纵隔淋巴结分区(解剖及影像学分区)

纵隔淋巴结纵隔淋巴结解剖特点：纵隔淋巴结平均数目为64个，大多数位于气管，支气管附近和大血管及食道周围．ⅠⅡⅣ主要是位于气管旁的淋巴结ⅢAⅤⅥ主要是位于大血管旁的淋巴结ⅦⅩⅪⅩⅪ主要是位于支气管旁的淋巴结ⅢPⅧ主要是位于食管周围淋巴结ClassificationofRegionalLymphNodesinJapanJapanSocietyofClinicalOncology(ed),Kanehara,Tokyo,2002.ClassificationofRegionalLymphNodesinJapanJapanSocietyofClinicalOncology(ed),Kanehara,Tokyo,2002.ClassificationofRegionalLymphNodesinJapanJapanSocietyofClinicalOncology(ed),Kanehara,Tokyo,2002.MountainandDreslerclassificationsystemSchemaofMountainandDreslerclassificationsystem1997年,Mountain修订了肺癌胸内淋巴分区系统被美国癌症联合会(theAmericanJointCommitteeonCancer,AJCC)和国际抗癌联盟(theUnionInternationalContreleCancer,UICC)广泛采纳,但其只是根据外科解剖情况定义各组淋巴结界线,并未在横断面上详细描述各组淋巴结的边界。Chest1997;111;1718-1723MountainandDreslerclassificationsysteml区最高位纵隔气管前淋巴结2区气管旁淋巴结3区气管前、后或后纵隔（3P）前纵隔（3a）淋巴结4区气管与支气管交界处淋巴结5区主动脉或Botallo淋巴结6区主动脉（升主动脉）旁淋巴结7区隆突下淋巴结8区隆突下食管旁淋巴结9区下肺韧带淋巴结10区肺门（主支气管）淋巴结11区肺叶间淋巴结12区叶（上、中、下叶）支气管淋巴结13区段支气管淋巴结14区段以下远支气管淋巴结CT-basedDefinitionofThoracicLymphNodeStations:anatlasfromtheuniversityofMichiganOlvierChapetetal.Int.J.RadiationOncologyBiol.Phys.,Vol.63,No.1,pp.170–178,2005Ⅰ&Ⅱ（highestmediastinalandupperparatrachealnodes）Ⅰ区：最高位纵隔气管前淋巴结Ⅱ区：左、右上气管旁淋巴结Ⅰ-Ⅱ区:一般常以胸骨颈静脉切迹为上界主动脉弓为下界左右界为纵隔胸膜前界为左头臂动脉,右锁骨下动脉右颈总动脉等大血管.后界为气管的后壁注:在Mountain的淋巴结分区里,1R的下界定义为无名静脉横跨气管前,使得2区位于其下至主动脉弓的上缘的距离非常的短,故将Ⅰ区-Ⅱ区合并为Ⅰ-Ⅱ区+Ⅲ区（prevascularnodesandretrotrachealnodes（图中未显示）Ⅲ区：3区气管前、后或后纵隔（3P）和前纵隔（3A）淋巴结3A为气管前胸骨后淋巴结，上界：同1～2区(胸骨颈静脉切迹)下界：左：与Ⅵ区相连右：上腔静脉前缘两侧界：左右纵隔胸膜前界：胸骨，锁骨头和肋骨后界：1~2区前缘除外左锁骨下动脉左颈总动脉，头臂(动脉)干3P：气管后淋巴结：气管后隆突上淋巴结上界：同1～2区(胸骨颈静脉切迹)下界:气管隆突前界：气管后壁后界:椎体的前壁及外侧壁3A3PⅣ区（lowerparatrachealnodes）ⅣⅣ区：左右下气管旁淋巴结4R:上界：主动脉弓上缘层面下界：右上叶支气管开口后界：气管后壁前界:左颈总动脉和升主动脉、主动脉弓前份后缘4L:上界：主动脉弓上缘层面下界：左上叶支气管开口前界:左颈总动脉和升主动脉、主动脉弓前份后缘外界:主肺动脉窗层面以上位于主动脉内侧,主肺动脉窗层面位于动脉韧带内侧(左肺动脉干以上于升主动脉和降主动脉圆心连线内侧)左肺动脉干以下则在左肺动脉干和左肺动脉内侧)。Ⅴ区subaortic(aortic-pulmonarywindow)Ⅴ区:主动脉下淋巴结(又叫主肺动脉窗淋巴结)上界:主动脉弓最大横截面以下下界右肺动脉横跨纵隔的最大横截面内侧:左主支气管开口层面以上与4L组淋巴结交界外界:纵隔胸膜内前界:出现右肺动脉前位于:升主动脉冠状面中平面延长线后,出现右肺动脉后局限于:肺动脉前缘后界:在出现肺动脉前位于降主动脉冠状面中平面延长线前,出现肺动脉后则位于降主动脉前和肺动脉前在出现右上肺静脉层面后界延续到右上肺静脉前缘主肺动脉窗Ⅴ区与左喉返神经及膈神经的关系左右喉返神经与纵隔淋巴结的关系Ⅵ区（paraaorticnodes）Ⅵ区主动脉旁淋巴结上界:主动脉弓上缘层面下界:与5区淋巴结同一水平前界和侧界:主动脉和主动脉弓外1cm后界:在主动脉弓和升主动脉前1/2肺动脉干前缘?Ⅶ区(subcarinalnodes)Ⅶ区隆突下淋巴结上界:在隆突下层面;下界:到隆突下约3cm。前界:到左右主支气管前壁水平线或右肺动脉后缘;后界:椎体前缘左外界:在奇静脉外缘;右外界:在右主支气管和右中间段支气管内侧Ⅷ区（paraeosphagealnodes）Ⅷ区食管旁淋巴结上界:同7区,是3P向下的延续;下界:沿食管至膈肌食管裂孔Ⅸ区（Pulmonaryligamentnodes）ⅨⅨ区下肺韧带淋巴结未提Ⅹ区（hilarnodes）Ⅺ区（interlobarnodes）Ⅹ统称肺门淋巴结。上界为上叶支气管开口层面;下界为下叶段支气管开口以上。头臂静脉弓水平头臂静脉弓水平主动脉弓水平奇静脉弓水平隆突水平上叶支气管开口水平下叶支气管开口水平OR隆突下３cmⅠRⅡRⅣRⅤⅦⅧⅩⅪRⅣLⅡLⅠLⅠ-Ⅱ左上叶支气管开口水平各区肿大淋巴结左上腔静脉主动脉瘤ProspectiveevaluationofcomputedtomographyandmediastinoscopyinmediastinallymphnodestagingEurRespirJ1997;10:1547–1551n=100LNslargerthan1cmwereconsideredCTpositive.MediastinalLymphNodeStagingWithFDG-PETScaninPatientsWithPotentiallyOperableNon-smallCellLungCancerN=50LNslargerthan1.5cmwereconsideredCTpositiveChest1997;112;1480-1486PETblindedtoCTweresignificantlybetter(p=0.004):Meta-AnalysisofPositronEmissionTomographicandComputedTomographicImaginginDetectingMediastinalLymphNodeMetastasesinNon-smallCellLungCancerAnnThoracSurg2005;79:375–81Meta-AnalysisofPositronEmissionTomographicandComputedTomographicImaginginDetectingMediastinalLymphNodeMetastasesinNon-smallCellLungCancerAnnThoracSurg2005;79:375–81FDGPETCTSensitivityrange66%~100%overallsensitivity83%Specificityrange81%~100%Overallspecificity92%20%~81%44%~100%59%78%LymphNodeSizeandMetastaticInfiltrationinNon-smallCellLungCancerChest2003;123;463-467NonmetastaticlymphnodesMetastaticlymphnodesn2486(86%)405(14%)size7.05±3.75mm10.7±4.7mm(p＝0.005).size10mm1953(79%)170(44%)size10-14mm404(16%)137(34%)size≥15mm130(5%)87(22%)256patients2,891lymphnodesConclusion:LymphnodesizeisnotareliableparameterfortheevaluationofmetastaticinvolvementinpatientswithNSCLC.Real-timeendobronchialultrasoundguidedtransbronchialneedleaspirationforsamplingmediastinallymphnodesThorax2006;61;795-798;Sensitivitywas94%,specificity100%,andthepositivepredictivevaluewas100%Nocomplicationsoccurred.THANKYOU