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Significance of level III lymph nodes located in the anterior
fat recess between the sternocleidomastoid muscle, thyroid
cartilage and jugular vein in head and neck tumors
Poster No.:
C-0678
Congress:
ECR 2014
Type:
Educational Exhibit
Authors:
L. Oleaga Zufiría , J. Berenguer , E. Verger , I. Valduvieco , J.
1
2 1
2
2
2
2
Blanch ; Bilbao/ES, barcelona/ES
Keywords:
Head and neck, CT, Diagnostic procedure, Pathology
DOI:
10.1594/ecr2014/C-0678
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Page 1 of 27
Learning objectives
To show the anatomy of the anterior fat recess between the sternocleidomastoid muscle,
thyroid cartilage/gland and internal jugular vein
To describe the fixation jugular vein sign associated to metastatic lymph nodes located
in this area
To emphasize the relevance of evaluating this region on imaging studies
Background
The anterior fat recess between the sternocleidomastoid muscle (SCM), thyroid cartilage/
gland, carotid artery and the internal jugular vein (IJV) is a small triangle filled with fat
(Figures 1,2). The superior belly of the omohyoid muscle represents the anterior and
inferior anatomic landmarkfor this region.
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Fig. 1: Anatomical boundaries of the anterior fat recess (level III) (yellow triangle).
T- Thyroid cartilage, CA- Carotid Artery, IJV- Internal Jugular Vein, SCMSternocleidomastoid muscle.
References: Department of Radiology, Hospital Clinic Barcelona
Page 3 of 27
Fig. 2: Close view of the anatomical boundaries of the anterior fat recess (level III)
(yellow triangle). T-Thyroid cartilage,CA- Carotid Artery, IJV- Internal Jugular vein,
SCM- Sternocleidomastoid muscle.
References: Radiology Department Hospital Clinic Barcelona
It is bordered anterolaterally by the sternocleidomastoid muscle, anteromedially by the
thyroid cartilage lamina/gland and posteromedially by the internal jugular vein and the
Page 4 of 27
carotid artery. The superior limit is the hyoid bone and the inferior limit is the cricoid
cartilage.
The deep cervical lymph nodes lie along the course of the internal jugular vein. The vein
passes deep to the interval between the two heads of the sternocleidomastoid muscle.
Level III contains the middle jugular lymph nodes located around the middle third of the
IJV. It is the caudal extension of level II. The upper level II lymph nodes lye along the
lateral and anterior margins of the internal jugular vein; however the lymph nodes in the
anterior margin nearly disappear in the middle group.
It is limited cranially by the inferior edge of the body of the hyoid bone, and caudally by
the inferior edge of the cricoid cartilage. The anterior limit is the posterolateral border of
the sternohyoid muscle and the anterior border of the SCM muscle, and the posterior
limit is the posterior edge of the SCM muscle Laterally level III is limited by the medial
edge of the SCM muscle and medially by the medial edge of the internal carotid artery
and the scalenius muscles.
Level III receives efferent lymphatics from levels II and V, and some efferent lymphatics
from the retropharyngeal, pretracheal and recurrent laryngeal nodes. It also receives the
lymphatics from the base of the tongue, tonsils, larynx, hypopharynx and thyroid gland.
Level III nodes can be located in the anterior fat recess or in the posterior fat recess.
Lymph nodes located in the anterior fat recess can go unnoticed. This is a narrow region
with closed anatomical limits (Figure 3).
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Fig. 3: Level III lymph node in the anterior fat recess. ln- lymph node, T- Thyroid gland,
CA- Carotid Artery, IJV- Internal Jugular Vein, SCM- Sternocleidomastoid muscle.
References: Radiology Department, Hospital Clinic Barcelona
Most level III nodes are located in the posterior fat recess, this is a wider space with no
anatomical tight boundaries, lymph nodes in this recess are easier to depict on imaging
studies (Figures 4,5).
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Fig. 4: Posterior fat recess (blue triangle). T- Thyroid, CA- Carotid Artery, IJV- Internal
Jugular Vein, SCM- Sternocleidomastoid muscle.
References: Radiology Department, Hospital Clinic Barcelona
Fig. 5: Diagram showing both the anterior (yellow triangle) and posterior fat recesses
(blue triangle), corresponding to the location of level III lymph nodes.
Page 7 of 27
References: Radiology Department, Hospital Clinic Barcelona
Imaging techniques are important tools that can improve the accuracy of nodal neck
staging for better management of patients with head and neck tumors.
Recently, several authors have advocated the concept of limited treatment; selective
neck dissection and/or selective neck irradiation, for limited stage tumors and there have
been established consensus guidelines (DAHANCA, EORTC, GORTEC) and in North
America (NCIC, RTOG) on how to treated nodal disease in head and neck tumors. It
has been suggested that more selective treatment could decrease the radiation dose on
critical organs such the parotids, but an inadequate selection of target volumes could
have negative effects on disease control and prognosis.
Detection and classification of metastatic lymphadenopathy on imaging, in patients with
head and neck tumors, relays upon evaluation of nodal morphology and size. Nodal size
is one of the most important morphologic features to detect metastatic nodal disease
from head and neck tumors. However the sensitivity and specificity of morphologic and
size criteria is limited.
Images for this section:
Page 8 of 27
Fig. 1: Anatomical boundaries of the anterior fat recess (level III) (yellow
triangle). T- Thyroid cartilage, CA- Carotid Artery, IJV- Internal Jugular Vein, SCMSternocleidomastoid muscle.
Fig. 2: Close view of the anatomical boundaries of the anterior fat recess (level III)
(yellow triangle). T-Thyroid cartilage,CA- Carotid Artery, IJV- Internal Jugular vein, SCMSternocleidomastoid muscle.
Page 9 of 27
Fig. 9: (Table 1) Relation of patients with level III lymph nodes located in the anterior fat
recess with the fixation sign in the anterior wall of the jugular vein
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Fig. 3: Level III lymph node in the anterior fat recess. ln- lymph node, T- Thyroid gland,
CA- Carotid Artery, IJV- Internal Jugular Vein, SCM- Sternocleidomastoid muscle.
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Fig. 6: Normal lymph node in the anterior fat recess. No depression or fixation of the
anterior wall of the jugular vein (yellow arrows).
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Fig. 7: Small metastatic lymph node with no size criteria for malignancy, producing
depression and fixation of the anterior wall of the jugular vein (red arrows).
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Findings and procedure details
Petite normal lymph nodes can be found in the anterior fat recess (Figure 6).
Fig. 6: Normal lymph node in the anterior fat recess. No depression or fixation of the
anterior wall of the jugular vein (yellow arrows).
References: Radiology Department Hospital Clinic Barcelona
Small metastatic lymph nodes, with no size criteria for malignancy, growing in the
carotid triangle can infiltrate local structures such the jugular vein, producing fixation and
depression of the anterior wall (Figure 7).
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Fig. 7: Small metastatic lymph node with no size criteria for malignancy, producing
depression and fixation of the anterior wall of the jugular vein (red arrows).
References: Radiology Department, Hospital Clinic Barcelona
The jugular vein wall fixation can represent the first sign of malignancy, before the
metastatic lymph nodes enlarge to a size considered pathologic. It is important to check
for nodes located in this recess and always look for this sign.
The posterior triangle compartment is larger with no tight boundaries, lymph nodes can
enlarge with no effect on the jugular vein wall (Figure 8).
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Fig. 8: T4N2c left pyriform sinus tumor. Large level III lymph node (LN) in the posterior
triangle, pushing and producing a small deformity on the psoterior wall of IJV (red
arrow).
References: Radiology Department, Hospital Clinic Barcelona
We present 19 cases of head and neck tumors with level III nodes in this anterior fat
recess with the associated fixation and depression sign on the jugular vein.
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Fig. 9: (Table 1) Relation of patients with level III lymph nodes located in the anterior
fat recess with the fixation sign in the anterior wall of the jugular vein
References: Department of Radiology, Hospital Clinic Barcelona
Page 17 of 27
Fig. 10: T1N0 lateral right lingual edge squamous cell carcinoma. Small lymph node
with no size criteria for malignacy, no necrosis or extranodal extension (red arrow).
On CT a depression of the anterior wall of the IJV is depicted (small red arrows). The
patient underwent surgery of the lingual mass with no lymphadenectomy.
References: Radiology Department, Hospital Clinic Barcelona
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Fig. 11: Same patient as the one shown in Figure 8. Six months after surgery The
same lymphn node has increased in size (red arrow), with more depression of the
anterior wall of the IJV (small red arrows). Lymphadenectomy performed this time
revealed metastatic squamous cell carcinoma.
References: Radiology Department, Hospital Clinic Barcelona
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Fig. 12: T4N2b supraglottic tumor. Small level III lymph node in the anterior fat
recess(red arrow), demonstrating the depression and fixation sign on the anterior wall
of the IJV (small red arrows).
References: Radiology Department, Hospital Clinic Barcelona
Page 20 of 27
Fig. 13: Same patient as Figure 12. After treatment with Chemotherapy and Radiation
the lymph node has desappeared and the IJV recovers the usual shape.
References: Radiology Department, Hospital Clinic Barcelona
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Fig. 14: T3N1 right laryngeal tumor. Right level III lymph node with the fixation sign
on the anterior wall of IJV (small red arrows). Surgery+Lymphadenectomy. Histology
demonstrated squamous cell infiltration in level III node.
References: Radiology Department, Hospital Clinic Barcelona
Fig. 15: T2N1 left pyriform sinus tumor. Small left level III node in the anterior recess,
showing the fixation sign on the anterior wall of IJV (red arrows).
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References: Radiology Department, Hospital Clinic Barcelona
Fig. 16: T2N1 left pyriform sinus tumor after Chemotherapy and Radiotherapy, same
patient as the one shown in Figure 15. The small left level III node in the anterior
recess has decreased in size and the IJV has recover the regular shape (yellow
arrows).
References: Radiology Department, Hospital Clinic Barcelona
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Fig. 17: T4N2b supraglottic tumor (T). Level III large lymph node with necrosis and
fixation sign in the anterior wall of the IJV (red arrows)
References: Radiology Department, Hospital Clinic Barcelona
The depression and fixation sign of the IJV may be useful to identify pathologic lymph
nodes without morphological or size to be considered such.
It can contribute to improved N staging of head and neck tumors, allowing to better plan
selective surgery and/or radiotherapy.
Images for this section:
Page 24 of 27
Fig. 16: T2N1 left pyriform sinus tumor after Chemotherapy and Radiotherapy, same
patient as the one shown in Figure 15. The small left level III node in the anterior recess
has decreased in size and the IJV has recover the regular shape (yellow arrows).
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Conclusion
Optimal outcome in squamous cell carcinomas of the head and neck depends on effective
management of cervical lymph nodes. Selective removal of lymph node groups at risk,
or modified neck dissections are appropriate in many patients.
Careful selection of the type of neck dissection and the use of postoperative radiation
therapy can optimize treatment and improve the prognosis and quality of life of these
patients.
Proper nodal staging using imaging studies can lead to a better therapeutic decision. We
believe it is important to look for lymph nodes in the anterior fat recess and check for the
internal jugular vein fixation sign on imaging studies (CT and MRI) to detect and recognize
lymphadenopathies even if they do not fulfill size criteria to be considered as pathologic.
We want to emphasize the relevance of identifying lymph nodes in this recess with
the fixation sign in the jugular vein that may go unnoticed because most of the
lymphadenopathies at level III are located in the posterior triangle.
Personal information
Laura Oleaga
Hospital Clinic Barcelona. Spain
[email protected]
References
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Rana M. Assessment of cervical lymph node metastasis for therapeutic decision-making
in squamous cell carcinoma of buccal mucosa: a prospective clinical analysis. World
Journal of Surgical Oncology 2012 10:253
Page 26 of 27
2- Ojiri H., Mancuso A., Mendenhall W., Stringer S. Lymph nodes of patients with regional
metastases from head and neck squamous cell carcinoma as a predictor of pathologic
outcome: size changes at CT before and after radiation therapy. AJNR Am J Neuroradiol
2002; 23:1627-1631
3- Zhang Z., Helman J., Li L. Lymphangiogenesis, lymphatic endothelial cells and
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4- Bartlett E., Walters T., Yu E. Can axial-based nodal size criteria be used in other
imaging planes to accurately determine ''enlarged'' head and neck lymph nodes?. ISRN
OtolaryngologyVolume 2013, article IG 232968, 7 pages
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necessary?. Laryngoscope 2005; 115: 1624-1626
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