Abdominal Lymph Node Anatomy

Transcription

1 Adominl Lymph Node Antomy 3 Lymph node metstsis is frequently seen in most primry dominl mlignnt tumors. The tumor cells enter lymphtic vessels nd trvel to the lymph nodes long lymphtic dringe pthwys. The lymphtic vessels nd lymph nodes generlly ccompny the lood vessels supplying or drining the orgns. They re ll locted in the superitonel spce within the ligments, mesentery, mesocolon, nd extr peritoneum. Metstsis to the lymph nodes generlly follows the nodl sttion in stepwise direction i.e., from the primry tumor to the nodl sttion tht is closest to the primry tumor nd then progresses frther wy ut within the lymphtic dringe pthwys. Metstsis to nodl sttion tht is frther from the primry tumor without involving the nodl sttion close to the primry tumor ( skip metstsis) is rre. The key to understnding the pthwys of lymphtic dringe of ech individul orgn is to understnd the ligmentous, mesenteric, nd peritonel ttchments nd the vsculr supply of tht orgn [ 1 ]. The ene fi ts of understnding the pthwys of lymphtic dringe of ech individul orgn re threefold. First, when the site of the primry tumor is known, it llows identi fi ction of the expected fi rst lnding site for nodl metstses y following the vsculr supply to tht orgn [ 2, 3 ]. Second, when the primry site of tumor is not cliniclly known, identifying norml nodes in certin loctions llows trcking the rteril supply or venous dringe in tht region to the primry orgn. Third, it lso llows identi fi ction of the expected site of recurrent disese or nodl metstsis or the pttern of disese progression fter tretment y looking t the nodl sttion eyond the treted site. The loction of dringe pttern of dominl lymphtics is outlined in Tle 3.1. The ccurcy for chrcterizing mlignnt lymph nodes sed on size criteri (Tle 3.2 ) is low nd hs een descried in pulished reports. Norml-sized lymph nodes cn e mlignnt nd enlrged lymph nodes cn e nonmlignnt ( see Fig. 3.1 ) [6 8 ]. Newer imging technology such s positron emission tomogrphy (PET)/computed tomogrphy (CT) or mgnetic resonnce imging (MRI) with nnoprticles my e superior for ccurte nodl chrcteriztion [ 9 11 ]. M.G. Hrisinghni, (ed.), Atls of Lymph Node Antomy, DOI / _3, Springer Science+Business Medi New York

2 60 3 Adominl Lymph Node Antomy Tle 3.1 Lymphtics of the domen [ 4 ] Structure Loction Afferents from Efferents to Regions drined Notes Prcrdil nodes Around the esophgogstric junction Gstric nodes, left On the lesser curvture of the stomch, long the course of the left gstric vessels Gstric nodes, right On the lesser curvture of the stomch, long the course of the right gstric vessels Gstro-omentl nodes, left Gstro-omentl nodes, right On the greter curvture of the stomch, long the left gstro-omentl vessels On the greter curvture of the stomch, long the right gstro-omentl vessels Heptic nodes Along the course of the common heptic rtery Cystic node Ner the neck of the gll ldder Lymphtic vessels of the fundus nd crdi of the stomch Lymphtic vessels from the lesser curvture of the stomch Lymphtic vessels from the lesser curvture of the stomch Lymphtic vessels from the greter curvture of the stomch Lymphtic vessels from the greter curvture of the stomch Right gstric nodes, pyloric nodes Lymphtic vessels of the gll ldder Left gstric nodes Fundus nd crdi of the stomch Celic nodes Lesser curvture of the stomch Celic nodes Lesser curvture of the stomch Splenic nodes Left hlf of the greter curvture of the stomch Pyloric nodes Greter curvture of the stomch Celic nodes Liver nd gll ldder; extrheptic iliry pprtus; respirtory diphrgm; hed of pncres nd duodenum Prcrdil nodes re 5 or 6 in numer Left gstric nodes re in numer Right gstric nodes re two to three in numer Left gstro-omentl nodes re 1 or 2 in numer Right gstro-omentl nodes re 6 12 in numer Heptic nodes drin portion of the respirtory diphrgm ecuse of the common emryonic origin of the diphrgm nd the liver (septum trnsversum) Heptic nodes Gll ldder Cystic node drins to the node of the omentl formen, then to heptic nodes

3 Adominl Lymph Node Antomy 61 Pyloric nodes Ner the termintion of the gstroduodenl rtery. Pncreticoduodenl nodes Pncreticoduodenl nodes Along the pncreticoduodenl rcde of vessels Lymphtic vessels from the duodenum nd pncres Pncreticosplenic nodes Along the splenic vessels Lymphtic vessels from the pncres nd greter curvture of the stomch Celic nodes Around the celic rteril trunk Mesenteric nodes Along the vs rect nd rnches of the superior mesenteric. Between the leves of peritoneum forming the mesentery Mesenteric nodes, superior Along the course of the superior mesenteric rtery Heptic nodes, gstric nodes, pncreticosplenic nodes Peripherl nodes locted long the ttchment of the mesentery Mesenteric nodes, ileocolic nodes, right colic nodes, middle colic nodes Heptic nodes Hed of pncres nd duodenum; right hlf of greter curvture of stomch Pyloric nodes Duodenum nd hed of the pncres Celic nodes Neck, ody nd til of the pncres; left hlf of the greter curvture of the stomch Intestinl lymph trunk Liver, gll ldder, stomch, spleen, pncres Superior mesenteric nodes Celic nodes, intestinl lymph trunk Pyloric nodes re six to eight in numer Lymph from the pncres is drined in three different directions: pncreticoduodenl nodes, pncreticosplenic nodes, superior mesenteric nodes Lymph from the pncres is drined in three different directions: pncreticoduodenl nodes, pncreticosplenic nodes, superior mesenteric nodes Celic nodes re from three to six in numer Smll intestine Mesenteric nodes my numer s mny s 200; n importnt node group in cses of intestinl cncer Gut nd viscer supplied y the superior mesenteric rtery Superior mesenteric nodes re importnt in the spred of cncer from the smll nd lrge intestine (continued)

4 62 3 Adominl Lymph Node Antomy Tle 3.1 (continued) Structure Loction Afferents from Efferents to Regions drined Notes Inferior mesenteric nodes Around the root of the inferior mesenteric rtery. Ileocolic nodes Along the origin nd terminl end of the ileocolic vessels Colic nodes, right Along the course of the right colic vessels Colic nodes, middle Along the course of the middle colic vessels Colic nodes, left Along the course of the left colic vessels Prrectl nodes Along the course of the superior rectl vessels Lterl ortic nodes Along the inferior ven cv nd dominl ort from the ortic ifurction to the ortic hitus of the diphrgm Peripherl nodes locted long the mrginl rtery. Peripherl nodes locted long the ttchment of the mesentery Peripherl nodes locted long the mrginl. Peripherl nodes locted long the ttchment of the mesentery Peripherl nodes locted long the mrginl. Lymphtic vessels from the rectum nd nl cnl Common ilic nodes; lymphtic vessels from the posterior dominl wll nd viscer Lumr chin of nodes, superior mesenteric nodes Superior mesenteric nodes Superior mesenteric nodes Superior mesenteric nodes Inferior mesenteric nodes Inferior mesenteric nodes Efferents form one lumr trunk on ech side Distl one-third of the trnsverse colon, descending colon, sigmoid colon, rectum Inferior mesenteric nodes my numer s high s 90; n importnt node group in cses of cncer of the colon nd rectum Ileum, cecum, ppendix Ileocolic nodes locted ner the ileocecl junction my e divided into two susidiry groups: cecl nodes nd ppendiculr nodes Ascending colon, cecum Right colic nodes re pproximtely 70 in numer Trnsverse colon Middle colic nodes re pproximtely 40 in numer Descending colon, sigmoid Left colic nodes re pproximtely 30 in numer Rectum nd nl cnl Prrectl nodes re smll lymph nodes tht re not well loclized Lower lim; pelvic orgns; perineum; nterior nd posterior dominl wll; kidney; suprrenl glnd; respirtory diphrgm Also known s: lumr nodes; the intestinl trunk drins into to the left lumr trunk; the lumr trunks unite to form the thorcic duct/ cistern chili

5 Lymphtic Spred of Mlignncies 63 Tle 3.2 Size criteri for detecting dominl mlignnt lymph nodes [ 5 ] Loction Short xis nodl dimeter, mm Retrocrurl >6 Prcrdic >8 Medistinl ³10 Gstroheptic ligment >8 Upper prortic >9 Portcvl >10 Portheptis > 7 Lower prortic > 11 Fig. 3.1 (, ) Axil CT imge in ptient with cirrhosis shows prominent portocvl lymph node ( lue ) Lymphtic Spred of Mlignncies Liver Heptocellulr crcinom (HCC) is the most common primry viscerl mlignncy [12 ]. Lymph node metstses (LNM) re rre nd generlly ssocited with poor prognosis in heptocellulr crcinom ( see Fig. 3.2 ). The medin survivl time of ptients with single nd multiple LNM fter surgery ws 52 nd 14 months, respectively [ 13 ]. Tle 3.4 outlines the regionl lymph nodes for heptocellulr crcinom. There re severl potentil pthwys for tumor spred, including super fi cil nd deep pthwys, elow nd ove the diphrgm. The super fi cil lymphtic network ( see Fig. 3.3 ) is extensive nd is locted eneth Glisson s cpsule. The dringe of super fi cil lymphtics cn e clssi fi ed into three mjor groups: 1. Through the heptoduodenl nd gstroheptic ligment pthwy, it is the most common distriution of lymph node metstsis. 2. The diphrgmtic lymphtic plexus is nother importnt pthwy of dringe ecuse lrge portion of the liver is in contct with the diphrgm either directly t the re re or indirectly through the coronry nd tringulr ligments. However, nodl metstsis through this pthwy is often overlooked.

6 64 3 Adominl Lymph Node Antomy Fig. 3.2 (, ) Axil CT imge in ptient with heptom shows metsttic low density portocvl lymph node ( lue ) Fig. 3.3 Superficil pthwys of lymphtic dringe for the liver. The nterior diphrgmtic nodes consist of the lterl nterior diphrgmtic group nd the medil group, which includes the pericrdic nodes nd the suxiphoid nodes ehind the xiphoid crtilge. The nodes in the flciform ligment drin into the nterior dominl wll long the superficil epigstric nd deep epigstric lymph nodes. The epigstric nd the suxiphoid nodes drin into the internl mmmry nodes 3. The rre pthwy for nodl metstsis is long the flciform ligment to the deep superior epigstric node in the nterior dominl wll long the deep superior epigstric rtery elow the xiphoid crtilge. The deep lymphtic network follows the portl veins, drins into the lymph nodes t the hilum of the liver, the heptic lymph nodes, then to the nodes in the heptoduodenl ligment. The nodes in the heptoduodenl ligment cn e seprted into two mjor chins: the heptic rtery chin nd posterior periportl chin ( see Figs. 3.4 nd 3.5 ). The heptic rtery chin follows the common heptic rtery to the node t the celic xis nd then into the cistern chyli. The posterior periportl chin is locted posterior to the portl vein in the heptoduodenl ligment ( see Fig. 3.6 ).

7 Lymphtic Spred of Mlignncies 65 Fig. 3.4 (, ) Axil CT imge in ptient with heptocellulr crcinom shows enlrged hypervsculr nodes ( green ) in the periportl loctions Fig. 3.5 (, ) Axil CT imge in ptient with heptom shows enlrged nodes in the periportl ( green ) nd peripncretic loction cusing secondry iliry ostruction Fig. 3.6 Deep pthwys of lymphtic dringe for the liver. The deep pthwys follow the heptic veins to the inferior ven cv nodes nd the juxtphrenic nodes tht follow long the phrenic nerve. The pthwys tht follow the portl vein drin into the heptic hilr nodes nd the nodes in the heptoduodenl ligment, which then drin into the celic node nd the cistern chyli

8 66 3 Adominl Lymph Node Antomy Fig. 3.7 Axil CT imge in ptient with cholngiocrcinom shows enlrged prepncretic ( yellow ) nd retroperitonel lymph nodes ( red ) Tle 3.3 N-stge clssifiction for heptocellulr crcinom Stge NX N0 N1 Findings Regionl nodes cnnot e ssessed No regionl nodl metstsis Metstsis in regionl lymph nodes Tle 3.4 Regionl lymph nodes for heptocellulr crcinom (7) Heptocellulr crcinom Heptoduodenl ligment Cvl lymph nodes Heptic rtery It drins into the retropncretic nodes nd the ortocvl node ( see Fig. 3.7 ) nd then into the cistern chyli nd the thorcic duct [ 1 ]. Tles 3.3 nd 3.4 list the N stging for heptocellulr crcinom nd the regionl lymph nodes for heptocellulr crcinom. No consensus hs yet een reched on the tretment strtegy for LNM from HCC. Long-term survivl cn e expected fter selective lymphdenectomy, especilly in ptients with single LNM. On the other hnd, ef fi ccy of selective lymphdenectomy for multiple LNM seemed equivocl due to its dvnced nd systemic nture of the disese [ 13 ]. Stomch Gstric cncer is the third most common gstrointestinl mlignncy [ 7 ]. Lymph node metstsis in gstric cncer is common nd the incidence increses with dvnced stges of tumor invsion [ 14 ]. The lymphtic dringe of the stomch consists of intrinsic nd extrinsic systems ( see Fig. 3.8 ). The intrinsic system includes intrmurl sumucosl nd suserosl

9 Lymphtic Spred of Mlignncies 67 Fig. 3.8 Lymphtic dringe pthwys for the stomch Tle 3.5 N-stge clssifiction for gstric cncer Stge NX N0 N1 N2 N3 Findings Regionl lymph node(s) cnnot e ssessed No regionl lymph node metstsis Metstsis in one to six regionl lymph nodes Metstsis in 7 15 regionl lymph nodes Metstsis in more thn 15 regionl lymph nodes networks nd the extrinsic system forms lymphtic vessels outside the stomch nd generlly follows the course of the rteries in vrious peritonel ligments round the stomch. These lymphtic vessels drin into the lymph nodes t nodl sttions in the corresponding ligments nd drin into the centrl collecting nodes t the root of the celic xis nd the superior mesenteric rtery [ 1 ]. Tles 3.5 nd 3.6 list the nodl stging for gstric crcinom nd the regionl drining lymph nodes. The extent of nodl metstsis s de fi ned y pthologic stging on surgicl specimens hs een used s prognostic indictors sed on the numer of positive nodes. However, the nodl groups descried in this section re sed on ntomic loctions ccording to the Jpnese Clssi fi ction of Gstric Cncer (JCGC). The JCGC clssi fi ed the nodes into three groups ( see Fig. 3.9 ): Group 1 re lymph nodes round the stomch including the left crdic, right crdic, greter nd lesser curvture, nd supr- nd infrpyloric nodes. Resection of these nodes is de fi ned s D1 ctegory ( see Fig ). Group 2 re lymph nodes wy from the perigstric lymph nodes. They include the left gstric, common heptic, splenic rtery, splenic hilum, proper heptic, nd celic nodes. Resection of nodes in group 1 nd group 2 is de fi ned s D2 ctegory.

10 68 3 Adominl Lymph Node Antomy Tle 3.6 Regionl lymph nodes for gstric cncer [ 7 ] Gstric cncer Greter curvture of stomch Greter curvture Greter omentl Gstroduodenl Gstroepiploic Pyloric Pncreticoduodenl lymph nodes Pncretic nd splenic re Pncreticolienl Peripncretic Splenic Lesser curvture of stomch Lesser curvture Lesser omentl Left gstric Crdio-oesophgel Common heptic Heptoduodenl ligment Fig. 3.9 The JCGC clssi fi ction for perigstric lymph nodes. Group 1 : 1 Right crdil nodes, 2 left crdil nodes, 3 nodes long the lesser curvture, 4 nodes long the greter curvture, 5 suprpyloric nodes, 6 infrpyloric nodes. Group 2 : 7 nodes long the left gstric rtery, 8 nodes long the common heptic rtery, 9 nodes round the celic xis, 10 nodes t the splenic hilus, 11 nodes long the splenic rtery. Group 3 : 12 nodes in the heptoduodenle ligment, 13 nodes t the posterior spect of the pncres hed, 14 nodes t the root of the mesenterium, 15 nodes in the mesocolon of the trnsverse colon, 16 pr-ortic nodes

11 Nodl Metstses in the Gstroheptic Ligment 69 Fig (, ) Axil CT imge in ptient with gstric crcinom shows enlrged gstroheptic lymph nodes ( ornge ) long the lesser curvture Group 3 re lymph nodes in the heptoduodenl ligment, posterior pncres, root of the mesentery, presophgel, nd diphrgmtic nodes. Resection of the three nodl groups nd prortic nodes is de fi ned s D3 ctegory. Presophgel nd Prcrdic Nodes The lymph from the distl esophgus nd the crdic ori fi ce of the stomch drins to the presophgel lymph nodes round the esophgus ove the diphrgm nd the prcrdic nodes elow the diphrgm. They cn spred upwrd long the esophgus to the medistinl lymph nodes nd long the thorcic duct to the left or right suprclviculr nodes or downwrd long the esophgel rnches of the left gstric rtery to the left gstric nodes nd the celic nodes ( see Fig ) [1 ]. Nodl Metstses in the Gstroheptic Ligment Tumors rising from the re of the stomch long the lesser curvture nd the esophgogstric junction, supplied y the left gstric rtery, generlly metstsize to the lymph nodes in the gstroheptic ligment ( see Fig ). The primry nodl group (group 1) consists of nodes long the left nd right gstric rtery nstomosis long the lesser curvture. Group 2 nodes include the nodes long the left gstric rtery nd vein in the gstropncretic fold tht drin towrd the nodes t the celic xis. Tumors rising from the re of the stomch in the distriution of the right gstric rtery long the lesser curvture of the gstric ntrum drin into the perigstric nodes nd the suprpyloric nodes ner the pylorus (group 1). They then drin into the nodes t the common heptic rtery (group 2), from where the right gstric rtery origintes or the re where the right gstric vein drins into the portl vein. From these nodes, dringe continues long the heptic rtery towrd the celic xis (group 2). The lymphtic nstomoses in the gstroheptic ligment long the lesser

12 70 3 Adominl Lymph Node Antomy c Fig ( c) Axil CT imge in ptient with esophgel cncer shows enlrged celic lymph node ( yellow ). The node shows FDG ctivity on PET scn curvture form the lternte dringe pthwys for the tumors rising from this region. Less commonly they re involved in pncretic cncer due to retrogrde tumor extension from the celic nodes [ 1 ]. Nodl Metstses in the Gstrosplenic Ligment Lymphtic dringe of tumors t the posterior wll nd the greter curvture of the gstric fundus spreds to the perigstric nodes (group 1) in the superior segment of the gstrosplenic ligment, then follows long the rnches of the short gstric rtery to the nodes t the hilum of the spleen (group 2). The tumors from the greter curvture of the ody of the stomch lso spred to the perigstric nodes (group 1) nd then dvnce long the left gstroepiploic vessels nd drin into the lymph nodes in the splenic hilum (group 2). From the splenic hilum, they my spred to the nodes long the splenic rtery to the nodes t the celic xis (group 2). In ddition, the tumors from the posterior wll of the gstric fundus nd upper segment of the ody my drin long the posterior gstric rtery to the nodes long the splenic

13 Inferior Phrenic Nodl Pthwys 71 Fig (, ) Coronl reformtted CT imge in ptient with stomch cncer show prominent gstroheptic ligment lymph nodes ( ornge ) rtery tht re known s the suprpncretic nodes or the nodes in the splenorenl ligment nd then to the nodes t the celic xis [ 1 ]. Nodl Metstses in the Gstrocolic Ligment Primry tumors involving the greter curvture of the ntrum of the stomch in the distriution of the right gstroepiploic rtery spred to the perigstric nodes (group 1) ccompnying the right gstroepiploic vessels tht course long the greter curvture of the stomch. They drin into the nodes t the gstrocolic trunk (group 2) ( see Fig ) or the nodes t the origin of the right gstroepiploic rtery nd the nodes long the gstroduodenl rtery (the supyloric or infrpyloric node). From there, they my proceed to the celic xis or the root of the superior mesenteric rtery [ 1 ]. Inferior Phrenic Nodl Pthwys Tumors involving the esophgogstric junction or the gstric crdi my invde the diphrgm s they penetrte eyond its wll. The lymphtic dringe of the peritonel surfce of the diphrgm is vi the nodes long the inferior phrenic rtery nd veins tht course long the left crus of the diphrgm towrd the celic xis or the left renl vein [ 1 ].

14 72 3 Adominl Lymph Node Antomy Fig (, ) Coronl reformtted CT imge in ptient with stomch cncer shows prominent gstrocolic ligment lymph nodes ( ornge ) Fig (, ) Axil CT imge in ptient with lymphom shows enlrged, clustered mesenteric root lymph nodes ( red ) A CT scn of the domen nd pelvis is the most widely recommended method for preopertive stging of gstric cncer [ 15 ]. The ccurcy of MRI is considered to e inferior to CT for exmining LN involvement, ut my e more ccurte thn CT for non-nodl metsttic disese [ 16 ]. Further dignostic imging vi 18 F- fl uorodeoxy-d-glucose (FDG) PET is not replcement for CT in gstric cncer cses, ut cn complement CT for stging nd prognostic informtion [ 15 ]. Smll Intestine The three most common mlignnt tumors of the smll intestine re lymphom, denocrcinom, nd crcinoid tumor. The pth of regionl nodl metstsis follows the vessels of the involved segment to the root of the superior mesentery rtery (SMA) ( see Fig ) ner the hed of the pncres nd to the extr peritoneum [ 1 ].

15 Colorectl 73 Tle 3.7 N-stge clssifiction for colorectl cncer Stge NX N1 N2 Findings Regionl nodes cnnot e ssessed Metstsis in one to three regionl lymph nodes Metstsis in four or more regionl lymph nodes Fig (, ) Axil CT imge in ptient with primry colon cncer shows n enlrged celic lymph node ( yellow ) Appendix Similr to the smll intestine, crcinoid tumor, noncrcinoid epithelil tumor, nd lymphom re the three most common tumors of the ppendix. Lymph node metstsis is rre in the tumors of the ppendix. Generlly, nodl metstsis follows the ileocolic vessels long the root of the mesentery to the origin of the SMA nd the prortic region [ 1 ]. Colorectl Colorectl denocrcinom is the third most common cncer nd the third most common cuse of cncer deths [ 7 ]. Lymph node metstsis is one of the most importnt prognostic fctors in the TNM clssi fi ction de fi ning the numer of positive nodes in stepwise incrementl groups tht correltes with poorer outcome (Tle 3.7 ) (see Fig ) [1 ]. Accurte identi fi ction of norml lymph nodes is importnt s it ids in preopertive plnning of the extent of surgery. Ptients with T1 T2 rectl tumors cn e treted with resection lone. If there re nodl metstses (or if the tumor is T3), neodjuvnt tretment is required. It lso helps in identifying regions of possile recurrence in treted cses, in the clinicl setting of incresing crcinoemryonic ntigen levels [ ]. Tle 3.8 lists regionl lymph nodes for colorectl cncer. Lymph from the wll of the lrge intestine nd rectum drins into the lymph nodes ccompnying the rteries nd veins of the corresponding colon nd rectum [ ]. The nodes cn e clssi fi ed ccording to the loction s follows ( see Fig ).

16 74 3 Adominl Lymph Node Antomy Tle 3.8 Regionl lymph nodes for colorectl cncer [ 7 ] Colorectl cncer Pericolic/perirectl Ileocolic Right colic Middle colic Left colic Inferior mesenteric rtery Superior rectl (hemorrhoidl) Fig Lymphtic dringe pthwys for the colon The epicolic nodes ccompnying the vs rect outside the wll. The prcolic nodes long the mrginl vessels. The intermedite mesocolic nodes long the ileocolic, right colic, middle colic, left scending nd descending colic, left colic, nd sigmoidl rteries. The principl nodes t the gstrocolic trunk, the origin of the middle colic rtery, nd the origin of the inferior mesenteric rtery. Cecum nd scending colon. The lymphtic dringe is vi the epicolic nodes nd the prcolic nodes, which re seen in proximity with the mrginl vessels long the mesocolic side of the colon. From the prcolic nodes ( see Fig ), lymphtic dringe follows the vessels in the ileocolic ( see Fig ) nd right colic

17 Colorectl 75 Fig (, ) Coronl T2-weighted imge in ptient with scending colon denocrcinom with metsttic pericolic lymph node ( red ) Fig (, ) Coronl reformtted CT imge in ptient with cecl cncer shows prominent ileocolic lymph node ( red ) mesentery, where the intermedite nodl group is locted nd drins into the principl nodes t the root of the SMA. Trnsverse colon. The lymphtic dringe is from the epicolic nodes nd the prcolic nodes (long the mrginl vessels) to the intermedite nodl group situted long the middle colic vessels nd then into the principl node t the root of the SMA ( see Fig ). Left side of colon nd upper rectum. The lymphtic dringe is from the epicolic nd the prcolic (long the mrginl vessels) group to the intermedite mesocolic nodes including the left colic nodes, nd then to the principl inferior mesenteric rtery (IMA) nodes ( see Fig ).

18 76 3 Adominl Lymph Node Antomy Fig (, ) Axil CT imge in ptient with mlignncy in the trnsverse colon shows pericolonic ( red ), mesenteric ( yellow ), nd left periortic ( green ) lymph nodes Fig (, ) Axil olique T2-weighted imges in ptient with rectl cncer shows metsttic inferior mesenteric lymph node ( lue ) Lower rectum. There re two different lymphtic pthwys: one is long the superior hemorrhoidl vessels towrd the mesorectum ( see Figs. 3.21, 3.22, 3.23, nd 3.24 ) nd mesocolon; the other is the lterl route, long the middle nd inferior hemorrhoidl vessels towrd the hypogstric nd oturtor nodes, nd then to the prortic nodes ( see Figs nd 3.26 ). Anus. Anl tumors usully spred to the super fi cil inguinl nodes nd then to the deep inguinl nodes long the common femorl vessels. From here they scend to the externl ilic, common ilic, nd prortic groups ( see Figs nd 3.28 ). A key pthologic chrcteristic in determining the stge of disese in colon cncer is the sttus of the drining lymph nodes [ 22 ]. The criteri for distnce etween tumor nd mesorectl fsci in cse of T3 tumors, lso pplies for mesorectl nodes lying within the mesorectl ft ( see Fig ). Nodes re more thn 3 mm in size,

19 Retroperitonel Lymph Nodes 77 Fig (, ) Axil CT imge in ptient with primry rectl cncer shows n enlrged left perirectl lymph node ( lue ) Fig (, ) Axil CT imge in ptient with rectl cncer showing metsttic perirectl lymph nodes ( lue ) wheres tumor deposits re smller. If lymph nodes re involved with tumor (Stge III disese), 5- fl uorourcil sed djuvnt therpy improves survivl [ 23 ]. However, for node-negtive disese (stge II disese), the ene fi ts of djuvnt chemotherpy re not well-estlished. MRI with the use of ultrsmll superprmgnetic iron oxide (USPIO) contrst gents hs promising role, however further evlution in rectl cncer needs to e ssessed [24 ]. Becuse of the nonspeci fi city on ntomic imging, dditionl imging studies nd spirtion iopsy re frequently used to estlish the dignosis of metsttic disese efore tretment decision. Retroperitonel Lymph Nodes Renl, Upper Urothelil, nd Adrenl Mlignncies Lymphtics drining the kidney re derived from three plexuses: one eneth the renl cpsule, the second round the renl tuules, nd the third in the perirenl ft. These plexuses drin into lymphtic trunks tht run from the renl hilum long the renl vein

20 78 3 Adominl Lymph Node Antomy Fig (, ) Axil T2-weighted imge ( left ) nd Apprent Diffusion Coef fi cient (ADC) mp ( right ) of ptient with rectl cncer showing metsttic perirectl lymph nodes ( lue ) with restricted diffusion nd drk signl on ADC Fig Fused xil PET-CT imge shows FDG vid metsttic left perirectl lymph node

21 Retroperitonel Lymph Nodes 79 Fig (, ) Axil CT imge in ptient with rectl cncer ( not shown ) shows metsttic retrocvl ( purple ) nd left periortic lymph node ( green ) Fig Coronl reformtted CT imge in ptient with primry colonic mucinous denocrcinom shows clci fi ed metsttic left periortic lymph nodes ( rrows ) Fig (, ) Axil CT imge in ptient with nl cncer shows metsttic left inguinl lymph node ( lue )

22 80 3 Adominl Lymph Node Antomy Fig (, ) Axil T2-weighted imge in ptient with nl cncer shows metsttic left externl ilic lymph node ( purple ) Fig (, ) Axil T2-weighted imge in ptient with rectl cncer shows heterogenous metsttic perirectl lymph node ( lue ) to the prortic nodes, which then drin into the cistern chyli nd predominntly the left suprclviculr nodes vi the thorcic duct. The lymphtic dringe for the proximl ureters is to the prortic nodes in the region of the renl vessels nd gondl rtery. The middle ureterl lymphtics drin to the common ilic nodes nd the lower ureterl lymphtics to the externl nd internl ilic nodes. All the ilic nodes drin to the prortic nodes, cistern chyli, nd predominntly the left suprclviculr nodes vi the thorcic duct. The drenl lymphtics drin to the prortic nodes [ 1 ].

23 Lymphtic Spred of Mlignncies 81 Fig (, ) Axil CT imge in ptient with left nephrectomy for renl cell cncer shows enlrged ortocvl ( red ) lymph node with iopsy-proven recurrent RCC Tle 3.9 N-stge clssi fi ction for renl cncer Stge NX N0 N1 N2 Findings Regionl nodes cnnot e ssessed No regionl nodl metstses Metstses in single regionl lymph node Metstsis in more thn one regionl lymph node Lymphtic Spred of Mlignncies Renl Tumor Renl tumors ccount for 3 % of ll cncer cses nd deths [ 25 ] ; the mjority of these re renl cell crcinoms. Lymph node sttus is strong prognostic indictor in ptients with kidney cncer [ 26, 27 ] with 5-yer disese-specific survivl for ptients with node-positive disese reported etween 21 % nd 38 % [ 28, 29 ]. Lymphtic spred of renl cell crcinoms (RCC) is initilly to regionl lymph nodes. These include nodes long the renl rteries from the renl hilum to the prortic nodes t this level ( see Fig ). Ten to fi fteen percent of ptients hve regionl nodl involvement without distnt spred. Lymphtic spred my continue ove or elow the level of the renl hilum, with susequent spred to the cistern chyli nd to the left suprclviculr nodes vi the thorcic duct. Occsionlly, there is spred from these nodes to the medistinum nd pulmonry hilr nodes [ 1 ]. Tle 3.9 lists the N-Stge clssi fi ction for kidney cncer. Dignosis of pthologic lymph nodes is prolemtic, s pproximtely 50 % of enlrged regionl nodes re hyperplstic [ 30 ]. Criteri currently used for suspect nodes re those 1 cm or

24 82 3 Adominl Lymph Node Antomy Fig (, ) Axil post gdolinium-enhnced T1-weighted imge shows metsttic left periortic lymph nodes ( red ) in ptient with left trnsitionl cell crcinom more in short xis nd loss of ovl shpe nd ftty hilus. Clustering of three or more nodes in the regionl re is lso suggestive of metsttic spred. Urothelil Tumors Periureterl extension from ureterl trnsitionl cell crcinom (TCC) is secondry to growth through the ureterl wll nd involvement of the extensive lymphtic dringe. The sites of regionl lymphtic spred re dependent on the loction of the tumor. The prortic nodes re involved initilly in the renl pelvic nd upper ureterl tumors ( see Fig ). If the origin is from the middle ureter, metstses re to the common ilic nodes, wheres lower ureterl tumors involve the internl nd externl nodes initilly. The ilic nodes drin into the pr-ortic nodes. Lymphtics within the wll of the ureter llow for direct extension within the wll [ 1 ]. Adrenl Tumors Primry mlignnt tumors of the drenl glnd rise from the cortex s drenocorticl crcinoms or from the medull s pheochromocytoms or in the spectrum of the neurolstom gnglioneurom complex. Most of these tumors spred y lymphtic spred to the pr-ortic lymph nodes [ 1 ]. Pncretic Cncer Pncretic cncer is the second most common gstrointestinl mlignncy nd is the fi fth leding cuse of cncer-relted deth. The mjority of cses re ductl denocrcinoms (exocrine ductl epithelium, 95 % of cses). Up to two thirds my e locted in the hed of the pncres. Lymph node metstses re common in pncretic nd duodenl cncer nd they crry poor prognosis [ 31, 32 ].

25 Lymphtic Spred nd Nodl Metstsis 83 Lymphtic Spred nd Nodl Metstsis Lymphtic dringe of the hed of the pncres is different from tht of the ody nd til (Tle 3.10 ; see Fig ). The hed of the pncres nd the duodenum shre similr dringe pthwys y following rteries round the hed of the pncres [ 32, 33 ]. They cn e divided into three mjor routes: the gstroduodenl, the inferior pncreticoduodenl, nd the dorsl pncretic: 1. Around the hed of the pncres, multiple lymph nodes cn e found etween the pncres nd duodenum ove nd elow the root of the trnsverse mesocolon nd nterior nd posterior to the hed of the pncres. Although mny nmes re used for these nodes such s the inferior nd superior pncreticoduodenl nodes ( see Fig ), they cn e designted peripncretic nodes ( see Fig ). The gstroduodenl route collects lymphtics from the nterior pncreticoduodenl nodes ( see Figs. 3.35, 3.36, nd 3.37 ), which drin lymphtics long the nterior surfce of the pncres, nd the posterior pncreticoduodenl nodes, which follow the ile duct long the posterior pncreticoduodenl vein to the posterior periportl node. 2. The inferior pncreticoduodenl route lso receives lymphtic dringe from the nterior nd posterior pncreticoduodenl nodes y following the inferior pncreticoduodenl rtery to the superior mesenteric rtery node. Occsionlly, they my lso drin into the node t the proximl jejunl mesentery. Tle 3.10 Lymph node groups in tumors of the pncretic hed, ody, nd til Lymph node sttion group Tumor of hed Tumor of ody/til 1 13, 13, 17, 17 8, 8p, 10, 11p, 11d, , 8, 8p, 12, 12, 12p, 14p, 14d 7, 9, 14p, 14d, , 2, 3, 4, 5, 7, 9, 10, 11p, 11d, 15, 162, 16l, 18 5, 6, 12, 12, 12p, 13, 13, 17, 17, 162, 161 Fig Lymph node sttions ccording to the clssifiction of pncretic crcinom proposed y the Jpn Pncres Society ( see Tle 3.11 )

26 84 3 Adominl Lymph Node Antomy Tle 3.11 Lymph node sttions in pncretic crcinom s proposed y the Jpn Pncres Society Sttion Nme 1 Right crdil lymph nodes 2 Left crdil lymph nodes 3 Lymph nodes long the lesser curvture of the stomch 4 Lymph nodes long the greter curvture of the stomch 5 Suprpyloric lymph nodes 6 Infrpyloric lymph nodes 7 Lymph nodes long the left gstric rtery 8 Lymph nodes in the nterosuperior group long the common heptic rtery 8p Lymph nodes in the posterior group long the common heptic rtery 9 Lymph nodes round the celic rtery 10 Lymph nodes t the splenic hilum 11p Lymph nodes long the proximl splenic rtery 11d Lymph nodes long the distl splenic rtery 12 Lymph nodes long the heptic rtery 12p Lymph nodes long the portl vein 12 Lymph nodes long the ile duct 13 Lymph nodes on the posterior spect of the superior portion of the hed of the pncres 13 Lymph nodes on the posterior spect of the inferior portion of the hed of the pncres 14p Lymph nodes on the proximl superior mesenteric rtery 14d Lymph nodes long the distl superior mesenteric rtery 15 Lymph nodes long the middle colic rtery 16 Lymph nodes round the dominl ort 161 Lymph nodes round the ortic hitus of the diphrgm 161 Lymph nodes round the dominl ort (from the superior mrgin of the celic trunk to the inferior mrgin of the inferior mesenteric rtery) 162 Lymph nodes round the dominl ort (from the superior mrgin of the inferior mesenteric rtery to the ortic ifurction) 17 Lymph nodes on the nterior surfce of the superior portion of the hed of the pncres 17 Lymph nodes on the nterior surfce of the inferior portion of the hed of the pncres 18 Lymph nodes long the inferior mrgin of the pncres 3. The dorsl pncretic route is uncommon. It collects lymphtics long the medil order of the hed of the pncres nd follows the rnch of the dorsl pncretic rtery to the superior mesenteric rtery or celic node. The lymphtic dringe of the ody nd til of the pncres follows the dorsl pncretic rtery, the splenic rtery, nd vein to the celic lymph node. The lymphtic dringe of the ody nd til of the pncres follows the dorsl pncretic rtery, the splenic rtery, nd vein to the celic lymph node. The nodl stging for pncretic cncer sed on Americn Joint Committee on Cncer (AJCC) criteri is listed in Tle Tle 3.13 lists the regionl lymph nodes for pncretic cncer.

27 Lymphtic Spred nd Nodl Metstsis 85 Tle 3.12 N-stge clssifiction for pncretic cncer Stge NX N0 N1 Findings Regionl nodes cnnot e ssessed No regionl nodl metstses Regionl lymph node metstsis Tle 3.13 The regionl lymph nodes for pncretic cncer Pncretic cncer Peripncretic Heptic rtery Celic xis Pyloric Splenic region Fig (, ) Axil CT imge in ptient with metsttic srcom with multiple metstses to the pncres ( rrows ) nd to the superior pncreticoduodenl lymph node ( lue ) Fig (, ) Axil CT imge in ptient with primry pncretic denocrcinom shows metsttic retropncretic lymph node ( lue )

28 86 3 Adominl Lymph Node Antomy Fig Axil CT imge in ptient with heled tuerculosis shows clci fi ed lymph node in superior pncreticoduodenl loction Fig (, ) Axil T2-weighted imge in ptient with pncretitis shows n enlrged superior pncreticoduodenl lymph node ( lue ) Fig (, )Coronl reformtted imge in ptient with primry pncretic denocrcinom ( not shown ) shows prominent inferior pncreticoduodenl lymph node ( lue )

29 References 87 Preopertive imging studies, using the size of the nodes s dignostic criteri, re not ccurte for the dignosis of nodl metstsis. Becuse of the lck of ccurcy, peripncretic lymph nodes nd the nodes long the gstroduodenl rtery nd inferior pncreticoduodenl rtery re included in rdition fi eld, nd they re routinely resected t the time of pncreticoduodenectomy. However, it is importnt to note when n norml node, such s one with low density nd/or irregulr order, is detected eyond the usul dringe sin nd outside the routine surgicl or rdition fi eld, such s in the proximl jejunl mesentery or t the se of the trnsverse mesocolon, s these cn e the site of recurrent disese [ 1 ]. References 1. Meyers MA, Chrnsngvej C, Oliphnt M. Meyers dynmic rdiology of the domen: norml nd pthologic ntomy. New York: Springer; McDniel KP, Chrnsngvej C, DuBrow RA, et l. Pthwys of nodl metstsis in crcinoms of the cecum, scending colon, nd trnsverse colon: CT demonstrtion. AJR Am J Roentgenol. 1993;161: Grn fi eld CA, Chrnsngvej C, Durow RA, Vrm DG, et l. Regionl lymph node metstses in crcinom of the left side of the colon nd rectum: CT demonstrtion. AJR Am J Roentgenol. 1992;159: Gest TPP. Antomy: Medchrts. New York: Iloc; Dorfmn RE, Alpern MB, Gross BH, Sndler MA. Upper dominl lymph nodes: criteri for norml size determined with CT. Rdiology. 1991;180: Dodd 3rd GD, Bron RL, Oliver 3rd JH, et l. Enlrged dominl lymph nodes in end-stge cirrhosis: CT-histopthologic correltion in 507 ptients. Rdiology. 1997;203: Morón FE, Szklruk J. Lerning the nodl sttions in the domen. Br J Rdiol. 2007;80: Hrisinghni MG, Brentsz J, Hhn PF, et l. Noninvsive detection of cliniclly occult lymphnode metstses in prostte cncer. N Engl J Med. 2003;348: Tori M, Aquino SL, Hrisinghni MG. Current concepts in lymph node imging. J Nucl Med. 2004;45: Frij J, Bourrier P, Zgdnski AM, De Kerviler E. Dignosis of mlignnt lymph node. J Rdiol. 2005;86: Hrisinghni MG, Sksen MA, Hhn PF, et l. Ferumoxtrn-10-enhnced MR lymphngiogrphy: does contrst-enhnced imging lone suf fi ce for ccurte lymph node chrcteriztion? AJR Am J Roentgenol. 2006;186: Egner JR. AJCC cncer stging mnul. JAMA. 2010;304: Koyshi S, Tkhshi S, Kto Y, et l. Surgicl tretment of lymph node metstses from heptocellulr crcinom. J Heptoiliry Pncret Sci. 2011;18: Hrtgrink HH, vn de Velde CJH, Putter H, et l. Extended lymph node dissection for gstric cncer: who my ene fi t? Finl results of the rndomized Dutch gstric cncer group tril. J Clin Oncol. 2004;22: Courn NG. Lymph nodes nd gstric cncer. J Surg Oncol. 2009;99: Dicken BJ, Bigm DL, Css C, et l. Gstric denocrcinom. Ann Surg. 2005;241: Tylor FGM, Swift RI, Blomqvist L, Brown G. A systemtic pproch to the interprettion of preopertive stging MRI for rectl cncer. AJR Am J Roentgenol. 2008;191: Steup WH, Moriy Y, vn de Velde CJH. Ptterns of lymphtic spred in rectl cncer. A topogrphicl nlysis on lymph node metstses. Eur J Cncer. 2002;38:911 8.

30 88 3 Adominl Lymph Node Antomy 19. Grn fi eld CA, Chrnsngvej C, Durow RA, et l. Regionl lymph node metstses in crcinom of the left side of the colon nd rectum: CT demonstrtion. AJR Am J Roentgenol. 1992;159: McDniel K, Chrnsngvej C, DuBrow R, et l. Pthwys of nodl metstsis in crcinoms of the cecum, scending colon, nd trnsverse colon: CT demonstrtion. Am J Roentgenol. 1993;161: Grn fi eld C, Chrnsngvej C, Durow R, et l. Regionl lymph node metstses in crcinom of the left side of the colon nd rectum: CT demonstrtion. Am J Roentgenol. 1992;159: Rjput A, Romnus D, Weiser MR, et l. Meeting the 12 lymph node (LN) enchmrk in colon cncer. J Surg Oncol. 2010;102: Wolpin BM, Meyerhrdt JA, Mmon HJ, Myer RJ. Adjuvnt tretment of colorectl cncer. CA Cncer J Clin. 2007;57: Ifrte F, Lghi A, Polntonio P, et l. Preopertive stging of rectl cncer with MR imging: correltion with surgicl nd histopthologic fi ndings. Rdiogrphics. 2006;26: Americn Cncer Society. Cncer fcts nd fi gures Accessile t: org/reserch/cncerfctsfigures/cncerfctsfigures/cncer-fcts-figures Accessed 31 My Krkiewicz PI, Lewinshtein DJ, Chun FK-H, et l. Tumor size improves the ccurcy of TNM predictions in ptients with renl cncer. Eur Urol. 2006;50: discussion Lughezzni G, Cpitnio U, Jeldres C, et l. Prognostic signi fi cnce of lymph node invsion in ptients with metsttic renl cell crcinom: popultion-sed perspective. Cncer. 2009;115: Cpitnio U, Jeldres C, Ptrd J-J, et l. Stge-speci fi c effect of nodl metstses on survivl in ptients with non-metsttic renl cell crcinom. BJU Int. 2009;103: Pntuck AJ, Zismn A, Dorey F, et l. Renl cell crcinom with retroperitonel lymph nodes: role of lymph node dissection. J Urol. 2003;169: Isrel GM, Bosnik MA. Renl imging for dignosis nd stging of renl cell crcinom. Urol Clin North Am. 2003;30: Tkhshi T, Ishikur H, Motohr T, et l. Perineurl invsion y ductl denocrcinom of the pncres. J Surg Oncol. 1997;65: Kyhr M, Nkgwr H, Kitgw H, Oht T. The nture of neurl invsion y pncretic cncer. Pncres. 2007;35: Pwlik TM, Gleisner AL, Cmeron JL, et l. Prognostic relevnce of lymph node rtio following pncreticoduodenectomy for pncretic cncer. Surgery. 2007;141:610 8.