Lymph node bifurcation. Tuberculosis of the intrathoracic lymph nodes (TB bronchoadenitis)

Any inflammatory process or infection are characterized by an increase lymph nodes. Inflamed lymph nodes can be seen with the naked eye or by palpation. For example, intrathoracic lymph nodes are located in the cavitary parts of the body, and it is not possible to detect them without special techniques.

Why are VGLUs enlarged?

They are located in the human body in such a way that they prevent infection from entering the most important internal organs and systems. Enlargement of the lymph nodes occurs due to the penetration of a foreign agent into the lymph flow.

Whether they are microbes, viruses or cancer cells, lymph carries them throughout the body, which provokes the body's immune response. Lymphoid fluid, seeping between the lymph nodes, passes further into the cardiovascular system, and the pathogenic proteins brought by it accumulate in lymphoid tissue. An inflamed and enlarged lymph node looks like a lump. The location of the lump is directly related to the inflammation of a specific organ or internal system.

Localization of VGLU

Intrathoracic (thoracic or mediastinal) lymph nodes, depending on their location, belong to internal localizations. As the name suggests, lymph nodes are located in the area chest.

They are presented in the form of group clusters and have the following classification:

1. Parietal - located near the wall of the chest cavity. These include intercostal and parasternal lymph nodes.
2. Organ - located next to thoracic organs. There are paraesophageal and bronchopulmonary lymph nodes.
3. Thoracic solar plexus lymph nodes in turn, they are divided into anterior, posterior and middle VGLUs of the mediastinum.

The mediastinum is the organs and vessels located between the lungs. Being a sternal organ, it is represented by a whole group of lymph nodes:

• paratracheal;
• tracheobronchial;
• bifurcation;
• bronchopulmonary;
• retrosternal;
• paraesophageal.

Reasons for the increase

There are no physiological reasons for enlarged lymph nodes. Basic pathological causes, leading to enlargement of intrathoracic lymph nodes, can be divided into two groups: tumor-like and non-tumor-like etiology.

Pneumonia, bronchitis, tuberculosis, sarcoidosis and malignant formations in the lung tissue are diseases that bring the immune system, namely the lymph nodes of the intrathoracic region, into a state of increased activity. It is worth noting that with various types of diseases, not only the size of the lymph node changes (normally it is 0.5 - 30 mm), but also other estimated indicators:

• the surface changes: from smooth to lumpy;
• the consistency becomes softer (normally the lymph node is hard);
• merging with each other due to inflammatory or other processes, the lymph nodes lose their mobility, moreover, the infected areas are replaced by connective tissue, which generally renders the lymph node unusable.

The main causes and diseases leading to an increase in VGLU

Lung cancer

Lung cancer - severe cancer. The higher the stage of cancer, the more severe the symptoms, the more difficult it is to alleviate the patient’s suffering and return him to a full life.

Reasons for development lung cancer:

• active and passive smoking;
• exposure to carcinogens (nickel, asbestos, chromium, beryllium and arsenic);
• uranium decomposition product – radon gas;
• unfavorable environment;
• genetic predisposition.

Characteristic signs oncological process in the lungs:

• persistent hoarseness in the voice;
• constant shortness of breath;
• chest pain;
• general malaise (headaches, fever, photosensitivity);
• emergency weight loss.

Thanks to the lymphatic system, cancer cells cannot immediately enter the bloodstream, but are located in the lymph node. When lymph leaks through the cracks of the lymph node, large protein particles are retained. The lymph node restrains the tumor process, so that by detecting cancer in time, it is possible to prevent its transition to the 4th metastatic stage.

Enlarged lymph nodes in lung cancer depend on the size of the tumor and the presence of metastases, as well as the location of the diseased organ.

The treatment methods used depend on the stage of the process and the histological type of cancer. In the first stages, control measures such as radiation therapy, radiotherapy, chemotherapy, and surgery are applicable. Stage 3 cancer is quite difficult to treat.

The patient receives supportive care in the form of strong painkillers, narcotics and antitussive medications. In some cases, chemotherapy is used. Stage 4 cannot be treated, because if the cancer affects all vital organs and systems, the person dies.

Enlarged mediastinal lymph nodes after bronchopneumonia

Bronchopneumonia- an inflammatory process involving lung tissue and bronchioles. The disease is microbial in nature - the causative agents are often pneumococci and streptococci. With bronchopneumonia, a slight increase in lymph nodes is observed. Most often it appears after suffering from acute respiratory viral infections and acute respiratory infections. In addition, the lymphatic and vascular system, increased formation of lymphocytes occurs, resulting in persistent lymphadenopathy.

Increased VGLU in tuberculosis

Tuberculosis is an infectious disease caused by Koch's bacillus (Mycobacterium tuberculosis). The main symptom is the formation of tuberculous tubercles. With pulmonary tuberculosis, the bifurcation lymph nodes are most often inflamed and enlarged. The disease is accompanied by chest pain, hemoptysis and general ailments. Characteristic feature Tuberculosis is the process of draining the lymph nodes. After healing, the affected lung tissue is replaced by fibrous tissue, and scars form.

Sarcoidosis as a cause of lymphadenitis

Sarcoidosis – autoimmune disease. The exact reasons for the development of the disease have not been established. Because of long-term exposure viruses, bacteria and fungi, the human immune system does not function properly. In the early stages, sarcoidosis is accompanied by enlargement and asymmetrical damage to the tracheobronchial and bronchopulmonary lymph nodes.

Symptoms of enlarged mediastinal lymph nodes

– immune response to pathological processes occurring in the lungs and other nearby organs.

A distinctive feature is the clear clinical manifestation of the disease:

1. Sharp pain in the chest, pain extends to the shoulders and neck.
2. Hoarseness occurs and a cough appears.
3. Tinnitus and headaches.
4. In severe cases, the passage of food is difficult.

The reasons for the development of inflammation of the mediastinal lymph nodes are associated with the ingress of foreign agents, bacteria and pathogenic microbes, provoking the body to produce large quantity leukocytes, including lymphocytes. Malignant formations in the lymph nodes of the mediastinum are called lymphoma.

It is customary to distinguish three stages of disease development:

• acute (occurs suddenly and unexpectedly)
• chronic (temperature rises, weakness and swelling appear)
• recurrent (repeated outbreak of the disease).

Diagnostic measures

Diagnosis is based on the history of the disease. Blood is donated for biochemical testing and the Wasserman reaction (confirmation of syphilis). A general blood test, bacterial culture of sputum and microscopic examination of the native drug are prescribed. Gram staining of the smear and for atypical cells.

X-ray examination, as well as bronchoscopy and fluoroscopy are performed. Sometimes a biopsy of the lung tissue may be performed and spinal fluid may be taken if cancer is suspected.

Treatment

Treatment methods depend on the disease itself, as well as on the degree of its development. Apply treatment medicines, physiotherapeutic and folk methods.

Disease	Treatment method	Treatment regimen
Tuberculosis	Medication	Taking 3–4 anti-tuberculosis drugs: 1. Rifampicin 2. Pyrazinamide 3. Isoniazid 4. Taking immunomodulators
	Physiotherapeutic	Laser and ultrasound, however, in case of hemoptysis and acute course of the disease, physiotherapy is contraindicated
Sarcoidosis	Medication	Reception hormonal drugs, for example, prednisolone. Medications, correcting immune processes.
	Physiotherapy	Inhalations with large doses fluticasone
Bronchopneumonia	Medication	Taking antibiotics and intravenous injections.
	Physiotherapeutic	Laser, ultrasound, UV inhalation with berodual

1. Surgical treatment is used for mediastinal tumors. Surgeries in the final stages of oncology are not performed due to lack of results.
2. Vitamin therapy. The need for vitamins is also observed in absolutely healthy citizens. With lymphadenopathy of various pathogenesis, the need for vitamin complexes to maintain the body's immune defense.
3. Traditional methods of treatment are used only with the advice of a doctor. By effective means are inhalations with eucalyptus oil. More often traditional methods common in tuberculosis patients:

• Mix 100 g of aloe, honey, Cahors, add a spoonful of pork fat and beet juice. Stir and leave for at least 2 weeks.
• Mix badger fat with honey and butter. Leave for 3 days in a dark place.

Prevention

Since the main reason for the development of lymphadenopathy lies in an incorrect lifestyle, it is necessary to adhere to a healthy lifestyle: engage in physical activity, eat right. Avoid hypothermia and contact with sick people, wash your hands and wash your face after visiting public places.

As tuberculosis progresses, the intrathoracic lymph nodes become involved in the disease. Disease dangerous if not diagnosed in time and with insufficient information to the residents of the country.

Today, thanks to preventive efforts, with the help of vaccination of patients and special therapeutic measures during primary infection, it is observed reduction in morbidity rates.

What kind of disease is this?

Tuberculosis of the intrathoracic lymph nodes (HTLU) determined by the manifestation of tuberculosis at the initial stage. Occurs in eighty percent of infected patients. The process is caused by the bacteria M.tuberculosis and M.bovis.

This disease can begin to develop as a result of the primary hematogenous or lymphogenous spread of tuberculosis bacteria. In other cases, VGLU may be the cause of activation of tuberculosis that the patient already had.

Tuberculosis VGLU usually occurs unilaterally. Much less often it is double-sided, which is more dangerous for humans.

Forms of VGLU tuberculosis:

1. Tumor-like forms. The most difficult to flow forms. Quite often diagnosed in pediatric patients. Appears in the form of up to five centimeters in diameter;
2. Infiltrative forms. Determined by a slight enlargement of the lymph nodes;
3. Small forms. Diagnosed by specialists quite often. It is characterized by a barely noticeable enlargement of lymph nodes in patients.

Prognosis for recovery

With VGLU tuberculosis, complications may appear, which in turn are divided into early and late:

• The initial complication of VGLU tuberculosis is the presence of exudative pleurisy.
• Damage to the bronchi appears as a result of the process transferring from the lymph nodes to the walls of the bronchi. These are late complications. Characterized by heavy cough and the appearance of breathing problems.

Course of the disease in children

The main form of tuberculosis in children and adolescent patients is VGLU tuberculosis. The main importance in the medical history is pulmonary lesion, bronchoadenitis can be considered as the second of the components that began to develop after the formation of a lesion in the lungs.

Thanks to the vaccination of children using the BCG method, increasing immunity and resistance, in today's conditions the pulmonary affect, which is located subpleurally, separates lung tissue and will not develop in the future.

The course of the disease is determined by lesions in the nodes.

Signs of the disease in children:

• Sick babies may develop coughing, caused by compressed bronchi and due to enlarged lymph nodes.
• Cough causes breathing problems and pain. In pediatric patients, the volume of bifurcation lymph nodes rapidly increases, and due to this reaction, a feeling of suffocation may occur. The cough is dry at first, and then with sputum.
• In addition, the symptoms of asphyxia in patients may be accompanied by cyanosis, difficult breathing, flaring of the wings of the nose and the process of retraction of the intercostal spaces. Lying on the patient's back is painful. When the baby turns onto his stomach, the condition will be alleviated due to the forward movement of the affected lymph node.
• Also in pediatric patients there appears severe sweating at night. Appetite decreases and severe weakness and fatigue occur. Symptoms appear intoxication and fever. The child becomes whiny and nervous.

Symptoms

Symptoms appear as general intoxication, slight increase in temperature, loss of appetite, apathy, sweating, sleep disturbances and psycho-emotional state of the patient.

A dry cough may be replaced by a cough with sputum. It becomes difficult for the patient to breathe, there is pain behind the sternum. The patient may experience bronchospasms.

Main groups of symptoms:

• Symptoms Widergoffer. They are characterized by an expanded venous network in the first and second intercostal space on 1 or 2 sides (the azygos vein is compressed).
• Frank. They are characterized by dilated vessels in the area between the shoulder blades.
• Parsley. This method allows you to identify painful sensations when pressure is applied to the spinous processes of the 3-7 thoracic vertebrae.
• Filosofova(also called the “chalice” symptom). Characterized by parasternal dullness percussion sounds in the first and second intercostal space (paratracheal lymph nodes are affected).
• De la Campa may be detected by a dull pulmonary sound between the shoulder blades in the area of ​​the second to fourth vertebrae.
• Koran determined by a dull sound below the first thoracic vertebra(in children one to two years old), below the second vertebra (in children under ten years of age) and below the third vertebra (in patients over ten years of age). This sign is characteristic of enlarged bifurcation lymph nodes.
• D'Espina. Bronchophony can be heard on the spine.
• Geibner. Tracheal breathing can be heard above the spine.

Diagnostic methods

Diagnostic measures will allow you to recognize and identify the stage of development. The first thing a patient with primary symptoms should do is contact a specialist - phthisiatrician.

At the doctor’s appointment, the source of infection is identified, and contacts with the patient’s tuberculosis carrier in the family and among friends are determined. The doctor will prescribe the following measures:

Diagnosis as well as therapy must be comprehensive and not consist of only one of the measures. Only A complex approach makes it possible to obtain a detailed clinical picture.

Watch a video about determining the type of tuberculosis using an x-ray:

Treatment

Patients are prescribed treatment only in stationary conditions.

Therapeutic measures are complicated by the fact that innovative, sought-after antimycobacterial agents reach the lymph nodes in very small dosages. Much greater effectiveness of treatment is observed in patients with the infiltrative form of bronchoadenitis.

Patients are prescribed therapy with special medications for four to six months in hospital. The treatment is complex and continues in the sanatorium, and after discharge on an outpatient basis under the supervision of a doctor.

The duration of these stages is from one to one and a half years; an appointment is scheduled for two effective drugs(Isoniazid plus Ethambutol or Isoniazid plus Ethionamide or Isoniazid plus Pyrazinamide).

After completion of treatment, the patient must follow important rules and conduct healthy way life. Important complete cessation of bad habits.

Proper balanced nutrition is also a mandatory measure. The patient is prohibited from prolonged exposure to the cold and any hypothermia. It is important to maintain a rational drinking regime.

Another treatment option is surgery. But there is an intervention for serious indications:

1. Absence positive dynamics for a long period of up to 2 years from the start of treatment;
2. Formation of tuberculoma of the lymph nodes.

Difference between lung cancer and tuberculosis

VGLU tuberculosis can be compared to lung cancer. Disease data can occur with the same clinical picture and changes noticeable on x-ray (the presence of darkening at the base of the lung). There are factors that distinguish lung cancer from tuberculosis.

Features of oncology:

• Lung cancer is diagnosed in most cases in males aged over forty years;
• in case of cancer, symptoms are more often associated with cough and difficulty breathing, while tuberculosis is characterized by symptoms of intoxication;
• dynamic course of the disease;
• in certain cases, the lymph nodes on the side where the tumor grows may become enlarged;
• in the results general analysis blood observed increased level leukocytes, ESR is significantly increased, anemia can be diagnosed;
• on an x-ray for oncology, the shadow of the lung root has quite distinct contours, unlike other diseases;
• determining importance is given to bronchoscopic examination, which is one of the most effective methods. Often, along with this, bronchial lumen may be observed.

Prevention

Prevention is critical to prevent VGLU tuberculosis. They give a result that reduces the number of cases. Each patient is informed about how to behave so as not to infect others.

Tuberculosis is listed serious illnesses society. But still, the disease is not spreading at the same rate as several years ago.

Thanks to timely vaccination of children, a relative reduction in morbidity has been achieved. Modern drugs, preventive measures and treatment methods have given positive result.

In medical practice, the following ways of spreading malignant neoplasms are known:

• lymphogenous;
• hematogenous;
• mixed.

Lymphogenic metastasis is characterized by the penetration of tumor cells into the lymphatic vessel and then through the flow of lymph to nearby or distant lymph nodes. Epithelial cancers (eg, melanoma) are more likely to spread through the lymphatic route. Tumor processes in internal organs: stomach, colon, larynx, uterus - can thus create metastases in the lymph nodes.

The hematogenous route includes the spread of tumor processes using blood flow from the affected organ to the healthy one. Moreover, the lymphogenous route leads to regional (close to the affected organ) metastases, and the hematogenous route promotes the spread of affected cells to distant organs. Lymphogenic metastasis has been well studied, which makes it possible to recognize most tumors at their inception stages and provide timely medical care.

In the neck area, the lymph nodes form a collector that accumulates lymph coming from the organs of the head, sternum, upper limbs, as well as from the peritoneum, torso and legs. Doctors have established a pattern between the path of metastasis and the course of the lymphatic bed. In this regard, metastases in the lymph nodes located at the level of the chin and under the jaw are detected in tumor processes of the lower lip, anterior part of the tongue and the oral cavity, upper jaw. Metastases of malignant neoplasms posterior sections tongue, floor of mouth, thyroid gland, areas of the pharynx and larynx spread to the lymph nodes of the neck area, namely to the area of ​​the carotid neurovascular bundle. Metastases in the lymph nodes of the area above the collarbone (outside the sternocleidomastoid muscle) often develop with breast or lung cancer. Malignant neoplasms of the peritoneal region metastasize to the lymph nodes above the collarbone (inside the sternocleidomastoid muscle). Inguinal lymph nodes contain metastases from cancer of the lower extremities, areas of the sacrum and buttocks, as well as the external genitalia.

Metastasis means secondary pathological lesion cells growing in tissues human body from the site of the primary disease.

The function of the lymphatic system is to maintain metabolic processes, as well as cleansing (filtering) at the cellular level, as a complement to the cardiovascular system. Lymph nodes are grouped according to their location in the human body and serve to produce lymphocytes - immune cells, fighting harmful foreign microorganisms that penetrate the body.

Reasons influencing the development of metastases:

• age factor (metastases appear more often at older ages);
• development of concomitant diseases (chronic, debilitating protective forces organism);
• the size and localization of the initial focus of the malignant neoplasm (the presence of a large tumor increases the possibility of metastases);
• spread of tumor cells (the growth of malignant tumors into the wall of an organ is most dangerous and more often causes metastasis than neoplasms growing into the lumen of the organ).

Symptoms of metastases in the lymph nodes

International Classification of Tumors malignant type defines metastases in lymph nodes with the Latin letter N. The stage of the disease is described by the number of metastases, and not by the size of the affected tissue. N-0 indicates the absence of metastases, N-1 means a single metastasis of nodes close to the tumor, N-2 – a large number of metastasis of regional lymph nodes. The designation N-3 means simultaneous damage to nearby and distant lymph nodes, which is inherent in the fourth stage of the tumor process.

The primary symptoms of metastases in the lymph nodes are a significant increase in size, which is determined by visual inspection and palpation. Most often, changes are differentiated in the cervical, supraclavicular, axillary and inguinal lymph nodes, which have a soft-elastic structure and are painless.

The growth of lymph nodes in size is often accompanied by weight loss, and the patient’s condition is characterized by general weakness and anemia. Warning signs also include temperature, frequent colds, neuroses, enlarged liver, migraines, redness of the skin. The appearance of metastases indicates the progression of the malignant neoplasm. If you independently detect lymphadenopathy (enlarged lymph node), you should consult a specialist without self-medicating.

It is important to note that often metastases in the lymph nodes are recognized earlier than the source of the problem - a malignant tumor.

Metastases in the lymph nodes of the neck

Tumors of the neck area are grouped into a small, but quite diverse group of clinical manifestations group. Neoplasms are observed both in the organ itself (larynx, pharynx, esophagus, thyroid etc.), and in the soft tissues of the neck not related to the organ.

The main lymphatic collector is located on the neck, and the formation of metastases in its nodes occurs due to damage to lymphoreticular tissue, as a result of lymphogranulomatosis, hematosarcoma, lymphosarcoma, metastasis of malignant tumors (Virchow's metastasis).

Metastases in the lymph nodes of the neck lead to changes in the shape, size, structure and echogenicity of the nodes. Lymphogranulomatosis most often (60% of cases) occurs with metastases to the nodes of the neck. In this case, pathological processes can be observed in the axillary, inguinal, mediastinal, as well as lymph nodes of the retroperitoneal zone. There are cases of simultaneous damage to the thyroid gland and lymph nodes of the neck, which is clinically similar to thyroid cancer with metastasis to the cervical nodes.

Lymphogranulomatosis is more common in 20-30 year old patients or people over 60 years old (usually male). The primary manifestation of the disease is an enlargement of a lymph node or a group of nodes with an elastic consistency. Further, the fusion of lymph nodes of various densities and sizes into a single conglomerate is noted. Patients complain of: general weakness, sweating, itching of the skin, fever and lack of appetite. Clinical picture varies depending on the individual course and stage of the disease, so the described symptoms may be vague or completely absent.

Metastases in the lymph nodes are often detected in lymphosarcoma. The nodes are enlarged and have a dense structure, and the speed internal changes of the affected conglomerate can cause compression of adjacent organs within a couple of weeks. During the examination, the patient may be diagnosed with growth of inguinal and axillary nodes.

Along with malignant tumors of the head and neck (tumor processes of the tongue, salivary glands, thyroid gland, larynx), metastases in the lymph nodes of the neck are detected in breast cancer, damage to the lungs or organs abdominal cavity, which indicates the fourth stage of the disease.

About 30% of cases of primary tumor processes remain undifferentiated. To examine a patient for the presence of cancer of the neck, diagnostics using anesthesia is used. Thyroid cancer can take hidden form, manifesting itself only as metastases in cervical lymph nodes. The palpation method and ultrasound do not always reveal dense neoplasms, therefore puncture and excisional biopsies are widely used.

Metastases to cervical lymph nodes

Damage to the cervical lymph nodes - metastases to the cervical lymph nodes are characterized by general symptoms:

• significant growth of nodes;
• change in shape (contours are uneven, unclear);
• anechoic areas are noted.

An ultrasound examination reveals a violation of the ratio of the transverse and longitudinal size of the node or a difference (less than 1.5) between the long and short axes. In other words, if the lymph node acquires a round shape, then there is a high probability of its damage.

Cancer processes in the lymph nodes increase the fluid content in them. An ultrasound scan shows a blurred outline of the node. The lymph node capsule is still recognizable at an early stage of the disease. As malignant cells grow, the contours are erased, the tumor grows into nearby tissues, and it is also possible for several affected lymph nodes to fuse into a single conglomerate.

Metastases to the cervical lymph nodes are formed from lymphomas, cancers of the lung, gastrointestinal tract, prostate or breast. Most often, when metastases are detected in the lymph nodes of the neck, the localization is primary tumor – upper sections respiratory or digestive system.

Enlargement of the lymph nodes in the neck area occurs with the following oncological diseases:

• cancer processes of the larynx, tongue, oral mucosa;
• damage to the thyroid gland;

Diagnosis is made by puncture or excisional biopsy. Treatment methods include irradiation and surgical removal of the affected node.

Metastases in the lymph nodes in the groin

The lymph nodes of the groin area are retained and destroyed pathogenic microorganisms, penetrating the lymphatic system from the pelvic organs (usually the genital area) and lower extremities. Primary malignant neoplasms or lymphomas can form in the inguinal lymph nodes themselves.

Inguinal lymph nodes are divided into deep and superficial. The latter are located in the area of ​​the so-called “femoral triangle” and on the surface of the lata fascia of the thigh, their number varies from four to twenty pieces. The inguinal nodes communicate with the tissues of the lower extremities, the perineal area, and the anterior wall of the peritoneum below the navel. The number of deep lymph nodes in the groin ranges from one to seven. Their location is under the surface of the plate of the fascia lata of the thigh. These nodes are interconnected with lymphatic vessels located on the surface of the groin area and deep in the femoral area.

A painless symptom with a characteristic increase in node size may indicate metastases in the lymph nodes in the groin. The growth of inguinal lymph nodes occurs in the following oncological diseases:

• lumbar melanoma or skin cancer of the lower extremities;
• malignant neoplasm in the rectum;
• genital cancer;
• lymphogranulomatosis (Hodgkin's lymphoma).

Cases of defeat inguinal nodes require a thorough examination of the condition of the skin of the legs, as well as organs located in the pelvis and peritoneal cavity. For diagnostic purposes, the following are used: computed tomography (CT), colonoscopy, cystoscopy, hysteroscopy, FEGDS.

Metastases to inguinal lymph nodes

The lymph nodes of the inguinal zone pass lymph coming from the genitals, the lower rectum and abdominal wall, and the lower extremities. Based on their location, nodes are divided into superficial and deep.

Malignant neoplasms of the legs, sacro-gluteal area, and external genitalia form metastases to the inguinal lymph nodes. Lymph nodes take on the appearance of rounded area seals inguinal folds. The nodes are tightly welded to nearby tissues and are inactive, which is observed when trying to move them.

Types of cancer that cause enlarged lymph nodes in the groin:

• melanoma or cancer of the skin of the legs (lumbar area);
• rectal oncology;
• malignant formations of the genital area;
• Hodgkin's lymphoma (lymphogranulomatosis).

The initial development of lymphogranulomatosis with damage to the lymph nodes in the groin is quite rare (10%). The disease is characterized by weight loss, an unreasonable rise in temperature, and excessive sweating at night.

During the examination, the doctor examines the lymph nodes by palpation, first along and then across the groin fold, using sliding circular movements, and moves to the area of ​​the lata fascia of the thigh.

Metastases to retroperitoneal lymph nodes

The retroperitoneal space is the area of ​​the abdomen behind the peritoneal wall, bounded by the peritoneum, back muscles, sacrum, diaphragm and lateral abdominal walls. Lymphatic system The retroperitoneal space includes regional lymph nodes, vessels and large lymph collectors, from which the thoracic lymphatic duct originates.

Localization of malignant neoplasms in the peritoneal area has the following symptoms: increased temperature, cramping pain in the abdomen (appears in paroxysms), stool disorder in the form of diarrhea (less commonly, constipation). Metastases to the retroperitoneal lymph nodes are observed in germ cell tumor processes in the testicle, kidney, cancer diseases gastrointestinal tract. Enlargement of the retroperitoneal lymph nodes leads to severe pain in the back due to compression nerve roots, sometimes covering the lumbar muscle. Gastrointestinal symptoms are common, and sudden weight loss is observed.

The condition of the lymph nodes and organs of the retroperitoneal space is assessed based on the results of ultrasound, computed tomography and magnetic resonance imaging. An ultrasound scan shows nodes with metastases as round or oblong, characterized by clear contours and uniformity of structure. The CT method determines metastases in the lymph nodes according to rounded shape, soft tissue structure. The affected lymph nodes of the retroperitoneal cavity have a uniform structure and density, as well as clear contours, and can merge into large conglomerates. In the case when the lymph node arrays cover the spine, the aorta in the peritoneal zone and the inferior vena cava, intravenous contrast is used to better recognize tumor processes.

Metastases to para-aortic lymph nodes

Location of para-aortic lymph nodes - anterior lumbar region spine, along the aorta.

Metastases to the para-aortic lymph nodes are observed in patients with cancer of the genital area, kidneys and adrenal glands, and gastrointestinal tract. For example, with malignant neoplasms of the stomach, in 40% of cases, affected para-aortic lymph nodes are detected. Tumor processes with metastasis to the para-aortic lymph nodes are classified as the third or fourth stages of the disease. Moreover, the frequency of damage to para-aortic nodes of the third degree of oncology reaches 41%, and the fourth degree – 67%. It should be noted that, for example, metastases to para-aortic lymph nodes of ovarian cancer are resistant to chemotherapy.

The development of pancreatic cancer has its own stages of lymphogenous metastasis:

• first stage - metastases reach the head of the pancreas;
• second stage – retropyloric and hepatoduodenal lymph nodes are affected;
• third stage - penetration of metastases into the celiac and superior mesenteric nodes;
• the fourth stage is metastasis to the para-aortic lymph nodes.

Doctors note that malignant tumors of the pancreas are characterized by an aggressive course and have a poor prognosis. Deaths from pancreatic cancer rank 4-5 among all cancers. High mortality rate associated with recurrence of tumor processes in postoperative period(K-ras mutations in para-aortic lymph nodes).

Metastases in the lymph nodes of the abdominal cavity

A large number of lymph nodes are located in the abdominal cavity, representing a barrier to infection and cancer cells. Lymph nodes of the peritoneum are divided into parietal (concentrated in the lumbar area) and intramural (located in rows).

Damage to the peritoneal lymph nodes is the result of a lymphoproliferative disease (the primary tumor forms in the lymph node itself) or a consequence of metastasis. Lymphogranulomatosis and lymphosarcoma are lymphoproliferative diseases that cause compaction and growth in the size of the node without pain. Metastases in the lymph nodes of the abdominal cavity are detected in a number of cancers, when tumor cells penetrate into the lymph nodes from the affected organ with the lymph flow. Thus, malignant tumors of the peritoneal organs (for example, the stomach) and the pelvis (for example, the ovary) cause the formation of metastases in the peritoneal lymph nodes.

The main criterion confirming the presence of metastases in the lymph nodes is an increase in size of the node (up to 10 cm or more). CT and MRI studies of the peritoneal cavity also come to the rescue in order to obtain visualization of anatomical structures.

Melanoma metastases to lymph nodes

Melanoma is a rare malignant tumor that most often affects residents of the southern regions. It should be noted that in 70% of cases, melanoma forms in place of an existing pigmented nevus or birthmark.

The development of melanomas occurs in two phases:

• horizontal – growth within the epithelial layer (lasts from 7 to 20 years);
• vertical - ingrowth of layers of the epidermis and subsequent invasion through the basement membrane into the dermis and subcutaneous fatty tissue.

The vertical stage is distinguished by its rapidity and ability to metastasize. Metastases of melanoma to lymph nodes are determined primarily by the biological characteristics of the tumor. Lymphogenous metastasis occurs in skin, regional lymph nodes. The affected lymph nodes become dense in consistency and increase in size.

Diagnostic methods include aspiration biopsy of the formation, surgical biopsy of lymph nodes, radiography, CT and MRI of the whole body. Removal of melanoma metastases to the lymph nodes is carried out by complete excision of the regional lymph node or removal of lymph nodes close to the tumor (if the diagnosis is made on the basis of a biopsy).

Metastases to supraclavicular lymph nodes

Metastases to the supraclavicular lymph nodes occur when:

• undifferentiated cancer (the primary tumor is located in the neck or head);
• tumor processes in the lungs;
• cancer of the gastrointestinal tract.

Identification of Virchow's (Troisier's) nodes in the left supraclavicular region indicates the presence of a malignant neoplasm of the abdominal cavity. Damage to the supraclavicular nodes on the right side makes it possible to suspect lung cancer or prostate gland. Metastases in the lymph nodes of the subclavian triangle may indicate lung or breast cancer.

One of the most common tumors, gastric cancer, is diagnosed by identifying “Virchow metastases” (usually in the left supraclavicular lymph nodes). Malignant ovarian cells sometimes penetrate through lymphatic vessels diaphragm and lumbar lymph nodes, which causes lymphatic metastasis above the diaphragm - metastases to the supraclavicular lymph nodes.

Enlargement of the supraclavicular nodes is an alarming symptom, most often indicating tumor processes in the sternum or abdominal area. In 90% of cases, similar symptoms occur in patients over 40 years of age, the proportion of patients younger age accounts for 25% of cases. Damage to the lymph nodes on the right corresponds to a tumor of the mediastinum, lungs, and esophagus. An increase in the size of nodes on the left in the supraclavicular zone indicates cancer of the ovaries, testes, prostate, bladder, kidneys, stomach, pancreas.

Metastases in the mediastinal lymph nodes

The mediastinum is a section of the thoracic cavity, which is bounded in front by the sternum, costal cartilages and substernal fascia, in the back by the anterior zone of the thoracic spine, the neck of the ribs, the prevertebral fascia, and on the sides by the layers of the mediastinal pleura. The mediastinum area is indicated below by the diaphragm, and above by a conventional horizontal line. The mediastinal zone includes the thoracic lymph duct, retrosternal lymph nodes, and anterior mediastinal lymph nodes.

In addition to lung cancer, metastases in the lymph nodes of the mediastinum form tumor processes of the thyroid gland and esophagus, kidney hypernephroma, testicular cancer (seminoma), pigmented malignancy (melanosarcoma), uterine cancer (chorionepithelioma) and other neoplasms. Damage to the mediastinal lymph nodes ranks third in the development of malignant processes after lymphogranulomatosis and lymphosarcoma. Cancer cells cover all groups of mediastinal lymph nodes, the paratracheal and bifurcation ones are most often affected.

Small primary tumors often give extensive metastases in the lymph nodes of the mediastinum. A striking example of such metastasis is mediastinal lung cancer. The clinical picture describes swelling of the soft tissues of the neck and head, swelling and interweaving of the veins in the front of the chest (“jellyfish head”), dysphagia, hoarseness, and stridor-type breathing. X-ray in most cases reveals the predominance of metastases in posterior mediastinum.

In breast cancer, the accumulation of affected lymph nodes is localized in anterior mediastinum. For the clarification method, mammariography (contrast study of the veins of the mammary glands) is used. Interruption of the venous bed, compression, and the presence of marginal defects serve as evidence of the presence of metastases that require removal or treatment through radiation.

Treatment of metastases in lymph nodes

The main rule of oncology is to study the condition of the lymph nodes, both in the tumor zone itself and in remote ones. This allows you to most accurately establish a diagnosis and prescribe an effective treatment program.

Lying lymph nodes that are accessible to external inspection are examined by biopsy and puncture. The condition of deeper lymph nodes is examined using ultrasound, CT, and MRI. The most precise method Positron emission tomography (PET) is considered to be used to detect metastases in lymph nodes, thanks to which it is possible to recognize the origin of malignant cells in the most inaccessible and slightly enlarged lymph nodes.

Treatment of metastases in lymph nodes is based on the same principles as the fight against a primary cancer tumor - surgery, chemotherapy, radiotherapy. A combination of these techniques is used individually, depending on the stage of the disease (malignancy) and the degree of damage to the lymphatic system.

Excision of the primary tumor is usually accompanied by removal of all its regional lymph nodes (lymphadenectomy). To lymph nodes with diseased cells located further away cancerous tumor, apply radiotherapy methods or perform bloodless radiosurgery using a cyber knife.

Timely diagnosis and treatment of metastases in the lymph nodes makes it possible to block the proliferation of tumor cells and prolong the patient’s life.

Prognosis of metastases in lymph nodes

Factors influencing patient survival are conventionally divided into related:

• with a cancerous tumor;
• with the patient’s body;
• with the treatment provided.

Most important factor the prognosis is damage to regional lymph nodes without the presence distant metastases. For example, the prognosis for metastases in the lymph nodes of the neck of “non-squamous cell carcinoma” remains disappointing – 10-25 months. The survival rate of patients with stomach cancer depends on the possibility of radical surgery. Only a small proportion of non-operated or non-radically operated patients reach the five-year mark. The average life expectancy is 3-11 months, and this figure is influenced by the presence or absence of distant metastases.

The presence of metastases in the lymph nodes in breast cancer significantly worsens the prognosis. As a rule, relapses and metastasis are observed in the first five years after surgical intervention in 35-65% of women, which indicates an activation of the process. Life expectancy after treatment is 12-24 months.

Patients with melanoma of the head, neck, and trunk have more poor prognosis than persons with melanoma of the extremities, since the risk of metastasis to the lymph nodes of these tumors is 35% higher.

The criterion for successful treatment can be the five-year survival rate. The prognosis after tumor excision is determined not only by the presence or absence of metastases in regional lymph nodes, but also by the number of affected nodes.

If metastases are found in lymph nodes without a primary tumor site, the prognosis may be favorable. The outcome of special treatment based on the five-year survival rate for isolated metastasis to the lymph nodes is: in the case of damage to the axillary lymph nodes - more than 64%, inguinal - over 63%, cervical - 48%.

Lymphadenopathy is a condition in which the lymph nodes increase in size. Such pathological changes indicate a serious disease that is progressing in the body (often of an oncological nature). To make an accurate diagnosis, several laboratory and instrumental analyzes. Lymphadenopathy can form in any part of the body and even affects internal organs.

Etiology

It is possible to find out the exact cause of lymphadenopathy only after conducting appropriate studies. Most common reasons enlarged lymph nodes may be the following:

• viral diseases;
• lymph node infection;
• connective tissue injuries and diseases;
• serum sickness (effect of medications);
• fungus;
• infectious diseases that suppress the immune system.

The child most often develops abdominal lymphadenopathy. The reason for this is bacterial and viral infection of the body. Lymphadenopathy in children requires immediate examination by a physician, as symptoms may indicate a severe infectious disease.

Symptoms

Besides pathological change lymph nodes, additional symptoms may be observed. The nature of their manifestation depends on what caused the development of such pathology. In general, the following symptoms can be identified:

• skin rashes;
• elevated temperature;
• increased sweating (especially at night);
• attacks of fever;
• increased splenomegaly and hepatomegaly;
• sudden loss weight, for no apparent reason.

In most cases, enlarged lymph nodes are a marker of other complex diseases.

Classification

Depending on the nature of the manifestation and localization of the disease, there are following forms lymphadenopathy:

• local;
• reactive;
• generalized.

Generalized lymphadenopathy

Generalized lymphadenopathy is considered the most complex form of the disease. Unlike local lymphadenopathy, which affects only one group of lymph nodes, generalized lymphadenopathy can affect any area of ​​the human body.

Generalized lymphadenopathy has the following etiology:

• allergic disease;
• autoimmune processes;
• acute inflammatory and infectious diseases.

If enlarged lymph nodes are observed during a chronic infectious disease, then persistent generalized lymphadenopathy is implied.

Most often, the pathological process affects nodes in non-overlapping areas - in the anterior and posterior cervical chain, in the axillary and retroperitoneal region. In some cases, enlarged lymph nodes are possible in the groin and supraclavicular areas.

The most common diagnosis is neck lymphadenopathy. Cervical lymphadenopathy may indicate illnesses caused by insufficient or excessive production of hormones or cancer.

Reactive lymphadenopathy

Reactive lymphadenopathy is the body's response to infectious diseases. Any number of lymph nodes can be affected. The symptoms are not expressed, there is no painful sensation.

Stages of disease development

According to the statute of limitations, lymphadenopathy can be divided into the following groups:

• acute;
• chronic;
• recurrent.

In addition, any form of lymphadenopathy can take both tumor and non-tumor forms. However, any of them is dangerous to human life.

Characteristic localization of lesions

There are more than 600 lymph nodes in the human body, so the pathological process can develop in almost any system of the human body. But most often lesions are diagnosed in the following places:

• abdomen;
• mammary gland;
• mediastinal area;
• groin area;
• lungs;
• submandibular region;
• armpit area;

Each of these types of pathology indicates background disease. Often this cancer. The exact causes of the formation of such a pathological process can only be established after a complete diagnosis.

Abdominal lymphadenopathy

An increase in nodes in the abdominal cavity indicates an infectious or inflammatory disease. Less often, such a pathological process acts as a marker of an oncological or immunological disease. The symptoms, in this case, correspond to the points described above. In a child, the list can be added with the following symptoms:

• increased temperature at night;
• weakness and malaise;
• nausea.

Diagnosis, if damage to the abdominal cavity is suspected, begins with laboratory tests:

When diagnosing, special attention is paid to the patient’s medical history and age, since some ailments are unique to children.

Treatment

The main course of treatment for lesions of the abdominal cavity is aimed at localizing the pathological process and stopping the growth of the tumor. Therefore, chemotherapy and radiotherapy are used. At the end of the course, restorative therapy is prescribed to restore the immune system. If treatment of such a plan does not bring the desired results or a pathology of unknown pathogenesis develops, then surgical intervention- the affected lymph node is completely removed.

Lymphadenopathy of the breast

Enlarged lymph nodes of the mammary gland may indicate a dangerous cancer, including. Therefore, if you have such symptoms, you should immediately consult a doctor.

In this case, it is worth noting the nature of the tumor manifestation. If an increase in nodes is observed in the upper part of the mammary gland, then a benign formation can be assumed. However, almost any benign process can degenerate into a malignant tumor.

Enlarged nodes in the lower area of ​​the breast may indicate formation malignant process. You should consult a doctor immediately.

Enlarged lymph nodes in the area of ​​the mammary glands can be easily noticed visually. As a rule, the formation is noticed by the woman herself. Painful sensations not visible.

Any extraneous formation in the area of ​​the mammary glands of both women and men requires immediate examination by a specialized doctor to clarify the diagnosis and correct, timely treatment. The earlier the disease is detected, the greater the chance of a positive result. Especially with regard to intrathoracic pathological changes.

Mediastinal lymphadenopathy

Mediastinal lymphadenopathy, according to statistics, is diagnosed in 45% of patients. To understand what pathology is, it is necessary to clarify what the mediastinum is.

The mediastinum is an anatomical space that forms in the chest cavity. The mediastinum is closed in front by the chest, and in the back by the spine. On both sides of this formation there are pleural cavities.

Pathological enlargement of nodes in this area is divided into the following groups:

• primary enlarged lymph nodes;
• malignant tumors;
• damage to organs located in the mediastinum;
• pseudotumor formations.

The latter may be due to defects in the development of large vessels, severe viral and infectious diseases.

Symptoms

Mediastinal lymphadenopathy has a well-defined clinical picture. During the development of such a pathological process, the following symptoms are observed:

• sharp, intense pain in the chest area, which radiates to the neck and shoulder;
• dilated pupils or sunken eyes eyeball;
• hoarseness (more often observed during the chronic stage of development);
• headaches, noise in the head;
• heavy passage of food.

In some cases, bluishness of the face and swelling of the veins in the neck may be observed. If the disease has chronic stage development, then the clinical picture is more detailed:

• elevated temperature;
• weakness;
• swelling of the limbs;
• heart rhythm disturbance.

The child may experience shortness of breath and increased sweating, especially at night. If such symptoms appear, the child must be hospitalized immediately.

Pulmonary lymphadenopathy

Enlarged lymph nodes of the lungs signal a current underlying disease. In this case, the formation of metastases () is not excluded. But under no circumstances should you make such a diagnosis yourself, based on primary signs alone.

Simultaneously with the enlargement of the lymph nodes of the lungs, the same pathological process may form in the neck and mediastinum. The clinical picture is as follows:

• cough;
• pain when swallowing;
• labored breathing;
• increased temperature, especially at night;
• pain in the chest area.

Lung damage can be caused by severe infectious diseases and previous injuries. Smoking and excessive alcohol intake should also not be excluded.

Submandibular pathology

Submandibular lymphadenopathy is most often diagnosed in preschool children and adolescents. As shown medical practice, in most cases, such changes are temporary and do not pose a threat to the child’s life. But this does not mean that such symptoms should not be paid attention to. The cause of enlarged lymph nodes may be a dangerous oncological formation. Therefore, you should not postpone a visit to the therapist.

Axillary lymphadenopathy

The axillary type of pathology (axillary lymphadenopathy) can even develop due to a hand injury or an infectious disease. But inflammation of the axillary lymph nodes may indicate inflammation of the mammary gland. Therefore, you should not postpone a visit to the therapist.

As statistics show, it is the enlargement of lymph nodes in axillary area and in the mammary glands is the first sign of the appearance of metastases in the body of the mammary gland. If the disease is detected in a timely manner, then the chances of complete cure from breast cancer increase significantly.

Diagnostics

Diagnostic methods depend on the location of the pathology. To prescribe the correct course of treatment, it is necessary not only to make an accurate diagnosis, but also to identify the cause of the progression of the pathological process.

The standard procedure includes:

• UAC and OAM;
• tumor markers;
• radiography.

Since PAP is a kind of marker of another disease, the cause of the development of the disease should first be diagnosed.

Treatment

The choice of treatment method depends on the diagnosis. In addition, when prescribing a treatment plan, the doctor takes into account the following factors:

• individual characteristics of the patient;
• anamnesis;
• survey results.

Treatment folk remedies may be appropriate with the permission of a physician and only in tandem with drug therapy. Self-medication for such pathological processes is unacceptable.

Prevention

Unfortunately, there is no prevention of such manifestations as such. But, if you lead a correct lifestyle, monitor your health and consult a doctor in a timely manner, you can minimize the risk of progression of dangerous illnesses.

Robin Smithuis
Radiology department of the Rijnland Hospital in Leiderdorp, the Netherlands

This is an update of a 2007 article that used Mountain-Dresler regional lymph node division for lung cancer staging (MD-ATS cards) (1).
In order to reconcile the differences between the Naruke and MD-ATS classifications, in 2009 the International Association for the Study of Lung Cancer (IASLC) proposed a classification of regional lymph nodes.
This article provides illustrations and CT images to better understand this classification.

2009 IASLC Regional Lymph Node Classification

Supraclavicular lymph nodes
1 Lower cervical, supraclavicular and lymph nodes of the sternal notch (left and right).
They are located on both sides of the midline of the trachea in the lower third of the neck and supraclavicular areas, the upper border is the lower edge of the cricoid cartilage, the lower border is the clavicle and the jugular notch of the manubrium of the sternum.

Upper mediastinal lymph nodes 2-4
2L The left upper paratracheals are located along the left wall of the trachea, from the upper edge of the manubrium to the upper edge of the aortic arch.
2R The right upper paratracheal are located along the right wall of the trachea and in front from the trachea to its left wall, from the level of the upper edge of the manubrium of the sternum to the lower wall of the left brachiocephalic vein in the area of ​​intersection with the trachea.
3A Prevascular lymph nodes are not adjacent to the trachea like nodes of group 2, but are located anterior to the vessels (from back wall sternum, to the anterior wall of the superior vena cava on the right and the anterior wall of the left carotid artery left)
3P Prevertebral (Retrotracheal) are located in the posterior mediastinum, do not adjoin the trachea like group 2 nodes, but are localized posterior to the esophagus.
4R Lower paratracheal from the intersection of the lower edge of the brachiocephalic vein with the trachea to the lower border of the azygos vein, along the right wall of the trachea to its left wall.
4L Inferior paratracheal from the upper edge of the aortic arch to the upper edge of the left main pulmonary artery

Aortic lymph nodes 5-6
5. Subaortic lymph nodes are located in the aortopulmonary window, lateral to the ligament arteriosus; they are located not between the aorta and the pulmonary trunk, but lateral to them.
6. Para-aortic lymph nodes lie anterior and lateral to the ascending aortic arch

Lower mediastinal lymph nodes 7-9
7. Subcarinal lymph nodes.
8. Paraesophageal lymph nodes. Lymph nodes below the level of the carina.
9. Pulmonary ligament nodes. They lie within the pulmonary ligament.

Root, lobar and (sub) segmental lymph nodes 10-14
All these groups belong to N1 lymph nodes.
The nodes of the lung root are located along the main bronchus and the vessels of the lung root. On the right they extend from the lower edge of the azygos vein to the area of ​​division into the lobar bronchi, on the left - from the upper edge of the pulmonary artery.

Systematization of the lymph nodes of the lungs and mediastinum

1. Supraclavicular lymph nodes
This group includes the lower cervical, supraclavicular and lymph nodes of the sternal notch.
Superior border: inferior border of the cricoid cartilage.
Inferior border: clavicles and jugular notch of the manubrium of the sternum.
The midline of the trachea is the boundary between the right and left groups.

2R. Right superior paratracheal lymph nodes
They are located up to the left wall of the trachea.

Inferior edge: intersection of the lower edge of the brachiocephalic vein with the trachea.

2L. Left superior paratracheal lymph nodes
Superior border: the upper edge of the manubrium of the sternum.
Inferior edge: the upper edge of the aortic arch.

The image on the left shows 2 lymph nodes anterior to the trachea, that is, 2R, and a small prevascular lymph node of group 3A is also visible.

3. Right vascular and prevertebral lymph nodes
Lymph nodes of group 3 are not adjacent to the trachea, unlike lymph nodes of group 2.
They are divided into:
3A anterior to the vessels
3P behind the esophagus/prevertebral
They are not available with mediastinoscopy. 3P group can be accessed with transesophageal echocardiography.

In the image on the left there is a 3A nodule in the prevascular space. Also pay attention to the lower paratracheal nodes on the right belonging to group 4R.

4R. Right lower paratracheal lymph nodes
Upper border: intersection of the lower edge of the left brachiocephalic vein with the trachea.
Inferior border: the lower edge of the azygos vein.
4R nodes extend to the left edge of the trachea.

4L. Left lower paratracheal lymph nodes
4L nodes located to the left of the left wall of the trachea, between horizontal lines drawn tangent to the upper wall of the aortic arch and a line passing through the left main bronchus at the level of the upper edge of the upper lobe bronchus. They include paratracheal nodes located medially to the ligamentum arteriosus.
The nodes of group 5 (aortopulmonary window) are located outside the arterial ligament.

The image on the left is above the level of the carina. There are 4L nodes to the left of the trachea. Note that they are located between the pulmonary trunk and the aorta, but not in the aortopulmonary window, because they lie medial to the ligamentum arteriosus. Lymph nodes lateral to the pulmonary trunk belong to group 5.

5. Subaortic lymph nodes
The subaortic or aortopulmonary window is located lateral to the ligamentum arteriosus and proximal to the first branch of the left pulmonary artery and lies within the mediastinal pleura.

6. Para-aortic lymph nodes
The para-aortic lymph nodes lie anterior and lateral to the ascending aorta and between the superior and inferior edges of the aortic arch.

7. Subcarinal lymph nodes
These lymph nodes are located below the level of the tracheal bifurcation (carina), but do not belong to the lower lobe bronchus and artery. On the right, they are located caudal to the lower wall of the intermediate bronchus. On the left, they are located caudal to the upper wall of the lower lobe bronchus.
On the left is the group 7 lymph node to the right of the esophagus.

8. Paraesophageal lymph nodes
These lymph nodes are inferior to the subcarinal lymph nodes and extend caudally to the diaphragm.
In the image on the left, below the level of the carina, a group 8 lymph node is indicated to the right of the esophagus.

The PET image on the left shows the accumulation of 18P-deoxyglucose in the group 8 node. The corresponding CT image shows that this lymph node (blue arrow) is not enlarged. The probability that there is metastatic lesion of this node is extremely high, since the specificity of PET is higher than measuring the size of lymph nodes.

9. lymph nodes of the pulmonary ligament
These lymph nodes lie within the pulmonary ligament, including along the lower pulmonary vein. The pulmonary ligament is represented by a duplication of the mediastinal pleura covering the root of the lung.

10. lymph nodes of the lung root
The lymph nodes of the root are located proximal to the lobar nodes, but distal to the mediastinal duplication and nodes of the intermediate bronchus on the right.
All lymph nodes of groups 10-14 are N1 nodes, since they are located outside the mediastinum.

Groups of lymph nodes on axial computed tomograms

1. lymph nodes of the sternal notch are visible only at this level and above it
2. upper paratracheal lymph nodes: below the clavicles, on the right above the intersection of the lower edge of the left brachiocephalic trunk and trachea, and on the left above the aortic arch
3. Prevascular and retrotracheal: anterior to the vessels (3A) and prevertebral (3P)
4. Lower paratracheal: below the upper edge of the aortic arch to the level of the main bronchus
5. Subaortic (aortopulmonary window): lymph nodes lateral to the ligament arteriosus or lateral to the aorta or left pulmonary artery.
6. Para-aortic: nodes lying anterior and outward from the ascending aorta and the aortic arch under top edge aortic arch.
7. Subcarinal lymph nodes.
8. Paraesophageal lymph nodes (below the carina).
9. Lymph nodes of the pulmonary ligament: lie within the pulmonary ligament.
10-14 lymph nodes N1

Mediastinoscopy and transesophageal ultrasound
Lymph nodes available for biopsy during mediastinoscopy: upper paratracheal nodes of groups 2L and 2R, right and left lower paratracheal lymph nodes of groups 4R and 4L, subcarinal lymph nodes of group 7. Group 1 is located above the suprasternal notch and is not accessible during routine mediastinoscopy.

Extended mediastinoscopy
Tumors of the left upper lobe can metastasize to the subaortic (group 5) and para-aortic lymph nodes (group 6). These nodes are not available for biopsy during routine mediastinoscopy. Extended mediastinoscopy is an alternative to parasternal mediastinotomy. This procedure is used less frequently due to more high risk complications.

Fine needle aspiration biopsy under ultrasound control
Can be used for all lymph nodes accessible by ultrasound imaging from the esophagus. In particular, access to the lymph nodes of the lower mediastinum (groups 7-9) is provided. In addition, with this type of study, the left lobe of the liver and the left adrenal gland are available for visualization.

Last update: 04/01/2016

Literature

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3. Conventional mediastinoscopy by Paul De Leyn and Toni Lerut. in the Multimedia Manual of Cardiothoracic Surgery
4. Christian Lloyd, Gerard A.Silvestri, Gerard A.Silvestri. Mediastinal Staging of Non Small-Cell Lung Cancer
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