Imaging and Oncology Flashcards Preview

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Flashcards in Imaging and Oncology Deck (70):
1

Imaging in the Management of Cancer: Indications for Imaging?

1. Screening

2. Making the diagnosis

3. Staging

4. Operative planning

5. Response to treatment

6. Follow-up (recurrence)

2

1. What kind of X-rays are used for cancer dx?

2. Bone scans options? 2

3. What are the other two imaging options? 2

1.

-Plain films

-CT scans

-Fluoroscopy

-Mammography

2. Bone scans

-SPECT scans

-PET scans

3.

-MRI

-Ultrasound

3

XRAYS

1. Relies on what for imaging?

2. Ionizing radiation can cause what complications? 2

3. Good for what? 5

4. Not as good for what? 2

5. Disadvantage?

1. Relies on differential absorption

-air, fat, water, bone densities

2. Ionizing radiation can damage tissue

-developmental issues,

-cancer

3. Good for

-lungs,

-kidney/gall stones,

-bones

-anywhere there are air/fluid contrasts

-or bone/soft tissue contrasts

4. Not as good for

-soft tissues

-brain

5. Pathology can be hidden by normal structures

4

What is going on in each film?

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1  Normal PA chest film

2  Mediastinal masses – lymph nodes

5

What is going on in each film?

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On the right – solitary nodule, might be benign or resectable

On the left - pulmonary mets from rectosigmoid cancer

6

What is going on in the CXR below?

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Small nodule by right main stem bronchus

7

What is going on in the picture below?

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LARGE TUMOR L UPPER LOBE WITH IRREGULAR EDGES, LUNG CANCER

8

What is going on in the pic below?

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Probable Diagnosis

BRONCHOALVEOLAR CELL CARCINOMA

9

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Irregular mass in the central portion upper lobe of the right lung  lung cancer

10

1. What is the most valuable initial imaging technique for bone lesions?

2. What should we look at with the imgaing we ordered? 4

3. What will a benign finding look like?

4. What will a malignant finding look like?

1. X-RAYS   most valuable initial imaging technique

2.

-Look at the nature of the bone matrix

-Look at interface of lesion and bone

-Is the cortex intact?  Which part of the bone is involved?

-Most lesions at metaphysis near major growth centers

3. Benign:  Well-defined, no cortical destruction or periosteal reaction

4. Malignant:  Ill-defined, destructive, infiltrative, lytic or blastic

11

1. What are CT scans best at evaluating? 2

2. MRI is good for what? 2

3. Bone scans are good for what? 2

1. CT SCANS  

-best for evaluating subtle bone changes

-Good for areas hard to see on plain films

2. MRI   better for

-soft-tissue and

-infiltrative marrow lesions

3. BONE SCANS 

-show metabolic activity, looking for metastases

-PET/CT  becoming imaging of choice

12

What is going on in each of the following pictures?

Q image thumb

A image thumb
13

1. What are latent lesions surrounded by?

2. How would you describe active lesions?

3. How would you describe aggressive lesions?

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14

What is the following picture showing?

Q image thumb

Extra-cortical involvement

15

1. DDx for bone lesions? 4

2. DDx for aggressive bone lesions? 3

1. In general

-trauma,

-benign lesions

-infection,

-inflammatory condition

2. Aggressive bone lesions: 

-metastatic tumor

-primary malignant bone tumor

-infection

16

What are the following pictures showing?

Q image thumb

1. LYTIC AREA BELOW PHYSIS AND IN METAPHYSIS AND PERIOSTEAL NEW BONE – LEUKEMIA

2. LOCULATED CYSTIC TUMOR DISTAL RADIUS – CORTEX EXPANDED BUT INTACT – GIANT CELL TUMOR

3. DIFFUSE LYTIC PROCESS DISTAL RADIUS - OSTEOMYELITIS

17

What are the following showing?

Q image thumb

1. Bone forming tumor extending past cortex and invading soft tissues, osteogenic sarcoma

2. and 3.  benign appearing lytic lesion distal tibia – non-ossifying fibroma

4. Blastic lesions throughout the pelvis – prostatic CA

5. Multiple ytic lesions of pelvis and femurs – multiple myeloma

18

1. What is Fluoroscopy?

2. Can be used to help with what?

3. Prolonged procedures can lead to what?

4. Small risk of what?

1. Continuous X-rays used to obtain real time moving images of internal structures

2. Can use to help guide fine needle biopsies

3. Prolonged procedures can lead to skin burns

4. Small cancer risk 

19

Upper GI studies are a combination of what?

Contrast allows for exam of what? 3

Evaluation of which pathologies? 5

1. Barium swallow + fluoroscopy

2. Contrast allows for exam of

-esophagus,

-stomach, and

-duodenum

3. Evaluation of

-ulcers,

-GERD,

-vomiting,

-blood loss,

-hiatal hernia

20

What are the following pictures showing?

Q image thumb

1 & 2.  - irregular mass encroaching into the lumen of the esophagus – esophageal cancer

3. Irregular mass partially filling the stomach – gastric cancer

4. Smooth outpouching from the esophagus – benign diverticulum

21

1. CT scans are part of what other scans? 2

2. Subject to what? 2

3. When do you get your best images?

1. Part of PET and SPECT scans.

2. Subject to artifacts and distortion

3. Best images with highest doses 

  of radiation 

22

Advantages of CT scans

8

Greater detail than regular x-rays

1. Can differentiate structures of close physical density

2. Eliminates superimposition of organs

3. Show calcified and hemorrhagic lesions

4. Can be shown in multiple planes or even as a 3D image

Particular use in neoplastic disease 

1. Very good in the abdomen for staging

2. Very good for evaluation of masses in the chest

3. Can do virtual colonoscopy – screening for colorectal tumors

4. Most intracranial neoplasms are visible on CT

23

CT Scans….Downsides

4

1. Risk of cancer  (may increase as CTs used more)

    radiation dose of abdominal CT scan = 200 chest x-rays

    1 study, 0.4% of cancers in US due CT   (29,000/year)

    -worse in children and immunocompromised patients

 

2. When contrast agents used

   allergic reactions: 1-3% non-ionic and 7-12% ionic contrast agent

   anaphylaxis:  old ionic agents 1%, now 2-30/million

   contrast-induced nephropathy in 2-7%

  

3. Expensive

4. Observer variation

24

What do you see in the following?

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Left – smooth – benign

Right – spiculated, infiltrative margin – bronchiole leads to it

25

What do you see in the following?

Q image thumb

A image thumb
26

What do you see in the following?

Q image thumb

Irregular mass with infiltrations, perhaps to the pleura

Peripheral lesion – pleuritic chest pain – could be asymptomatic

27

1. What are pancoast's tumors?

2. What kind of pain?

1. Extension of tumor at apex of the lung involving  C8, T1, T2, nerves and possible destruction of ribs

2. Shoulder pain radiating in the ulnar distribution

A image thumb
28

What is happening in the following picture?

Q image thumb

BRONCHOALVEOLAR CELL CARCINOMA

29

1. Virtual Colonoscopy is usually done with what?

2. Requires what?

3. What should we inject with?

4. Compare its sensitivity with colonscopy?

5. What can't you do with these?

1. Usually done with CT

-Can be done with MRI

2. Requires bowel prep like colonoscopy

3. No need for sedation, quick recovery

-Injection of Butylscopolamine

4. Not as sensitive as colonoscopy

5. Cannot do biopsies

30

Imaging and Operative Planning 

3D CT Reconstructions

1. Used when?

2. Excellent evaluation for what?

3. Helpful in evaluating what? 3

4. Preoperative planning for sites of what? 2

1. When planning local resection

2. Excellent for evaluation of bony architecture

3. Helpful in evaluating

-bony integrity

-alignment

-stability

4. Preoperative planning for sites of

-fixation and

-reconstruction… 3D CT

31

What should we look for to differentiate normal and abnormal breast masses?

-Normal breast has masses, is not homogenous

-Look for masses, asymmetries, micro-calcification 

 

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32

What do the following images show?

Q image thumb

1. Normal breast

2. Benign cyst – smooth edges

3. Breast cancer – irregular, infiltrating lesion

33

What does the following show?

Q image thumb

CANCER ON R – MASS, INFILTRATIONS, CALCIFICATION

34

The following is a picture of?

Q image thumb

BREAST CANCER

35

Find the breast masses

Q image thumb

36

If we get an abnormal mammogram what do we need to followup with?

1. Needs breast examination by skilled clinician

2. Further mammography to confirm if the finding is real

3. Additional imaging tests - ultrasound - for better definition

4. BIRAD classification helps with further testing/follow-up

5. Can use MRI w/gadolinium – implants, very dense tissue

6. Needle or surgical biopsy may be recommended

7. The tissue diagnosis is key for planning treatment

37

Most mammogram abnormalities are what?

NOT cancer; most are due to benign changes

38

Nuclear Imaging:

1. What is injected intravenously?

2. How long after is the pt scanned?

3. Functional test measures what?

4. Half of the material goes to the bones – osteoblasts. What does this show? 3 (what is not seen)

5. Radioactive material is eliminated through what?

1. Radio-isotope is injected intravenously

-Usually technitium 99m, occasionally Gadolinium

2. 3 hours later the patient is scanned with a gamma camera

3. Functional test – measures bone metabolism or remodeling

4. Half of the material goes to the bones – osteoblasts. These show: 

-fractures,

-infections

-most tumors

-Lytic tumors may not trigger a healing response – not seen

5. Radioactive material is eliminated through the kidneys

39

Bone Scans assess what? 4

1. Show increased metabolic activity or increased blood flow

2. Assess activity of known lesions find unknown lesions

3. Sensitive test that can overestimate lesions

4. Marrow replacing tumors (MM) are cold until cortical disruption occurs

40

What are the bright spots in the bone scan and the dark spots in the liver scan?

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Bone scan:  bright spots are either arthritis or metastases

Liver scan: dark spots are metastases

                         

41

PET SCANS

1. What does it stand for?

2. What is the usual tracer?

3. What is usually performed in the same setting as PET?

4. Especially useful in what cancers? 2

1. Positron emission tomography

2. Usual tracer is fludeoxyglucose (FDG)

3. CT X-ray scan usually performed in the same sitting

4. Especially useful in lymphomas and lung cancers

42

FDG collects in highly metabolic tissue   (fludexoyglucose)

1. So what is detected? 2

2. Which kind of tumors are detected more? So what is the issue with this?

1.

-Detects active, rapidly growing tumors

-Used to detect metastatic disease

2. Higher-grade malignancies detected more than benign processes

-Low-grade cartilage lesions underestimated

-Hard to differentiate benign and low grade malignant lesions

43

1. Describe the resolution and localization of Single Photon Emission Computer-Assisted Tomography?

2. Gamma/nuclear camera (bone scan) + CT scanner

-What kind of isotopes are used? 4

-Emit what that is measured directly?

3. Good for what kind of lesions? (which tumors? 2)

4. More expensive than what?

1. High resolution + accurate localization

2. Gamma/nuclear camera (bone scan) + CT scanner

-Thallium,

-Technetium,

-Iodine,

-Gallium isotopes used

- Emit gamma radiation that is measured directly

3. Good for small spinal lesions

(Osteoid osteoma and osteoblastoma)

4. More expensive than bone scans

 

44

Which kind of imaging shows soft tissue, bone and distnguishes white matter from gray matter in the brain?

MRI

45

Down sides of MRI?

 

7

1. Expensive, slow

2. Claustrophobia

3. Pacemakers, stents

4. Small metal fragments

5. Metal artifact

6, Need calm patient

7. May be genotoxic

46

What kind of scans are the following?

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T1 and T2

47

What are the following pictures showing?

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Astrocytomas on MRI

48

Usually __________… improves visibility of structures, especially small tumors that don’t cause much edema?

gadolinium

49

What are the following pictures showing?

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Mengioma-MRI

50

What is the following showing?

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T1   malignant – infiltrating tendrils

LYMPHOMA IN AIDS PATIENT

51

MRI of the spine

1. Advantages?4

2. What are the pictures showing?

Q image thumb

1.

-Radiation free

-Superior for soft tissue imaging

-Can see subtle  differences

-Gadolinium assists in   delineating surrounding   vascularity

2. 

-L3-4 discitis…loss of disc space

-reactive edema in vertebrae

52

Advantages of US? 3

 

Disadvantages? 2

 

Imaging modality of choice for what?

 

Can use to supplement what?

1. cheap, quick, easy

2. safe, comfortable

3. shows solids and fluids

muscle, tendon, bone surface

 

1. hampered by bone, air, fat

2. very operator dependent

 

 

1. Imaging modality of choice for thyroid  tumors/lesions

 

1. Can use to supplement

     mammography   

53

Find the following breast masses

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54

Thyroid US

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55

What do you need to remember about making the diagnosis with cancer and tumors?

1. Tissue is the issue

-May need open biopsy

-May be able to do needle biopsy

-CT, fluoroscopic, or ultrasound guidance

56

What are FNBs the best for?

What kind of needle?

Image guidance? 3

Risks? 2

1. Peripheral lung lesions

2. Out-patient procedure.  22 gauge needle

3. Image guidance: 

-fluoroscopy,

-CT,

-ultrasound

4. Lung Bx: 

-pneumothorax  (10-30%) 

-hemoptysis (30%)

57

What are the following guided bx of?

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1. BX of thoracic vertebrae

2. Bx of cervical vertebrae

3. Biopsy forceps introduced through bronchoscope

58

What are the following images showing?

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1. Multiple lytic lesions skull – multiple myeloma

2. Multiple lung lesions – GI cancer

3. Multiple lesions in liver – most likely GI tract / could be breast, ovaries, bronchus kidney,

4. Blastic pelvic lesions – prostate cancer

59

1. What four cancers often met to the spine? 4

2. Early spine mets usually seen where?

3. What sign does this produce?

 

1.

-Breast,

-prostate,

-lung,

-kidney go to bones

2. Early spine mets usually seen at base of pedicle

3. Unilateral destruction of pedicle winking owl sign

–Early-on x-rays of limited use

60

Describe the winking owl sign

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61

Spine Imaging for mets:

Of those who present with isolated back pain….abnormal x-rays in:

1. 94% of those w/?

2. 74% of those w/?

3. 40% of those w/?

Of those who present with neuro compromise… 90% abnormal x-rays

4. 70% will have a lesion in the ?

5. 10% will have a lesion in the ?

6. What is usually not involved?

Unlike infections that thrive in avascular areas

1. breast mets

2. lung mets

3. lymphoma

4. vertebral body

5. posterior elements

6. Disc

62

Imaging to assess response to treatment

3

Can use

-bone scan,

-CT, and

-PET

 

 

Here….. bone scans before and

after 2 months of treatment

A image thumb
63

What is the best predictor of survival after cancer Rx?

PET Scans

 

 

64

•If PET scan is negative

     after therapy, the tumor

     is likely to be ______ at

     the time of surgery.   

dead

65

Pathologic Fractures: Occur through an area of weakened bone. Examples? 3

•Occur through area of weakened bone

–Osteoporosis

–Benign cystic tumor

–Malignant tumor

66

What are the following pictures of?

Q image thumb

1. Pathologic proximal humeral shaft fracture through pre-existing bone cyst (probably benign as smooth wall with reactive bone)

2. Oblique fracture proximal humeral shaft – well-aligned

67

What are the following pics showing?

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1. Subtrochanteric hip fracture – healthy bone

2. Subtrochanteric hip fracture – bone moth eaten around fracture with some lysis going down the canal

68

What are the following pics showing?

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1. Undisplaced fracture in benign bone cyst proximal humerus

2. Completely displaced transverse Fx proximal humerus just below the physis

69

What are the following pics showing?

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1. Pathologic Fx L3

2. Pathologic Fx L1

3. Compression Fx – possibly pathologic

4. Compression Fx’s L1 and L3 in osteoporotic spine

70

1. Pros and cons of XRAYS?

2. CT scans?

3. Bone scans?

4. MRI?

5. PET/CT or MRI?

6. US?

1. X-RAYS

-Simple, inexpensive, readily available, easily interpreted

-Radiation, poor tissue contrast, technician dependent, 2D

2. CT SCAN

-Rapid, 3D capability, axial imaging, good bony detail

-Highest radiation, motion & metal artifact, limited ST contrast

3. BONE SCANS

-Images metabolic activity, very sensitive in bones, low cost

-Non-specific, poor detail, anatomic changes not visualized

4. MRI

-Superior tissue resolution

-Expensive, motion & metal artifact, can’t use in some patients

5. PET/CT or MRI

-Combines function and anatomy, best imaging for most cancers

-Expensive (pre-authorization)

6. ULTRASOUND

-Very safe, inexpensive, quick

-Small field of view, technician and radiologist dependent, artifacts