Imaging-Based Nodal Classification for Evaluation of Neck Metastatic Adenopathy
Peter M. Som1,
Hugh D. Curtin2 and
Anthony A. Mancuso3
1
Department of Radiology, Mount Sinai School of Medicine, City University of
New York, One Gustave Levy PI., New York, NY 10029.
2
Department of Radiology, Massachusetts Eye and Ear Infirmary, 243 Charles St.,
Boston, MA 02114.
3
Department of Radiology, Shands Hospital, University of Florida College of
Medicine, 1600 Southwest Archer Rd., Gainesville, FL 32610.
View larger version (57K):
[in a new window]
|
Fig. 1A. —Neck as seen from left anterior view. Drawing shows anatomy
pertinent to nodal classification.
|
|
View larger version (59K):
[in a new window]
|
Fig. 1B. —Neck as seen from left anterior view. Drawing shows specific margins
of anatomy seen in A that relate to definitions of classification
levels. Note that line of separation between levels I and II is posterior
margin of submandibular gland. Separation between levels II and III and IV is
posterior edge of sternocleidomastoid muscle. Line of separation between
levels IV and V is oblique line extending from posterior edge of
sternocleidomastoid muscle to posterior edge of anterior scalene muscle.
Posterior edge of internal jugular vein separates level IIA and IIB nodes.
Carotid arteries separate levels III and IV from level VI. Top of manubrium
separates levels VI and VII. (Reprinted with permission from
[16])
|
|
View larger version (126K):
[in a new window]
|
Fig. 2A. —44-year-old man with lymphoma. ad = anterior belly of digastric
muscle, S = submandibular gland, vn = internal jugular vein, Sc =
sternocleidomastoid muscle. Axial contrast-enhanced CT scan of neck through
floor of mouth and above level of hyoid bone. White line is drawn through back
of each submandibular gland. Nodes anterior to lines are level I nodes and,
because they are lateral to medial margin of each anterior belly of the
digastric muscle, they can be subclassified as level IB nodes. Level II nodes
are posterior to white lines, but anterior to posterior edge of
sternocleidomastoid muscle. Level II nodes, either anterior to the internal
jugular vein or posterior to it but touching it, are subclassified as level
IIA nodes. Nodes posterior to internal jugular vein and not touching it are
subclassified as level IIB nodes.
|
|
View larger version (118K):
[in a new window]
|
Fig. 2B. —44-year-old man with lymphoma. ad = anterior belly of digastric
muscle, S = submandibular gland, vn = internal jugular vein, Sc =
sternocleidomastoid muscle. Axial contrast-enhanced CT scan of neck through
floor of mouth and at level of hyoid bone. Because level is cranial to that of
bottom of body of hyoid bone, internal jugular nodes are classified as level
II, not level III. On each side of neck, transverse white line (Ant) has been
drawn through posterior edge of each submandibular gland. Second white line
(Post) has been drawn through posterior edge of each sternocleidomastoid
muscle. Nodes anterior to line (Ant) are level I nodes. Nodes between line
(Ant) and line (Post) are level II nodes. Nodes posterior to line (Post) are
level V nodes. Because level V nodes are cranial to level of bottom of body of
cricoid cartilage arch, they are subclassified as level VA nodes.
|
|
View larger version (124K):
[in a new window]
|
Fig. 3. —36-year-old HIV-positive man. Axial contrast-enhanced CT scan of
neck through level of lower mandible and above hyoid bone shows level IA node
between medial margins of anterior bellies of digastric muscles (ad). Level IB
nodes are lateral to level IA nodes and anterior to back of submandibular
glands (S). Levels IIA and IIB nodes are seen bilaterally. v = internal
jugular veins, Sc = sternocleidomastoid muscles.
|
|
View larger version (105K):
[in a new window]
|
Fig. 4. —Axial contrast-enhanced CT scan of neck through level of hyoid bone
in 57-year-old man with squamous cell carcinoma of pharynx. White line has
been drawn through posterior edge of right sternocleidomastoid muscle (Sc).
Note conglomerate mass of necrotic level IIA nodes in right neck posterior to
submandibular gland (S). Small necrotic level VA nodes are also present on
right side.
|
|
View larger version (117K):
[in a new window]
|
Fig. 5A. —14-year-old boy (A) and 46-year-old man (B) with
nasopharyngeal carcinomas. Axial contrast-enhanced CT scans show neck at level
just below skull base. Sagittal black line has been drawn along medial aspect
of right internal carotid artery (C). Note retropharyngeal necrotic node (R)
medial to this line. Also note necrotic high level II node (A), which
can be subclassified as level IIA node because it is inseparable from carotid
sheath.
|
|
View larger version (133K):
[in a new window]
|
Fig. 5B. —14-year-old boy (A) and 46-year-old man (B) with
nasopharyngeal carcinomas. Axial contrast-enhanced CT scans show neck at level
just below skull base. Sagittal black line has been drawn along medial aspect
of right internal carotid artery (C). Note retropharyngeal necrotic node (R)
medial to this line. Also note necrotic high level II node (A), which
can be subclassified as level IIA node because it is inseparable from carotid
sheath.
|
|
View larger version (101K):
[in a new window]
|
Fig. 6. —47-year-old woman with lymphoma. Axial contrast-enhanced CT scan of
neck at level of supraglottic larynx shows transverse white line drawn on each
side at posterior edge of sternocleidomastoid muscle (Sc). Bilateral level III
nodes and rightsided level VA node are seen. V = internal jugular vein.
|
|
View larger version (95K):
[in a new window]
|
Fig. 7A. —46-year-old woman with lymphoma. Axial contrast-enhanced CT scans of
neck at level of cricoid cartilage. On each side of neck, transverse white
line has been drawn at posterior edge of sternocleidomastoid muscle (Sc).
Because scan level is above bottom of cricoid arch, internal jugular nodes are
classified as level III and not level IV. Level VA nodes are posterior to
lines.
|
|
View larger version (97K):
[in a new window]
|
Fig. 7B. —46-year-old woman with lymphoma. Axial contrast-enhanced CT scans of
neck through thyroid gland shows oblique white line drawn on each side of neck
through posterolateral margin of anterior scalene muscle (A) and posterior
margin of sternocleidomastoid muscle (Sc). Levels IV and VB nodes are seen. No
portion of clavicle is present on either side so supraclavicular nodes cannot
be diagnosed.
|
|
View larger version (81K):
[in a new window]
|
Fig. 8. —48-year-old man with nasopharyngeal carcinoma. Axial
contrast-enhanced CT scan of neck through level of thyroid gland (T) shows
oblique white line drawn on each side of neck through posterolateral margins
of anterior scalene muscle (A) and posterior margin of sternocleidomastoid
muscle (Sc). Necrotic nodes are seen at level IV and VB.
|
|
View larger version (86K):
[in a new window]
|
Fig. 9A. —54-year-old woman with lymphoma. Axial contrast-enhanced CT scans of
neck through level of lower thyroid gland show incidental thyroid adenoma
(TA). A is slightly more cranial than B. On each side of neck
oblique white line has been drawn through posterolateral margins of anterior
scalene muscles (A) and posterior margin of sternocleidomastoid muscles (Sc).
Level IV and VB nodes are seen. On left side, portion of clavicle (C) is seen
on both images; thus, left level V nodes are classified as supraclavicular
nodes (S).
|
|
View larger version (74K):
[in a new window]
|
Fig. 9B. —54-year-old woman with lymphoma. Axial contrast-enhanced CT scans of
neck through level of lower thyroid gland show incidental thyroid adenoma
(TA). A is slightly more cranial than B. On each side of neck
oblique white line has been drawn through posterolateral margins of anterior
scalene muscles (A) and posterior margin of sternocleidomastoid muscles (Sc).
Level IV and VB nodes are seen. On left side, portion of clavicle (C) is seen
on both images; thus, left level V nodes are classified as supraclavicular
nodes (S).
|
|
View larger version (71K):
[in a new window]
|
Fig. 10A. —28-year-old woman with lymphoma. Axial contrast-enhanced CT scans
through level of lower neck. A is slightly more cranial than B.
On each side of neck oblique white line has been drawn through posterior and
lateral margins of anterior scalene muscles (A) and posterior margins of
sternocleidomastoid muscles (Sc). Sagittal white line is drawn through medial
margin of each carotid artery (ca). Necrotic levels IV and VI nodes, right
supraclavicular nodes (S), and level VB nodes are seen. C = clavicle.
|
|
View larger version (69K):
[in a new window]
|
Fig. 10B. —28-year-old woman with lymphoma. Axial contrast-enhanced CT scans
through level of lower neck. A is slightly more cranial than B.
On each side of neck oblique white line has been drawn through posterior and
lateral margins of anterior scalene muscles (A) and posterior margins of
sternocleidomastoid muscles (Sc). Sagittal white line is drawn through medial
margin of each carotid artery (ca). Necrotic levels IV and VI nodes, right
supraclavicular nodes (S), and level VB nodes are seen. C = clavicle.
|
|
View larger version (61K):
[in a new window]
|
Fig. 11. —67-year-old man with lymphoma. Axial contrast-enhanced CT scan of
neck through level just below top of manubrium (M) shows medial clavicle (C)
on each side. Level VII node is seen in superior mediastinum. Multiple
axillary nodes (A) lie lateral to ribs on each side of upper chest.
|
|
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Copyright © 2000 by the American Roentgen Ray Society.
