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CT Depiction of Regional Nodal Stations for Lung Cancer Staging

¹ Department of Radiology, Founders 202, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114
² Division of Cardiothoracic Surgery, University of California, San Diego, 200 W. Arbor Dr., San Diego, CA 92103.
³ SmithKline Beecham Consumer Healthcare, 1500 Littleton Rd., Parsippany, NJ 07054.

View larger version (78K): [in a new window]   Fig. 1A —Regional nodal stations for lung cancer staging. (Modified and reprinted with permission from [1]). Drawings show revised nodal staging system. Mediastinum is viewed from frontal (A) and left anterior oblique (B) projections. Heart and proximal great vessels have been cut away in both drawings. Trachea and bronchi, aortic arch (Ao), and main pulmonary artery (PA) are anatomic landmarks used to define various nodal stations. In these diagrams, nodes occupying nodal stations are assigned colors, and nodes on CT scans have been colored to correspond to assigned colors. Some colors have been changed from original drawing [1] for greater contrast on CT scans.

View larger version (76K): [in a new window]   Fig. 1B —Regional nodal stations for lung cancer staging. (Modified and reprinted with permission from [1]). Drawings show revised nodal staging system. Mediastinum is viewed from frontal (A) and left anterior oblique (B) projections. Heart and proximal great vessels have been cut away in both drawings. Trachea and bronchi, aortic arch (Ao), and main pulmonary artery (PA) are anatomic landmarks used to define various nodal stations. In these diagrams, nodes occupying nodal stations are assigned colors, and nodes on CT scans have been colored to correspond to assigned colors. Some colors have been changed from original drawing [1] for greater contrast on CT scans.

View larger version (23K): [in a new window]   Fig. 1C —Regional nodal stations for lung cancer staging. (Modified and reprinted with permission from [1]). Color legend for A and B correlates nodal colors with station numbers and descriptors.

View larger version (54K): [in a new window]   Fig. 1D —Regional nodal stations for lung cancer staging. (Modified and reprinted with permission from [1]). Lines placed on drawing in A reveal cross-sectional levels shown on subsequent figures in this article.

View larger version (108K): [in a new window]   Fig. 2A —68-year-old man with small cell lung carcinoma. Contrast-enhanced CT scan (A) and same scan with nodes colored (B) show station 1 highest mediastinal node (light green, B). Node is in left paratracheal region between left common carotid artery and left subclavian artery. This level is cranial to brachiocephalic vein where it crosses trachea. Note that station 3 prevascular node (bright pink, B) lies anterior to and left of major arterial vessels. More peripheral part of brachiocephalic vein is unopacified (arrow), medial to station 3 node.

View larger version (115K): [in a new window]   Fig. 2B —68-year-old man with small cell lung carcinoma. Contrast-enhanced CT scan (A) and same scan with nodes colored (B) show station 1 highest mediastinal node (light green, B). Node is in left paratracheal region between left common carotid artery and left subclavian artery. This level is cranial to brachiocephalic vein where it crosses trachea. Note that station 3 prevascular node (bright pink, B) lies anterior to and left of major arterial vessels. More peripheral part of brachiocephalic vein is unopacified (arrow), medial to station 3 node.

View larger version (101K): [in a new window]   Fig. 2C —68-year-old man with small cell lung carcinoma. Contrast-enhanced CT scan (C) and same scan with nodes colored (D) show station 2 upper paratracheal node (dark purple, D), which is extension of station 1 node in A. Brachiocephalic vein (arrows) crosses midline anterior to trachea and demarcates station 1 nodes from station 2 nodes. Station 3 prevascular node (bright pink, D) is again seen.

View larger version (110K): [in a new window]   Fig. 2D —68-year-old man with small cell lung carcinoma. Contrast-enhanced CT scan (C) and same scan with nodes colored (D) show station 2 upper paratracheal node (dark purple, D), which is extension of station 1 node in A. Brachiocephalic vein (arrows) crosses midline anterior to trachea and demarcates station 1 nodes from station 2 nodes. Station 3 prevascular node (bright pink, D) is again seen.

View larger version (99K): [in a new window]   Fig. 3A —65-year-old man with small cell lung carcinoma and superior vena cava syndrome. Contrast-enhanced CT scan shows station 2 upper paratracheal node.

View larger version (132K): [in a new window]   Fig. 3B —65-year-old man with small cell lung carcinoma and superior vena cava syndrome. Same scan with node colored dark purple shows station 2 upper paratracheal node, which is below top of left brachiocephalic vein but above top of aortic arch. IV contrast injection was made through left brachiocephalic vein. Note reflux into anterior chest wall collaterals (curved arrows) and both internal mammary veins (straight arrows).

View larger version (93K): [in a new window]   Fig. 4A —38-year-old man with B-cell lymphoma. Contrast-enhanced CT scan shows 1-cm station 3 retrotracheal node.

View larger version (151K): [in a new window]   Fig. 4B —38-year-old man with B-cell lymphoma. Same scan as A with node colored bright pink shows station 3 retrotracheal node, which is posterior to trachea at midline between esophagus (straight arrow) and azygos vein and arch (curved arrow). Azygos vein is opacified by retrograde contrast material from superior vena cava.

View larger version (119K): [in a new window]   Fig. 4C —38-year-old man with B-cell lymphoma. Unenhanced CT scan 4 months later than A shows decrease in size of lymph node (arrow) as result of therapy.

View larger version (124K): [in a new window]   Fig. 5A —65-year-old man with small cell lung carcinoma and superior vena cava syndrome. Contrast-enhanced CT scan (A) and same scan with nodes colored (B) show station 4 lower paratracheal nodes (bright orange, B). Station 4 lower paratracheal nodes can be separated into superior and inferior subsets. Nodes shown are in superior subset, meaning they are inferior to top of aortic arch and above azygos vein. Along with other mediastinal nodes, these station 4 superior lower paratracheal nodes can be separated into those to right (4R) (curved arrow) or left (4L) (straight thick arrow) of midline, as seen in Figures 1B and 1D, Midline nodes (thin arrow) are considered to be on same side as primary lung tumor. Therefore, in this patient with right lower lobe mass, midline nodes anterior to trachea are categorized as station 4 superior lower paratracheal nodes. Enhancing chest wall venous collaterals are again shown.

View larger version (139K): [in a new window]   Fig. 5B —65-year-old man with small cell lung carcinoma and superior vena cava syndrome. Contrast-enhanced CT scan (A) and same scan with nodes colored (B) show station 4 lower paratracheal nodes (bright orange, B). Station 4 lower paratracheal nodes can be separated into superior and inferior subsets. Nodes shown are in superior subset, meaning they are inferior to top of aortic arch and above azygos vein. Along with other mediastinal nodes, these station 4 superior lower paratracheal nodes can be separated into those to right (4R) (curved arrow) or left (4L) (straight thick arrow) of midline, as seen in Figures 1B and 1D, Midline nodes (thin arrow) are considered to be on same side as primary lung tumor. Therefore, in this patient with right lower lobe mass, midline nodes anterior to trachea are categorized as station 4 superior lower paratracheal nodes. Enhancing chest wall venous collaterals are again shown.

View larger version (111K): [in a new window]   Fig. 5C —65-year-old man with small cell lung carcinoma and superior vena cava syndrome. Contrast-enhanced scan (C) and same scan with nodes colored (D) illustrate station 4 inferior lower paratracheal nodes (bright orange, D), which are below horizontal line drawn at superior aspect of azygos vein. Nodes are contiguous with station 4 superior lower paratracheal nodes in A and B.

View larger version (139K): [in a new window]   Fig. 5D —65-year-old man with small cell lung carcinoma and superior vena cava syndrome. Contrast-enhanced scan (C) and same scan with nodes colored (D) illustrate station 4 inferior lower paratracheal nodes (bright orange, D), which are below horizontal line drawn at superior aspect of azygos vein. Nodes are contiguous with station 4 superior lower paratracheal nodes in A and B.

View larger version (105K): [in a new window]   Fig. 6A —66-year-old woman with lymphadenopathy. Contrast-enhanced CT scan reveals station 5 subaortic or aorticopulmonary (AP) window nodes and station 4 superior lower paratracheal nodes.

View larger version (157K): [in a new window]   Fig. 6B —66-year-old woman with lymphadenopathy. Same scan as A, with nodes colored light purple shows station 5 AP window nodes. AP window nodes are lateral to, and station 4 superior lower paratracheal nodes (bright orange) are medial to, ligamentum arteriosum.

View larger version (100K): [in a new window]   Fig. 7. —32-year-old healthy man. Unenhanced CT scan shows calcified ligamentum arteriosum (arrow) that extends from inferior and posterior aspect of aortic arch to top of main pulmonary artery.

View larger version (123K): [in a new window]   Fig. 8A —41-year-old woman with poorly differentiated adenocarcinoma of left lower lobe. Contrast-enhanced CT scan shows station 6 paraaortic (ascending aortic or phrenic) nodes and station 5 nodes.

View larger version (144K): [in a new window]   Fig. 8B —41-year-old woman with poorly differentiated adenocarcinoma of left lower lobe. Same scan with nodes colored shows red station 6 paraaortic nodes anterior to superior vena cava on right and anterior to aorta and main pulmonary artery to left of midline. Station 5 node is light purple.

View larger version (117K): [in a new window]   Fig. 9A —65-year-old man with small cell lung carcinoma and superior vena cava syndrome. Contrast-enhanced CT scan shows station 7 subcarinal nodes and station 4 lower paratracheal, station 8 paraesophageal, station 10 hilar, and station 13 segmental nodes.

View larger version (131K): [in a new window]   Fig. 9B —65-year-old man with small cell lung carcinoma and superior vena cava syndrome. Same scan with nodes colored shows teal blue station 7 subcarinal adenopathy extending anterior and posterior to main bronchi. Anterior aspect of subcarinal nodes can be reached by cervical mediastinoscopy via approach anterior to trachea and carina. Station 8 paraesophageal (tan) node lies posterolateral to esophagus (white arrow) between azygos vein (black arrow) and aorta. Station 13 segmental nodes are light pink, station 10 hilar nodes are yellow, and station 4 inferior lower paratracheal nodes are bright orange.

View larger version (123K): [in a new window]   Fig. 10A —66-year-old woman with adenopathy. Contrast-enhanced CT scan (A) and same scan with nodes colored (B) show station 10 hilar nodes (yellow, B), which are anterior and posterior to right upper lobe bronchus. They are inferior to top of right upper lobe bronchus, demarcation point between station 4 mediastinal and station 10 hilar nodes. Note station 7 subcarinal node (teal blue, B). Station 13 segmental node (light pink, B) lies between right upper lobe anterior and posterior segmental bronchi (arrows).

View larger version (152K): [in a new window]   Fig. 10B —66-year-old woman with adenopathy. Contrast-enhanced CT scan (A) and same scan with nodes colored (B) show station 10 hilar nodes (yellow, B), which are anterior and posterior to right upper lobe bronchus. They are inferior to top of right upper lobe bronchus, demarcation point between station 4 mediastinal and station 10 hilar nodes. Note station 7 subcarinal node (teal blue, B). Station 13 segmental node (light pink, B) lies between right upper lobe anterior and posterior segmental bronchi (arrows).

View larger version (106K): [in a new window]   Fig. 10C —66-year-old woman with adenopathy. Contrast-enhanced CT scan (C) and same scan with nodes colored (D) at level of main pulmonary artery and proximal bronchus intermedius depict station 11 interlobar nodes (dark green, D). On left, they lie between lingular and left lower lobe superior segmental bronchi (arrows). On right, they are lateral to bronchus intermedius and inferior to right upper lobe bronchus. Subcarinal station 7 nodes (teal blue, D) are present.

View larger version (161K): [in a new window]   Fig. 10D —66-year-old woman with adenopathy. Contrast-enhanced CT scan (C) and same scan with nodes colored (D) at level of main pulmonary artery and proximal bronchus intermedius depict station 11 interlobar nodes (dark green, D). On left, they lie between lingular and left lower lobe superior segmental bronchi (arrows). On right, they are lateral to bronchus intermedius and inferior to right upper lobe bronchus. Subcarinal station 7 nodes (teal blue, D) are present.

View larger version (114K): [in a new window]   Fig. 11A —38-year-old man with lymphoma. Contrast-enhanced CT scan shows station 8 paraesophageal node.

View larger version (134K): [in a new window]   Fig. 11B —38-year-old man with lymphoma. Same scan with node colored tan shows station 8 paraesophageal node, which is anterior to azygos vein (curved arrow) and lateral to esophagus (straight arrow).

View larger version (124K): [in a new window]   Fig. 12A —66-year-old woman with adenopathy. Contrast-enhanced CT scan (A) and same scan with nodes colored (B) show station 12 lobar nodes (light pink, B) that are adjacent to distal lobar bronchi. Level is just inferior to right middle lobe bronchus near branching of medial basal bronchus (arrow) that is bifurcating from truncus basalis. Station 9 inferior pulmonary ligament node (dark blue, B) lies medially within inferior pulmonary ligament.

View larger version (169K): [in a new window]   Fig. 12B —66-year-old woman with adenopathy. Contrast-enhanced CT scan (A) and same scan with nodes colored (B) show station 12 lobar nodes (light pink, B) that are adjacent to distal lobar bronchi. Level is just inferior to right middle lobe bronchus near branching of medial basal bronchus (arrow) that is bifurcating from truncus basalis. Station 9 inferior pulmonary ligament node (dark blue, B) lies medially within inferior pulmonary ligament.

View larger version (109K): [in a new window]   Fig. 12C —66-year-old woman with adenopathy. Same scan as A and B viewed with lung window settings shows inferior pulmonary ligament (white arrows) adjacent to node (black arrow). Pulmonary ligaments course caudally from inferior hilum to diaphragm. Nodes in inferior pulmonary ligaments are contained in four pleural reflections and therefore are in mediastinum.

View larger version (111K): [in a new window]   Fig. 13A —80-year-old-man with small cell lung carcinoma of right lower lobe. Lung window CT scan (A) and same scan with nodes colored (B) show spread of lung cancer to right hilar nodes. Station 13 segmental nodes (light pink, B) are anterior to lateral basal bronchus.

View larger version (136K): [in a new window]   Fig. 13B —80-year-old-man with small cell lung carcinoma of right lower lobe. Lung window CT scan (A) and same scan with nodes colored (B) show spread of lung cancer to right hilar nodes. Station 13 segmental nodes (light pink, B) are anterior to lateral basal bronchus.

View larger version (87K): [in a new window]   Fig. 13C —80-year-old-man with small cell lung carcinoma of right lower lobe. Lung window CT scan (C) and same scan with nodes colored (D) show station 14 subsegmental node (light pink, D) adjacent to subsegmental bronchus (curved arrow). Ground-glass opacity (straight arrow) in right lower lobe periphery represents top of primary tumor.

View larger version (109K): [in a new window]   Fig. 13D —80-year-old-man with small cell lung carcinoma of right lower lobe. Lung window CT scan (C) and same scan with nodes colored (D) show station 14 subsegmental node (light pink, D) adjacent to subsegmental bronchus (curved arrow). Ground-glass opacity (straight arrow) in right lower lobe periphery represents top of primary tumor.

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