The IASLC Lymph Node Map - Society of Thoracic Radiology

The IASLC Lymph Node Map 

Ahmed H. El-Sherief, MD 

Th The IASLC Lymph L h Node N d Map: M 

Ahmed H El-Sherief, MD 

Staff, ff, Section of f Thoracic Imaging g g 

Cleveland Clinic 

Evolution of Thoracic Lymph Node Maps 

First lymph node map developed by Naruke in the 1960s, was widely used in 

North America America, Europe Europe, and Japan 

In the 1980s/1990s subsequent attempts to refine the anatomic descriptors of the 

NNaruke k map lled d ttoth the ddevelopment l t of f ttwo notable t bl NNorth thAAmerican i llymph h 

node maps: 

A schema advocated byy the American Thoracic Society y( (ATS) ) 

A schema advocated by the American Joint Committee of Cancer (AJCC)- an 

adaptation of the Naruke lymph node map 

In 1996, the so-called Mountain-Dressler modification of the ATS-map (MD-ATS) 

was developed which attempted to unify the ATS and AJCC schemas into a 

single map 

MD-ATS was fully accepted across North America but was only sporadically 

used in Europe 

Japan continued to use the Naruke lymph node map 

1960s 1980s 1990s 2000s 

IASLC Lymph Node Map 

To reconcile the differences between the Naruke and MD-ATS lymph node maps, the 

International Association for the Study of Lung Cancer (IASLC) developed a 

revised lymph node map 

Notable changes included the following: 

1. Anatomically distinct descriptions provided for all lymph node stations, 

with the upper and lower anatomic borders described in particular 

ddetail t il 

2. The boundary between right and left sided level 2 and level 4 nodes is 

reset to the left lateral wall of the trachea due to lymphatic drainage 

patterns 

3. Supraclavicular and sternal notch lymph nodes, which are not 

previously considered to constitute a lymph node station station, are now 

categorized as level 1 nodes 

4. Certain lymph nodes stations are grouped into zones for future 

prognostic ti analyses l and d ddo not t represent t current t standard t d d 

nomenclature 

Learning Objectives 

After this lecture you will be able to: 

Accurately define and label thoracic lymph nodes to conform to the new 

IASLC lymph node map 

Recognize the differences between the new IASLC lymph node map and 

old MD-ATS MD ATS lymph node map 

Recognize size criteria and pitfalls associated with each lymph node 

station 

Understand thoracic lymph node drainage patterns in lung cancer 

Evolution of Thoracic Lymph Node Maps 

Therefore in the 1990s and for the first decade of the 2000s, two different 

thoracic lymph node maps were commonly being used: 

Naruke lymph node map 

MD-ATS lymph node map 

Important differences in the descriptors of mediastinal lymph nodes existed 

between the Naruke and MD-ATS MD ATS lymph node maps 

Most significant discrepancy was that level 7 subcarinal lymph nodes in the 

MD-ATS map corresponded to levels 7 and 10 in the Naruke map 

As a result, some tumors staged as N2 according to the MD-ATS map, 

were staged N1 by the Naruke map 

correspond to 

correspond correspond to 

correspond to 

An adaptation of the IASLC Lymph Node Map 

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IASLC Lymph Node Map Map- Anatomic Descriptors and Numerical Levels 

Upper Paratracheal Lymph Nodes (Station 2) 

Right Upper Paratracheal Lymph Nodes 

(Station 2R) 

Superior p extent: 

Upper border of the manubrium 

Inferior extent: 

Intersection of caudal margin of 

left innominate vein with the 

ttrachea h 

Left lateral extent: 

Left lateral border of the trachea 

Left Upper Paratracheal Lymph Nodes 

(Station 2L) 




Superior border of the aortic arch 

Right lateral extent: 

LLeft ft llateral t l bborder d of f th the ttrachea h 


Prevascular and Retrotracheal Lymph Nodes 

(Stations 3a and 3p) 

Prevascular Lymph Nodes 

(Station 3a) 

Superior extent: 



Carina 

Anterior extent: 

Posterior aspect of the sternum 

Posterior extent: 

On the right: anterior border of the SVC 

OOn th the lleft: ft lleft ft common carotid tid artery t 

Retrotracheal Lymph Nodes 

(Station 3p) 


Apex of chest 


Carina 

Anterior extent: 

Posterior aspect of the trachea 


Subaortic Lymph Nodes (aka: AP Window) 

(Station 5) 

Lymph nodes lateral to ligamentum 

arteriosum 


Lower border of aortic arch 


Upper rim of left main pulmonary 

artery t 

Paraaortic Lymph nodes 

(Station 6) 

Lymph nodes anterior and lateral to 

ascending aorta and aortic arch 


Line tangential to the upper border 

of the aortic arch 


Th The lower l border b d of f the th aortic ti arch h 


Lower Paratracheal Lymph Nodes (Station 4) 

Right Lower Paratracheal Lymph Nodes 

(Station 4R) 


Intersection of caudal margin of left 

innominate vein with the trachea 


Lower border of the azygous vein 

LLeft ft llateral t l extent: t t 

Left lateral border of the trachea 

Left Lower Paratracheal Lymph Nodes 

(Station 4L) 


Superior p border of the aortic arch 


Upper rim of the left main pulmonary 

artery 

Right lateral extent: 

LLeft ft llateral t l bborder d of f th the ttrachea h 


Subaortic Lymph Nodes (aka: AP Window) 

(Station 5) 

Lymph nodes lateral to ligamentum 

arteriosum 


Lower border of aortic arch 


Upper rim of left main pulmonary 

artery t 

Paraaortic Lymph nodes 

(Station 6) 

Lymph nodes anterior and lateral to 

ascending aorta and aortic arch 


Line tangential to the upper border 

of the aortic arch 


Th The lower l border b d of f the th aortic ti arch h 


Subcarinal Lymph Nodes 

(Station 7) 


Upper border of the carina 


On the right: lower border of the 

bronchus intermedius 

On the left: upper border of the 

left lower lobe bronchus 

* *


Paraesophageal Lymph Nodes 

(Station 8) 

Lymph nodes lying adjacent to the wall of 

the esophagus, and to the right or left of the 

midline (excluding subcarinal lymph nodes) 


On the right: Lower border of the 

bronchus intermedius 

On the left: Upper border of the left 

lower lobe bronchus 


Diaphragm 

Pulmonary ligament Lymph Nodes 

(Station 9) 

Lymph nodes lying within the pulmonary 

ligament 


Inferior pulmonary vein 


Diaphragm 


Hilar Lymph Nodes 

(Station 10) 

Includes lymph nodes immediately adjacent 

to the mainstem bronchus including 

proximal p pportions of the pulmonary p y veins 

and main pulmonary artery 

Right Hilar Lymph Nodes 

(Station 10R) 


Lower rim of the azygous vein 


Interlobar region 

Left Hilar Lymph Nodes 

(Station ( 10L) ) 


Upper rim of the pulmonary artery 


IInterlobar t l b region i 

IASLC Lymph Node Map Map- Drainage of Thoracic Lymph Nodes (Pulmonary Lymph Nodes) 

Pulmonary Lymph Nodes 

Hilar (10) 

Intrapulmonary 

Interlobar (11) 

Lobar (12) ( ) 

Segmental (13) 

Subsegmental (14) 

CCommon ddrainage i pathway: th 

Lobar LNs -> Interlobar/Hilar LNs -> Subcarinal 

LN/or directly to Lower paratracheal LNs 


Low Cervical, Supraclavicular, and Sternal 

Notch Lymph Nodes 

(St (Station ti 1) 

Right Low Cervical, Supraclavicular, and Sternal Notch Lymph Nodes 

(Station 1R) 


Lower margin of the cricoid 

cartilage 


Clavicles bilaterally 

Manubrium (in the midline) 

Left lateral margin 

Midline of the trachea 

Left Low Cervical, Supraclavicular, and Sternal Notch Lymph Nodes 

(Station 1L) 


Lower margin of the cricoid 

cartilage 


Clavicles bilaterally 

Manubrium (in the midline) 

Right lateral margin 

Midline of the trachea 


Interlobar Lymph Nodes 

(Station 11) 

Includes lymph nodes between the origin of the lobar 

bronchi, on the right classified into two groups (11s and 

11i) 

Station 11s: between the upper lobe bronchus and 

bronchus intermedius on the right 

Station 11i: between the middle and lower lobe bronchi on 

the right 

Lobar Lymph Nodes 

(Station 12) 

IIncludes l d llymphh nodes d adjacent dj t tto llobar b bbronchi hi 

Segmental Lymph Nodes 

(Station 13) 

Includes lymph nodes adjacent to segmental bronchi 

Subsegmental Lymph Nodes 

(Station 14) 

Includes lymph nodes adjacent to subsegmental bronchi 

IASLC Lymph Node Map Map- Drainage of Thoracic Lymph Nodes (Mediastinal Lymph Nodes) 

Mediastinal Lymph Nodes 

Paratracheal and Tracheobronchial Group 

Upper Paratracheal (2R, 2L) 

Lower Paratracheal (3R, 3L) 

Sub-aortic/AP Window (5) ( ) 

Subcarinal (7) 

Afferent drainage from: 

L Lungs/bronchi /b hi 

Thoracic trachea 

Heart 

Upper paraesophageal lymph nodes 

Common drainage pathways: 

1. Lower paratracheal p LNs -> upper pp 

paratracheal LNs-> lower cervical LNs 

2. Hilar LNs -> subcarinal -> paratracheal (R>L) 

(therefore, LLL tumor is the most common site 

ffor contralateral t l t l mediastinal di ti l llymph h node d 

metastasis in lung cancer) 

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IASLC Lymph Node Map Map- Drainage of Thoracic Lymph Nodes (Mediastinal Lymph Node Group) 


Anterior Mediastinal Group 

Prevascular (3A) 

Paraaortic(6) 


Thymus 

Thyroid 

HHeart/pericardium t/ i di 

Diaphragmatic/Mediastinal pleura 

Middle diagphragmatic lymph nodes 

Efferent drainage to: 

Right and left bronchomediastinal trunks -> right 

lymphatic duct, thoracic duct, independently into 

the jugulo-subclavian venous confluence 

IASLC Lymph Node Map Map- Patterns of Lymph Node Involvement in Lung Cancer 

Lymph node metastasis according to location of primary tumor 

RUL lung cancer 

Pulmonary lymph nodes 

Right Hilar (10) 

Right Intrapulmonary (11- 

14) 

MMediastinal di i l llymph h nodes d 

Right paratracheal (4) 

Anterior mediastinal (3) 

RML/RLL lung cancer 


Right Hilar (10) 

Right Intrapulmonary (11- 

14) 

Mediastinal lymph nodes 





LLL lung cancer 


Left Hilar (10) 

Left Intrapulmonary (11-14) 



Left paratracheal (4) 


IASLC Lymph Node Map Map- Drainage of Thoracic Lymph Nodes (Mediastinal Lymph Node Group) 


Posterior Mediastinal Group 

Paraesophageal (8) 

Pulmonary ligament(9) 

Paraesophageal LNs 


Thoracic esophagus 

PPosterior t i pericardium i di 

Diaphragm 

Posterior diaphragmatic lymph nodes 

Left hepatic lobe 

Pulmonary ligaments LNs 


Basilar segments of the lower lobes and lower half 

of the esophagus p g 

Efferent drainage to: 

Tracheobronchial group (esp: subcarinal) 

Th Thoracic i dduct t 

Subdiaphragmatic para-aortic/celiac nodes 



LUL lung cancer (excluding lingular 

segment) g t) 





Subaortic (5) 

Paraaortic (6) 

LUL lung cancer (lingular segment) 






Subaortic (5) 

Paraaortic (6) 

IASLC Lymph Node Map Map- Size Criteria and Common Pitfalls 

Size Criteria 

Lymph nodes measuring 10 10-mm mm or more in the 

short axis are considered significant in size and 

suspicious for metastatic disease, although the 

predictive p accuracy y 

of this criterion is limited 

Lower paratracheal and subcarinal can measure up to 11- 

mm 

Upper paratracheal are generally small and measure up 

to to 7 77-mm mm 

Right hilar LNs can measure up to 10 10-mm mm 

Left hilar LNs can measures up to 77-mm 

mm 

Paraesophageal Paraesophageal LNs can measure up to to 7 77-10 

10 10-mm mm 

Peridiaphragmatic LNs can measure up to 5-mm 5 mm 

No size criteria for internal mammary, retrocrural, and 

extrapleural nodes, and detection of these nodes should 

be considered abnormal 

Comparison studies to evaluate for new or 

enlarging lymph nodes (even if the lymph nodes 

are less than 1 cm in short axis diameter) ) are 

helpful in evaluating for metastatic disease


Common Pitfalls 

Pericardial recesses/sinuses are often 

mistaken for lymph nodes 

For example: p 

Superior aortic recess (and its “high 

riding” variant): 

Oft Often confused f d ffor paratracheal, t h l 

paraaortic, prevascular, or subaortic 

lymph nodes 

Oblique sinus: 

Often confused for subcarinal 

lymph nodes 

Pulmonaryy venous recesses: 

Often confused for pulmonary 

lymph nodes 

Miscellaneous Thoracic Lymph Nodes 

Axillary Lymph Nodes 

4 Groups 

Anterior group: lie deep to pectoralis 

major 

Lateral group: g p lie on the lateral wall of 

the axilla 

Posterior group: lie to the lateral edge of 

the subscapularis muscle on the 

posterior wall of the axilla 

AApical i l group: lie li att th the apex of f th the axilla ill 

immediately behind the clavicle 

Internal Mammary Lymph Nodes 

Located at the anterior ends of the intercostal 

spaces, along the internal mammary (internal 

th thoracic) i ) vessels l 

Posterior Intercostal Lymph Nodes 

Located near the heads and necks of the 

posterior ribs 

* 

* 

* 

* 

* 

* * 


Common Pitfalls 

Pericardial recesses/sinuses are often 

mistaken for lymph nodes 

For example: p 

Superior aortic recess (and its “high 

riding” variant): 

Oft Often confused f d ffor paratracheal, t h l 

paraaortic, prevascular, or subaortic 

lymph nodes 

Oblique sinus: 

Often confused for subcarinal 

lymph nodes 

Pulmonaryy venous recesses: 

Often confused for pulmonary 

lymph nodes 

Miscellaneous Thoracic Lymph Nodes 

Diaphragmatic Lymph Nodes 

3 Groups 

Anterior (aka: cardiophrenic) 

Located anterior to the 

pericardium, p ,p posterior to the 

xiphoid process, and in the right 

and left cardiophrenic fat 

Middle (aka: juxtraphrenic, lateral) 

LLocated t d llateral t l ttoth the iintrathoracic t th i 

end 

of the IVC 

Posterior (aka: retrocrural) 

Located behind the diaphragmatic 

crura and anterior the spine 

Posterior Intercostal Lymph Nodes 

Located near the heads and necks of the 

posterior ribs 

References Author Correspondence Information 

Ahmed H El-Sherief, MD ahelsherief@gmail.com 

Section of Thoracic Imaging 

Imaging Institute 

Cl Cleveland l d Cli Clinic i 

* 

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The IASLC Lymph Node Map - Society of Thoracic Radiology

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