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PICTORIAL REVIEW
1
Baylor College of Medicine, One Baylor Plaza, BCM 360 and 2Diagnostic Radiology, The University of Texas, M.D.
Anderson Cancer Center, 1515 Holcombe Boulevard Box 57, Houston, Texas 77030, USA
ABSTRACT. The normal pathways of lymphatic drainage from the abdominal organs
have been well described in the classic anatomy literature. Knowledge of the location
and nomenclature of the common nodal stations in the abdomen are essential for
complete report of radiological findings. CT is ubiquitous in the evaluation of oncology
patients. Utilizing colour-coded CT images of the abdomen we will present the
nomenclature and location of the nodal stations for common abdominal neoplasms, Received 25 October 2005
including those of the stomach, pancreas, liver, colon and the kidney. Understanding Revised 13 January 2006
the nomenclature and the usual lymphatic pathways of metastasis will help radiologists Accepted 6 February 2006
detect disease spread from abdominal tumours. The goal of this pictorial review is to
DOI: 10.1259/bjr/64292252
present the nodal stations, nomenclature and location of regional lymph nodes for the
most common abdominal neoplasms. In addition, the reader can use this document as a ’ 2007 The British Institute of
handbook to learn and review this information. Radiology
Gastric cancer
Gastric cancer is the third most common gastrointestinal
malignancy and is the sixth leading cause of cancer death.
The most common histological type is adenocarcinoma
Figure 4. Diagram of the abdomen: right colic (dark green); (95%). It is most commonly located in the lesser curvature
superior mesenteric (aqua); middle colic (light green); (60%). Some of the related risk factors are smoking, nitrites,
paracolic (red); left colic (pink); sigmoid (purple); inferior nitrates, pernicious anaemia, chronic atrophic gastritis and
mesenteric (orange). villous polyp. The 5 year survival rate for a curative
Hepatocellular carcinoma
NX Regional lymph nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Regional lymph node metastasis
surgical resection ranges from 30% to 50% (stage II) and adenocarcinomas (exocrine ductal epithelium, 95% of
from 10% to 25% for patients with stage III disease [14]. cases). Pancreatic cancer generally develops without early
Adjuvant therapy has been considered. symptoms, except when it is close to the bile duct and causes
The nodal staging for gastric cancer based on AJCC biliary obstruction. Up to two-thirds may be located in the
criteria is listed in Table 1. Table 2 lists the regional head of the pancreas. Approximately 30% of cases are
lymph nodes for gastric cancer and the corresponding related to smoking and 20% are associated with the type of
CT colour-coded images of the abdomen demonstrating
the anatomical location.
Table 3. Additional lymph nodes for lymphoproliferative
disorders
Figure 6. CT image of the abdomen demonstrates the Figure 9. CT image of the abdomen demonstrates the
following nodal stations: left gastric (pink); greater curva- following nodal stations: gastroduodenal (green); pericolic
ture (blue); left inferior phrenic (green). (pink); superior mesenteric (light blue); interaortocaval
(yellow); right gastroepiploic (red).
Figure 8. CT image of the abdomen demonstrates the Figure 11. CT image of the abdomen demonstrates the
following nodal stations: greater curvature (blue); right following nodal stations: splenic (yellow); periportal (green);
gastric (red); right colic (yellow). anterior pancreatic (red); hepatic (orange).
Figure 12. CT image of the abdomen demonstrates the Figure 15. CT image of the abdomen demonstrates the
following nodal stations: coeliac axis (green); hepato- following nodal stations: lateral aortic (light blue); right
duodenal (blue); common hepatic (red). gastroepiploic (yellow); interaortocaval (blue); pyloric
(green); superior mesenteric (pink).
Figure 18. CT image of the abdomen demonstrates the Figure 20. CT image of the abdomen demonstrates the
following nodal stations: lateral aortic (light blue); retrocaval following nodal stations: juxtaintestinal (yellow); medial
(green); lateral caval (pink); pre-aortic (red); pre-caval (dark common iliac (light blue); lateral common iliac (green);
blue). ileocolic (pink); anterior cecal (dark blue); posterior cecal (red).
Hepatocellular carcinoma
diet (high in fat). Risk is also increased with obesity, chronic Hepatocellular carcinoma (HCC) is the most common
pancreatitis, prior gastric surgery, diabetes, cirrhosis and primary visceral malignancy [14]. The age at diagnosis is
exposure to radiation or chemicals [15, 16]. It is resectable usually between 60 and 70 years with a male predomi-
only in approximately 10% of the cases at presentation. The nance of 5:1. HCC originates from the hepatocytes and
resectability of a local tumour depends on the involvement has fatty and fibrous elements. The main risk factor is
of major vascular structures, mainly arterial structures cirrhosis in up to 90% of cases (alcohol, viral hepatitis B
(coeliac axes, superior mesenteric artery), and length of and C). The mean survival time is 10 months. However,
involvement or occlusion of major venous structures with limited-stage disease and aggressive treatment
(superior mesenteric vein) [14]. The identification of nodal survival of 5 years may be achieved.
disease is difficult. The accuracy of both CT and MRI is The nodal staging for HCC based on AJCC criteria is
limited [17, 18]. The survival without treatment is 5 months listed in Table 1. Table 2 lists the regional lymph nodes
and with treatment (surgery¡neoadjuvant chemoradiation for hepatocellular carcinoma and the corresponding CT
with poor results) 8–14 months [16]. colour-coded images of the abdomen demonstrating the
The nodal staging for pancreatic cancer based on AJCC anatomical location.
criteria is listed in Table 1. Table 2 lists the regional
lymph nodes for pancreatic cancer and the correspond-
ing CT colour-coded images of the abdomen demonstrat- Colorectal cancer
ing the anatomical location.
Colorectal adenocarcinoma is the third most common
cancer and the third most common cause of cancer
Lymphoproliferative diseases
Abnormal lymph nodes can be seen in the abdomen
outside the described regional lymph nodes. Lymphoma
and some other lymphoproliferative disorders can
Figure 23. CT image of the abdomen demonstrates the present as enlarged, abnormal morphology and/or low
following nodal stations: retrocrural (red), inferior diaphrag- attenuation lymph nodes. Table 3 lists additional com-
matic (blue), middle colic (green). mon nodal stations in the abdomen that were not
included in Table 2 but are common sites of disease infiltration in non-small cell lung cancer. Chest 2003;123:
presentation in lymphoproliferative disorders. 463–7.
9. Tiguert R, Gheiler EL, Tefilli MV, Oskanian P, Banerjee M,
Grignon DJ, et al. Lymph node size does not correlate with
the presence of prostate cancer metastasis. Urology
Conclusion 1999;53:367–71.
10. Harisinghani MG, Barentsz J, Hahn PF, Deserno WM,
This pictorial review can be used as a handbook to
Tabatabaei S, van de Kaa CH, et al. Noninvasive detection
learn the nomenclature, location and regional lymph of clinically occult lymph-node metastases in prostate
nodes for the most common abdominal neoplasms as cancer. N Engl J Med 2003;348:2491–9.
detected with CT imaging. 11. Dodd GD 3rd, Baron RL, Oliver JH 3rd, Federle MP,
Baumgartel PB. Enlarged abdominal lymph nodes in end-
stage cirrhosis: CT-histopathologic correlation in 507
Acknowledgment patients. Radiology 1997;203:127–30.
12. Frija J, Bourrier P, Zagdanski AM, De Kerviler E. [Diagnosis
We would like to thank Nicholas Lang for his of a malignant lymph node]. J Radiol 2005;86:113–25.
assistance with the artwork and Nancy L Villarreal for 13. Harisinghani MG, Saksena MA, Hahn PF, King B, Kim J,
helping in the preparation of the manuscript. Torabi MT, et al. Ferumoxtran-10-enhanced MR lymphan-
giography: does contrast-enhanced imaging alone suffice
for accurate lymph node characterization? Am J Roentgenol
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