Cross Sectional Anatomy of the

Chest, Abdomen, and Pelvis

Eric M. Rohren, M.D. Ph.D.

Chief, Positron Emission
Tomography
MD 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
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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 orto be reproduced
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lung carcinoma, and would be most consistent with
 Example
Thyroidectomy and
radioiodine ablation

Completed
RoRx

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 Slides
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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,
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l i di l ff i
 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 rhinectomy
and 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 geniohyoid
musculature. There are no hypermetabolic lymph nodes along the cervical
chains. Slight asymmetry in radiotracer activity in the prevertebral
musculature 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 the
junction 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 Slides are not to be reproduced
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CT Anatomy of the Chest

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Netter images used with permission from Netter Presentor™
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

L L

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 M
U
U

L L

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M U

L L

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Pulmonary Segments

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 Right Lung:
10 Segments
• Right Upper Lobe
– Apical
– Anterior
– Posterior
• Right Middle Lobe
– Lateral
– Medial
• Right Lower Lobe
– Superior
– Medial basal
– Lateral basal
– Anterior basal
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 Left Lung:
9 Segments
• Left Upper Lobe
– Apicoposterior
– Anterior
– Superior lingular
– Inferior lingular
• Left Lower Lobe
– Superior
– Medial basal
– Lateral basal
– Anterior basal
– Posterior basal

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 FDG Uptake in the Lungs
Normal Uptake Metastatic Tumors
- No - Lung
- Breast
Primary Tumors - Colon
- Non-small cell cancer - Melanoma
- Small cell cancer - Bladder
- Carcinoid tumor - Renal cell cancer
- Lymphoma - Osteosarcoma
Infection/Inflammation - Etc.
- Histoplasmosis
- Tuberculosis
- Sarcoidosis
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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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 Right Ventricle

Left Ventricle

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 Right Ventricle

Aortic Root

Left Ventricle

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 Right Ventricle

Aortic Root

Left Ventricle

LeftSlidesAtrium
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 Right Ventricle

Aortic Root

Left Ventricle

Right Atrium

LeftSlidesAtrium
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Pulmonary Outflow

Aorta

Right Atrium
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Left Atrium
Aortic Arch and Great Vessels

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Pulmonary Arteries

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 FDG Uptake in Vessels
Normal Uptake Infection/Inflammation
- No - Atherosclerosis
- Vasculitis

Primary Tumors
- Rare

Metastatic Tumors
- Rare

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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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 Lymphatics
• Hilar groups
– Right hilar
– Left hilar

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 Lymphatics
• Thoracic groups above the hila
– Precarinal

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 Lymphatics
• Thoracic groups above the hila
– Precarinal
– Azygous

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

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

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

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

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

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

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 Lymphatics
• Thoracic groups below the hila
– Subcarinal

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 Lymphatics
• Thoracic groups below the hila
– Subcarinal
– Azygoesophageal

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

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 Lymphatics
• Extrathoracic groups
– Scalene

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 Lymphatics
• Extrathoracic groups
– Scalene
– Supraclavicular

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 Lymphatics
• Extrathoracic groups
– Scalene
– Supraclavicular
– Axillary

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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 Infection/Inflammation
- Yes (+/-) - Reflux esophagitis
- Candida
Primary Tumors - Mucositis (RoRx)
- Squamous cell cancer
- Adenocarcinoma
- Lymphoma

Metastatic Tumors
- Rare

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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 Infection/Inflammation
- Yes - Peptic ulcer disease

Primary Tumors
- Adenocarcinoma Benign Conditions
- Leiomyosarcoma - Leiomyoma
- Lymphoma

Metastatic Tumors
- Uncommon
- Breast
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 Gastric carcinoma

Gastric carcinoma

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 Gastric sarcoma

Gastric lymphoma

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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 Infection/Inflammation
- Yes - Crohn’s disease
- Other entertitis

Primary Tumors
- Lymphoma
- Adenocarcinoma (rare)

Metastatic Tumors
- Melanoma

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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 Slides are not to be reproduced

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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 Infection/Inflammation
- Yes - Crohn’s disease
- Ulcerative colitis
- Other colitis
Primary Tumors
Benign Conditions
- Adenocarcinoma
- Adenomatous polyps
- Mucinous carcinoma

Metastatic Tumors
- Rare

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Colon cancer

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Colon cancer

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Adenomatous
polyp

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CT Imaging: Liver

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Lobar Anatomy

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 Lobar Anatomy

Lateral left
Medial left
Anterior right
Posterior right
Caudate

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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

Segment II
Segment IVA LHV
MHV
Segment VIII
Segment VII
RHV

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 Segmental Anatomy

Falciform ligament

Gallbladder fossa

Right hepatic vein

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 Segmental Anatomy

Segment III
Segment IVB
Segment V
Segment VI

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 Segmental Anatomy

Segment I

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 Hepatic Segments I-VIII

II
VIII IVa
VII III
IVb
V
VI
Caudate: I
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 FDG Uptake in the Liver
Normal Uptake Infection/Inflammation
- Yes - Hepatic abscess
- Cholangitis
Primary Tumors
- Hepatocellular carcinoma
Benign Conditions
- Cholangiocarcinoma - Hemangioma
Metastatic Tumors - Cyst
- Hepatic adenoma
- Colon
- Focal nodular hyperplasia
- Breast
- Pancreas
- Gastric
- Renal Slides are not to be reproduced
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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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Metastasis
Gallstones Slides are not to be reproduced
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Abdominal Vasculature

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Abdominal Aorta

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

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Celiac
CeliacTrunk
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 Infection/Inflammation
- No - G-CSF
- Sarcoidosis

Primary Tumors
- Lymphoma

Metastatic Tumors
- Uncommon
- Melanoma
- Colon cancer
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G-CSF effect

Metastatic
colon cancer

Lymphoma

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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 Infection/Inflammation
- No - Adrenal adenoma

Primary Tumors
- Pheochromocytoma
- Adrenocortical carcinoma

Metastatic Tumors
- Lung cancer
- Melanoma
- Renal cell cancer
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Metastatic lung
carcinoma

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Bilateral adrenal
metastases

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 Follow up CT
1 year later

Metastatic lung
carcinoma

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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 Infection/Inflammation
- No - Pancreatitis

Primary Tumors
- Pancreatic cancer
- Islet cell tumors

Metastatic Tumors
- Unusual
- Renal cell cancer
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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

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without permission of author.