肺癌淋巴结图谱(2009年最新)

肺癌淋巴结分区定义（附CT影像图）01-肺癌淋巴结各区边界-根据2009年由国际肺癌研究联合会(International Association for the Study of Lung Cancer，IASLC)给出的肺癌淋巴结定义[1]，以及后续相关研究[2]，将肺癌淋巴结分区的边界整理成表。

来源于《胸部肿瘤放疗规范和靶区定义》2009 IASLC map-AJCC来源于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]. J Thorac Oncol，2009，4(5)：568-577.FIGURE:The International Association for the Study of Lung Cancer (IASLC) lymph node map, including the proposed grouping of lymph node stations into “zones” for the purposes of prognostic analyses.FIGURE A–F: Illustrations of how the International Association for the Study of Lung Cancer (IASLC) lymph node map can be applied to clinical staging by computed tomography scan in axial (A–C), coronal (D), and sagittal (E, F) views. The border between the right and left paratracheal region is shown in A and B. Ao, aorta; AV, azygos vein; Br, bronchus; IA, innominate artery; IV, innominate vein; LA, ligamentum arteriosum; LIV, left innominate vein; LSA, left subclavian artery; PA, pulmonary artery; PV, pulmonary vein; RIV, right innominate vein; SVC, superior vena cava.02-肺癌淋巴结各区CT影像勾画-图1 环状软骨下缘水平(1组上界)图2 第2胸椎上缘水平(1组)此处第1肋骨连线的前方为1组。

图谱：十分钟搞懂肺癌淋巴结分区国际肺癌研究委员会（IASLC）提出的肺癌淋巴结图谱，统一了 Naruke 和 MD-ATS 图谱中的差别，并进一步规范了纵膈和肺部淋巴结的分区，此处让我们一起回顾一下肺癌淋巴结 CT 图和相关描述吧。

肺癌淋巴结一览图各站淋巴结详解锁骨上区淋巴结（1）和上气管旁淋巴结（2）示意图肺 CT 横断面上的上气管旁淋巴结（2）和血管前淋巴结（3A）血管前淋巴结（3A）与气管后淋巴结（3P）示意图肺 CT 横断面上的血管前淋巴结（3A）右下气管旁淋巴结（4R ）示意图：上界：无名静脉尾端与气管交叉点的横截面，下界：奇静脉的下界，4R 延伸至气管的左边界。

肺 CT 横断面右下气管旁淋巴结（4R ）和主动脉旁淋巴结（6）左下气管旁淋巴结（4L）：图中所示上横线为主动脉弓上缘，下横线位于左肺上叶支气管上缘水平，穿过左主支气管。

4L 淋巴结位于上下横线间的区域，包括所有位于肺动脉韧带内侧的气管旁淋巴结。

AP 区的主动脉弓下淋巴结（5）位于肺动脉韧带外侧。

肺动脉干上 CT 横断面的左下气管旁淋巴结（4L）、右下气管旁淋巴结（4R）、血管前淋巴结（3A）、主动脉弓下淋巴结（5）、奇静脉（蓝字）。

气管下段、隆突之上肺 CT 横断面的左下气管旁淋巴结（4L）、右下气管旁淋巴结（4R）、血管前淋巴结（3A）、主动脉弓下淋巴结（5）主动脉肺动脉区（AP区）：包括主动脉下淋巴结（5）、主动脉旁淋巴结（6）肺 CT 横断面上的隆突下淋巴结（7）、肺门淋巴结（10）隆突下肺 CT 横断面上的隆突以下食管旁淋巴结（8）、肺门淋巴结（10）PET 图像，显示淋巴结 FDG 摄取增加，而同一横断面 CT 未显示淋巴结增大（蓝色箭头），该淋巴结癌症转移的可能性很高，PET 检查对不增大淋巴结的特异性高于增大的淋巴结。

肺 CT 横断面上的肺韧带淋巴结（9）肺 CT 横断面上的隆突下淋巴结（7）、肺门淋巴结（10）淋巴结活检：纵膈镜、超声内镜下细针抽吸活检术（EUS）传统纵膈镜：如下各组淋巴结可以通过颈部纵膈镜进行活检：上气管旁淋巴结（2L、2R）、下气管旁淋巴结（4L、4R）、隆突下淋巴结（7）。

The Radiology AssistantLung cancer - Lymph Node Map - Updateby Robin SmithuisRadiology department of the Rijnland Hospital in Leiderdorp, the NetherlandsIASLC lymph node map 2009Specific Lymph Node StationsAxial CT of Lymph NodesMediastinoscopy and EUSConventional mediastinoscopyExtended mediastinoscopyEUS-FNAThis is an update of the 2007 article, which used theMountain-Dresler regional lymph node classificationfor lung cancer staging (MD-ATS maps)(1).In 2009 a new Lung cancer lymph node map wasproposed by the International Association for theStudy of Lung Cancer (IASLC) in order to reconcile thedifferences between the Naruke and the MD-ATSmaps and refine the definitions of the anatomicboundaries of each of the lymph node stations (2).In this article we provide illustrations and CT-imagesfor a better understanding of this IASLC lymph nodemap.Publicationdate:8-6-2010IASLC lymph node map 2009Regional lymph node classification for lung cancer stagingadapted from the American Thoracic Society mappingschemeSupraclavicular nodes1. Low cervical, supraclavicular and sternal notchnodesFrom the lower margin of the cricoid to the claviclesand the upper border of the manubrium.The midline of the trachea serves as border between1R and 1L.Superior Mediastinal Nodes 2-42R. Upper Paratracheal2R nodes extend to the left lateral border of thetrachea.From upper border of manubrium to the intersectionof caudal margin of innominate (left brachiocephalic)vein with the trachea.2L. Upper ParatrachealFrom the upper border of manubrium to the superiorborder of aortic arch.2L nodes are located to the left of the left lateralborder of the trachea.3A. Pre-vascularThese nodes are not adjacent to the trachea like thenodes in station 2, but they are anterior to thevessels.3P. Pre-vertebralNodes not adjacent to the trachea like the nodes instation 2, but behind the esophagus, which isprevertebral.4R. Lower ParatrachealFrom the intersection of the caudal margin ofinnominate (left brachiocephalic) vein with the tracheato the lower border of the azygos vein.4R nodes extend from the right to the left lateralborder of the trachea.4L. Lower ParatrachealFrom the upper margin of the aortic arch to the upperrim of the left main pulmonary artery.Aortic Nodes 5-65. SubaorticThese nodes are located in the AP window lateral tothe ligamentum arteriosum.These nodes are not located between the aorta andthe pulmonary trunk but lateral to these vessels.6. Para-aorticThese are ascending aorta or phrenic nodes lyinganterior and lateral to the ascending aorta and theaortic arch.Inferior Mediastinal Nodes 7-97. Subcarinal8. ParaesophagealNodes below carina.9. Pulmonary LigamentNodes lying within the pulmonary ligaments.Hilar, Lobar and (sub)segmental Nodes 10-14These are all N1-nodes.10. Hilar nodesThese include nodes adjacent to the main stembronchus and hilar vessels.On the right they extend from the lower rim of theazygos vein to the interlobar region.On the left from the upper rim of the pulmonaryartery to the interlobar region.Specific Lymph Node Stations1. Supraclavicular zone nodes 1. Supraclavicular zone nodesThese include low cervical, supraclavicular and sternal notch nodes.Upper border: lower margin of cricoid.Lower border: clavicles and upper border of manubrium.The midline of the trachea serves as border between1R and 1L.2R. Right Upper Paratracheal2R nodes extend to the left lateral border of the trachea.Upper border: upper border of manubrium.Lower border: intersection of caudal margin of innominate (left brachiocephalic) vein with the trachea.2L. Left Upper ParatrachealUpper border: upper border of manubrium.Lower border: superior border of aortic arch.On the left a station 2 node in front of the trachea, i.e.a 2R-node.There is also a small prevascular node, i.e. a station3A node.3. Prevascular and Prevertabral nodesStation 3 nodes are not adjacent to the trachea like station 2 nodes.They are either:3A anterior to the vessels or3B behind the esophagus, which lies prevertebrally. Station 3 nodes are not accessible with mediastinoscopy.3P nodes can be accessible with endoscopicultrasound (EUS).3A and 3P nodesOn the left a 3A node in the prevascular space.Notice also lower paratracheal nodes on the right, i.e. 4R nodes.4R. Lower Paratracheal nodes4R. Right Lower ParatrachealUpper border : intersection of caudal margin of innominate (left brachiocephalic) vein with the trachea.Lower border :lower border of azygos vein.4R nodes extend to the left lateral border of thetrachea.On the left we see 4R paratracheal nodes.In addition there is an aortic node lateral to the aortic arch, i.e. station 6 node.4L. Lower paratracheal nodes4L. Left Lower Paratracheal4L nodes are lower paratracheal nodes that arelocated to the left of the left tracheal border , between a horizontal line drawn tangentially to the uppermargin of the aortic arch and a line extending across the left main bronchus at the level of the upper margin of the left upper lobe bronchus.These include paratracheal nodes that are located medially to the ligamentum arteriosum.Station 5 (AP-window) nodes are located laterally to the ligamentum arteriosum.On the left an image just above the level of the pulmonary trunk demonstrating lower paratracheal nodes on the left and on the right.In addition there are also station 3 and 5 nodes.On the left an image at the level of the lower trachea just above the carina.To the left of the trachea 4L nodes.Notice that these 4L nodes are between the pulmonary trunk and the aorta, but are not located in the AP-window, because they lie medially to the ligamentum arteriosum.The node lateral to the pulmonary trunk is a station 5 node.5. Subaortic nodesSubaortic or aorto-pulmonary window nodes are lateral to the ligamentum arteriosum or the aorta or left pulmonary artery and proximal to the first branch of the left pulmonary artery and lie within the mediastinal pleural envelope.6. Para-aortic nodesPara-aortic (ascending aorta or phrenic) nodes are located anteriorly and laterally to the ascending aorta and the aortic arch from the upper margin to the lower margin of the aortic arch.7. Subcarinal nodesThese nodes are located caudally to the carina of the trachea, but are not associated with the lower lobe bronchi or arteries within the lung.On the right they extend caudally to the lower border of the bronchus intermedius.On the left they extend caudally to the upper border of the lower lobe bronchus.On the left a station 7 subcarinal node to the right of the esophagus.8 Paraesophageal nodesThese nodes are below the carinal nodes and extend caudally to the diafragm.On the left an image below the carina.To the right of the esophagus a station 8 node..On the left a PET image demonstrating FDG uptake ina station 8 node.On the corresponding CT image the node is notenlarged (blue arrow).The probability that this is a lymph node metastasis isextremely high since the specificity of PET inunenlarged nodes is higher than in enlarged nodes.9. Pulmonary ligament nodesPulmonary ligament nodes are lying within thepulmonary ligament, including those in the posteriorwall and lower part of the inferior pulmonary vein.The pulmonary ligament is the inferior extension ofthe mediastinal pleural reflections that surround thehila.10 Hilar nodesHilar nodes are proximal lobar nodes, distal to themediastinal pleural reflection and nodes adjacent tothe intermediate bronchus on the right.Nodes in station 10 - 14 are all N1-nodes, since theyare not located in the mediastinum.Axial CT of Lymph NodesScroll through the images on the left.1.Sternal notch nodes are just seen at this level andabove this level2.Upper Paratracheal: below clavicles and on the rightabove the intersection of caudal margin ofinnominate (left brachiocephalic) vein with thetrachea and on the left above the aortic arch.3.Pre-vascular and Retrotracheal : anterior to thevessels (3A) or prevertebral (3P)4.Lower Paratracheal : below upper margin of aorticarch down to level of main bronchus5.Subaortic (A-P window): nodes lateral toligamentum arteriosum or lateral to aorta or leftpulmonary arteryView more images: 1/86.Para-aortic: nodes lying anterior and lateral to the ascending aorta and the aortic arch beneath the upper margin of the aortic arch 7.Subcarinal8.Paraesophageal (below carina)9.Pulmonary Ligament: nodes lying within the pulmonary ligament.10.-14: nodes are all N1 nodesMediastinoscopy and EUSConventional mediastinoscopyThe following nodal stations can be biopsied by cervical mediastinoscopy: the left and right upper paratracheal nodes (station 2L and 2R), left and right lower paratracheal nodes (station 4L and 4R) and the subcarinal nodes (station 7).Station 1 nodes are located above the suprasternal notch and are not routinely accessed by cervicalmediastinoscopy.Extended mediastinoscopyLeft upper lobe tumors may metastasize to the subaortic lymph nodes (station 5) and paraaortic nodes (station 6).These nodes can not be biopsied through routine cervical mediastinoscopy.Extended mediastinoscopy is an alternative for the anterior-second interspace mediastinotomy which is more commonly used for exploration of mediastinal nodal stations.This procedure is far less easy and therefore less routinely performed than conventional mediastinoscopy.EUS-FNAEndoscopic Ultrasound with Fine Needle Aspiration can be performed of all the mediastinal nodes that that can be assessed from the oesophagus.In addition the left adrenal gland and the left liver lobe can be visualized.EUS particularly provides access to nodes in the lower mediastinum (station 7,8 and 9)References1.Regional lymph node classification for lung cancer stagingby CF Mountain and CM DreslerChest, Vol 111, 1718-17232.The IASLC Lung Cancer Staging Project: A Proposal for a New International Lymph Node Map in the ForthcomingSeventh Edition of the TNM Classification for Lung Cancerby Valerie Rusch et alJournal of Thoracic Oncology: May 2009 - Volume 4 - Issue 5 - pp 568-5773.Conventional mediastinoscopyby Paul De Leyn and Toni Lerut.in the Multimedia Manual of Cardiothoracic Surgery4.Mediastinal Staging of Non Small-Cell Lung Cancerby Christian Lloyd, MD, and Gerard A.Silvestri, MD, FCCP Christian Lloyd, MD, and Gerard A.Silvestri, MD, FCCP Cancer Control, July/August 2001,Vol.8, No.4 Cancer Control 3115.State of the art lecture: EUS and EBUS in pulmonary medicineby J. T. Annema, and K. F. RabeEndoscopy 2006; 38: 118-1226.Imaging of the Patient with Non Small Cell Lung Cancer, What the Clinician Wants to Knowby Reginald F. Munden, MD, DMD, Stephen S. Swisher, MD, Craig W. Stevens, MD, PhD and David J. Stewart, MDRadiology 2005; 237:803-818。