Ao = aortic arch,
PA = main pulmonary artery,
3 (pink) = pre-vascular and retrotracheal
nodes,
5 (black) = subaortic nodes,
6 (red) = para-aortic nodes.

CHEST WALL NODES

Chest Wall Nodes (1)

The axillary nodes receive superficial lymphatic drainage from the upper limbs, breasts
and pectoral muscles
excluding their medial portions, parietal pleura, and skin and muscles of the trunk above the
umbilicus and iliac crest.

The lymph flow is directed toward the terminal nodal group in the axillary apices.
The efferent vessels from this group unite as the subclavian trunk, which finally drains
directly or indirectly into the jugulo-subclavian venous confluence
A few efferents usually reach the supraclavicular nodes a well-recognized route for
the spread of breast cancer.

Figure 2. Enhanced CT scan in a 66-year-old woman with

lymphoma showing multiple enlarged bilateral axillary
lymph nodes (arrows).

Figure 3 (a). A 65-year-old man with

chronic lymphocytic leukaemia.
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.

Figure 3 (b). A 65-year-old man with

chronic lymphocytic leukaemia.
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.

Chest Wall Nodes (2)

The internal mammary (internal thoracic or parasternal) nodes lie at the anterior ends
of the intercostal spaces, along the internal mammary (internal thoracic) vessels.
They receive lymphatic drainage from
the anterior diaphragmatic nodes,
anterosuperior portion of the liver,
medial part of the breasts, and
deeper structures of the anterior chest and upper anterior abdominal wall.

Their efferent channels may empty into

the right lymphatic duct,
the thoracic duct, or
the inferior deep cervical nodes.

Figure 4. Enhanced CT scan

at the level of the main
pulmonary artery in a 55year-old woman with left
breast cancer demonstrating
enlarged left internal
mammary node (arrow).
Note normal right internal
mammary vessels (wavy
arrow) and a portion of
primary cancer in the left
breast (asterisk).

Chest Wall Nodes (3)

The posterior intercostal nodes, located near the heads and necks of the posterior ribs
Receive lymphatic drainage from
the posterolateral intercostal spaces,

posterolateral breasts,
parietal pleura,
vertebrae and spinal muscles.

The efferent vessels from the upper intercostal spaces end in the thoracic duct on the
left, and in one of the lymphatic trunks on the right.
Those from the lower four to seven intercostal spaces unite to form a common trunk,
which empties into the thoracic duct or cisterna chyli.

Chest Wall Nodes (4)

The juxtavertebral (pre-vertebral or paravertebral) nodes lie along the anterior

and lateral aspects of the vertebral bodies, most numerous from T8 to T12.
They communicate with posterior mediastinal lymph nodes and the posterior
intercostal nodes, and similarly drain to the right lymphatic duct or thoracic
duct.

Figure 5. Enhanced CT
scan of a 31-year-old
man with lymphoma
showing enlarged,
necrotic right and left
intercostal nodes (white
arrows) as well as
enlarged left
paravertebral
(arrowheads) and
retrocrural (black arrows)
nodes. Note a left pleural
effusion (E) with pleural
nodules (small white
arrows), splenectomy
clips and coeliac
adenopathy (N). A =
aorta.

Figure 6.
Enhanced CT
scan in a 69year-old woman
with lymphoma
showing
enlarged
bilateral
paravertebral
nodes (white
arrows), left
intercostal node
(open arrow)
and anterior
diaphragmatic
nodes (black
arrows). Note
bilateral pleural
effusions (E).

Chest Wall Nodes (5)

The diaphragmatic nodes are located on or just above the thoracic surface of
the diaphragm
Divided into 3 groups :
The anterior (pre-pericardial or cardiophrenic) group
The middle (juxtaphrenic or lateral) group
The posterior (retrocrural) group

The anterior (pre-pericardial or

cardiophrenic) group
Located anterior to the pericardium, posterior to the xiphoid process, and in
the right and left cardiophrenic fat.
Receives 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.

The middle (juxtaphrenic or lateral)

group

Receives lymph from the central diaphragm and from the convex surface of
the liver on the right.

Figure 7. Nonenhanced CT scan

in a 28-year-old
woman with
metastatic
papillary serous
adenocarcinoma
of the ovary
revealing
enlarged, densely
calcified right
middle
diaphragmatic
nodes (arrow),
located lateral to
the intrathoracic
end of the inferior
vena cava (V) and
near the insertion
of the right phrenic
nerve.

The posterior (retrocrural) group

Located behind the diaphragmatic 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.

When diaphragmatic nodes are enlarged, widespread disease in other

locations is usually present, so biopsy of these sites is uncommon.

Figure 8. CT scan
through the upper
abdomen in a 45year-old man with
distal
oesophageal
carcinoma (not
shown) revealing
enlarged
retrocrural lymph
nodes (large
arrows) and liver
metastases (small
arrows).

MEDIASTINAL LYMPH
NODES

Anterior Mediastinal Group (1)

Consist of:
1.

2.
3.

Highest
mediastinal
nodes
Pre-vascular
nodes
Para-aortic
nodes

heart and
pericardium
diaphragmatic
and mediastinal
pleura

thyroid

thymus

Receive
afferent
vessels
from

middle
diaphragmatic
nodes

Anterior Mediastinal Group (2)

Efferent channels
join those from
Paratracheal nodes
Tracheobronchial
nodes
Internal Mammary
nodes

to form the right

and left
bronchomediastinal
trunks

which may
empty to
the right lymphatic
duct,
the thoracic duct, or
open independently
into the jugulosubclavian venous
confluence

Paratracheal and Tracheobronchial

Groups (1)
These groups receive drainage from
the lungs and bronchi,
thoracic trachea,
heart and
some efferents from the upper para-oesophageal nodes of the posterior mediastinal group.

The nodes comprising these groups include

the upper and lower paratracheal nodes,
subaortic (aortopulmonary window) nodes,
Retrotracheal nodes, and
Subcarinal nodes.

Paratracheal and Tracheobronchial

Groups (2)
The azygos node, located medial to the azygos arch.
The upper paratracheal nodes link the lower paratracheal and inferior deep cervical
nodes.
The subcarinal nodes are contiguous with the hilar nodes and drain to the
paratracheal nodes, preferentially to the right.
The left lower lobe is the most common primary site for contralateral mediastinal lymph
node metastasis in lung cancer.

Figure 9. Nonenhanced CT scan in

the same patient as in
Figure 7 revealing
enlarged, calcified
para-aortic nodes
(station 6; arrows),
lying anterior and
lateral to the aortic
arch (A) below its
superior margin. Also
seen is right lower
paratracheal
lymphadenopathy
(station 4R; open
arrow). V = superior
vena cava.
(From Glazer HS,
Molina PL, Siegel MJ,
Sagel SS. Highattenuation
mediastinal masses on
unenhanced CT. AJR
Am J Roentgenol
1991;156:4550.
Reprinted with
permission).

Figure 10. Enhanced CT

scan in a 73-year-old man
with left lower lobe lung
cancer (not shown)
showing enlarged right
lower paratracheal nodes
(large arrow) lying medial
to the azygos vein (V) and
enlarged left lower
paratracheal nodes
(station 4L; open arrow)
lying medial to ligamentum
arteriosum (small arrows).
Lower paratracheal nodes
lie caudal to the top of the
aortic arch.
(From Sagel SS, Slone RM.
Lung. In: Lee JKT, Sagel SS,
Stanley RJ, Heiken JP,
editors. Computed body
tomography with MRI
correlation, 3rd edn.
Philadelphia, PA:
Lippincott-Raven Publishers,
1998:351 454. Reprinted
with permission).

Figure 11. Enhanced

CT scan in a 58-yearold woman with
carcinoid tumour
showing enhancing
subaortic
lymphadenopathy
(station 5; arrows)
within the
aortopulmonary
window region. This
group is located
lateral to the
ligamentum
arteriosum (not seen).
Note primary tumour
in the left upper lobe
(open arrow).

Figure 12. Enhanced CT scan in

a 65-year-old man with diffuse
pulmonary lymphangitic
carcinomatosis secondary to
non-small cell lung cancer (not
shown) demonstrating
enlarged subcarinal (station 7;
curved arrow), paraoesophageal (black arrow),
right hilar (station 10R; large
white arrows) and left hilar
(station 10L; open arrow)
nodes. Hilar nodes are outside
the mediastinal pleura, below
the top of the upper lobe
bronchi. Note enlarged
subaortic (arrowhead) and
para-aortic (small white arrow)
nodes. Oe = oesophagus.

Posterior Mediastinal Group (1)

Comprised of the para-oesophageal and pulmonary ligament nodes.

Diaphragm

Posterior
diaphragmatic
nodes

Posterior
pericardium

The thoracic
oesophagus

The left hepatic

lobes

The paraoesophageal
nodes receive
afferent vessels
from

More numerous
on the left

Posterior Mediastinal Group (2)

The basilar
segments of
lower lobes

Lower half
of the
oesophagus
The
pulmonary
ligament
nodes receive
drainage
from

Posterior Mediastinal Group (3)

The
efferents
from the
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.

Figure 13. Enhanced CT

scan in a 65-year-old man
with non-small cell lung
cancer demonstrating
metastasis to left
pulmonary ligament node
(station 9; curved arrow)
from left lower lobe lung
cancer (straight arrow).
Oe = oesophagus, A =
aorta.
(From Sagel SS, Slone RM.
Lung. In: Lee JKT, Sagel SS,
Stanley RJ, Heiken JP,
editors. Computed body
tomography with MRI
correlation, 3rd edn.
Philadelphia, USA:
Lippincott-Raven
Publishers, 1998:351 454.
Reprinted with permission).

Lymph Nodes of The Lungs (1)

Located along the bronchi and can be divided into
hilar
intrapulmonary nodes

The latter consist of

Interlobar
lobar
segmental
subsegmental
intraparenchymal intrapulmonary nodes.

Most of the lymphatic flow directed toward the interlobar and hilar nodes which
drain into the subcarinal nodes or directly into the lower paratracheal nodes.

Lymph Nodes of The Lungs (2)

The normal hilar and interlobar nodes are frequently visible, particularly with thinner (13
mm) collimation and intravenous contrast administration.
Recognition of these nodes is important to avoid misdiagnosis of pulmonary
embolism.

Intraparenchymal intrapulmonary nodes may present as indeterminate subpleural

pulmonary nodules in the lower parts of the lungs.

Figure 14. Enhanced

CT scan in a 29-yearold woman with
sarcoidosis
demonstrating
enlarged right lobar
node (station 12R;
arrowhead) at the
bifurcation of the
bronchus intermedius,
right segmental node
(open arrow) adjacent
to the right middle
lobe lateral segmental
bronchus, and left
interlobar nodes
(station 11R and 11L;
white arrows) between
the lingular and left
lower lobe superior
segmental bronchus.
Note enlarged
subcarinal nodes
(black arrows) and
bilateral pulmonary
involvement.

Figure 15. Enhanced

CT scan in the same
patient as in Figure 12
showing enlarged
right and left
segmental nodes
(station 13R and 13L;
large white arrows)
lying adjacent to the
segmental bronchi
(small white arrows)
and enlarged paraoesophageal nodes
(black arrows).

Figure 16. Axial CT scan with

lung-window setting in a 59year-old man with
myocardial infarction
showing a 1 cm,
indeterminate, solitary
pulmonary nodule containing
an eccentric calcific focus in
the right middle lobe (arrow).
Wedge resection revealed a
subsegmental lymph node
(station 14R) with calcified
granuloma.

Figure 17 (a). A 58-year-old man with bronchioloalveolar

carcinoma of the left upper lobe (not shown).

CT scan with lung-window setting

demonstrates a tiny, subpleural nodule in the
lingular segment (arrow).

Figure 17 (b). A 58-year-old man with bronchioloalveolar

carcinoma of the left upper lobe (not shown).

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 40).

Reference
1. Suwatanapongched T, Gierada DS. CT of thoracic lymph nodes. Part I: anatomy and
drainage. Br J Radiol 2006 Nov;79(947):922-8.

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