AJR 2000; 174:775-782
© American Roentgen Ray Society
CT Depiction of Regional Nodal Stations for Lung Cancer Staging
Jane P. Ko1,
Elizabeth A. Drucker1,
Jo-Anne O. Shepard1,
Clifton F. Mountain2,
Carolyn Dresler3,
Bradley Sabloff1 and
Theresa C. McLoud1
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.
Received June 23, 1999;
accepted after revision August 12, 1999.
Address correspondence to J. P. Ko.
Introduction
Detection of mediastinal, hilar, and intrapulmonary lymphadenopathy is
crucial for staging lung cancer. Precise staging is essential for determining
treatment options and assessing patient response to therapy. Definitions of
the lymph node locations used in staging have been based on surgical landmarks
relevant to mediastinoscopy and thoracotomy
[1] (Fig.
1A,1B,1C,1D).
These surgical landmarks are not always easily translated to cross-sectional
imaging. Cross-sectional diagrams at six levels accompanied the original
American Thoracic Society nodal staging system
[2], but, to our knowledge,
correlation with CT scans has not previously been done. Because
mediastinoscopy is not always performed for staging
[3], CT may be the only
procedure used for evaluation of intrathoracic lymph nodes. This pictorial
essay provides cross-sectional definitions of regional intrathoracic lymph
node stations, depicts them on CT, and describes recent changes in the lymph
node staging system for lung cancer.
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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.
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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.
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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.
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Classification of Regional Intrathoracic Lymph Nodes
Nodal metastases in lung cancer staging are classified as N1, N2, or N3, on
the basis of the location of the nodes in relation to the primary lung cancer.
N1 refers to local spread to intrapulmonary peribronchial and ipsilateral
hilar nodes. N2 refers to more distant spread, including ipsilateral
mediastinal and midline prevascular, retrotracheal, and subcarinal nodes. N3
is defined as even more distant spread to contralateral mediastinal or hilar
nodes or to ipsilateral or contralateral supraclavicular nodes. N1 nodes lie
within the visceral pleura, and N2 nodes lie within the mediastinal or
parietal pleural reflection, also termed the mediastinal pleural envelope.
To identify nodal location more precisely, nodes are assigned to one of 14
numbered stations. These stations are defined by adjacent anatomic structures.
Stations 1-9 are within the mediastinum. Metastatic nodes are classified as N2
disease if ipsilateral or N3 disease if contralateral to the primary tumor.
Stations 10-14 are within the hila or along the bronchi in the lung
parenchyma. Involved nodes are classified as N1 disease if ipsilateral or N3
disease if contralateral to the primary tumor. Metastatic supraclavicular
nodes, which are also N3 disease, are extrapleural and do not receive a
station designation. The descriptor "R" or "L" is
added if a node is right- or left-sided, respectively.
Anatomic Definitions of Stations with CT Correlation
The nodal stations defined in this section are shown in the figures. Both
enlarged and normal nodes in various nodal stations were colored on CT scans
to maximize clarity of the figures and to facilitate correlation with the
popular reference diagram introduced by Mountain and Dresler
[1] in 1997 (Fig.
1A,1B,1C,1D).
Nodal enlargement is commonly defined as greater than 1 cm in short-axis
diameter.
Station 1: Highest mediastinal nodes. These nodes lie cranial to the
superior aspect of the left innominate or brachiocephalic vein where the vein
crosses the trachea (Figs. 2A
and 2B).
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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.
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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.
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Station 2: Upper paratracheal nodes. These nodes are located below the
inferior boundary of station 1 nodes and cranial to the superior aspect of the
aortic arch (Figs. 2C,
2D, and
3A,3B).
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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.
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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.
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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).
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Station 3: Prevascular and retrotracheal nodes. Prevascular nodes are
anterior to the great vessel branches and cranial to the superior aspect of
the aortic arch (Figs. 2A and
2B). Retrotracheal nodes are
posterior to the trachea (Fig.
4A,4B,4C),
inferior to the thoracic inlet, and cranial to the inferior aspect of the
azygos vein.
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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.
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Station 4: Lower paratracheal nodes. The lower right paratracheal nodes
(4R) lie to the right of the trachea's midline. They are caudal to the
superior aspect of the aortic arch and cranial to the superior aspect of the
right upper lobe bronchus. The lower left paratracheal nodes (4L) lie to the
left of the trachea's midline. They are caudal to the superior aspect of the
aortic arch and cranial to the superior aspect of the left upper lobe
bronchus. Nodes designated 4L are medial to the ligamentum arteriosum (Figs.
5A,5B,5C,5D
and
6A,6B).
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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.
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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.
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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.
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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.
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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.
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The lower paratracheal nodes are further divided into superior (Figs.
5A and
5B) and inferior (Figs.
5C and
5D) subsets. Station 4
superior nodes are cranial to the superior aspect of the azygos arch, whereas
station 4 inferior nodes are caudal to the superior aspect of the azygos
arch.
Station 5: Subaortic or aorticopulmonary window nodes. These nodes lie
lateral to the ligamentum arteriosum and are medial to the origin of the first
branch of the left pulmonary artery (Figs.
6A,6B,7,8A,8B).
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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.
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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.
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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.
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Station 6: Paraaortic (ascending aortic or phrenic) nodes. These nodes are
anterior and lateral to the aortic arch at levels caudal to the superior
aspect of the aortic arch (Fig.
8A,8B).
Station 7: Subcarinal nodes. These nodes are caudal to the tracheal carina
between the main bronchi (Figs.
9A,9B
and
10A,10B,10C,10D).
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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.
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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.
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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).
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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).
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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.
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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.
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Station 8: Paraesophageal nodes. These nodes are adjacent to the wall of
the esophagus and to the right or left of the trachea's midline (Figs.
8A,8B
and
11A,11B).
The anterior paraesophageal nodes are considered generally caudal to the
subcarinal nodes, but no explicit boundary exists.
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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).
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Station 9: Pulmonary ligament nodes. These nodes are within the pulmonary
ligament (Fig.
12A,12B,12C).
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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.
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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.
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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.
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Station 10: Hilar nodes. These nodes are the proximal lobar nodes. As
opposed to the lower paratracheal nodes that are cranial to the superior
aspect of the right upper lobe bronchus, right hilar nodes are caudal to the
superior aspect of the right upper lobe bronchus and lie adjacent to the right
main bronchus and the proximal bronchus intermedius (Figs.
9A,9B,
10A, and
10B). Similarly, the left
hilar nodes are caudal to the superior aspect of the left upper lobe bronchus
adjacent to the left main bronchus.
Station 11: Interlobar nodes. These nodes are between lobar bronchi and are
adjacent to the proximal lobar bronchi (Figs.
10C and
10D).
Station 12: Lobar nodes. These nodes are located adjacent to distal
portions of the lobar bronchi (Fig.
12A,12B,12C).
Station 13: Segmental nodes. These nodes are adjacent to the segmental
bronchi (Figs.
9A,9B,
10A,
10B,
13A, and
13B).
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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.
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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.
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Station 14: Subsegmental nodes. These nodes are adjacent to the
subsegmental bronchi in the lung parenchyma (Figs.
13C and
13D). Stations 12, 13, and 14
cannot always be differentiated.
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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.
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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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Recent Changes in Nodal Station Classification
The Naruke lymph node map was introduced in the 1970s and was adopted by
the American Joint Committee on Cancer
[4]. An adaptation of this
lymph node map was accepted by the American Thoracic Society and the North
American Lung Cancer Study Group in 1981 and was reported in 1983
[2]. In 1996, a new
classification unifying features of both systems was accepted by the American
Joint Committee on Cancer and the Prognostic Factors Committee of the Union
Internationale Contre le Cancer, and a report was issued by Mountain and
Dresler [1] in 1997. The new
classification differs from the preceding one because it designates the azygos
node as station 4 rather than station 10. Therefore, an azygos node is
considered an N2 rather than an N1 node. Other changes involve the
retrotracheal and prevascular nodes, but these changes do not alter nodal
staging.
In conclusion, this pictorial essay illustrates with cross-sectional
imaging the recently revised nodal classification system for lung cancer. The
ability to identify these nodal stations on thoracic CT and a working
knowledge of their significance in the staging of lung cancer are important
for accurate communication among radiologists, oncologists, and surgeons.
Acknowledgments
We thank Susanne Loomis for photography and Virginia Raulinaitis for help
with manuscript preparation.
References
-
Mountain CF, Dresler CM. Regional lymph node classification for
lung cancer staging. Chest
1997;111:1718-1723[Abstract/Free Full Text]
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American Thoracic Society. Clinical staging of primary lung cancer.
Am Rev Respir Dis
1983;127:659-664[Medline]
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The Canadian Lung Oncology Group. Investigation for mediastinal
disease in patients with apparently operable lung cancer. Ann Thorac Surg
1995;60:1382-1389.[Abstract/Free Full Text]
-
Naruke T, Suemasu K, Ishikawa S. Lymph node mapping and curability
at various levels of metastasis in resected lung cancer. J Thorac
Cardiovasc Surg
1978;76:832-839[Abstract]
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Introduction
Classification of Regional...
