Transcript 投影片 1 - 台灣臨床腫瘤醫學會 Taiwan Clinical Oncology

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
}Lack of ionizing radiation

MR I
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
- Barrett’s 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
 Usually
malignancy of GI tract.
adenocarcinoma
Colonic carcinoma
Imaging modalities
- Plain films.
- Barium
- Ultrasound
- CT/MRI
colonoscopy
staging
Colonic carcinoma
Radiological features
Annular carcinoma - irregular luminal
narrowing ,
apple-core 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.