1. Contouring of CTV_Lymph nodes in NSCLC (Part III)
Mohammed Fathy Bayomy, MSc, MD
Lecturer
Clinical Oncology & Nuclear Medicine
Faculty of Medicine
Zagazig University
3. Station 1: Low cervical, Supraclavicular, Sternal notch Nodes
Border Definition
Upper border Lower margin of cricoid cartilage.
Lower border Laterally: clavicles.
Medially: upper border of manubrium.
Medial border Upper part: medial extension to include carotid artery
& internal jugular vein, excluding thyroid gland.
Lower part: 1R & 1L are separated by midline of
trachea.
Anterior
border
Upper part: deep surface of sternomastoid muscle &
deep cervical fascia.
Lower part: posterior parts of ribs & clavicle excluding
sternohyoid & sternothyroid muscles.
Posterolateral
border
Upper part: anterior & lateral border of anterior
scalene muscle.
Lower part: medial anterior border of subclavian
artery.
Posteromedial
border
Upper part: vertebral vessels & esophagus.
Lower part : anterior borders of subclavian artery.
4. Station 2: Upper Paratracheal Nodes
Border Definition
Upper border Midline: upper border of manubrium.
Lateral: apex of lung & pleural space.
Inferior border 2R: intersection of caudal margin of
brachiocephalic vein with trachea, which can
extend obliquely across trachea.
2L: superior border of aortic arch.
Medial borders Vertical line passing tangentially along left
lateral tracheal border (not midline).
Lateral borders Lung apex.
Anterior border Above sternal notch: imaginary horizontal line
from most anterior point of lung, pleura.
Inferior to this level: posterior to vessels,
imaginary line drawn to midpoint of vessel in
anterior to posterior plane, contact station 3a.
Posterior
border
Imaginary horizontal line extending from
posterior wall of trachea
5. Station 3a: Prevascular Nodes
Border Definition
Superior border Apex of chest (upper border of
manubrium).
Inferior border Carina.
Lateral border Lung
Anterior border Left brachiocephalic vein is included within
station 3a, until it reaches superior junction
of right & left brachiocephalic vessels.
Posterior border Above aortic arch: limited by station 2R &
2L, but excludes great vessels (imaginary
line joins midpoint of vessel in anterior to
posterior plane).
At aortic arch: separated from station 6 by
imaginary horizontal line running from
anterior aspect of aortic arch
Below aortic arch: separated from station 5
by imaginary horizontal line extending from
anterior wall of ascending aorta on left side
6. Station 3p: Retrotracheal Nodes
Border Definition
Superior border Apex of chest, extend above superior border of station 3a, as
apex of lung on right & left side are not on same slice so
more inferior of 2 apices is considered as upper border.
Inferior border Carina, abuts station 7.
Lateral borders Pleural envelope.
Right border Medial border of azygos vein (azygos vein as it moves
anteriorly is also excluded from nodal station, as it is for
station 4R).
Anterior border Imaginary horizontal line extending along posterior wall of
trachea.
Posterior border Soft tissues surrounding esophagus
with esophagus being excluded from this nodal station
Along anterior & lateral borders of vertebral body until it
reaches imaginary horizontal line running 1 cm posterior to
anterior aspect of vertebral body.
7. Station 4R: Right Lower Paratracheal Nodes
Border Definition
Superior border Intersection of caudal margin of brachiocephalic vein with
trachea. Essentially station 4R continues on from station
2R.
Inferior border Lower border of azygos vein (on sagittal image)
Medial border Imaginary line running vertically from left lateral tracheal
border
Lateral border Superiorly: pleural envelope.
Inferiorly: medial to arch of azygos vein.
Anterior border Superior vena cava (SVC) & aorta, in between extending
halfway between 2 vessels
Posterior border Imaginary horizontal line extending from posterior wall of
trachea.
8. Station 4L: Left Lower Paratracheal Nodes
Border Definition
Upper border Superior border of aortic arch, being a direct continuation
from station 2L.
Lower border Upper margin of left main pulmonary artery.
Lateral border Superiorly: medial aspect of aorta arch.
Inferiorly: ligamentum arteriosum (imaginary line from most
posterior part of ascending aorta to most anterior part of
descending aorta)
Medial border Imaginary line running vertically from left lateral tracheal
border.
Anterior border Superiorly: aorta arch.
Inferiorly: ascending aorta.
Posterior border Imaginary horizontal line extending from posterior wall of
trachea.
9. Station 5: Subaortic Nodes (aortopulmonary window)
Border Definition
Superior border Lower border of aortic arch, station 6 abuts station 5 at its
superior border.
Inferior border Upper rim of left main pulmonary artery or level of carina
corresponds with lower level for station 3a.
Medial border Ligamentum arteriosum (imaginary line from most posterior
part of ascending aorta to most anterior part of descending
aorta)
Lateral border Pleural envelope.
Anterior border Imaginary horizontal line extending from anterior wall of
aorta. Station 3a abuts this anterior border of station 5.
Posterior border Anterior part of descending aorta
10. Station 6: Para-aortic Nodes (ascending aorta or phrenic)
Border Definition
Superior
border
Upper border of aortic arch
(sagittal).
Inferior
border
Lower border of aortic arch
(sagittal), abuts station 5
(coronal)
Anterior
border
Imaginary horizontal line
extending from anterior wall
of aortic arch, abuts station
3a.
Posterolateral
border
aortic arch & pleura
11. Station 7: Subcarinal Nodes
Border Definition
Upper border Carina of trachea.
Lower border On left: upper border of lower
lobe bronchus.
On right: lower border of
bronchus intermedius (coronal-
pul. window)
Lateral border Space between right main & left
main bronchi (imaginary vertical
line running along medial
border of right & left main
bronchi)
Posterior border Imaginary horizontal line that
runs 1 cm posterior to anterior
border of vertebral body.
12. Station 8: Paraesophageal Nodes
Border Definition
Superior border On left: upper border of lower lobe
bronchus.
On right: lower border of bronchus
intermedius (coronal-pul. window)
Inferior border Diaphragm
Lateral border Pleural envelope, esophagus, descending
aorta, & azygos vein are excluded from
nodal station.
Anterior border Heart & inferior pulmonary vein.
Posterior border Imaginary horizontal line that runs 1 cm
posterior to anterior border of vertebral
body.
13. Station 9: Pulmonary Ligament Nodes
Border Definition
Upper border Inferior pulmonary vein (CT + IV contrast).
Inferior border Variable & can terminate above
diaphragm. The length of this ligament can
also vary in same individual from side to
side.
Medial border Soft tissue beak extending laterally from
posterior mediastinum & esophagus.
Lateral border Half ellipse, at base 1.5 cm centered on
pulmonary ligament then extends laterally
1.5 cm into lung parenchyma.
14. Station 10: Hilar Nodes
Border Definition
Upper
border
Right side: lower rim of azygos vein
Left side: upper rim of left main
pulmonary artery.
Medial
border
Above carina: 10L & 10R are separated by
midline of trachea.
Below carina: vertical line drawn from
medial aspect of main bronchus, abuts
station 7.
Lateral
border
Right side: vertical line drawn from lateral
aspect of right main bronchus.
Left side
Superior to station 11 commence: left
pulmonary artery & pleura.
Inferior to station 11 commence: vertical
line running along lateral aspect of left
main bronchus.
15. Station 11: Interlobar Nodes
Border Definition
Medial border Vertical line running along lateral
aspect of main bronchus, abuts station
10.
Left border 11R: lung-soft tissue interface (lung
window)
11L: lung-soft tissue interface, excluding
segmental bronchi.
17. Line Definition
Line 1 Vertical, midline of trachea to separate left & right LNS.
Line 2 Horizontal, intersection of trachea & brachiocephalic
vein.
Line 3 Horizontal, transecting main-stem bronchi just below
carina.
Line 4 Horizontal, passing through caudal limit of main-stem
bronchi.
Line 5 Horizontal, running 1 cm posterior to anterior border of
vertebral body.
18. Recurrent nerve lymph nodes (106rec R/L)
= Upper paratracheal nodes (2R/L)
Border Definition
Location Along recurrent laryngeal nerves in
mediastinum.
Anterior boundary Right, left common carotid artery,
subclavian artery.
Posterior boundary No. 105.
Superior boundary Cephalic border of subclavian
arteries to suprasternal notch.
Inferior boundary Caudal border of recurrent
laryngeal nerve curving upward on
both sides (right subclavian artery
for 106rec R & aorta for 106rec L).
Laterally Lungs.
19. Upper thoracic paraesophageal lymph nodes (105)
= Retrotracheal nodes (3p)
Border Definition
Location Around upper thoracic esophagus
with right vagus nerve on right
side.
Anterior boundary Trachea
Posterior boundary Line 5
Superior boundary Cephalic border of subclavian
arteries to suprasternal notch.
Inferior boundary Line 3
Laterally Limited by No. 106recR, 106recL,
106pre, the vessels (left
subclavian artery, left common
carotid artery, aortic arch,
descending aorta, azygos vein arch
& cephalic trunk) & lungs
20. Anterior mediastinal lymph nodes (114)
= Prevascular nodes/paraaortic nodes (3A/6)
Border Definition
Location Anterior mediastinum & includes
lymph nodes of brachiocephalic
venous angle & lymph nodes
around thymus gland.
Anterior boundary Inner surface of sternum
Posterior boundary Superior vena cava, pericardium,
& ascending aorta
Superior boundary Sternal angle
Inferior boundary Diaphragm
Laterally Lungs
21. Pretracheal lymph nodes (106pre)
= Right lower paratracheal nodes (4R)
Border Definition
Location In front of anterior wall of thoracic
trachea
Anterior boundary No. 114.
Posterior boundary Right vagus nerve.
Superior boundary Line 2.
Inferior boundary Line 3.
Right boundary Right lung.
Left boundary Brachiocephalic artery, left
common carotid artery & aortic
arch.
22. Right tracheobronchial lymph nodes (106tb R)
= Right lower paratracheal nodes (4R)
Border Definition
Location On right side wall of trachea & in
right tracheobronchial angle.
Anterior boundary No. 106pre.
Posterior boundary No. 105.
Superior boundary Azygos vein.
Inferior boundary Line 3.
Right boundary Right lung.
23. Left tracheobronchial lymph nodes (106tb L)
= Left lower paratracheal nodes (4L)
Border Definition
Location On left side wall of trachea & in
left tracheobronchial angle.
Anterior boundary No. 106pre.
Posterior boundary No. 105.
Superior boundary Inferior wall of aortic arch.
Inferior boundary Line 3.
Right boundary Pulmonary artery, pulmonary
arterial ligament & No. 113.
24. Ligamentum arteriosum lymph nodes (Botallo lymph nodes) (113)
= Subaortic nodes (5)
Border Definition
Location Left side of arterial ligament
Anterior boundary No. 114 .
Posterior boundary Descending aorta
Superior boundary Bottom of aortic arch.
Inferior boundary Start of arterial ligament.
Left boundary Left lung
Right boundary No. 105, 106tbL, 106pre.
25. Anterior mediastinal lymph nodes (114)
= Prevascular nodes/paraaortic nodes (3A/6)
Border Definition
Location Anterior mediastinum & includes
lymph nodes of brachiocephalic
venous angle & lymph nodes
around thymus gland.
Anterior boundary Inner surface of sternum
Posterior boundary Superior vena cava, pericardium,
& ascending aorta
Superior boundary Sternal angle
Inferior boundary Diaphragm
Laterally Lungs
26. Subcarinal lymph nodes (107)
= Subcarinal nodes (7)
Border Definition
Location Caudal to tracheal & superior to
bottom of right pulmonary artery.
Anterior boundary Pulmonary trunk & left atrium.
Posterior boundary No. 108 lymph node region &
esophagus
Superior boundary Line 3
Inferior boundary Line 4
Lateral boundary Internal walls of bilateral main
bronchus.
27. Middle thoracic paraesophageal lymph nodes (108)
= Paraesophageal nodes (8)
Border Definition
Location Around middle thoracic
esophagus.
Anterior boundary No. 107, right pulmonary artery &
left atrium.
Posterior boundary Line 5.
Superior boundary Line 3.
Inferior boundary Root of inferior pulmonary vein.
Lateral boundary No. 109 & lungs
28. Lower thoracic paraesophageal lymph nodes (110)
= Paraesophageal nodes (8)
Border Definition
Location Around lower thoracic esophagus.
Anterior boundary Left atrium & left ventricle
Posterior boundary Line 5.
Superior boundary Root of inferior pulmonary vein.
Inferior boundary Gastroesophageal junction
Right boundary Lung & No. 112pulR.
Left boundary No. 112pulL, No. 112ao,
descending aorta & esophagus
29. Thoracic paraaortic lymph nodes (112ao)
= Paraesophageal nodes (8)
Border Definition
Location Around descending aorta,
including lymph nodes along
thoracic duct.
Anterior boundary No. 112pulL.
Posterior boundary Descending aorta and line 5.
Superior boundary Tracheal carina.
Inferior boundary Gastroesophageal junction.
Right boundary Lower thoracic esophagus (No.
110)
Left boundary Descending aorta.
31. Main bronchus lymph nodes (109 R/L)
= Hilar nodes (10 R/L)
= Pulmonary ligament nodes (9)
Border Definition
Location Caudal area of main-stem bronchus.
Superior boundary Line 3.
Inferior boundary Line 4.
Medial boundary Mediastinal CT settings were used.
No. 107 & 108.
Right side: imaginary lines drawn between
lateral border of superior vena cava & middle
of vertebral body
Left side: imaginary lines drawn between left
border of pulmonary trunk & left border of
descending aorta.
Lateral boundary Lung, may be difficult to distinguish hilum
from lobar & segmental bronchus, & careful
review of coronal & sagittal views may be
necessary.
32. Japan Lung Cancer Society (JLCS)
and
Japanese Society for Radiation Oncology (JASTRO)
Consensus-based CT atlas
(Komiyama - Itazawa map 2015-2017)
34. Station 1 (1R & 1L): Low cervical, Supraclavicular, Sternal notch Nodes
Border Definition
Cranial border Lower margin of cricoid cartilage.
Caudal border Laterally: clavicles, Apex of lung (upper marginal
slice of the lung), align to upper side
Medially: upper border of manubrium.
Medial border Midline of trachea.
Lateral border Clavicle and anterior scalene muscle including fat
surrounding ant. scalene muscle
Anterior border Posterior aspect of clavicles
Posterior border Muscles & bones
35. Station 2R: Right Upper Paratracheal Nodes
Border Definition
Cranial border Apex of right lung (caudal border of station 1).
Caudal border Intersection of the caudal margin of left
brachiocephalic vein with midline of trachea (cranial
border of station 4R).
Left border Left lateral border of trachea (Right border of
station 2L).
Right border Pleura.
Anterior border Above upper border of manubrium: anterior border
is muscles and blood vessels
Below: imaginary line that smoothly connects
anterior aspects of right brachiocephalic vein,
brachiocephalic artery, left common carotid artery,
and left subclavian artery (Line A) abuts station 3a.
(line transverse anteriorly to trachea)
Posterior border Membranous wall of trachea abuts station 3p.
36. Station 2L: Left Upper Paratracheal Nodes
Border Definition
Cranial border Apex of left lung (caudal border of station 1).
Caudal border Upper margin of aortic arch, abuts station 4L
Right border Left lateral border of trachea (left border of station
2R).
Left border Pleura.
Anterior border Above upper border of manubrium: anterior border
is muscles and blood vessels
Below: imaginary line that smoothly connects
anterior aspects of right brachiocephalic vein,
brachiocephalic artery, left common carotid artery,
and left subclavian artery (Line A) abuts station 3a.
(line transverse anteriorly to trachea)
Posterior border Membranous wall of trachea, virtual horizontal line
extending along posterior wall of trachea on lateral
side of esophagus, abuts station 3p
37. Station 3a: Prevascular Nodes
Border Definition
Cranial border Upper border of manubrium.
Caudal border Level of carina.
Lateral border Pleura
Anterior border Posterior aspect of sternum.
Posterior border Above upper margin of aortic arch:
Imaginary line that smoothly
connects anterior aspects of right
brachiocephalic vein,
brachiocephalic artery, left common
carotid artery, and left subclavian
artery (Line A) abuts station 2R & 2L.
Below: posterior border is virtual
horizontal line extending from
anterior wall of ascending aorta &
anterior aspect superior vena cava
(SVC), abuts station 6.
38. Station 3p: Retrotracheal Nodes
Border Definition
Cranial border Apex of lung, abuts station 1.
Caudal border Level of carina, abuts station 8.
Left border Pleura & descending aorta.
Right border Pleura & azygos vein.
Anterior border Membranous wall of trachea & a
virtual horizontal line extending
along posterior wall of trachea
on lateral side of esophagus,
abuts stations 2R, 2L, 4R, 4L.
Posterior border Anterior aspect of vertebral
body, due to individual
differences in relative positions
of vertebral body & esophagus,
fat tissue adjacent to esophagus
& descending aorta is included.
39. Station 4R: Right Lower Paratracheal Nodes
Border Definition
Cranial border Intersection of caudal margin of left
brachiocephalic vein with midline of
trachea, level of intersection is included
in station 4R.
Caudal border Lower margin of azygos arch, abuts
station 10R
Left border Cranial: left lateral border of trachea
including fat between trachea & azygos
vein, abuts station 4L.
Caudal: virtual line that passes along
left tracheal border, abuts station 10L.
Right border Pleura and azygos vein.
Anterior border SVC and aorta, including fat between
aorta and SVC.
Posterior border Membranous wall of trachea, abuts
station 3p
40. Station 4L: Left Lower Paratracheal Nodes
Border Definition
Cranial border Upper margin of aortic arch, abuts station 2L.
Caudal border Upper margin of the main pulmonary artery,
abuts station 10L.
Left border Imaginary line that connects ascending and
descending aorta at shortest distance (Line B)
as a surrogate for ligamentum arteriosum,
abuts station 5.
Right border Cranial: left lateral border of trachea, abuts
station 4R.
Caudal: virtual line that passes along left
tracheal border.
Anterior border Aortic arch and ascending aorta.
Posterior
border
Membranous wall of trachea & a virtual
horizontal line extending along posterior wall
of trachea on lateral side of esophagus, abuts
station 3p
41. Station 5: Subaortic Nodes (aortopulmonary window)
Border Definition
Cranial border Lower margin of aortic arch, abuts
station 6.
Caudal border Upper margin of main pulmonary
artery, abuts station 10L.
Left border Pleura.
Right border Line B, abuts station 4L
Anterior border Imaginary line that is tangential to
posterior aspect of ascending aorta
and is at a right angle to Line B
(Line C), abuts station 6
Posterior border Descending aorta
42. Station 6: Paraaortic Nodes (ascending aorta or phrenic)
Border Definition
Cranial border Upper margin of aortic arch.
Caudal border Level of carina.
Left border Pleura.
Right border Aortic arch & ascending aorta.
Anterior
border
Virtual horizontal line extending from
anterior wall of ascending aorta, abuts
station 3a.
Posterior
border
Aortic arch level: intersection of
aortic arch and pleura, up to where fat
tissue is detected
Below Ao arch: Line C
Below upper margin of left main pulmonary
artery: imaginary line in which Line C is
moved parallel to anterior border of the
main pulmonary artery, abuts stations 5
and 10L
43. Station 7: Subcarinal Nodes
Border Definition
Cranial border Carina.
Caudal border On left: upper border of lower lobe
bronchus.
On right: lower border of bronchus
intermedius.
Left border Above upper margin of left lower lobe
bronchus: left main bronchus.
Below that level: right lateral border of
esophagus, abuts station 8.
Right border Right main bronchus & truncus intermedius
Anterior border Above level of main bronchus: virtual line
that connects anterior aspects of main
bronchi bilaterally, abuts stations 10R & 10L.
Below that level: heart and great vessels
Posterior border Virtual line that connects posterior aspects
of main bronchi bilaterally, abuts station 8.
44. Station 8: Paraesophageal Nodes
Border Definition
Cranial border Level of carina, abuts station 3p.
Caudal border Diaphragm (Esophageal hiatus?).
Left border Between level of upper border of left lower
lobe bronchus and level of lower border of
bronchus intermedius: right lateral border of
esophagus, abuts station 7.
Right border Pleura.
Anterior border Above level of main bronchus: virtual line
that connects posterior aspects of main
bronchi bilaterally, abuts stations 7.
Below that level: heart and great vessels
Posterior border Anterior aspect of vertebral body, due to
individual differences in relative positions of
vertebral body & esophagus, fat tissue
adjacent to esophagus & descending aorta is
included.
45. Station 9: Pulmonary Ligament Nodes
Border Definition
Cranial border Inferior pulmonary vein.
Caudal border Diaphragm (up to level at which pulmonary
ligament can be detected.
Left border Area at which pulmonary ligament can be
detected.
Right border Area at which pulmonary ligament can be
detected.
Anterior border Area at which pulmonary ligament can be
detected.
Posterior border Area at which pulmonary ligament can be
detected.
46. Station 10R: Right Hilar Nodes
Border Definition
Cranial border Lower margin of azygos arch,
abuts station 4R.
Caudal border Right interlobar regions (lower
margin of right upper lobe
bronchus).
Left border Midline of trachea, abuts station
10L.
Right border Lateral border of right main
bronchus (vertical line drawn
from lateral aspect of right main
bronchus), abuts station 11s.
Anterior border Ascending aorta, SVC & right
pulmonary artery.
Posterior border Pleura & azygos vein.
47. Station 10L: Left Hilar Nodes
Border Definition
Cranial border Upper margin of left main
pulmonary artery , abuts station
4R.
Caudal border Left interlobar regions (upper
margin of left lower lobe
bronchus).
Right border Midline of trachea, abuts station
4R.
Left border Pulmonary artery, pleura, lateral
border of left main bronchus
(vertical line drawn from lateral
aspect of left main bronchus),
abuts station 11.
Anterior border Ascending aorta, & left
pulmonary artery.
Posterior border Descending aorta, esophagus &
pleura
48. Station 10L*: Left Hilar Nodes*
Border Definition
Cranial border Upper margin of left main
pulmonary artery , abuts
station 5.
Caudal border Lower margin of left superior
pulmonary vein
Right border Left main pulmonary artery.
Left border Pleura, left pulmonary artery
& left superior pulmonary
vein.
Anterior border Line C, abuts station 6.
Posterior border Left pulmonary artery & left
superior pulmonary vein.
49. Station 11s: Superior Interlobar Nodes
Border Definition
Cranial border Lower margin of right upper lobe
bronchus (caudal slice where right
B3 branches off).
Caudal border Lower margin of truncus
intermedius (just above cranial
slice where middle lobe bronchus
& right lower lobe bronchus
branch off completely), abuts
station 11i.
Right border Lung
Left border Lateral border of right main
bronchus (vertical line drawn from
lateral aspect of right main
bronchus), abuts station 10R.
Anterior border Lung
Posterior border Lung
50. Station 11i: Inferior Interlobar Nodes
Border Definition
Cranial border Lower margin of truncus
intermedius (just above cranial
slice where middle lobe bronchus
& right lower lobe bronchus
branch off completely), abuts
station 11s.
Caudal border Upper margin of right lower lobe
bronchus (level where right B6
branches off completely)
Right border Lung.
Left border Middle lobe bronchus & right
lower lobe bronchus.
Anterior border Lung & middle lobe bronchus.
Posterior border Lung & right lower lobe bronchus.
51. Station 11: Left Interlobar Nodes
Border Definition
Cranial border Lower margin of left upper lobe
bronchus (level where left B4+5
branches off)
Caudal border Upper margin of left lower lobe
bronchus (level where left B6
branches off)
Right border Cranial part: Lateral border of left
main bronchus (vertical line drawn
from lateral aspect of left main
bronchus in cranial area of Station
11), abuts station 10L.
Caudal part: left upper & lower
lobe bronchi.
Left border Lung.
Anterior border Lung & left upper lobe bronchus.
Posterior border Lung & left lower lobe bronchus.