Oncology Imaging

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Oncology Imaging
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Principal Imaging Modalities

• Plain films (images)
• Ultrasound (US)
• Computed Tomography (CT)
• Magnetic Resonance Imaging (MRI)
• Nuclear Medicine

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Contrast media

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

4
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.

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Radiation Protection (1)

• Although ionizing radiation is deemed to be
  potentially hazardous, the risks should be
  weighed in context of benefits to the patient.

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Radiation Protection (2)

• Clear requests with relevant clinical details.
• Discussion of complex cases with radiologists.

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Radiation Protection (3)

• Ultrasound
• Lack of ionizing radiation
• M R I

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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

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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Magnetic Resonance Imaging

• Disadvantages
• High operating costs.
• Poor images of lung fields.
• Inability to show calcification with accuracy.

22
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).

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Respiratory Tract
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Modalities for Respiratory Tract Investigations

• Plain films (images)
• Computed tomography (CT)
• Ultrasound (US)
• Isotopes
• Pulmonary angiography
• Magnetic resonance imaging (MRI)

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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.

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US for Respiratory tract

• Presence of the pleural effusions and
• loculated fluid.
• Biopsy of pleural lesions.

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MRI-for respiratory tract

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

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Bronchial carcinoma

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

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Bronchial carcinoma

• Haemoptysis
• Respiratory symptoms

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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.

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

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Bronchial carcinoma
Common sites of distant metastases - Brain -
Bone - Adrenals - Liver
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Mediastinal mass

• Imaging modalities
• Plain film
• CT
• MRI

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Mediastinal mass

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

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Gastrointestinal tract (GI)
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Gastrointestinal tract (GI)

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

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Gastrointestinal tract (GI)

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

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Esophageal Carcinoma

• Squamous cell type
• Distal third
• Male gt Female
• Predisposing factors
• - Achalasia
• - Barretts esophagus

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Esophageal Carcinoma

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

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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.

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Gastric Carcinoma

• A general decrease in the
• incidence of gastric carcinoma.

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Gastric Carcinoma

• Clinical Presentations
• Dyspepsia , anorexia, nausea, vomiting,
• Body weight loss,
• Haematemesis or melaena.

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Gastric Carcinoma

• Imaging modalities
• - Barium meal
• - CT
• preoperative evaluation
• - US

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Gastric Carcinoma

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

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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.

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Colonic carcinoma

• Commonest malignancy of GI tract.
• Usually adenocarcinoma

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Colonic carcinoma

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

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Colonic carcinoma

• Radiological features
• Annular carcinoma - irregular luminal
• narrowing
  ,
• apple-core
  deformity.
• Polypoidal mass - intraluminal filling
• defect.

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Colonic carcinoma

• Complications
• - Obstruction
• - Perforation
• - Fistula formation

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Colonic carcinoma

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

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Colonic carcinoma

• Differential diagnosis of colonic narrowing
• - Extrinsic inflammatory / neoplastic
• 
  infiltration.
• - Radiotherapy
• - Tuberculosis.
• - Ischaemia.

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Hepatocellular carcinoma
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Hepatocellular carcinoma

• Common tumour in Chinese.
• Chronic hepatitis B carriers.
• Fungal aflatoxin food contamination.

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Hepatocellular carcinoma

• Clinical Presentation
• - upper abdominal pain
• - weight loss
• - fever

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Hepatocellular carcinoma

• Three principal types
• - Multinodular
• - Infiltrative
• - Solitary mass

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Hepatocellular carcinoma

• Radiological features
• - CT/MRI
• precontrast low/isodense mass
• arterial phase hypervascular mass
• delayed phase wash-out mass

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Hepatocellular carcinoma

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

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Hepatocellular carcinoma

• About 20 ( ? ) are suitable
• for liver resection.

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Liver Metastases

• The liver is the most common organ of secondary
  deposits.
• The primary sites are colon, stomach, pancreas,
  breast and lung.

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Pancreatic carcinoma

• The most frequent pathological
• type arises from the pancreatic
• duct epithelium (Adenocarcinoma).

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Pancreatic carcinoma

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

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Pancreatic carcinoma

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

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Pancreatic carcinoma

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

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Pancreatic carcinoma

• MRI
• Reduced signal from
• pancreas on T l sequence.

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The Urinary Tract
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The Urinary Tract

• Imaging modalities
• - KUB
• - Intravenous urography (IVU)
• - Retrograde pyelography
• - Antegrade pyelography

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The Urinary Tract

• Imaging modalities
• - Percutaneous nephrostomy
• - Micturating cystogram
• - Urethrography

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The Urinary Tract

• Imaging modalities
• - Ultrasound
• - Computed Tomography
• - Arteriography

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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

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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

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Testicular tumour

• US extremely effective in evaluation of well
  defined low echogenicity mass

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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

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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

75
Osteosarcoma

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

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Bone metastases

• Plain films (images)
• Radiological features
• - Lytic deposits poor definition of margins,
• pathological
  fracture
• - Sclerotic deposits an area of ill-
• defined
  increased
• density

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Bone metastases

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

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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

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• Choose the most appropriate
• imaging modality is the key
• for accurate effective
• diagnosis and treatment.