Radiological approach to leukemia Dr. Myhammad Bin Zulfiqar PGR IV SIMS/SHL In this presentation we shall discuss the role of radiologist in the management of leukemia

1. Radiological Approach to
Leukemia
DR. Muhammad Bin Zulfiqar
PGR IV New Radiology Department
SHL/SIMS
radiombz@gmail.com

2. Hematopoietic
stem cell
Neutrophils
Eosinophils
Basophils
Monocytes
Platelets
Red cells
Myeloid
progenitor
Lymphoid
progenitor
B-lymphocytes
T-lymphocytes
Plasma
cells
naïve
ALL
AML
Leukemia Cure, Causes, Diagnosis,
Symptoms, Types and Treatment -
MedicineNet. (n.d.). MedicineNet.
Retrieved March 30, 2014, from
http://www.medicinenet.com/leuke
mia/article

3. What is Leukemia
• Leukemia: is a cancer of the blood or bone
marrow characterized by abnormal
proliferation of blood cells,usually
WBCs(Leukocytes).
• Acute leukemia: rapid increase of immature
blood cells.
• Chronic leukemia: excessive build up of
relatively mature, but still abnormal blood
cells.
Leukemia Cure, Causes, Diagnosis, Symptoms, Types and Treatment - MedicineNet. (n.d.). MedicineNet. Retrieved
March 30, 2014, from http://www.medicinenet.com/leukemia/article

5. Common Types of Leukemia
• Acute lymphocytic leukemia is the most common type of leukemia
in children, but it can also affect adults. In this type of leukemia,
immature lymphoid cells grow rapidly in the blood.
• Acute myeloid leukemia involves the rapid growth of myeloid cells.
It occurs in both adults and children
• Chronic lymphocytic leukemia (CLL) is a slow-growing cancer of
lymphoid cells .that usually affects people over 55 years of age. It
almost never occurs in children or adolescents.
• Chronic myeloid leukemia (CML, also known as chronic
myelogenous leukemia) primarily affects adults
Leukemia Cure, Causes, Diagnosis, Symptoms, Types and Treatment - MedicineNet. (n.d.). MedicineNet. Retrieved March
30, 2014, from http://www.medicinenet.com/leukemia/article

7. Extramedullary Involvement
• Eye:
– Infiltration of local vessels,
• CNS:
– at time of diagnosis less than 5% have CNS leukemia with meningeal
signs (morning headache, vomiting, papilla edema, focal neurological
signs)
• Ear, nose, throat:
– lymph nodes infiltration (isolated or multiple)
– Mikulicz syndrome (infiltration of salivary glands and/or tear glands)
Leukemia Cure, Causes, Diagnosis, Symptoms, Types and Treatment - MedicineNet. (n.d.). MedicineNet. Retrieved March
30, 2014, from http://www.medicinenet.com/leukemia/article

8. Extramedullary Involvement
• Skin:
– maculopapular skin infiltration, often of deep red
color (infants)
• Lymph nodes:
– Lymphadenopathy
• Gastrointestinal involvement:
-hepato- and/or splenomegaly
Leukemia Cure, Causes, Diagnosis, Symptoms, Types and Treatment - MedicineNet. (n.d.). MedicineNet. Retrieved
March 30, 2014, from http://www.medicinenet.com/leukemia/article

9. Extramedullary Involvement
• Cardiac involvement:
– leukemic infiltration
– occasionally cardiac tamponade due to pericardial
infiltration
– Mediastinum:
enlargement due to leukemic infiltration by lymph nodes
and /or thymus (observed in T-cell leukemia)
• Pleura/and pericardium: effusion
• Kidney enlargement
Leukemia Cure, Causes, Diagnosis, Symptoms, Types and Treatment - MedicineNet. (n.d.). MedicineNet. Retrieved
March 30, 2014, from http://www.medicinenet.com/leukemia/article

10. Extramedullary Involvement
• Testicular involvement:
– enlargement of one or both testes
• Penis:
– priapism is occasionally associated with elevated WBC
• Bone and joint involvement:
-bone pain initially present in 25 % to 50% of patients
-bone or joint pain, sometimes with swelling and tenderness
due to leukemic infiltration of the periosteum.
Leukemia Cure, Causes, Diagnosis, Symptoms, Types and Treatment - MedicineNet. (n.d.). MedicineNet. Retrieved
March 30, 2014, from http://www.medicinenet.com/leukemia/article

11. Objectives of Imaging
• Nothing to do with diagnosis
• Our role;
– Secondary effects e.g. infections
– Extramedullary manifestations
– Extent of disease process
Riquelme S et al. Imaging studies in early diagnosis of childhood leukemia. Revista Chilena de Radiología. Vol. 18
Nº 1, año 2012; 24-29.

12. Our Scheme
• Classical
– Plain Radiograph
– Ultrasound
• Specific
– CECT
– MRI
– PET CT
• Interventional Radiology
Riquelme S et al. Imaging studies in early diagnosis of childhood leukemia. Revista Chilena de Radiología. Vol. 18
Nº 1, año 2012; 24-29.

13. Role of Plain Radiography
• Chest
– Infections e.g. Consolidation, lymphadenopathy
and pleural effusion.
• MSK
– Metaphyseal bands in long bones
– Local or diffuse osteopenia
– Focal or generalized osteolysis
Riquelme S et al. Imaging studies in early diagnosis of childhood leukemia. Revista Chilena de Radiología. Vol. 18 Nº 1, año
2012; 24-29.

14. • CXR reveals perihilar and
retrocardiac infiltration.
Abnormal shaped vertebra is
suspicious.
• Thoracolumbar Lat X-Rays
reveal multiple collapsed
vertebrae.
Riquelme S et al. Imaging studies in early diagnosis of
childhood leukemia. Revista Chilena de Radiología. Vol. 18
Nº 1, año 2012; 24-29.

15. • Wrist X-ray reveals metaphyseal lucent band (arrow head) in radial
and ulnar metaphysis. Note the lucent bony lesions of the first and
third metacarpal bone on the right side (arrows).
Riquelme S et al. Imaging studies in early diagnosis of childhood leukemia. Revista Chilena de
Radiología. Vol. 18 Nº 1, año 2012; 24-29.

16. Ultrasound
• Look at lymph nodes
– near the surface of the body
– abdomen for enlarged lymph nodes
• Organs such as the liver, spleen, and kidneys.
• Scrotal Infiltration.
• Help guide a biopsy needle into an enlarged
lymph node.
Riquelme S et al. Imaging studies in early diagnosis of childhood leukemia. Revista Chilena de
Radiología. Vol. 18 Nº 1, año 2012; 24-29.

17. • Scrotal transverse color Doppler US image
showing an enlarged left testicle, with an area
of slightly low echogenicity and increased
vascular flow in the testicular anterior half.
Riquelme S et al. Imaging studies in early diagnosis of childhood leukemia. Revista Chilena de Radiología. Vol. 18 Nº 1, año 2012; 24-29.

18. • USG image show 9 cm right kidney with
increased cortical echogenicity
Riquelme S et al. Imaging studies in early diagnosis of childhood leukemia. Revista Chilena de Radiología. Vol. 18 Nº 1,
año 2012; 24-29.

19. CT Scan
• Lymphadenopathy
• Organomegaly e.g. liver, spleen and Kidney.
• CNS manifestations e.g Hemorrhage, post
radiotherapy imaging, Posterior reversible
leukoencephalopathy
• CT guided Biopsy
1. Lee et al. Utility of FDG PET/CT in the Assessment of Myeloid Sarcoma. AJR:198, May 2012.
2. El Rassi et al. Early Diagnosis of Acute Myeloid Leukemia by Computed Tomography Scan. VOLUME 30 NUMBER
23 AUGUST 10 2012. JOURNAL OF CLINICAL ONCOLOGY.
3. Baur A, Dietrich O, Reiser M: Diffusion-weighted imaging of bone marrow: Current status. Eur Radiol 13:1699-
1708, 2003

20. • Abdominal CT scan
shows in axial (a) and
coronal reconstruction
(b), enlargement of
both kidneys, with
multiple areas of low
attenuation in the
parenchyma (arrows).
The child also had
hepatosplenomegaly.
Riquelme S et al. Imaging studies in early diagnosis of childhood
leukemia. Revista Chilena de Radiología. Vol. 18 Nº 1, año 2012; 24-
29.

21. • Chest CT scan shows a large anterior mediastinal mass, displacing
the vascular structures and reveals (a) compression and
displacement of the trachea (arrow), (b) marked narrowing of the
left main bronchus (arrow), (c) pericardial effusion (arrow). In a 3D
reconstruction of the airway (d) compression of the left main
bronchus is clearly seen (arrow). Riquelme S et al. Imaging studies in early diagnosis of childhood leukemia. Revista
Chilena de Radiología. Vol. 18 Nº 1, año 2012; 24-29.

22. • Above image shows ICH
in a child suffering from
ALL with
thrombocytopenia
• Optic nerve infiltration by
leukemoid cells in a child
with recurrent disease
process.
Va´zquez et al. Neuroimaging in Pediatric
Leukemia and Lymphoma: Differential
Diagnosis. RadioGraphics 2002; 22:1411–1428

23. Mineralizing microangiopathy in a 17-year-old boy who had
been treated for ALL with irradiation and intrathecal
chemotherapy. Several years after remission, he developed
seizures. Nonenhanced axial CT scan shows calcifications in
the subcortical parenchyma and basal ganglia.
Va´zquez et al. Neuroimaging in Pediatric Leukemia and Lymphoma: Differential Diagnosis. RadioGraphics 2002; 22:1411–1428

24. PET/CT
• Hybrid CT scan with a PET scan
• Mechanism
– Glucose containing a radioactive atom
– Because cancer cells in the body grow rapidly, they
absorb large amounts of the radioactive sugar
– A special camera then detects areas of radioactivity in
the body.
• Compare areas of higher radioactivity on the PET
scan with the more detailed appearance of that
area on the CT.
1. Lee et al. Utility of FDG PET/CT in the Assessment of Myeloid Sarcoma. AJR:198, May 2012.
2. El Rassi et al. Early Diagnosis of Acute Myeloid Leukemia by Computed Tomography Scan. VOLUME 30 NUMBER 23 AUGUST 10 2012.
JOURNAL OF CLINICAL ONCOLOGY.

25. PET CT
• PET CT is even helpful in suggesting multifocal
extramedullary Lesion.
• Most common sites of MS are.
– Bones
– Lymph nodes
– Soft tissues
– Skin
– Breast
1. Lee et al. Utility of FDG PET/CT in the Assessment of Myeloid Sarcoma. AJR:198, May 2012.
2. El Rassi et al. Early Diagnosis of Acute Myeloid Leukemia by Computed Tomography Scan. VOLUME 30 NUMBER 23
AUGUST 10 2012. JOURNAL OF CLINICAL ONCOLOGY.

26. PET CT
• Increased sensitivity in early disease detection
• Identifies diseased sites
– facilitates biopsy
– diagnosis.
• Staging of the disease for treatment planning.
• Assessment tool for
– treatment response
– disease monitoring.
1. Lee et al. Utility of FDG PET/CT in the Assessment of Myeloid Sarcoma. AJR:198, May 2012.
2. El Rassi et al. Early Diagnosis of Acute Myeloid Leukemia by Computed Tomography Scan. VOLUME 30 NUMBER 23
AUGUST 10 2012. JOURNAL OF CLINICAL ONCOLOGY.

27. • PET/CT, coronal maximum-intensity-projection PET image (A) demonstrated
focal areas of increased 18F-FDG uptake within right forearm and both
upper thighs (arrows). Diffusely increased 18F-FDG uptake within bone
marrow represented physiologic marrow stimulation secondary to therapy.
Thighs showed no obvious corresponding abnormality on axial CT images
(B), but hypermetabolic intramuscular masses (arrowheads) were evident
on axial fused PET/CT images (C). Fine-needle aspiration of a right forearm
nodule revealed diffuse large cell lymphoma.
1. Lee et al. Utility of FDG PET/CT in the Assessment of Myeloid Sarcoma. AJR:198, May 2012.
2. El Rassi et al. Early Diagnosis of Acute Myeloid Leukemia by Computed Tomography Scan. VOLUME 30 NUMBER 23 AUGUST 10 2012. JOURNAL OF CLINICAL ONCOLOGY.

28. • Fig. 8—34-year-old man with acute
myeloid leukemia. A, FDG PET maximum-
intensity-projection image shows
heterogeneous hypermetabolic mediastinal
focus (arrow). B, Axial fused FDG PET/CT
image shows corresponding soft-tissue
mediastinal mass (maximum standardized
uptake value [SUVmax], 5.2). C, Axial fused
FDG PET/CT image shows further
hypermetabolic foci in right chest, which
are pleural deposits (SUVmax, 1.5–7.1).
1. Lee et al. Utility of FDG PET/CT in the Assessment of Myeloid
Sarcoma. AJR:198, May 2012.
2. El Rassi et al. Early Diagnosis of Acute Myeloid Leukemia by
Computed Tomography Scan. VOLUME 30 NUMBER 23 AUGUST 10
2012. JOURNAL OF CLINICAL ONCOLOGY.

29. • (A) 18F-FDG-PET scan of patient UPN 1 at diagnosis of extramedullary AML.
(B) Coronal and transversal 18F-FDG-PET/CT fusion images of the EM in the
left mammary gland at diagnosis. (C) 18F-FDG-PET scan of the same patient
after salvage chemotherapy (note: higher bone marrow 18F-FDG uptake
due to higher bone marrow activity). (D) Coronal and transversal 18F-FDG-
PET/CT fusion images of the EM in the left mammary gland after salvage
chemotherapy (note: higher bone marrow 18F-FDG uptake due to higher
bone marrow activity).
1. Lee et al. Utility of FDG PET/CT in the Assessment of Myeloid Sarcoma. AJR:198, May 2012.
2. El Rassi et al. Early Diagnosis of Acute Myeloid Leukemia by Computed Tomography Scan. VOLUME 30 NUMBER 23 AUGUST 10 2012.
JOURNAL OF CLINICAL ONCOLOGY.

30. DW MRI and CE MRI
• Lymphadenopathy
• Organomegaly
• Myeloid Sarcoma
• Diffusion-weighted methods have proved to
be capable of differentiating between benign
edema and tumorous involvement of bone
marrow.
3. Baur A, Dietrich O, Reiser M: Diffusion-weighted imaging of bone marrow: Current status. Eur Radiol 13:1699-
1708, 2003

31. • A soft tissue mass which is
of low T2 signal and
demonstrates vivid
contrast enhancement is
located within the occipital
bone. It displaces the
torcual anteriorly without
invasion or occlusion.

32. • Well defined long segment of homogenously
enhancing tissue in the upper/mid thoracic epidural
space, which is partially effacing the cord, but
without signal change within.

33. • Axial CT scan (a) and coronal T1-weighted (b), T2-weighted (c), and
gadolinium-enhanced T1-weighted (d) MR images show a mass in the
left inferior preseptal region (arrow). The mass is isoattenuating relative
to muscle on the CT scan (a) with no bone involvement. It is slightly
hypointense on the T2-weighted image (c) and has homogeneous
enhancement on the gadolinium-enhanced image (d). Surgical biopsy
demonstrated a granulocytic sarcoma.

34. • T2 weighted MRI of the patient’s spine. (A+B): Images taken at presentation
showing an intraspinal mass (white arrows) located extradurally between T2 and
T4 vertebral bodies with multiple hyperintense bony lesions (black arrows) on T12,
L1, L2, L4 and L5 vertebral bodies. (C+D): Images taken 1 month after treatment
showing no evidence of intraspinal mass but the bony lesions on thoracic and
lumbar vertebral bodies were persistent (black arrows). (E): Image taken after the
third consolidation therapy showing a few residual bony lesions on L1 and L2
vertebral bodies (black arrows).

35. Interventional Radiology
• Under Ultrasound Guidance;
– Lymph nodes
– Soft tissue sarcoma
• CT Guidance;
– Pulmonary nodules
– Spinal

36. Take Home Message
• In particular, the radiologist should considered
leukemia in the differential diagnosis of bone
pain, visceromegaly and anterior mediastinal
masses in children in particular and adults in
usual.
• A radiologist can help physician in management
by
– Response to therapy
– Recurrence
– Complications

37. Thank You