Idor 2012 oncology_imaging


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Idor 2012 oncology_imaging

  1. 1. PREVENTION MAKING CANCER VISIBLEAND SCREENING THE ROLE OF IMAGING IN ONCOLOGYmakingcancervisiblethe role of imaging in oncology 1
  2. 2. An Introduction Page 4 Prevention & Screening Page 7 1. The value of screening in cancer care Page 8 2. National screening programmes: objectives and reality Page 11 3. Patient information Page 12 4. Things to keep in mind before an examination is carried out Page 14 5. Future developments Page 17 AN INITIATIVE OF THE ESR, ACR AND RSNA Detection Page 19 1. Medical imaging in the detection of cancer Page 21 2. The role and skills of the radiologist Page 24 3. The communication flow Page 27 4. Informing the public Page 28 5. Future developments Page 30 Staging Page 33 1. The importance of staging Page 34 2. The radiologist takes centre stage Page 36 3. The communication chain Page 38 4. Looking forward Page 40Published by the Treatment & Therapy Page 43 1. Treatment monitoring with imaging: saving time Page 44ESR – European Society of Radiology 2. The growing use of image-guided therapies Page 46In cooperation with 3. Interventional radiology and minimally invasive treatments Page 48ESOI – European Society of Oncologic ImagingOctober 2012 4. Future developments Page 50Coordination:ESR Office, Neutorgasse 9, 1010 Vienna, Austria Follow-up Care Page 53Phone: (+ 43 1) 533 40 64-0 1. The importance of follow-up care Page 54Fax: (+ 43 1) 533 40 64-441 2. Tools of the trade Page 56E-Mail: 3. The radiologist’s role Page 59 4. What the public should know about imaging in follow-up care Page 60Managing Editor: Julia Patuzzi About the Interviewees Page 63Editors: Simon Lee, Michael CreanContributing Writers: Michael Crean (Chapter 5), Simon Lee (Chapter 3), Mélisande Rouger (Chapter 1+4), David Zizka (Chapter 2)Art Direction & Layout: Robert Punz Glossary Page 69Photo Credits: see page 94The logo for the International Day of Radiology was been created with the help of the MR Center of Excellence in Vienna, Austria.We would like to thank Prof. Siegfried Trattnig and Ms. Claudia Kronnerwetter for their valuable help.
  3. 3. PREVENTION MAKING CANCER VISIBLE MAKING CANCER VISIBLE PREVENTION AND SCREENING THE ROLE OF IMAGING IN ONCOLOGY THE ROLE OF IMAGING IN ONCOLOGY AND SCREENING Making Cancer Visible: the Role of Imaging in Oncology An Introduction Cancer, in all of its more-than-200 forms, is one a very large proportion of this progress is being medical imaging, as well as the expertise of those ing, from every continent, each of whom has pro- of the leading causes of death worldwide. Accord- made in the field of medical imaging. who practise it, is indispensable. vided their valuable input via short interviews. ing to the World Health Organisation, the disease This material has been put together with the lay- accounted for around 13% of all deaths in 2008. Although oncology is the branch of medicine that This booklet, which has been produced especially person in mind, but as an aid to the newcomer to Due to its high incidence, most people know some- traditionally deals with cancer, modern cancer for the first International Day of Radiology, aims radiology and medical imaging, we have included thing about the disease and, inevitably, the major- care is a multidisciplinary undertaking, and spe- to highlight the essential contribution imaging a glossary of terms at the back of the booklet. ity also know someone who has been afflicted by cialists in medical imaging – whether they are makes to five major steps in the cancer care chain: it. But its prevalence also makes cancer a very high radiologists or practitioners of nuclear medicine screening and prevention; detection; staging; We hope that this publication will provide some priority for research and healthcare investment. – are essential members of the team. The techno- treatment and therapy; and follow-up. useful insights into the role of radiology and med- Aside from the continuing search for a cure, huge logical advances made in imaging equipment and ical imaging in cancer care, and we sincerely hope global efforts are being made to improve the pre- the development of specific techniques for every The whole booklet has been written with the gen- it provides a few reasons to celebrate the Interna- vention, detection, and treatment of cancer, and stage of cancer care mean that the contribution of erous assistance of 15 experts in oncologic imag- tional Day of Radiology with us on November 8.4 5
  5. 5. PREVENTION MAKING CANCER VISIBLE MAKING CANCER VISIBLE PREVENTION AND SCREENING THE ROLE OF IMAGING IN ONCOLOGY THE ROLE OF IMAGING IN ONCOLOGY AND SCREENING THE VALUE OF SCREENING IN CANCER CARE Dynamic Contrast- Enhanced MR image of breast cancer Radiology’s role is central to cancer man- Early detection and prevention of disease There are many ways for radiologists to mography screening has helped reduce agement, with a wide choice of tools and has become crucial in the fight against identify the early signs of an individual breast cancer mortality by 30%, according techniques available for the detection, cancer, especially in people at higher risk developing cancer. Of the various tools to a recent study, which was conducted staging and treatment of the disease. But of developing malignancy, a part of the available, those that use x-ray technology, over almost three decades1. what is less well known is the value of general population that will continue to such as mammography for breast cancer medical imaging in recognising early man- grow worldwide in the decades to come. screening, are standard examinations. A recent National Lung Screening Trial ifestations of cancer and small clinically Recently, multidetector computed tomo- (NLST) in the United States showed a reduc- undetectable tumours before they become graphy (CT), a computerised imaging tool tion of 20% in lung cancer mortality among clinically apparent; a capacity that pushes “Of course, there is no which is used to create 3D images based on heavy smokers who were screened with radiology to the fore of oncologic care. guarantee that radiology can x-rays, has shown its strength in applica- low-dose spiral CT versus those screened prevent cancer before it is tions such as colorectal cancer screening. with traditional chest x-ray. Medical experts agree that most cancers there, but it is of tremendous Multidetector CT is now being used much can be dealt with effectively if detected help in detecting pre- more frequently in the detection of pre- early. In this respect, imaging is, second cancerous situations like malignant lesions, so-called polyps, in the “This adds to existing only to lab tests, when it comes to the most colonic polyps and liver large bowel, the discovery – followed by successful imaging cirrhotic nodules. If we screening studies such as valuable tools cancer care teams have at endoscopic resection – of which may sig- detect a tumour early, it breast and colon. Without their disposal. In particular, different radio- nificantly improve patient prognosis by may make treatment much question, early detection of The study ‘Swedish Two-County Trial’ was published in logical tests have become very helpful in prompting appropriate management. simpler and cheaper and 1 disease is greatly improved 2011 in Radiology by Dr. László Tabár et al. The longest study screening as they can show precancerous may even save lives.” with imaging.” ever conducted, it demonstrated that, 29 years after their first mammogram, women who were invited to get routine lesions before they become malignant and The benefits of screening have been proven Prof. Yves Menu, France Dr. Reginald Munden, USA screening had a significant reduction in breast cancer mor- cause symptoms. repeatedly since its introduction. Mam- tality compared to those who received usual care.8 9
  6. 6. PREVENTION MAKING CANCER VISIBLE MAKING CANCER VISIBLE PREVENTION AND SCREENING THE ROLE OF IMAGING IN ONCOLOGY THE ROLE OF IMAGING IN ONCOLOGY AND SCREENING NATIONAL SCREENING PROGRAMMES: OBJECTIVES AND REALITY Most countries acknowledge the impor- screening programmes for breast and cer- dence is expected to increase by as much as tance of running national screening pro- vical cancer, and many of those who have 90% by 2030, according to a recent study2. grammes for certain groups of patients. not already launched nationwide pro- However, today, the only widespread grammes for colorectal cancer are plan- screening programmes are for breast cancer ning to introduce them soon. Lung cancer “In most developing in women usually aged roughly between 40 is also under evaluation as a possible sub- countries, access to screening and 74, who represent the group with the ject of screening in many countries. is extremely limited or highest risk of developing cancer. even non-existent. Given Setting up a national screening pro- that cancer incidence is gramme is a complex task, partly because expected to rise dramatically “Large series seem to it is difficult to define precise target groups in some of these countries prove the benefit of such in the coming decades, the with age limits, similar clinical histories, a screening, at least global medical community and various other characteristics. Guide- in a carefully selected should work together to lines for screening are determined locally population.” define minimum screening and based on the resources of healthcare recommendations for all Prof. Yves Menu, France systems, the health concerns of the popu- countries and to provide lation, and cultural attitudes and priorities. the necessary resources – Screening practices vary considerably from including equipment and one country to another. While Korea offers High rates of under-reported disease pres- training – for essential screening on a national level for stom- ent another challenge in collecting clear screening programmes.” ach, liver, colorectal, breast and uterine and reliable figures, while restricted access Prof. Hedvig Hricak, USA cervix cancer, the most common types in to the latest technology remains a problem that country, China and South Africa, for in many parts of the world. The absence of 2 The study ‘Global cancer transitions according to the example, do not yet have any established adequate tools for detecting early or pre- Human Development Index (2008–2030): a population- based study’ was led by Dr. Freddie Bray of the International national screening programmes. Most cancerous conditions is all the more alarm- Agency for Research on Cancer (IARC) and published in The countries in America and Europe operate ing in poorer countries, where cancer inci- Lancet Oncology in June 2012.10 11
  7. 7. PREVENTION MAKING CANCER VISIBLE MAKING CANCER VISIBLE PREVENTION AND SCREENING THE ROLE OF IMAGING IN ONCOLOGY THE ROLE OF IMAGING IN ONCOLOGY AND SCREENINGPATIENTINFORMATION Diffusion cellularity map reflects the probability of cancer in the central prostate gland.Without such global guidelines or nation- should be screened for lung cancer. Forwide screening programmes, it is all the women with a lifetime cancer risk of 20% or “Providing the public with “A lot depends on themore important to provide clear recom- greater, for instance women with a genetic complete information is educational level of themendations to patients. Some people are risk, a breast examination with magnetic really a key issue for the population. Unfortunately, inmore at risk than others due to their clini- resonance imaging (MRI) is recommended. success of a screening developing countries, therecal history or family background, and doc- People with liver cirrhosis and/or hepatitis campaign. Having the are still great challengestors can advise them on how to proceed to B or C virus should be screened to detect patient as a partner makes to achieving a satisfactoryavoid any future complications. any signs of liver cancer. everything easier.” level of understanding of Prof. Yves Menu, France these issues. The population needs to be informed People can obtain information about about the importance of “People who have high risk screening from their general practitioners, Public awareness campaigns play a major imaging in cancer screening factors, such as a family gynaecologists, urologists, and any other role in this dialogue, and the participation programmes, in order forhistory of particular cancers specialist, who should be able to advise of institutional partners is highly desir- them to be able to demand and some related gene when to screen and for what. Some patients able. Healthcare stakeholders and cancer health authorities to set upcarriers, should be screened.” may also benefit from their companies’ patient societies should be incorporated such programmes.” Prof. Feng Feng, China medical insurance, which in some coun- into these campaigns. Prof. Marcos Duarte Guimaraes, Brazil tries may cover the annual health-checkIt is generally accepted that people aged for their employees over a certain age. The Information is also key to improving pub-over 55, with a smoking history of one pack success of screening depends entirely on lic healthcare. The more informed the pub-per day over 30 years, and former smok- how well-informed the public is and on the lic is, the likelier they are to push their gov-ers, who have quit within the last 15 years, health policies of each country. ernments to take action.12 13
  8. 8. PREVENTION MAKING CANCER VISIBLE MAKING CANCER VISIBLE PREVENTION AND SCREENING THE ROLE OF IMAGING IN ONCOLOGY THE ROLE OF IMAGING IN ONCOLOGY AND SCREENINGTHINGS TO KEEP IN MINDBEFORE AN EXAMINATIONIS CARRIED OUT F-fluorodeoxyglucose (FDG) PET-CT of lung cancer 18 with mediastinal lymph node metastasesCancer screening undoubtedly brings ben- image, may also cause allergies and kidneyefits, when it leads to the identification of “Disadvantages are minor dysfunction in sensitive patients. On the “False positive diagnosis maycancer before it poses a real danger and compared to the lives saved other hand, ultrasound examinations used result in over-investigation ofrequires intensive and often expensive by the technology. Most in ovarian cancer screening, for example, what ultimately turns out totreatment. But one should also be aware of radiological tests used for have no side effects at all. As for multide- be a benign condition. This canthe risks that are associated with imaging early detection of disease tector CT colonography, it causes much less in turn result in unnecessaryexaminations. have no or minimal side discomfort than conventional colonoscopy anxiety in the patient and effects that are greatly in screening for colon cancer, and can be unnecessary costs.” outweighed by the benefits.” Dr. Adriana Dieguez, ArgentinaMammography, for instance, involves a carried out much more rapidly. Prof. Anno Graser, Germanysmall amount of ionising radiation, whichcan have a potentially carcinogenic effect. Finally, one should not underestimate the The best option for patients is to discuss allBecause it also uses x-ray technology, CT is Some examinations, like mammography, risk of false positive diagnosis and the series these issues directly with their doctors, whonot a risk free procedure either. However, may also cause discomfort to patients, of costly examinations it can trigger. A false should inform them of all the possible risks,radiation risks remain very low and must because they will have a device pressed positive result indicates that a person has as well as the benefits, before deciding tobe weighed against the benefits brought firmly against their bodies. The use of con- a given condition when they do not. For undergo screening tests. Patients shouldby the examination. trast products, media swallowed or injected instance, a cancer test might return positive know that screening is not perfect; it may into the body to enhance the contrast of an when the person is actually healthy. not detect every cancer, but it can detect can- cer early enough to achieve remission.14 15
  9. 9. PREVENTION MAKING CANCER VISIBLE MAKING CANCER VISIBLE PREVENTION AND SCREENING THE ROLE OF IMAGING IN ONCOLOGY THE ROLE OF IMAGING IN ONCOLOGY AND SCREENING FUTURE DEVELOPMENTS Imaging techniques have significantly Radiologists are increasingly using radia- rent trend in screening is toward person- improved in recent decades. As technolo- tion dose reduction strategies, which min- alisation, to find out the individual’s risk gies are constantly being refined, imag- imise the potential risks of radiation in of cancer, based on very specific biological ing modalities will become even more x-ray-based imaging modalities without tests. accurate and reliable in the future. Low- compromising image quality. Computer- dose chest spiral CT in lung cancer screen- aided detection and diagnosis systems ing is very promising. But there are still can reduce the rate of missed cancers “We all know that some enormous challenges and questions to be and may also help to characterise early people are more predisposed answered before this technique can be lesions. Researchers are also working on to some cancers, and we approved for use around the world. One ways to identify high-risk subjects, based should maintain our of the main problems remains the sig- on molecular or genetic studies, which progress in the ability to nificant disparity in access to and use of may enhance screening effectiveness. propose to the individual a tools for prevention and early detection screening programme that is tailored, rather than a ‘mass of cancer. Cooperation with other medical specialties product’.” is key to these achievements. Radiologists Prof. Yves Menu, France already work in multidisciplinary teams to A 3-dimensional image from a neurosurgical navigational system, “It is desirable to develop treat cancer patients. Close collaboration which allows the neurosurgeon to see functional information during strategies to enable with other specialists, for instance biolo- In addition to the benefits brought by the operation. The tumour is in yellow. The motor cortex (the part of new technologies to be gists, physicists and doctors of nuclear imaging, diet and obesity management, as the brain that controls motor function) is in red. Purple indicates the implemented universally in medicine is fundamental to the develop- well as environmental and lifestyle modi- order to reduce mortality.” large veins overlying the surface of the brain. Dr. Adriana Dieguez, Argentina ment of new screening tools. As is the case fications, may also help to prevent cancer in many other areas of medicine, the cur- in the future.16 17
  11. 11. MAKING CANCER VISIBLE MAKING CANCER VISIBLE DETECTION THE ROLE OF IMAGING IN ONCOLOGY THE ROLE OF IMAGING IN ONCOLOGY DETECTION MEDICAL IMAGING IN THE DETECTION OF CANCER Imaging plays a major role in the detection tion of a malignancy while participating in onance imaging (MRI) and mammography, of cancer as it provides a detailed insight a screening programme. the latter being used specifically to detect into the exact location and extent of the breast cancer. disease. It can also provide detailed infor- mation about structural or cancer-related “Certainly radiology is by far changes. Emerging methods of molecular the best method for cancer “The technique of choice imaging, which combine traditional imag- detection in the majority of depends on the type and site ing technology and nuclear medicine tech- cancers. However, the vast of the cancer. All of these niques, can also be used to obtain more majority of tumours are only modalities provide cross- detailed information about abnormalities, apparent with an advanced sectional anatomical images. including their distinct metabolism. test, especially at the initial US and CT are generally stage, and radiology is less expensive and more certainly the major player.” widely available than MRI There are various ways to detect cancer Prof. Yves Menu, France and are therefore used more Contrast-Enhanced Spectral using imaging methods. Cancer may be detected incidentally, when an examina- frequently around Mammography shows the world.” tion is carried out for other reasons, or there Modern medical technology offers a wide enhancing cancer that was not may be clear symptoms and the patient range of imaging methods to imaging spe- Prof. Hedvig Hricak, USA seen on mammography may undergo imaging to confirm, locate, cialists. Well known methods used for the and determine the extent of the disease. detection of cancer are ultrasound (US), In many cases cancer is identified based Another possibility is of course the detec- computed tomography (CT), magnetic res- on the discovery of abnormalities in the20 21
  12. 12. MAKING CANCER VISIBLE MAKING CANCER VISIBLE DETECTION THE ROLE OF IMAGING IN ONCOLOGY THE ROLE OF IMAGING IN ONCOLOGY DETECTION appearance of soft tissue and bone. But changes, which opens up a completely new ity are collected for further examination, is improved to generate higher resolution there are also functional imaging tech- field of possibilities such as earlier detec- necessary. images while significantly decreasing the niques, which detect physiological or func- tion and better understanding of tumour amount of radiation and exposure time. tional changes, such as specific changes in development. One of the most promising Side-effects may occur and vary depend- blood flow that can also signify the pres- molecular imaging techniques is positron ing on the method used and the area of ence of cancer. emission tomography (PET), which is most the body to be examined. The use of con- “Effects on the patient can often combined with CT (PET-CT) and used trast agents may cause allergies and may be considered as related A very promising set of imaging techniques to track probes in order to detect meta- pose risks to patients with renal insuf- to discomfort during the are available to radiologists through the static disease. ficiency. Techniques such as US and MRI test, use of contrast agents, methods of molecular imaging, which dif- do not entail any radiation exposure and irradiation and directly fers from traditional imaging in that bio- When it comes to the characterisation of are generally considered to be very safe. invasive tests such as marker probes are used to target specific a finding, or the differentiation between In some situations however, MRI is not biopsies. Radiation effects are from ionising radiation areas or suspicious findings. In general, a malignant or benign abnormality, it is recommended, for instance in patients from x-ray and CT. Effects a biomarker is anything that can be used sometimes difficult to reach a final diag- with a pacemaker or other metallic are proportional to the dose as an indicator of disease or changes in nosis. To avoid unnecessary invasive pro- implant, because of the magnetic field of radiation and cumulative the human body, which interacts chemi- cedures and save the patient further dis- used during the examination. Methods like effects of multiple cally with its surroundings to produce an comfort, a comparison of various images, x-ray and CT, on the other hand, expose the examinations although effect that can then be seen on the screen. often obtained through different methods, patient to ionising radiation. Radiologists these are seldom relevant in In comparison to other methods which is the first step towards a final diagnosis. If always use the lowest radiation dose pos- daily practice.” show changes in size, density or water con- a definite diagnosis still cannot be made, a sible to get the desired results and mod- Dr. Jean de Villiers, South Africa tent, the radiologist can observe molecular biopsy, where small parts of the abnormal- ern imaging devices are constantly being22 23
  13. 13. MAKING CANCER VISIBLE MAKING CANCER VISIBLE DETECTION THE ROLE OF IMAGING IN ONCOLOGY THE ROLE OF IMAGING IN ONCOLOGY DETECTIONTHE ROLE AND THE SKILLSOF THE RADIOLOGIST Detection of hepatocellular carcinomaThe radiologist is likely to be the first per- When it comes to cancer, patient care isson to detect a tumour based on either “Image interpretation is the a team effort and not the work of a sin- “A lot of communicationclear symptoms or previous suspicions. most visible contribution of gle doctor. A multidisciplinary approach takes place with the clinicalImaging specialists also detect cancer radiologists. Diagnosis by expert and good teamwork between the various oncologists and surgeons,during routine screening and are the radiologists is based on the physicians are crucial to the successful usually in the context ofmost experienced physicians in choos- extensive knowledge of anatomy, care of cancer patients from detection to regular multidisciplinarying from a wide range of available imag- normal variations, pathology treatment and follow-up. The role of the committee techniques in order to get the best and technical principles of the radiologist is not limited to the phase However, it is good practice to imaging modality.” communicate with colleaguesresults. When a tumour or an abnormal- between detection and diagnosis but Prof. Hiroshi Honda, Japan who have referred patients fority is detected, the first task of the radi- extends further, as radiology will also examinations and, obviously,ologist is to identify the exact location of be involved in the choice of therapy, its are in charge of the patient.the tumour and the extent of the disease. A radiologist is not only an expert in the field monitoring, delivery, and follow-up. In This communication canAfter the detection of cancer, the radiolo- of imaging techniques, but also an expert in hospitals especially, a multidisciplinary be by telephone, e-mail orgist interprets the cross-sectional images understanding the patterns and appearance approach to the fight against cancer is videoconference.”of the patient, makes the diagnosis and of cancer in various body parts and organs very common and radiologists frequently Dr. Adriana Dieguez, Argentinadetermines the stage and extent of the as well as ways of local and distant spread of work in a team together with other spe-disease based on their findings. different tumours, so-called metastases. cialists.24 25
  14. 14. MAKING CANCER VISIBLE MAKING CANCER VISIBLE DETECTION THE ROLE OF IMAGING IN ONCOLOGY THE ROLE OF IMAGING IN ONCOLOGY DETECTION THE COMMUNICATION FLOWCharacterisation of When the final diagnosis is reached and more involved. When working in multidis-equivocal ultrasound clarified, the next step is to inform the ciplinary teams, the attending physician “For instance, if a cancer is detected, the patient shouldfindings (not shown) patient of their condition and the further often requests that the radiologist be pres- be very clearly encouragedwith CT. CT of the kidney steps and treatment options available. At this stage, the role and the involvement of ent when the patient is informed of a find- ing, so that specific questions regarding to consult his referringshows a cystic structure the radiologist vary and are strongly depen- imaging can be answered by a specialist. clinician very soon in orderin the left kidney (white dent upon the local situation. In most cases to organise the medicalarrow). However, this it is referring physicians who will inform The radiologist is in many cases the first strategy. More and moreis not a simple cyst. CT the patient about the results, as they are person to detect a tumour, but rarely the the patients ask for clearly shared comprehensivedemonstrates a solid generally the people who have the most one who informs the patient. But the radi- information. However, thisnodule (green arrow), detailed knowledge of the patient’s medi- ologist is still left with a degree of per- is not a simple situation,which is suspicious for a cal history. There are also cases, where sonal responsibility as the patient has to because it may changecystic cancer. the final diagnosis can only be reached be advised to see their attending physician the patient’s life, so the by performing a pathological test, which quickly to discuss their diagnosis and fur- way the information is excludes the participation of a radiologist. ther options. He should make it clear to the communicated should be But the conventional background role of patient that they should seek further treat- considered very carefully.” the radiologist is changing slightly as the ment and see their doctor. In these situa- Prof. Yves Menu, France multidisciplinary approach and patients’ tions, patients might also ask the radiolo- demands make the radiologist more and gist directly for clear information.26 27
  15. 15. MAKING CANCER VISIBLE MAKING CANCER VISIBLE DETECTION THE ROLE OF IMAGING IN ONCOLOGY THE ROLE OF IMAGING IN ONCOLOGY DETECTION INFORMING “The population should THE PUBLIC be informed about the importance of imaging in cancer detection. With imaging being one of the major play- undergo a specific procedure. It is also in the ers in the fight against cancer, it is impera- public’s best interests to be aware of the spe- tive that the public be well informed about cific costs of imaging and whether a referral Thus the population its benefits and possibilities. The early detec- is needed if they want to see a specialist or tion of cancer, its prognosis and detailed undergo a specific imaging examination. information about the extent of the disease will be able to require wouldn’t be available to patients without Besides all the information on the benefits medical imaging. All further treatment of modern imaging, the public should also that health authorities decisions are based on these findings. be made aware of the possible disadvan- tages and side effects which go hand inComputed tomography There is also a need to inform the public hand with some techniques. Some methods take action aimed at about the wide range of imaging tech- expose the human body to larger amountsimage of the chest using niques available and which are the best of radiation than others and some such aslow radiation dose implementing cancer diagnostic tests for a specific cancer or ultrasound and MRI use no radiation at all. condition. More recently developed meth- It is important for patients to be aware of ods such as PET-CT are not well known to those facts in order to understand why the detection.” patients, but bring crucial benefits to the radiologist has to decide in each individ- field of oncologic imaging. ual case which method is the most appro- priate. This is particularly important for Information on the availability of the dif- patients with special conditions, who may Prof. Marcos Duarte Guimaraes, Brazil ferent methods, whether they are available for instance be allergic to contrast agents at all or only in specialised hospital depart- or have metal implants, in the case of MRI ments, would make it easier for patients to examination. Pregnancy also limits the use consider their options when they have to of some methods.28 29
  16. 16. MAKING CANCER VISIBLE MAKING CANCER VISIBLE DETECTION THE ROLE OF IMAGING IN ONCOLOGY THE ROLE OF IMAGING IN ONCOLOGY DETECTION FUTURE DEVELOPMENTS Breast MR image of Invasive Lobular Carcinoma Medical imaging strongly depends on tech- PET, which is able to produce a 3D image of nology, so progress and further develop- a functional process in the body, has become “PET-MR is a cutting-edge imaging modality and has been ments in the field of imaging technology an integral part of cancer diagnosis. As released by some vendors very recently. Compared to are vital to the progress of the discipline tumours or inflammation use up high levels PET-CT, PET-MR provides a better background image with itself. Over the last 40 years, there have of glucose, the radiologist can easily track the improved soft tissue contrast without radiation exposure. been major innovations in the field of med- location and spread of the disease. Moreover, integration of molecular and functional ical imaging, such as CT and MRI, which information generated from PET and MR could provide currently achieve a high level of diagnos- But it is not only newly developed meth- useful information in characterising the cancer.” tic accuracy and spatial resolution when ods that bring about improvements in can- Prof. Hiroshi Honda, Japan combined with the methods of molecular cer detection; established methods such as imaging, which is for many radiologists MRI also have a lot to offer. At the moment the most promising tool for the future. most MR devices operate at a magnetic field- results, and will certainly see further devel- logic imaging and when patients will ben- strength of 1.5 and 3 Tesla, but in experiments opments that will aid understanding of the efit from it. What can be said for sure is that The very early stages of cancer and other ill- strengths of up to 11 Tesla have been achieved function, structure and evolution of tissues imaging will become an even more power- nesses should then become detectable using and provide extremely high quality images. like cancer when treatment is administered. ful cancer detection tool in the future espe- customised biomarkers which can detect Diffusion-weighted imag­ ng, which allows i cially when biomarkers and molecular the smallest traces of the disease. The use of the mapping of the diffu­ ion process of mol- s It is of course hard to predict how new methods have been developed to their full radiolabelled glucose in combination with ecules, has already shown some very positive methods or devices will influence onco- potential.30 31
  17. 17. StagingCT for tumour staging 1. THE IMPORTANCE OF STAGINGCT in a patient with long-standing 2. THE RADIOLOGIST TAKES CENTRE STAGEupper abdominal pain shows a 3. THE COMMUNICATION CHAINlarge, advanced pancreatic cancer 4. LOOKING FORWARD(arrows), which infiltrates thesurrounding vessels. The cancerwas found to be unresectablebecause of the advanced stage atthe time of diagnosis. 33
  18. 18. MAKING CANCER VISIBLE MAKING CANCER VISIBLE STAGING THE ROLE OF IMAGING IN ONCOLOGY THE ROLE OF IMAGING IN ONCOLOGY STAGINGTHE IMPORTANCEOF STAGING “Once a histologic diagnosis is made, imaging is the key diagnostic tool used to stage the cancer – that is, to Chemical exchange determine exactly where the primary tumour is located saturation transfer and how far the cancer has (CEST) imaging of a spread. For some tumours, malignant brain tumor imaging findings are still Post-contrast T1-weighted imageThere are many clinical factors that might characterising tumours that have been supplemented by findings As Prof. Hricak says, as soon as cancer is diag- is where the radiologist’s skill, and experi- from surgery – but with theraise the initial suspicion of cancer, and evidenced via other methods, but it is also nosed, the most important thing to establish, ence of medical images, plays a very impor- continuous advancementthere are various methods used to con- extremely useful in taking the next step. which will determine the first steps of treat- tant part. of cross-sectional imagingfirm its presence in one form or another. Being able to visualise the exact location and the development of ment – if not the entire treatment plan – isThe actual diagnosis of cancer is generally of a suspected tumour allows doctors to molecular imaging, staging the precise extent of the cancer. Doctors willmade through laboratory tests of a tissue closely examine the surrounding area, laparotomy is becoming only know how to proceed by finding out “Accurate staging is widelysample collected through biopsy or sur- providing a first impression of whether or obsolete. Accurate staging exactly where cancer is in the original site based on imaging. No othergery, the need for which is usually deter- not any potential cancer may have spread, is essential in order to (the primary tumour), whether it has spread test allows for the depictionmined by blood tests, imaging, or both. and if so, how far. Not only does this mean select the appropriate to other parts of the body (the process known of both the primary tumourSo, imaging alone cannot provide definite doctors can visually pick the best point in treatment. Thus, by staging as ‘metastasis’), and how large any tumours and its potential metastases.diagnosis, but it very often helps doctors to that area for the biopsy sample to be taken cancer, radiologists and are. In this sense, staging is essentially the The prognosis of anyreach their conclusion. from, but it also provides the first hints other imaging specialists reconnaissance, which informs exactly how given malignant condition significantly influence depends on the initial stage as to the ‘stage’ of what may later be con- the ‘battle plan’ of treatment will be drawn cancer care.” at the time of diagnosis.”As the previous chapter explained, radiol- firmed as cancer. up. Imaging is by far the most effective Prof. Hedvig Hricak, USA Prof. Anno Graser, Germanyogy provides vital tools for detecting and method to accurately stage cancer, and this34 35
  19. 19. MAKING CANCER VISIBLE MAKING CANCER VISIBLE STAGING THE ROLE OF IMAGING IN ONCOLOGY THE ROLE OF IMAGING IN ONCOLOGY STAGINGTHE RADIOLOGISTTAKES CENTRE STAGE The broad range of radiological tools and scope (a very small tube containing a light While complete staging relies on a com- ciplinary team of doctors, responsible for techniques available means radiologists can and camera) into the body. bination of clinical findings, including “The radiologist has a the management of each cancer patient. choose how to examine the body when stag blood tests, radiology provides the cen- fundamental understanding Images obtained in the examinations will ing cancer. The decision of which method No single method is guaranteed to spot tral and pivotal staging process, so the of the strengths and be presented and commented on by the to use can be influenced by various factors, everything, but the big advantage of hav- radiologist’s role at this point in the can- weaknesses of the imaging radiologist, before being discussed by the such as the area of the body where the pri- ing so many options to choose from is that cer care continuum is absolutely essen- tools available and which team, usually including oncologists and mary tumour is located, the areas to which they can often be used in combination to tial. As well as managing and operating imaging modalities are best pathologists. Frequently, new questions cancer is most likely to spread, the sensitiv- provide a more comprehensive picture. the equipment used for staging and diag- suited for the investigation may be raised, due to new events or bio- of particular tumour types. ity of the patient to radiation (influenced by nosis, and selecting the methods used to logical findings, and very commonly, the Particular cancers are best age, physical condition, pregnancy, etc.) and, carry out the examinations, the radiolo- radiologist will return to previous exami- appreciated with certain in some cases, the cost of the examination. “In order to answer different gist is also the person who will analyse types of investigations and nations with the same or another imaging questions, the radiologist can and interpret the resulting images, with a radiologist is best situated tool, in order to characterise images or to CT, PET-CT and, increasingly, MRI are perhaps use all imaging techniques. reference to important clinical knowl- to know which is the most ensure that nothing was missed. the most commonly used methods employed But it is important to edge about the patient’s current condi- appropriate investigation in staging, particularly where a whole-body understand that there is no tion and medical history. The radiologist to use.” exam is required, but other techniques such single perfect examination. is therefore relied upon not only to detectChemical exchange as ultrasound, x-ray, and mammography are In most cases, a combination already evident findings, but to know to Prof. Andrew Little, Australiasaturation transfer of examinations is the also commonly used. Aside from these meth- where a given tumour may spread and to appropriate strategy, even if(CEST) imaging of a ods, all of which are used to look inside the computed tomography is the confirm or exclude the presence of local The radiologist’s expert analysis will bemalignant brain tumor body from outside, doctors may also occa- usual starting point.” and distant metastases (the new sites an integral factor in the decision aboutCEST image sionally use endoscopy in the course of stag- of spread) through detailed analysis of the course of action to be taken, but the Prof. Yves Menu, France ing, which involves the insertion of an endo- these locations. decisions are usually made by a multidis-36 37
  20. 20. MAKING CANCER VISIBLE MAKING CANCER VISIBLE STAGING THE ROLE OF IMAGING IN ONCOLOGY THE ROLE OF IMAGING IN ONCOLOGY STAGING THE COMMUNICATION CHAIN There are usually many people involved doctors from various branches of medi- well as numerous other physicians, includ- tion findings for the team, as well as pro- When it comes to informing the patient in the management of an individual case cine, all of whom work together closely to ing those who specialise in the particular viding recommendations and coordination of the actual diagnosis, this is done by the of cancer, some of whom the patient will achieve the best possible results. At every body regions affected. of follow-up (covered in chapter five of this oncologist or referring physician in the have close contact with and some of whom stage of a patient’s progress, meetings usu- booklet). Although patients may not neces- majority of cases, although occasionally the remain very much ‘behind the scenes’. ally take place that draw on the expertise Individual team members are involved to sarily hear directly from radiologists, their radiologist will be involved. This varies from Most healthcare institutions take a mul- of oncologists (cancer specialists), patholo- varying degrees in the different steps of can- involvement in meetings, and particularly country to country, but in general the radiol- tidisciplinary approach to cancer care, gists (specialists in disease processes), radi- cer care, but communication is still vital. For through frequent contact with the referring ogist will only be consulted when the patient meaning that the management of each ation oncologists (specialists in treating the radiologist, this means compiling clear, clinician, is an important factor in cancer has a particular question. patient is the responsibility of a team of cancer with radiation), and radiologists, as detailed and accurate reports on examina- management. “At a local level good communication with all members “In China, patients receive their “Depending on local clinical practice, the radiologist of the multidisciplinary team managing a patient is medical imaging reports from the either talks to the patient directly, or to the referring key to quality care. It is now routine in many countries department of radiology, and they physician. In Germany, for example, most private for the initial diagnosis, imaging staging and potential will see their physicians/surgeons radiology centres offer direct patient interviews and management strategies for cancer patients to be discussed in with the reports. Occasionally, the discussion of findings after the imaging. In most a multidisciplinary team meeting. This ensures that there is patient will consult the radiologist hospitals, however, that is impossible to provide and good communication between all parties.” directly and the radiologist will findings will be communicated to the patient during Prof. Vicky Goh, United Kingdom provide the necessary explanations.” clinical rounds on the ward.” Prof. Feng Feng, China Prof. Anno Graser, Germany38 39