University Comprehensive Cancer Center, James Cancer Hospital and Solove Research Institute. I specialize in diagnostic imaging of the abdomen and pelvis as well as interventional radiology procedures for the diagnosis and treatment of cancer. Basically, I use imaging to diagnose and treat cancers using minimally invasive image guided techniques. Today, I'm here to tell you about imaging and cancer. We will discuss the types of imaging tests and procedures that oncologist might order to help detect, diagnose and treat cancer patients. These images are read by physicians like me, who are radiologists. Imaging also plays an important role in cancer research both in human trials, to evaluate new, innovative drug therapies and in animal studies to help us learn how cancer develops and progresses. Imagine tests for cancer use different forms of energy to evaluate what is happening inside the body. The science and practice of imaging began with the discovery of X-rays in 1895 by Wilhelm Roentgen. He used x to refer to these rays because they were an unknown form of radiation. Today, this radiation plays an essential role in the detection, diagnosis, and treatment of cancer. We also use forms of energy that are not as energetic as ionizing radiation to diagnose and treat cancer such as MRI and ultrasound. Diagnostic imaging of cancer helps physicians locate a tumor in a body when a patient complains about something like pain or fatigue. Using imaging, we can learn whether a malignancy is present, where it may have originated and evaluate whether the cancer has metastasized or spread to other organs in the body. In this presentation, I'm going to introduce to use several diagnostic imaging modalities and help you to understand the role they play in cancer diagnosis and treatment. Modalities include X-rays and mammograms, computer tomography or CT scans, magnetic resonance imaging or MRI scans, nuclear medicine scans,
specifically positron emission
tomography and ultrasound. I'll begin with X-rays which are useful for seeing bone and joint problems, imaging of the lung, bowel, bladder and kidneys. In most circumstances however, other imaging methods such as CT and MRI Scans are far better at showing details of soft tissues. Here is an example of an X-ray that was used to evaluate a patient with right leg pain. In this radiograph of the pelvis, you can see numerous small, metallic densities located over the central pelvis. The patient has a history of prostate cancer and these are small brachytherapy seeds used to deliver radiation to the prostate to treat prostate cancer. So we know that this patient has a history of prostate malignancy. You can see in the image there are two arrows. Notate that the left femur is normal compared to the right femur which is abnormal. The arrow over the right femur points to a halusinasi in the head of the Right femur. Note the bony abnormality. Given the presence of this abnormality and knowing that the patient has a history of prostate cancer we are concerned about metastatic disease. Therefore we decided to advance to MRI imaging. Here is the MRI image. You see the tumor that occupies the proximal femur and femoral head as well as a soft tissue lymph node located anterior to the bone tumor. These findings strongly suggest a malignancy. To confirm this, the patient underwent an image guided biopsy, shown in this CT image. We used a biopsy needle to go into the leg and extract tissue from the soft tissue for diagnosis. Here's a chest X-ray. A patient presented with a cough. Note the central venous catheter is located over the right chest. This catheter is used to administer chemotherapy drugs in a patient who has a history of cancer. The soft tissue densities throughout both lungs are called pulmonary nodules.
These lung nodules are very worrisome for
metastatic cancer therefore the patient underwent a CT scan for better evaluation. Here in the CT scan which was taken in the coronal plane, which shows the patient is basically standing in the upright position. Again, we can see the numerous pulmonary nodules. Given the history of malignancy and potential need for a new drug or clinical research trial, the patient underwent a CT guided biopsy of one of these pulmonary nodules. This CT scan shows the use of imaging guidance to obtain a biopsy of one of the patient's nodules. This tissue would be very important for diagnosis and to test for molecular markers that help identify new patient therapies. Mammography is a type of imaging technique that uses low energy X-rays to take specialized images of the breast. They show details of the breast tissue and are used for the evaluation of malignancies. During the past ten years, older X-ray machines that captured images on film have been replaced with X-rays that capture images in a digital format. These digital images are cleaner, clearer and capture more information. They can also be exchanged more easily by doctors in consultation. There are two categories of mammography, screening and diagnostic mammography. Screening mammography is designed to detect breast cancer in women who have no signs or symptoms of the disease. They can detect tumors that are only a few millimeters in size. Sometimes too small to otherwise to be felt during a clinical self breast exam. Diagnostic mammography is used to show details of breast tissue and help determine whether a breast abnormality detected in a screen mammogram or a lesion which is palpitated on a clinical exam might be cancerous. Here is an example of a diagnostic mammogram. The image demonstrates a nodular focus or density located in the upper outer breast. This lesion has speculated margins. It was therefore worrisome for primary breast malignancy. A diagnostic mammogram shows only one lesion
therefore a targeted ultrasound
was performed, shown here. The targeted ultrasound demonstrates a hypoechoic stellate lesion located in the same region which is also suspicious for malignancy. Therefore, an ultrasound guided biopsy was obtained of this lesion which proved to be a malignancy. The patient went on to receive a curative surgery. When performing breast imaging, we use the Breast Imaging Reporting and Data System or the BIRAD system. The BIRADS system categorizes a possible malignancy using a scale of one to five, with one being benign and five being very suggestive of malignancy. This lesion we just discussed was designated a BIRADS 5. Therefore, a ultrasound guided biopsy was obtained. Computerized tomography scans which are sometimes called CAT scans, which is an acronym for Computerized Axial Tomography are X-ray like images of internal organs and structures of the body. CT scans record changes by using low energy X-rays as they pass through different organs which all have different densities. Computers compile that data and produce scans that are cross sectional slices through the body. Computers also stack those slices to produce 3D images that provide additional information about some cancers. Our newest CT scanners have focused on reducing radiation doses that are delivered during imaging. These low dose CT scanners are helpful for patients who are young or for those undergoing screening studies such as people who are suspected to have kidney stones or cigarette smokers that are at high risk for lung cancer. CT scans can be used for a number of reasons when evaluating a patient's symptoms including evaluation of a patient's organs which are suspected to be abnormal based on clinical history of physical exam to help locate a tumor within the body. To learn if a patient's cancer is responding to the prescribed treatment and follow up imaging and cancer patients to exclude an early occurrence of disease. Here is an example of the CT scan of a patient who went to the emergency room,
complaining of blood in the urine or
what we call hematuria. This exam is used to exclude renal stones in renal cancer. Here are two examples of delayed phase imaging that show the IV contrast being excreted in the collecting systems in the kidneys such as the kerasys in ureters. The collecting systems is well opacified with excreted IV contrast allowing you to see them clearly. While these are only two representative sizes, you can see that when 3D information is compiled by computers, we can make beautiful reformats of the patient's collecting systems in three dimensions. So the doctors can better see and find details of this. Because CT scans emit radiation some patients worry about whether repeated CT scans are safe. Whether they might cause a second cancer later in life. There are two ways to look at this. As radiologists, we prescribe radiation very judiciously. We use doses of radiation that are as low as possible, after determining the benefit versus risk of radiation exposure for the patient. If the patient needs ionizing radiation for imaging, it is likely more important to make an urgent diagnosis than worry about the potential risk of a theoretical malignancy later in life. Sometimes, these decisions are made by a group of physicians especially in patients who are pregnant or young like children. Typically, people who are having imaging performed are a much older age group or people who are much less likely to develop a secondary malignancy, which can take 20 to 30 years to develop. The amount of radiation that a patient is exposed to during diagnostic imaging is very small. Some people say that you can absorb more radiation during a transcontinental flight than you do from an imaging study. MRI scan are extremely powerful magnets that use radio waves rather than ionizing radiation to create detailed cross sectional images of the body. These magnets induce hydrogen ions in the body to respond to radio waves which produce signals based
on the water content of the organ.
MRI scans are used for many of the same reasons as CT scans, although MRI is sometimes used rather than CT scans because they can produce better images of soft tissues. Here are two examples of the brain. One is a CT scan and the other is an MRI scan. You can see that the MRI shows much great soft tissue details. A trained radiologist can see details in the CT scan, but it is more difficult. Patients must be carefully screened for MRI studies because of the strong magnetic fields involved. Certain implants, medical devices and other objects ranging from artificial joints and pacemakers to shrapnel are certified according to whether they are magnetic resonance safe, conditional or unsafe. MR unsafe devices contain iron and present a clear danger to the patient. Iron containing objects cannot be worn or brought into the MRI scanner because highly magnetic objects can become dangerous projectiles in the presence of a strong MRI magnetic field. Nuclear medicine involves the injection of radioactive tracers that release small doses of radiation for a short time, for the diagnosis and treatment of cancer and other diseases. Unlike the forms of imaging we discussed earlier, nuclear medicine involves making the patient radioactive then using a crystal to detect the radiation. When the photons emitted from the patient interact with the crystal, a small light is produced. These flashes of light become data points which a computer turns into images. Examples of nuclear medicine imaging include whole body bone scans which can reveal the presence of cancer in bones administering radioactive phosphate molecules to patients which are used in bone production. Thyroid scans are obtained by using radioactive iodine which the thyroid gland normally absorbs and metabolizes. Heart or cardiac scans are produced by injecting small amounts of radiotracers which also use naturally acquired ions such as thallium and potassium analog to detect heart muscle damage. Gallium imaging uses radioactive Gallium salts, which are taken up by tumors and
areas of inflammation such as inflamed or
infected tissue. This technique is used for patients with fevers where we cannot find an apparent origin or in patients with lymphoma. SPECT imaging stand for Single Photon Emission Computerized Tomography. SPECT imaging takes the information from nuclear medicine scans and makes a 360 degree image which therefore comes together as a 3D image. This provides information that can also be used to help locate tumors that are in the body in three dimensions. In cancer imaging, the most common nuclear medicine study is Positron Emission Tomography or PET imaging. This is similar to other forms of nuclear medicine in that a small amount of radiation is administered into the patient. However PET imaging is different than other nuclear medicine tests in that it produces two photons which emit in equal and opposite directions. That is 180 degrees apart from each other. Allow the crystals to rotate around the patient taking a 180 degree picture and produce the images. The most common imaging agent in PET imaging is FDG, Fluoro Deoxy Glucose. For FDG imaging, the patient is injected with a radioactive sugar that is taken up by cells that are metabolically active. The sugar is then trapped within the cell. The theory is that the faster a cell is growing, the more sugar it can take up. Therefore, PET scans are used in the detection of patients evaluated for cancer because cancer cells tend to grow much faster than other cells within the body. PET scans can help stage diseases and localize certain tumors within organs. Here is a PET image that shows multiple areas of normal uptake. They include the brain which is yellow in color and tells us it is very metabolically active. The heart muscle is also metabolically active. Some activity is shown in the bladder because sugar is excreted by the kidneys. Ultrasound uses high frequency sound waves that bounce off organs and tissues and are detected by probes and produce images called sonograms. Also special transducers can be used to evaluate blood flow through vessels
called doppler flow.
As I mentioned earlier imaging plays an important role in cancer research. X-rays, CT scans and nuclear medicine imaging can help provide critical information to help understand how cancer develops and progresses. Micro imaging technologies enable us to use CT and PET to produce images of small animals used in research. The information obtained from these images allows scientists to gain information about how cancer develops and spreads in animal models. Animal research helps scientists to study the safety and efficacy of experimental new drugs in animals, hopefully preventing harm in patients. As you can see, imaging is a multimodality area of healthcare. We have seen examples of radiographs, CT scans, thermography, ultrasound, MRI, nuclear medicine and PET imaging. Most of these technologies were discovered after 1975. The rapid progression of scientific advancements will only allow imaging to become a more integral part of patient diagnosis and treatment.