Anatomic distribution of [18F] fluorodeoxyglucose-avid lymph nodes ...

48 H.P. Fontanilla et al Practical Radiation Oncology: January-March 2013Figure 1 “Atlas” of positron emission tomography (PET)-positive LNs. Representative axial images (superior to inferior) showingthe location of all 190 identified PET-positive lymph nodes. All nodes from each patient are contoured in the same color; each coloris used for 2 patients.We identified 190 FDG-avid LNs; 122 in group 1 (the41 consecutive initially identified patients) and 68 in group2 (the additional 9 patients with positive paraortic LNs).The median number of positive LNs per patient was 3(range, 1-6) in group 1 and 5 (range, 3-17) in group 2. Thedistribution of FDG-avid LNs by disease stage is shownin Table 1.Anatomic distribution of FDG-avid LNsAxial images depicting the anatomic distribution of all190 FDG-avid LNs (from groups 1 and 2) are shown inFig 1. There were 94 external iliac lymph nodes, 40common iliac lymph nodes, and 2 parametrial lymphnodes in groups 1 and 2 combined. Our mapping analysisrevealed that most PET-positive nodes were locatedaround major vessels, between the psoas muscle and thevascular bundle as seen in Fig 1. The FDG-avid externaliliac nodes were generally posterior to the external iliacvessels and extended laterally to the pelvic musculature orbones. Several FDG-avid LNs were located posterior andcaudal to the distal external iliac vessels, classically definedas the medial external iliac nodes; these LNs extendedjust inferior to the level of the superior femoralheads. Two FDG-avid parametrial nodes were noted andthese were primarily lateral, most likely because of thedifficulty of identifying distinct nodal volumes in thevicinity of the primary tumor. There were also multiplepositive common iliac nodes located between the commoniliac vein and psoas muscle, extending posteriorly betweenthe psoas muscle and the sacrum. Positive common iliacnodes were also noted lateral to the vessels and anterior tothe psoas muscle.The anatomic distribution of positive LNs in group 1 issummarized in Table 2 and Fig 2. The most commonlocations of positive LNs were the external iliac region(63.9% of positive LNs) and the common iliac region(17.2%). In group 1, all 41 patients had at least 1 positivedistal pelvic LN (ie, at or distal to the bifurcation of thecommon iliac vessels). Sixteen of the 41 patients (39%)