Kuliah Blok Neoplasma Januari 2011 2

8/12/2019 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

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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



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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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