Map of human lymph nodes. Comprehensive Guide to Cervical Lymph Node Mapping: Understanding Anatomy and Clinical Significance

17.11.202113.07.2023 by alexxlab

What are the key levels of cervical lymph nodes. How does the cervical lymph node map aid in cancer diagnosis and treatment. What are the anatomical boundaries and clinical implications of each lymph node level.

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The Importance of Cervical Lymph Node Mapping in Radiology and Oncology

Cervical lymph node mapping plays a crucial role in the diagnosis, staging, and treatment of head and neck cancers. Understanding the intricate anatomy and clinical significance of these lymph nodes is essential for radiologists, oncologists, and surgeons alike. This comprehensive guide delves into the cervical lymph node map, exploring its various levels, anatomical boundaries, and clinical implications.

Anatomical Overview of the Cervical Lymph Node System

The cervical lymph node system is divided into distinct levels, each with its own anatomical boundaries and clinical significance. The American Head and Neck Society and the American Academy of Otolaryngology-Head and Neck Surgery have proposed a nomenclature that defines 10 node groups. These groups are further subdivided to align with the TNM atlas, providing a more detailed classification system.

Key Anatomical Landmarks

Hyoid bone
Cricoid cartilage
Carotid arteries
Sternocleidomastoid muscle
Manubrium of sternum

These landmarks serve as crucial reference points for accurately identifying and locating the various cervical lymph node levels on imaging studies and during surgical procedures.

Level I: Submental and Submandibular Lymph Nodes

Level I is further divided into two sublevels: Ia (submental) and Ib (submandibular). These nodes are particularly important in the context of oral cavity cancers and other malignancies of the head and neck region.

Level Ia: Submental Nodes

The submental nodes are located in a median region between the anterior belly of the digastric muscles. They primarily drain the anterior oral cavity, lower lip, and anterior floor of the mouth.

Level Ib: Submandibular Nodes

Submandibular nodes are found in the space between the inner aspect of the mandible laterally and the digastric muscle medially. They extend from the symphysis menti anteriorly to the submandibular gland posteriorly. These nodes receive drainage from the oral cavity, anterior nasal cavity, soft tissues of the mid-face, and the submandibular gland.

Level II: Upper Jugular Lymph Nodes

Level II nodes are of paramount importance in head and neck oncology due to their extensive drainage network. They receive lymphatics from various structures, including the face, parotid gland, and other lymph node groups.

Level IIa vs. Level IIb

Level II is subdivided into IIa and IIb, separated by a line drawn at the posterior edge of the internal jugular vein. This distinction is clinically relevant as the risk of metastasis varies between these sublevels.

Level IIa nodes are at risk for metastases from a wide range of head and neck cancers, including those of the nasal cavity, oral cavity, nasopharynx, oropharynx, hypopharynx, larynx, and major salivary glands.
Level IIb nodes are more commonly associated with primary tumors of the oropharynx or nasopharynx, and less frequently with tumors of the oral cavity, larynx, or hypopharynx.

Level III: Mid Jugular Lymph Nodes

Level III nodes play a critical role in the lymphatic drainage of several key structures in the head and neck region. They receive efferent lymphatics from levels II and V, as well as from retropharyngeal, pretracheal, and recurrent laryngeal nodes.

Anatomical Boundaries and Clinical Significance

The inferior border of the cricoid cartilage serves as the demarcation between level III and level IVA. This anatomical landmark is crucial for accurate identification on imaging studies and during surgical procedures.

Level III nodes are at risk of harboring metastases from cancers originating in the:

Oral cavity
Nasopharynx
Oropharynx
Hypopharynx
Larynx

Understanding the drainage patterns and metastatic potential of these nodes is essential for proper staging and treatment planning in head and neck oncology.

Level IV: Lower Jugular and Medial Supraclavicular Lymph Nodes

Level IV is further subdivided into IVa and IVb, with the border between them set approximately 2 cm cranial to the sternoclavicular joint. This distinction is important due to the varying risk profiles and drainage patterns of these sublevels.

Level IVa: Lower Jugular Nodes

Level IVa nodes are at risk for harboring metastases from cancers of the:

Hypopharynx
Larynx
Thyroid
Cervical esophagus

Interestingly, metastases from the anterior oral cavity may occasionally manifest in this location with minimal or no proximal nodal disease, highlighting the importance of thorough evaluation of this level.

Level IVb: Medial Supraclavicular Nodes

Level IVb nodes are particularly susceptible to metastases from cancers of the:

Hypopharynx
Subglottic larynx
Trachea
Thyroid
Cervical esophagus

The involvement of level IVb nodes often indicates more advanced disease and may impact treatment decisions and prognosis.

Level V: Posterior Triangle and Supraclavicular Lymph Nodes

Level V encompasses the nodes of the posterior triangle group, located posteriorly to the sternocleidomastoid muscle. These nodes are found around the lower part of the spinal accessory nerve and the transverse cervical vessels.

Clinical Significance and Drainage Patterns

Level V nodes are of particular importance in the context of certain head and neck cancers. They are at risk of harboring metastases from:

Nasopharyngeal carcinoma
Oropharyngeal carcinoma
Cutaneous malignancies of the posterior scalp and neck

Additionally, level V nodes may be involved in cases of thyroid cancer and certain non-head and neck malignancies, such as lung cancer, breast cancer, and gastrointestinal tract cancers.

Advanced Imaging Techniques for Cervical Lymph Node Evaluation

Accurate assessment of cervical lymph nodes is crucial for proper staging and treatment planning in head and neck oncology. While traditional imaging modalities like CT and MRI remain the cornerstone of evaluation, advanced techniques have emerged to enhance diagnostic accuracy.

Ultrasound-Guided Fine Needle Aspiration (US-FNA)

US-FNA has become an invaluable tool in the evaluation of cervical lymph nodes. This technique allows for real-time visualization and targeted sampling of suspicious nodes, improving diagnostic yield and reducing false-negative results.

PET-CT Imaging

Positron Emission Tomography-Computed Tomography (PET-CT) has revolutionized the assessment of cervical lymph nodes in oncology. By combining functional and anatomical information, PET-CT can detect metastatic disease with high sensitivity and specificity, aiding in both initial staging and post-treatment surveillance.

Clinical Applications of Cervical Lymph Node Mapping

Understanding the cervical lymph node map has numerous practical applications in clinical practice, particularly in the fields of oncology, radiology, and surgery.

Tumor Staging and Treatment Planning

Accurate mapping of cervical lymph nodes is essential for proper TNM staging of head and neck cancers. The extent and location of nodal involvement directly impact treatment decisions, including the choice between surgery, radiation therapy, chemotherapy, or a combination approach.

Surgical Planning and Neck Dissection

For surgeons, a thorough understanding of cervical lymph node anatomy is crucial when planning and executing neck dissections. The lymph node map serves as a guide for determining the extent of dissection required based on the primary tumor site and the pattern of nodal spread.

Radiation Therapy Field Design

In radiation oncology, the cervical lymph node map is instrumental in designing treatment fields. Precise delineation of nodal levels ensures adequate coverage of at-risk areas while minimizing radiation exposure to critical structures.

Emerging Trends in Cervical Lymph Node Assessment

The field of cervical lymph node evaluation continues to evolve, with new technologies and approaches emerging to enhance diagnostic accuracy and guide treatment decisions.

Artificial Intelligence in Imaging Analysis

Machine learning algorithms are being developed to assist radiologists in the detection and characterization of metastatic lymph nodes. These AI-powered tools have the potential to improve diagnostic accuracy and efficiency in cervical lymph node assessment.

Sentinel Lymph Node Biopsy in Head and Neck Cancer

While sentinel lymph node biopsy (SLNB) is well-established in breast cancer and melanoma, its role in head and neck cancer is still evolving. Recent studies have shown promising results for SLNB in early-stage oral cavity cancers, potentially allowing for more targeted and less morbid surgical approaches.

Molecular Imaging Techniques

Advanced molecular imaging techniques, such as novel PET tracers and nanoparticle-enhanced MRI, are being investigated for their potential to improve the detection of micrometastases and provide more accurate nodal staging in head and neck cancers.

As our understanding of cervical lymph node anatomy and pathophysiology continues to grow, so too does our ability to accurately diagnose and treat head and neck cancers. The cervical lymph node map remains a fundamental tool in this ongoing quest, serving as a bridge between anatomical knowledge and clinical practice.

By mastering the intricacies of cervical lymph node mapping, healthcare professionals can ensure optimal patient care, from early detection to precise treatment planning and long-term follow-up. As we look to the future, continued research and technological advancements promise to further refine our approach to cervical lymph node assessment, ultimately improving outcomes for patients with head and neck malignancies.

The Radiology Assistant : Cervical Lymph Node Map

modified from Robbins

Aurelia Fairise and Robin Smithuis

Institut de Cancérologie de Lorraine in Nancy, France and the Alrijne hospital in Leiderdorp, the Netherlands

Publicationdate 2022-07-11

This article is based on the nomenclature proposed by the American Head and Neck Society and the American Academy of Otolaryngology-Head and Neck Surgery.

10 node groups are defined with a concise description of their main anatomic boundaries, the normal structures juxtaposed to these nodes, and the main tumor sites at risk for harboring metastases in those levels [1].

Overview

In this cervical lymph node map the levels were extended to 10.

Some of these are being divided into sub-levels to correspond more completely with the TNM atlas.

Borders

Important landmarks are:

Hyoid bone
Cricoid
Carotids
Sternocleidomastoid muscle
Manubrium of sternum

Axial CT

Axial CT slices in correlation to overview illustration.

Axial CT slices in more detail.
Enlarge images by clicking on them.

Levels

I – Submental and submandibular

Nodes in level I are at risk of developing metastases from cancers of the oral cavity, anterior nasal cavity and the soft tissues of the mid-face and the submandibular gland.

Level Ia
is a median region located between the anterior belly of the digastric muscles, which contains the submental nodes.

Level Ib
contains the submandibular nodes located in the space between the inner side of the mandible laterally and the digastric muscle medially, from the symphysis menti anteriorly to the submandibular gland posteriorly.

II – Upper jugular

Level II receives lymphatics from the face, the parotid gland, and the submandibular, submental and retropharyngeal nodes.
Level II also directly receives the collecting lymphatics from the nasal cavity, the pharynx, the larynx, the external auditory canal, the middle ear, and the sublingual and submandibular glands [1].

Level II can be divided into level IIa and level IIb by drawing a line at the posterior edge of the internal jugular vein.

The nodes in level IIa and IIb are at risk of harboring metastases from cancers of the nasal and oral cavity, nasopharynx, oropharynx, hypopharynx, larynx and major salivary glands.

Level IIb is more likely associated with primary tumors of the oropharynx or nasopharynx, and less frequently with tumors of the oral cavity, larynx or hypopharynx [1].

III – Mid jugular

Level III receives efferent lymphatics from levels II and V, and some efferent lymphatics from the retropharyngeal, pretracheal and recurrent laryngeal nodes.
It collects the lymphatics from the base of the tongue, tonsils, larynx, hypopharynx and thyroid gland.

The inferior border of the cricoid is the border between level III and IVA.

Nodes in level III are at risk of harboring metastases from cancers of the oral cavity, nasopharynx, oropharynx, hypopharynx and larynx.

IV – Lower jugular and medial supraclavicular

The border between level IVa and IVb is set arbitrarily 2 cm cranial to the sterno-clavicular joint.

Level IVa
These nodes are at risk for harboring metastases from cancers of the hypopharynx, larynx, thyroid and cervical esophagus.
Rarely metastases from the anterior oral cavity may manifest in this location with minimal or no proximal nodal disease.

Level IVb
These nodes are at risk for harboring metastases from cancers of the hypopharynx, subglottic larynx, trachea, thyroid and cervical esophagus.

V – Posterior triangle and Supraclavicular

Level V contains the nodes of the posterior triangle group located posteriorly to the sternocleidomastoid muscle around the lower part of the spinal accessory nerve and the transverse cervical vessels.

Nodes in level V are most often associated with primary cancers of the nasopharynx, the oropharynx, the cutaneous structures of the posterior scalp, and the thyroid gland.

Level Vc – Supraclavicular

This level contains the lateral supraclavicular nodes located in the continuation of the posterior triangle nodes (level Va and Vb) from the cervical transverse vessels down to a limit set arbitrarily 2 cm cranial to the sternal manubrium.
It corresponds partly to the area known as the supraclavicular fossa.

Level Vc receives efferent lymphatics from the posterior triangle nodes (level Va and Vb) and is more commonly associated with nasopharyngeal tumors [1].

Transverse cervical artery
Scroll through the images for the anatomy of the transverse cervical artery.

VI – Anterior cervical

This level contains the superficial anterior jugular nodes (level VIa) and the deeper prelaryngeal, pretracheal, paratracheal and recurrent laryngeal nerve nodes (level VIb).

Level VIa
This level contains the superficially located anterior jugular nodes.

Level VIb
This level is contained between the medial borders of the common carotid arteries.
The nodes in this area are:

pre-laryngeal nodes in front of the larynx and cricoid
pre-tracheal nodes in front of the trachea
paratracheal nodes also called recurrent laryngeal nerve nodes

Delphian lymph node

The Delphian lymph node derived its name from the oracle of Delphi, whose prophecy would be a death secondary to laryngeal cancer.

It is a pretracheal node in level VIa located anterior to the cricoid and in between the cricothyroid muscles.

The recurrent laryngeal nerves branch off the vagus, the left at the aortic arch, and the right at the right subclavian artery.

The left laryngeal nerve can be compressed by subaortic lymph node metastases in the aorto-pulmonary window as seen in patients with lung cancer.

VII – Retropharyngeal and retrostyloid

Retropharyngeal nodes receive lymphatics from the mucosa of the nasopharynx, the Eustachian tube and the soft palate.

These nodes are at risk of harboring metastases from cancers of the nasopharynx, the posterior pharyngeal wall and the oropharynx (mainly the tonsillar fossa and the soft palate).

Level VIIa – retropharyngeal

These nodes lie within the retropharyngeal space, extending cranially from the upper edge of the first cervical vertebrae (massa lateralis) to the cranial edge of the body of the hyoid bone caudally (figure).

This space is bounded anteriorly by the pharyngeal constrictor muscles and posteriorly by the longus capitis and longus colli muscles.
Laterally, the retropharyngeal nodes are limited by the medial edge of the internal carotid artery.

Retropharyngeal nodes receive efferent lymphatics from the mucosa of the nasopharynx, the Eustachian tube and the soft palate.
These nodes are at risk of harboring metastases from cancers of the nasopharynx, the posterior pharyngeal wall and the oropharynx (mainly the tonsillar fossa and the soft palate).

Level VIIb – retrostyloid

The retro-styloid nodes are the cranial continuation of the level II nodes.
They are located in the fatty space around the jugulo-carotid vessels up to the base of skull at the jugular foramen.

Click to enlarge

The retro-styloid space is delineated by the internal carotid artery medially, by the styloid process and the deep parotid lobe laterally, by the vertebral body of C1 and the base of skull posteriorly and by the pre-styloid para-pharyngeal space anteriorly.

VIII – Parotid

This level contains the parotid node group, which includes the subcutaneous pre-auricular nodes, the superficial and deep intraparotid nodes and the subparotid nodes.

These nodes extend from the zygomatic arch and the external auditory canal down to the mandible.

They extend from the subcutaneous tissue laterally to the styloid process medially, and from the posterior edge of the masseter and the pterygoid muscles anteriorly to the anterior edge of the sternocleidomastoid muscle and the posterior belly of the digastric muscle posteriorly [1].

Click to enlarge

The parotid group receive lymphatic from the frontal and temporal skin, the eyelids, the conjunctiva, the auricle, the external acoustic meatus, the tympanum, the nasal cavities, the root of the nose, the nasopharynx, and the Eustachian tube.

They are at risk of harboring metastases from cancers of the frontal and temporal skin, orbit, external auditory canal, nasal cavities and parotid gland.

IX – Buccofacial

Level IX contains the malar and bucco-facial node group, which includes inconsistent superficial lymph nodes around the facial vessels on the external surface of the buccinator muscle.
These nodes extend from the caudal edge of the orbit (cranially) down to the caudal edge of the mandible (caudally) where they reached level Ib.

They lay on the buccinators muscle (medially) in the sub-cutaneous tissue, from the anterior edge of the masseter muscle and the Bichat’s fat pad (posteriorly) to the anterior sub-cutaneous tissue of the face.

The bucco-facial nodes receive efferent vessels from the nose, the eyelids, and the cheek.

They are at risk of harboring metastases from cancers of the skin of the face, the nose, the maxillary sinus (infiltrating the soft tissue of the cheek) and the buccal mucosa.

X – Retroauricular and occipital

Level Xa contains the retroauricular (also called mastoid) and subauricular nodes, which includes superficial nodes lying on the mastoid process from the cranial edge of the external auditory canal cranially to the tip of the mastoid caudally.

Level Xb contains the occipital lymph nodes, which are the cranial and superficial continuation of the level Va nodes up to the cranial protuberance. They lie from the posterior edge of the sternocleidomastoid muscle to the anterior (lateral) edge of the trapezius muscle.

Lymph node metastases in level X are from skin cancers of the retro-auricular area (Xa) and skin cancers of the occipital area (Xb).

Click on the image below to get more information about Medical Action Myanmar, a medical organization run by Nini Tun and Frank Smithuis, who happens to be the brother of Robin Smithuis.

Delineation of the neck node levels for head and neck tumors: A 2013 update. DAHANCA, EORTC, HKNPCSG, NCIC CTG, NCRI, RTOG, TROG consensus guidelines
DAHANCA, EORTC, HKNPCSG,NCIC CTG, NCRI, RTOG, TROG consensus guidelines.
by V Grégoire et al.
Radiother Oncol 2014 ;110:172–81.
Integrating radiological criteria into the classification of cervical lymph node disease.
by Robbins KT.
Arch Otolaryngol Head Neck Surg 1999 ;125:385–7.
International association for the study of lung cancer (IASLC) lymph node map: radiologic review with CT illustration.
by El-Sherief AH, Lau CT, Wu CC, Drake RL, Abbott GF, Rice TW.
Radiographics. 2014 Oct;34(6):1680-91.

Thoracic Lymph Nodes Anatomy, Diagram & Function

Thoracic Lymph Nodes Anatomy, Diagram & Function | Body Maps

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Medically reviewed by the Healthline Medical Network — By The Healthline Editorial Team on July 6, 2020

Thoracic lymph nodes are separated into two types: parietal lymph nodes located in the thoracic wall, and visceral lymph nodes, which are associated with the internal organs. Due to their location, abnormalities of the lymph nodes in the thorax, or chest, are not easily detected. However, any changes in the size or amount of these lymph nodes could be indicative of several types of extrapulmonary or pulmonary diseases. For diagnostic purposes, lymph nodes of the thorax can be further divided into sub-categories. The lung lymph nodes can be found along the bronchi. The paratracheal and tracheobronchial groups of lymph nodes are located in the neck and also in the junction where the trachea meets the bronchi, respectively. These accept drainage from the heart, lungs, bronchi, and thoracic trachea as well as other lymph nodes. The posterior mediastinal group of lymph nodes, located near the thoracic aorta, is closely linked to the tracheobronchial group and primarily drains into the thoracic duct. The chest wall thoracic lymph nodes receive drainage from the breasts, arms, pectoral muscles, and other muscles and skin located in the upper section of the chest.

Last medically reviewed on July 6, 2020

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Medically reviewed by the Healthline Medical Network — By The Healthline Editorial Team on July 6, 2020

IASLC Intrathoracic Lymph Node Map – e-Anatomy

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Anatomy of the lymphatic system–Lymphosurgery Center

The lymphatic system – is an important part of the human cardiovascular system and complements it.

Unlike the circulatory system, the lymphatic system does not have its own pump and is open. The lymph circulating in it moves slowly and under little pressure. Lymph is a fluid that is constantly formed by drainage of interstitial fluid into the lymphatic capillaries.

The structure of the lymphatic system includes:

• Lymphatic capillaries
• Lymphatic vessels
• Lymphatic nodes
• Lymphatic trunks and ducts of

from lymph capillaries enters the lymph vessels, and then to the ducts and trunks: to the left in the sternum (the very thoracic duct (itself large duct), left jugular and left subclavian trunks; on the right into the right lymphatic duct, right jugular and right subclavian trunks. The ducts and trunks flow into the large veins of the neck, and then into the superior vena cava. In this way, lymph is transferred from the interstitial spaces back into the blood.

Lymphatic vessels pass through the lymph nodes. They are combined into several groups and are located along the vessels. Many afferent vessels carry lymph to the node, and it flows out from there only through one or two efferent vessels. Lymph nodes are small formations of a round, oval, bean-shaped, less often ribbon-shaped form up to 2 cm long. Here, lymph is filtered, foreign matter is separated and destroyed, and lymphocytes are produced here to fight infection. Lymph nodes that perform a barrier and immune role.

Basic functions of the lymphatic system:

• Transport function – carrying lymph, metabolic products from tissues to the venous bed.

• Drainage function – the return of proteins, water, salts, toxins and metabolites from tissues to the blood. Removal of fluid, pus, effusion from the wound, cavities. Stability of the “capillary lymphatic pump”

• Lymphocytopoiesis, hematopoietic function – formation, maturation, differentiation of lymphocytes involved in immune reactions.

• Immune, protective functions – formation of the body’s immune defense, neutralization of foreign particles, bacteria, viruses, fungi, protozoa that enter the body.