Where are the thoracic and mediastinal lymph nodes located. How do lymph node maps aid in bronchoscopic procedures. What are the benefits of virtual bronchoscopic navigation systems for lymph node localization. How does Wang’s lymph node map differ from the IASLC map. Which lymph node stations are most important for clinical diagnosis and staging.

Understanding Thoracic and Mediastinal Lymph Node Anatomy

Thoracic and mediastinal lymph nodes play a crucial role in the diagnosis and staging of various chest diseases, particularly lung cancer. A comprehensive understanding of their anatomical locations and relationships to surrounding structures is essential for accurate diagnosis and effective treatment planning.

The lymphatic system in the chest consists of a complex network of nodes and vessels that drain lymph from the lungs, heart, and surrounding tissues. These nodes are strategically positioned throughout the chest cavity and are typically grouped into stations based on their anatomical location.

Key Lymph Node Stations in the Chest

• Hilar lymph nodes
• Subcarinal lymph nodes
• Paratracheal lymph nodes
• Aortopulmonary window lymph nodes
• Mediastinal lymph nodes

Each of these stations has specific anatomical landmarks that help in their identification during imaging studies and bronchoscopic procedures. For instance, the subcarinal lymph nodes are located below the carina, where the trachea divides into the left and right main bronchi.

Lymph Node Mapping Systems: IASLC vs. Wang’s Map

Two primary lymph node mapping systems are used in clinical practice: the International Association for the Study of Lung Cancer (IASLC) lymph node map and Wang’s lymph node map. These systems provide a standardized approach to describing and locating lymph nodes in the chest.

IASLC Lymph Node Map

The IASLC map, introduced in its eighth edition in 2009, defines lymph node stations primarily based on the positions of blood vessels. This system is widely used for cancer staging and research purposes. However, it can be challenging to use during bronchoscopy without ultrasound guidance, as blood vessels are not easily visible through the bronchoscope.

Wang’s Lymph Node Map

Proposed in 1994, Wang’s map uses airway landmarks visible during bronchoscopy to locate target lymph nodes. This approach is more practical for bronchoscopists, as it relies on structures that can be directly visualized during the procedure. Wang’s map includes 11 lymph node stations, each with specific anatomical descriptions and recommended puncture sites for transbronchial needle aspiration (TBNA).

The choice between these mapping systems often depends on the clinical context and the specific procedure being performed. For bronchoscopic procedures, Wang’s map may offer advantages in terms of ease of use and practicality.

Advanced Techniques for Lymph Node Localization

As technology advances, new methods for lymph node localization have emerged, improving the accuracy and safety of diagnostic procedures. These techniques aim to provide better visualization and guidance for bronchoscopists during TBNA and other interventional procedures.

Electromagnetic Navigation Bronchoscopy (ENB)

ENB uses electromagnetic fields to create a three-dimensional map of the patient’s airways and guide the bronchoscope to the target lesion. This technology has shown improved diagnostic accuracy for both peripheral pulmonary lesions and mediastinal lymph nodes. However, ENB requires specialized equipment and training, limiting its availability to select medical centers.

Virtual Bronchoscopic Navigation (VBN)

VBN systems use CT imaging data to create a virtual 3D model of the patient’s airways. This allows bronchoscopists to plan and simulate the procedure before performing it, potentially improving accuracy and reducing procedure time. VBN has shown promising results in diagnosing peripheral pulmonary lesions, with reported diagnostic yields ranging from 62.5% to 81.6% when combined with other techniques.

Multi-Dimensional Display of Wang’s Lymph Node Map

Recent advancements in virtual bronchoscopic navigation systems have led to the development of multi-dimensional displays of Wang’s lymph node map. This innovative approach combines virtual extrabronchial and endobronchial views with cross-sectional CT images to provide a comprehensive visualization of mediastinal and hilar lymph nodes.

Key Features of the Multi-Dimensional Display

• 3D reconstruction of lymph node stations
• Virtual extrabronchial perspective
• Endobronchial view
• Horizontal, coronal, and sagittal CT views
• Color-coded markers for lymph node locations

This multi-dimensional approach allows clinicians to gain a comprehensive understanding of the spatial relationships between lymph nodes and surrounding structures. By providing both internal and external views, along with cross-sectional imaging, the system enhances the operator’s ability to accurately locate and access target lymph nodes during TBNA procedures.

Detailed Anatomy of Key Lymph Node Stations

Understanding the specific anatomical locations and relationships of individual lymph node stations is crucial for accurate diagnosis and staging. The multi-dimensional display of Wang’s map provides detailed information on 11 key lymph node stations, which can be grouped into four main categories:

Right Mediastinal Stations

These include lymph nodes located in the right side of the mediastinum, such as the right paratracheal and right tracheobronchial nodes. For example, the W1 station (anterior carina) corresponds to the IASLC 4R station and is located in front of and between the proximal portions of the right and left main bronchi.

Left Mediastinal Stations

Left-sided mediastinal lymph nodes include the left paratracheal and left tracheobronchial nodes. These stations are important for staging left-sided lung cancers and can be challenging to access due to their anatomical position relative to major blood vessels.

Central Mediastinal Stations

Central stations include lymph nodes located in the middle of the mediastinum, such as the subcarinal nodes. These nodes are particularly important as they receive drainage from both lungs and can be involved in various pathological processes.

Hilar Stations

Hilar lymph nodes are located near the root of each lung and are often the first nodes involved in lung cancer spread. Accurate identification and sampling of these nodes are crucial for proper staging and treatment planning.

Clinical Applications of Advanced Lymph Node Mapping

The multi-dimensional display of Wang’s lymph node map, combined with virtual bronchoscopic navigation, offers several potential benefits for clinical practice:

Improved TBNA Accuracy

By providing a comprehensive view of lymph node anatomy, this technology may help bronchoscopists more accurately locate and sample target nodes. This could lead to improved diagnostic yield and reduced need for more invasive surgical procedures.

Enhanced Preoperative Planning

Surgeons and interventional pulmonologists can use the multi-dimensional display to plan procedures in advance, potentially reducing operative time and improving outcomes.

Better Patient Education

The 3D visualizations can be used to educate patients about their condition and planned procedures, potentially improving understanding and reducing anxiety.

Training Tool for Bronchoscopists

The system can serve as an effective training tool for novice bronchoscopists, allowing them to practice navigation and develop a better understanding of thoracic anatomy before performing procedures on patients.

Challenges and Future Directions in Lymph Node Mapping

While advanced lymph node mapping techniques offer significant advantages, there are still challenges to overcome and areas for future development:

Integration with Real-Time Imaging

Combining virtual navigation systems with real-time imaging modalities, such as endobronchial ultrasound (EBUS), could further improve accuracy and allow for dynamic adjustments during procedures.

Artificial Intelligence Applications

Machine learning algorithms could potentially enhance lymph node detection and characterization, aiding in the identification of suspicious nodes and guiding biopsy decisions.

Standardization and Validation

As new mapping techniques emerge, there is a need for standardization and large-scale validation studies to establish their clinical utility and cost-effectiveness.

Accessibility and Training

Efforts should be made to increase the accessibility of advanced navigation systems and provide comprehensive training programs to ensure widespread adoption and optimal use.

The field of thoracic and mediastinal lymph node mapping continues to evolve, driven by technological advancements and a growing understanding of chest anatomy. Multi-dimensional displays of lymph node maps, combined with virtual navigation systems, offer promising tools for improving the accuracy and safety of diagnostic and therapeutic procedures in the chest. As these technologies continue to develop and integrate with other imaging modalities, they have the potential to significantly impact patient care and outcomes in thoracic medicine.

Thoracic and mediastinal lymph nodes play a crucial role in the diagnosis and staging of various chest diseases, particularly lung cancer. Their complex anatomy and relationships to surrounding structures necessitate advanced mapping and localization techniques to ensure accurate diagnosis and effective treatment planning. The development of multi-dimensional displays of Wang’s lymph node map, combined with virtual bronchoscopic navigation systems, represents a significant advancement in this field.

These innovative approaches provide clinicians with comprehensive visualizations of lymph node anatomy, incorporating both internal and external perspectives along with cross-sectional imaging. By offering a more intuitive understanding of spatial relationships within the chest, these tools have the potential to improve the accuracy of transbronchial needle aspiration procedures, enhance preoperative planning, and serve as valuable educational resources for both patients and medical trainees.

As the field continues to evolve, integration with real-time imaging modalities, application of artificial intelligence, and efforts towards standardization and increased accessibility will likely shape the future of thoracic lymph node mapping. These advancements promise to further refine our ability to diagnose and stage thoracic diseases, ultimately leading to improved patient outcomes and more personalized treatment approaches.

The ongoing development and refinement of lymph node mapping techniques underscore the importance of continued research and collaboration in this field. As our understanding of thoracic anatomy and pathology grows, so too will our ability to navigate and intervene in this complex region of the body. The multi-dimensional approach to lymph node mapping represents a significant step forward in this journey, offering a bridge between traditional anatomical knowledge and cutting-edge technological capabilities.

In conclusion, the field of thoracic and mediastinal lymph node mapping is at an exciting juncture, with new technologies and approaches promising to enhance our ability to diagnose and treat chest diseases. As these tools become more refined and widely available, they have the potential to significantly impact clinical practice, improving outcomes for patients with a wide range of thoracic conditions. The continued development and integration of these advanced mapping techniques will undoubtedly play a crucial role in shaping the future of thoracic medicine and surgery.

Multi-Dimensional Display of Wang’s Lymph Node Map Using Virtual Bronchoscopic Navigation System

Introduction

Transbronchial needle aspiration (TBNA) is a classical bronchoscopic technique for diagnosing benign and malignant mediastinal-hilar lymph node enlargement. With technological progress, endobronchial ultrasound-guided TBNA (EBUS-TBNA) provides real-time ultrasound imaging, resulting in a higher diagnostic yield than conventional TBNA (cTBNA) and has been widely practiced in clinical settings worldwide (Herth et al., 2004; Bonifazi et al., 2017; Madan et al., 2017). However, even with ultrasound guidance, the diagnostic yield of TBNA varies, largely due to the skill and experience of the operator (Rodriguez de Castro et al., 1997; Hsu et al., 2004). Therefore, whether the operator can accurately locate the target lymph nodes is of great importance, and requires a comprehensive understanding of the anatomy of mediastinal-hilar lymph nodes.

The International Association for the Study of Lung Cancer (IASLC) lymph node map and Wang’s lymph node map are the two most commonly used lymph node maps (Wang, 1994; Rusch et al. , 2009). The eighth edition of the IASLC map was introduced in 2009 and most of the lymph node stations are defined according to the positions of blood vessels (El-Sherief et al., 2014). Without ultrasound, it is challenging to identify the blood vessels under bronchoscopy. Wang’s map was proposed in 1994 and the targeted lymph nodes are located by airway landmarks under endoscopic view, which is more practical for practitioners (Wang, 1994).

Electromagnetic navigation bronchoscopy (ENB) was first applied in human subjects in 2006 (Schwarz et al., 2006). Compared with traditional bronchoscopy, ENB improved the diagnostic accuracy for peripheral pulmonary lesions (PPLs) and mediastinal lymph nodes (Gildea et al., 2006). However, the EBN process requires expensive equipment and special training for operators, and therefore it can only be applied in qualified medical centers. On the other hand, virtual bronchoscopy can simulate a three-dimensional view of the bronchi and adjacent structures using. The reported diagnostic yield of virtual bronchoscopic navigation (VBN) system for peripheral pulmonary lesions was 70.9%–76.8% for peripheral pulmonary lesions, that of thin bronchoscopy combined with computed tomography (CT) and VBN was 65.4%–81.6% and that of X-ray fluoroscopy plus VBN was 62.5%–78.7% (Asano et al., 2014). Electromagnetic navigation and virtual navigation could also be used as advanced lymph node localisation systems. Previously, we reported the intrabronchial display of hilar-mediastinal lymph nodes by the SPiN Thoracic Navigation System (Wu et al., 2018). However, only an endobronchial map of mediastinal-hilar lymph nodes was generated, without demonstration of the extrabronchial anatomical position of each lymph node. Here, we further devised a virtual extrabronchial and endobronchial map together with horizontal, coronal and sagittal views on chest CT for each mediastinal and hilar lymph node using the Lungpoint Virtual Bronchoscopic Navigation System, in accordance with the recommended lymph node puncture site in Wang’s map. Therefore, clinicians can gain an overall impression of the three-dimensional (3D) spatial structure of the most frequently punctured lymph nodes, thus improving the accuracy and safety of TBNA.

Methods

CT images 1 mm thick were acquired and transferred to a workstation where the Lungpoint Virtual Bronchoscopic Navigation System (Broncus Technologies, Inc., Mountain View, CA, United States) automatically generated a 3D model of the airway. We set up 3D markers of the locations of intrathoracic lymph nodes. The extrabronchial anatomical positions of each target lymph node were shown as green spheres. The positions and borders of 11 target lymph nodes were described according to Wang’s lymph node map.

Results

We generated an overall view of 11 lymph node stations in Wang’ map under 3D reconstruction (Figure 1). Next, we collected the horizontal, coronal and sagittal views of chest CT, labeled extrabronchial 3D anatomical locations of the 11 nodal stations in terms of Wang’s lymph node map and generated a virtual view from an extrabronchial perspective. We classified the 11 stations into four groups: right mediastinal stations (Figure 2), left mediastinal stations (Figure 3), central mediastinal stations (Figure 4) and hilar stations (Figure 5). The recommended TBNA puncture sites of particular lymph nodes were also described in detail (Wang, 1994; Wang, 1995; Xia and Wang, 2013) (see Supplementary Table S1).

W1 station, anterior carina (correlated with IASLC 4R).

Location: In front and between the proximal portions of the right and left main bronchi.

Posterior border: The carina of the trachea.

Puncture point: The first trachea cartilage ring gap at 12–1 o’clock.

W2 station, posterior carina (correlated with IASLC-7).

Location: Behind and between the proximal portions of the right and left main bronchi or directly behind the right main bronchus.

Upper border: tip of the carina.

Lower border: The superior portion of the opening of the right upper lobe bronchus.

Puncture point: The opposite side of W1, 5–6 o’clock at the posterior wall of the carina.

W3 station, right paratracheal (correlated with IASLC-4R).

Location: Behind the superior vena cava and in front of the anterolateral aspect of the lower trachea near the azygous arch.

Upper border: The inferior margin of the brachiocephalic vein or superior margin of the aortic arch.

Lower border: The superior margin of the azygous arch.

Puncture point: Second to fourth trachea cartilage ring gaps at 1–2 o’clock.

W4 station, left paratracheal (A-P window, correlated with IASLC-4L).

Location: Lateral to trachea near the tracheobronchial angulation, below the aortic arch and above the left main pulmonary artery.

The W4 lymph nodes are divided into interior, middle and exterior windows.

Puncture point: First or second cartilage ring gap from the distal trachea at 9 o’clock or one trachea cartilage ring distal or proximal from the tracheobronchial angle.

W5 station, right main bronchus (distal W5 correlated with IASLC-10R, proximal W5 correlated with IASLC-4R).

Location: In front of the proximal proportion of the right main bronchus.

Puncture point: The first or second trachea cartilage ring gap of the right main bronchus at 12 o’clock.

W6 station, left main bronchus (correlated with IASLC-10L).

Location: In front of the proximal proportion of the left main bronchus. The W6 lymph node is a mediastinal lymph node.

Puncture point: The first or second trachea cartilage ring gap of the left main bronchus at 12 o’clock.

W7 station, right upper hilar (correlated with IASLC-11Rs).

Location: In front and between the right upper lobe bronchus and bronchus intermedius.

Puncture point: Anterolateral direction of the right upper lobe crest.

W8 station, subcarina (correlated with IASLC-7).

Location: Between the right and left main bronchi, at or near the level of the right upper lobe bronchus.

Upper border: The superior margin of the opening of the right upper lobe bronchus.

Lower border: The opening of the right intermediate bronchus.

Puncture point: Right main bronchus at the level of the opening of the right upper lobe bronchus, at 9 o’clock.

W9 station, right lower hilar (correlated with IASLC-11Ri).

Location: Lateral or in front of the bronchus intermedius, at or near the level of the right middle lobe bronchus. The W9 lymph nodes consist of lymph nodes at the right lateral side of the right intermediate bronchus and near the ridge of the right middle and lower lobe bronchi.

Puncture point: Lateral side of the right intermediate bronchus.

W10 station, subsubcarina (correlated with the lower part of IASLC-7).

Location: Between the bronchus intermedius and the left main bronchus, at or near the level of the right middle lobe bronchus.

Upper border: The opening of the right intermediate bronchus.

Lower border: The distal end of the right intermediate bronchus, extending to the inferior side of the opening of the right middle lobe.

Puncture point: Right intermediate bronchus at 9 o’clock.

W11 station, left hilar (correlated with IASLC-11L).

Location: Between the left upper lobe and the left lower lobe bronchus.

Puncture point: The opening of the dorsal segment of the left lower lobe at 9 o’clock.

FIGURE 1. Note: The overall view of eleven lymph node stations of Wang’ map in a 3D reconstructed imaging.

FIGURE 2. Right mediastinal lymph node (N2) Note: (W1) anterior carina lymph nodes. (W3) right paratracheal lymph nodes. (W5) right main bronchus lymph nodes. (A) Intraluminal view and puncture sight (green). (B) Axial view. (C) Coronal view. (D) Sagittal view. (E) Reconstruction image.

FIGURE 3. Left mediastinal lymph node (N2). Note: (W4) left paratracheal lymph nodes or aortic pulmonary (A-P) window lymph nodes. (W6) left main bronchus lymph nodes. (A) Intraluminal view and puncture sight (green). (B) Axial view. (C) Coronal view. (D) Sagittal view. (E) Reconstruction image.

FIGURE 4. Central mediastinal lymph node (N2). Note: (W2) posterior carina lymph nodes. (W8) subcarinal lymph nodes. (W10) subsubcarinal lymph nodes. (A) Intraluminal view and puncture sight (green). (B) Axial view. (C) Coronal view. (D) Sagittal view. (E) Reconstruction image.

FIGURE 5. Hilar lymph node (N1). Note: (W7) right upper hilar lymph nodes. (W9) right lower hilar lymph nodes. (W11) left hilar lymph nodes. (A) Intraluminal view and puncture sight (green). (B) Axial view. (C) Coronal view. (D) Sagittal view. (E) Reconstruction image.

Discussion

In the present study, we introduced a virtual map of lymph node landmarks under the assistance of a VBN system. Our map displays the intrabronchial and extrabronchial spatial relationships of 11 lymph node stations and their recommended puncture sites corresponding to Wang’s map.

The VBN system in combination with CT of the 11 mediastinal and hilar lymph nodes and their surrounding structures from extrabronchial and endobronchial, sagittal, coronal as well as horizontal views provided a full understanding of the thoracic lymph nodes and their intrabronchial and extrabronchial relationships with adjacent tissues and blood vessels. A detailed view of the lymph nodes and their adjacent tissues can reinforce the understanding of the anatomy and assist in training of operators for TBNA.

There are two major differences between Wang’s map and the IASLC map (Xia et al., 2015). First, stations five and six in Wang’s map are located in front of the proximal proportion of the right and left main bronchi, respectively. Both W5 and W6 stations are defined as mediastinal lymph nodes. Second, W5 covers two IASLC lymph nodal stations: the distal end of 4R as well as 10R station. Third, compared with the previous edition of the IASLC lymph node map, the lower border is extended to the azygos vein on the right, which fits the principle of Wang’s map that 4R is correlated with station W1 and W3 as well as proximal W5 station. Similarly, the lower border of station seven in the IASLC map is extended to the upper border of the lower lobe bronchus on the left and the lower border of the bronchus intermedius on the right. This changed definition is also correlated with the definitions of W8 and W10.

VBN is generally conducted for guidance in treatment of PPLs. PPLs cannot be accessed easily by cTBNA because they are distinct from the trachea and central bronchus. The development of image-guided bronchoscopy techniques significantly enhances the diagnostic accuracy of PPLs. The VBN system was designed to reach and guide aspiration of PPLs with a diagnostic value of 72.0%–73.8% (Wang Memoli et al., 2012; Asano et al., 2014), and the diagnostic value reached 67.4% for lesions <2 cm in diameter (Asano et al. , 2014). In combination with CT-guided ultrathin bronchoscopy, the diagnostic value of VBN increases to 65.4%–81.6% (Asano et al., 2014). On the other hand, the VBN system has also been applied in diagnosis of thoracic lymph node adenopathy. The sensitivity and diagnostic accuracy are both significantly increased for mediastinal lymph nodes by VBN (McAdams et al., 1998; Fiorelli et al., 2017), suggesting that the VBN system is also valuable in cases of mediastinal lymph node enlargement.

Aside from the advantages of the VBN system, the bronchoscopist still has to perform cTBNA blindly in clinical practice, as the exact puncture site cannot be confirmed in real-time. In general, the main purpose of generating our multi-dimensional virtual Wang’s lymph node map is for training junior interventional pulmonology fellows or bronchoscopists. Compared with EBUS-TBNA, our approach does not require the use of a regular scope for the airway survey. In addition, although EBUS-TBNA allows real-time visualisation of a punctured lymph node, the operator cannot precisely identify the puncture site. In contrast, our system probes the 3D anatomy of each lymph node station with the puncture site. We expect that our multi-dimensional virtual Wang’s lymph node map would allow precise targeting of lymph nodes 1–2 cm in diameter. Hence, the two methods are not competitive but complementary for bronchoscopists within the learning curve. The diagnostic yield is satisfactory upon combining virtual endobronchial ultrasound with EBUS-TBNA bronchoscopy when diagnosing mediastinal-hilar lymph node enlargement (Sato et al., 2013), but its necessity is doubtful. In addition, rapid on-site evaluation (ROSE) may be a good alternative to EBUS for combination with the VBN system. In addition, we recommend a probe designed to determine whether the needle is aligned in the puncture site. When it is aligned properly, the inducer could turn from green to red to alert the practitioner of puncture. Such a device may further improve the diagnostic value of VBN-guided TBNA.

There was a significant limitation of this study in that the diagnostic yield of this particular VBN-assisted TBNA has not yet been verified. A clinical trial is required to examine the validity of this VBN plus TBNA system. In addition, the quality of the CT image can also affect the accuracy of the derived 3D images.

Overall, we have proposed a virtual map for intra- and extrabronchial landmarks of hilar and mediastinal lymph nodes based on the Lungpoint VBN system. This map can help in training bronchoscopists as well as enhancing the diagnostic value of the VBN system. Further clinical trials are required to determine the efficacy of this strategy.

Data Availability Statement

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding authors.

Author Contributions

KW, QLiu, HoS, and YX contributed to study conception and design. FL, YY, HuS, QW, XY, QLi, LC, and YX conducted data collection and data analysis. QLiu, HoS, HuS, KW, YY, FL, and YX drafted the manuscript. All authors contributed to revision of the manuscript, and confirmed the final approval of manuscript.

Funding

This work was supported by the National Natural Science Foundation of China (81870022) and the Zhejiang Provincial Natural Science Foundation (LY20H010004).

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fmolb.2021.679442/full#supplementary-material

References

Asano, F., Eberhardt, R., and Herth, F. J. F. (2014). Virtual bronchoscopic navigation for peripheral pulmonary lesions. Respiration 88 (5), 430–440. doi:10.1159/000367900

PubMed Abstract | CrossRef Full Text | Google Scholar

Bonifazi, M., Tramacere, I., Zuccatosta, L., Mei, F., Sediari, M., Paonessa, M.C., et al. (2017). Conventional versus Ultrasound-Guided Transbronchial Needle Aspiration for the Diagnosis of Hilar/Mediastinal Lymph Adenopathies: A Randomized Controlled Trial. Respiration. 94 (2), 216–223. doi:10.1159/000475843

PubMed Abstract | CrossRef Full Text | Google Scholar

El-Sherief, A. H., Lau, C. T., Wu, C. C., Drake, R. L., Abbott, G. F., and Rice, T. W. (2014). International association for the study of lung cancer (IASLC) lymph node map: radiologic review with CT illustration. Radiographics 34 (6), 1680–1691. doi:10.1148/rg.346130097

PubMed Abstract | CrossRef Full Text | Google Scholar

Fiorelli, A., Raucci, A., Cascone, R., Reginelli, A., Di Natale, D., Santoriello, C., et al. (2017). Three-dimensional virtual bronchoscopy using a tablet computer to guide real-time transbronchial needle aspiration. Interact Cardiovasc Thorac Surg 24 (4), ivw404–575. doi:10.1093/icvts/ivw404

PubMed Abstract | CrossRef Full Text | Google Scholar

Gildea, T. R., Mazzone, P. J., Karnak, D., Meziane, M., and Mehta, A. C. (2006). Electromagnetic Navigation Diagnostic Bronchoscopy. Am J Respir Crit Care Med 174 (9), 982–989. doi:10.1164/rccm.200603-344OC

PubMed Abstract | CrossRef Full Text | Google Scholar

Herth, F., Becker, H. D., and Ernst, A. (2004). Conventional vs Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration. Chest 125 (1), 322–325. doi:10.1378/chest.125.1.322

PubMed Abstract | CrossRef Full Text | Google Scholar

Hsu, L.-H., Liu, C.-C., and Ko, J.-S. (2004). Education and Experience Improve the Performance of Transbronchial Needle Aspiration. Chest 125 (2), 532–540. doi:10.1378/chest.125.2.532

PubMed Abstract | CrossRef Full Text | Google Scholar

Madan, K., Dhungana, A., Mohan, A., Hadda, V., Jain, D., Arava, S., et al. (2017). Conventional Transbronchial Needle Aspiration Versus Endobronchial Ultrasound-guided Transbronchial Needle Aspiration, With or Without Rapid On-Site Evaluation, for the Diagnosis of Sarcoidosis: A Randomized Controlled Trial. J Bronchology Interv Pulmonol 24 (1), 48–58. doi:10.1097/LBR.0000000000000339

PubMed Abstract | CrossRef Full Text | Google Scholar

McAdams, H. P., Goodman, P. C., and Kussin, P. (1998). Virtual bronchoscopy for directing transbronchial needle aspiration of hilar and mediastinal lymph nodes: a pilot study. American Journal of Roentgenology 170 (5), 1361–1364. doi:10.2214/ajr.170.5.9574616

PubMed Abstract | CrossRef Full Text | Google Scholar

Rodriguez de Castro, F., López, F. D., Serdá, G. J., Navarro, P. C., López, A. R., and Gilart, J. F. (1997). Relevance of training in transbronchial fine-needle aspiration technique. Chest 111 (1), 103–105. doi:10.1378/chest.111.1.103

PubMed Abstract | CrossRef Full Text | Google Scholar

Rusch, V. W., Asamura, H., Watanabe, H., Giroux, D. J., Rami-Porta, R., Goldstraw, P., et al. (2009). The IASLC lung cancer staging project: a proposal for a new international lymph node map in the forthcoming seventh edition of the TNM classification for lung cancer. Journal of Thoracic Oncology 4 (5), 568–577. doi:10.1097/JTO.0b013e3181a0d82e

PubMed Abstract | CrossRef Full Text | Google Scholar

Sato, M. , Chen, F., Aoyama, A., Yamada, T., Ikeda, M., Bando, T., et al. (2013). Virtual endobronchial ultrasound for transbronchial needle aspiration. The Journal of Thoracic and Cardiovascular Surgery 146 (5), 1204–1212. doi:10.1016/j.jtcvs.2013.01.019

PubMed Abstract | CrossRef Full Text | Google Scholar

Schwarz, Y., Greif, J., Becker, H. D., Ernst, A., and Mehta, A. (2006). Real-Time Electromagnetic Navigation Bronchoscopy to Peripheral Lung Lesions Using Overlaid CT Images. Chest 129 (4), 988–994. doi:10.1378/chest.129.4.988

PubMed Abstract | CrossRef Full Text | Google Scholar

Wang, K.-P. (1994). Staging of bronchogenic carcinoma by bronchoscopy. Chest 106 (2), 588–593. doi:10.1378/chest.106.2.588

PubMed Abstract | CrossRef Full Text | Google Scholar

Wang, KP (1995). Transbronchial needle aspiration and percutaneous needle aspiration for staging and diagnosis of lung cancer. Clin Chest Med 16 (3), 535–52.

PubMed Abstract | Google Scholar

Wang Memoli, J. S., Nietert, P. J., and Silvestri, G. A. (2012). Meta-analysis of guided bronchoscopy for the evaluation of the pulmonary nodule. Chest 142 (2), 385–393. doi:10.1378/chest.11-1764

PubMed Abstract | CrossRef Full Text | Google Scholar

Wu, X., Shi, L., Xia, Y., Wang, K.-p., and Li, Q. (2018). Intrabronchial display of hilar-mediastinal lymph nodes by virtual bronchoscopic navigation system. Thorac Cancer 9 (3), 415–419. doi:10.1111/1759-7714.12555

PubMed Abstract | CrossRef Full Text | Google Scholar

Xia, Y., Ma, Y., Arias, S., Lee, H., and Wang, K.-P. (2015). Utilization of the International Association for the Study of Lung Cancer and Wang’s nodal map for the identification of mediastinum and hilar lymph nodes. Thoracic Cancer 6 (4), 464–468. doi:10.1111/1759-7714.12206

PubMed Abstract | CrossRef Full Text | Google Scholar

Xia, Y, and Wang, KP (2013). Transbronchial needle aspiration: where are we now? J Thorac Dis 5 (5), 678–82. doi:10.3978/j.issn.2072-1439.2013.09.11

PubMed Abstract | CrossRef Full Text | Google Scholar

Lung Cancer – Non-Small Cell: Stages

Approved by the Cancer.Net Editorial Board, 12/2022

ON THIS PAGE: You will learn about how doctors describe a cancer’s growth or spread. This is called the stage. Use the menu to see other pages.

What is cancer staging?

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting other parts of the body. Doctors use diagnostic tests to find out the cancer’s stage, so staging may not be complete until all of the tests are finished. Knowing the stage helps the doctor recommend the best kind of treatment and can help predict a patient’s prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.

In general, a lower number stage of non-small cell lung cancer (NSCLC) is linked with a better outcome. However, no doctor can predict how long a patient will live with lung cancer based only on the stage of disease. This is because lung cancer is different in each person and treatment works differently for each tumor.

This page provides detailed information about the stage groups for NSCLC, such as stage II or stage IV, and what this means for prognosis.

• Stage groups for NSCLC

• Prognosis

Stage groups for NSCLC

The stage of NSCLC is based on a combination of several factors, including:

There are 5 stages for NSCLC: stage 0 (zero) and stages I through IV (1 through 4). One way to determine the staging of NSCLC is to find out whether the cancer can be completely removed by a surgeon. To completely remove the lung cancer, the surgeon must remove the cancer, along with the surrounding, healthy lung tissue and often nearby lymph nodes. Learn more about treatment options for NSCLC.

Stage 0

This is called in situ disease, meaning the cancer is “in place” and has not grown into nearby normal lung tissues or spread outside the lung.

Stage I

A stage I lung cancer is a small tumor that has not spread to any lymph nodes. Stage I is divided into 2 substages based on the size of the tumor:

• Stage IA tumors are 3 centimeters (cm) or less in size. Stage IA tumors may be further divided into IA1, IA2, or IA3 based on the size of the tumor.

• Stage IB tumors are more than 3 cm but 4 cm or less in size.

Stage II

Stage II lung cancer is divided into 2 substages:

• A stage IIA cancer describes a tumor larger than 4 cm but 5 cm or less in size that has not spread to the nearby lymph nodes.

• Stage IIB lung cancer describes a tumor that is 5 cm or less in size that has spread to the lymph nodes within the lung, called the N1 lymph nodes. A stage IIB cancer can also be a tumor more than 5 cm wide that has not spread to the lymph nodes.

Usually, stage II tumors can be removed with surgery, but often additional treatments are recommended.

Stage III

Stage III lung cancers are classified as either stage IIIA, IIIB, or IIIC. The stage is based on the size of the tumor and which lymph nodes the cancer has spread to. Stage III cancers have often spread extensively to the lymph nodes, but have not spread to other distant parts of the body.

If stage III NSCLC is suspected, the doctor will want to make sure the cancer has not spread to other parts of the body. For this evaluation, ASCO recommends a physical examination, assessment of the patient’s medical history, a CT scan of the chest and upper abdomen, and a PET-CT scan and MRI of the brain (see Diagnosis). For some people, lymph nodes may also need to be tested for cancer by endoscopy or surgery. A team of cancer care specialists generally work together to recommend the most appropriate treatment plan based on the stage and other characteristics of the cancer as well as other medical conditions the patient may have.

For many stage IIIA and stage IIIB cancers, it may be difficult, or sometimes impossible, to remove the tumor completely with surgery alone. Stage IIIC cancers, in general, cannot be removed with surgery and may need to be treated with a combination of chemotherapy and radiation followed by immunotherapy. For example, the lung cancer may have spread to the lymph nodes located in the center of the chest, which is outside the lung. Or the tumor may have grown into nearby structures in the lung. In either situation, it is less likely that the surgeon can completely remove the cancer. Stage III NSCLC that cannot be treated with surgery is generally treated with systemic therapy and radiation therapy (see Types of Treatment).

This information is based on the ASCO guideline, “Management of Stage III NSCLC.” Please note that this link takes you to a different ASCO website.

Stage IV

Stage IV means the lung cancer has spread to more than 1 area in the other lung, the fluid surrounding the lung or the heart, or distant parts of the body through the bloodstream. Once cancer cells get into the blood, the cancer can spread anywhere in the body. But, NSCLC is more likely to spread to the brain, bones, liver, and adrenal glands. Stage IV NSCLC is divided into 2 substages:

In general, surgery is usually not an option for most stage IIIB, IIIC, or IV lung cancers. It can be difficult to remove lung cancer that has spread to the lymph nodes above the collarbone or into vital structures within the chest. These include the heart, large blood vessels, or the main breathing tubes leading to the lungs. In these situations, the doctor will carefully consider if surgery is an option or recommend other treatment options. Surgery is usually not be recommended if the tumor cannot be completely removed. But for some people with stage IV lung cancer that have a good response to treatment, surgery and/or radiation therapy may be offered to treat the remaining sites of cancer.

Recurrent NSCLC

Recurrent cancer is cancer that has come back after treatment. If the cancer does return, there will be another round of tests to learn about the extent of the recurrence. These tests and scans are often similar to those done at the time of the original diagnosis.

Used with permission of the American College of Surgeons, Chicago, Illinois. The original and primary source for this information is the AJCC Cancer Staging Manual, Eighth Edition (2017), published by Springer International Publishing.

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Prognosis

The type and stage of NSCLC and the patient’s overall health influence the prognosis. NSCLC is treatable at any stage and new treatments in recent years have led to improvements in overall survival for people with all stages of NSCLC. But only some people with certain stages can be cured.

Your doctor may use an index known as “performance status” or “functional status” to guide your treatment and determine your prognosis. This index measures a person’s general strength and health. People who are strong enough to continue daily activities without assistance can safely receive cancer medication, radiation therapy, or surgery. For people with bone or liver metastases from lung cancer, excessive weight loss, ongoing tobacco use, or certain pre-existing medical conditions, such as heart disease or emphysema, treatment may not be as safe or effective.

It is important to note that a person’s age has never been useful in predicting to predict if a person will benefit from treatment for NSCLC. The average age of people with lung cancer in the United States is 71. Age should never be used as the only reason for deciding what treatment is best, especially for older patients who are otherwise physically fit and have no medical problems besides lung cancer.

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Information about the cancer’s stage will help the doctor recommend a specific treatment plan. The next section in this guide is Types of Treatment. Use the menu to choose a different section to read in this guide.

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Soft tissues and lymph nodes of the chest Ultrasound in Voronezh – price, phone, online appointment around the clock

Lymph nodes are the so-called “filters” of the lymph. They are the first to react to the developing pathological process. The study of lymph nodes allows you to clarify the diagnosis, as well as adjust the previously prescribed treatment.

Time: 15-30 minutes.

Preparation for the examination: not required.

Presence of contraindications: no.

Preparation of the conclusion: 10-15 minutes.

Equipment: Hitachi Aloka Arietta V60.

Ultrasound of the lymph nodes is a non-invasive informative diagnostic method widely used by doctors of various specialties.

Benefits of soft tissue and thoracic lymph node ultrasound at SmartClinic

In Smart Clinic, ultrasound is performed using modern equipment. Hitachi Aloka Arietta V60 expert class equipment has high resolution. This allows doctors to accurately determine the localization of pathological changes in the area under study.

Our team consists of the best professionals in the city. Doctors have many years of experience and regularly improve their skills at specialized courses. SmartClinic diagnostics detect diseases with high accuracy even at early stages of development.

You can view the results of your research in your personal account. Not only ultrasound data is loaded into the medical information system, but also MRI, CT, X-ray and mammography data. This is convenient, as you will have access to electronic medical reports at any time.

When there is a need for ultrasound of soft tissues and lymph nodes

Our doctors recommend performing ultrasound of the soft tissues and lymph nodes of the chest in the presence of the following conditions:

• pain in soft tissues or in the region of lymph nodes;
• enlargement of the lymph nodes, their soreness;
• fever, weakness, sweating;
• emerging neoplasms.

The procedure is informative for injuries and damage to soft tissues. Ultrasound is prescribed for dynamic monitoring of various conditions, as well as for assessing the effectiveness of the treatment.

Understanding the availability of indications for conducting a study on your own can be difficult. Sign up for a consultation with our doctors by phone +7 (473) 211-42-24. Specialists will carefully listen to complaints, collect an anamnesis and make a conclusion about the need to perform an ultrasound scan of the soft tissues and lymph nodes of the chest.

How to prepare for an ultrasound

Ultrasound examination of soft tissues and lymph nodes of the chest does not require special preparation. If you have previously performed a similar study and you have the conclusions on hand, we recommend that you take them with you. If you performed the procedure in our clinic, the results of all examinations carried out are stored in the medical information system.

Ultrasound of soft tissues and lymph nodes of the chest

During the study, you are located on a comfortable couch. The diagnostician may ask you to take a certain position depending on the location of the nodes being examined. A special gel is applied to the skin to facilitate the sliding of the sensor. During the study, tissues located on the path of ultrasonic waves are visualized on the monitor screen. The whole procedure is absolutely painless. On average, it takes 15-30 minutes to complete.

Interpretation of results

The medical report is handed out 10-15 minutes after the completion of the procedure. You can expect results in the comfort of your clinic or outside. In conclusion, the diagnostician indicates the main characteristics, as well as the identified changes, if any. If necessary, the results of the survey can be transferred to electronic media.

Appointment for ultrasound of soft tissues and lymph nodes of the chest

You can sign up for the procedure, as well as ask all your questions to Smart Clinic specialists by phone +7 (473) 211-42-24.

Causes of swollen lymph nodes in children

Lymph nodes are immune organs.

Role of lymph nodes:

Barrier. Lymph nodes (LN) are the “first line of defense” against the penetration of various foreign agents into the child’s body. A natural reaction to this “acquaintance” is an increase in lymph nodes.

Filtration. Various substances, microbial cells, particles of the body’s own tissues settle in the LU.

Very often enlarged lymph nodes are called “glands” by parents.

The lymph node itself is a small oval formation (several millimeters in diameter). Outside, it is covered with a special capsule of connective tissue, and inside it is divided by partitions into separate sections. These elements of the immune system are located in groups throughout the body at the confluence of several lymphatic vessels. In newborns, the capsule of the lymph nodes is still very delicate and thin, so it is difficult to feel them under the skin. By the age of one year, lymph nodes can already be felt in almost all healthy children.

The maximum number of lymph nodes appears by 10 years of age. In an adult, their total number is 420-460.

Assessment of the size and condition of the lymph nodes is carried out by palpation. In this case, it is necessary to probe the lymph nodes in all groups (and there are 15 of them) – from the occipital to the popliteal. With a significant increase in the lymph nodes, the parents or the child themselves can pay attention to this symptom. With inflammation of the lymph node (lymphadenitis), due to the appearance of pain, children clearly indicate the localization of the process.

Normally, in healthy children, no more than three groups of lymph nodes are usually palpable.

Must not be palpable:

• chin;
• supraclavicular;
• subclavian;
• nursing;
• elbow;
• popliteal lymph nodes.

Signs of normal lymph nodes :

• their size does not exceed the diameter of a small pea,
• they are single,
• soft elastic consistency.
• movable,
• not connected to the skin and to each other (doctors say “not soldered”),
• painless.

An increase in the size of the lymph nodes with a change in their consistency is called lymphadenopathy, a quantitative increase in the lymph nodes is called polyadenia (from aden- iron, since previously the lymph nodes were mistakenly considered glands).

Causes of swollen lymph nodes in children:

• infections;
• tumor processes;
• is a specific metabolic disorder called “storage diseases”.

Local (regional) isolated enlargement of lymph nodes is always due to changes in the corresponding zone (region) of the body from which lymph comes.

In all cases of unusual local enlargement of the lymph nodes, a thorough examination of the child is necessary to determine how generalized (spread) the process has occurred.

Stages of diagnosis in isolated enlargement of lymph nodes:

Clinical diagnostics. It consists in the fact that at first the doctor makes a diagnosis based on the complaints of the child or parents, clinical data and the results of a blood test, urine, X-ray, etc.

Tuberculin diagnostics. Needed to rule out tuberculosis.

Special (serological) blood tests (carried out if another infection is suspected).

Usually, with an isolated increase in any group of LUs, antibacterial agents are prescribed for 8-10 days. An improvement in the child’s condition and a decrease in the swelling of the lymph nodes are regarded as confirmation of the bacterial nature of the disease.

Biopsy of the lymph node or its puncture with examination of the tissue of the lymph node under a microscope. It is carried out in the most difficult diagnostic cases.

Peculiarities of lesions of lymph nodes in individual zones:

Enlarged occipital lymph nodes : found in inflammatory processes of the scalp (purulent rash, boils, osteomyelitis of the bones of the cranial vault, fungal infection). With rubella, in addition to the occipital, other groups of LU are also increased to a lesser extent.

Swollen parotid lymph nodes : characteristic of inflammation of the middle and outer ear, purulent inflammation of the scalp (pyoderma), lice, furunculosis. Often, these groups of LUs react to infection with an allergic rash in atopic dermatitis and eczema, especially when it is localized behind the ears.

Enlarged lymph nodes behind the angle of the lower jaw and along the back muscles of the neck . It develops during inflammatory processes in the nasopharynx or after them: tonsillitis, infectious mononucleosis (as a manifestation of a generalized process), with chronic tonsillitis and adenoid growths, with tuberculosis of the tonsils.

Enlargement of lymph nodes behind the angle of the lower jaw and in the median triangle of the neck : severe forms of angina, scarlet fever. With diphtheria of the tonsils, a symmetrical increase in the LN to the size of an apple occurs. At the same time, they are elastic, painful. Swelling of the surrounding tissues develops with an increase in the size of the neck. In the case of a severe course of angina, acute inflammation of the LU can develop – lymphadenitis and even its purulent lesion. With cat scratch disease (caused by a special microorganism), this group of LUs may increase. The combination of tonsillitis, lymphadenitis and peeling of the palms and feet is characteristic of a streptococcal infection (streptococcal tonsillitis, scarlet fever). A few more reasons for the reaction of this group of LU: Kawasaki syndrome (combined with damage to the eyes, skin, coronary arteries, fever, rash), toxoplasmosis, tumors of the blood and lymphatic system (Hodgkin’s disease – lymphogranulomatosis, non-Hodgkin’s lymphoma – lymphosarcoma).

Swollen lymph nodes in the lateral triangle of the neck may be a sign of infection in the nasopharyngeal cavity, tuberculosis of the lymph nodes, tumors.

Enlargement of lymph nodes in the chin zone develops with an abscess in the jaw areas, with damage to the front teeth – incisors, stomatitis, inflammation of the lower lip.

Enlargement of the submandibular lymph nodes is characteristic of inflammation of the jaw due to damage to the teeth, stomatitis and gingivitis (inflammation of the gums). After treatment with antibiotics, LNs decrease and regain their mobility when palpated.

Enlarged axillary lymph nodes occurs with infectious diseases of various causes in the arm and shoulder area (purulent skin lesions, chicken pox). Unilateral LN enlargement may develop after vaccination or injury to the hand, cat-scratch disease.

Swollen elbow lymph nodes is a sign of an infection in the hand or forearm.

Swollen inguinal lymph nodes indicates an infection in the lower extremities with its localization in the bones, muscles or on the skin. This symptom appears with inflammation of the joints, with severe diaper dermatitis, with furunculosis in the gluteal region, inflammation of the genital organs, after BCG vaccination with the introduction of the vaccine into the thigh area. Moreover, an isolated increase in LU for 3 months after BCG is normal, and a longer persistence of the symptom is regarded as an indirect sign of a decrease in the activity of the immune system or high virulence of the grafting material, or as an individual feature of the child’s reactivity. A biopsy of these lymph nodes can reveal a large number of blood cells called macrophages. After BCG, the LNs can be soaked with lime and palpated through thin skin for many years. In the case of infection through the skin of the leg, a group of inguinal LUs also reacts with cat scratch disease.

Frequent injuries of the skin of the legs and feet, infection of these wounds in children of preschool and school age lead to the fact that in most of them significantly enlarged lymph nodes are clearly palpable in the inguinal region. Such children are not considered sick in the absence of other signs of pathology.

A lot of diseases begin with an increase in the LU in any one zone, and then the LU increases in almost all groups. This pattern is observed with influenza, measles, rubella, infectious mononucleosis, viral pneumonia, viral hepatitis, widespread eczema, congenital syphilis, toxoplasmosis, etc.

In addition to the LN, other formations can also lift the skin and be felt under the skin. One of the reasons for this is lymphangioma (parents are more familiar with the close formation of blood vessels – hemangioma), a soft swelling under the skin without clear boundaries. Lymphangioma is localized mainly on the neck and can cause difficulties during childbirth, swallowing and breathing. Often requires surgical treatment.

It must be remembered that the LNs are located both in the chest and in the abdominal cavity.

Signs of increased lymph nodes in the chest:

• respiratory disorders;
• difficulty swallowing;
• prolonged hiccups.

An abdominal nodule reaction to a viral or bacterial infection may present with very severe abdominal pain, sometimes requiring a differential diagnosis with appendicitis.