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The British Journal of Radiology, 79 (2006), 922–928

PICTORIAL REVIEW

CT of thoracic lymph nodes. Part I: anatomy and drainage


1
T SUWATANAPONGCHED, MD and 2D S GIERADA, MD

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

ABSTRACT. CT is the primary non-invasive technique for the diagnostic evaluation of


thoracic lymph nodes. The CT patterns and anatomic location of thoracic lymph node Received 11 April 2005
involvement can provide important clues in the diagnosis of many diseases. Part I of the Revised 23 June 2005
pictorial review illustrates the anatomic location and drainage of thoracic lymph nodes Accepted 11 July 2005
in the chest wall, mediastinum and lungs through examples of pathologic involvement.
DOI: 10.1259/bjr/26411607
Part II of the pictorial review focuses on CT patterns of lymph node involvement in
various pulmonary and extrapulmonary diseases, differential diagnoses based on CT ’ 2006 The British Institute of
findings and pitfalls. Radiology

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].

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Pictorial review: CT of thoracic lymph nodes

(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).

The British Journal of Radiology, November 2006 923


T Suwatanapongched and D S Gierada

(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.

Figure 5. Enhanced CT scan of a 31-year-old man with


Figure 4. Enhanced CT scan at the level of the main lymphoma showing enlarged, necrotic right and left inter-
pulmonary artery in a 55-year-old woman with left breast costal nodes (white arrows) as well as enlarged left
cancer demonstrating enlarged left internal mammary node paravertebral (arrowheads) and retrocrural (black arrows)
(arrow). Note normal right internal mammary vessels (wavy nodes. Note a left pleural effusion (E) with pleural nodules
arrow) and a portion of primary cancer in the left breast (small white arrows), splenectomy clips and coeliac adeno-
(asterisk). pathy (N). A 5 aorta.

924 The British Journal of Radiology, November 2006


Pictorial review: CT of thoracic lymph nodes

Figure 6. Enhanced CT scan in a 69-year-old woman with


lymphoma showing enlarged bilateral paravertebral nodes
(white arrows), left intercostal node (open arrow) and
anterior diaphragmatic nodes (black arrows). Note bilateral Figure 8. CT scan through the upper abdomen in a 45-year-
pleural effusions (E). old man with distal oesophageal carcinoma (not shown)
revealing enlarged retrocrural lymph nodes (large arrows)
and liver metastases (small arrows).

nodes [2, 3, 5, 8]. They receive afferent vessels from the


thymus, thyroid, heart and pericardium, diaphragmatic
and mediastinal pleura, and middle diaphragmatic these groups include the upper (station 2R, 2L, Figures 1
nodes [2, 3]. Their efferent channels join those from the and 3b) and lower (station 4R, 4L, Figures 1, 9 and 10)
paratracheal, tracheobronchial and internal mammary paratracheal, subaortic (aortopulmonary window, sta-
nodes, to form the right and left bronchomediastinal tion 5, Figures 1, 11, and 12), retrotracheal (station 3P,
trunks, which may empty to the right lymphatic duct, the Figures 1 and 3b), and subcarinal (station 7, Figures 1
thoracic duct, or open independently into the jugulo- and 12) nodes [2, 3, 5]. The azygos node, located medial
subclavian venous confluence [2, 3]. to the azygos arch, is included in station 4R [5]. The
upper paratracheal nodes link the lower paratracheal
and inferior deep cervical nodes [10]. The subcarinal
Paratracheal and tracheobronchial groups nodes are contiguous with the hilar nodes and drain to
These groups receive drainage from most parts of the paratracheal nodes, preferentially to the right [11].
the lungs and bronchi, thoracic trachea, heart and some
efferents from the upper para-oesophageal nodes of the
posterior mediastinal group [2, 4]. The nodes comprising

Figure 9. Non-enhanced 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
Figure 7. Non-enhanced CT scan in a 28-year-old woman arch (A) below its superior margin. Also seen is right lower
with metastatic papillary serous adenocarcinoma of the paratracheal lymphadenopathy (station 4R; open arrow). V
ovary revealing enlarged, densely calcified right middle 5 superior vena cava. (From Glazer HS, Molina PL, Siegel MJ,
diaphragmatic nodes (arrow), located lateral to the Sagel SS. High-attenuation mediastinal masses on unen-
intrathoracic end of the inferior vena cava (V) and near the hanced CT. AJR Am J Roentgenol 1991;156:45–50 [8].
insertion of the right phrenic nerve. Reprinted with permission).

The British Journal of Radiology, November 2006 925


T Suwatanapongched and D S Gierada

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 Figure 12. Enhanced CT scan in a 65-year-old man with
caudal to the top of the aortic arch. (From Sagel SS, Slone diffuse pulmonary lymphangitic carcinomatosis secondary to
RM. Lung. In: Lee JKT, Sagel SS, Stanley RJ, Heiken JP, editors. non-small cell lung cancer (not shown) demonstrating
Computed body tomography with MRI correlation, 3rd edn. enlarged subcarinal (station 7; curved arrow), para-oesopha-
Philadelphia, PA: Lippincott-Raven Publishers, 1998:351–454 geal (black arrow), right hilar (station 10R; large white
[9]. Reprinted with permission). 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 (arrow-
head) and para-aortic (small white arrow) nodes. Oe 5
oesophagus.

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
Figure 11. Enhanced CT scan in a 58-year-old woman with left lower lobe lung cancer (straight arrow). Oe 5 oesopha-
carcinoid tumour showing enhancing subaortic lymphade- gus, A 5 aorta. (From Sagel SS, Slone RM. Lung. In: Lee JKT,
nopathy (station 5; arrows) within the aortopulmonary Sagel SS, Stanley RJ, Heiken JP, editors. Computed body
window region. This group is located lateral to the tomography with MRI correlation, 3rd edn. Philadelphia,
ligamentum arteriosum (not seen). Note primary tumour in USA: Lippincott-Raven Publishers, 1998:351–454 [9].
the left upper lobe (open arrow). Reprinted with permission).

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Pictorial review: CT of thoracic lymph nodes

Figure 14. Enhanced CT scan in a 29-year-old woman with


sarcoidosis demonstrating enlarged right lobar node (station
12R; arrowhead) at the bifurcation of the bronchus inter-
medius, 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.

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].

Lymph nodes of the lungs


Lymph nodes are located along the bronchi and can be
divided into hilar (station 10R, 10L, Figures 1 and 12)
and intrapulmonary nodes [5, 10]. The latter consist of
interlobar (station 11R, 11L, Figures 1 and 14), lobar
(station 12R, 12L, Figures 1 and 14), segmental (station
13R, 13L, Figures 1, 14 and 15), subsegmental (station
14R, 14L, Figures 1 and 16) and intraparenchymal
intrapulmonary (Figure 17) nodes [5, 9, 12]. Most of
the lymphatic flow of the lungs is directed toward the
interlobar and hilar nodes, which drain into the
subcarinal nodes or directly into the lower paratracheal
nodes [3, 4, 10, 11].
The normal hilar and interlobar nodes are frequently
visible, particularly with thinner (1–3 mm) collimation and
Figure 15. Enhanced CT scan in the same patient as in intravenous contrast administration [13]. Recognition of
Figure 12 showing enlarged right and left segmental nodes these nodes is important to avoid misdiagnosis of
(station 13R and 13L; large white arrows) lying adjacent to pulmonary embolism. Intraparenchymal intrapulmonary
the segmental bronchi (small white arrows) and enlarged nodes may present as indeterminate subpleural pulmon-
para-oesophageal nodes (black arrows). ary nodules in the lower parts of the lungs [12].

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T Suwatanapongched and D S Gierada

(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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