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Non-small cell lung cancer invading the visceral pleura is characterized by a particular richness of mediastinal lymph node (LN) metastases. This may be due to subpleural lymphatic drainage of tumor cells. The aim of this study was to determine mediastinal LN lymphatic drainage from the diaphragmatic pleura. Subpleural lymphatics of 30 adult cadavers and 12 fetuses were injected with a modified Gerota's medium to permit lymph vessels and nodes to be visualized and then dissected. Each stage of the dissection was described and photographed. In 32 cadavers mediastinal visceral LN chains were injected, of which 29 originated from the mediolateral portion of the diaphragm. On the right, injections (n=16) demonstrated lymph vessels (n=20) ascending directly along the inferior pulmonary ligaments (n=8) or after having encircled the inferior vena cava (n=8), and lymph vessels passing between the pulmonary veins (n=4); all these lymphatics were connected to the intertracheobronchial nodes and some ascended along the tracheobronchial LN chains in the upper mediastinum. On the left, injections (n=13) demonstrated lymph vessels (n=16) ascending along the inferior pulmonary ligament (n=5) or along the esophagus (n=11) and connecting to the intertracheobronchial nodes, some of which ascended further in the upper mediastinum (left paratracheobronchial LN chain). These mediastinal LN chains are the same as those that receive lymph from the pulmonary segments. Lymphatic drainage of the diaphragmatic pleura may add to that of the lung involved in cancer and potentially increases lymphatic spread of tumor cells.

Upper limb lymphoedema and associated radiation-damaged chest wall are complications occurring after breast cancer treatment. Previous anatomical and clinical studies have demonstrated the usefulness of inguinal lymph node autotransplantation in managing lymphoedema. The present anatomical study is a complement to previous studies about the cutaneous inguinal flap. It has demonstrated the feasibility of using a free inguinal cutaneo-lymph node flap supplied by the superficial circumflex iliac artery. The useful vascularized abdominal skin area ranged from 176 to 288 cm2 and was contained within a vascularized skin area extending up to 928 cm2. However, the vascularization never extended widely beyond the abdominal midline line. Although it mainly remains unilateral, this flap combining skin and lymph nodes may help in the management of lymphoedema and chest wall damage when they occur simultaneously as complications of breast cancer treatment. The French version of this article is available in the form of electronic supplementary material and can be obtained by using the Springer LINK server located at http://dx.doi.org/10.1007/s00276-002-0024-7.

The lymphatic drainage of the pericardium may have a prognostic value in lung cancer and its anatomical pattern was the purpose of this study. The lymphatic vessels of the pericardium were visualized on 12 fresh adult human cadavers by injection of a green colorant by means of the classical equipment for pedal lymphography. Seventeen injections were performed on the right side and 22 injections on the left side, visualizing 20 and 29 lymphatic pathways respectively. Whatever the side injected, the lymphatic vessels mainly directed toward the tracheobronchial nodes (n = 35) and less frequently toward the prepericardial lymphatic vessels and nodes (n = 14). Such results demonstrate the aggravating role played by the lymphatic drainage in the prognosis of the lung cancers invading the pericardium.

The prognosis of non small cell lung cancer (NSCLC) invading the diaphragm is poor, probably due to the richness of the lymphatic drainage of the diaphragm. The aim of this study was to determine mediastinal lymphatic efferents from the diaphragm. The diaphragms of 20 adult cadavers (77-104 years) were injected with a dye (modified Gerota's medium) to permit the lymph vessels to be catheterised and then dissected. Each stage of the dissection was described and photographed: 23 injections on the right and 25 on the left. Diaphragmatic lymph vessels passed to one of three lymph centres: posterior (paraaortic nodes, n = 16), anterior (juxtasternal nodes, n = 16) and mediastinal (visceral nodes, n = 16). From these lymph centres arose ascending lymph pathways: posteriorly to the thoracic duct (8/16), anteriorly along the internal thoracic vessels (10/16) and in the mediastinum to the peritracheobronchial nodes (6/10). Lymphatics from the diaphragm are abundant and drain towards mediastinal node lymph centres connecting to the blood stream via the thoracic duct. These lymph pathways are common with those of the pulmonary segments. Poor prognosis of NSCLC invading the diaphragm may be explained by the common lymphatic drainage of both the lung and diaphragm.

In its anatomy and physiology the pig is comparable with humans and its organs can be considered for xenotransplantation. We have studied the lymphatic drainage of the heart and lungs in 15 pigs. A coloured mass was injected into the myocardium and/or beneath the visceral pleura. The first nodes coloured were directly injected again. No lymph node was observed inside the heart and lungs. The first lymph nodes coloured were the peritracheobronchial nodes. There was no node in front of the thoracic trachea (Barety's compartment in man). Left suprabronchial nodes were connected with the thoracic duct in the mediastinum. The lymphatics of the heart and lungs in the pig are similar to those of human. Phylogenesis explains "skipping" metastases and the significance of N1 disease in lung cancer, as well as chylothorax occurring after heart and lung surgery.

The aim of this study was to describe in detail the anastomoses between the pulmonary lymphatic vessels and the veins of the neck so as to better understand their role in certain aspects of thoracic surgery. The lymphatic vessels of 687 pulmonary segments in 360 cadavers were injected. A detailed study of the proximal end of the right paratracheal, right tracheo-esophageal, left preaortocarotid and left recurrent lymph node chains was undertaken. The results showed the absence of any major right lymphatic "vein". There were, however, many lymphatic arches draining into the jugulo-subclavian confluence ipsilaterally, and, in 10 to 15% of cases, contralaterally as well. The intertracheobronchial lymph nodes also drained into the venous confluence of the neck via direct lymphatic vessels, without lymph node relays. Finally, the left mediastinal lymph node chains were frequently found to drain into the arch of the thoracic duct (40% of cases), and reflux due to valvular incompetence at this level may account for chylous pericarditis and some cases of chylothorax after surgery.

Correlation of the anatomic and surgical features in 360 cadavers and in 260 patients operated for bronchial carcinoma reveals that the lymphatics of the lung reach the ipsilateral mediastinum, sometimes directly and sometimes by sites which do not correspond to the anatomic site of the injection or of the pulmonary lesion. This implies the need for systematic eradication of all the lymph nodes of the ipsilateral mediastinum during surgery for bronchial carcinoma. In cases of tumoral lesions (N2), the prognosis is better when only one site is involved, whether the nodal disease is microscopic, uni- or multiglandular, with or without rupture of the capsule and whatever treatment is carried out, even when resection seems macroscopically complete to the surgeon. This is explicable in the light of the anatomic study, which shows that the lymph node chain is a functional entity which channels the lymph into the systemic circulation, either at the venous confluence of the neck or into the thoracic duct in the mediastinum. When only a single chain is affected, there is a greater than 70% chance that systemic metastases are already present, 90% when N2 affects 2 chains, while in N3 cases (lymph passage to contralateral chains) the incidence reaches virtually 100%. However, macroscopically satisfactory excision allows management of the local problem, and involvement of the mediastinal nodes, even with capsular rupture, cannot be considered as a contraindication in the absence of clinically detectable systemic metastases.

Lymphatic spread of carcinoma of the lung to the mediastinum is an essential factor determining prognosis. An anatomic study of the mediastinal lymph nodes was made on 360 cadavers of adult subjects based on injection of the pulmonary segment. Eleven anatomic sites were involved. In 20 to 40% of cases the lymph reached these sites without any relay in the intrapulmonary lymph nodes. Within these sites the lymph flow continued towards the systemic circulation by traversing a variable number of lymph nodes, or sometimes none. The lymph flow reached the venous circulation in the neck, but in more than one case in ten the lymph had already entered the thoracic duct in the mediastinum, and in an intermediate number of cases the sites in the opposite mediastinum.