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Lymph Nodes of the Thorax and Abdomen

Contents

Introduction

Lymph nodes are important structures of the lymphatic system of the thorax and abdomen. They are small, oval or kidney-shaped encapsulated centres of antigen presentation and lymphocyte activation, differentiation and proliferation. They vary in size from 0.1 to 2.5 cm in length. Lymph nodes generate mature, antigen-primed, B and T cells, and filter particles, including microbes, from the lymph by the action of numerous phagocytic macrophages.

A normal young adult body contains up to 450 lymph nodes, of which 60-70 are found in the head and neck, 100 in the thorax and as many as 250 in the abdomen and pelvis. Lymph nodes are particularly numerous in the neck, mediastinum, posterior abdominal wall, abdominal mesenteries, pelvis and proximal regions of the limbs (axillary and inguinal lymph nodes). By far the greatest number lie close to the viscera, especially in the abdominal mesenteries.

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Thoracic Nodes

The lymph nodes of the thorax may broadly be divided into parietal and visceral regions — the former being situated in the thoracic wall, the latter in relation to the viscera. Those forming the parietal group include the axillary nodes, subscapular nodes, pectoral nodes, parasternal nodes, intercostal nodes, and diaphragmatic nodes. Lymph from the thoracic visceral nodes or deep tissues of the thorax drain ultimately into the diaphragmatic, intercostal or parasternal lymph nodes.

Parasternal Lymph Nodes

This is also referred to as the internal thoracic nodes. There are 4 or 5 parasternal nodes along each internal thoracic artery, at the anterior ends of the intercostal spaces. They drain afferents from the breast, deeper structures of the supra-umbilical anterior abdominal wall, the superior hepatic surface (through a small group of nodes behind the xiphoid process), and deeper parts of the anterior thoracic wall.

Parasternal lymph nodes - ventral view

Their efferents usually unite with those from the tracheobronchial and brachiocephalic nodes to form the bronchomediastinal trunk. The later may open, on either side, directly into the jugulo-subclavian junction. Alternatively, it may open into either the great vein near the junction or may join the right subclavian trunk or right lymphatic duct. It can also join the thoracic duct on the left.

Intercostal Lymph Nodes

The intercostal nodes occupy the intercostal spaces near the heads and necks of the ribs. They receive the deep lymph vessels from the posterolateral aspects of the chest and the breast, some of which are interrupted by small lateral intercostal nodes. Efferents of nodes in the lower 4 – 7 intercostal spaces unite into a trunk that descends to the abdominal confluence of lymph trunks or to the start of the thoracic duct. Efferents of nodes in the left upper spaces end in the thoracic duct, while those of the right upper spaces end in one of the right lymph trunks.

Intercostal lymph nodes - lateral-left view

Diaphragmatic Lymph Nodes

This group of nodes is located on the thoracic surface of the diaphragm. They are arranged in anterior, lateral (right and left), and posterior groups.

  • Anterior group: this group consists of two or three small nodes behind the base of the xiphoid process, draining the convex hepatic surface, and one or two nodes on each side near the junction of the 7th rib and cartilage, which receive anterior lymph vessels from the diaphragm. The anterior group drains to the parasternal nodes.
  • Lateral group: the lateral group each contain two or three nodes, and lie close to the point where the phrenic nerves enter the diaphragm. On the right, some nodes lie within the fibrous pericardium anterior to the intra-thoracic end of the inferior vena cava. Their afferents drain the central diaphragm, while those on the right also drain the convex surface of the liver. Their efferents pass to the posterior mediastinal, parasternal and brachiocephalic nodes.
  • Posterior group: the posterior group consists of a few nodes that lie on the posterior aspect of the crura and connects with the lateral aortic and posterior mediastinal nodes.

The visceral lymph nodes drain deeper structures of the thorax and muscles attached to the ribs. They empty lymph from these structures into the intercostal, parasternal and the axillary nodes. Some of the most important nodes draining the thoracic viscera include the brachiocephalic node and tracheobronchial nodes which return lymph from the lungs and heart.

Tracheobronchial lymph nodes - lateral-left view

Axillary Lymph Nodes

Groups

The axillary nodes receive more than 75% of the lymph from the breast. There are 20-40 nodes arranged in five principal groups: pectoral, subscapular, humeral, central, and apical. The groups are arranged in a manner that reflects the pyramidal shape of the axilla. Three groups of axillary nodes are related to the triangular base and one group is located at each corner of the pyramid. The fibrofatty connective tissue of the axilla (axillary fat) also contains many lymph nodes.

  • Pectoral group: the pectoral (anterior) nodes consist of three to five nodes that lie along the medial wall of the axilla, around the lateral thoracic vein and the inferior border of the pectoralis minor. The pectoral nodes receive lymph mainly from the anterior thoracic wall, including most of the breast (especially the superolateral {upper outer} quadrant and subareolar plexus).

Pectoral axillary lymph nodes - ventral view

  • Subscapular group: the subscapular (posterior) nodes consist of six or seven nodes that lie along the posterior axillary fold and subscapular blood vessels. These nodes receive lymph from the posterior aspect of the thoracic wall and scapular region.

Subscapular axillary lymph nodes - ventral view

  • Humeral group: the humeral (lateral) nodes consist of four to six nodes that lie along the lateral wall of the axilla, medial and posterior to the axillary vein. These nodes receive nearly all the lymph from the upper limb, except that carried by the lymphatic vessels accompanying the cephalic vein. The latter nodes primarily drain directly to the apical and infraclavicular nodes.
  • Central group: the central nodes are three or four large nodes situated deep to the pectoralis minor near the base of the axilla, in association with the second part of the axillary artery.

Central axillary lymph nodes - ventral view

  • Apical group: the apical nodes are located at the apex of the axilla along the medial side of the axillary vein and the first part of the axillary artery. They receive lymph from all other groups of the axillary lymph nodes as well as from lymphatics accompanying the proximal cephalic vein.

Apical axillary lymph nodes - ventral view

Surgically, the nodes are described in relation to pectoralis minor. Those lying below pectoralis minor are the low nodes (level 1), those behind the muscle are the middle group (level 2), while the nodes between the upper border of the clavicle are the upper or apical nodes (level 3). There may be one or two other nodes between the pectoralis minor and major; this interpectoral group of nodes are also known as Rotter’s nodes.

Drainage

Efferent vessels directly from the breast pass around the anterior axillary border through the axillary fascia to the pectoral lymph nodes. Some pass directly to the subscapular nodes. A few vessels pass from the superior part of the breast to the apical axillary nodes, sometimes interrupted by the infraclavicular nodes or by small, inconstant, interpectoral nodes. Most of the remainder drains to the parasternal nodes from the medial and lateral part of the breast. They accompany perforating branches of the internal thoracic artery. Lymphatic vessels occasionally follow lateral cutaneous branches of the posterior intercostal arteries to the intercostal nodes.

Efferent lymphatic vessels from the pectoral, subscapular and humeral groups pass to the central nodes. In turn, efferent vessels from the central nodes pass to the apical ones. Subsequently, vessels from the apical group of nodes traverse the cervicoaxillary canal. These efferent vessels ultimately unite to form the subclavian lymphatic trunk, although some vessels may drain en route through the clavicular (infraclavicular and supraclavicular) nodes. Once formed, the subclavian trunk may be joined by the jugular and bronchomediastinal trunks on the right side to form the right lymphatic duct, or it may enter the right venous angle independently. On the left side, the subclavian trunk most commonly joins the thoracic duct.

Abdominal Lymph Nodes

Superficial group

The abdominal lymphatic nodes are also arranged into superficial and deep groups. The superficial group primarily drains the abdominal wall. The deep group returns lymph from the abdominal viscera and are usually associated and named according to such viscera.

Superficial lymphatic vessels accompany the subcutaneous blood vessels. Vessels from the lumbar and gluteal regions run with the superficial circumflex iliac vessels. Those from the infra-umbilical skin run with the superficial epigastric vessels. Both drain into the superficial inguinal lymph nodes. The supra-umbilical region is drained by vessels running obliquely up to the pectoral and subscapular axillary nodes, and there is some drainage to the parasternal nodes.

Deep group

The deep lymphatic vessels of the abdomen accompany the deep arteries. The vessels from the posterior portion of the abdominal wall pass with the lumbar arteries to drain into the lateral aortic and retro-aortic nodes. Vessels from the upper anterior abdominal wall run with the superior epigastric vessels to the parasternal nodes. Vessels of the lower abdominal wall drain into the circumflex iliac, inferior epigastric and external iliac nodes. Furthermore, the lymphatic drainage of the abdominal viscera occurs almost exclusively through the cisterna chyli and the thoracic duct.

Some lymphatic drainage may occur across the diaphragm from the bare area of the liver and the uppermost retro-peritoneal tissues, but this is probably of little clinical consequence other than during obstruction of the thoracic duct. The lymph nodes of the retro-peritoneal tissues lie around the abdominal aorta and form pre-aortic, lateral aortic and the retro-aortic groups. Collectively, they are referred to as the para-aortic lymph nodes and clinically it is difficult to distinguish between them, either at operation or on cross sectional imaging.

Pre-aortic Group of Lymph Nodes

The pre-aortic groups tend to lie around the origins of the anterior (visceral) arteries and receive lymph from the gastrointestinal tract and its accessory structures (liver, spleen, pancreas) from the abdominal oesophagus to the level of the anus. They give rise to lymphatic vessels, which drain upwards to form the intestinal trunks that enter the abdominal confluence of lymph trunks. They are divisible into coeliac, superior mesenteric and inferior mesenteric groups, being near the origins of these arteries.

Preaortic lymph nodes - ventral view

Coeliac Lymph Nodes

The coeliac nodes lie anterior to the abdominal aorta around the origin of the coeliac artery. They are a terminal group and receive lymph draining from the regional lymph nodes around the branches of the coeliac artery (left gastric, hepatic and pancreaticosplenic nodes) and from the lower pre-aortic groups (the superior mesenteric and inferior mesenteric). The coeliac nodes give rise to the right and left intestinal lymph trunks.

Celiac lymph nodes - ventral view

  • Gastric Lymph Nodes: There are numerous gastric lymph node groups. They drain the stomach, upper duodenum, abdominal oesophagus and the greater omentum into the coeliac group.
  • Hepatic Lymph Nodes: The hepatic nodes extend in the lesser omentum along the hepatic arteries and bile duct. They vary in number and site, but almost always occur at the junction of the cystic and common hepatic ducts (the cystic node), alongside the upper common bile duct and in the anterior border of the epiploic foramen. Hepatic nodes drain the majority of the liver, gallbladder and bile ducts, but also receive drainage from some parts of the stomach, duodenum and pancreas. They drain into the coeliac nodes and thence to the intestinal trunks.
  • Pancreaticosplenic Lymph Nodes: The pancreaticosplenic nodes drain the spleen, pancreas and parts of the stomach into the coeliac nodes.

Superior Mesenteric and Inferior Mesenteric Lymph Nodes

These nodes lie anterior to the aorta near the origin of their respective arteries. The superior and inferior mesenteric nodes are preterminal groups of the alimentary canal from the duodenojejunal flexure to the upper anal canal. They collect lymph from the outlying groups, including the mesenteric, ileocolic, colonic and pararectal nodes and drain into the coeliac nodes.

Superior mesenteric lymph nodes - ventral view

Lateral Aortic Group of Lymph Nodes

The lateral aortic nodes lie on either side of the abdominal aorta anterior to the medial margins of psoas major, diaphragmatic crura and sympathetic trunks. On the right, some nodes lie lateral and anterior to the inferior vena cava near the end of the right renal vein. Nodes rarely lie between the aorta and inferior vena cava where they are closely related.

The lateral aortic nodes drain the viscera and other structures supplied by the lateral and dorsal aortic branches. The upper lateral groups receive the lymph drainage directly from the suprarenal glands, kidneys, ureters, gonads, uterine tubes and upper uterus. They also receive lymph directly from the deeper tissues of the posterior abdominal wall. The lateral aortic group drains into the two lumbar lymph trunks, one on each side, which terminate in the confluence of lymph trunks. A few vessels may pass to the pre-aotic and retro-aortic nodes, while others cross the midline to flow into the contralateral nodes, forming a loose plexus.

Left lateral aortic lymph nodes - ventral view

Retro-aortic Group of Lymph Nodes

This is the smallest of all the para-aortic lymph nodes and has no particular areas of drainage, although it may receive some lymph directly from the paraspinal posterior abdominal wall. Retro-aortic nodes are effectively peripheral nodes of the lateral aortic groups and provide interconnections between surrounding groups.

Retroaortic lymph nodes - ventral view

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Show references

References:

  • K. L. Moore and A. F. Dalley: Clinically oriented anatomy, 5th edition, (2006), p. 131, 171, 210, 254 -257, 342, 772-773.
  • Last's Anatomy (Regional and Applied), 9th Edition, (2014), p. 362, 69, 71, 328 – 329, 279, 522.
  • Healthline: Thoracic lymph nodes. (accessed 04/09/2015).
  • S. Standring: Gray’s Anatomy: The Anatomical Basis of Clinical Practice, 40th edition, (2008), p.1077-1078, 1059, 982, 932, 928.

Author, Review and Layout:

  • Onome Okpe
  • Ryan Sixtus
  • Catarina Chaves

Illustrators:

  • Parasternal lymph nodes - ventral view - Samantha Zimmerman
  • Intercostal lymph nodes - lateral-left view - Irina Münstermann
  • Tracheobronchial lymph nodes - lateral-left view - Irina Münstermann
  • Pectoral axillary lymph nodes - ventral view - Samantha Zimmerman
  • Subscapular axillary lymph nodes - ventral view - Samantha Zimmerman
  • Central axillary lymph nodes - ventral view - Samantha Zimmerman
  • Apical axillary lymph nodes - ventral view - Samantha Zimmerman
  • Preaortic lymph nodes - ventral view - Esther Gollan
  • Celiac lymph nodes - ventral view - Begoña Rodriguez
  • Superior mesenteric lymph nodes - ventral view - Esther Gollan
  • Left lateral aortic lymph nodes - ventral view - Irina Münstermann
  • Retroaortic lymph nodes - ventral view - Irina Münstermann
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