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Delineation guidelines
for the regional lymph
node areas in breast
radiotherapy
Supra-Clavicular and Retro-Clavicular
Fossa
Cranial
Cranial edge of the Subclavian Artery Arch
Caudal
5 mm caudal of the caudal edge of the junction of the Subclavian Vein and the
Internal Jugular Vein
Rem: If LABC, up to the level of transverse cervical artery (usually more visible with contrast)
- Cranially: Dorsal surface of Sternocleidomastoid muscle
Anterior
Rem: Not crossing medially the ‘imaginary’ vertical line drawn through the medial part of the internal
jugular vein
- Caudally: the Infrahyoid muscles (Strap muscles) and Clavicle
Posterior
Medial
Lateral
- Cranially: Ventral surface of the Subclavian Artery, but not if the distance is more
than 1 cm from the posterior border of the internal jugular vein
- Caudally: lung
Including the medial edge of the Internal Jugular Vein, without any margin, excluding
the Carotid Artery, Thyroid gland. Check the Internal Mammary Artery is included
- Cranially: lateral border of the Anterior Scalene muscle
- Caudally: behind the Clavicle, joining Axillary level III, but excluding the Subclavian
Artery.
Rem: The anterior scalene muscle separates the SC fossa in 2, with vein anteriorly and the artery
posteriorly (indentation)
Axillary level III
(Infra-Clavicular Fossa)
Cranial
When the Subclavian Artery exits the thorax, between the
Clavicle and the first rib, and becoming there the Axillary Artery
Rem: if LABC, cranial extension up to the coracoid insertion of the pectoralis minor muscle.
Caudal
5mm below the Axillary Vein when it crosses the medial border
of Pectoralis Minor muscle
Rem: if LABC, medial border of pectoralis major muscle merge with the ribs/intercostal
muscles.
Anterior
Posterior surface of the Pectoralis Major muscle and the
clavicle
Posterior
Ribs and Intercostal muscles
Medial
Clavicle and/or lateral border of the Junction of the Subclavian
Vein and the Internal Jugular Vein (joins lateral border of
supraclavicular space)
Lateral
Medial border of Pectoralis Minor muscle
Rem: If visible, try to exclude the brachial plexus.
Axillary level II
Cranial
Caudal
When the Axillary Artery crosses the medial edge of
Pectoralis Minor muscle
5 mm below the Axillary Vein when it crosses the lateral
border of Pectoralis Minor muscle
Rem: if LABC, more caudally, to the caudal CT-slice of the free edge pectoralis minor
muscle.
Anterior
Dorsal surface of Pectoralis Minor muscle
Posterior
Ribs and Intercostal muscles
Rem: Exclude the pectoralis minor m. from delineation.
Medial
Medial border of Pectoralis Minor muscle
Lateral
Lateral border of Pectoralis Minor muscle
Rem: If visible, try to exclude the brachial plexus.
The ROTTER Space (transpectoral secondary
drainage)
Cranial
When the Axillary Artery crosses the medial edge of
Pectoralis Minor muscle
Caudal
5 mm below the caudal edge of the Axillary Vein
Anterior
Dorsal surface of Pectoralis Major muscle
Posterior
Anterior surface of Pectoralis Minor muscle
Rem: Exclude the Pectoralis Minor m. from delineation.
Medial
Medial border of Pectoralis Minor muscle
Lateral
Lateral border of Pectoralis Major muscle
Axillary level I
Cranial
The top of the Axillary Artery or 5 mm above the axillary vein
when it crosses the lateral edge of Pectoralis Minor muscle,
including the clips and seroma, avoiding the Humeral Vessels.
Guided by the clips and seroma (surgeon, preop imaging)
Caudal
Rem: if LABC (also use the information of the initial PET-CT) or no clips and seroma
visible or only sentinel node biopsy: Lateral border Pectoralis Major muscle merge with
the ribs (around 4-5th rib).
Not external to the ‘imaginary’ line between the anterior
Anterior
surface of Pectoralis Major muscle and latero-anterior border
and External of the Deltoid muscle (cranially) and the Latissimus Dorsi
muscle (caudally)(include seroma and/or clips).
Anterior
and internal
Posterior
Lateral border of Pectoralis Major and Minor muscle and
Thoracic Wall
Rem: include seroma if visible, also if it extends medially to the anterior and internal
border of axillary level I.
Anterior border of Subscapularis muscle and anterior border
of the Latissimus Dorsi muscle, excluding the Subscapular
Vessels (drain the back)
Rem: If visible, try to exclude the brachial plexus.
Internal Mammary Node Region
Cranial
Caudal edge of the Junction of the Subclavian Vein and the
Jugular Vein, joins SC region
Caudal
Cranial aspect of the 4th rib.
Rem: Caudally, the IM vein divides in 2
Anterior
- Cranially: Manubrium Sterni
- Caudally: The dorsal surface of the Intercostal muscles,
including the perivascular fatty zone (triangle shaped)
Posterior
5 mm fatty space dorsal of IM Vessels, not beyond the pleura
Medial
5 mm medial of IM vessels
Lateral
5 mm lateral of IM Vessels