Neck Lymph Nodes Levels - CT Anatomy

Transcrição

Neck Lymph Nodes Levels - CT Anatomy
Poster No.:
C-1664
Congress:
ECR 2015
Type:
Educational Exhibit
Authors:
A. E. A. G. Costa , M. S. R. O. Faustino , M. L. D. Fernandes , I.
1
2 1
2
2
2
Távora ; Vila Nova De Gaia/PT, Lisbon/PT
Keywords:
Head and neck, CT, Diagnostic procedure, Neoplasia
DOI:
10.1594/ecr2015/C-1664
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Page 1 of 21
Learning objectives
To review the most important neck CT landmarks, to help identifying lymph node level in
CT scans using a visual and practical approach and to name the most important features
to distinguish normal nodes from adenopathy.
Background
Cervical lymph node staging is very important in oncologic patient management,
especially in patients with head and neck cancer. Following the anatomic classification
by Rouvière, various classifications have been created grouping lymph nodes together
on the basis of clinical and pathophysiologic information, which influence treatment
procedures. Consensus groups, such as the American Joint Committee on Cancer and
the American Academy of Otolaryngology-Head and Neck Surgery, developed clinically
based nodal classifications. However these clinically based classifications are not always
accurate, especially in deep tissue lymph nodes. In this poster we will use imaging-based
nodal classification developed by Som. et al, which groups lymph nodes in levels and
improves lymph node staging accuracy. CT scan offers detailed evaluation of the neck,
including lymph nodes, therefore it is an essential tool in tumor staging. To correctly
interpret neck CT scans it is very important to have good anatomy knowledge.
Findings and procedure details
To use the imaging-based nodal classification developed by Som its essential to know the
anatomic landmarks of the classification: the skull base at the jugular fossa, the bottom
of the body of the hyoid bone, the bottom of the cricoid arch, the top of the manubrium,
the back edge of the submandibular gland, the back edge of the sternocleidomastoid
muscle, the lateral posterior edge of the anterior scalene muscle, the anterior edge of
the trapezius muscle, both the internal carotid and common carotid arteries, the internal
jugular vein, the clavicle, the medial margin of the anterior belly of the digastric muscle,
and the mylohyoid muscle.
Page 2 of 21
Fig. 1
References: Imagiologia Geral, Centro Hospitalar Lisboa Norte, Hospital de Santa
Maria - Vila Nova De Gaia/PT
Page 3 of 21
Fig. 2
Page 4 of 21
Fig. 3
Level I includes all nodes above the hyoid bone, below the mylohyoid muscle, and anterior
to the posterior edge of the sub-mandibular gland.
Level IA represents the nodes that lie between the medial margins of the anterior bellies
of the digastric muscles,
Level IB represents the nodes that lie posterior and lateral to the medial edge of the
anterior belly of the digastric muscle
Page 5 of 21
Fig. 4
Page 6 of 21
Fig. 5
Level II is limited cranially by the skull base and extends caudally to the the lower body of
the hyoid bone. Level II nodes lie anterior to the posterior edge of the sternocleidomastoid
muscle and lie posterior to the posterior edge of the submandibular gland. Level II nodes
can be subclassified into levels IIA and IIB. Level IIA nodes are level II nodes that lie
posterior to the internal jugular vein and are inseparable from the vein or that lie anterior,
lateral, or medial to the vein. Level IIB nodes lie posterior to the internal jugular vein and
have a fat plane separating the nodes and the vein
Page 7 of 21
Fig. 6
Page 8 of 21
Fig. 7
Level III nodes lie between the of the lower body of the hyoid bone and the level of
the lower margin of the cricoid cartilage arch, anterior to the posterior edge of the
sternocleidomastoid muscle and lateral to the medial margin of either the common carotid
artery or the internal carotid artery.
Page 9 of 21
Fig. 8
Page 10 of 21
Fig. 9
Level IV nodes lie between the level of the lower margin of the cricoid cartilage arch the
level of the clavicle, anterior and medial to an oblique line drawn through the posterior
edge of the sternocleidomastoid muscle and the posterolateral edge of the anterior
scalene muscle. The medial aspect of the common carotid artery is the landmark that
separates level IV nodes (lateral to this artery) from level VI nodes (medial to this artery).
Page 11 of 21
Fig. 10
Page 12 of 21
Fig. 11
Level V nodes extend from the skull base, at the posterior border of the attachment of
the stermocleidomastoid muscle, to the level of the clavicle. Level V nodes all lie anterior
to the anterior edge of the trapezius muscle. Between the levels of the skull base and the
bottom of the cricoid arch, these nodes are situated posterior to the posterior edge of the
sternocleidomastoid muscle. Between the axial level of the bottom of the cricoid arch and
the level of the clavicle, level V nodes lie posterior and lateral to an oblique line through
the posterior edge of the sternocleidomastoid muscle and the posterolateral edge of the
anterior scalene muscle. The level V nodes can be subdivided into VA and VB nodes.
The lower margin of the cricoid is the landmark that separates level VA (superior to the
cartilage) and level VB (inferior to the cartilage)
Page 13 of 21
Fig. 12
Page 14 of 21
Fig. 13
Page 15 of 21
Fig. 14
Level VI nodes lie inferior to the lower body of the hyoid bone, superior to the top of the
manubrium, and between the medial margins of the left and right common carotid arteries
or the internal carotid arteries.
Page 16 of 21
Fig. 15
Page 17 of 21
Fig. 16
Level VII nodes lie caudal to the top of the manubrium in the superior mediastinum,
between the medial margins of the left and right common carotid arteries. These superior
mediastinal nodes extend caudally to the level of the innominate vein.
Page 18 of 21
Fig. 17
Page 19 of 21
Fig. 18
Conclusion
The presence and extent of nodal metastases in head and neck cancer has a great
impact on treatment and prognosis. CT of the neck is commonly performed to identify
nodal metastases. Therefore radiologists should be familiar with neck CT anatomy and
lymph node levels to correctly interpret and report the exam.
Personal information
References
Page 20 of 21
-Som, P; Curtin, H; Imaging-Based Nodal Classification for Evaluation of Neck Metastatic
Adenophaty; AJR 2000;174:837-744
-Hoang, J;Vanka, J; Ludwig, B; Glastonbury, C; Evaluation of Cervical Lymph Nodes in
Head and Neck Cancer With CT and MRI: Tips, Traps, and a Systematic Approach; AJR
2013;200:W17-W25
-Harnsberger, H R. Diagnostic Imaging: Head & Neck (2nd Edition). Amirsys, 2011.
Page 21 of 21

Neck Lymph Nodes Levels - CT Anatomy

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