TheIASLCLymphNodeMap - Society of Thoracic Radiology

Transcription

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
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
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:
Inferior extent:
Superior border of the aortic arch
Right lateral extent:
L ft llateral
Left
t lb
border
d off th
the ttrachea
h
Prevascular and Retrotracheal Lymph Nodes
(Stations 3a and 3p)
Prevascular Lymph Nodes
(Station 3a)
Superior extent:
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
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)
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
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
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
*
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
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
Low Cervical, Supraclavicular, and Sternal
Notch Lymph Nodes
(St ti 1)
(Station
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
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
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
Map-- Drainage of Thoracic Lymph Nodes (Mediastinal Lymph Node Group)
Anterior Mediastinal Group
Prevascular (3A)
Paraaortic(6)
MONDAY
Map-- Drainage of Thoracic Lymph Nodes (Mediastinal Lymph Node Group)
Posterior Mediastinal Group
Paraesophageal (8)
Pulmonary ligament(9)
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
Thoracic esophagus
P t i pericardium
Posterior
i di
Diaphragm
Posterior diaphragmatic lymph nodes
Left hepatic lobe
Pulmonary ligaments LNs
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
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)
Left Hilar (10)
Left Intrapulmonary (11-14)
Mediastinal lymph nodes
Subaortic (5)
Paraaortic (6)
RML/RLL lung cancer
Right Hilar (10)
Right Intrapulmonary (1114)
Subcarinal (7)
LUL lung cancer (lingular segment)
Left Hilar (10)
Subcarinal (7)
Subaortic (5)
Paraaortic (6)
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
Left Hilar (10)
Subcarinal (7)
Left 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
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
ahelsherief@gmail.com
Section of Thoracic Imaging
Imaging Institute
Cl
Cleveland
l d Cli
Clinic
i
227