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Oncology Imaging

Principal Imaging Modalities

Plain films (images)


Ultrasound (US)
Computed Tomography (CT)
Magnetic Resonance Imaging
(MRI)
Nuclear Medicine

Contrast media
Barium sulphate
Organic iodine preparations
Ultrasound contrast agents
Magnetic Resonance Imaging
contrast agents.
Contrast media may have
allergic reactions.

Reactions related to Iodinated


contrast media

Minor reactions: nausea,


vomiting, urticarial rash,
headache.
Intermediate reactions:
hypotension, bronchospasm
Major reactions: convulsions,
pulmonary oedema, cardiac
arrhythmias, cardiac arrest.

Radiation Protection (1)

Although ionizing radiation is


deemed to be potentially
hazardous, the risks should be
weighed in context of benefits
to the patient.

Radiation Protection (2)

Clear requests with relevant


clinical details.

Discussion of complex cases


with radiologists.

Radiation Protection (3)

Ultrasound

radiation
MR I

}Lack of ionizing

Digital Radiography

The principal advantages of digital


radiography are:
significant reduction in radiation
exposure;
digital enhancement ensures all
images are of an adequate quality;
transfer of images out of the
radiology department to other
sites;

Digital Radiography

elimination of storage problems


associated with conventional
films:
no missing films;
rapid retrieval of previous
images and reports for
comparison;
ease of availability of
examinations to clinicians.

Ultrasound
USES
Brain:
Imaging the neonatal brain.
Thorax: Confirms pleural effusions and
pleural masses.
Abdomen: Visualizes liver, gallbladder,
pancreas, kidneys, etc.
Pelvis: Useful for monitoring pregnancy,
uterus and ovaries.
Peripheral: Assesses thyroid, testes and
soft-tissue lesions.

Ultrasound
Advantages

Relatively low cost of equipment.

Non-ionizing radiation and safe.

Scanning can be performed in any


plane.

Can be repeated frequently, for


example pregnancy follow up.

Ultrasound
Advantages

Detection of blood flow, cardiac and


fetal movement.

Portable equipment can be taken to


the
bedside for ill patients.

Aids biopsy and drainage procedures.

Ultrasound
Disadvantages
Operator dependent.
Inability of sound to cross an
interface with either gas or bone
causes unsatisfactory
visualization of underlying
structures.
Scattering of sound through fat
produces poor images in obesity.

Computed Tomography
USES
Any region of the body can be scanned;
brain, neck, abdomen, pelvis and limbs.
Staging primary tumours such as colon
and lung for secondary spread, to
determine operability or a baseline for
chemotherapy.
Radiotherapy planning.
Exact anatomical detail when
ultrasound is not successful.

Computed Tomography
Advantages
Good contrast resolution.
Precise anatomical detail.
Rapid examination technique, so
valuable for ill patients.
In contrast to ultrasound,
diagnostic images are obtained in
obese patients as fat separates the
abdominal organs.

Computed Tomography
Disadvantages

High cost of equipment and scan.


Bone artefacts in brain scanning,
especially the posterior fossa, degrade
images.
Scanning mostly restricted to the
transverse plane, although
reconstructed images can be obtained
in other planes.
High dose of ionizing radiation for each
examination.

Magnetic Resonance Imaging


USES
Central nervous system (CNS):
technique of choice for brain and
spinal imaging.
Musculoskeletal: accurate imaging of
joints, tendons, ligaments and
muscular abnormalities.
Cardiac: imaging with gating
techniques related to the cardiac cycle
enables the diagnosis of many cardiac
conditions.

Magnetic Resonance Imaging


USES
Thorax: assessment of vascular
structures in the mediastinum.
Abdomen: abdominal organs are
well visualized, surrounded by
high signal from surrounding fat.
Pelvis: staging of prostate, bladder
and pelvic neoplasms.

Magnetic Resonance Imaging


Advantages

Can image in any plane-axial, sagittal or


coronal.
Non-ionizing and hence believed to be
safe
to use.
No bony artefacts due to lack of signal
from
bone.

Magnetic Resonance Imaging


Advantages

Excellent anatomical detail especially of


soft
tissues.
Visualizes blood vessels without
contrast:
magnetic resonance angiography (MRA).
Intravenous contrast utilized much less
frequently than CT.

Magnetic Resonance Imaging


Disadvantages

High operating costs.


Poor images of lung fields.
Inability to show calcification
with accuracy.

Magnetic Resonance Imaging


Disadvantages

Fresh blood in recent haemorrhage


not as well visualized as by CT.
MRI more difficult to tolerate with
examination times longer than CT.
Contraindicated in patients with
pacemakers, metallic foreign
bodies in the eye and arterial
aneurysmal clips (may be forced
out of position by the strong
magnetic field).

Respiratory Tract

Modalities for Respiratory Tract


Investigations

Plain films (images)

Computed tomography (CT)

Ultrasound (US)

Isotopes

Pulmonary angiography

Magnetic resonance imaging


(MRI)

CT for Respiratory tract

Excellent detail for localizing and


staging mediastinal masses and
bronchial neoplasms.
Assesses hilar areas to identify
lymphadenopathy, and to
differentiate from prominent
pulmonary arteries.
Visualizes accurately pleural
masses, plaques and fluid
associated with asbestos exposure.

US for Respiratory tract

Presence of the pleural


effusions and
loculated fluid.

Biopsy of pleural lesions.

MRI-for respiratory tract

Evaluation of mediastinal
masses,
aortic dissection and
staging bronchial carcinoma.

Evaluation of vascular
invasion.

Bronchial carcinoma
A common primary tumour
Histological types:
squamous, small (oat) cell,
anaplastic, adenocarcinoma,
alveolar cell carcinoma.

Bronchial carcinoma
Haemoptysis
Respiratory

symptoms

Bronchial carcinoma
Radiological features

Lobulated or spiculated mass but sometimes


with a smooth outline.

Tumours at the lung apex (Pancoast's


tumour) can invade the brachial plexus,
resulting in shoulder and arm pain with
wasting of the hand, or invasion of the
sympathetic chain may give rise to Horner's
syndrome.

Bronchial carcinoma
CT/MRI
-Assesses spread.
-Determines operability.

Differential diagnosis of
solitary lung mass

Metastasis:
-Breast, kidney, colon,
testicular tumours.
Tuberculoma
Benign neoplasms
-Bronchial adenoma , hamartoma
round pneumonia, hydatid cyst,
haematoma , arteriovenous
malformation.

Bronchial carcinoma
Common sites of distant
metastases
-

Brain
Bone
Adrenals
Liver

Mediastinal mass
Imaging modalities
Plain film
CT
MRI

Mediastinal mass
Anterior mediastinal masses
- thyroid , thymus ,
teratodermoid
Middle mediastinal masses
- lymphoma, metastases,
sarcoid or tuberculosis.
Posterior mediastinal masses
- neurogenic tumours
neurofibromas
ganglioneuroma

Gastrointestinal
tract (GI)

Gastrointestinal tract (GI)


Imaging modalities
-Plain films (images)
-Barium studies
-Angiography
-Computed tomography
-Ultrasonography
-Magnetic resonance imaging

Gastrointestinal tract (GI)


CT
- to assess for operability by
staging
oesophageal, gastric and colonic
tumours.
- to evaluate adjacent infiltration
and secondary deposits.

Esophageal Carcinoma

Squamous cell type

Distal third
Male > Female

Predisposing factors
- Achalasia
- Barretts esophagus

Esophageal Carcinoma
Imaging modalities
- Barium
- CT: tumour confinement to the
wall or extraluminal
spread.
- US: secondary deposits

Esophageal Carcinoma
Radiological features

Polypoidal type: an intraluminal mass


protrudes out into the oesophageal lumen
causing a filling defect in the barium column.
Infiltrative type: the tumour spreads under
the oesophageal mucosa without extending
into the lumen, causing narrowing. Later
there is mucosal infiltration resulting in
ulceration and an irregular outline to the
oesophagus.

Gastric Carcinoma

A general decrease in
the
incidence of gastric
carcinoma.

Gastric Carcinoma
Clinical Presentations:
Dyspepsia , anorexia, nausea,
vomiting,
Body weight loss,
Haematemesis or melaena.

Gastric Carcinoma
Imaging modalities
- Barium meal
- CT
}preoperative evaluation
- US

Gastric Carcinoma
Radiological features

Barium meal
Polypoidal type - soft-tissue mass causing
a
filling defect.
Ulcerating type - ulcerating within the
margin of the
stomach.

Gastric Carcinoma

Diffuse infiltrating type - diffuse submucosal


infiltration
( linitis plastica)
small rigid
stomach
( leather bottle stomach) { poor distensibility

Local infiltrating type

- focal area of mucosal


irregularity and

narrowing
at the site of the
tumour.

Colonic carcinoma

Commonest

malignancy of

GI tract.
Usually

adenocarcinoma

Colonic carcinoma
Imaging modalities
- Plain films.
- Barium
- Ultrasound
- CT/MRI
colonoscopy
staging

Colonic carcinoma
Radiological features
Annular carcinoma - irregular luminal
narrowing ,
applecore deformity.
Polypoidal mass
- intraluminal filling
defect.

Colonic carcinoma
Complications

- Obstruction
- Perforation
- Fistula formation

Colonic carcinoma
Differential

diagnosis of
colonic narrowing
- Diverticular disease
- Crohn's disease
- Ulcerative colitis

Colonic carcinoma
Differential

diagnosis of colonic

narrowing
- Extrinsic: inflammatory / neoplastic
infiltration.

- Radiotherapy
- Tuberculosis.
- Ischaemia.

Hepatocellular
carcinoma

Hepatocellular carcinoma

Common tumour in Chinese.

Chronic hepatitis B carriers.

Fungal aflatoxin food


contamination.

Hepatocellular carcinoma
Clinical

Presentation

- upper abdominal pain


- weight loss
- fever

Hepatocellular carcinoma
Three

principal types

- Multinodular
- Infiltrative
- Solitary mass

Hepatocellular carcinoma
Radiological

features

- CT/MRI
precontrast : low/isodense mass
arterial phase : hypervascular
mass
delayed phase : wash-out mass

Hepatocellular carcinoma
The

tumor should be
assessed for invasion of
the vascular system and
the biliary system.

Hepatocellular carcinoma
About

20% ( ? ) are
suitable
for liver resection.

Liver Metastases
The

liver is the most


common organ of
secondary deposits.
The primary sites are :
colon, stomach, pancreas,
breast and lung.

Pancreatic carcinoma

The

most frequent pathological


type arises from the pancreatic
duct epithelium
(Adenocarcinoma).

Pancreatic carcinoma
Clinical

Presentation
Abdominal pain
Weight loss, anorexia.
Obstructive jaundice.
Malabsorption, diarrhoea.
Diabetes.

Pancreatic carcinoma
Clinical

symptoms usually
occur late and at the time of
presentation there is often
local invasion of blood
vessels or bowel.

Pancreatic carcinoma
Radiological

features

US/CT
- focal pancreatic enlargement with
a hypoechoic /hypodense mass.
- pancreatic and bile duct dilatation
- distended gallbladder.

Pancreatic carcinoma
MRI

Reduced signal from


pancreas on T l
sequence.

The Urinary Tract

The Urinary Tract


Imaging

modalities

- KUB
- Intravenous urography (IVU)
- Retrograde pyelography
- Antegrade pyelography

The Urinary Tract


Imaging

modalities

- Percutaneous
nephrostomy
- Micturating cystogram
- Urethrography

The Urinary Tract


Imaging

modalities

- Ultrasound
- Computed Tomography
- Arteriography

Renal carcinoma

Radiological features
Plain film Renal mass (calcifications)
IVP Renal Mass, pelvicalyceal
distortion
and irregularity
US Solid mass with increase
vascularity
CT/MRI Useful for staging,
perinephric tissue invasion,
venous invasion,
lymph node metastasis

Bladder carcinoma
Radiological features
IVP Filling defect in the bladder
Irregular mucosa
CT/MRI Useful for staging
Intramural /extramural
spread , local invasion ,
lymph node metastasis

Testicular tumour

US extremely effective
in evaluation of well
defined low
echogenicity mass

MR imaging of clinical stage


I and IIa cervical carcinoma:
a reappraisal of efficacy and
pitfalls

Parametrial invasion: 96.7%


Vaginal invasion: 87%
LAP: 87%
Staging accuracy
MRI: 83.8%, Clinical staging: 61.3%
stage IIa vs. stage IIB
MRI: 96.7%, Clinical staging: 80.6%
Europ Radiol 2001

Skeletal system
Imaging modalities
Plain films (images) still remain
the mainstay of investigation
Isotopes Tc 99m phosphate
compounds
US/CT/MR for tumour vascularity,
infiltration of surrounding tissure
relationship to nerves and vessels

Osteosarcoma
Plain films (images)
Radiological features
Irregular medullary destruction
Periosteal reaction
Cortical destruction
Soft tissure mass
New bone formation

Bone metastases
Plain films (images)
Radiological features
- Lytic deposits : poor definition of
margins,
pathological fracture
- Sclerotic deposits : an area of illdefined increased
density

Bone metastases
- Most frequent primary are
Breast
Prostate
Lung
Kidney
Thyroid
Adrenal gland

Multiple myeloma
Radiological features
Plain films (images)
- Generalized osteoporosis
- Compression fracture of vertebral
bodies
- Scattered pounch-out lytic lesions
with well-defined margins
- Bone expansion with soft-tissue
masses

Choose the most appropriate


imaging modality is the key
for accurate effective
diagnosis and treatment.