rohren - part i.pdf

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Cross Sectional Anatomy of the Chest, Abdomen, and Pelvis

Eric M. Rohren, M.D. Ph.D.Chief, Positron Emission

TomographyMD Anderson Cancer Center

Houston, TX

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Why CT Anatomy

• Improved accuracy

• Communication

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Why CT Anatomy

• Improved accuracy– Differential diagnosis– Primary tumors– Pattern of metastatic disease

• Communication

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Example

Hypermetabolic mass in the mediastinum

Clinical History: NSCLC Irregular, hypermetabolic 2.8 cm nodal mass in the AP window (station 5), consistent with ipsilateral metastatic disease from NSCLC

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Example

Hypermetabolic mass in the mediastinum

Clinical History: Indeterminate thoracic mass Smoothly-marginated 4.5 x 3.1 cm lobular mass in the anterior mediastinum, centered in the retrosternal fat. Although metabolically active, the intensity of uptake (SUV=3.2) is less than typically seen with lymphoma or lung carcinoma, and would be most consistent with

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Example

Hypermetabolic mass in the mediastinum

Clinical History: Thyroid cancer with rising Tg 9 mm intensely hypermetabolic (SUV=8.8) lymph node in the high retrosternal space below the sternal notch, consistent with recurrent thyroid carcinoma. This node would likely be amenable to biopsy via ultrasound

Thyroidectomy and radioiodine ablation

CompletedRoRx

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Example

Hypermetabolic mass in the mediastinum

Clinical History: History of squamous cell carcinoma of the scalp 4.4 x 3.7 cm hypermetabolic mass with central necrosis in the anterior heart, arising from the apical left ventricular myocardium, consistent with metastatic disease. There is an associated l i di l ff i

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Why CT Anatomy

• Improved accuracy

• Communication– Results– Biopsy planning– Therapy planning

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Sample Report

• 67 year old man• Nasal carcinoma

– surgical resection– radiation therapy

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Head and neck: Again seen are postsurgical changes of prior rhinectomyand septectomy, stable in the interim. There is no hypermetabolism in or adjacent to the surgical bed. Intense tracer activity is seen in the anterior oral cavity. This region is partially obscured on the CT portion of the examination by dense metallic streak artifact from non removable dental hardware, but the activity appears to localize to the geniohyoidmusculature. There are no hypermetabolic lymph nodes along the cervical chains. Slight asymmetry in radiotracer activity in the prevertebralmusculature is likely physiologic.

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Chest: Air-space consolidation in the right upper lobe posteriorly has increased in size and density since the prior examination. There is now a coalescent region of peripheral consolidation measuring approximately 11 x 5 cm (previously 5 x 2 cm) which is diffusely hypermetabolic on PET (SUV=15.4). Subpleural consolidation at the left lung base posteriorly has also increased in density, measuring 3.3 x 1.5 cm. This region is also intensely hypermetabolic on PET scanning, with an SUV of 10.0. Regions of subpleural septal thickening in the posterobasal segments of the lower lobes bilaterally demonstrate low-grade radiotracer uptake. There are changes of centrilobular emphysema in the mid and upper lungs. Intense myocardial activity is physiologic. There is no nodal hypermetabolism in the chest. There is low-grade (SUV=3.2) radiotracer activity in the right and left pulmonary hila. There is no nodal hypermetabolism in mediastinal, axillary, or supraclavicular chains. There are no pleural or pericardial effusions.

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Abdomen and pelvis: Although morphologically stable in the interim, the left adrenal gland now demonstrates nodular hypermetabolism at thejunction of the body and medial limb (image 107, SUV=4.5). There may be a tiny focus of radiotracer activity in the body of the right adrenal gland (image 102, SUV=3.4) although this is located in close proximity to probable physiologic uptake in the right diaphragmatic crus. There is no nodal hypermetabolism in retroperitoneal or pelvic chains. Tracer uptake in the hepatic parenchyma is homogeneous. Peripheral activity outlining the upper peritoneal surfaces likely represents uptake in the lateral diaphragmatic musculature bilaterally. The spleen is normal in size and FDG avidity. The pancreas is diffusely fatty replaced, with scattered punctate calcifications particularly in the pancreatic head, possibly the sequela of chronic pancreatitis.

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Musculoskeletal: There are scattered degenerative changes in the spine, including asymmetric activity in the left C5/6 facet joint. Marrow uptake is otherwise normal.

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Selected Topics• Chest

– Lungs and Airways– Vascular anatomy– Nodal stations– GI

• Abdomen and Pelvis– GI– Hepatic segmental anatomy– Vascular anatomy– Nodal groups

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CT Anatomy of the Chest

Netter images used with permission from Netter Presentor™

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Lungs

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Lungs

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Lungs

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Pulmonary Lobes

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Right Major Fissure

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Left (Major) Fissure

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Right Minor Fissure

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Pulmonary Fissures

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Upper Lobes

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Lower Lobes

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Middle Lobe

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Lingula

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Pulmonary Lobes

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Right Major Fissure

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Left Fissure

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Right Minor Fissure

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Right Minor Fissure

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Right Minor Fissure

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Pulmonary Lobes on CT

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U U

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U U

LL

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U

M

L

U

L

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M

L

U

L

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Pulmonary Segments

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• Right Upper Lobe– Apical– Anterior– Posterior

• Right Middle Lobe– Lateral– Medial

• Right Lower Lobe– Superior– Medial basal– Lateral basal– Anterior basal– Posterior basal

Right Lung:

10 Segments

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• Left Upper Lobe– Apicoposterior– Anterior– Superior lingular– Inferior lingular

• Left Lower Lobe– Superior– Medial basal– Lateral basal– Anterior basal– Posterior basal

Left Lung:

9 Segments

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FDG Uptake in the Lungs

Normal Uptake

Primary Tumors

Infection/Inflammation

Metastatic Tumors- No

- Non-small cell cancer

- Histoplasmosis- Tuberculosis

- Small cell cancer

- Sarcoidosis

- Lung- Breast

- Carcinoid tumor- Lymphoma

- Colon- Melanoma- Bladder- Renal cell cancer- Osteosarcoma- Etc.

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Left upper lobe Left upper lobe

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Right upper lobe Right lower lobe

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Left lower lobe

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Right lower lobe

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Trachea

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Carina

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Heart

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• 4 Chambers– Pulmonary circuit

• Right atrium – venous blood from body• Right ventricle – pumps blood to lungs

– Systemic circuit• Left atrium – oxygenated blood from lungs• Left ventricle – pumps blood to body

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Left Ventricle

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Right Ventricle

Left Ventricle

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Left Ventricle

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Left Ventricle

Right Ventricle

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Left Ventricle

Right Ventricle

Aortic Root

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Left Ventricle

Right Ventricle

Aortic Root

Left Atrium

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Left Ventricle

Right Ventricle

Aortic Root

Right Atrium

Left Atrium

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Aorta

Pulmonary Outflow

Right Atrium

Left Atrium

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Aortic Arch and Great Vessels

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Pulmonary Arteries

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FDG Uptake in Vessels

Normal Uptake

Primary Tumors

Metastatic Tumors

Infection/Inflammation- No

- Rare

- Rare

- Atherosclerosis- Vasculitis

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Takayasu’s arteritis

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Lymphatics

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Lymphatics• Hilar groups

– Right hilar

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• Hilar groups– Right hilar– Left hilar

Lymphatics

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• Thoracic groups above the hila– Precarinal

Lymphatics

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• Thoracic groups above the hila– Precarinal– Azygous

Lymphatics

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• Thoracic groups above the hila– Precarinal– Azygous– Right paratracheal

Lymphatics

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• Thoracic groups above the hila– Precarinal– Azygous– Right paratracheal– Left paratracheal

Lymphatics

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• Thoracic groups above the hila– Precarinal– Azygous– Right paratracheal– Left paratracheal– Aortopulmonary

Lymphatics

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• Thoracic groups above the hila– Precarinal– Azygous– Right paratracheal– Left paratracheal– Aortopulmonary– Prevascular

Lymphatics

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• Thoracic groups above the hila– Precarinal– Azygous– Right paratracheal– Left paratracheal– Aortopulmonary– Prevascular– Retrosternal

Lymphatics

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• Thoracic groups above the hila– Precarinal– Azygous– Right paratracheal– Left paratracheal– Aortopulmonary– Prevascular– Retrosternal– Superior Mediastinal

Lymphatics

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• Thoracic groups below the hila– Subcarinal

Lymphatics

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• Thoracic groups below the hila– Subcarinal– Azygoesophageal

Lymphatics

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• Thoracic groups below the hila– Subcarinal– Azygoesophageal– Retrocrural

Lymphatics

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• Extrathoracic groups– Scalene

Lymphatics

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• Extrathoracic groups– Scalene– Supraclavicular

Lymphatics

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• Extrathoracic groups– Scalene– Supraclavicular– Axillary

Lymphatics

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Digestive System

• Esophagus• Stomach• Small intestine• Large intestine

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Esophagus

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FDG Uptake in the Esophagus

Normal Uptake

Primary Tumors

Metastatic Tumors

Infection/Inflammation- Yes (+/-)

- Squamous cell cancer

- Rare

- Adenocarcinoma

- Reflux esophagitis- Candida

- Lymphoma

- Mucositis (RoRx)

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Esophageal Cancer

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CT Anatomy of the Abdomen

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Stomach

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Stomach

Fundus

Body

Antrum

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FDG Uptake in the Stomach

Normal Uptake

Primary Tumors

Metastatic Tumors

Infection/Inflammation

Benign Conditions

- Yes

- Adenocarcinoma

- Uncommon- Breast

- Leiomyosarcoma

- Peptic ulcer disease

- Leiomyoma- Lymphoma

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Gastric carcinoma

Gastric carcinoma

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Gastric lymphoma

Gastric sarcoma

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Small Intestine

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Duodenum

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Jejunum

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Ileum

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FDG Uptake in the Small Bowel

Normal Uptake

Primary Tumors

Metastatic Tumors

Infection/Inflammation- Yes

- Lymphoma

- Melanoma

- Adenocarcinoma (rare)

- Crohn’s disease- Other entertitis

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Metastatic melanoma

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Ileocecal Valve

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Appendix

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Appendix

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CT Imaging: Colon

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Cecum

Appendix

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Ascending Colon

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Hepatic Flexure

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Transverse Colon

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Splenic Flexure

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Descending Colon

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Sigmoid Colon

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Rectum

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Anal canal

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FDG Uptake in the Colon

Normal Uptake

Primary Tumors

Metastatic Tumors

Infection/Inflammation

Benign Conditions

- Yes

- Adenocarcinoma

- Rare

- Mucinous carcinoma

- Crohn’s disease- Ulcerative colitis

- Adenomatous polyps

- Other colitis

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Colon cancer

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Colon cancer

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Adenomatouspolyp

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CT Imaging: Liver

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L

R

Lobar Anatomy

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Lobar Anatomy

Lateral leftMedial leftAnterior rightPosterior rightCaudate

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Segmental Anatomy

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Segmental Anatomy

Bifurcation of right and left portal venous

branches

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Segmental Anatomy

LHVMHV

RHV

Segment IISegment IVASegment VIIISegment VII

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Segmental Anatomy

Falciform ligament

Gallbladder fossa

Right hepatic vein

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Segmental Anatomy

Segment IIISegment IVBSegment VSegment VI

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Segmental Anatomy

Segment I

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Hepatic Segments I-VIII

III

IIIVa

IVb

VIII

V

VII

VICaudate: I

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FDG Uptake in the Liver

Normal Uptake

Primary Tumors

Metastatic Tumors

Infection/Inflammation

Benign Conditions

- Yes

- Hepatocellular carcinoma

- Colon- Breast

- Cholangiocarcinoma

- Hepatic abscess- Cholangitis

- Hemangioma

- Pancreas- Gastric- Renal

- Cyst- Hepatic adenoma- Focal nodular hyperplasia

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Segment V Segments V, VI, VII, VIII

Segment VII Segment VI

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Segments VII & IVa

All Segments

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GallstonesMetastasis

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Abdominal Vasculature

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• 5 Major Branches– Celiac Trunk– Superior Mesenteric Artery– Renal Arteries– Inferior Mesenteric Artery– Iliac Arteries

Abdominal Aorta

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Celiac TrunkCeliac Trunk

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Superior Mesenteric Artery

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Renal Arteries

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Mid Aorta

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Inferior Mesenteric Artery

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Aortic Bifurcation

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Common Iliac Arteries

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Internal and External Iliac Arteries

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External Iliac Arteries

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Femoral Arteries

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Femoral Veins

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Iliac Veins

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Inferior Vena Cava

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Inferior Vena Cava

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Renal Veins

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Inferior Vena Cava

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Superior Mesenteric Vein

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Portosplenic Confluence

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Portal and Splenic Veins

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Portal Vein

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Lymph Node Groups

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• Abdominal groups

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• Abdominal groups– Gastrohepatic

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• Abdominal groups– Gastrohepatic– Portocaval

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• Abdominal groups– Gastrohepatic– Portocaval– Aortocaval

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• Abdominal groups– Gastrohepatic– Portocaval– Aortocaval– Left paraaortic

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• Abdominal groups– Gastrohepatic– Portocaval– Aortocaval– Left paraaortic– Mesenteric

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• Abdominal groups– Gastrohepatic– Portocaval– Aortocaval– Left paraaortic– Mesenteric– Aortic bifurcation

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• Pelvic groups

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• Pelvic groups– Common iliac

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• Pelvic groups– Common iliac– Internal iliac

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• Pelvic groups– Common iliac– Internal iliac– External iliac

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• Pelvic groups– Common iliac– Internal iliac– External iliac

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• Pelvic groups– Common iliac– Internal iliac– External iliac– Inguinal

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• Pelvic groups– Common iliac– Internal iliac– External iliac– Inguinal

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Gallbladder and Bile Ducts

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Spleen

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Accessory Spleen

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Accessory Spleen

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FDG Uptake in the Spleen

Normal Uptake

Primary Tumors

Metastatic Tumors

Infection/Inflammation- No

- Lymphoma

- Uncommon- Melanoma- Colon cancer

- G-CSF- Sarcoidosis

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G-CSF effect

Lymphoma

Metastaticcolon cancer

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Adrenal Glands

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Body

Medial Limb

Lateral Limb

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FDG Uptake in the Adrenal Gland

Normal Uptake

Primary Tumors

Metastatic Tumors

Infection/Inflammation- No

- Pheochromocytoma

- Lung cancer- Melanoma

- Adrenocortical carcinoma

- Renal cell cancer

- Adrenal adenoma

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Metastatic lungcarcinoma

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Bilateral adrenalmetastases

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Metastatic lungcarcinoma

Follow up CT1 year later

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Pancreas

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Pancreatic body and tail

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Pancreatic head

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Uncinate process

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FDG Uptake in the Pancreas

Normal Uptake

Primary Tumors

Metastatic Tumors

Infection/Inflammation- No

- Pancreatic cancer

- Unusual- Renal cell cancer

- Islet cell tumors

- Pancreatitis

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Conclusion

• Basic anatomic knowledge can improve the diagnostic value of PET

• Correct use of anatomic terms facilitates communication with referring clinicians

“Anatomy is destiny.”- Sigmund Freud