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首页 全身淋巴结

全身淋巴结.pdf

全身淋巴结

dongdong
2011-02-15 0人阅读 举报 0 0 暂无简介

简介:本文档为《全身淋巴结pdf》,可适用于人文社科领域

SpecialReportRafaelMartinezMonge,MDPatrickSFernandes,MDNilenduGupta,PhDReinhardGahbauer,MDCrosssectionalNodalAtlas:AToolfortheDefinitionofClinicalTargetVolumesinThreedimensionalRadiationTherapyPlanningVirtualthreedimensionalclinicaltargetvolumedefinitionrequirestheidentificationofareassuspectedofcontainingmicroscopicdisease(frequentlyrelatedtonodalstations)onasetofcomputedtomographic(CT)images,ratherthanthetraditionalapproachbasedonanatomiclandmarksThisatlasdisplaystheclinicallyrelevantnodalstationsandtheircorrelationwithnormallymphaticpathwaysonasetofCTimagesWhenradiationisusedwithcurativeintent,theradiationvolumeusuallyencompassesthedetectabletumorandtheanatomicareasthoughttobeatriskformetastaticspreadTheInternationalCommissiononRadiationUnitsandMeasurementsReportNo()definesgrosstumorvolume(GTV)asthegrosspalpableorvisibleordemonstrableextentandlocationofthemalignantgrowthThesamereportdefinesclinicaltargetvolume(CTV)asavolumethatcontainsademonstrableGTVandorisconsideredtocontain(only)microscopic,subclinicalextensionsatacertainprobabilitylevelInclinicalpractice,thedeterminationoftheextentoftheCTVisbasedontheknowledgeofthepatternsofspreadforeachspecificdiseasepresentationAdditionalreliableinformationcanbeobtainedfrompatternsoffailureanalysisandnecropsyseriesFormosttumors,theCTVwillencompassoneormorenodalstations,usuallyneartheprimarylesionTraditionally,thelocationandboundariesofthesenodalstationshavebeenestablishedinreferencetoanatomiclandmarksduringthestandardsimulationsetupTherefore,theradiationoncologisthasbeenspecificallytrainedtodeterminetheboundariesofthedifferentnodalstationsonstandardtwodimensionalradiographs,especiallyintheanteroposteriorandposteroanteriorviewsWiththeadventofthreedimensional(D)virtualclinicaltargetdefinition,theradiationoncologistfacesthechallengeofdefiningtheCTVoncrosssectionalCTormagneticresonanceimagesUnfamiliaritywiththisnewtechniquecanmakecorrelationswiththeknownspatialreferencesdifficulttoestablishThepresentnodalatlasisintendedtoassistradiationoncologistswhowillusenewDvirtualclinicaltargetdefinitionandtreatmentplanningprogramsCLASSIFICATIONANDNOMENCLATURETheanatomicpatternsoflymphaticdrainagefordifferentorganstotheirfirstechelon(orefferent)nodalstationsweretakenfromRouviere’sAnatomyoftheHumanLymphaticSystem()andconfirmedwithotherlymphaticanatomytextbooks(,)ThemainandaccessorylymphaticroutesfordifferentorgansthatarerelevantinradiationoncologyaresummarizedinTables–,withanexplanationoftheabbreviationsappearingintheKeyBoxWhendifferentsubsiteswithinanorganhaduniquedrainagepatterns,thesewereindividualizedintheTablesaswellTheclassificationofandnomenclatureforthedifferentnodalareasusuallyfollowedtheguidelinesofRouviere’ssystem()Intheclassificationofthemediastinalnodes,thewidelyusedAmericanJointCommitteeonCancerclassificationIndexterms:Computedtomography(CT),threedimensional,,Lymphaticsystem,,SpecialreportsTreatmentplanning,Radiology:–Abbreviations:CTVclinicaltargetvolumeGTVgrosstumorvolumeDthreedimensionalFromtheDivisionofRadiationOncology,theArthurGJamesCancerHospital,OhioStateUniversity,WTenthAve,Columbus,OHReceivedJuly,revisionrequestedAugustrevisionreceivedOctoberacceptedNovemberAddressreprintrequeststoRMrRSNA,Authorcontributions:Guarantorofintegrityofentirestudy,RM,RGstudydesign,RMdefinitionofintellectualcontent,RMliteratureresearch,RM,PSFdataacquisitionandanalysis,RM,NGmanuscriptpreparation,RMmanuscriptreview,RGwaschoseninstead()ThenodalareasrepresentedarelistedintheKeyBoxWhenclinicallyrelevant,somenodalstationswerefurtherdividedintosubgroups,whicharenotedaslowercaselettersaftertheabbreviationcodesprovidedintheTablesandtheFiguresThenonparenthesizedlowercaselettersindicatedifferentiatedsubgroups,usuallyinthedirectionofthezzaxisParenthesizedlettersindicatesubgroupsubdivision,usuallyinthedirectionofthexxaxis(shownonlyforinguinalandexternaliliacnodes)LOCALIZATIONOFNODALSTATIONSThedifferentnodalstationswereoutlinedandlabeledonfivedifferentsetsofconsecutiveandequidistantCTimages(headandneck,thorax,abdomen,malepelvis,andfemalepelvis)(Figs–)WeelectedtouseCTimagesbecausetheyarethecustomaryimagesupportinmostDvirtualclinicaltargetdefinitionprogramsThenodalstationsonthecrosssectionalimageswerelocalizedbyexKeyBoxforAbbreviationsinTablesandFiguresAbbreviationNodalGroupAbbreviationNodalGroupAPWNAortopulmonarywindownodesPFLPyriformfossalymphaticsATLAnteriortonguelymphaticsPGNParotidglandandnodesAxNAxillarynodesPHNHilarnodesBTLBasetonguelymphaticsPLParametriallymphaticplexusCINCommoniliacnodesPLNPrelaryngealnodesCNCeliacaxisnodesPPLPeriprostaticlymphaticplexusCPNCervicalpretrachealnodesPRLPerirectallymphaticplexusDNDiaphragmaticnodesPSLParanasalsinuseslymphaticsEINGLExternaliliacnodesGlotticlymphaticsPsRNSuperiorposteriorpharyngealwalllymphaticsandretropharyngealnodesHMNHighmediastinalnodesPiLInferiorposteriorpharyngealwalllymphaticsHNHepaticnodesPTrNMediastinalpretrachealnodesHPLHardpalatelymphaticplexusPVgLParavaginallymphaticplexusIGLInfraglotticlymphaticsPVLPerivesicallymphaticplexusIINInternaliliacnodesPVsNPrevascularnodesIJNInternaljugularnodesRANRetroaorticnodesIMNInternalmammarynodesRCPRightcervicalparatrachealnodesINSuperficialinguinalnodes,deepinguinalRRHRighthilumrenalnodesnodesRLPRightlowerparatrachealnodesIPNInternalpudendalnodesRPNRightparaaorticnodesIRNInferiorrectalnodesRUPRightupperparatrachealnodesJVNJuxtavertebralnodesSANSpinalaccessorynodesLCPLeftcervicalparatrachealnodesScINSupraclavicularnodesLGNLeftgastricnodesSCNSubcarinalnodesLPNLeftparaaorticnodesSGLSupraglotticlymphaticplexusLRHLeftrenalhilumnodesSMaNSubmandibularnodesLUPLeftupperparatrachealnodesSMeNSubmentalnodesMNMastoidnodesSMNSuperiormesentericnodesNLNasopharyngeallymphaticplexusSNSacralnodesPANPreaorticnodesSPLSoftpalatelymphaticsPAuNPreauricularnodesSplNSplenicnodesPCLPostcricoidlymphaticplexusSRNSuperiorrectalnodesPecNPectoralnodesSVLSeminalvesicleslymphaticplexusPENParaesophagealnodesTLTonsillymphaticplexusTABLEHeadandNeckLymphaticSystem(I)AnatomicSiteFirstEchelonNodalGroupSubgroupCategoryAbbreviationLacrimalglandPreauricularnodesMainPAuNParotidnodesMainPGNSubmandibularnodesMainSMaNEyelids,conjunctivaPreauricularnodesMainPAuNParotidnodesMainPGNSubmandibularnodesMainSMaNPinnaPreauricularnodesMainPAuNParotidnodesMainPGNMastoidnodesMainMNInternaljugularnodesUpperMainIJNuExternalauditorycanalParotidnodesMainPGNInternaljugularnodesUpperMainIJNuMiddleearPreauricularnodesMainPAuNRetropharyngealnodesMainPsRNInternaljugularnodesUpperMainIJNuExternalnoseSubmandibularnodesMainSMaNNasalcavityRetropharyngealnodesMainPsRNInternaljugularnodesUpperMainIJNuParanasalsinusesRetropharyngealnodesMainPsRNInternaljugularnodesUpperMainIJNuLip,upperSubmandibularnodesMainSMaNSubmentalnodesAccessorySMeNPreauricularnodesAccessoryPAuNLip,lowerSubmandibularnodesMainSMaNSubmentalnodesMainSMeNCheek,cutaneousSubmandibularnodesMainSMaNSubmentalnodesMainSMeNParotidnodesMainPGNBuccalmucosaSubmandibularnodesMainSMaNTongue,apexSubmentalnodesMainSMeNInternaljugularnodesUpper,middleMainIJNu,mTongue,lateralandposteriorSubmandibularnodesMainSMaNInternaljugularnodesUpperMainIJNuxRadiologyxJuneMartinezMongeetalFigureCTimagesdepictheadandnecknodalstationsatlevelshnthroughhnonthetopograminFigureVolumexNumberCrosssectionalNodalAtlasforDefinitionofClinicalTargetVolumesxtrapolatinginformationfromcrosssectionalanatomyatlases(),lymphaticatlases(),andvascularatlases()Toalloweasycorrelation,thefivesetsofCTimageswereconnectedwitharecognizablebonestructureonatopogram(Fig)REPRESENTATIONOFTHEANATOMYOFTHELYMPHATICSYSTEMINTHENODALATLASTheinitiallymphaticsystemiscomposedofcapillarylymphatics,whichoriginateintheintimaofthetissueandareimmersedinthegroundsubstanceofthetissuespaceThesecapillariesanastomoseinnetworkstoformtheperipherallymphaticplexusesTheseplexusesareonlyrepresentedintheatlasforcertainorgansthatarefrequentlyirradiatedwhileintact(prostate,rectum,someheadandnecksubsites,etc)tofacilitatetherecognitionoftheorganorsiteanditsspatialrelationshipwiththesurroundingnodalstationsThelymphaticplexusesdraintothefirstechelonlymphnodalstationsthroughprecollectingandcollectingductsSometimes,thereareintercalatinglymphnodesinthepathofthecollectingductsIngeneral,nointermediatepathsbetweentheorganofinterestandthefirstechelonnodalstationhavebeenrepresentedintheatlastoavoidunnecessarycomplexityHowever,someclinicallyrelevantintercalatingnodeshavebeenrepresented(superiorandinferiorrectalnodesandinternalpudendalnodes)ThefirstnodalstationreachedbythelymphaticdrainageofagivenorganiscalledthefirstechelonnodalgroupThefirstechelonlymphnodesconnecttoeachotherthroughpostlymphonodalcollectingductsandfinallydraintomorecentralefferentlymphnodesordirectlyintothevenoussystemthroughthemainlymphatictrunks,dependingonanatomiclocationAsarule,thefirstechelonnodalstationsforallthedifferentorgansoftheheadandneck,thorax,abdomen,andpelvisarerepresentedThesearelistedintheTables–OneexceptiontothisrulehasbeenthecaseofthesmallbowelandmostofthelargebowelDuetotheTABLEHeadandNeckLymphaticSystem(II)AnatomicSiteFirstEchelonNodalGroupSubgroupCategoryAbbreviationFloorofmouthSubmentalnodesMainSMeNSubmandibularnodesMainSMaNInternaljugularnodesUpper,middleMainIJNu,mLowergumSubmandibularnodesMainSMaNSubmentalnodesMainSMeNInternaljugularnodesUpper,middleMainIJNu,mUppergumSubmandibularnodesMainSMaNRetropharyngealnodesMainPsRNHardpalate,softInternaljugularnodesUpperMainIJNupalateinferiorSubmandibularnodesAccessorySMaNRetropharyngealnodesAccessoryPsRNSoftpalate,superiorRetropharyngealnodesMainPsRNInternaljugularnodesUpperMainIJNuTonsilInternaljugularnodesUpperMainIJNuNasopharynxRetropharyngealnodesMainPsRNInternaljugularnodesUpperMainIJNuSpinalaccessorynodesMainSANPyriformfossaInternaljugularnodesUpper,middleMainIJNu,mPosteriorcricoidInternaljugularnodesUpper,middleMainIJNu,mPosteriorpharyngealRetropharyngealnodesMainPsRNwall,superiorInternaljugularnodesUpperMainIJNuPosteriorpharyngealwall,inferiorInternaljugularnodesMiddleMainIJNmSupraglotticlarynxInternaljugularnodesUpper,middleMainIJNu,mInfraglotticlarynxInternaljugularnodesMiddle,lowerMainIJNm,lCervicalpretrachealnodesCervicalMainCPNPrelaryngealnodesMainPLNTracheaCervicalpretrachealnodesCervicalMainCPNCervicalparatrachealnodesCervicalMainLCP,RCPPrelaryngealnodesAccessoryPLNThyroidCervicalpretrachealnodesCervicalMainCPNCervicalparatrachealnodesCervicalMainLCP,RCPInternaljugularnodesUpper,middle,lowerMainIJNu,m,lRetropharyngealnodesAccessoryPsRNParotidglandParotidnodesMainPGNSubmandibularnodesMainSMaNSubmandibularglandSubmandibularnodesMainSMaNInternaljugularnodesUpperMainIJNuSublingualglandSubmandibularnodesMainSMaNInternaljugularnodesUpperMainIJNuxRadiologyxJuneMartinezMongeetalFigureCTimagesdepictheadandnecknodalstationsatthelevelshnthroughhnonthetopograminFigureVolumexNumberCrosssectionalNodalAtlasforDefinitionofClinicalTargetVolumesxanatomicmobilityoftheseorgans,theefferentpreandparaaorticnodalgroups(fixedstructureswithreproduciblelocation),ratherthanthefirstechelonnodalgroups(juxtaintestinalandparacolic),arerepresentedintheatlasPatternsofanomalousnodalspread,suchasretrogradespread,arenotshowninthisatlasERRORSINLOCALIZATIONOFNODALSTATIONSLymphographyisthetechniqueofchoicetovisualizenodalgroupsHowever,itsdeclineinthefieldofdiagnosticradiologyhasledtothedeclineofitsuseasatoolforradiationtherapyplanning,andithasbeenvirtuallyabandonedforbothpurposesHowever,currentlyusedstandardradiationportsstillfollowtheboundariesdeterminedduringthelymphographiceraDuringstandardsimulation,thedifferentnodalstationsarenotactuallyseenonthesimulationradiographstherefore,amarginofnormaltissueistakenaroundtheCTVtoallowforanylocalizationuncertaintiesThreedimensionalvirtualclinicaltargetdefinition,likestandardsimulation,lacksvisualizationofnodalstationsHowever,becauselocalizationerrorsoncrosssectionalimagesareminimized(asaretheassociatedincreasesinCTVuncertaintyandsizeoftheplanningtagetvolume),thisproblemisnotasgreatDuringDvirtualclinicaltargetdefinition,onlyafewofthenodalstationsrepresentedintheatlasarevisibleonaCTimageSo,theexactlocationofagivenstationinanindividualisdifficulttodetermineFurthermore,theinternalstructureofthelymphaticsystem(differentnormalvariantsamongsubjects)precludesanycategoricalstatement(–)Therefore,wechosetooutlinewideareasratherthandiscretelocationsforeachnodalstationtoaccountforthedifferencesinnormalanatomicTABLEThoracicLymphaticSystemAnatomicSiteFirstEchelonNodalGroupSubgroupCategoryAbbreviationLungRULanteromedialRightparatrachealnodesUpper,lowerMainRUP,RLPLungRULposterolateral,RML,RLLsuperiorRightparatrachealnodesRighthilarnodesSubcarinalnodesUpper,lowerMainMainMainRUP,RLPPHNrSCNLungRLLinferiorRighthilarnodesMainPHNrSubcarinalnodesMainSCNLungLULsuperiorLeftupperparatrachealnodesMainLUPPrevascularnodesMainPVsNAortopulmonarywindownodesMainAPWNLungLULinferior,LLLsuperior,LLLmiddleLeftupperparatrachealnodesPrevascularnodesAortopulmonarywindownodesLefthilarnodesSubcarinalnodesMainMainMainMainMainLUPPVsNAPWNPHNlSCNLung,LLLinferiorLefthilarnodesMainPHNlSubcarinalnodesMainSCNCostalpleura,SupraclavicularnodesMainSclNsuperiorInternaljugularnodesLowerMainIJNlCostalpleura,JuxtavertebralnodesAnylevelMainJVNs,m,imiddleInternalmammarynodesAnylevelMainIMNs,m,iCostalpleura,AxillarynodesMainAxNinferiorJuxtavertebralnodesAnylevelMainJVNs,,m,iInternalmammarynodesAnylevelMainIMNs,m,iRightdiaphragm,DiaphragmaticnodesRightlateralMainDNlatsubperitonealRetroaorticnodesSuprarenal,thoracicMainRANsr,tLeftdiaphragm,ParaesophagealnodesInferiorMainPENisubperitonealRetroaorticnodesSuprarenal,thoracicMainRANsr,tRightandleftdiaphragm,subpleuralDiaphragmaticnodesParaesophagealnodesRetroaorticnodesAnterior,lateralInferiorSuprarenalMainMainMainDNa,latPENiRANsrBreastAxillarynodesMainAxNInternalmammarynodesAnylevelMainIMNs,m,iSupraclavicularnodesAccessorySclNPectoralnodesAccessoryPecNxRadiologyxJuneMartinezMongeetalFigureCTimagesdepictthenodalstationsinthethorax(th)VolumexNumberCrosssectionalNodalAtlasforDefinitionofClinicalTargetVolumesxTABLEGastrointestinalLymphaticSystem(I)AnatomicSiteFirstEchelonNodalGroupSubgroupCategoryAbbreviationGastriccardiaLeftgastricnodesJuxtacardiacMainLGNcGastriclessercurLeftgastricnodesGastropancreaticMainLGNlcvatureLessercurvatureMainLGNlcGastricantrumHepaticnodesRightgastroepiploicMainHNrgandpylorusInfrapyloricMainHNpSuprapyloricMainHNpGreateromentumHepaticnodesRightgastroepiploicMainHNrgInfrapyloricMainHNpSuprapyloricMainHNpGastricgreatercurvatureSplenicnodesSuprapancreaticMainSplNsDuodenumHepaticnodesInfrapyloricMainHNpRetropyloricMainHNpPancreaticoduodenalMainHNpdSuperiormesentericnodesPostpancreaticoduodenalMainSMNPancreasHepaticnodesInfrapyloric,suprapyloricMainHNpPancreaticoduodenalMainHNpdHepaticarteryMainHNhaSplenicnodesSuprapancreaticMainSplNsSplenichilumMainSplNhLeftgastricnodesGastropancreaticMainLGNlcSuperiormesentericnodesRootofmesenteryMainSMNMiddlecolicMainSMNPostpancreaticoduodenalMainSMNRightparaaorticnodesSuperiorMainRPNsLeftparaaorticnodesSuperiorMainLPNsSpleenSplenicnodesSplenichilumMainSplNhLiverHepaticnodesGallbladder,hepaticarteryMainHNhaCeliacaxisnodesMainCNLeftgastricnodesLessercurvatureMainLGNlcDiaphragmaticnodesAnterior,lateralMainDNa,latParaesophagealnodesInferiorMainPENiRenalhilumnodesMainRRH,LRHGallbladderandHepaticnodesGallbladderMainHNhacysticductForamenofWinslowMainHNhaHepaticductHepaticnodesForamenofWinslowMainHNhaCommonbileductHepaticnodesForamenofWinslowMainHNhaPostpancreaticoduodenalMainHNpdTABLEGastrointestinalLymphaticSystem(II)AnatomicSiteEfferentNodalGroup*SubgroupCategoryAbbreviationJejunum,ileumSuperiormesentericnodesMainSMNCecumandappendixSuperiormesentericnodesMainSMNAscendingcolonSuperiormesentericnodesMainSMNTransversecolon,rightSuperiormesentericnodesMainSMNTransversecolon,leftSuperiormesentericnodesMainSMNDescendingcolonLeftparaaorticnodesAnylevelMainLPNsr,s,m,i,LRHSuperiormesentericnodesMainSMNSigmoidcolonPreaorticnodesInferiormesentericMainPANs,mLeftparaaorticnodesSuperior,middleMainLPNs,mRectumPreaorticnodesInferiormesentericMainPANs,mInternaliliacnodesAccessoryIINSacralnodesAccessorySN*Inthesmallandlargeintestine,thefirstechelonnodalgroupisrepresentedbythejuxtaintestinal(smallbowel)orparacolic(largebowel)nodeslocatedinthemesentericborderoftheorganBecauseofthemobilityoftheseorgans,theefferentnodalgroups(fixedstructureswithreproduciblelocation),ratherthanthefirstechelonnodalgroups,arerepresentedintheatlasxRadiologyxJuneMartinezMongeetalvariabilityandnodalinterconnectionAnotherdifficultproblemisthemobilityofthenodalstationslocatedproximallyinthelimbs(inguinal,axilla)Thelocationofthesenodalgroupswillvarygreatly,dependingonsimulationpositioningThecrosss

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