LII:Radiation Oncology/Anatomy

Front Page: Radiation Oncology | RTOG Trials | Randomized Trials

This page is for Anatomy Pearls useful for radiation oncology. Suitable examples include radiographic landmarks, location of lymph node groups, and lymph drainage patterns.

Anatomy atlases

HeadNeckBrainSpine Neuroradiology
Gray's Anatomy @ Bartleby.com
Basic Anatomy @ Dartmouth
Wesley Norman Anatomists
AnatomyAtlases.org
Radiology Assistant
Cross-sectional nodal atlas, 1999 (Ohio State) - PMID 10352611 Full text — "Cross-sectional nodal atlas: a tool for the definition of clinical target volumes in three-dimensional radiation therapy planning." Martinez-Monge R et al. Radiology. 1999 Jun;211(3):815-28.
- Atlas of everything (H&N, lung, GI, GU, Gyn) on CT images with nodal regions shaded.
Wayne State University link
- Brain: MRI (Sagittal, Coronal, Axial)
- Upper Abdomen: CT
- Thorax: CT
- Pelvis + Upper Thigh: CT

Dissections

SUNY Downstate

Vertebral Levels

D means disc below level
Categorized:

Vocal Cord —> C5
Cricoid —> C6
Start of trachea —> C6-C7
Thyroid gland —> C7
Lung apex —> T1
Origin SVC —> T3
AO arch —> T4/DT3
Carina —> T5
- 25 cm from the incisors
Liver
- Upper level: T7-8

Suprasternal Notch —> T3
Manubrium —> T4
Angle of louis —> T5
Xiphoid Process —> T10

Ant costodiaphragm —> T10
Post costodiaphragm —> L3

GEJ —> T10/T11 ( 2-3cm to left of midline )
- 40cm from incisors
Spleen —> T10-T11 ( 5cm left to midline )
Pancreas body —> L1
Cysterna chili —> L1-L2
Umbilicus —> L4
- If standing and in infants —> lower
Gallbladder —> at 9th rib; right lat border of rectus abdomens ( transpyloric plane )
Start of large bowel ( Cecum ) —> L4
- Ascending Colon : 15cm
- Descending Colon : 25cm
Rectum —>
- Starts : S3
- Ends : 4cm from anus

R Kidney hilum —> L2
L Kidney hilum —> L1

Para-AO nodes —> T12-L4
Common Iliac nodes —> L4 ( Bifurcation of AO )
Bifurcation of common iliac —> L5-S1

Uncategorized:

Hyoid Bone C4
Right Lung T1-T11
Left Lung T1-DT10
Suprasternal Notch T3
Aortic arch DT3
Origin SVC T3
Bifurcation of Trachea T5
SVC Heart junction T7
IVC Heart T9
Apex of Heart T10
Fundus stomach T10
Spleen T10-L1
GE Junction T11
Xiphoid Apex DT11
Left Kidney DT11-L3
Right Adrenal T11-L1
Left Adrenal T12-L1
Superior duodenum DT12
Colon splenic Flexure T12
Pancreas Body T12
Right lobe of Liver T9-DL3
Right Kidney T12-L3
Duodenal Jejeunal Flexure L1
Stomach pylorus L1
Colon hepatic flexure L2
Bottom of gallbladder L2
Aortic bifurcation L4
Iliac Crest L4
Umbilicus L4
Ileo Cecal Valve L5
Base of Appendix L5
IVC origin L5
Lower border of Cecum DS2

Clinical Syndromes with CN Palsy

Please see the Clinical Syndromes with CN Palsy page

Head & Neck

Please see the H&N anatomy page

Regional breast lymph nodes

Please see the axilla RT technique section

Supraclavicular

Brachial plexus:

Please see the Brachial plexus section
Also see the section on this page Radiation_Oncology/Anatomy#Thorax

Thorax

See also: Radiation Oncology/Thorax/Anatomy (Lung lymph node stations)

Abdomen

Vessels

In order, superior to inferior:

Celiac artery
At T12 (75%) or L1 (25%)
SMA
Renal arteries/veins
Ovarian/testicular vein - Right side, drains into IVC 1 cm below R renal vein. Left side, drains into L renal vein lateral to the aorta.
Ovarian/testicular arteries - 5 to 6 cm above aortic bifurcation
IMA - 3 to 4 cm above aortic bifurcation

Lymphatics

Pancreaticoduodenal nodes - lie in C-loop of duodenum

Paraaortic lymph nodes (may also be called para-aortic, periaortic, or peri-aortic) - located adjacent to aorta, anterior to lumbar spine, extending bilaterally to the medial margins of the psoas major muscles, up to diaphragmatic crura.
For a paraaortic lymph node dissection, the surgeon usually dissects from aortic bifurcation up to SMA or renal veins.

CT Atlas

Baylor; 2007 PMID 17959923 -- "Learning the nodal stations in the abdomen." (Moron FE, Br J Radiol. 2007 Oct;80(958):841-8.)

Pelvic lymph nodes

Beth Israel, 2010 - PMID 20032141 -- "Lymphatic metastases from pelvic tumors: anatomic classification, characterization, and staging." (McMahon CJ, Radiology. 2010 Jan;254(1):31-46.)
- Comment: shows subdivisions of lymph node groups. Normal node size cutoffs.
Park (MDACC), 1994 - PMID 7855343 — "Pathways of nodal metastasis from pelvic tumors: CT demonstration." (Park JM, Radiographics. 1994 Nov;14(6):1309-21.)

Prostate

Please see Radiation_Oncology/Prostate/Anatomy

Skin LN drainage

Auckland; 2007 (New Zealand) PMID 17643351 -- "Three-dimensional visualisation of lymphatic drainage patterns in patients with cutaneous melanoma." (Reynolds HM, Lancet Oncol. 2007 Sep;8(9):806-12.)
- Heat maps based on 5239 SLN analyses of cutaneous melanoma patients
- Conclusion: Sappey's lines not effective

Pterygopalatine ganglion

Suspended from V2 branch of trigeminal (CNV) nerve
Parasympathetic input from superior salivary nucleus in brain stem travel via facial nerve (CNVII) to greater superficial petrosal nerve
Sympathetic fibers from carotid plexus travel via deep petrosal nerve
The deep petrosal nerve and greater superficial petrosal nerves join to form the vidian nerve, which passes through (sympathetic fibers)/into (parasympathetic fibers) the pterygopalatine nucleus
Postganglionic parasympathetic fibers and passing-through sympathetic fibers travel through trigeminal nerve to lacrimal gland and nasal/oral mucosa