2. Mediastinal Lymphadenopathy
By
Gamal Rabie Agmy , MD , FCCP
Professor of Chest Diseases ,Assiut University

3. Lymph
nodes
3
3
Retrosternal
Prevascular
Retrocaval
Aortic window
Carinal
Subcarinal
Hilar
Z-esophageal
Circm-cardiac
Anatomic Considerations

4. Lymph
nodes
Anatomic Considerations
5
Retrosternal
Prevascular
Retrocaval
Aortic window
Carinal
Subcarinal
Hilar
Z-esophageal
Circm-cardiac
6

5. Anatomic Considerations
Lymph
nodes
7
7
8
9
Retrosternal
Prevascular
Retrocaval
Aortic window
Carinal
Subcarinal
Hilar
Z-esophageal
Circm-cardiac

6. Lymph
nodes
Enlarged hilar shadow with lobulated outlines
Normal
X-Rays

7. Lymph
nodes
Multiple masses at the anatomic locations of lymph nodes
CT
MRI

8. Regional lymph node classification for lung cancer staging
adapted from the American Thoracic Society mapping scheme
Supraclavicular nodes
1. Low cervical, supraclavicular and sternal notch
nodes
From the lower margin of the cricoid to the clavicles
and the upper border of the manubrium.
The midline of the trachea serves as border between
1R and 1L.
Superior Mediastinal Nodes 2-4
2R.Upper Paratracheal
•
2R nodes extend to the left lateral border of the
trachea.
From upper border of manubrium to the intersection
of caudal margin of innominate (left brachiocephalic)
vein with the trachea.
2L.Upper Paratracheal
From the upper border of manubrium to the superior
border
of
aortic
arch.
2L nodes are located to the left of the left lateral
border of the trachea.

9. Regional lymph node classification for lung cancer staging
adapted from the American Thoracic Society mapping scheme
3A. Pre-vascular
These nodes are not adjacent to the trachea like
the nodes in station 2, but they are anterior to the
vessels.
3P.Pre-vertebral
Nodes not adjacent to the trachea like the nodes
in station 2, but behind the esophagus, which is
prevertebral.
•
4R. Lower Paratracheal
From the intersection of the caudal margin of
innominate (left brachiocephalic) vein with the
trachea to the lower border of the azygos vein.
4R nodes extend from the right to the left lateral
border of the trachea.
4L. Lower Paratracheal
From the upper margin of the aortic arch to the
upper rim of the left main pulmonary artery.

10. Regional lymph node classification for lung cancer staging
adapted from the American Thoracic Society mapping scheme
Aortic Nodes 5-6
5. Subaortic
These nodes are located in the AP window lateral
to the ligamentum arteriosum.
These nodes are not located between the aorta
and the pulmonary trunk but lateral to these
vessels.
•
6. Para-aortic
These are ascending aorta or phrenic nodes
lying anterior and lateral to the ascending aorta
and the aortic arch.
Inferior Mediastinal Nodes 7-9
7.Subcarinal Nodes below carina.
8. Paraesophageal
9. Pulmonary Ligament
Nodes lying within the pulmonary ligaments.

11. Regional lymph node classification for lung cancer staging
adapted from the American Thoracic Society mapping scheme
Hilar, Lobar
Nodes 10-14
and
(sub)segmental
These are all N1-nodes.
10. Hilar nodes
These include nodes adjacent to the main
stem bronchus and hilar vessels.
On the right they extend from the lower rim
of the azygos vein to the interlobar region.
On the left from the upper rim of the
pulmonary artery to the interlobar region.

12. 1. Supraclavicular zone nodes
1. Supraclavicular
zone
nodes
These 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 between 1R
and 1L.

13. 2R. Right Upper Paratracheal
2R 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 Paratracheal
Upper 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 station 3A node

14. 3. Prevascular and Prevertabral
nodes
Station 3 nodes are not adjacent to
the trachea like station 2 nodes.
They are either:
3A anterior to the vessels or
3B behind the esophagus, which
lies prevertebrally.
Station 3 nodes are not accessible
with mediastinoscopy.
3P nodes can be accessible with
endoscopic ultrasound (EUS).
3A and 3P nodes

15. On the left a 3A node in the
prevascular space.
Notice also lower paratracheal
nodes on the right, i.e. 4R nodes.

16. 4R. Right Lower Paratracheal
Upper
border:
Lower
border:lower
intersection of
caudal margin of innominate (left
brachiocephalic) vein with the
trachea.
azygos
border of
vein.
4R nodes extend to the left lateral
border of the trachea.

17. On the left we see
paratracheal nodes.
4R
In addition there is an aortic
node lateral to the aortic arch,
i.e. station 6 node.

18. 4L. Left Lower Paratracheal
4L nodes are lower paratracheal nodes
that are located to the left of the left
tracheal border, between a horizontal
line drawn tangentially to the upper
margin 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.

19. 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

20. 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.

21. 5. Subaortic nodes
Subaortic 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 nodes
Para-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.

22. 7. Subcarinal nodes
These 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.

23. 8 Paraesophageal nodes
These nodes are below the carinal nodes and extend caudally
to the diaphragm.
On
the
left
an
image
below
the
carina.
To the right of the esophagus a station 8 node.

24. On the left a PET image demonstrating FDG uptake in a
station 8 node.
On the corresponding CT image the node is not enlarged
(blue arrow).
The probability that this is a lymph node metastasis is
extremely high since the specificity of PET in unenlarged
nodes is higher than in enlarged nodes.

25. 9. Pulmonary ligament nodes
Pulmonary ligament nodes are lying within the pulmonary
ligament, including those in the posterior wall and lower part
of the inferior pulmonary vein.
The pulmonary ligament is the inferior extension of the
mediastinal pleural reflections that surround the hila.

26. 10 Hilar nodes
Hilar nodes are proximal lobar nodes, distal to the mediastinal
pleural reflection and nodes adjacent to the intermediate
bronchus on the right.
Nodes in station 10 - 14 are all N1-nodes, since they are not
located in the mediastinum.

27. 10 Hilar nodes
Hilar nodes are proximal lobar nodes, distal to the mediastinal
pleural reflection and nodes adjacent to the intermediate
bronchus on the right.
Nodes in station 10 - 14 are all N1-nodes, since they are not
located in the mediastinum.

28. Axial CT of Lymph Nodes
•
Scroll through the images on the left.
1-Sternal notch nodes are just seen at this level
and above this level
2-Upper Paratracheal: below clavicles and on the
right above the intersection of caudal margin of
innominate (left brachiocephalic) vein with the
trachea and on the left above the aortic arch.
3-Pre-vascular and Retrotracheal : anterior to the
vessels (3A) or prevertebral (3P)
4-Lower Paratracheal : below upper margin of
aortic arch down to level of main bronchus
5-Subaortic (A-P window): nodes lateral to
ligamentum arteriosum or lateral to aorta or left
pulmonary artery
6-Para-aortic: nodes lying anterior and lateral to
the ascending aorta and the aortic arch beneath
the upper margin of the aortic arch
7-Subcarinal
8-Paraesophageal (below carina)
9-Pulmonary Ligament: nodes lying within the
pulmonary ligament.
10--14: nodes are all N1 nodes

29. •
•
Conventional mediastinoscopy
The 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 cervical mediastinoscopy.

30. Extended mediastinoscopy
Left 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.

31. EUS-FNA
Endoscopic 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)

32. References
Regional lymph node classification for lung cancer staging by CF Mountain
and CM Dresler
Chest, Vol 111, 1718-1723
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 by Valerie Rusch et al
Journal of Thoracic Oncology: May 2009 - Volume 4 - Issue 5 - pp 568-577
Conventional mediastinoscopy by Paul De Leyn and Toni Lerut.
in the Multimedia Manual of Cardiothoracic Surgery
Mediastinal Staging of Non Small-Cell Lung Cancer by 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 311
State of the art lecture: EUS and EBUS in pulmonary medicine by J. T.
Annema,
and
K.
F.
Rabe
Endoscopy 2006; 38: 118-122
Imaging of the Patient with Non Small Cell Lung Cancer, What the Clinician
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Radiology 2005; 237:803-818