Lymphatic System

The lymphatic system is a network of tissues, vessels and organs that

work together to move a colorless, watery fluid called lymph back into your
circulatory system (your bloodstream).

Some 20 liters of plasma flow through your body’s arteries and smaller
arteriole blood vessels and capillaries every day. After delivering nutrients
to the body’s cells and tissues and receiving their waste products, about 17
liters are returned to the circulation by way of veins. The remaining three
liters seep through the capillaries and into your body’s tissues. The
lymphatic system collects this excess fluid, now called lymph, from tissues
in your body and moves it along until it's ultimately returned to your
bloodstream.

Your lymphatic system has many functions. Its key functions include:

 Maintains fluid levels in your body: As just described, the lymphatic

system collects excess fluid that drains from cells and tissue
throughout your body and returns it to your bloodstream, which is
then recirculated through your body.
 Absorbs fats from the digestive tract: Lymph includes fluids from
your intestines that contain fats and proteins and transports it back
to your bloodstream.
 Protects your body against foreign invaders: The lymphatic system
is part of the immune system. It produces and releases lymphocytes
(white blood cells) and other immune cells that monitor and then
destroy the foreign invaders — such as bacteria, viruses, parasites
and fungi — that may enter your body.
 Transports and removes waste products and abnormal cells from
the lymph.

What are the parts of the lymphatic system?

The lymphatic system consists of many parts. These include:

 Lymph: Lymph, also called lymphatic fluid, is a collection of the

extra fluid that drains from cells and tissues (that is not reabsorbed
into the capillaries) plus other substances. The other substances
include proteins, minerals, fats, nutrients, damaged cells, cancer
 cells and foreign invaders (bacteria, viruses, etc). Lymph also
transports infection-fighting white blood cells (lymphocytes).
 Lymph nodes: Lymph nodes are bean-shaped glands that monitor
and cleanse the lymph as it filters through them. The nodes filter out
the damaged cells and cancer cells. These lymph nodes also store
lymphocytes and other immune system cells that attack and destroy
bacteria and other harmful substances in the fluid. You have about
600 lymph nodes scattered throughout your body. Some exist as a
single node; others are closely connected groups called chains. A
few of the more familiar locations of lymph nodes are in your armpit,
groin and neck. Lymph nodes are connected to others by the
lymphatic vessels.·
 Lymphatic vessels: Lymphatic vessels are the network of capillaries
(microvessels) and a large network of tubes located throughout your
body that transport lymph away from tissues. Lymphatic vessels
collect and filter lymph (at the nodes) as it continues to move
toward larger vessels called collecting ducts. These vessels operate
very much like your veins do: They work under very low pressure,
have a series of valves in them to keep the fluid moving in one
direction.
 Collecting ducts: Lymphatic vessels empty the lymph into the right
lymphatic duct and left lymphatic duct (also called the thoracic
duct). These ducts connect to the subclavian vein, which returns
lymph to your bloodstream. The subclavian vein runs below your
collarbone. Returning lymph to the bloodstream helps to maintain
normal blood volume and pressure. It also prevents the excess
buildup of fluid around the tissues (called edema).

 The lymphatic system collects excess fluid that drains from cells and
tissue throughout the body and returns it to the bloodstream, which is then
recirculated through the body.

 Spleen: This largest lymphatic organ is located on your left side

under your ribs and above your stomach. The spleen filters and
stores blood and produces white blood cells that fight infection or
disease.
 Thymus: This organ is located in the upper chest beneath the breast
bone. It matures a specific type of white blood cell that fights off
foreign organisms.
  Tonsils and adenoid: These lymphoid organs trap pathogens from
the food you eat and the air you breathe. They are your body’s first
line of defense against foreign invaders.
 Bone marrow: This is the soft, spongy tissue in the center of certain
bones, such as the hip bone and breastbone. White blood cells, red
blood cells, and platelets are made in the bone marrow.
 Peyer’s patches: These are small masses of lymphatic tissue in the
mucous membrane that lines your small intestine. These lymphoid
cells monitor and destroy bacteria in the intestines.

 Appendix: Your appendix contains lymphoid tissue that can destroy

bacteria before it breaches the intestine wall during absorption.
Scientists also believe the appendix plays a role in housing “good
bacteria” and repopulating our gut with good bacteria after an
infection has cleared.

Cisterna chyli and Thoracic duct

The cisterna chyli is the abdominal origin of the thoracic duct, and it
receives the bilateral lumbar lymphatic trunks. It is located in the
retrocrural space, to the right side and behind of the abdominal aorta. It is
at the level of the lower border of the Th12 vertebral body or L1–2
vertebrae, and it lies lateral to the right crus of the diaphragm [5-7].
The thoracic duct starts from the cisterna chyli, and it is at the level of the
second or third lumbar vertebra. It then enters the thorax through the aortic
hiatus of the diaphragm and ascends in the posterior mediastinum,
between the descending thoracic aorta on the left and the azygos vein on
the right. When it reaches the level of the fifth thoracic vertebral body, it
gradually inclines to the left side and enters the superior mediastinum. It
first crosses anteriorly by the aortic arch, and it runs posterior to the left
subclavian artery, and forms an arch. Finally, the duct terminates by
opening into the junction of the left subclavian and jugular veins. However,
the duct may open into either of the great veins near the junction or it may
divide into a number of smaller vessels before termination. In adults, the
thoracic duct varies in length from 38 to 45 cm. It is approximately 3–5
mm in diameter at its commencement, but diminishes in calibre at the mid-
thoracic level and then slightly dilates before its termination.
Where Lymph Nodes Are Located
Lymph nodes are classified by their location, including:
 Axillary lymph nodes (armpits)
 Cervical lymph nodes (neck)
 Inguinal lymph nodes (groin)
 Mediastinal lymph nodes (in the chest cavity)
 Pelvic lymph nodes (in the pelvis)
 Retroperitoneal lymph nodes (back of the abdomen)
 Supraclavicular lymph nodes (above the collarbone)

Regional Lymph Nodes

There are between 100 and 150 lymph nodes in the mesentery of
the colon. Regional lymph nodes are the nodes along the colon, plus the nodes along the
major arteries that supply blood to that particular colon segment.

Lymph nodes along a "named vascular trunk" (as defined by the fourth edition of

the AJCC staging manual) are those along a vein or artery that carries blood to a specific
part of the colon, for example, the inferior and superior mesenteric arteries, sigmoidal
artery, left or right colic artery. In the fifth and sixth editions, the location of the nodes
does not affect assignment of the N category.
 Axillary Lymph Nodes
The axilla is a small anatomical space located between the upper
thoracic wall and the arm. The main contents include the brachial
plexus, axillary artery and vein, and axillary lymph nodes.[1] Lymph
nodes contain a range of immune cells, including lymphocytes and
macrophages. These remove damaged cells, foreign material, and
microorganisms from the lymphatic fluid before returning it to the
venous circulation.[2] The axillary lymph nodes arrange into five groups
based on their anatomical relations. Collectively, they drain the wall of
the thorax, breast, arm, and upper abdominal wall above the umbilicus.
The axillary lymph nodes are of particular clinical significance as they are
often the first site of breast cancer metastasis.[3] Axillary node
involvement is the single most significant prognostic variable for breast
cancer patients.[4] Axillary lymphadenopathy is also associated with
hematological malignancies, infection, and various autoimmune
etiologies.[5] It is, therefore, crucial to have a thorough understanding of
this region.
The axillary lymph nodes reside in the axillary pad of fat and fall into five
groups.[3] Every group of lymph nodes receives lymph from a specified,
nearby region.
Anterior (pectoral) lymph nodes are along the inferior border of
pectoralis minor, near the lateral thoracic vessels. They receive
lymph from the breast, skin, and muscles of the supraumbilical
anterolateral body wall. They drain into the central and apical
nodes.
Posterior (subscapular) lymph nodes are located on the posterior
wall of the axilla along the inferior border of the
subscapularis. They receive lymph from the scapular region, as
well as the posterior thoracic wall. They drain into the central and
apical nodes.
Lateral (humeral) lymph nodes are over the lateral wall of the
axilla. They receive lymph from the arm and drain into the central,
apical, and deep cervical nodes.
Central lymph nodes appear in the base of the axilla. They receive
lymph from the anterior, posterior, and lateral groups, and drain
to the apical lymph nodes
Apical (terminal) lymph nodes are located deep in the apex of the
axilla. They receive lymph from all of the groups mentioned
above, in addition to the upper breast. The efferent vessels from
the apical group converge to form the subclavian lymphatic trunk.
On the left, this drains directly drains into the thoracic duct, and
on the right, the subclavian trunk drains into the right venous
angle via the right lymphatic duct
The function of the axillary lymph nodes, like that of the rest of
the lymphatic system, is to defend against foreign particles,
provide immunity against microorganisms, and return excess
interstitial fluid back to the systemic circulation.[2] Lymph enters
the lymph node through the afferent lymphatic vessel and
subsequently flows through a system of sinuses within the node.
The series of sinuses begin with the subcapsular sinus and
continues to the cortical sinuses and finally, the medullary sinuses.
Lymph then exits the node via the efferent lymphatic vessel.
Structurally a lymph node consists of three basic compartments; a
cortex, paracortex, and medulla.[7] There are many types of
specialized cells within the lymph node concentrated in these
areas.[7] The B cell lymphocytes are classically found in the outer
cortex and may form lymphoid follicles, while T cells and dendritic
cells are classically present in the paracortex. The medulla
contains macrophages, plasma cells, and B cells. Activation of a
lymph node leads to the development of germinal centers within
lymphoid follicles. These are areas in which mature B cells
hypermutate, proliferate, and differentiate, to mount an immune
response.[7]
Further, the area in the axilla divides into three levels based on
where the lymph nodes are traceable. They are:
Level I: In this level, the lymph nodes are traced inferior and
lateral to the pectoralis minor muscleLevel II: The lymph nodes are
traced deep to the pectoralis minor muscleLevel III: Lymph nodes
here can be traced medial and deep to the medial border of the
muscle of pectoralis minor

Lingual lymph nodes

Lingual lymph nodes comprise an inconstant group of in-transit nodes,
which are located on the route of lymph drainage from the tongue
mucosa to the regional nodes in neck levels I and II. This group of lymph
nodes may represent a site of tongue cancer metastasis or locoregional
recurrence. These nodes are not currently included in diagnostic and
treatment protocols for oral tongue cancer. The reported rate of
anatomical existence, as well as metastatic lingual node involvement
incidence, may not be considered low. As these lesions were shown to
significantly influence survival prognosis, special efforts for their
detection must be carried out.