Nodes

Anatomy ^{1 2}

Neck

Definitions

Level 1 Submandibular & Submental
- Level 1A: Submental Nodes. Between anterior bellies of digastric M.
- Level 1B: Submandibular Nodes.

Level 2 Jugulodigastric
- Level 2A: Anterior, medial, lateral, or posterior to IJV; if posterior to IJV, node must be inseparable from IJV; contains jugulodigastric nodal group.
- Level 2B: Posterior to the IJV and MUST have fat plane separating them.

Level 3 Deep Cervical
From Hyoid to the lower border of the Cricoid.

Level 4 Virchow
From lower border of Cricoid to the clavicle.

Level 5 Accessory Spinal or Posterior Triangle
Posterior to the posterior border of the SCM.
- Level 5A: Skull base to the level of the cricoid.
- Level 5B: From level of the cricoid to the clavicle.

Level 6 "Visceral Space". Prelaryngeal/Pretracheal/Delphian node
From Hyoid to top of the manubrium.

Level 7 Superior Mediastinal
From the top of the manubrium to the innominate vein and between the carotids.

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Chest ³

This is used for staging lung cancers but is excessive for other tumours.

Divides into 14 nodal stations and 7 Stations.

Lymph node zones:
- Supraclavicular zone: Station 1
- Upper zone (superior mediastinal): Stations 2, 3, and 4
- Aortopulmonary zone: Stations 5 and 6
- Subcarinal zone: Station 7
- Lower zone (inferior mediastinal): Stations 8 and 9
- Hilar and interlobar zone (pulmonary): Stations 10 and 11
- Peripheral zone (pulmonary): Stations 12, 13, and 14

For other carcinomas then use:

1. Chest Wall
2. Anterior Mediastinal
3. Paratracheal and Tracheobronchial
4. Hilar
5. Intrapulmonary
6. Diaphragmatic Nodes
7. Paracardiac nodes

Chest Wall = Axillary, Supraclavicular, Internal Mammary & Posterior Intercostal.
Anterior Mediastinal = Prevascular & Para-aortic.
Paratracheal & Tracheobronchial = Paratracheal, Retrotracheal, Aortopulmonary, Azygos & Subcarinal.
Posterior Mediastinal = Para-oesophageal and pulmonary ligament.

In Lymphoma then use Nodal REGIONS.

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Abdomen

Region	Sites	Notes
Retroperitoneum	Paracaval, precaval, retrocaval, aortocaval, preaortic and para-aortic
Celiac Axis	include Greater & lesser curvature nodes, pancreaticoduodenal nodes and porta hepatis
SMA	Mesenteric nodes
IMA	including mesenteric nodes in sigmoid mesentery and the superior rectal vessels.

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Pelvis

Confusing nomenclature and lack of definitions.

Generally Common Iliac, External Iliac and Inguinal (inferior to the inguinal ligament) are easy to define.
and behind them are the Presacral nodes.

The internal iliacs are more challenging to be categorical about.

But, I would say: ⁵

• Obturator nodes follow the anterior division of the Internal Iliacs. But Husband says it is medial chain of External Iliac
• Hypogastric nodes follow the middle/posterior division of the Internal Iliacs
  • and the internal iliacs are sometimes conglomorated with them
• Also there is the 3rd branch which is the gluteal.

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Normal & Abnormal ⁴

Region	Site	RCR SAD (mm)	Husband & Resnek
Head + Neck	Facial	Not visible
	Cervical	8 or 10 for Jugulodigastric
Axilla		10
Mediastinum	Subcarinal	12
	Paracardiac	8	12
	Retrocrural	6	6
	All other sites	10
Abdomen	Gastrohepatic	8	8
	Porta hepatis	8	7
	Portocaval	10	10 or 13
	Celiac Axis to Renal Artery	10	9
	Renal Artery to Bifurcation	12	11
	Mesenteric		5
Pelvis	Common Iliac	9	10
	External Iliac	10	10
	Internal Iliac	7	10
	Obturator	8	10
Inguinal		10	15

RCR criteria based on AXIAL slices.

Neck

1-cm cutoff in largest axial diameter shows 88% sensitivity & 39% specificity,
whereas 1.5-cm cutoff shows 56% sensitivity & 84% specificity for metastatic head & neck cancer ²

Drainage Pathway.¹

Tumour	Initial Drain Site	Then to...
Vulval, Penis, Anus	Inguinal Nodes
Prostate	Any of the lower pelvic groups	Common Iliac / Para-aortic
	60% go to Obturator and Ext Iliacs
	but 20% are ONLY in presacral locally.
Bladder	Paravesical	Obturator & External Iliacs then Common Iliacs
		or Hypogastric & Presacral then Common Iliacs
Cervix, Ovary & Uterine	Obturator	External Iliac then Commmon Iliac
Right Side Colonic	Ileocolic	SMV
Left Side Colonic	IMV
Rectum	Mesorectal	Superior Rectal
	Occasional to pelvic side wall.
Testes	RIGHT: Right retroperitoneal LEFT: Left retroperitoneal at level of the renal vein
Upper GI Malignancy	Hepatoduodenal, peripancreatic and aortocaval
Kidneys	Ipsilateral Renal Vein	Para-aortic / paracaval nodes
Lung	Ipsi hilar nodes	Mediastinal Nodes (esp Paratracheal + Tracheobronchial Nodes)
Pleura	Nodes along chest wall (inc posterior intercostal, internal mammary, diaphrgamatic )
Breast	Axillary	Subpectoral & Supraclavicular

Upper GI = Gastric, pancreatic, liver, gallbladder and bile ducts.
Breast = Tumours tend to spread to one node first = "Sentinel" nodes.
GCT in testes are usually to abdomen in the first place, unless prior scrotal sugery, tumour in undescended testis, retrograde lymphatic spread secondary to bulky retroperitoneal disease or prior nodal dissection.
Echelon Node = In testicular Ca is anterior to the iliopsoas. Uncommon.

Probability of Involvement

Tumour	T1	T2	T3	T4
Prostate	<5%	<5%	15-30%	>40%
Bladder	<5%	10-20%	40%	45%
CRC	5%	20%	>50%	>50%
Ovary	10%	15%	35%	>50%

Other features also predict nodal Involvement including grade, vascular invasion, depth of invasion, high PSA etc

Treatment Change.

Post Therapy the pattern of relapse changes so,
Prostate post RT or RP with LND, relapse is outside pelvis.
Bladder post radical cystectomy, relapse often in hypogastric / internal iliac nodes, presacral and para-aortic nodes.

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1. Sahdev A and Vinnicombe S. Husband & Resnek Imaging in Oncology. CRC Press 2020. ↩↩

2. Vattoth S & Chapman P. 2023 https://my.statdx.com/document/cervical-lymph-nodes ↩↩

3. Carter B. 2023 https://my.statdx.com/document/iaslc-lymph-node-map/f1a3b872-134d-435a-a362-3cec0606bed8 ↩

4. Padhani A. 2014. RCR Recommendations for Cross-Sectional Imaging in Cancer Management. 2022 Update. ↩

5. Stanford S. Grays Anatomy 2021. ↩