10. Importance of the Lymph Nodes Nodes on the side (hilar or N1) are not as significant if nodes in the middle or higher up are involved (N2 or mediastinal nodes)
11.
12.
13. Lymph Node Stations N2 Nodes: all N2 nodes lie within the mediastinal pleural envelope on the ipsilateral side 10. hilar, 11. interlobar, 12 lobar nodes bronchi, 12 segmental, 14. subsegmental N1 Nodes: all N1 nodes lie distal to the mediastinal pleural reflection and within the visceral pleura 1. highest mediastinal, 2. upper paratracheal, 3. prevascular/ retrotracheal, 4. lower paratracheal, 5. subaortic/AP window, 6. para-aortic, 7.subcarcinal, 8. paraesophageal, 9. pulmonary ligament
14. Superior Mediastinal Nodes (1-4) 1. Highest Mediastinal: above the left brachiocephalic vein. 2. Upper Paratracheal: above the aortic arch, but below the left brachiocephalic vein. 3. Pre-vascular or Pre-vertebral: these nodes are not adjacent to the trachea like the nodes in station 2. They are either anterior to the vessels (3A) or behind the esophagus, which is prevertebral (3P). 4. Lower Paratracheal (including Azygos Nodes): below upper margin of aortic arch down to level of main bronchus. Aortic Nodes (5-6) 5. Subaortic (A-P window): nodes lateral to ligamentum arteriosum. These nodes are not located between the aorta and the pulmonary trunk, but lateral to these vessels. 6. Para-aortic (ascending aorta or phrenic): nodes lying anterior and lateral to the ascending aorta and the aortic arch. Inferior Mediastinal Nodes (7-9) 7. Subcarinal. 8. Paraesophageal (below carina). 9. Pulmonary Ligament: nodes lying within the pulmonary ligaments. Hilar, Interlobar, Lobar, Segmental and Subsegmental Nodes (10-14) 10-14: these are located outside of the mediastinum. They are all N1-nodes.
33. Initial CT PET Scan Fused on Treatment Planning Computer
34. In the treatment the lasers are used to line up the beam and the patient receives the radiation treatment
35.
36. Combine a CT scan and linear accelerator to ultimate in targeting (IGRT) and ultimate in delivery (dynamic, helical IMRT) ability to daily adjust the beam (ART or adaptive radiotherapy)
37. Computer generated images of small lung cancer (in blue) in the left upper lung and the radiation target zone (green) that surrounds it
38. Computer generated images showing the radiation beam passing through the patient to hit the small lung cancer
39. Computer generated images showing the volume and dose of normal lung receiving radiation The computer monitors the total lung dose to keep it below a dose level that could cause problems
44. Tomotherapy images showing the radiation zone in red surrounds the cancer area (in blue) and limits the dose of radiation that hits the normal lung, heart or spinal cord
47. Radiation Results Some lung cancers (like small cell) shrink quickly, other cancers may take weeks or months to slowly regress
48. PET Scan showing complete remission of the cancer in the left lung at 7 months
49. PET scan showing near complete remission, 2 months after radiation alone for NSCL
50. PET scan showing degree of tumor shrinkage 6 weeks after completion chemoradiation for NSCL lung cancer (the tumor will continue to shrink for weeks to months)
52. PET scan of the same patients, 2 years later, there is still a large density in the lung, but it is ‘cold’ on the PET scan, so just radiation fibrosis or scar tissue