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Transcript of Kuliah Blok Neoplasma Januari 2011 2
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DIAGNOSTIC IMAGING
NEOPLASMA
Dr. Yanto Budiman, Sp.Rad., M.Kes
Bagian Radiologi FK/RS Atma JayaJakarta
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Imaging is emerging as an important adjunct to
the clinical assessment of cancer, contributing
to :
Tumor detection,
Characterization,
Staging, Treatment planning and follow-up.
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Imaging may be requested in the
following situations:
As a routine investigation at the time of presentation fordiagnostic and staging purposes.
To answer a specific clinical question in an individualpatient on cancer treatment.
As a routine investigation on patients being treated withestablished therapy (chemotherapy, radiotherapy).
As a surveillance tool in patients undergoing a watchand wait policy (e.g. testicular cancer).
Screeningas a mechanism to identify clinicallyoccult cancers (e.g. breast cancer)
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NUCLEAR MEDICINE : Gamma Camera
SPECT
PET Scan
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Bone Scintigraphy
Nuclear medicine
99mTc-MDP
Mechanism :
Radiopharmaceuticals(99mTc-MDP) , will be
uptaken by osteoblast chemicallybone
metabolic activities (increase/decreaseradiopharmaceuticals uptake)
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Normal Bone Scan
Normal increased uptake in :
Growth plate
Kidney and bladder
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Bone Metastase
(multiple hot nodule/spot)
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Sof Tissue neoplasms
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Key Points
X-rays always first line
Ultrasound best second test
MRI best overall for
Characterisation
Staging & extent
Progress evaluation
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Role of Imaging
Confirmation
Mass? What mass?
Classification
Normal or variant
Developmental
Benign or non-aggressive
Indeterminate/Suspicious/Malignant
Staging & Extent
Progress and surveillance
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Algorithm for ST Masses
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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
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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
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Role of Ultrasound
Easily distinguish solid from cystic
Inexpensive, quick, rapid comparison
Detect hypervascularity (Doppler)
Excellent depiction of superficial mass
relationships
Guide needle biopsy
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MRI Best for Staging
Global overview of relationships
Lesion characterisation
Lesion extent
Detection of contrast enhancement
Blood supply, tissue necrosis
Suspicious components
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Benign Masses
Sebaceous cyst
Intramuscular
lipoma
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ST Calcinosis
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Elbow Ganglion Cyst
Palpable Cystic
Mass
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MFH
Solid indeterminate mass
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Soft Tissue Chondrosarcoma
High signal heterogeneous mass with internal septations and
marked rim enhancement (MRI)
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Conclusions
Imaging is not histology
Clinical evaluation critical
X-rays ALWAYS first
Ultrasound second
MRI next
Imaging classification beforesurgery
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Bone Neoplasms
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Diagnostic Algorithm for Bone Tumours
Bone Lesion X-Ray
Manage
&
Review
Yes
No
Benign?No
Malignant?
MRI or CT
??
Diagnostic
BIOPSY
Staging
Path-Rad Correlation
Variant?
Yes
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Diagnostic Gamut
Developmental
Dysplastic/dystrophic
Traumatic
Metabolic
Infective
Ischaemic necrosis
Tumour-like conditions
Tumours
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Why X-Rays?
Mandatory for MSK lesions
New bone formation
Periosteal reaction
Bone expansion & growthLesion boundaries
Host marginal reaction
Patterns of destruction Still the most specific imaging modality for
most bone lesions
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Age at Diagnosis
Age Tumo urs
111 NNNeeeuuurrrooobbblllaaassstttooommmaaa
111111000 EEEwwwiiinnngggsssaaarrrcccooommmaaa(((tttuuubbbuuulllaaarrr)))
111000333000 OOOsssttteeeooosssaaarrrcccooommmaaa,,,EEEwwwiiinnnggg(((ffflllaaattt )))
333000
444000 NNNHHHLLL,,,MMMFFFHHH,,,fffiiibbbrrrooosssaaarrrcccooommmaaa,,,GGGCCCTTT,,,pppaaarrrooosssttteeeaaalllooosssttteeeooosssaaarrrcccooommmaaa
444000+++ MMMeeetttaaassstttaaasssiiisss,,,mmmyyyeeelllooommmaaa,,,ccchhhooonnndddrrrooosssaaarrrcccooommmaaa
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X-Ray Features
Pattern of bone destruction or sclerosis
Internal architecture & density
Expansion, endosteal scalloping
Periosteal reaction & new bone
formation
Soft tissue mass
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X-ray AggressiveFeatures
Bone destruction
Geographic
Moth-eaten
Permeative
Interrupted periosteal reaction
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X-ray BenignFeatures
Elongated growth pattern
Narrow zone of transition
Sclerotic margin
Dense focal sclerosis
Dense incorporated solid periosteal
reaction
RCC M t t i
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RCC Metastasis
Ewings Sarcoma
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Ewing s Sarcoma
Osteosarcoma
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Osteosarcoma
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Diaphyseal Aclasia
Nonossifying Fibroma
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Nonossifying Fibroma
TUMORS AND TUMORLIKE
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TUMORS AND TUMORLIKE
PROCESSES
1.METASTATIC BONE TUMORS
2.PRIMARY MALIGNANT BONE TUMOR
Multiple myeloma
Osteosarcoma
Ewings Sarcoma
3.PRIMARY QUASIMALIGNANT BONETUMOR
Giant Cell Tumor
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4.PRIMARY BENIGN BONE TUMORS
Osteochondroma
Osteoma
Bone islandOsteoid osteoma
Simple bone cyst
Aneurysmal bone cyst
Metastatic Bone Tumors
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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 females70% from breast Ca
In males60% from prostate Ca
Metastatic.. (contd)
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Metastatic.. (cont d)
Radiologic Features
Technetium bone scan
80% of all metastase are located in the
central or axial skeleton
- Spine and Pelvis being a most commonAlteration in bone density and architecture
75% osteolytic, moth eaten or permeative
15% osteoblasticPeriosteal respose is rare
Metastatic bone tumor
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Metastatic bone tumor
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Prostatic Metastases
Multiple myeloma
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p y
Primary bone tumor
Bone scan are cold
Gross Osteoporosis may be the only early
sign
Punched out lesions
Preservation of pedicles
Multiple Myeloma
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p y
Osteosarcoma
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75% of cases occurs in the 10 to 25 ageMetaphysesof the distal femur, proximal
humerusare the most common sites
Permeative or ivory medulary lesion inmetaphysis of a long tubular bone
A sunburst or sunrayperiosteal response
Cortical disruption with soft tissue mass
formation
ScleroticLyticMixed lesion
Osteosarcoma
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Ewings Sarcoma
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g
Most cases occur in the 1025 age rangeMay mimic infection
Diaphysealpermeative lesion
Femur, tibia and fibulaOnion skinperiosteal response
Most common primary malignant bone
tumor to metastasize to bone
Ewings Sarcoma
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onion-skin
Ewing s Sarcoma
Osteochondroma
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Aneurysmal Bone Cyst
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Giant Cell Tumour
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Simple bone cyst
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Respiratory Neoplasm
Pleural tumor
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Pleural tumor
Benign
Lipoma
- Fibroma
- Angioma
Malignant
- Mesothelioma
- Sarcoma
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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
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Pulmonary Carcinomaa. Bronchogenic Ca
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a. Bronchogenic Ca- Most common
- Male > Female- Right > often
- Age : 5060 y.o.
- Related : Smoking, radioactive/industry material,TBC
- Classified into :
a. Central type
b. Perifer nodularc. Pneumonic type
d. Miliary type
BronchogenicCa
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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
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b. Pancoast s tumor
Posterior superior pulmonary sulcus tumor
Posterior costae 1- 3 destruction with
vertebral erosion
Cervicalis symphatis paralysis Horner
syndrome
Pancoasts tumor
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3 Alveolar cell ca
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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
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4. Hamartoma
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. a a to aOvergrowth 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
2.59 cm.
Calsification inside : pop corncalcification
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Metastastic tumor in lung
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Emboli through pulmonaryartery &bronchial artery
From adjacent organ:
Oesophagus
Thyroid
Mammae
Appearance of metastatic tumor in
lung
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lung
a. Golf ball typeSarcoma
Renal clear cell
Seminoma
b. Coin lesion type
Thyroid
Gaster
Ovarium-uterus
Lymphosarcoma
Chorio Ca
Metastase intrapulmonal
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c. Milliary type
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Thyroid Ca
Mammae CaSarcoma
Lung Ca
d. Pleural metastase : Pleura effusion
Mammae Ca
MesotheliomaLung Ca
e. Pneumonic type
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Oesophagus
Lung
Mammae
f. Lymphatic type
Lung
Gaster
Mammae
Pancreas, etc.
Lymphatic type:Coarse reticular shadowing
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GI Tract Neoplasm
GIT Diagnostic Tools:
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Sialografi
Esophagograhi
Maagduodenographi
Colon in loop
Barium Follow Through CT Scan, MRI
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Single Contrast Barium EnemaDouble Contrast Barium Enema
Abdominal Imaging
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g g
In the hollow organ segments of the GI tract, contrastimaging studies remain the cornerstone in characterizingthe tumor, but lack the ability to stage the tumor, either interms of depth of penetration through the wall or indefining regional nodal involvement.
CT Scan remains the most widely used for axial imaging
Magnetic resonance imaging has shown only limitedadvantage over CT
Ca oesophagus
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Tumours of the stomach
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Benign tumours of the stomach:- Adenoma
- Leiomyoma
- Lipoma
- Abberant pancreas- Inflammatory polyps, etc
Location:
- pyloric portion (75%)
- body (20%)
- fundus & cardia (5%)
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Usual histologic pattern: well-differentiated adenoca
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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.
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Polypoid gastric
adenocarcinoma.
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leather bottle type
scirrhous ca.
Tumors of the duodenum
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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
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lobulated villous adenocarcinoma
arising at junction of second and third parts
of duodenum.
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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
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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)
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Malignant lymphoma
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Colorectal tumors
Polyps:
A l l ti
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- 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
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Colorectal cancer
Fungating type:
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u g g ype:
- Medullary carcinoma
- Sites: caecum, ascending colon, rectum
- Complication: bleeding, fistula
Polypoid type:
- Sites: ascending colon usually
- Complication: Intussusception
Annular type:
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- Mucoid adenocarcinoma, scirrhousfibrocarcinoma
- Sites: sigmoid, descending colon, flexures
- Complication: fistula, obstruction
Radiological appearances:
- Filling defect
- Obstruction
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Polip colon
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Liver malignancy
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CT Scan
USG
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Cranial Neoplasm
INTRACRANIAL MASSES
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1. Radiografic Characteristic of Lesion
a. Intrinsic CTdensity
b. Contrast enhancement BBB(ring, gyriform, homogenous)
c. Multiple lesions
d. MR appearance
DD/ : Intracranial Mass
(TEACH )
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( )
Tumor
EdemaAbcess, AVM, aneurysm
Cyst
Hematoma
A. Primary Tumor
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1. Glioma
a. Astrocytoma
b. Ependymoma
c. Oligodendrogliomad. Ganglioglioma
2. Meningioma
3. Lymphoma
B. Metastatic Tumor
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DIFFERENTIAL DIAGNOSIS BYLOCATION
Diagnosa banding berdasarkan pola
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Enhancement lesi pada parenkim otakA. Cerebral parenchymal lesion
Ring : - Glioma
- Meta- Abcess
- Resolving hematoma
- Resolving infarctionHomogenous :
- Lymphoma
B.DD/ :
Intraventicular
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Mass Lesion
Meningioma, Astrocytoma,
Choroid plexus papilloma,
Colloid cyst, Meta,
Ependymoma,
Subependymoma, AVM, Oligo,
Lymphoma
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Mamografi
USG
MRI
BIRADS (Breast Imaging Reporting and DataSystem)= Standardised Terminology, American
College of Radiology
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Category 0 Needs further views/comp
Category 1 Normal
Category 2 Benign
Category 3 Probably benign
Category 4 Suspicious for malignancy
Category 5 Probable malignancy
Category 6 Proven or known malignancy
BIRADS Classification &Risk of CA Category 0, 4 & 5
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Positive findings needing further action (10-80%
chance of cancer)
Category 1 & 2
Benign with
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p g y
Palpable lesion, atypical FA, complex cyst etc.
Benign biopsy expected = discharge or short-term FU
4BIntermediate suspicion
Lesion with suspicious features
Benign biopsy = close correlation, ?re-biopsy
4CModerate suspicion
Not classic for CA Prominent suspicious features
Benign biopsy not expected = should re-biopsy or excise
BIRADS 3 & ScreeningAssessment BIRADS 3 is refuge for indecision
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Intended for highly likely to be benign, but I am justmaking 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
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X R d i d h
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X-Ray dosis rendah Massa < 5 mm
Massa tidak teraba
Tanda keganasan
Check-up post operasi
Tidak invasif
Indikasi:B j l
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Benjolan
Rasa tidak enak pada mammae
Keluarnya cairan dari puting susu
Kelainan kulit mammae
Cancer Phobia
Post operasi
Skrining
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Kranio-kaudal
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Mediolateral-obl ique
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Kriter ia Keganasan
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Tanda Primer :
Lesi Radioopak irreguler
Mikrokalsifikasi
Tanda Sekunder:
P b l & t k i k lit
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Penebalan & retraksi kulit
Vaskularisasi
Posisi papila & areola berubah
Jar. fibroglandular tidak teratur
Distorsi lemak retromammae
Metastasis KGB aksila
Mammogram
Batas tegasBatas tegas/
Irregular
Densitas lemak?
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Densitas lemak?
Ya Tidak
Lipoma, fat necrosisHamartoma
Galactocele, LNUSG
Anechoic kompleks
Solid
Kista Hematoma, Papillary
Tumor
Fibroadenoma
Phyllodes tumor
Abscess
Hematoma
Fat necrosis
Scleroing adenosis
Radial scarPost surgical scar
Batas tegas? Ya
Densitas lemak ? Tidak
USG? Anechoic
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Kista
Fibroadenoma
Batas tegas? Ya
Densitas lemak ? Tidak
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Densitas lemak ? Tidak
USG? Hipoechoic
Kalsifikasi: Tanda penting keganasan, tapiyang jenisnya mikrokalsifikasi
Kalsifikasi pada mammae yang bukan malignansi:
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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
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Secretory calcifications
Dilated duct with periductalinflammation
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inflammation
Thick linear, rod likecalcification, internallucency
Radiate from theretroareolar area
Follow the course of the
ducts Usually bilateral
Rim calcification Lucent calcificationDermal calcification
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Dermal calcification
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ULTRASONOGRAPHY
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USG
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Non radiasi
Non invasif
Digunakan berulang
Murah
Cepat
Indikasi
Wanita muda, hamil atau menyusui
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, y Mammografi abnormal
Klinis (+), mammografi (-)
Peradangan payudara Pembengkakan payudara laki-laki
Biopsi / aspirasi
Follow up
Gambaran USG lesi payudara
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Gambaran USG lesi payudara
Tanda pr imer :
Batas Bentuk
Pola ekho
Bayangan retro tumor
Tanda Sekunder
Penebalan kulit
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e eb u
Perubahan jaringan
Kekakuan Lig. Cooperi
Tes Dinamik
Efek kompresi
Mobilitas
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Arah scanningUSG payudara
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TECHNIQUE
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USG Colour Dopplernilai vaskularisasitumor payudara.
L i
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Lesi ganas =
feeding vessel
pembuluh darah bagian perifer lesi
tumour vessel
pembuluh darah yang terletak didalam lesi payudara
Mammograf i & ul trasonograf i:
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Bersama-sama 97 %
Mammografi 95 %
Ultrasonografi 78 %
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Malignant Lesion
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