Ημερίδα 2012 Ε.Πν.Ελ. Πολεμικό Μουσείο Αθήνα, 22/9/2012 CT-LESSONS. By A.S.Bastas, MD

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1 Ημερίδα 2012 Ε.Πν.Ελ. Πολεμικό Μουσείο Αθήνα, 22/9/2012 CT-LESSONS By A.S.Bastas, MD

2 CT-LESSONS 1. NORMAL MEDIASTINUM

3 Normal (schematic) Anatomy of Mediastinum (F.H.Netter) Για την κατανόηση των εικόνων της CT στο επίπεδο του μεσοθωρακίου, όπως & αλλού, απαραίτητη προϋπόθεση είναι η καλή γνώση της ανατομίας & της τοπογραφίας.

4 Normal (schematic) Anatomy of Mediastinum (F.H.Netter) Μετά αφαίρεση της καρδίας διακρίνονται οι οπισθιαίτερες δομές του μεσοθωρακίου, όπως ο οισοφάγος, η άζυγος φλέβα & η κατιούσα θωρακική αορτή, αλλά και οι θωρακικοί σπόνδυλοι.

5 CT-SCAN: General Principles Η πραγματική γωνία θέασης του «σώματος» του εξεταζομένου κατά την «ανάγνωση» της αξονικής τομογραφίας.

6 CT-SCAN: Mediastinum 01 Τραχεία Οισοφάγος Πρόσθιες δομές: Φλέβες (βραχιοκεφαλικές) Οπίσθιες δομές: Αρτηρίες (ανώνυμη δεξιά, προτραχειακά και κοινή καρωτίδα υποκλείδια αριστερά, με την τελευταία να είναι η οπισθιαίτερη δομή Προσπονδυλικά: τραχεία & οισοφάγος

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8 CT-SCAN: Mediastinum 02 Πρόσθιες δομές: Φλέβες (βραχιοκεφαλικές), με τάση προς τα δεξιά, όπου θα συνενωθούν προς σχηματισμό της Άνω Κοίλης Φλέβας (SVC) Οπίσθιες δομές: Αρτηρίες (ανώνυμη δεξιά, προτραχειακά και κοινή καρωτίδα υποκλείδια αριστερά, με την τελευταία να είναι η οπισθιαίτερη δομή Προσπονδυλικά: τραχεία & οισοφάγος

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10 CT-SCAN: Mediastinum 03 Πρόσθιες δομές: Φλέβες (βραχιοκεφαλικές), με τάση προς τα δεξιά, όπου θα συνενωθούν προς σχηματισμό της Άνω Κοίλης Φλέβας (SVC) Οπίσθιες δομές: Αρτηρίες (ανώνυμη δεξιά, προτραχειακά και κοινή καρωτίδα υποκλείδια αριστερά, που εδώ συμπλησιάζουν καθώς πορεύονται προς το αορτικό τόξο, απ όπου εκφύονται Προσπονδυλικά: τραχεία & οισοφάγος

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12 CT-SCAN: Mediastinum 04 Μία από τις πιο απλές τομές του μεσοθωρακίου Αορτικό τόξο αριστερά Άνω Κοίλη Φλέβα (SVC) Προσπονδυλικά: τραχεία & οισοφάγος Ο προτραχειακός χώρος απαρτίζεται κυρίως από κυτταρολιπώδη ιστό, ενίοτε όμως μπορεί να περιέχει υπολείμματα του θύμου αδένα

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14 CT-SCAN: Mediastinum 05 Ίδια διατομή με την προηγούμενη Αορτικό τόξο αριστερά Άνω Κοίλη Φλέβα (SVC) Προσπονδυλικά: τραχεία & οισοφάγος Ο προτραχειακός χώρος (κυτταρολιπώδης ιστός, ενίοτε & με υπολείμματα του θύμου αδένα) Προ- & παρατραχειακά, αλλά και παρααορτικά ενίοτε διακρίνονται μικροί λεμφαδένες

15 CT-SCAN: Mediastinum 06 Αζυγοοισοφαγική γωνία Διατομή, κατώτερα από το αορτικό τόξο (γι αυτό φαίνεται η ανιούσα & η κατιούσα αορτή) Άνω Κοίλη Φλέβα (SVC) & η σύνδεσή της με το τόξο της αζύγου φλέβας, που εκκινεί από αυτή και πορεύεται προς τα οπίσω για να «τοποθετηθεί» προσθιοπλάγια δεξιά των σπονδυλικών σωμάτων). Η γωνία μεταξύ οισοφάγου-αζύγου είναι γνωστή ως αζυγοοισοφαγική γωνία (recess) Προσπονδυλικά: τραχεία & οισοφάγος Η γραμμοειδής σκίαση που πορεύεται σχεδόν παράλληλα με την ανιούσα αορτή είναι πτυχή του περικαρδιακού σάκου (recess) Ο προτραχειακός χώρος (κυτταρολιπώδης ιστός, ενίοτε & με υπολείμματα του θύμου αδένα) Προ- & παρατραχειακά, αλλά και παρααορτικά ενίοτε διακρίνονται μικροί λεμφαδένες

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17 CT-SCAN: Mediastinum 07 Ανώτερη πτυχή του περικαρδίου & υπόλλειμα βοταλλείου πόρου Αμέσως κατώτερη διατομή, με εμφάνιση του κώνου της πνευμονικής αρτηρίας «δεξιά» της ανιούσης αορτής Οπισθιαίτερα της ανιούσης αορτής και σε επαφή με αυτήν, μόρφωμα τοξοειδές, με πυκνότητα μεταξύ ύδατος & λίπους, παριστά υπόλλειμα του βοταλλείου πόρου με πτύχωση του περικαρδίου (superior pericardial recess)

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19 CT-SCAN: Mediastinum 08 Στο ύψος του 4ου 5ου θωρακικού σπονδύλου διακρίνεται ο διχασμός της τραχείας & οι στελεχιαίου βρόγχοι (RMB, LMB) Στο ίδιο επίπεδο διακρίνονται καλύτερα οι κύριοι κλάδοι της πνευμονικής αρτηρίας, αλλά & οι ανιόντες κλάδοι αυτών Στην προέκταση του δεξιού στελεχιαίου διακρίνεται ο άνω λοβαίος δεξιά & συχνά οι πρόσθιος (RB3) & ο οπίσθιος (RB2) τμηματικοί του

20 CT-SCAN: Mediastinum 09 Υπό την κύρια τρόπιδα, διακρίνονται ο διάμεσος βρόγχος (δεξιά) & ο αριστερός στελεχιαίος (LMB) Παράλληλα με την πνευμονική αρτηρία (κώνος, trunk) & προς τα «δεξιά» της διακρίνεται η πτύχωση του περικαρδιακού σάκου

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23 CT-SCAN: Mediastinum 10 Στο επίπεδο αυτό διακρίνονται τα ωτία των δύο κόλπων της καρδίας, αλλά & ο δεξιός κόλπος (RA) Από τον αριστερό στελεχιαίο (LMB) φαίνεται η έκφυση του αριστερού άνω λοβαίου (LUL)

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25 CT-SCAN: Mediastinum 11 Στην κατώτερη τομή του μεσοθωρακίου διακρίνονται ο αριστερός κόλπος (LA) με τις άνω πνευμονικές φλέβες, ο δεξιός κόλπος (RA), η δεξιά κοιλία στο επίπεδο της αρχής της πνευμονικής αρτηρίας (RV, outflow), & η αριστερή κοιλία (LV) με την αορτική ρίζα Παρά τους κάτω λοβαίους βρόγχους οι συνοδοί κατιόντες κλάδοι της ΠΑ

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27 Case-related CT-theory of the Radiology of the Mediastinum Part II A.S.Bastas, MD

28 Mediastinal Radiology / CT / Cases

29 Mediastinal Anatomy/Compatrments Anterosuperior Mediastinum Ascending Aortic Aneurysm Parathyroid Tumor Angiomatous Tumor Thymoma Teratoma Pericardial Cyst Lymphoma Morgagni s Hernia Lipoma Seminoma Middle Mediastinum Goiter Lymphoma Lymph Node Hyperplasia Bronchogenic Cyst Bronchogenic Tumor Posterior Mediastinum Neurogenic Tumor -- Esophageal Tumor Aortic Aneurysm -- Bronchogenic Tumor Hiatal Hernia -- Enteric Cyst Paraspinal Abscess Extrapulmonary hematopoiesis

30 Mediastinal Anatomy/Alternative classification of mediastinal compartments

31 Mediastinal Anatomy/Compatrments Anterosuperior Mediastinum Malignant Tumors 59 % Middle Mediastinum Malignant Tumors 29 % Posterior Mediastinum Malignant Tumors 16 % Azarow KS, Pearl RH, Zurcher R, et al. Primary mediastinal masses. A comparison of adult and pediatric populations. J Thorac Cardiovasc Surg 1993; 106:67.

32 Mediastinal Lymph Nodes Stations: : Mediastinal 11-12: Intrapulmonary How to approach each station (methods) EUS-TBNA EBUS-TBNA (see Lesson on: TBNA of mediastinal LNs ) UpToDate 2011 (19.2)

33 NEJM 2011;364(13): Images in clinical medicine A 76-year-old man presented with progressive dyspnea and leg swelling. He had a remote history of syphilis, which had gone untreated until quite recently. Auscultation of the precordium was notable for the diastolic blowing murmur of aortic regurgitation. ECG: evidence of LV hypertrophy. CXR: a mediastinal mass with tracheal deviation (Panel A, arrowhead).

34 NEJM 2011;364(13): Images in clinical medicine CE-CT of the Chest revealed an aortic aneurysm measuring 11,4 X 11.5 by 18,0 cm (Panel B, axial image, asterisk, & Panel C, sagittal reconstruction image, asterisk), its caliber markedly different from that of the normal descending aorta (Panels B & C, daggers).

35 NEJM 2011;364(13): Images in clinical medicine The patient underwent replacement of the aortic valve and repair of the aneurysm. Findings on pathological examination of the excised tissue were consistent with syphilitic aortitis, a condition in which spirochetal invasion of the aortic adventitia causes an obliterative endarteritis of the vasa vasorum. Blood supply to the aortic wall is impaired, which results in weakening of the tunica media and formation of the aneurysm.

36 NEJM 2011;364(13): Images in clinical medicine Final Diagnosis: Giant Syphilitic Aortic Aneurysm Taufiek Konrad Rajab, M.D., Robert P. Gallegos, M.D., Ph.D. Brigham and Women s Hospital -- Boston, MA

37 NEJM 2010;362(15): Mediastinal Mass A 32-year-old man with a 20-year history of smoking presented with a 1month history of nonproductive cough at night, dyspnea, left thoracic pain, and an involuntary weight loss of 7 kg. Physical examination: shallow breathing & diminished cardiac sounds. No evidence of palpable masses or LNs. CXR: showed a mediastinal mass extending to the right and left of the midline without deviation of the trachea (Panel A, red arrow)

38 NEJM 2010;362(15): Mediastinal Mass IV CE Thoracic-CT: confirmed a large, relatively homogeneous mass in the anterior mediastinum with no calcifications or fat and no posterior displacement of vascular structures (Panel B). Coronal reconstruction from the CT scan showed a large mass extending to the Right and Left of midline (Panel C), corresponding to findings on the radiograph, and downward displacement of the heart.

39 NEJM 2010;362(15): Mediastinal Mass A biopsy showed a seminoma. The patient received 15 sessions of RT (a total of 800 cgy) and a 6-day cycle of CT with cisplatin & etoposide phosphate. Currently, he is doing well and has no symptoms. Jorge Chirino Romo, M.D. [Hospital Angeles del Pedregal Mexico City, Mexico] Israel Hernandez, M.D. [Hospital Central Militar Mexico City, Mexico]

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41 Compensatory extramedullary hematopoiesis In B-thalassemia

42 UpToDate-2011: Mediastinal Masses Neurogenic (posterior mediastinal) Tumors Large mixed attenuation right paraspinal mass extends anteromedially and displaces and narrows the trachea to the left. The tumor originates most likely from the sympathetic chain. Courtesy of Paul Stark, MD. Paraspinal ganglioneuroma

43 UpToDate-2011: Mediastinal Masses Neurogenic (posterior mediastinal) Tumors Large rounded paraspinal mass originating from an intercostal nerve. Courtesy of Paul Stark, MD. Paraspinal neurilemmoma

44 UpToDate-2011: Mediastinal Masses CT scan of a mass originating from the right lobe of the thymus. A large rounded mass is seen in the retrosternal location, to the right of the midline (arrow). Courtesy of Paul Stark, MD. Thymoma

45 UpToDate-2011: Mediastinal Masses CT scan of a mass originating from the left lobe of the thymus. There is a large rounded inhomogeneous mass located to the left of the midline (arrow). Courtesy of Paul Stark, MD. Thymoma

46 UpToDate-2011: Mediastinal Masses This plain CXR from a 56-year-old male demonstrates a mass abutting the right cardiophrenic angle, a typical appearance and location of a pericardial cyst. (arrows). Photo courtesy of Jonathan Kruskal, MD. Pericardial Cyst

47 UpToDate-2011: Mediastinal Masses Large subcarinal mass of low attenuation coefficient is clearly visible occupying the azygoesophageal recess. Courtesy of Paul Stark, MD. Bronchogenic Cyst

48 UpToDate-2011: Mediastinal Masses CT scan of a retrosternal goiter seen as an inhomogeneous mass anterior to the trachea. The airway is narrowed and displaced to the left and posteriorly. The aortic branches are peeled off the trachea and displaced anteriorly. Courtesy of Paul Stark, MD. Retrosternal Goiter

49 UpToDate-2011: Mediastinal Masses Large mass in the region of the left lobe of the thymus with a second smaller lymph node adjacent to it. Note the lower attenuation center of the mass, not unusual in lymphoma. Courtesy of Paul Stark, MD. Lymphoma (Hodgkin s)

50 UpToDate-2011: Mediastinal Masses Hodgkin s disease, nodular sclerosis variant, presenting as a multilobulated mass in the anterior mediastinum. The enlarged lymph nodes are homogeneous and tend to be matted together. Courtesy of Paul Stark, MD. Lymphoma (Hodgkin s)

51 UpToDate-2011: Mediastinal Masses Hodgkin s disease, nodular sclerosis variant, in a 35 Y-O man who presented at the ER for pain in the chest. Mediastinoscopy & biopsy proved the diagnosis. Courtesy of Antony Bastas, MD. Lymphoma (Hodgkin s)

52 NEJM 2009;359(14):28 -- Mediastinal Air 47 years old man with chest pain & leucocytosis. CT: pneumopericardium, circumferential wall thickening of the distal esophagus, esophagopericardial fistula. Esophagoscopy: deep esophageal ulcer Esophageal-biopsy: intestinal metaplasia with inflammation and high-grade dysplasia. Diagnosis: Barrett s esophagus. Pneumopericardium

53 NEJM 2009;361(17): Mediastinal Masses Coronal (Panel B) & sagittal (Panel C) CT-scans: right kidney (large arrows) and part of the liver protruding above the diaphragm (small arrows) and into the posteromedial aspect of the right hemithorax through the foramen of Bochdalek (arrowheads indicate the defective fusion of the diaphragm). Thoracic kidney: rare congenital anomaly, much less common on the Right (because of the liver). Twice as common in men than in women (M:F = 2:1) Bochdalek s hernia (thoracic kidney)

54 NEJM 2010;362(19):e61 -- Mediastinal Masses A 41-YO-woman with a 5-mo history of dyspnea+cardiac arrhythmia. CXR: enlarged right mediastinum wit h air content on the right side (Panel A, arrow; and Panel B, lateral view). CT-scans: a Morgagni s hernia (with herniation of the transverse colon & part of the omentum into the thorax (Panels C & D). The bowel contents compress the right side of the heart. Morgagni s hernias are secondary to congenital defects in the anterior diaphragm. Morgagni s hernia

55 NEJM 2010;363(9): Mediastinal Masses A 46-YO-woman with a 2-mo history of a large, palpable, fixed, firm, nontender mass in the lower neck (Panel A, arrow). CXR: a mass (Panel B, arrows) in the lower neck & upper & middle mediastinal regions, causing tracheal deviation to the right (Panel B, arrowhead). CT: a heterogeneous mass in the left lower neck & anterior mediastinum (Panels C-D, black arrows), with compression of the supraaortic trunks (Panels C-D, white arrows), trachea (Panel C, arrowhead), and cervical & thoracic esophagus (Panel D, arrowhead) Liposarcoma

56 NEJM 2008;359(8): Mediastinal Masses A 23-YO-male marine recruit passed out while bending over after a 2.4-km run. CXR: a mass in the anterior mediastinum (Panel A, arrow). Medical history: removal of a benign thyroid cyst at the age of 12 years. No use of medications or tobacco & no drug allergies. Physical examination & initial laboratory studies: unremarkable, except for prominent varicosities noted on his chest (Panel B). CE-CT of the chest: a large anterior mediastinal mass with fluid, fat, and calcific densities (Panel C, arrow), that was compressing the right pulmonary artery (Panel D, arrow). Collateral circulation in the chest wall was noted (Panels C & D, arrowheads). DD: thymoma, teratoma, lymphoma, thyroid. Resection & full recovery Benign Mediast. Teratoma

57 NEJM 2008;359(15): Case 31 A 39-YO-male admitted for chest pain, arthralgias & mediast. mass. CE-CT: soft tissue in the mediastinum that encases and narrows the pulmonary artery (Panel A, arrows). [2 mo before admission] Axial CE-CT scan at the Level of the origin of the right PA (Panel D): increased soft tissue in the mediastinum, extending around the PA and its branches (arrow) [3rd day after admission] Image at the origin of the left coronary artery shows encasement of the artery and displacement of the atrium (Panel E, arrow). WG, mediast & pulm artery

58 Mediastinal Masses: Questionnaire 1. What is the most common primary tumor of the anterior mediastinum? (a) Thymoma (b) Intrathoracic goiter (c) Teratoma 2. What is the most common anatomic location of a bronchogenic cyst? (a) Paratracheal (b) Subcarinal (c) Parenchymal 3. What is the most diagnostic CT finding in mediastinal mature teratoma? (a) Calcifications (b) Fatty densities (c) Fluid-fluid levels

59 CT & MRI: Evaluation of Mediastinal Masses (comparison)

60 Case-related CT-theory of the Radiology of the Mediastinal Lymph Nodes (LNs) Part III Am J Respir Crit Care Med 2000;174: [J.P. Ko et al] A.S.Bastas, MD

61 Malignant Lymphadenopathy Sensitivity Specificity Accuracy CT 68% 61% 63% MRI 87% 91% 82%

62 Mediastinal LNs Mountain CF, Dresler CM. Regional lymph node classiﬁcation for lung cancer staging. Chest 1997;111:

63 Mediastinal LNs Stations yo man w SCLC L (CE) & R (CE, colored LNs) Station 1 (Light Green) Highest Mediastinal LNs, paratracheal, between LSA & LCCA Station 3 (Pink) Prevascular LNs, Left to LSA, LCCA & RAA Station 2 (dark purple) demarcated from higher Station 1 by top of Left Brachiocephalic Vein (LBCV), Arrows (white or black)

64 Mediastinal LNs Station 2 68 yo man w SCLC & SVC syndrome Station 2 (Deep purple) Below top of LBCV but superior to Aortic Arch. Arrows (white): Distended Mammary Veins with reflux of contrast media to Left Brachiocephalic Vein (LBCV) due to SCV syndrome.

65 Mediastinal LNs Station 3 38 yo man w B-cell Lymphoma A: CE-CT scan: Station 3 retrotracheal node (1-cm). B: Same scan: node colored bright pink, 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 SVC]. C: Unenhanced CT scan (4 mo later): shows decrease in size of lymph node (arrow) as result of therapy.

66 Mediastinal LNs Station 4 (superior) 65 yo man w SCLC & SVC syndrome A & B: CE-CT scan (A) & CE-CT with nodes colored (B): Station 4 Lower paratracheal nodes (bright orange, B). These can be separated into superior and inferior subsets. Nodes shown are in superior subset (inferior to top of aortic arch & above azygos vein).

67 Mediastinal LNs Station 4 (inferior) 65 yo man w SCLC & SVC syndrome C & D: CE-CT scan (C) & CE-CT with nodes colored (D): 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 (previous slides).

68 Mediastinal LNs Station 4 (c) 65 yo man w SCLC & SVC syndrome Β & D: CE-CT scan with nodes colored: Station 4 Lower paratracheal nodes (bright orange, B & D). The station 4 superior Lower paratracheal nodes can be separated into those to right (4R) (curved arrow) or left (4L) (straight thick arrow) of midline, [Figures B & D]. Midline nodes (thin arrow) are considered to be on same side as primary lung tumor. In this case (RLL mass): midline nodes anterior to trachea are categorized as station 4 superior lower paratracheal nodes. Enhancing chest wall venous collaterals are again shown.

69 Mediastinal LNs Station 5 [AP] Ligamentum arteriosum 66 yo man w Lymphadenopathy A: CE-CT scan: station 5 subaortic or aorticopulmonary (AP) window nodes and station 4 superior lower paratracheal nodes. B: CE-CT scan with nodes colored (light purple): station 5 AP window nodes. AP window nodes are lateral to, & station 4 superior lower paratracheal nodes (bright orange) are medial to, ligamentum arteriosum.

70 Mediastinal LNs Stations yo woman with poorly differentiated adenoca of LLL A: CE-CT scan shows station 6 paraaortic (ascending aortic or phrenic) nodes and station 5 nodes. B: As in A, with LNs colored: 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.

71 Mediastinal LNs Stations 4,7-8,10,13 65-yo man with SCLC and SVC syndrome. A: CE-CT scan: station 7 subcarinal nodes & station 4 lower paratracheal, station 8 paraesophageal, station 10 hilar, & station 13 segmental nodes. B: As in A, 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.

72 Mediastinal LNs Stations 4,7,10,13 66-yo woman with adenopathy. A & B: CE-CT scan (A) & same scan with nodes colored (B): station 10 hilar nodes (yellow, B), which are anterior and posterior to right upper lobe bronchus. They are inferior to top of RUL bronchus, demarcation point between station 4 mediastinal & station 10 hilar nodes. Note station 7 subcarinal node (teal blue, B). Station 13 segmental node (light pink, B) lies between RUL anterior and posterior segmental bronchi (arrows).

73 Mediastinal LNs Stations 7,11 66-yo woman with adenopathy. C & D: CE-CT scan (C) & same scan with nodes colored (D): at level of main pulmonary artery & 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.

74 Mediastinal LNs Station 8 38-yo man with lymphoma. A: CE-CT scan shows station 8 paraesophageal node. B: 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).

75 Mediastinal LNs Stations 9,12 Inferior pulmonary ligament (Left) 66-yo woman with adenopathy. A & B: CE-CT scan (A) & 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. C: Same scan as A and B viewed with lung window settings shows inferior pulmonary ligament (white arrows, red lines) 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.

76 Mediastinal LNs Station yo man with SCLC of RLL. A & B: 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.

77 Mediastinal LNs Stations 7,11 80-yo man with SCLC of RLL. C & D: 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 RLL periphery represents top of primary tumor.

78 Εύχομαι ολόψυχα... Οι εικόνες και τα κείμενα να αποτελέσουν χρήσιμα εργαλεία για τους συναδέλφους που μάχονται σε πολλά μετερίζια της ιατρικής προσφοράς & δράσης Οι συνάδελφοι να βρουν «έναυσμα» για συνεχή μελέτη & κατάρτιση σ ένα σύστημα που μόνο ευοδωτικό αυτής της λειτουργίας δεν είναι Να είμαστε όλοι γεροί μπροστά στις νέες προκλήσεις αλλά και απειλές, που δεχόμαστε εμείς, οι εργαζόμενοι, οι άνεργοι και τελικά η Πατρίδα μας... Και να θυμάστε! Η Πατρίδα μας είμαστε εμείς και τα παιδιά μας!!! Με αγάπη, Αντώνης Μπάστας