Lymphatic Pathways of the Upper Limbs PDF

Lymphatic Pathways VASCULAR PATHOLOGY AND PHYSIOTHERAPY: UNIT 3 Unit Objectives To gain knowledge of the pathways in which lymph travels through the vessels and lymph nodes to the terminus in the following regions: ◦ Head and neck ◦ Upper limbs ◦ Lower limbs ◦ Pelvis and abdomen ◦ Thorax Upper L...

Lymphatic Pathways VASCULAR PATHOLOGY AND PHYSIOTHERAPY: UNIT 3 Unit Objectives To gain knowledge of the pathways in which lymph travels through the vessels and lymph nodes to the terminus in the following regions: ◦ Head and neck ◦ Upper limbs ◦ Lower limbs ◦ Pelvis and abdomen ◦ Thorax Upper Limbs Upper Limb Lymphatic Pathways and Nodes Lymphatic Pathways Superficial Nodes of the Upper Limb Superficial Deep axillary Deltopectoral Pectoral Superficial Cubital/ Supratrochlear Subscapularis Deep Middle forearm Radial Medial Ulnar Lateral Anterior and posterior interosseous Brachial Lateral Central Apical Superficial Vessel Pathways •Subcutaneous tissue of the upper limb •Accompany the path of the superficial veins •More numerous than those of the deep pathways Superficial Vessel Pathways: The Hand Fingers: collectors run each side of each finger, inclining towards dorsum. Web space collectors pass to dorsum. Ulnar group: collectors drain hypothenar eminence and pass medially to wrist dorsum (posterior). Radial group: collectors drain thenar eminence and pass laterally to wrist dorsum (posterior). Middle forearm territory: some collectors drain the central palm and medial forearm on anterior side. Superficial Vessel Pathways: The Lower Arm The middle forearm territory ascends the anterior surface, the radial bundle follows the cephalic vein, and the ulnar territory follows the basilic vein. The medial, lateral and middle forearm bundles pass anteriorly at the elbow. Capillaries continue to anastomose and drain lymph from the surrounding superficial tissues. Superficial Vessel Pathways: The Upper Arm Some cephalic collectors converge with the basilic collectors following the median cubital vein. Other cephalic collectors continue laterally up the arm, and the basilic collectors continue the anteromedial route towards the axilla. Some lateral vessels drain into the superficial deltopectoral nodes and the deep apical lymph nodes, or supraclavicular nodes Some medial vessels drain into the superficial cubital nodes, and more proximally into the deep axillary nodes The Superficial direction of flow Variation in People… ICG lymphographies performed on 102 patients, and the resulting flows were examined3. • 3 territories of the forearm • 2 territories of the upper arm • Varying convergence at the elbow Derivative Vessel Pathways The derivative pathways from the upper limb derive from some cephalic and posterior lymphatic vessels of the upper limb. Two example pathways: o Mascagni pathway (cephalic bundles → supraclavicular nodes) o Caplan pathway (posterior → subscapular nodes) The presence of these pathways is not consistent between people, but may represent a reason why not all breast cancer patients with the top two secondary lymphoedema risk factors (node dissection and radiation) develop lymphoedema Derivative Vessel Pathways The presence/access of these pathways varies from one patient to another Research in 20192 shows MLD increases the uptake of lymph to these alternative pathways Lymph entering clavicular nodes post MLD Lymph entering subscapular nodes post MLD Deep Vessel Pathways •Drain tissues deep to the fascia •These tissues include muscles, tendons and joint capsules •They are not as numerous as the superficial pathways. Deep Vessel Pathways The lymphatic collector vessels follow the course of the following vascular bundles: o Radial o Ulnar o Anterior and posterior interosseous o Brachial The vessels flow to the deep axillary nodes They may pass through deep interval nodes additionally, commonly near the deep brachial artery. Upper Limb Lymphatic Pathways and Nodes Lymphatic Pathways Superficial Nodes of the Upper Limb Superficial Deep axillary Deltopectoral Pectoral Superficial Cubital/ Supratrochlear Subscapularis Deep Middle forearm Radial Medial Ulnar Lateral Anterior and posterior interosseous Brachial Lateral Central Apical Superficial Nodes of the Upper Limb Deltopectoral Located in the gap in musculature between the deltoids and pec major. The Cephalic vein runs through this gap before piercing deep fascia. • Afferent and efferent vesselslateral collectors Cubital/supratrochlear Located 5cm superior to the medial epicondyle, in close proximity to the basilic vein. • Afferent and efferent vessels- medial collectors Superficial Nodes of the Upper Limb These nodes are located in the superficial fascia of the upper limb. They can be divided into 2 groups: o Deltopectoral o Superficial cubital/supratrochlear Deep Nodes of the Upper Limb Anterior Posterior Deep Nodes of the Upper Limb The deep nodes occur mainly in the axilla, however there are also some nodes running along vessel pathways medial to the brachial vein and within the cubital fossa. There are 10-24 axilla nodes, divided into 5 groups: o Pectoral o Subscapular o Lateral o Central o Apical Deep Nodes of the Upper Limb Lateral nodes sit laterally in the axilla. ◦ Primarily from superficial basilic, and deep brachial collectors Subscapular nodes sit in the posterior wall of the axilla. ◦ drain the shoulder, inferior neck and superior back. Pectoral nodes sit within the pecs (anterior axilla). ◦ drain the anterolateral thorax, anterior part of the abdomen, and the mammary gland. Deep Nodes of the Upper Limb The central nodes sit centrally in the axilla. ◦ Drain from the lateral, subscapular and pectoral nodes, as well as some lymph directly from the mammary gland. Apical nodes (/infraclavicular nodes) sit just inferior to the clavicle. ◦ Drain primarily from central nodes (as well as other axillary nodes), the superficial lateral upper limb collectors, and the mammary gland Deep Nodes of the Upper Limb The axillary lymph nodes are intercommunicated by lymphatic vessels, forming the axillary plexus. Generally, there is an order of flow: oFirst station: lateral, pectoral (anterior) and subscapular (posterior) groups drain into oSecond station: the central group, and then into oThird station: the apical group. Upper Limb Lymphatic Pathways and Nodes Lymphatic Pathways Superficial Nodes of the Upper Limb Superficial Deep axillary Deltopectoral Pectoral Superficial Cubital/ Supratrochlear Subscapularis Deep Middle forearm Radial Medial Ulnar Lateral Anterior and posterior interosseous Brachial Lateral Central Apical From the Upper Limb Pathways to the Venous System The apical post nodal collectors anastomose and form the left and right subclavian trunks. Some collectors may otherwise join the left and right bronchomediastinal trunks (lots of the chains of nodes overlap between upper limb and thorax). These then enter the right lymphatic duct and the thoracic duct respectively. The lymph flowing within these vessels then reaches it’s terminus; the venous system. REMEMBER: This gives an example of general routes of flow, but there is variation in people, and lots of collateral vessels Node Group Pathway/Tissue Area Drained (Superficial) Deltopectoral Superficial lateral vessels (Superficial) Cubital/supratrochlear Superficial medial vessels (Deep) Lateral axillary _______ vessels, ______ vessels (Deep) Apical axillary Superficial lateral vessels (some via deltopectoral), primarily (deep) _______ axillary nodes (Deep) Subscapular axillary Some derivative vessels ________, ________, ________ (Deep) Central axillary From other deep node groups; _______, _______, ________ (Deep) Pectoral axillary Anterolateral thorax, mammary gland, part of abdomen References: 1. Földi, Michael, et al., eds. Földi's textbook of lymphology: for physicians and lymphedema therapists. Elsevier Health Sciences, 2012. 2. Medina-Rodríguez, María Elena, et al. "Visualization of accessory lymphatic pathways, before and after manual drainage, in secondary upper limb lymphedema using indocyanine green lymphography." Journal of Clinical Medicine 8.11 (2019): 1917. 3. Granoff, Melisa D., et al. "The superficial and functional lymphatic anatomy of the upper extremity." Plastic and reconstructive surgery 150.4 (2022): 900.