Idor 2012 oncology_imaging

PREVENTION MAKING CANCER VISIBLE
AND SCREENING THE ROLE OF IMAGING IN ONCOLOGY

making
cancer
visible
the role of
imaging in
oncology

1

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

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 40

Published by the
Treatment & Therapy Page 43
1. Treatment monitoring with imaging: saving time Page 44
ESR – European Society of Radiology
2. The growing use of image-guided therapies Page 46
In cooperation with 3. Interventional radiology and minimally invasive treatments Page 48
ESOI – European Society of Oncologic Imaging
October 2012

Coordination:
ESR Office, Neutorgasse 9, 1010 Vienna, Austria Follow-up Care Page 53
Phone: (+ 43 1) 533 40 64-0 1. The importance of follow-up care Page 54
Fax: (+ 43 1) 533 40 64-441
2. Tools of the trade Page 56
E-Mail: communications@myESR.org
www.myESR.org 3. The radiologist’s role Page 59
4. What the public should know about imaging in follow-up care Page 60
Managing Editor: Julia Patuzzi

About the Interviewees Page 63
Editors: Simon Lee, Michael Crean
Contributing 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 69
Photo Credits: see page 94

The 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.

MAKING CANCER VISIBLE PREVENTION
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


Prevention &
Screening
1. THE VALUE OF SCREENING IN CANCER CARE
2. NATIONAL SCREENING PROGRAMMES: OBJECTIVES AND REALITY
3. PATIENT INFORMATION
4. THINGS TO KEEP IN MIND BEFORE AN EXAMINATION IS CARRIED OUT
5. FUTURE DEVELOPMENTS

6 7


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


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


PATIENT
INFORMATION
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. For
wide screening programmes, it is all the women with a lifetime cancer risk of 20% or “Providing the public with “A lot depends on the
more important to provide clear recom- greater, for instance women with a genetic complete information is educational level of the
mendations to patients. Some people are risk, a breast examination with magnetic really a key issue for the population. Unfortunately, in
more at risk than others due to their clini- resonance imaging (MRI) is recommended. success of a screening developing countries, there
cal history or family background, and doc- People with liver cirrhosis and/or hepatitis campaign. Having the are still great challenges
tors 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 satisfactory
avoid 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 for
history 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 up
carriers, 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-check
It 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


THINGS TO KEEP IN MIND
BEFORE AN EXAMINATION
IS CARRIED OUT F-fluorodeoxyglucose (FDG) PET-CT of lung cancer
18

with mediastinal lymph node metastases

Cancer screening undoubtedly brings ben- image, may also cause allergies and kidney
efits, when it leads to the identification of “Disadvantages are minor dysfunction in sensitive patients. On the “False positive diagnosis may
cancer before it poses a real danger and compared to the lives saved other hand, ultrasound examinations used result in over-investigation of
requires intensive and often expensive by the technology. Most in ovarian cancer screening, for example, what ultimately turns out to
treatment. 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 can
the risks that are associated with imaging early detection of disease tector CT colonography, it causes much less in turn result in unnecessary
examinations.
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, Argentina
Mammography, for instance, involves a carried out much more rapidly.
Prof. Anno Graser, Germany
small amount of ionising radiation, which
can have a potentially carcinogenic effect. Finally, one should not underestimate the The best option for patients is to discuss all
Because 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, who
not 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 to
be 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 should
by 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


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

MAKING CANCER VISIBLE
THE ROLE OF IMAGING IN ONCOLOGY DETECTION

Breast MR image
of Invasive Ductal
Carcinoma

Detection

1. MEDICAL IMAGING IN THE DETECTION OF CANCER
2. THE ROLE AND SKILLS OF THE RADIOLOGIST
3. THE COMMUNICATION FLOW
4. INFORMING THE PUBLIC
5. FUTURE DEVELOPMENTS

18 19

DETECTION THE ROLE OF IMAGING IN ONCOLOGY

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 the

20 21


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 function 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 being

22 23


THE ROLE AND THE SKILLS
OF THE RADIOLOGIST Detection of hepatocellular
carcinoma

The radiologist is likely to be the first per- When it comes to cancer, patient care is
son to detect a tumour based on either “Image interpretation is the a team effort and not the work of a sin- “A lot of communication
clear symptoms or previous suspicions. most visible contribution of gle doctor. A multidisciplinary approach takes place with the clinical
Imaging 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 of
most experienced physicians in choos- extensive knowledge of anatomy, care of cancer patients from detection to regular multidisciplinary
ing from a wide range of available imag-
normal variations, pathology treatment and follow-up. The role of the
committee meetings.
ing 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 colleagues
results. When a tumour or an abnormal- between detection and diagnosis but
Prof. Hiroshi Honda, Japan who have referred patients for
ity 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 can
After the detection of cancer, the radiolo- of imaging techniques, but also an expert in hospitals especially, a multidisciplinary be by telephone, e-mail or
gist 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, Argentina
determines 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


THE COMMUNICATION
FLOW

Characterisation 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 should
findings (not shown) patient of their condition and the further often requests that the radiologist be pres-
be very clearly encouraged
with 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 referring
shows a cystic structure the radiologist vary and are strongly depen- imaging can be answered by a specialist. clinician very soon in order
in the left kidney (white dent upon the local situation. In most cases
to organise the medical
arrow). However, this it is referring physicians who will inform The radiologist is in many cases the first
strategy. More and more
is 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 comprehensive
demonstrates a solid generally the people who have the most one who informs the patient. But the radi-
information. However, this
nodule (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 change
cystic 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


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 in

Computed 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 amounts
image of the chest using niques available and which are the best of radiation than others and some such as
low 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


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

Staging

CT for tumour staging 1. THE IMPORTANCE OF STAGING
CT in a patient with long-standing 2. THE RADIOLOGIST TAKES CENTRE STAGE
upper abdominal pain shows a 3. THE COMMUNICATION CHAIN
large, advanced pancreatic cancer 4. LOOKING FORWARD
(arrows), which infiltrates the
surrounding vessels. The cancer
was found to be unresectable
because of the advanced stage at
the time of diagnosis.

33

STAGING THE ROLE OF IMAGING IN ONCOLOGY
THE ROLE OF IMAGING IN ONCOLOGY STAGING

THE IMPORTANCE
OF 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 image

There 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 the
raise 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 advancement
there 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 imaging
firm 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 – is
The actual diagnosis of cancer is generally of a suspected tumour allows doctors to molecular imaging, staging the precise extent of the cancer. Doctors will
made 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 widely
sample 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 other
gery, 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 depiction
mined 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 tumour
So, 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 any
reach 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, Germany
ogy provides vital tools for detecting and method to accurately stage cancer, and this

34 35


THE RADIOLOGIST
TAKES 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 detect
Chemical exchange as ultrasound, x-ray, and mammography are
In most cases, a combination already evident findings, but to know to
Prof. Andrew Little, Australia

saturation 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 be
malignant brain tumor body from outside, doctors may also occa-
usual starting point.” and distant metastases (the new sites an integral factor in the decision about
CEST 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


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, Germany

38 39


“Not only can the same type of cancer
behave differently in different patients, but
LOOKING even within a single patient, metastatic
FORWARD tumours arising from the same cancer
may behave differently. In fact, even
different regions within a single tumour
may have their own distinct molecular
Due to the nature of the tasks involved, Arguably, the most significant advances Molecular imaging in general is an
many of the advances being made in radiol- being made are related to molecular imag- extremely promising field, which benefits

characteristics. Because molecular
ogy to benefit cancer staging are the same ing, which is used to observe molecular all the stages of cancer management where
as, or similar to, those benefitting detec- changes on a cellular level, and specifi- images are involved, i.e. diagnosis, staging,

imaging can distinguish differences in
tion and characterisation (described in the cally positron emission tomography (PET), treatment evaluation, and follow-up. The
previous chapter). Incremental improve- which is usually used in combination with most important feature of these tests is that
ments in the many technical components of
today’s common imaging equipment mean
high quality CT or MR scans. PET is an espe-
cially sensitive imaging tool, which relies
they combine, in a single scan, morphologi-
cal (anatomical), physiological (functional) these characteristics within and between
that progress is always being made and that
the resolution and clarity of images are on
on the unusually high rate of metabolic
activity that occurs in cancer tissue to pro-
and metabolic information. This means that
doctors can obtain an unprecedented level tumours, the role of imaging specialists
the rise. But new developments also include
the additional features that are being added
duce three-dimensional images of particu-
lar functional processes. The combination
of detail about the nature of cancer tissue,
even to the extent that fine differences can
in diagnosing, characterising, and staging
to existing technology, such as functional of PET with CT or MR provides far superior be detected between individual tumours
cancer, as well as determining the
appropriate treatment, is likely to become
imaging: the ability to visualise processes images, which help the radiologist to accu- in a single patient, which could prove to
in the body, such as blood flow and other rately localise the active cancer tissue to a be invaluable when it comes to planning

even more pronounced with progress in
functional (or physiological) processes. particular site or organ. therapy.

molecular imaging and targeted therapy.”
Prof. Hedvig Hricak, USA

40 41

Idor 2012 oncology_imaging

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