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

¹ Department of Radiology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, 270, Rama VI Road, Rajthevi, Bangkok 10400, Thailand, ² Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 South Kingshighway Blvd, Campus Box 8131, Saint Louis, Missouri 63110, USA

View larger version (60K): [in a new window]   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 = 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 segmental nodes, 14R and 14L (pink) = right and left subsegmental nodes. (b) 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.

View larger version (103K): [in a new window]   Figure 2. Enhanced CT scan in a 66-year-old woman with lymphoma showing multiple enlarged bilateral axillary lymph nodes (arrows).

View larger version (51K): [in a new window]   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.

View larger version (122K): [in a new window]   Figure 4. Enhanced CT scan at the level of the main pulmonary artery in a 55-year-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).

View larger version (164K): [in a new window]   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.

View larger version (125K): [in a new window]   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 pleural effusions (E).

View larger version (106K): [in a new window]   Figure 7. Non-enhanced 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.

View larger version (162K): [in a new window]   Figure 8. CT scan through the upper abdomen in a 45-year-old man with distal oesophageal carcinoma (not shown) revealing enlarged retrocrural lymph nodes (large arrows) and liver metastases (small arrows).

View larger version (100K): [in a new window]   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 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. High-attenuation mediastinal masses on unenhanced CT. AJR Am J Roentgenol 1991;156:45–50 [8]. Reprinted with permission).

View larger version (108K): [in a new window]   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 [9]. Reprinted with permission).

View larger version (78K): [in a new window]   Figure 11. Enhanced CT scan in a 58-year-old 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).

View larger version (141K): [in a new window]   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), para-oesophageal (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.

View larger version (144K): [in a new window]   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 [9]. Reprinted with permission).

View larger version (115K): [in a new window]   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 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.

View larger version (94K): [in a new window]   Figure 15. Enhanced CT scan in the same patient as inFigure 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 para-oesophageal nodes (black arrows).

View larger version (155K): [in a new window]   Figure 16. Axial CT scan with lung-window setting in a 59-year-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.

View larger version (73K): [in a new window]   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 x40).