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Th IASLC L h N d MThe IASLC Lymph Node Map:

Ahmed H El-Sherief, MD

Staff, Section of Thoracic Imagingff, f g gCleveland Clinic

Learning ObjectivesLearning Objectives

After this lecture you will be able to:After this lecture you will be able to:

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 lymph node mapold 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

Evolution of Thoracic Lymph Node MapsEvolution of Thoracic Lymph Node Maps

First lymph node map developed by Naruke in the 1960s, was widely used in North America Europe and JapanNorth America, Europe, and Japan

In the 1980s/1990s subsequent attempts to refine the anatomic descriptors of the N k l d t th d l t f t t bl N th A i l hNaruke map led to the development of two notable North American lymph

node maps:

A schema advocated by the American Thoracic Society (ATS)y y ( )A schema advocated by the American Joint Committee of Cancer (AJCC)- an

adaptation of the Naruke lymph node map

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

MD-ATS was fully accepted across North America but was only sporadically used in Europe

Japan continued to use the Naruke lymph node map

1960s1960s 1980s1980s 1990s1990s 2000s2000s

Evolution of Thoracic Lymph Node MapsEvolution of Thoracic Lymph Node Maps

Therefore in the 1990s and for the first decade of the 2000s, two different thoracic lymph node maps were commonly being used:thoracic lymph node maps were commonly being used:

Naruke lymph node mapMD-ATS lymph node map

Important differences in the descriptors of mediastinal lymph nodes existed between the Naruke and MD-ATS lymph node mapsbetween the Naruke and MD ATS lymph node maps

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

correspond tocorrespond to

correspond tocorrespond tocorrespond tocorrespond to

correspond tocorrespond to

IASLC Lymph Node MapIASLC 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: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 ildetail

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 are nowpreviously considered to constitute a lymph node station, are nowcategorized as level 1 nodes

4. Certain lymph nodes stations are grouped into zones for future ti l d d t t t t d dprognostic analyses and do not represent current standard

nomenclature

An adaptation of the IASLC Lymph Node Map

The IASLC Lymph Node MapAhmed H. El-Sherief, MD

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IASLC Lymph Node MapIASLC Lymph Node Map-- Anatomic Descriptors and Numerical LevelsAnatomic Descriptors and Numerical Levels

Upper Paratracheal Lymph Nodes (Station 2)

Right Upper Paratracheal Lymph Nodes(Station 2R)

Superior extent:pUpper border of the manubrium

Inferior extent: Intersection of caudal margin of left innominate vein with the t htrachea

Left lateral extent:Left lateral border of the trachea

Left Upper Paratracheal Lymph Nodes(Station 2L)

Superior extent:pUpper border of the manubrium

Inferior extent: Superior border of the aortic arch

Right lateral extent:L ft l t l b d f th t hLeft lateral border of the trachea


Lower Paratracheal Lymph Nodes (Station 4)

Right Lower Paratracheal Lymph Nodes(Station 4R)

Superior extent:pIntersection of caudal margin of left innominate vein with the trachea

Inferior extent: Lower border of the azygous vein

L ft l t l t tLeft lateral extent:Left lateral border of the trachea

Left Lower Paratracheal Lymph NodesLeft Lower Paratracheal Lymph Nodes(Station 4L)

Superior extent:Superior border of the aortic archp

Inferior extent: Upper rim of the left main pulmonary artery

Right lateral extent:L ft l t l b d f th t hLeft lateral border of the trachea


Prevascular and Retrotracheal Lymph Nodes(Stations 3a and 3p)

Prevascular Lymph Nodes(Station 3a)

Superior extent: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 SVCO th l ft l ft tid tOn the left: left common carotid artery

Retrotracheal Lymph Nodes(Station 3p)(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)


(Station 5)

Lymph nodes lateral to ligamentum arteriosum

Superior extent:Lower border of aortic arch

Inferior extent: Upper rim of left main pulmonary

tartery

Paraaortic Lymph nodes(Station 6)(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 l b d f th ti hThe lower border of the aortic arch

Subaortic Lymph Nodes (aka: AP Window)(Station 5)


(Station 5)

Lymph nodes lateral to ligamentum arteriosum

Superior extent:Lower border of aortic arch

Inferior extent: Upper rim of left main pulmonary

tartery

Paraaortic Lymph nodes(Station 6)(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 l b d f th ti hThe lower border of the aortic arch

Subcarinal Lymph Nodes (Station 7)


(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

* *

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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)

Superior extent:On the right: Lower border of the bronchus intermediusOn the left: Upper border of the leftOn the left: Upper border of the leftlower lobe bronchus

Inferior extent: Diaphragm

Pulmonary ligament Lymph Nodes(Station 9)

Lymph nodes lying within the pulmonaryLymph nodes lying within the pulmonaryligament

Superior extent:Inferior pulmonary veinInferior pulmonary vein

Inferior extent: Diaphragm

Low Cervical, Supraclavicular, and Sternal Notch Lymph Nodes(St ti 1)


(Station 1)

Right Low Cervical, Supraclavicular, and Sternal Notch Lymph Nodes

(Station 1R)

Superior extent:Lower margin of the cricoid cartilage

Inferior extent: Clavicles bilaterallyClavicles bilaterallyManubrium (in the midline)

Left lateral marginMidline of the trachea

Left Low Cervical, Supraclavicular, and Sternal Notch Lymph Nodes

(Station 1L)

Superior extent:pLower margin of the cricoid cartilage

Inferior extent: Clavicles bilaterallyManubrium (in the midline)

Right lateral marginMidline of the trachea

Hilar Lymph Nodes(Station 10)


(Station 10)

Includes lymph nodes immediately adjacent to the mainstem bronchus including proximal portions of the pulmonary veins p p p yand main pulmonary artery

Right Hilar Lymph Nodes(Station 10R)

Superior extent:Lower rim of the azygous vein

Inferior extent:Interlobar regionInterlobar region

Left Hilar Lymph Nodes(Station 10L)( )

Superior extent:Upper rim of the pulmonary artery

Inferior extent: I t l b iInterlobar region

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 andbronchus intermedius on the right

Station 11i: between the middle and lower lobe bronchi on the right

Lobar Lymph Nodes(Station 12)

I l d l h d dj t t l b b hiIncludes lymph nodes adjacent to lobar bronchi

Segmental Lymph Nodes(Station 13)

Includes lymph nodes adjacent to segmental bronchi

Subsegmental Lymph Nodes(Station 14)(Station 14)

Includes lymph nodes adjacent to subsegmental bronchi

IASLC Lymph Node MapIASLC Lymph Node Map-- Drainage of Thoracic Lymph Nodes Drainage of Thoracic Lymph Nodes (Pulmonary Lymph Nodes)(Pulmonary Lymph Nodes)

Pulmonary Lymph Nodes

Hilar (10)Intrapulmonary

Interlobar (11)Lobar (12)( )Segmental (13)Subsegmental (14)

C d i thCommon drainage pathway:Lobar LNs -> Interlobar/Hilar LNs -> Subcarinal LN/or directly to Lower paratracheal LNs

Mediastinal Lymph Nodes

IASLC Lymph Node MapIASLC Lymph Node Map-- Drainage of Thoracic Lymph Nodes Drainage of Thoracic Lymph Nodes (Mediastinal Lymph Nodes)(Mediastinal Lymph Nodes)

Paratracheal and Tracheobronchial GroupUpper Paratracheal (2R, 2L)Lower Paratracheal (3R, 3L)Sub-aortic/AP Window (5)( )Subcarinal (7)

Afferent drainage from:L /b hiLungs/bronchi

Thoracic tracheaHeartUpper paraesophageal lymph nodes

Common drainage pathways:

1. Lower paratracheal LNs -> upper p ppparatracheal LNs-> lower cervical LNs

2. Hilar LNs -> subcarinal -> paratracheal (R>L)(therefore, LLL tumor is the most common site f t l t l di ti l l h dfor contralateral mediastinal lymph nodemetastasis in lung cancer)

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IASLC Lymph Node MapIASLC Lymph Node Map-- Drainage of Thoracic Lymph Nodes Drainage of Thoracic Lymph Nodes (Mediastinal Lymph Node Group)(Mediastinal Lymph Node Group)

Anterior Mediastinal GroupPrevascular (3A)Paraaortic(6)

Afferent drainage from:ThymusThyroidH t/ i diHeart/pericardiumDiaphragmatic/Mediastinal pleuraMiddle diagphragmatic lymph nodes

Efferent drainage to:Efferent drainage to:Right and left bronchomediastinal trunks -> right lymphatic duct, thoracic duct, independently into the jugulo-subclavian venous confluence


IASLC Lymph Node MapIASLC Lymph Node Map-- Drainage of Thoracic Lymph Nodes Drainage of Thoracic Lymph Nodes (Mediastinal Lymph Node Group)(Mediastinal Lymph Node Group)

Posterior Mediastinal GroupParaesophageal (8)Pulmonary ligament(9)

Paraesophageal LNsAfferent drainage from:Thoracic esophagusP t i i diPosterior pericardiumDiaphragmPosterior diaphragmatic lymph nodesLeft hepatic lobe

Pulmonary ligaments LNsAfferent drainage from:Basilar segments of the lower lobes and lower half of the esophagusp g

Efferent drainage to:Tracheobronchial group (esp: subcarinal)Th i d tThoracic ductSubdiaphragmatic para-aortic/celiac nodes

IASLC Lymph Node MapIASLC Lymph Node Map-- Patterns of Lymph Node Involvement in Lung Cancer

Lymph node metastasis according to location of primary tumor

RUL lung cancerPulmonary lymph nodes


Pulmonary lymph nodesRight Hilar (10)Right Intrapulmonary (11-

14)M di i l l h dMediastinal lymph nodes

Right paratracheal (4)Anterior mediastinal (3)

RML/RLL lung cancerPulmonary lymph nodesPulmonary lymph nodes

Right Hilar (10)Right Intrapulmonary (11-

14)Mediastinal lymph nodesMediastinal lymph nodes

Subcarinal (7)Right paratracheal (4)



LUL lung cancer (excluding lingular g t)


segment)Pulmonary lymph nodes

Left Hilar (10)Left Intrapulmonary (11-14)

Mediastinal lymph nodesSubaortic (5)Paraaortic (6)

LUL lung cancer (lingular segment)Pulmonary lymph nodesPulmonary lymph nodes


Mediastinal lymph nodesSubcarinal (7)Subcarinal (7)Subaortic (5)Paraaortic (6)




LLL lung cancerPulmonary lymph nodes


Mediastinal lymph nodesSubcarinal (7)Left paratracheal (4)Left paratracheal (4)Right paratracheal (4)

IASLC Lymph Node MapIASLC Lymph Node Map-- Size Criteria and Common Pitfalls

Size Criteria

Lymph nodes measuring 10Lymph nodes measuring 10--mm or more in the mm or more in the short axis are considered significant in size and short axis are considered significant in size and suspicious for metastatic disease, although the suspicious for metastatic disease, although the predictive accuracy of this criterion is limited predictive accuracy of this criterion is limited p yp y

Lower paratracheal and subcarinal can measure up to 11Lower paratracheal and subcarinal can measure up to 11--mmmm

Upper paratracheal are generally small and Upper paratracheal are generally small and measure up measure up to 7to 7--mmmmto 7to 7 mmmm

Right hilar LNs can measure up to 10Right hilar LNs can measure up to 10--mmmm

Left hilar LNs can measures up to 7Left hilar LNs can measures up to 7--mmmm

Paraesophageal LNs can measure up to 7Paraesophageal LNs can measure up to 7 1010 mmmmParaesophageal LNs can measure up to 7Paraesophageal LNs can measure up to 7--1010--mmmm

Peridiaphragmatic LNs can measure up to 5Peridiaphragmatic LNs can measure up to 5--mmmm

No size criteria for internal mammary, retrocrural, and No size criteria for internal mammary, retrocrural, and extrapleural nodes, and detection of these nodes should extrapleural nodes, and detection of these nodes should be considered abnormalbe 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

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Common Pitfalls

Pericardial recesses/sinuses are often mistaken for lymph nodes

For example:*

*p

Superior aortic recess (and its “high riding” variant):

Oft f d f t h lOften confused for paratracheal,paraaortic, prevascular, or sub-aortic lymph nodes

Oblique sinus:Oblique sinus:Often confused for subcarinal lymph nodes

Pulmonary venous recesses:*

** *

*

yOften confused for pulmonary lymph nodes


Common Pitfalls

Pericardial recesses/sinuses are often mistaken for lymph nodes

For example:

*

p

Superior aortic recess (and its “high riding” variant):

Oft f d f t h lOften confused for paratracheal,paraaortic, prevascular, or sub-aortic lymph nodes

Oblique sinus:Oblique sinus:Often confused for subcarinal lymph nodes

Pulmonary venous recesses:yOften confused for pulmonary lymph nodes

Axillary Lymph Nodes

Miscellaneous Thoracic Lymph NodesMiscellaneous Thoracic Lymph Nodes

4 GroupsAnterior group: lie deep to pectoralis

majorLateral group: lie on the lateral wall of g p

the axillaPosterior group: lie to the lateral edge of

the subscapularis muscle on the posterior wall of the axilla

A i l li t th f th illApical group: lie at the apex of the axillaimmediately behind the clavicle

Internal Mammary Lymph Nodes

Located at the anterior ends of the intercostal spaces, along the internal mammary (internal th i ) lthoracic) vessels

Posterior Intercostal Lymph Nodes

Located near the heads and necks of the posterior ribs

Diaphragmatic Lymph Nodes

Miscellaneous Thoracic Lymph NodesMiscellaneous Thoracic Lymph Nodes

3 GroupsAnterior (aka: cardiophrenic)

Located anterior to the pericardium, posterior to the p , pxiphoid process, and in the right and left cardiophrenic fat

Middle (aka: juxtraphrenic, lateral)L t d l t l t th i t th iLocated lateral to the intrathoracic

end of the IVC

Posterior (aka: retrocrural)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

ReferencesReferences Author Correspondence InformationAuthor Correspondence Information

Ahmed H El-Sherief, MD [email protected]

Section of Thoracic ImagingImaging InstituteCl l d Cli iCleveland Clinic

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