DIAGNOSTIC IMAGING

NEOPLASMA
Dr. Yanto Budiman, Sp.Rad., M.Kes
Bagian Radiologi FK/RS Atma Jaya
Jakarta

Imaging is emerging as an important adjunct to
the clinical assessment of cancer, contributing
to :
Tumor detection,
Characterization,
Staging,
Treatment planning and follow-up.

Imaging may be requested in the
following situations:

As a routine investigation at the time of presentation for
diagnostic and staging purposes.
To answer a specific clinical question in an individual
patient on cancer treatment.
As a routine investigation on patients being treated with
established therapy (chemotherapy, radiotherapy).
As a surveillance tool in patients undergoing a watch
and wait policy (e.g. testicular cancer).
Screening as a mechanism to identify clinically
occult cancers (e.g. breast cancer)

Diagnostic Tools
Rontgen X-ray
USG
CT Scan
MRI
Nuclear Medicine

NUCLEAR MEDICINE :

Gamma Camera
SPECT
PET Scan




Bone Scintigraphy
Nuclear medicine

99m
Tc-MDP
Mechanism :
Radiopharmaceuticals(
99m
Tc-MDP) , will be
uptaken by osteoblast chemically bone
metabolic activities (increase/decrease
radiopharmaceuticals uptake)


Normal Bone Scan
Normal increased uptake in :
Growth plate
Kidney and bladder
Bone Metastase
(multiple hot nodule/spot)
Sof Tissue neoplasms
Key Points
X-rays always first line
Ultrasound best second test
MRI best overall for
Characterisation
Staging & extent
Progress evaluation

Role of Imaging
Confirmation
Mass? What mass?
Classification
Normal or variant
Developmental
Benign or non-aggressive
Indeterminate/Suspicious/Malignant
Staging & Extent
Progress and surveillance
Algorithm for ST Masses
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

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
Role of Ultrasound
Easily distinguish solid from cystic
Inexpensive, quick, rapid comparison
Detect hypervascularity (Doppler)
Excellent depiction of superficial mass
relationships
Guide needle biopsy
MRI Best for Staging
Global overview of relationships
Lesion characterisation
Lesion extent
Detection of contrast enhancement
Blood supply, tissue necrosis
Suspicious components
Benign Masses
Sebaceous cyst

Intramuscular
lipoma
ST Calcinosis
Elbow Ganglion Cyst
Palpable Cystic
Mass
MFH
Solid indeterminate mass
Soft Tissue Chondrosarcoma
High signal heterogeneous mass with internal septations and
marked rim enhancement (MRI)
Conclusions
Imaging is not histology
Clinical evaluation critical
X-rays ALWAYS first
Ultrasound second
MRI next
Imaging classification before surgery
Bone Neoplasms
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
Diagnostic Gamut
Developmental
Dysplastic/dystrophic
Traumatic
Metabolic
Infective
Ischaemic necrosis
Tumour-like conditions
Tumours
Why X-Rays?
Mandatory for MSK lesions
New bone formation
Periosteal reaction
Bone expansion & growth
Lesion boundaries
Host marginal reaction
Patterns of destruction
Still the most specific imaging modality for
most bone lesions
Age at Diagnosis
Age Tumo urs
1
1
1
N
N
N
e
e
e
u
u
u
r
r
r
o
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b
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1
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1
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s
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3
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4
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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
X-ray Aggressive Features
Bone destruction
Geographic
Moth-eaten
Permeative
Interrupted periosteal reaction
X-ray Benign Features
Elongated growth pattern
Narrow zone of transition
Sclerotic margin
Dense focal sclerosis
Dense incorporated solid periosteal
reaction
RCC Metastasis
Ewings Sarcoma
Osteosarcoma
Diaphyseal Aclasia
Nonossifying Fibroma
TUMORS AND TUMORLIKE
PROCESSES
1.METASTATIC BONE TUMORS
2.PRIMARY MALIGNANT BONE TUMORS
Multiple myeloma
Osteosarcoma
Ewings Sarcoma
3.PRIMARY QUASIMALIGNANT BONE
TUMOR
Giant Cell Tumor

4.PRIMARY BENIGN BONE TUMORS
Osteochondroma
Osteoma
Bone island
Osteoid osteoma
Simple bone cyst
Aneurysmal bone cyst
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 females 70% from breast Ca
In males 60% from prostate Ca
Metastatic.. (contd)
Radiologic Features
Technetium bone scan
80% of all metastase are located in the
central or axial skeleton
- Spine and Pelvis being a most common
Alteration in bone density and architecture
75% osteolytic, moth eaten or permeative
15% osteoblastic
Periosteal respose is rare
Metastatic bone tumor
Prostatic Metastases
Multiple myeloma
Primary bone tumor
Bone scan are cold
Gross Osteoporosis may be the only early
sign
Punched out lesions
Preservation of pedicles
Multiple Myeloma
Osteosarcoma

75% of cases occurs in the 10 to 25 age
Metaphyses of the distal femur, proximal
humerus are the most common sites
Permeative or ivory medulary lesion in
metaphysis of a long tubular bone
A sunburst or sunray periosteal response
Cortical disruption with soft tissue mass
formation
Sclerotic Lytic Mixed lesion
Osteosarcoma
Ewings Sarcoma

Most cases occur in the 10 25 age range
May mimic infection
Diaphyseal permeative lesion
Femur, tibia and fibula
Onion skin periosteal response
Most common primary malignant bone
tumor to metastasize to bone
onion-skin
Ewings Sarcoma

Osteochondroma
Aneurysmal Bone Cyst
Giant Cell Tumour
Simple bone cyst
Respiratory Neoplasm
Pleural tumor
Benign
Lipoma
- Fibroma
- Angioma

Malignant
- Mesothelioma
- Sarcoma
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
Pulmonary Carcinoma
a. Bronchogenic Ca
- Most common
- Male > Female
- Right > often
- Age : 50 60 y.o.
- Related : Smoking, radioactive/industry material,
TBC
- Classified into :
a. Central type
b. Perifer nodular
c. Pneumonic type
d. Miliary type

A Posteroanterior (PA) chest radiograph demonstrates a spiculated
right upper lobe mass.
B Chest CT (lung window) demonstrates a peripheral mass with spiculated
borders

Bronchogenic Ca
b. Pancoasts tumor

Posterior superior pulmonary sulcus tumor
Posterior costae 1- 3 destruction with
vertebral erosion
Cervicalis symphatis paralysis Horner
syndrome

Pancoasts tumor

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
4. Hamartoma
Overgrowth 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
2.5 9 cm.
Calsification inside : pop corn
calcification
Hamartoma
Metastastic tumor in lung
Emboli through pulmonary
artery &bronchial artery
From adjacent organ:
Oesophagus
Thyroid
Mammae

Appearance of metastatic tumor in
lung
a. Golf ball type
Sarcoma
Renal clear cell
Seminoma

b. Coin lesion type
Thyroid
Gaster
Ovarium-uterus
Lymphosarcoma
Chorio Ca


Metastase intrapulmonal
c. Milliary type
Thyroid Ca
Mammae Ca
Sarcoma
Lung Ca

d. Pleural metastase : Pleura effusion
Mammae Ca
Mesothelioma
Lung Ca
e. Pneumonic type
Oesophagus
Lung
Mammae

f. Lymphatic type
Lung
Gaster
Mammae
Pancreas, etc.

Lymphatic type:
Coarse reticular shadowing
GI Tract Neoplasm
GIT Diagnostic Tools:
Sialografi
Esophagograhi
Maagduodenographi
Colon in loop
Barium Follow Through
CT Scan, MRI



Single Contrast Barium Enema
Double Contrast Barium Enema
Abdominal Imaging
In the hollow organ segments of the GI tract, contrast
imaging studies remain the cornerstone in characterizing
the tumor, but lack the ability to stage the tumor, either in
terms of depth of penetration through the wall or in
defining regional nodal involvement.
CT Scan remains the most widely used for axial imaging
Magnetic resonance imaging has shown only limited
advantage over CT

Ca oesophagus
Tumours of the stomach

Benign tumours of the stomach:
- Adenoma
- Leiomyoma
- Lipoma
- Abberant pancreas
- Inflammatory polyps, etc

Location:
- pyloric portion (75%)
- body (20%)
- fundus & cardia (5%)


Radiographic appearances:
- A sharply circumscribed filling defect
projecting within the lumen

Malignant tumors of the stomach:
Gross morphologic types:
- Ulcerative (28%)
- Fungating/polypod (22%)
- Spreading/infiltrating (13%)
- Remainder unclassifiable

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.
Ulcerative gastric
adenocarcinoma
Polypoid gastric
adenocarcinoma.
leather bottle type
scirrhous ca.
Tumors of the duodenum
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
lobulated villous adenocarcinoma
arising at junction of second and third parts
of duodenum.

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

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)

SMALL Bowel :
Benign tumors and malignant tumors,
Benign tumours:
- Adenoma
- Leiomyoma (the commonest)

Malignant tumours:
- Lymphoma (the commonest)
- Leiomyosarcoma
- Carcinoid
- Metastases (malignant melanoma & bronchial ca)
Malignant lymphoma
Colorectal tumors
Polyps:
- 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

Virtual Endoscopy, using CT Scan
Colorectal cancer
Fungating type:
- Medullary carcinoma
- Sites: caecum, ascending colon, rectum
- Complication: bleeding, fistula

Polypoid type:
- Sites: ascending colon usually
- Complication: Intussusception

Annular type:
- Mucoid adenocarcinoma, scirrhous
fibrocarcinoma
- Sites: sigmoid, descending colon, flexures
- Complication: fistula, obstruction

Radiological appearances:
- Filling defect
- Obstruction
Polip colon
Liver malignancy
CT Scan
USG
Cranial Neoplasm
INTRACRANIAL MASSES

1. Radiografic Characteristic of Lesion
a. Intrinsic CT density
b. Contrast enhancement BBB
(ring, gyriform, homogenous)
c. Multiple lesions
d. MR appearance
DD/ : Intracranial Mass
(TEACH )

Tumor
Edema
Abcess, AVM, aneurysm
Cyst
Hematoma
A. Primary Tumor

1. Glioma
a. Astrocytoma
b. Ependymoma
c. Oligodendroglioma
d. Ganglioglioma
2. Meningioma
3. Lymphoma

B. Metastatic Tumor
DIFFERENTIAL DIAGNOSIS BY
LOCATION
Diagnosa banding berdasarkan pola
Enhancement lesi pada parenkim otak
A. Cerebral parenchymal lesion
Ring : - Glioma
- Meta
- Abcess
- Resolving hematoma
- Resolving infarction
Homogenous :
- Lymphoma
- Aneurysm
B.DD/ :
Intraventicular
Mass Lesion

Meningioma, Astrocytoma,
Choroid plexus papilloma,
Colloid cyst, Meta,
Ependymoma,
Subependymoma, AVM, Oligo,
Lymphoma
C.DD/: Pineal
Region Mass
Germ cell tumor,
Pineal cell tumor
Germinoma,
Pineoblastoma,
Teratoma, Glial cell
tumor, Dermoid,
Epidermoid,
Choriocarcinoma,
Meta
D.DD/Tumor di daerah Juxta Sellar and
Supra Sellar

Adenoma
Craniopharyngioma
Aneurysm
Meningioma
Uncommon : Meta, Arachnoid
cyst, Glioma
Breast Neoplasm
Mamografi
USG
MRI
BIRADS (Breast Imaging Reporting and Data
System)= Standardised Terminology, American
College of Radiology


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
Positive findings needing further action (10-80%
chance of cancer)
Category 1 & 2
Benign with <1% chance of cancer
Category 3
Probably benign with <2% chance of cancer
Most problematic category
Cannot use this well without local audit
BIRADS Category 4
All require initial biopsy
4A Low suspicion of malignancy
Palpable lesion, atypical FA, complex cyst etc.
Benign biopsy expected = discharge or short-term FU
4B Intermediate suspicion
Lesion with suspicious features
Benign biopsy = close correlation, ?re-biopsy
4C Moderate suspicion
Not classic for CA
Prominent suspicious features
Benign biopsy not expected = should re-biopsy or excise
BIRADS 3 & Screening
Assessment
BIRADS 3 is refuge for indecision
Intended for highly likely to be benign, but I am just
making 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


X-Ray dosis rendah
Massa < 5 mm
Massa tidak teraba
Tanda keganasan
Check-up post operasi
Tidak invasif
I ndikasi :
Benjolan
Rasa tidak enak pada mammae
Keluarnya cairan dari puting susu
Kelainan kulit mammae
Cancer Phobia
Post operasi
Skrining
Mengapa Skrining Harus Dilakukan ?
Ca mammae > usia 35 th

Kapan Skrining Diperlukan?
Usia 35 th
Usia 35 50 th 2 atau 3 th
Usia > 50 th Setiap tahun
Kranio-kaudal
Mediolateral-oblique
Kriteria Keganasan


Tanda Primer :
Lesi Radioopak irreguler
Mikrokalsifikasi




Tanda Sekunder :

Penebalan & retraksi kulit
Vaskularisasi
Posisi papila & areola berubah
Jar. fibroglandular tidak teratur
Distorsi lemak retromammae
Metastasis KGB aksila

Mammogram
Batas tegas
Batas tegas /
Irregular
Densitas lemak?
Ya Tidak
Lipoma, fat necrosis
Hamartoma
Galactocele, LN
USG
Anechoic kompleks
Solid
Kista Hematoma, Papillary
Tumor
Fibroadenoma
Phyllodes tumor


Abscess
Hematoma
Fat necrosis
Scleroing adenosis
Radial scar
Post surgical scar
Kista
Batas tegas? Ya
Densitas lemak ? Tidak
USG? Anechoic
Fibroadenoma

Batas tegas? Ya
Densitas lemak ? Tidak
USG? Hipoechoic
Kalsifikasi: Tanda penting keganasan, tapi
yang jenisnya mikrokalsifikasi

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

Secretory calcifications
Dilated duct with periductal
inflammation
Thick linear, rod like
calcification, internal
lucency
Radiate from the
retroareolar area
Follow the course of the
ducts
Usually bilateral

Rim calcification Lucent calcification
Dermal calcification
ULTRASONOGRAPHY


USG
Non radiasi
Non invasif
Digunakan berulang
Murah
Cepat
I ndikasi
Wanita muda, hamil atau menyusui
Mammografi abnormal
Klinis (+), mammografi (-)
Peradangan payudara
Pembengkakan payudara laki-laki
Biopsi / aspirasi
Follow up


Gambaran USG lesi payudara
Tanda primer :
Batas
Bentuk
Pola ekho
Bayangan retro tumor


Tanda Sekunder
Penebalan kulit
Perubahan jaringan
Kekakuan Lig. Cooperi

Tes Dinamik
Efek kompresi
Mobilitas

Arah scanning USG payudara

TECHNI QUE
USG Colour Doppler nilai vaskularisasi
tumor payudara.

Lesi ganas =
feeding vessel
pembuluh darah bagian perifer lesi
tumour vessel
pembuluh darah yang terletak di
dalam lesi payudara

Mammografi & ultrasonografi :

Bersama-sama 97 %

Mammografi 95 %

Ultrasonografi 78 %


Malignant Lesion