Anatomical cervical CT atlas for radiotherapy: A teaching model of lymph node levels for head and neck cancer treatment Poster No.: C-1690 Congress: ECR 2010 Type: Educational Exhibit Topic: Head and Neck Authors: B. Asenjo, A. Doroteo, S. Romero, M. Bernabé, A. del Toro, E. Cuartero; Málaga/ES Keywords: cervical lymph node levels, cervical CT, head and neck cancer, radiotherapy DOI: 10.1594/ecr2010/C-1690 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 42
Learning objectives 1. To offer a CT imaging guide of cervical lymph node levels, using standardized, easy reproducible anatomical limits. 2. To provide a CD of this teaching program as a tool for learning cervical lymph node levels and thus standardize the planning of radiotherapy volumes in head and neck cancer. Background Some historical notes 1. The exact definition of cervical lymphatic channel drainage of head and neck tumors is extremely important for patient management. 2. The American Academy for Head and Neck Surgery published in 1991 the theoretical limits of cervical lymph node spaces using anatomical landmarks such as muscles, bones, nerves and cervical vessels. 3. Several oncological groups adapted these anatomical limits to CT images for radiotherapic proposes, the best known of which are the Rotterdam and Brussels Groups. However, differences in the limits led to consensus guides with other groups, such as DAHANCA (Danish Head and Neck Cancer Study Group), EORTC (European Organization for Research and Treatment of Cancer), GORTEC (Groupe d'oncologie Radiothérapie Tête et Cou), NCIC (National Cancer Institute of Canada) and RTOG (Radiation Therapy Oncology Group). Page 2 of 42
We present a CT imaging guide where cervical lymph node levels are coloured separately, based on these consensus guides but with modifications, some taken from Palazzi and Som and others from our experience. These are: 1. The cranial limits of levels II and V reach the skull base (Som and Palazzi). 2. The posterior limit of level IV is an oblique line from posterior edge of the sternocleidomastoid muscle to the posterolateral edge of the anterior scalene muscle (Som). 3. The caudal limit of level V, "transverse cervical vessels", has been changed for "clavicle". This is because its anatomical landmark was not easily recognized on axial CT images, as opposed to the clearly visible clavicle (Asenjo, Moreno and Gomez). 4. The caudal limit of level IV is now the clavicle head, so as to include the supraclavicular fossa in level IV instead of being considered an independent region (Moreno et al). Imaging findings OR Procedure details ***HOW TO USE THIS GUIDE*** Our anatomical cervical atlas contains sequential neck CT slides from top to bottom with The cervical lymph node levels delineated in different colors on the right of each slide The theoretical limits (not the anatomical landmarks) levels delineated with lines Page 3 of 42
The names of anatomical landmarks for each level on the left of each slide The start and end of each level Fig.: HOW TO USE THIS GUIDE (I) References: B. Asenjo; Radiology, Hospital Carlos Haya, Málaga, SPAIN Page 4 of 42
Fig.: HOW TO USE THIS GUIDE (II) References: B. Asenjo; Radiology, Hospital Carlos Haya, Málaga, SPAIN In the sidebar it is possible to display all neck CT images Page 5 of 42
Images for this section: Fig. 1: LIMITS OF LYMPH NODE LEVELS Page 6 of 42
Fig. 2: Axial CT image with cervical lymph node levels Page 7 of 42
Fig. 3: Axial CT image with cervical lymph node levels Page 8 of 42
Fig. 4: Axial CT image with cervical lymph node levels Page 9 of 42
Fig. 5: Axial CT image with cervical lymph node levels Page 10 of 42
Fig. 6: Axial CT image with cervical lymph node levels Page 11 of 42
Fig. 7: Axial CT image with cervical lymph node levels Page 12 of 42
Fig. 8: Axial CT image with cervical lymph node levels Page 13 of 42
Fig. 9: Axial CT image with cervical lymph node levels Page 14 of 42
Fig. 10: Axial CT image with cervical lymph node levels Page 15 of 42
Fig. 11: Axial CT image with cervical lymph node levels Page 16 of 42
Fig. 12: Axial CT image with cervical lymph node levels Page 17 of 42
Fig. 13: Axial CT image with cervical lymph node levels Page 18 of 42
Fig. 14: Axial CT image with cervical lymph node levels Page 19 of 42
Fig. 15: Axial CT image with cervical lymph node levels Page 20 of 42
Fig. 16: Axial CT image with cervical lymph node levels Page 21 of 42
Fig. 17: Axial CT image with cervical lymph node levels Page 22 of 42
Fig. 18: Axial CT image with cervical lymph node levels Page 23 of 42
Fig. 19: Axial CT image with cervical lymph node levels Page 24 of 42
Fig. 20: Axial CT image with cervical lymph node levels Page 25 of 42
Fig. 21: Axial CT image with cervical lymph node levels Page 26 of 42
Fig. 22: Axial CT image with cervical lymph node levels Page 27 of 42
Fig. 23: Axial CT image with cervical lymph node levels Page 28 of 42
Fig. 24: Axial CT image with cervical lymph node levels Page 29 of 42
Fig. 25: Axial CT image with cervical lymph node levels Page 30 of 42
Fig. 26: Axial CT image with cervical lymph node levels Page 31 of 42
Fig. 27: Axial CT image with cervical lymph node levels Page 32 of 42
Fig. 28: Axial CT image with cervical lymph node levels Page 33 of 42
Fig. 29: Axial CT image with cervical lymph node levels Page 34 of 42
Fig. 30: Axial CT image with cervical lymph node levels Page 35 of 42
Fig. 31: Axial CT image with cervical lymph node levels Page 36 of 42
Fig. 32: Axial CT image with cervical lymph node levels Page 37 of 42
Fig. 33: Axial CT image with cervical lymph node levels Page 38 of 42
Fig. 34: Axial CT image with cervical lymph node levels Page 39 of 42
Fig. 35: Axial CT image with cervical lymph node levels Page 40 of 42
Conclusion This tool facilitates routine treatment planning in radiotherapy. The tool provides information about cervical lymph node levels that can aid the planning and standardization of radiotherapy volumes, used both in Intensity-Modulated Radiation Therapy and 3D radiotherapy. Personal Information References 1.Palazzi M, Soatti C, Bianchi E et al.guidelines for the delineation of nodal regions of the head and neck on axial computed tomography images. Tumori, 88:355-360, 2002. 2. Harnsberger HR. Handbook of head and neck imaging. Ed:Mosby-Year Book, 1995. 3.Sociedad Española de Oncología Radioterápica. Volumenes blanco en radioterapia conformada 3D. Ed: Visto bueno equipo creativo, 2006. 4.Som P, Curtin H, Mancuso A. An imaging-based classification for the cervical nodes designed as an adjunct to recentclinically based nodal classifications. Arch Otolaryngol Head Neck 5.Grégoire V, Coche E, Cosnard G, et al. Selection and delineation of lymph node target volumes in head and neck conformal radiotherapy. Proposal for atandardizing terminology and procedure based on the surgical experience. Radiother Oncol 2000; 56: 135-150. 6.Grégoire V, Levendag P, Ang KK, et al. CT-based delineation of lymph node levels and related CTVs in the node-negative neck: DAHANCA, EORTC, GORTEC, NCIC, RTOG consensus guidelines. Radiother Oncol 2003; 69: 227-236. Page 41 of 42
7.Palazzi M, Jereczeck-Fossa B, Soatti C. CT-based delineation of lymph node levels in the neck: can we optimize the Consensus? Letter to the Editor. Radiother Oncol 2004; 73(3): 383-384. Page 42 of 42