Last-intercalated node and direct lymphatic drainage into the thoracic duct from the thoracoabdominal viscera

  • Gen Murakami
  • Masato Abe
  • Tomio Abe


Objective: We clarified the configuration of the mediastinal lymphatics, focusing on the last intercalated lymph node and the direct drainage vessel to the thoracic duct, based on recent anatomical findings.Methods: We macroscopically observed the lymphatics during dissections of 205 cadavers in combination with routine histology. We also review the results of injection by other reserchers.Results: Efferent vessels draining directly into the thoracic duct or venous angle were frequently found in the following node groups: the right paratracheal node group corresponding to the last intercalated node in 98% of cadavers (201); the brachiocephalic angle node group in 85% of cadavers (174); the right recurrent nerve group in 46% (94); the left superior phrenic node group in 73% (150); the node group at the origin of the left common carotid artery (the preaortico-carotid node) in 37% (76); the pretracheal node group in 25% (51) and the left tracheobronchial node group in 36% (74). Last intercalated nodes appeared common for multiple drainage routes or regional lymphatics. These results were mostly consistent with injection studies by Riquet et al.1 Direct lymphatic drainage from the esophagus to the thoracic duct was observed in 19% of cadavers (39). Direct lymphatic drainage of lung segments to distant mediastinal nodes is also reviewed. The sentinel node concept is discussed in relation to the above observations.Conclusions: We hypothesize that the most critical sentinel node, if such usage is allowed, is situated as a guard for a limited specific route and for a common drainage route. We term it the “common terminal node”.

Key words

last intercalated node lymphatic drainage thoracic duct lung esophagus 


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  1. 1.
    Riquet M, Dupont P, Hidden G, Debesse B. Mediastinal lymphatic pathway of the azygos and aortic arches. Surg Radiol Anat. 1991; 13: 149–54.PubMedCrossRefGoogle Scholar
  2. 2.
    Veronesi U, Paganelli G, Galimberti V, Viale G, Zurrida S, Bedoni M, et al. Sentinel-node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph-nodes. Lancet 1997; 349: 1864–7.PubMedCrossRefGoogle Scholar
  3. 3.
    Borgstein PJ, Meijer S, Pijpers R. Intradermal blue dye to identify sentinel lymph-node in breast cancer. Lancet 1997; 349: 1668–9.PubMedCrossRefGoogle Scholar
  4. 4.
    Bass SS, Cox CE, Ku NN, Berman C, Reintgen DS. The role of sentinel lymph node biopsy in breast cancer. J Am Coll Surg 1999; 186: 183–94.CrossRefGoogle Scholar
  5. 5.
    Chu KU, Turner RR, Hansen NM, Brennan MB, Bilchik A, Giuliano AE. Do all patients with sentinal node metastasis from breast carcinoma need complete axillary node dissection? Ann of Surg 1999; 229: 536–41.CrossRefGoogle Scholar
  6. 6.
    Yano M. Anatomical study of the last mediastinal lymph nodes in relation to the progress of p-N2 non-small cell lung cancer. J Jpn Ass Chest Surg 1993; 7: 643–54.CrossRefGoogle Scholar
  7. 7.
    Yano M. Lymphatic drainage route in the mediastinum. Proc Ann Meet Lung Cancer Surgery with Midsternal Approach. 2000; 2: 16–7.Google Scholar
  8. 8.
    Aikou T, Shimazu H, Takao T, Baba M, Natsugoe S, Shimada M. Significance of lymph nodal metastases in treatment of esophagogastric adenocarcinoma. Lymphology 1992; 25: 31–6.PubMedGoogle Scholar
  9. 9.
    Hagiwara A, Takahashi T, Sawai K, Iwamoto A, Shimotsuma M, Yoneyama C, et al. Lymph nodal vital staining with newer carbon particle suspensions compared with india ink: experimental and clinical observations. Lymphology 1992; 25: 84–9.PubMedGoogle Scholar
  10. 10.
    Ueseka K, Yasui K, Morimoto T, Torii A, Yamamura Y, Kodera Y, et al. Visualization of routes of lympatic drainage of the gallbladder with a carbon particle suspension. J Am Coll Surg 1996; 183: 345–50.Google Scholar
  11. 11.
    Riquet M, Manac’h D, Dupont P, Dujon A, Hidden G, Debesse B. Anatomic basis of lymphatic spread of lung carcinoma to the mediastinum: anatomico-clinical correlations. Surg Radiol Anat 1994; 16: 229–38.PubMedCrossRefGoogle Scholar
  12. 12.
    Riquet M, Saab M, LePimpec-Barthes F, Hidden G. Lymphatic drainage of the esophagus in the adult. Surg Radiol Anat 1993; 15: 209–11.PubMedCrossRefGoogle Scholar
  13. 13.
    Murakami G, Sato I, Shimada K, Dong C, Kato K, Imazeki T. Direct lymphatic drainage of the esophagus to the thoracic duct. Surg Radiol Anat 1994; 16: 399–407.PubMedCrossRefGoogle Scholar
  14. 14.
    Japanese Society for Esophageal Diseases. Guidelines for the Clinical and Pathological Studies on Carcinoma of the Esophagus (in Japansese), 9th ed., Tokyo: Kanehara, 1994: 11–4.Google Scholar
  15. 15.
    The Japanese Lung Cancer Society. General Rules for Clinical and Pathological Record of Lung Cancer. 15th ed., Tokyo: Kanehara, 1999: 84–9.Google Scholar
  16. 16.
    Rusznyák, I, Földi M, Szabó G. Lymphatics and Lymph Circulation. Oxford: Pergamon Press, 1967: 54–78.Google Scholar
  17. 17.
    Haagensen CD, Feind CR, Herter FP, Weinberg JA. The Lymphatics in Cancer, Philadelphia: Saunders, 1972: 22–58.Google Scholar
  18. 18.
    Japanese Research Society for Gastric Cancer. Japanese Classification of Gastric Carcinoma. First English ed., Tokyo: Kanehara, 1995: 6–11.Google Scholar
  19. 19.
    Kutsuna M. Anatomy of the Lymphaticis of Japanese (in Japanese). Tokyo: Kanehara, 1968: 213-25.Google Scholar
  20. 20.
    Murakami G. Human lymphatics in the axillary, cervical and thoracic regions. In: Uchino S, Kato S, Ohtani O, eds. Lymphology. Niigata: Nishimura-shoten, 1997: 261–74.Google Scholar
  21. 21.
    Murakami G, Sato T, Takiguchi T. Topographical anatomy of the bronchomediastinal lymph vessels: their relationships and the formation of the collecting trunks. Arch Histol Cytol 1990; 53 (Suppl): 219–35.CrossRefGoogle Scholar
  22. 22.
    Fujii M, Murakami G, Yamaguchi T, Shimada K. Hoshi H, Tanaka T. Topographical anatomy of the internal mammary lymphatics in the superior mediastinum and anterior mediastinal nodes. Okajimas Folia Anat Jpn 1994; 71: 99–126.PubMedCrossRefGoogle Scholar
  23. 23.
    Sato T, Sakamoto H. Illustrations and photographs of surgical esophageal anatomy specially prepared for lymph node dissection. In: Sato, T, Iizuka T, eds. Color Atlas of Surgical Anatomy for Esophageal Cancer. Tokyo: Springer-Verlag, 1992: 25–90.CrossRefGoogle Scholar
  24. 24.
    Caplan I. Anatomical review of the lymph nodes of the human mediastinum. Surg Radiol Anat 1990; 12: 9–18.PubMedCrossRefGoogle Scholar
  25. 25.
    Riquet M, Hidden G, Debesse B. Direct lymphatic drainage of lung segments to the mediastinal nodes. J Thorac Cardiovasc Surg 1989; 97: 623–32.PubMedGoogle Scholar
  26. 26.
    Riquet M, Hidden G. Lymphatic drainage of the right atrium and ventricle of the heart. Surg Radiol Anat 1991; 13: 235–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Riquet M. Anatomic basis of lymphatic spread from carcinoma of the lung to the mediastinum: surgical and prognostic implications. Surg Radiol Anat 1993; 15: 271–7.PubMedCrossRefGoogle Scholar
  28. 28.
    Hirai I, Murakami G, Kimura W, Tanuma K, Ito H. Origin of the thoracic duct and pancreaticoduodenal lymphatic pathways to the para-aortic lymph node. J Hep Bil Pancr Surg 2001; 8: 441–8.CrossRefGoogle Scholar
  29. 29.
    Hirai I, Murakami G, Kimura W, Nara T, Dodo Y Long descending lympatic pathway from the pancreaticoduodenal region to the para-aortic node: its laterality and topographical relationship with celiac plexus. Okajimas Folia Anat Jpn 2001; 77: 189–99.PubMedCrossRefGoogle Scholar
  30. 30.
    Fisher B, Fisher ER. Barrier function of lymph node to tumor cells and erythrocytes. I. National node. Cancer 1967; 20: 1907–13.PubMedCrossRefGoogle Scholar
  31. 31.
    Fisher B, Fisher ER. Barrier function of lymph node to tumor cells and erythrocytes 2: effect of X-ray, inflammation, sensitization and tumor growth. Cancer 1967; 20: 1941–19Google Scholar
  32. 32.
    Fisher B, Saffer EA, Fisher ER. Studies concerning the regional lymph node in cancer 3: response of regional lymph node cells from breast and colon cancer patients to PHA stimulation. Cancer 1972; 30: 1202–15.PubMedCrossRefGoogle Scholar
  33. 33.
    Edwards JM, Kinmonth JB. Lymphovenous shunts in men. Br J Med 1969; 4: 579–81.CrossRefGoogle Scholar
  34. 34.
    Kinmonth JB. The Lymphatics: Diseases, Lymphography and Surgery. London: Williams and Wilkins, 1972: 56–69.Google Scholar
  35. 35.
    Negus D, Edwards ME, Kinmonth JB. Filling of cervical and mediastinal nodes from the thoracic duct and the physiology of Virchow’s node. Br J Surg 1970; 57: 267–71.PubMedCrossRefGoogle Scholar
  36. 36.
    Murakami G, Endo S, Dong C, Hoshi H, Tomita H. Collateral lymphatic configuration of the internal jugular chain and jugulo-omohyoid nodes. Okajimas Folia Anat Jpn 1994; 70: 313–8.PubMedCrossRefGoogle Scholar
  37. 37.
    Murakami G, Shimada K, Sato I, Kunieda H, Suzuki S, Hoshi H. Typology of the subclavian and axillary lymphatics. Clin Anat 1994; 7: 204–14.CrossRefGoogle Scholar
  38. 38.
    Japanese Society of Lymphology. Skipped metastasis of the lung and esophageal cancer (Abstracts, annual meeting symposium) (in Japanese). Jpn J Lymphology 1996; 19: 25–31.Google Scholar
  39. 39.
    Kosaka T, Ueshige N, Nakano Y, Akiyama T, Tomita F, Saito H, et al. Lymphatic routes of the stomach demonstrated by gastric carcinomas with solitary lymph node metastasis. Surg Today 1999; 29: 695–700.PubMedCrossRefGoogle Scholar
  40. 40.
    Kowalski LP, Bagietto R, Lara JRL, Santos RL, Silva JF, Magrin J. Prognostic significance of the distribution of neck node metastasis from oral carcinoma. Head Neck 2000; 23: 207–14.CrossRefGoogle Scholar
  41. 41.
    Teichman L. Das Saugadersystem von anatomichen Standpunkte. Leipzig: Engelmann, 1861. Cited from Rusznyák et al. (1967).Google Scholar
  42. 42.
    Shimada K, Fujii M, Sato H, Tanaka T, Murakami G, Goto N. Lymphatics of the thoracic surface of the diaphragm especially located around the inferior surface of the pericardial sac (Eng abstr). Acta Anat Nippon0 1995; 70: 11–19.Google Scholar
  43. 43.
    Kitagawa Y, Fujii H, Mukai M, Kubota T, Ando N, Watanabe M, et al. The role of the sentinel lymph node in gastrointestinal cancer. Surg Clin North Am 2000; 80: 1799–809.PubMedCrossRefGoogle Scholar
  44. 44.
    Hata E. Scintigraphical investigation of lymphatic drainage routes corresponding to the lung segment system (in Japanese). Nichi-Kyo (Chest Japan) 1985; 44: 17–24.Google Scholar
  45. 45.
    Little AG, DeHoyos A, Kirgan DM, Arcomano TR, Murray KD. Intraoperative lymphatic mapping for non-small-cell lung cancer: the sentinel node technique. J Thorac Cardiovasc Surg 1999; 117: 220–4.PubMedCrossRefGoogle Scholar
  46. 46.
    Sugi K, Sakamo H, Sato Y, Kaneda Y, Esato K. The accuracy and role of the sentinel node technique in patients with cT1N0M0 non-small-cell lung cancer. Jpn J Ass Chest Surg 2001; 15: 82–6.CrossRefGoogle Scholar
  47. 47.
    Naruke T, Suemasu K, Ishikawa S. Lymph node mapping and curability at various levels of metastasis in resected lung cancer. J Thorac Cardiovasc Surg 1978; 76: 832–9.PubMedGoogle Scholar
  48. 48.
    Asanuma H, Nakayama H, Kondo H, Tsuchiya R, Naruke T. Lobe-specific extent of systematic lymph node dissection for non-small cell lung carcinomas according to a retrospective study of metastasis and prognosis. J Thorac Cardiovasc Surg 1999; 117: 1102–11.CrossRefGoogle Scholar
  49. 49.
    Rice TW. Superficial oesophageal carcinoma: Is there a need for three-field lymphadenectomy? Lancet 1999; 354: 792–4.PubMedCrossRefGoogle Scholar

Copyright information

© Japanese Association for Thoracic Surgery 2002

Authors and Affiliations

  • Gen Murakami
    • 1
  • Masato Abe
    • 2
  • Tomio Abe
    • 3
  1. 1.Department of AnatomySapporo Medical University School of MedicineSapporoJapan
  2. 2.Department of Oral SurgerySapporo Medical University School of MedicineSapporoJapan
  3. 3.Department of Thoracic and Cardiovascular SurgerySapporo Medical University School of MedicineSapporoJapan

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