DIAGNOSTIC IMAGING NEOPLASMA

Dr. Yanto Budiman, Sp.Rad., M.Kes Bagian Radiologi FK/RS Atma Jaya Jakarta

Imaging is emerging as an important adjunct to the clinical assessment of cancer, contributing to : Tumor detection, Characterization, Staging, Treatment planning and follow-up.

Imaging may be requested in the following situations:

As a routine investigation at the time of presentation for diagnostic and staging purposes. To answer a specific clinical question in an individual patient on cancer treatment. As a routine investigation on patients being treated with established therapy (chemotherapy, radiotherapy). As a surveillance tool in patients undergoing a watch and wait policy (e.g. testicular cancer). Screening as a mechanism to identify clinically occult cancers (e.g. breast cancer)

Diagnostic Tools
Rontgen X-ray USG CT Scan MRI Nuclear Medicine

NUCLEAR MEDICINE :
Gamma Camera SPECT PET Scan

Bone Scintigraphy
Nuclear medicine 99mTc-MDP Mechanism : Radiopharmaceuticals(99mTc-MDP) , will be uptaken by osteoblast chemically bone metabolic activities (increase/decrease radiopharmaceuticals uptake)

Normal Bone Scan

Normal increased uptake in : Growth plate Kidney and bladder

Bone Metastase (multiple hot nodule/spot)

Soft Tissue neoplasm

Key Points
X-rays always first line Ultrasound best second test MRI best overall for
Characterisation Staging & extent Progress evaluation

Role of Imaging
Confirmation
Mass? What mass?

Classification
Normal or variant Developmental Benign or non-aggressive Indeterminate/Suspicious/Malignant

Staging & Extent Progress and surveillance

Algorithm for ST Masses

Soft Tissue Tumours

Most masses are NOT tumours
Cysts, ganglia, bursae Calcinosis, osteochondromatosis, myositis

Most soft tissue masses are benign

Estimated 100:1 benign:malignant

Risk of malignancy rises with age

X-Rays Crucial
Characteristic tissues detectable
Gas Fat Soft tissues Calcium & bone

Cheap, readily available Diagnosis sometimes obvious

Save money, time, other tests

CT can supplement for calcification

Role of Ultrasound
Easily distinguish solid from cystic Inexpensive, quick, rapid comparison Detect hypervascularity (Doppler) Excellent depiction of superficial mass relationships Guide needle biopsy

MRI Best for Staging

Global overview of relationships Lesion characterisation Lesion extent Detection of contrast enhancement
Blood supply, tissue necrosis Suspicious components

Benign Masses

Sebaceous cyst Intramuscular lipoma

ST Calcinosis

Elbow Ganglion Cyst

Palpable Cystic Mass

MFH

Solid indeterminate mass

Soft Tissue Chondrosarcoma

High signal heterogeneous mass with internal septations and marked rim enhancement (MRI)

Conclusions
Imaging is not histology Clinical evaluation critical X-rays ALWAYS first Ultrasound second MRI next Imaging classification before surgery

Bone Neoplasms

Diagnostic Algorithm for Bone Tumours

Bone Lesion X-Ray No Malignant? Staging No Benign? ?? Diagnostic MRI or CT Manage & Review

Variant?
Yes

Yes

BIOPSY

Path-Rad Correlation

Diagnostic Gamut
Developmental Dysplastic/dystrophic Traumatic Metabolic Infective Ischaemic necrosis Tumour-like conditions Tumours

Why X-Rays?
Mandatory for MSK lesions
New bone formation Periosteal reaction Bone expansion & growth Lesion boundaries Host marginal reaction Patterns of destruction

Still the most specific imaging modality for most bone lesions

Age at Diagnosis
Age 1 Tumo urs

N e ur o blast o ma 110 Ewing sar co ma (t ubular ) 1030 O st e o sar co ma, Ewing (flat ) 3040 N HL, MFH, fibr o sar co ma, GC T, par o st e al o st e o sar co ma 40+ Me t ast asis, mye lo ma, cho ndr o sar co ma

X-Ray Features
Pattern of bone destruction or sclerosis Internal architecture & density Expansion, endosteal scalloping Periosteal reaction & new bone formation Soft tissue mass

X-ray Aggressive Features

Bone destruction Geographic Moth-eaten Permeative Interrupted periosteal reaction

X-ray Benign Features

Elongated growth pattern Narrow zone of transition Sclerotic margin Dense focal sclerosis Dense incorporated solid periosteal reaction

RCC Metastasis

Ewings Sarcoma

Osteosarcoma

Diaphyseal Aclasia

Nonossifying Fibroma

TUMORS AND TUMORLIKE PROCESSES

1.METASTATIC BONE TUMORS 2.PRIMARY MALIGNANT BONE TUMORS Multiple myeloma Osteosarcoma Ewings Sarcoma 3.PRIMARY QUASIMALIGNANT BONE TUMOR Giant Cell Tumor

4.PRIMARY BENIGN BONE TUMORS Osteochondroma Osteoma Bone island Osteoid osteoma Simple bone cyst Aneurysmal bone cyst

Metastatic Bone Tumors

General Consideration
The most common malignant tumors CNS tumors and basal cell Ca rarely Life threatening complication

Insidence
70% are metastatic, 30% are primary In females 70% from breast Ca In males 60% from prostate Ca

Metastatic.. (contd)
Radiologic Features
Technetium bone scan 80% of all metastase are located in the central or axial skeleton - Spine and Pelvis being a most common Alteration in bone density and architecture 75% osteolytic, moth eaten or permeative 15% osteoblastic Periosteal respose is rare

Metastatic bone tumor

Prostatic Metastases

Multiple myeloma
Primary bone tumor Bone scan are cold Gross Osteoporosis may be the only early sign Punched out lesions Preservation of pedicles

Multiple Myeloma

Osteosarcoma
75% of cases occurs in the 10 to 25 age Metaphyses of the distal femur, proximal humerus are the most common sites Permeative or ivory medulary lesion in metaphysis of a long tubular bone A sunburst or sunray periosteal response Cortical disruption with soft tissue mass formation Sclerotic Lytic Mixed lesion

Osteosarcoma

Ewings Sarcoma
Most cases occur in the 10 25 age range May mimic infection Diaphyseal permeative lesion Femur, tibia and fibula Onion skin periosteal response Most common primary malignant bone tumor to metastasize to bone

Ewings Sarcoma

onion-skin

Osteochondroma

Aneurysmal Bone Cyst

Giant Cell Tumour

Simple bone cyst

 Respiratory Neoplasm

Pleural tumor
Benign Lipoma - Fibroma - Angioma Malignant - Mesothelioma - Sarcoma

Mesothelioma
* From the endothelial pleural layer * 2 type: - Nodular : > often - Diffuse haemorrhagic effusion

Metastase :
From bronchogenic Ca (40%) From Mammae Ca (20%) From Lymphosarcoma (10%)

Mesothelioma

Pulmonary Carcinoma
a. Bronchogenic Ca
- Most common - Male > Female - Right > often - Age : 50 60 y.o. - Related : Smoking, radioactive/industry material, TBC - Classified into : a. Central type b. Perifer nodular c. Pneumonic type d. Miliary type

Bronchogenic Ca

A Posteroanterior (PA) chest radiograph demonstrates a spiculated right upper lobe mass. B Chest CT (lung window) demonstrates a peripheral mass with spiculated borders

b. Pancoasts tumor
Posterior superior pulmonary sulcus tumor Posterior costae 1- 3 destruction with vertebral erosion Cervicalis symphatis paralysis Horner syndrome

Pancoasts tumor

3. Alveolar cell ca
= Pulmonary adenomatosis
Female = Male 40 years Ro: Small nodules on both lung field with large masses in right pulmonary base No visible node enlargement but shows nodal consolidation in perihiler Pleura ussualy not affected Heart normal

Alveolar cell ca

4. Hamartoma
Overgrowth of few tissue such as smooth muscle fibrous cartilage tissue and vascular Ro : Round/oval/lobulated shadow with soft tissue density, well-defined border, diameter 2.5 9 cm. Calsification inside : pop corn calcification

Hamartoma

Metastastic tumor in lung

Emboli through pulmonary artery &bronchial artery From adjacent organ:
Oesophagus Thyroid Mammae

Appearance of metastatic tumor in lung

a. Golf ball type Sarcoma Renal clear cell Seminoma b. Coin lesion type Thyroid Gaster Ovarium-uterus Lymphosarcoma Chorio Ca

Metastase intrapulmonal

c. Milliary type Thyroid Ca Mammae Ca Sarcoma Lung Ca

d. Pleural metastase : Pleura effusion Mammae Ca Mesothelioma Lung Ca

e. Pneumonic type Oesophagus Lung Mammae

f. Lymphatic type Lung Gaster Mammae Pancreas, etc.

Lymphatic type: Coarse reticular shadowing

GI Tract Neoplasm

GIT Diagnostic Tools:

Sialografi Esophagograhi Maagduodenographi Colon in loop Barium Follow Through CT Scan, MRI

Single Contrast Barium Enema

Double Contrast Barium Enema

Abdominal Imaging In the hollow organ segments of the GI tract, contrast imaging studies remain the cornerstone in characterizing the tumor, but lack the ability to stage the tumor, either in terms of depth of penetration through the wall or in defining regional nodal involvement. CT Scan remains the most widely used for axial imaging Magnetic resonance imaging has shown only limited advantage over CT

Ca oesophagus

Tumours of the stomach

Benign tumours of the stomach: - Adenoma - Leiomyoma - Lipoma - Abberant pancreas - Inflammatory polyps, etc Location: - pyloric portion (75%) - body (20%) - fundus & cardia (5%)

Radiographic appearances: - A sharply circumscribed filling defect projecting within the lumen Malignant tumors of the stomach: Gross morphologic types: - Ulcerative (28%) - Fungating/polypod (22%) - Spreading/infiltrating (13%) - Remainder unclassifiable

Usual histologic pattern: well-differentiated adenoca

Location: pyloric & prepyloric regions

Radiographic appearances: 1. Irregular filling defect. 2. Malignant ulcer within the filling defect. 3. A leather bottle type stomach suggesting scirrhous ca.

Ulcerative gastric adenocarcinoma

Polypoid gastric adenocarcinoma.

leather bottle type scirrhous ca.

Tumors of the duodenum

Benign tumors of the duodenum: - Very rare - Adenoma, papilloma, lipoma, fibroma, etc. - Radiographic appearance: Single smooth filling defect within duodenum Malignant tumors of the duodenum: - Rare - Carcinoma, malignant carcinoid, leiomyosarcoma

Ulcerating leiomyoma

lobulated villous adenocarcinoma arising at junction of second and third parts of duodenum.

Spot image of adenocarcinoma of the duodenum presenting as a classic tight annular apple core lesion in the second part of the duodenum

Peripapillary adenocarcinoma of duodenum

Ductal adenocarcinoma of the pancreatic head. unenhanced scan (A), CT shows an enlargement of the head,within which a hypodense mass is recognizable after contrast medium (B). The tumor looks smaller in the venous phase due to the peripheral enhancement (C)

SMALL Bowel : Benign tumors and malignant tumors,

Benign tumours: - Adenoma - Leiomyoma (the commonest)

Malignant tumours: - Lymphoma (the commonest) - Leiomyosarcoma - Carcinoid - Metastases (malignant melanoma & bronchial ca)

Malignant lymphoma

Colorectal tumors
Polyps: - A mucosal elevation - Radiographic appearance: * Bowler-hat sign * En face: target sign
Colorectal cancer: - The commonest cancers in western Europe & US - Men = women - Tumours tend to be right-sided - May be associated urinary tract & gynaecological malignancy

Colorectal cancer

Virtual Endoscopy, using CT Scan

Colorectal cancer
Fungating type: - Medullary carcinoma - Sites: caecum, ascending colon, rectum - Complication: bleeding, fistula Polypoid type: - Sites: ascending colon usually - Complication: Intussusception

 Annular type: - Mucoid adenocarcinoma, scirrhous fibrocarcinoma - Sites: sigmoid, descending colon, flexures - Complication: fistula, obstruction
Radiological appearances: - Filling defect - Obstruction

Polip colon

Liver malignancy
USG

CT Scan

Cranial Neoplasm

INTRACRANIAL MASSES
1. Radiografic Characteristic of Lesion

a. Intrinsic CT density
b. Contrast enhancement BBB (ring, gyriform, homogenous) c. Multiple lesions d. MR appearance

DD/ : Intracranial Mass (TEACH )

Tumor Edema Abcess, AVM, aneurysm Cyst Hematoma

A. Primary Tumor
1. Glioma a. Astrocytoma b. Ependymoma c. Oligodendroglioma d. Ganglioglioma

2. Meningioma 3. Lymphoma

B. Metastatic Tumor

DIFFERENTIAL DIAGNOSIS BY LOCATION

Diagnosa banding berdasarkan pola Enhancement lesi pada parenkim otak A. Cerebral parenchymal lesion Ring : - Glioma - Meta - Abcess - Resolving hematoma - Resolving infarction Homogenous : - Lymphoma

B.DD/ : Intraventicular Mass Lesion

Meningioma, Astrocytoma, Choroid plexus papilloma,

Colloid cyst, Meta,

Ependymoma, Subependymoma, AVM, Oligo,

Lymphoma

C.DD/: Pineal Region Mass

Germ cell tumor, Pineal cell tumor Germinoma, Pineoblastoma, Teratoma, Glial cell tumor, Dermoid, Epidermoid, Choriocarcinoma, Meta

D.DD/Tumor di daerah Juxta Sellar and Supra Sellar

Adenoma Craniopharyngioma Aneurysm Meningioma Uncommon : Meta, Arachnoid cyst, Glioma

Breast Neoplasm

 Mamografi USG MRI

BIRADS (Breast Imaging Reporting and Data System)= Standardised Terminology, American College of Radiology

Category 0 Category 1 Category 2 Category 3 Category 4 Category 5 Category 6

Needs further views/comp Normal Benign Probably benign Suspicious for malignancy Probable malignancy Proven or known malignancy

BIRADS Classification & Risk of CA

Category 0, 4 & 5
Positive findings needing further action (10-80% chance of cancer)

Category 1 & 2
Benign with <1% chance of cancer

Category 3
Probably benign with <2% chance of cancer Most problematic category Cannot use this well without local audit

BIRADS Category 4
All require initial biopsy 4A Low suspicion of malignancy
Palpable lesion, atypical FA, complex cyst etc. Benign biopsy expected = discharge or short-term FU

4B Intermediate suspicion
Lesion with suspicious features Benign biopsy = close correlation, ?re-biopsy

4C Moderate suspicion
Not classic for CA Prominent suspicious features Benign biopsy not expected = should re-biopsy or excise

BIRADS 3 & Screening Assessment

BIRADS 3 is refuge for indecision
Intended for highly likely to be benign, but I am just making sure Appropriate in setting with no biopsy facilities Implemented by 6-12 month followup

BIRADS 3 has wide variability of application

Depends on individual level of uncertainty

UK and Australian practice

No place in formal assessment centre Logistic problems, great anxiety, low yield Determine if benign (Cat 1, 2) or needs biopsy (Cat 4, 5) Cat 3 actively discouraged

MAMMOGRAPHY

X-Ray dosis rendah Massa < 5 mm Massa tidak teraba Tanda keganasan Check-up post operasi Tidak invasif

Indikasi :
Benjolan Rasa tidak enak pada mammae Keluarnya cairan dari puting susu Kelainan kulit mammae Cancer Phobia Post operasi Skrining

Mengapa Skrining Harus Dilakukan ? Ca mammae > usia 35 th Kapan Skrining Diperlukan? Usia 35 th Usia 35 50 th 2 atau 3 th Usia > 50 th Setiap tahun

Kranio-kaudal

Mediolateral-oblique

Kriteria Keganasan
Tanda Primer :
Lesi Radioopak irreguler
Mikrokalsifikasi

Tanda Sekunder :
Penebalan & retraksi kulit Vaskularisasi Posisi papila & areola berubah Jar. fibroglandular tidak teratur Distorsi lemak retromammae Metastasis KGB aksila

Mammogram
Batas tegas Densitas lemak?
Ya Lipoma, fat necrosis Hamartoma Galactocele, LN Tidak

Batas tegas / Irregular

Abscess Hematoma Fat necrosis Scleroing adenosis Radial scar Post surgical scar Solid

USG

Anechoic
Kista

kompleks
Hematoma, Papillary Tumor

Fibroadenoma Phyllodes tumor

 Batas tegas? Ya Densitas lemak ? Tidak USG? Anechoic

Kista

Fibroadenoma
Batas tegas? Ya Densitas lemak ? Tidak USG? Hipoechoic

Kalsifikasi: Tanda penting keganasan, tapi yang jenisnya mikrokalsifikasi

Kalsifikasi pada mammae yang bukan malignansi:
Vascular calcification Secretory calcification Calcified degenerating fibroadenoma Rim calcification Lucent calcification Round calcifications Milk of calcium in cyst

Vascular calcification

Secretory calcifications
Dilated duct with periductal inflammation Thick linear, rod like calcification, internal lucency Radiate from the retroareolar area Follow the course of the ducts Usually bilateral

Rim calcification

Lucent calcification
Dermal calcification

ULTRASONOGRAPHY

USG

Non radiasi Non invasif Digunakan berulang Murah Cepat

Indikasi
Wanita muda, hamil atau menyusui Mammografi abnormal Klinis (+), mammografi (-) Peradangan payudara Pembengkakan payudara laki-laki Biopsi / aspirasi Follow up

Gambaran USG lesi payudara Tanda primer :

Batas Bentuk Pola ekho Bayangan retro tumor

Tanda Sekunder
Penebalan kulit Perubahan jaringan Kekakuan Lig. Cooperi

Tes Dinamik
Efek kompresi Mobilitas

Arah scanning USG payudara

TECHNIQUE

 USG Colour Doppler nilai vaskularisasi tumor payudara.

Lesi ganas = feeding vessel pembuluh darah bagian perifer lesi tumour vessel pembuluh darah yang terletak di dalam lesi payudara

Mammografi & ultrasonografi :

Bersama-sama Mammografi
Ultrasonografi

97 % 95 %
78 %

Malignant Lesion