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Understanding Scans 101

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Presentation by David J. Eschelman, MD, FSIR. Presented at the 2018 Eyes on a Cure: Patient & Caregiver Symposium, hosted by the Melanoma Research Foundation's CURE OM initiative. 

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Understanding Scans 101

  1. 1. Radiology Basics David J. Eschelman, M.D., FSIR Professor of Radiology, Sidney Kimmel Medical College of Thomas Jefferson University Co-Director of Interventional Radiology, Thomas Jefferson University Hospital
  2. 2. So what is a radiologist?
  3. 3. So what is an interventional radiologist?
  4. 4. Imaging Modalities • CT (computed tomography) • US (ultrasound) • MRI (magnetic resonance imaging) • PET-CT (positron emission tomography)
  5. 5. CT • Pros: – Available everywhere, consistent quality, best option for whole-body evaluation – Fast • Cons: – Less sensitive for small liver metastases than MRI – Radiation (10-15 mSv)
  6. 6. Chest CT – Lung Metastases
  7. 7. Ultrasound • Pros: – Relatively inexpensive. – No radiation. – Can be very sensitive for small lesions • Cons: – Variable quality, depending on site and on patient. – Not useful for whole-body surveillance.
  8. 8. Biopsy
  9. 9. MRI • Pros: – Most sensitive for liver mets. – No radiation. No known harmful effects • Cons: – Does not cover entire body – Can’t use in SOME people with pacers, anxiety, etc. – Variability in how studies are done. – Slow, noisy, easily affected by motion, etc.
  10. 10. 8/11/2010
  11. 11. 10/27/2010
  12. 12. 12/23/2010
  13. 13. 4/09/2010
  14. 14. MRI is better than CT (another example) CT MRI
  15. 15. MRI is better than CT (yet another example) CT MRI
  16. 16. PET-CT
  17. 17. PET - CT • Pros – Unique: Images metabolic activity – May give information about efficacy of treatment • Cons – Not universally available – Expensive – Not sensitive for small metastases – Takes about 2 hours – Radiation (30 mSv)
  18. 18. Surveillance Imaging • Surveillance Scheduling – No consensus: Varies from center to center – Depends on tumor histology and genetics • Jefferson protocol – Low/intermediate risk: MRI q6-12 mo, CXR q12 mo for 5 years – High risk: MRI q3 mo + CT chest q 6 mo for 2 years, then MRI q6 mo + CT q 12 mo for 3 years
  19. 19. NCCN Guidelines v1.2018 RISK OF DISTANT METASTASIS - Low risk: • Class 1A(x) • Disomy 3 • Gain of chromosome 6p • EIF1AX mutation • T1 (AJCC) (See ST-1 and ST-2) • Spindle cells SYSTEMIC IMAGING BASED ON RISK STRATIFICATION • Imaging to evaluate signs or symptoms as clinically indicated • Consider surveillance imaging(y)
  20. 20. NCCN Guidelines v1.2018 RISK OF DISTANT METASTASIS - Medium risk: • Class 1B(x) • SF3B1 mutation • T2 and T3 (AJCC) (See ST-1 and ST-2) • Mixed histology (spindle and epithelioid cells) SYSTEMIC IMAGING BASED ON RISK STRATIFICATION • Imaging to evaluate signs or symptoms as clinically indicated • Consider surveillance imaging(y) every 6–12 months for 10 years, then as clinically indicated
  21. 21. NCCN Guidelines v1.2018 RISK OF DISTANT METASTASIS - High risk: • Class 2(x) • PRAME mutation • Monosomy 3 • Epithelioid cells • Gain of chromosome 8q • Extraocular extension • BAP1 mutation • Ciliary body involvement • T4 (AJCC) (See ST-1 and ST-2) SYSTEMIC IMAGING BASED ON RISK STRATIFICATION • Imaging to evaluate signs or symptoms as clinically indicated • Consider surveillance imaging(y) every 3-6 months for 5 years, then every 6-12 months for 10 years, then as clinically indicated
  22. 22. NCCN Guidelines v1.2018 Surveillance: The most frequent sites of metastasis are liver, lungs, skin/soft tissue, and bones. At minimum, all patients should have contrast-enhanced MR or ultrasound of the liver, with modality preference determined by expertise at the treating institution. Additional imaging modalities may include chest/abdominal/pelvic CT with contrast. However, screening should limit radiation exposure whenever possible. Scans should be performed with IV contrast unless contraindicated. . . . . . but also add: (y) Recognizing that there are limited options for systemic recurrence and that regular imaging may cause patient anxiety, some patients may elect to forgo surveillance imaging.
  23. 23. Background Radiation Sources: • Cosmic radiation • Naturally occurring radioactive materials (radon, radium) • Fallout Exposure in US: • Approximately 3 mSv/yr (low altitude) • 30-50% higher in Denver • Transatlantic flight – 0.08 mSv (2-3x higher over poles) • 2x higher in US Capitol (8 hrs/day) – granite, marble
  24. 24. Radiation Imaging Examples Effective Dose Range (mSv) Background Equivalent Radiation Time Radiation Risk Descriptora Probability of Cancer From Imaging (%) Probability of No Cancer From Imaging (%) CT scan or nuclear medicine scan 1-10 Years Minor ∼0.05 ∼99.95 Abdominal radiograph 0.1-1 Months Minimal ∼0.005 ∼99.995 Chest radiograph or mammogram < 0.1-0.1 Days to weeks Negligible ∼0.0005 ∼99.9995 aDescriptors are from [78] Dauer L et al. AJR 2011, 196
  25. 25. Brenner: DJ, Hall EJ: Computed Tomography — An Increasing Source of Radiation Exposure. N Engl J Med 357:2277, November 29, 2007
  26. 26. Contrast Risks • CT contrast and MR contrast are completely unrelated materials • Risk of reaction to CT contrast is very low (0.15%) • Risk of reaction to MR contrast is extremely low (0.04%) • Most reactions are minor
  27. 27. Contrast Reactions Contrast and Renal Insufficiency CT: “Contrast nephropathy” MR: NSF
  28. 28. FDA Drug Safety Communication: FDA warns that gadolinium-based contrast agents (GBCAs) are retained in the body; requires new class warnings May 22, 2017, updated December 19,2017
  29. 29. Gadolinium Contrast for MRI • Per FDA: Gadolinium retention has not been directly linked to adverse health effects in patients with normal kidney function, and we have concluded that the benefit of all approved GBCAs continues to outweigh any potential risks. • Linear vs. macrocyclic • Eovist is one of the lower linear “accumulators” (lower dose administered, excreted by kidneys and liver, more stable than other linear agents)
  30. 30. RECIST Criteria Complete Response (CR) Disappearance of liver lesions Partial Response (PR) > 30% decrease in the sum of the longest diameters (“sum LD”) relative to baseline sum Stable Disease (SD) Absence of change which would qualify as response or progression Progression (PD) > 20% increase in the sum LD in liver lesions OR appearance of one or more new liver lesions
  31. 31. Initial Presentation MRI was normal 6 months ago
  32. 32. Rapid Growth without Treatment 12/17/2013 4/30/2014 6/2/2014
  33. 33. Any Questions?

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