Lymph Drainage Map

Once this collection of substances enters the lymphatic vessels it is known as lymph; lymph is subsequently filtered by lymph nodes and directed into the venous system. This article will explore the anatomy of lymphatic drainage throughout the lower limb, and how this is relevant clinically. Lymph Chains & Their Drainage Areas Lymph Nodes of the Head and Neck. Lymph Nodes at Surface; Deep Lymph Nodes; Lymph Nodes of Breast and Arm. Lymph Nodes of the Breast and Upper Limb; Thoracic Lymph Nodes. Parietal Lymph Nodes of the Thorax; Visceral Lymph Nodes of the Thorax; Lymph Nodes of the Lower Thorax; Abdominal Lymph Nodes. In the early 1950s, Walker was the first to use radiotracers to map lymphatic drainage 5. Following this, Sherman et al. Developed the concept of lymphoscintigraphy 6, demonstrating that colloidal gold could be traced from the point of intradermal injection to the draining lymph nodes. This was the advent of cutaneous lymphoscintigraphy as. Lymphatic drainage map Lymphatic drainage poster that shows the drainage patterns and lymph nodes.

Thoracic lymph nodes are divided into 14 stations as defined by the International Association for the Study of Lung Cancer (IASLC) ¹, principally in the context of oncologic staging. For the purpose of prognostication, the stations may be grouped into seven zones. The IASLC definitions leave some ambiguous regions which can lead to misclassification ³.

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Supraclavicular zone

Station 1 (left/right): low cervical, supraclavicular, and sternal notch nodes

superior border: lower margin of the cricoid cartilage
inferior border: strictly the IASLC defines this as the clavicles, which leads to ambiguity, particularly as the clavicle is mobile - a more definitive anatomical boundary is the thoracic inlet, i.e. 1^st rib²
left (1L) and right (1R) are divided by the midline of the trachea
station 1 nodes are outsidethe mediastinum and staged as an N3 disease; despite this, they can sometimes be treated with radical intent if they are encompassable in a radiotherapy field

Upper zone (superior mediastinal nodes)

Station 2 (left/right): upper paratracheal nodes

superior border: apex of lung / pleural space, thoracic inlet ²
left (2L) and right (2R) are divided along the left lateral border of the trachea, not the midline
inferior border of 2R: at the intersection of caudal margin of the left brachiocephalic vein with the trachea, i.e. abuts 4R
inferior border of 2L: superior border of the aortic arch, i.e. abuts 4L

Station 3A and 3P: pre-vascular and retrotracheal nodes

superior border: thoracic inlet
inferior border: carina
3A: prevascular - anterior to the great vessels (superior vena cava on the right, left common carotid artery on the left), posterior to the sternum
3P: retrotracheal - posterior to the trachea

Station 4 (left/right): lower paratracheal nodes

left (4L) and right (4R) are divided along the left lateral border of the trachea,not the midline
4R:
- superior border: intersection of caudal margin of the left brachiocephalic vein with the trachea, i.e. abuts 2R
- inferior border: inferior border of the azygos vein
4L:
- superior border: superior border of the aortic arch, i.e. abuts 2L
- inferior border: superior border of the left main pulmonary artery

pre-carinal nodes
- lymph nodes anterior to the tracheal bifurcation are inferior to the above anatomic definitions and are thus technically unclassified by IASLC
- these nodes are in the mediastinum (N2) and their surgical management mirrors that of 4R/4L lymph nodes, hence, pre-carinal nodes are best classified as part of the 4R/4L stations ²

Aortopulmonary zone

Station 5: subaortic nodes (aortopulmonary window)

lateral to ligamentum arteriosum
superior border: inferior border of the aortic arch
inferior border: superior border of the left main pulmonary artery

Station 6: para-aortic nodes, ascending aorta or phrenic

anterior and lateral to the ascending aorta and aortic arch
superior border: line tangential to the upper border of the aortic arch
inferior border: lower border of the aortic arch

Subcarinal zone

Station 7: subcarinal nodes

superior border: carina
inferior border - left:upperborder of the lower lobe bronchus
inferior border - right: lowerborder of bronchus intermedius

Lower zone (inferior mediastinal nodes)

Station 8 (left/right): para-esophageal nodes (below carina)

superior border: station 7, i.e. upper border of lower lobe bronchus on left, and lower border of bronchus intermedius on right
inferior border: diaphragm

Station 9 (left/right): pulmonary ligament nodes

lying within the pulmonary ligament
superior border: inferior pulmonary vein
inferior border: diaphragm

Hilar and interlobar zone (pulmonary nodes)

Station 10 (left/right): hilar nodes

immediately adjacent to mainstem bronchus and hilar vessels
superior border: lower border of the azygos vein on the right, the upper border of the pulmonary artery on the left

Station 11: interlobar nodes

between the origin of the lobar bronchi

Peripheral zone (pulmonary nodes)

Station 12: lobar nodes

adjacent to lobar bronchi

Station 13: segmental nodes

adjacent to segmental bronchi

Station 14: subsegmental nodes

adjacent to subsegmental bronchi
subsegmental

1. Rusch VW, Asamura H, Watanabe H et-al. The IASLC lung cancer staging project: a proposal for a new international lymph node map in the forthcoming seventh edition of the TNM classification for lung cancer. J Thorac Oncol. 2009;4 (5): 568-77. doi:10.1097/JTO.0b013e3181a0d82e - Pubmed citation
2. El-Sherief AH, Lau CT, Wu CC, Drake RL, Abbott GF, Rice TW. International association for the study of lung cancer (IASLC) lymph node map: radiologic review with CT illustration. (2014) Radiographics : a review publication of the Radiological Society of North America, Inc. 34 (6): 1680-91. doi:10.1148/rg.346130097 - Pubmed
3. El-Sherief AH, Lau CT, Obuchowski NA, Mehta AC, Rice TW, Blackstone EH. Cross-Disciplinary Analysis of Lymph Node Classification in Lung Cancer on CT Scanning. (2017) Chest. 151 (4): 776-785. doi:10.1016/j.chest.2016.09.016 - Pubmed

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Thoracic lymph nodes are divided into 14 stations as defined by the International Association for the Study of Lung Cancer (IASLC) ¹, principally in the context of oncologic staging. For the purpose of prognostication, the stations may be grouped into seven zones. Grammarly on onenote online. The IASLC definitions leave some ambiguous regions which can lead to misclassification ³.