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Delineation of the neck node levels for
head and neck tumors : A 2013 update.
Veincent Gregoire, Kian Ang, Wilfried Budach, et al
Park Haryung
2015-06-19
Introduction
• In head and neck IMRT, it has been shown that heterogeneity in target volume selection and
delineation is an important source of variations among radiation oncologist.
• In previous framework
– Not all the neck node areas described in the TNM atlas were included
– Description of the anatomic boundaries of some of levels(e.g. in the lower neck) was not sufficiently
accurate and required some interpretation for the users
– Guidelines for the node into normal structures to generate the CTV was both arbitrary and potentially
imprecise
• New data on tumor extra-capsular extension in lymph nodes have emerged permitting specific
recommendations to be proposed
– Illustrations of nodal levels were not available in DICOM or DICOM-RT format
• consequently limiting the easy use of the atlas and preventing its direct importation into treatment
planning systems.
• In this context, update the previously published guidelines on target delineation in the neck
– Consensus guidelines for the delineation of the neck node levels
The consensus guidelines
• Level Ia
– median region located between the anterior belly of the digastric muscles, which contains the
submental nodes
– Level Ia is at greatest risk of harboring metastases from cancer arising from the floor of the mouth, the
anterior oral tongue, the anterior mandibular alveolar ridge, and the lower lip
Level Cranial Caudal Anterior Posterior Lateral Medial
Level Ia Mylo-hyoid m. Platysma m. Symphysis menti Body of hyoid
bone/mylo-
hyoid m.
Medial edge of
ant. belly of
digastric m.
n.a.
The consensus guidelines
• Level Ib
– Level Ib contains the submandibular nodes located in the space between the inner side of the mandible
laterally and the digastric muscle medially, from the symphysis menti anteriorly to the submandibular
gland posteriorly.
– Nodes in level Ib are at risk of developing metastases from cancers of the oral cavity, anterior nasal
cavity, soft tissue structures of the mid-face and the submandibular gland.
Level Cranial Caudal Anterior Posterior Lateral Medial
Level Ib Cranial edge of
submandibular
gland; anteriorly,
mylo-hyoid m.
caudal edge of
hyoid bone and
caudal edge of
mandible;
caudal edge of
submandibular
gland
Symphysis menti Posterior edge
of
submandibular
gland
(caudally)/posteri
or belly of
digastric m.
(cranially)
Medial aspect
(innerside) of
mandible down
to caudal edge
/platysma m.
(caudal)
/medial terygoid
m. (posteriorly)
Lateral edge of
ant. belly of
digastric m.
(caudally)
/posterior belly
of digastric m.
(cranially)
The consensus guidelines
• Level II
– Level II (Table 3) contains the upper jugular nodes located around the upper one-third of the internal
jugular vein (IJV) and the upper spinal accessory nerve (SAN).
– The nodes in level II are therefore at greatest risk of harboring metastases from cancers of the nasal
cavity, oral cavity, nasopharynx, oropharynx, hypopharynx, larynx, and the major salivary glands.
– Level IIb is more likely associated with primary tumors of the oropharynx or nasopharynx, and less
frequently with tumors of the oral cavity, larynx or hypopharynx.
Level Cranial Caudal Anterior Posterior Lateral Medial
Level II Caudal edge of
the lateral rocess
of C1
Caudal edge of
the body of the
hyoid bone
Posterior edge
of the
submandibular
gland/posterior
edge of
posterior belly
of digastric m.
Posterior edge
of
sternocleidomast
oid m.
Deep (medial)
surface of
Sternocleidomas
toid m.
/platysma m.
/parotid gland
/posterior belly
of digastric m.
Medial edge of
internal carotid
Artery
/scalenius m.
The consensus guidelines
• Level III
– Level III (Table 3) contains the middle jugular nodes located around the middle third of the IJV.
• It is the caudal extension of level II.
• It extends from the caudal edge of the body of the hyoid bone to the caudal edge of the cricoid cartilage
– Nodes in level III are at greatest risk of harboring metastases from cancers of the oral cavity,
nasopharynx, oropharynx, hypopharynx and larynx.
Level Cranial Caudal Anterior Posterior Lateral Medial
Level III Caudal edge of
the body of the
hyoid Bone
Caudal edge of
cricoid cartilage
Anterior edge of
Sternocleidomast
oid m.
/posterior third
of thyro-hyoid m.
Posterior edge
of
sternocleidomast
oid m.
Deep (medial)
surface of
sternocleidomast
oid m.
Medial edge of
common carotid
Artery
/scalenius mm.
The consensus guidelines
• Level IVa
– Level IVa (Table 3) contains the lower jugular lymph nodes located around the inferior third of the IJV
from the caudal limit of level III to a limit set arbitrarily 2 cm cranial to the sternoclavicular joint,
caudally.
– Level IVa nodes are at high risk for harboring metastases from cancers of the hypopharynx, larynx,
thyroid and cervical esophagus.
– Rarely metastases from the anterior oral cavity may manifest in this location with minimal or no
proximal nodal disease.
Level Cranial Caudal Anterior Posterior Lateral Medial
Level
IVa
Caudal edge of
cricoid cartilage
2 cm cranial to
sternal
manubrium
Anterior edge of
Sternocleidomast
oid m. (cranially)
/body of
Sternocleidomast
oid m. (caudally)
Posterior edge
of
sternocleidomast
oid m. (cranially)
/scalenius mm.
(caudally)
Deep (medial)
surface of
Sternocleidomast
oid m. (cranially)
/lateral edge of
Sternocleidomast
oid m. (caudally)
Medial edge of
common carotid
Artery
/lateral edge of
thyroid gland
/scalenius mm.
(cranially)
/medial edge of
Sternocleidomast
oid m. (caudally)
The consensus guidelines
• Level IVb
– Level IVb (Table 3) contains the medial supraclavicular lymph nodes located in the continuation of level
IVa down to the cranial edge of the sternal manubrium.
– Level Ivb nodes are at high risk for harboring metastases from cancers of the hypopharynx, sub-glottic
larynx, trachea, thyroid and cervical esophagus.
Level Cranial Caudal Anterior Posterior Lateral Medial
Level
IVb
Caudal border of
level IVa (2 cm
cranial to sternal
manubrium)
Cranial edge of
sternal
manubrium
Deep surface of
Sternocleidomas
toid m.
/deep aspect of
clavicle
Anterior edge of
scalenius mm.
(cranially)
/apex of lung,
the brachioceph-
alic vein(right
side) and the
carotid artery
and subclavian
artery on the left
side (caudally)
Lateral edge of
scalenius m.
Lateral border of
level VI (pre-
tracheal
component)
/medial edge of
common carotid
artery
The consensus guidelines
• Level Va and Vb
– Level Va and Vb (Table 4) contains the nodes of the posterior triangle group located posteriorly to the
sternocleidomastoid muscle around the lower part of the spinal accessory nerve and the transverse
cervical vessels.
– It extends from a plane crossing the cranial edge of the body of the hyoid bone to a plane crossing the
cervical transverse vessels caudally.
– level V is currently subdivided into levels Va and Vb using the caudal edge of the cricoid cartilage as an
anatomic landmark.
– Level V lymph nodes are at high risk for harboring metastases from cancers of the nasopharynx,
oropharynx and thyroid gland.
– Nodes in level V are most often associated with primary cancers of the nasopharynx, the oropharynx,
the cutaneous structures of the posterior scalp, and the thyroid gland (level Vb).
The consensus guidelines
• Level Va and Vb
– Level Va and Vb (Table 4) contains the nodes of the posterior triangle group located posteriorly to the
sternocleidomastoid muscle around the lower part of the spinal accessory nerve and the transverse
cervical vessels.
– It extends from a plane crossing the cranial edge of the body of the hyoid bone to a plane crossing the
cervical transverse vessels caudally.
– level V is currently subdivided into levels Va and Vb using the caudal edge of the cricoid cartilage as an
anatomic landmark.
– Level V lymph nodes are at high risk for harboring metastases from cancers of the nasopharynx,
oropharynx and thyroid gland.
– Nodes in level V are most often associated with primary cancers of the nasopharynx, the oropharynx,
the cutaneous structures of the posterior scalp, and the thyroid gland (level Vb).
Level Cranial Caudal Anterior Posterior Lateral Medial
Level V Cranial edge of
the body of
hyoid bone
Plane just below
transverse
cervical vessels
Posterior edge
of sternocleido-
mastoid m.
Anterior border
of trapezius m.
Platysma m./skin Levator scapulae
m./scalenius m.
(caudally)
The consensus guidelines
• Level Vc
– Level Vc (Table 4) contains the lateral supraclavicular nodes located in the continuation of the posterior
triangle nodes (level Va and Vb) from the cervical transverse vessels down to a limit set arbitrarily 2 cm
cranial to the sternal manubrium
– Level Vc receives efferent lymphatics from the posterior triangle nodes (level Va and Vb) and is more
commonly associated with nasopharyngeal tumors.
Level Cranial Caudal Anterior Posterior Lateral Medial
Level
Vc
Plane just below
transverse ervical
vessels (caudal
border of level V)
2 cm cranial to
sternal anubrium,
i.e. caudal
border of level
Iva
Skin Anterior border
of trapezius m.
(cranially)
/anterior to
serratus anterior
m. (caudally)
Trapezius m
(cranially)/clavicl
e (caudally)
Scalenius m.
/lateral edge of
sternocleidomast
oid m, lateral
edge of level IVa
The consensus guidelines
• Level VIa and VIb
– Level VI (Table 5) contains the anterior compartment nodes including superficially, the anterior jugular
nodes (level VIa), and in the deep previsceral space, the pre-laryngeal, pre-tracheal and para-tracheal
(recurrent laryngeal nerve) nodes (level VIb)
– These nodes are at high risk for harboring metastases from cancers of the lower lip, the oral cavity
(floor of mouth and tip of the tongue), the thyroid gland, the glottic and subglottic larynx, the apex of
the piriform sinus, and the cervical esophagus.
Level Cranial Caudal Anterior Posterior Lateral Medial
Level
VIa
Caudal edge of
the hyoid bone
or caudal edge
of the
submandibular
gland, whichever
is more caudal
Cranial edge of
the sternal
manubrium
Skin/platysma m. Anterior aspect
of the infrahyoid
(strap) mm.
Anterior edges
of both
sternocleidomast
oid mm.
n.a.
The consensus guidelines
• Level VIa and VIb
– Level VI (Table 5) contains the anterior compartment nodes including superficially, the anterior jugular
nodes (level VIa), and in the deep previsceral space, the pre-laryngeal, pre-tracheal and para-tracheal
(recurrent laryngeal nerve) nodes (level VIb)
– These nodes are at high risk for harboring metastases from cancers of the lower lip, the oral cavity
(floor of mouth and tip of the tongue), the thyroid gland, the glottic and subglottic larynx, the apex of
the piriform sinus, and the cervical esophagus.
Level Cranial Caudal Anterior Posterior Lateral Medial
Level
VIb
Caudal edge of
the thyroid
cartilage
Cranial edge of
the sternal
manubrium
Posterior aspect
of infrahyoid
(strap) mm.
Anterior aspect
of larynx, thyroid
gland and trache
(pre-laryngeal
and pre-tracheal
nodes)/prevertebr
al m. (right side)
/esophagus (left
side)
Common carotid
artery on both
sides
Lateral aspect of
trachea &
esophagus
(caudally)
The consensus guidelines
• Level VIIa
– Level VIIa (Table 6) contains the retropharyngeal nodes, which lie within the retropharyngeal space,
extending cranially from the upper edge of the first cervical vertebrae to the cranial edge of the body
of the hyoid bone caudally
– These nodes are at risk of harboring metastases from cancers of the nasopharynx, the posterior
pharyngeal wall and the oropharynx (mainly the tonsillar fossa and the soft palate).
Level Cranial Caudal Anterior Posterior Lateral Medial
Level
VIIa
Upper edge of
body of c1/hard
palate
Cranial edge of
the body of the
hyoid bone
Posterior edge
of the superior
or middle
pharyngeal
constrictor m.
Longus capitis m.
and longus colli
m.
Medial edge of
the internal
carotid artery
A line parallel to
the lateral edge
of the longus
capitis muscle
The consensus guidelines
• Level VIIb
– Level VIIb (Table 6) contains the retro-styloid nodes, which are the cranial continuation of the level II
nodes.
– They are located in the fatty space around the jugulo-carotid vessels up to the base of skull (jugular
foramen).
– Retro-styloid nodes are at risk of harboring metastases from cancers of the nasopharynx, and from any
other head and neck primary with massive infiltration of upper level II nodes through retrograde lymph
flow.
Level Cranial Caudal Anterior Posterior Lateral Medial
Level
VIIb
Base of skull
(jugular foramen)
Caudal edge of
the lateral
process of C1
(upper limit of
level II)
Posterior edge
of prestyloid
para-pharyngeal
space
Vertebral body
of C1, base of
skull
Styloid
process/deep
parotid lobe
Medial edge of
the internal
carotid artery
The consensus guidelines
• Level VIIb
Level Cranial Caudal Anterior Posterior Lateral Medial
Level
VIIb
Base of skull
(jugular foramen)
Caudal edge of
the lateral
process of C1
(upper limit of
level II)
Posterior edge
of prestyloid
para-pharyngeal
space
Vertebral body
of C1, base of
skull
Styloid
process/deep
parotid lobe
Medial edge of
the internal
carotid artery
Retrostyloid Space
Prestyloid Space
The consensus guidelines
• Level VIII
– Level VIII (Table 7) contains the parotid node group, which includes the subcutaneous pre-auricular
nodes, the superficial and deep intraparotid nodes and the subparotid nodes.
– They are at risk of harboring metastasis from cancers of these regions but especially from tumors of the
frontal and temporal skin, the orbit, the external auditory canal, the nasal cavities, and the parotid gland.
Level Cranial Caudal Anterior Posterior Lateral Medial
Level
VIII
Zygomatic arch,
external auditory
canal
Angle of the
mandible
Posterior edge of
mandidular
ramus &
posterior edge of
masseter m.
(laterally) medial
pterygoid muscle
(medially)
Anterior edge of
sternocleidomast
oid m. (laterally),
posterior
belly of digastric
m. (medially)
SMAS layer in
sub-cutaneous
tissue
Styloid process
and styloid m.
The consensus guidelines
• Level IX
– Level IX (Table 8) contains the malar and bucco-facial node group, which includes inconsistent
superficial lymph nodes around the facial vessels on the external surface of the buccinator muscle.
– They are at risk of harboring metastases from cancers of the skin of the face, the nose, the maxillary
sinus (infiltrating the soft tissue of the cheek) and the buccal mucosa.
Level Cranial Caudal Anterior Posterior Lateral Medial
Level IX Caudal edge of
the orbit
Caudal edge of
the mandible
SMAS layer in
sub-cutaneous
tissue
Anterior edge of
masseter m. &
corpus adiposum
buccae
(bichat’s fat pad)
SMAS layer in
sub-cutaneous
tissue
Buccinator m.
The consensus guidelines
• Level Xa
– Level Xa (Table 9) contains the retroauricular (also called mastoid) and subauricular nodes, which
includes superficial nodes lying on the mastoid process from the cranial edge of the external auditory
canal cranially to the tip of the mastoid caudally
– They are at risk of harboring metastases mainly from skin cancers of the retro-auricular area.
Level Cranial Caudal Anterior Posterior Lateral Medial
Level
Xa
Cranial edge of
external auditory
canal)
Tip of the
mastoid
Anterior edge of
the mastoid
(caudally)/poster
ior edge of the
external auditory
canal (cranially)
Anterior border
of occipital
nodes posterior
edge of
sternocleidomast
oid m.
Sub-cutaneous
tissue
Splenius capitis
m. (caudally)
/temporal bone
(cranially)
The consensus guidelines
• Level Xb
– Level Xb (Table 9) contains the occipital lymph nodes, which are the cranial and superficial continuation
of the level Va nodes up to the cranial protuberance.
– Level Xb nodes receive efferent vessels from the posterior part of the hair-bearing scalp and are at risk
of metastases from skin cancers of the occipital area.
Level Cranial Caudal Anterior Posterior Lateral Medial
Level
Xb
External occipital
protuberance
Cranial border of
level V
Posterior edge of
sternocleidomast
oid m.
Anterior (lateral)
edge of trapezius
m.
Sub-cutaneous
tissue
Splenius capitis
m.

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2015 06-25 delineation of the neck node levels for head and neck tummors

  • 1. Delineation of the neck node levels for head and neck tumors : A 2013 update. Veincent Gregoire, Kian Ang, Wilfried Budach, et al Park Haryung 2015-06-19
  • 2. Introduction • In head and neck IMRT, it has been shown that heterogeneity in target volume selection and delineation is an important source of variations among radiation oncologist. • In previous framework – Not all the neck node areas described in the TNM atlas were included – Description of the anatomic boundaries of some of levels(e.g. in the lower neck) was not sufficiently accurate and required some interpretation for the users – Guidelines for the node into normal structures to generate the CTV was both arbitrary and potentially imprecise • New data on tumor extra-capsular extension in lymph nodes have emerged permitting specific recommendations to be proposed – Illustrations of nodal levels were not available in DICOM or DICOM-RT format • consequently limiting the easy use of the atlas and preventing its direct importation into treatment planning systems. • In this context, update the previously published guidelines on target delineation in the neck – Consensus guidelines for the delineation of the neck node levels
  • 3. The consensus guidelines • Level Ia – median region located between the anterior belly of the digastric muscles, which contains the submental nodes – Level Ia is at greatest risk of harboring metastases from cancer arising from the floor of the mouth, the anterior oral tongue, the anterior mandibular alveolar ridge, and the lower lip Level Cranial Caudal Anterior Posterior Lateral Medial Level Ia Mylo-hyoid m. Platysma m. Symphysis menti Body of hyoid bone/mylo- hyoid m. Medial edge of ant. belly of digastric m. n.a.
  • 4. The consensus guidelines • Level Ib – Level Ib contains the submandibular nodes located in the space between the inner side of the mandible laterally and the digastric muscle medially, from the symphysis menti anteriorly to the submandibular gland posteriorly. – Nodes in level Ib are at risk of developing metastases from cancers of the oral cavity, anterior nasal cavity, soft tissue structures of the mid-face and the submandibular gland. Level Cranial Caudal Anterior Posterior Lateral Medial Level Ib Cranial edge of submandibular gland; anteriorly, mylo-hyoid m. caudal edge of hyoid bone and caudal edge of mandible; caudal edge of submandibular gland Symphysis menti Posterior edge of submandibular gland (caudally)/posteri or belly of digastric m. (cranially) Medial aspect (innerside) of mandible down to caudal edge /platysma m. (caudal) /medial terygoid m. (posteriorly) Lateral edge of ant. belly of digastric m. (caudally) /posterior belly of digastric m. (cranially)
  • 5. The consensus guidelines • Level II – Level II (Table 3) contains the upper jugular nodes located around the upper one-third of the internal jugular vein (IJV) and the upper spinal accessory nerve (SAN). – The nodes in level II are therefore at greatest risk of harboring metastases from cancers of the nasal cavity, oral cavity, nasopharynx, oropharynx, hypopharynx, larynx, and the major salivary glands. – Level IIb is more likely associated with primary tumors of the oropharynx or nasopharynx, and less frequently with tumors of the oral cavity, larynx or hypopharynx. Level Cranial Caudal Anterior Posterior Lateral Medial Level II Caudal edge of the lateral rocess of C1 Caudal edge of the body of the hyoid bone Posterior edge of the submandibular gland/posterior edge of posterior belly of digastric m. Posterior edge of sternocleidomast oid m. Deep (medial) surface of Sternocleidomas toid m. /platysma m. /parotid gland /posterior belly of digastric m. Medial edge of internal carotid Artery /scalenius m.
  • 6. The consensus guidelines • Level III – Level III (Table 3) contains the middle jugular nodes located around the middle third of the IJV. • It is the caudal extension of level II. • It extends from the caudal edge of the body of the hyoid bone to the caudal edge of the cricoid cartilage – Nodes in level III are at greatest risk of harboring metastases from cancers of the oral cavity, nasopharynx, oropharynx, hypopharynx and larynx. Level Cranial Caudal Anterior Posterior Lateral Medial Level III Caudal edge of the body of the hyoid Bone Caudal edge of cricoid cartilage Anterior edge of Sternocleidomast oid m. /posterior third of thyro-hyoid m. Posterior edge of sternocleidomast oid m. Deep (medial) surface of sternocleidomast oid m. Medial edge of common carotid Artery /scalenius mm.
  • 7. The consensus guidelines • Level IVa – Level IVa (Table 3) contains the lower jugular lymph nodes located around the inferior third of the IJV from the caudal limit of level III to a limit set arbitrarily 2 cm cranial to the sternoclavicular joint, caudally. – Level IVa nodes are at high risk for harboring metastases from cancers of the hypopharynx, larynx, thyroid and cervical esophagus. – Rarely metastases from the anterior oral cavity may manifest in this location with minimal or no proximal nodal disease. Level Cranial Caudal Anterior Posterior Lateral Medial Level IVa Caudal edge of cricoid cartilage 2 cm cranial to sternal manubrium Anterior edge of Sternocleidomast oid m. (cranially) /body of Sternocleidomast oid m. (caudally) Posterior edge of sternocleidomast oid m. (cranially) /scalenius mm. (caudally) Deep (medial) surface of Sternocleidomast oid m. (cranially) /lateral edge of Sternocleidomast oid m. (caudally) Medial edge of common carotid Artery /lateral edge of thyroid gland /scalenius mm. (cranially) /medial edge of Sternocleidomast oid m. (caudally)
  • 8. The consensus guidelines • Level IVb – Level IVb (Table 3) contains the medial supraclavicular lymph nodes located in the continuation of level IVa down to the cranial edge of the sternal manubrium. – Level Ivb nodes are at high risk for harboring metastases from cancers of the hypopharynx, sub-glottic larynx, trachea, thyroid and cervical esophagus. Level Cranial Caudal Anterior Posterior Lateral Medial Level IVb Caudal border of level IVa (2 cm cranial to sternal manubrium) Cranial edge of sternal manubrium Deep surface of Sternocleidomas toid m. /deep aspect of clavicle Anterior edge of scalenius mm. (cranially) /apex of lung, the brachioceph- alic vein(right side) and the carotid artery and subclavian artery on the left side (caudally) Lateral edge of scalenius m. Lateral border of level VI (pre- tracheal component) /medial edge of common carotid artery
  • 9. The consensus guidelines • Level Va and Vb – Level Va and Vb (Table 4) contains the nodes of the posterior triangle group located posteriorly to the sternocleidomastoid muscle around the lower part of the spinal accessory nerve and the transverse cervical vessels. – It extends from a plane crossing the cranial edge of the body of the hyoid bone to a plane crossing the cervical transverse vessels caudally. – level V is currently subdivided into levels Va and Vb using the caudal edge of the cricoid cartilage as an anatomic landmark. – Level V lymph nodes are at high risk for harboring metastases from cancers of the nasopharynx, oropharynx and thyroid gland. – Nodes in level V are most often associated with primary cancers of the nasopharynx, the oropharynx, the cutaneous structures of the posterior scalp, and the thyroid gland (level Vb).
  • 10. The consensus guidelines • Level Va and Vb – Level Va and Vb (Table 4) contains the nodes of the posterior triangle group located posteriorly to the sternocleidomastoid muscle around the lower part of the spinal accessory nerve and the transverse cervical vessels. – It extends from a plane crossing the cranial edge of the body of the hyoid bone to a plane crossing the cervical transverse vessels caudally. – level V is currently subdivided into levels Va and Vb using the caudal edge of the cricoid cartilage as an anatomic landmark. – Level V lymph nodes are at high risk for harboring metastases from cancers of the nasopharynx, oropharynx and thyroid gland. – Nodes in level V are most often associated with primary cancers of the nasopharynx, the oropharynx, the cutaneous structures of the posterior scalp, and the thyroid gland (level Vb). Level Cranial Caudal Anterior Posterior Lateral Medial Level V Cranial edge of the body of hyoid bone Plane just below transverse cervical vessels Posterior edge of sternocleido- mastoid m. Anterior border of trapezius m. Platysma m./skin Levator scapulae m./scalenius m. (caudally)
  • 11. The consensus guidelines • Level Vc – Level Vc (Table 4) contains the lateral supraclavicular nodes located in the continuation of the posterior triangle nodes (level Va and Vb) from the cervical transverse vessels down to a limit set arbitrarily 2 cm cranial to the sternal manubrium – Level Vc receives efferent lymphatics from the posterior triangle nodes (level Va and Vb) and is more commonly associated with nasopharyngeal tumors. Level Cranial Caudal Anterior Posterior Lateral Medial Level Vc Plane just below transverse ervical vessels (caudal border of level V) 2 cm cranial to sternal anubrium, i.e. caudal border of level Iva Skin Anterior border of trapezius m. (cranially) /anterior to serratus anterior m. (caudally) Trapezius m (cranially)/clavicl e (caudally) Scalenius m. /lateral edge of sternocleidomast oid m, lateral edge of level IVa
  • 12. The consensus guidelines • Level VIa and VIb – Level VI (Table 5) contains the anterior compartment nodes including superficially, the anterior jugular nodes (level VIa), and in the deep previsceral space, the pre-laryngeal, pre-tracheal and para-tracheal (recurrent laryngeal nerve) nodes (level VIb) – These nodes are at high risk for harboring metastases from cancers of the lower lip, the oral cavity (floor of mouth and tip of the tongue), the thyroid gland, the glottic and subglottic larynx, the apex of the piriform sinus, and the cervical esophagus. Level Cranial Caudal Anterior Posterior Lateral Medial Level VIa Caudal edge of the hyoid bone or caudal edge of the submandibular gland, whichever is more caudal Cranial edge of the sternal manubrium Skin/platysma m. Anterior aspect of the infrahyoid (strap) mm. Anterior edges of both sternocleidomast oid mm. n.a.
  • 13. The consensus guidelines • Level VIa and VIb – Level VI (Table 5) contains the anterior compartment nodes including superficially, the anterior jugular nodes (level VIa), and in the deep previsceral space, the pre-laryngeal, pre-tracheal and para-tracheal (recurrent laryngeal nerve) nodes (level VIb) – These nodes are at high risk for harboring metastases from cancers of the lower lip, the oral cavity (floor of mouth and tip of the tongue), the thyroid gland, the glottic and subglottic larynx, the apex of the piriform sinus, and the cervical esophagus. Level Cranial Caudal Anterior Posterior Lateral Medial Level VIb Caudal edge of the thyroid cartilage Cranial edge of the sternal manubrium Posterior aspect of infrahyoid (strap) mm. Anterior aspect of larynx, thyroid gland and trache (pre-laryngeal and pre-tracheal nodes)/prevertebr al m. (right side) /esophagus (left side) Common carotid artery on both sides Lateral aspect of trachea & esophagus (caudally)
  • 14. The consensus guidelines • Level VIIa – Level VIIa (Table 6) contains the retropharyngeal nodes, which lie within the retropharyngeal space, extending cranially from the upper edge of the first cervical vertebrae to the cranial edge of the body of the hyoid bone caudally – These nodes are at risk of harboring metastases from cancers of the nasopharynx, the posterior pharyngeal wall and the oropharynx (mainly the tonsillar fossa and the soft palate). Level Cranial Caudal Anterior Posterior Lateral Medial Level VIIa Upper edge of body of c1/hard palate Cranial edge of the body of the hyoid bone Posterior edge of the superior or middle pharyngeal constrictor m. Longus capitis m. and longus colli m. Medial edge of the internal carotid artery A line parallel to the lateral edge of the longus capitis muscle
  • 15. The consensus guidelines • Level VIIb – Level VIIb (Table 6) contains the retro-styloid nodes, which are the cranial continuation of the level II nodes. – They are located in the fatty space around the jugulo-carotid vessels up to the base of skull (jugular foramen). – Retro-styloid nodes are at risk of harboring metastases from cancers of the nasopharynx, and from any other head and neck primary with massive infiltration of upper level II nodes through retrograde lymph flow. Level Cranial Caudal Anterior Posterior Lateral Medial Level VIIb Base of skull (jugular foramen) Caudal edge of the lateral process of C1 (upper limit of level II) Posterior edge of prestyloid para-pharyngeal space Vertebral body of C1, base of skull Styloid process/deep parotid lobe Medial edge of the internal carotid artery
  • 16. The consensus guidelines • Level VIIb Level Cranial Caudal Anterior Posterior Lateral Medial Level VIIb Base of skull (jugular foramen) Caudal edge of the lateral process of C1 (upper limit of level II) Posterior edge of prestyloid para-pharyngeal space Vertebral body of C1, base of skull Styloid process/deep parotid lobe Medial edge of the internal carotid artery Retrostyloid Space Prestyloid Space
  • 17. The consensus guidelines • Level VIII – Level VIII (Table 7) contains the parotid node group, which includes the subcutaneous pre-auricular nodes, the superficial and deep intraparotid nodes and the subparotid nodes. – They are at risk of harboring metastasis from cancers of these regions but especially from tumors of the frontal and temporal skin, the orbit, the external auditory canal, the nasal cavities, and the parotid gland. Level Cranial Caudal Anterior Posterior Lateral Medial Level VIII Zygomatic arch, external auditory canal Angle of the mandible Posterior edge of mandidular ramus & posterior edge of masseter m. (laterally) medial pterygoid muscle (medially) Anterior edge of sternocleidomast oid m. (laterally), posterior belly of digastric m. (medially) SMAS layer in sub-cutaneous tissue Styloid process and styloid m.
  • 18. The consensus guidelines • Level IX – Level IX (Table 8) contains the malar and bucco-facial node group, which includes inconsistent superficial lymph nodes around the facial vessels on the external surface of the buccinator muscle. – They are at risk of harboring metastases from cancers of the skin of the face, the nose, the maxillary sinus (infiltrating the soft tissue of the cheek) and the buccal mucosa. Level Cranial Caudal Anterior Posterior Lateral Medial Level IX Caudal edge of the orbit Caudal edge of the mandible SMAS layer in sub-cutaneous tissue Anterior edge of masseter m. & corpus adiposum buccae (bichat’s fat pad) SMAS layer in sub-cutaneous tissue Buccinator m.
  • 19. The consensus guidelines • Level Xa – Level Xa (Table 9) contains the retroauricular (also called mastoid) and subauricular nodes, which includes superficial nodes lying on the mastoid process from the cranial edge of the external auditory canal cranially to the tip of the mastoid caudally – They are at risk of harboring metastases mainly from skin cancers of the retro-auricular area. Level Cranial Caudal Anterior Posterior Lateral Medial Level Xa Cranial edge of external auditory canal) Tip of the mastoid Anterior edge of the mastoid (caudally)/poster ior edge of the external auditory canal (cranially) Anterior border of occipital nodes posterior edge of sternocleidomast oid m. Sub-cutaneous tissue Splenius capitis m. (caudally) /temporal bone (cranially)
  • 20. The consensus guidelines • Level Xb – Level Xb (Table 9) contains the occipital lymph nodes, which are the cranial and superficial continuation of the level Va nodes up to the cranial protuberance. – Level Xb nodes receive efferent vessels from the posterior part of the hair-bearing scalp and are at risk of metastases from skin cancers of the occipital area. Level Cranial Caudal Anterior Posterior Lateral Medial Level Xb External occipital protuberance Cranial border of level V Posterior edge of sternocleidomast oid m. Anterior (lateral) edge of trapezius m. Sub-cutaneous tissue Splenius capitis m.

Editor's Notes

  1. 안테리얼 벨리의 가운데 위치한 부분으로 서브멘탈 노드를 포함하고있습니다. 크레니얼 방향으로는 마일로 하이오이드 머슬 코달방향으로는 플래타이스마 머슬을 경계로 하고있으며 안테리얼 방향으로는 심피시스맨티 포스테리얼방향을는 바디 옹브 하이오이드본 을 경계로 하고있습니다.
  2. 만디블의 안쪽과 다이가스트릭 머슬 사이에 위치하고있으며 심피시스 맨티, 서브만디블 글랜드를 경계로 하고있습니다. 크레니얼과 코달방향으로는 각각 서브만디블 글랜드의 끝부분을 경계로 하고있으며 코달쪽의 경우 하이오이드 본 또는 만디블이 끝나느 부분으로도 하며 이때 가장 코달한 것으로 경계를 구분짓고있습니다. 라타랄로는 맨디블, 메디얼 페리고이드 머슬과 platysma 머슬을 경계로 하며, 안쪽으로는 포스테리얼 벨리를 기준으로 하고있습니다.
  3. 노드II는 어퍼 쥬굴러 노드를 포함하는데 위에서 1/3의 인터널 쥬굴러 베인과 어퍼 스파이널 악세서리 너브 주위에 위치해있습니다. 노드는 스테노클레이도마스토이드 머슬의 측면으로 위치해있으며 안쪽으로는 인터널 캐로티드 아쳐리와 scalenius 머슬을 경계로 하고있습니다. 또한 첫번째 크래니얼 버태브라 프로세스와 바이오브 하이오이드 본이 끝나는 지점 사이에 위치해있습니다.
  4. 레벨 쓰리는 가운데 쥬굴라 노드를 포함하고있습니다. Level 2가 끝나는 바디오브 하이오이드본부터 시작해서 크라이코이드 카틸러지가 끝나는 지점까지이며 스테노크레이도마스토이드 머슬과 사이오하이오이드 머슬을 경계로 하고 있고 포스테리얼로는 스테노클레이도마스토이드 머슬의 끝부분을 경계로 하고있습니다. 안쪽으로는 코몬 캐로티드 아쳐리와 scalenius 머슬을 경계로 하고있습니다.
  5. 레벨 4a는 아래쪽 주률러 림프노드를 포함하고 레벨3 부터 스테노클라비큘러 조인트 2cm 위까지로 정의하고 있고 스테노클레이도마스토이드 머슬을 기준으로 그려지고 안쪽으로는 사이로이드 글랜드와 코몬 캐리티드 아쳐리를 경계로 합니다.
  6. 레벨 4b는 메디얼 슈프라클라비큘러 림프노드를 포함하고 있으며 레벨 4a에서 이어지며 스터널 맨브리엄의 cranial edge 까지입니다. 안테리얼은 레벨 4a와 마찬가지로 스테노클레이도마스토이드 머슬을 경계로 하고 caudal방향으로 가면 clavicle이 그 경계가 됩니다. 포스테리얼쪽으로는 scaleinius 머슬과 렁의 에이펙스이며 right의 경우 brachiocephalic vein left인 경우 subcalvian atrery 가 경계가 되어집니다. 바깥쪽으로는 scaleniums 머슬이 경계가 되며 코몬 캐로티드 아쳐리의 메디얼 엣지가 경계가 됩니다.
  7. 레벨 5는 포스테리얼 트라이엥글 그룹을 포함하고 스파이널 악세서리 너브 로워 파트와 프랜스버설 서비컬 베셀 주변의 스테노클레이도마스토이드 머슬 뒤쪽에 위치합니다.
  8. 하이오이드 바디의 크레니얼 엣지부터 서비컬 트랜스버스 베셀 까지 포함하며, 스테노클레이도마스토이드 머슬 뒤쪽을 경계로 프러피지어스 머슬 앞 경계까지 포함합니다.바깥쪽으로는 platyma 머슬과 스킨을 경계로 하고있습니다. 안쪽으로는 levator scapulae, scalenius 머슬까지 경계로 하고있습니다.
  9. 레벨 Vc는 lateral 슈프라 클라비큘러 노드를 포함하며 레벨 V에 이어져있습니다. 여기서 부터 스테널 맨브리움으로 2cm 위까지 포함하게 됩니다.안테리얼로는 스킨, 포스테리얼로는 프러퍼지어스 머슬과 세라토스 안테리얼 머슬을 경계로 하고있습니다. 라타랄로는 프러퍼지어스 머슬과 클리비클을 경계로 하고있습니다. 또한 scalenius 머슬로 구분짓고 스테노클레이도마스토이드 머슬의 라타랄 엣지부분을 경계를 따르게됩니다.
  10. 레벨 6는 6a와 6b로 나눠지는데 먼제 레벨 6a의 경우 안테리얼 주귤러 노드를 포함한 슈퍼피셜한 영역인데 하이오이드본의 코달 엣지 또는 서브맨디블 글랜드의 코달 엣지 중 보다 코달한 곳에서부터 시작해서 스터널 맨디브리엄까지이며 스킨, platysma와 하이오이드 머슬을 경계로 합니다.라타랄로는 스테노클레이도마스토이드 머슬을 경계로 하고있습니다.
  11. 레벨 6b 같은 경우는 비서럴 스페이스, 프리 라린스, 프리 트레이키아와 파라 트레이키아 노드를 포함하는 영역이며 싸이로이드 카틸러지의 코달부분부터 스터널 맨브리움의 그래니얼 엣지까지이며 안테리얼로 싸이로이드 글랜드와 하이오이드 머슬 포스테리얼로 에스펙트 라링스와 크라키아 그리고 라이트쪽으로 프리버테브라와 레프트는 에소파거스를 경계로 하며 커먼 캐로티드 아쳐리를 경계로 하고있습니다.
  12. 레벨 7a는 레트로파린졀 노드를 포함하며 C1스파인의 어퍼앳지 또는 하드팰럿부터 하이오이드본의 바디의 그래니얼 엣지까지입니다. 안테리얼로는 슈페리얼 또는 미들 파린졀 콘스트릭터 머슬을 경계로 하고 포스테리얼로는 롱구스 캐패티스 머슬을 기준으로 그 사이에 위치합니다. 라타랄로는 인터널 캐로티드 아쳐리 안쪽으로는 롱구스 캐피티스 머슬과 같은 라인이 경계가 됩니다.
  13. 레벨 7b는 레트로 스타일로이드 노드를 포함하고 레벨 2의 크래니얼 방향으로 이어져있습니다. 주귤로 캐로티드 베셀에서 베이스오브 스컬의 주귤러 포라맨 까지의 주변 패티 스페이스에 위치하며 주룰러 포라맨 부터 c1의 라타랄 프로세스의 코달 엣지까지 입니다. 안테리얼로는 프리스타일로이드의 포스테리얼 엣지 포스테리얼로는 c1의 버테브라와 베이스오브 스컬입니다. 라타랄로는 스타일로이드 프로세스와 패로티드 글랜드의 딥롭이 되겠으며 인터널 캐로티드 아쳐리를 경계로 합니다.
  14. 레벨 7b는 레트로 스타일로이드 노드를 포함하고 레벨 2의 크래니얼 방향으로 이어져있습니다. 주귤로 캐로티드 베셀에서 베이스오브 스컬의 주귤러 포라맨 까지의 주변 패티 스페이스에 위치하며 주룰러 포라맨 부터 c1의 라타랄 프로세스의 코달 엣지까지 입니다. 안테리얼로는 프리스타일로이드의 포스테리얼 엣지 포스테리얼로는 c1의 버테브라와 베이스오브 스컬입니다. 라타랄로는 스타일로이드 프로세스와 패로티드 글랜드의 딥롭이 되겠으며 인터널 캐로티드 아쳐리를 경계로 합니다.
  15. 레벨 8은 패로티드 노드 그룹이며 자이저매틱 아치 또는 익스터널 오디터리 커낼부터 앵글오브 맨디블까지이며 매시터 머슬의 뒷부분과 메디얼 테리고이드 머슬을 안테리얼 경계로 하고있습니다. 포스테리얼 경계로는 스테노클레이도마스토이드 머슬과 다이가스트릭 머슬의 포스테리얼 벨리입니다. 라타랄 경계로는 smas layer 그리고 메디얼 경계로는 스타일로이드 프로세스와 머슬이 됩니다.
  16. 레벨 9는 바코 페이셜 노드 그룹으로 바크셔네이터 머슬의 익스터널 서페이스의 페이션 베셀주변에 위치한 인콘시스턴트 슈퍼피셜 림프노드를 포함합니다. 오빗의 코달 앳지부터 만디블의 코달 앳지까지인데 여기서는 레벨 Ib와 만나는 지점으로 정의했습니다. 안테리얼은 SMAS layer, 포스테리얼로는 매시터 머슬 과 bichat’s fat pad ?? 경계로 지정하고있습니다. 메디얼로는 바크셔네이터 머슬을 경계로 하고있습니다. (바크셔네이터 뒤에 그림에 나옴)
  17. 레벨 텐a 는 마스토이드와 서브오리큘러 노드를 포함합니다. 그래니얼과 코달경계는 익스터널 오디터리부터 마스토이드 팁까지 이며 익스터널 오디터리 커낼의 포스테리얼 엣지또는 안테리얼 마스토이드 앳지를 안테리얼 경계로 가집니다. 또한 포스테이얼로는 스테노클레이도마스토이드 머슬 경계까지 잡고있습니다. 라타랄로는 서브큐테이니어스 티슈 메디얼로는 스플리니어스 캐피티스 머슬과 텀포럴 본을 경계로 합니다.
  18. 레벨 텐 b는 옵시피탈 림프노드를 포함하며 레벨 5a까지 이어져있습니다. 그래니얼 방향으로는 익스터널 옵시피탈 프로투버런스 까지이며 코달방향으로는 레벨 5까지 즉 바디 오브 하이오이드 본 의 그래니얼 엣지까지 입니다. 안테리얼로는 스테노클레이도마스토이드 머슬의 포스테리얼 엣지, 포스테리얼로는 프러피지어스 머슬이 경계가 되며 라타랄로는 서브큐테이니어스 티슈 메디얼로는 스플리니어스 캐피티스 머슬이 경계가 됩니다.