THE ROLE OF IMAGING INONCOLOGY

MAKING CANCER VISIBLELOOKING INSIDE THE BODY FROMLOOKING INSIDE THE BODY FROM

OUTSIDE

B.ZandiProfessor of Radiology

An Introduction

Cancer, in all of its more-than-200 forms, is one of the leading causes of death worldwide.

According to the WHO, the disease accounted for around 13% of all deaths in 2008.

Due to its High Incidence, most people know something about the disease and, inevitably, the majority also know someone who has been afflicted by it. someone who has been afflicted by it.

its prevalence also makes cancer a very high priority for Research and Healthcare Investment.

Aside from the continuing search for a cure, huge global efforts are being made to improve :

The Prevention, Detection, and Treatment of Cancer, and a very large proportion of this progress is being made in the Field of Medical Imaging.

Although Oncology is the branch ofMedicine that traditionally deals withCancer,

Modern Cancer Care is a Multidisciplinaryundertaking, and Specialists in Medicalimaging (Radiologists or practitioners ofimaging (Radiologists or practitioners ofnuclear medicine ) are Essential Membersof the team.

This presentation, aims : To highlight the Essential Contribution

which Imaging makes to Five Major Steps inthe Cancer care Chain:

1-Screening and prevention 1-Screening and prevention 2-Detection 3-Staging 4-Treatment and therapy 5-Follow-up.

Prevention & Screening

1. The value of screening in Cancer Care 2. National Screening Programmes :

Objectives and RealityObjectives and Reality 3. Patient Information 4. Things to keep in mind before an

examination is carried out 5. Future developments

1-THE VALUE OF SCREENING IN CANCER CARE

Early Dx :• Most Cancers can be dealt with effectively if

Detected Early. In this respect, Imaging , is second only to lab

tests.tests. Screening can show Precancerous lesions before

they become Malignant and causesymptoms.(Colonic Polyps, Cirrhotic Nodules )

Early detection and Prevention is crucial in thefight against cancer, especially in people atHigher Risk of developing malignancy

2-NATIONAL SCREENING PROGRAMMES: OBJECTIVES AND REALITY

Most countries acknowledge the importanceof running national screening programmesfor certain groups of patients.

However, today, the only widespread However, today, the only widespreadscreening programmes are for Breast Cancerin women usually aged roughly between 40and 74, (the highest risk of developingcancer).

Screening practices vary considerably from onecountry to another.

Korea : Screening on a national level forstomach, liver, colorectal, breast and uterinecervix cancer,

China and South Africa : do not yet have anyestablished national screening programmes.established national screening programmes.

Most countries in America and Europe operatescreening programmes for Breast and CervicalCancer, and some for Colorectal Cancer.

Lung cancer is also under evaluation as apossible subject of screening in manycountries.

3-PATIENT INFORMATION Besides such Global Guidelines or

Nationwide Screening Programmes, it is all the More Important to provide Clear

Recommendations to patients. Some people are more at Risk than others Some people are more at Risk than others

due to their Clinical History or FamilyBackground,

and doctors Can advise them on how toproceed to avoid any future complications.

It is generally accepted that : 1-People aged over 55, with a Smoking History

of one pack per day over 30 years, 2- Former Smokers, who have quit within the

last 15 years, should be screened for lung cancer. should be screened for lung cancer. For women with a lifetime cancer risk of 20%

or greater, (women with a Genetic Risk), abreast MRI is recommended.

People with Liver Cirrhosis and/or Hepatitis Bor C virus should be screened to detect anysigns of liver cancer.

THINGS TO KEEP IN MIND BEFORE AN EXAMINATION IS CARRIED OUT

Costs and Benefits of an Examination (i.eMammography )

Discomfort to patients ( Compression,Contrast Media, Endoscopy … )

A false positive result

The best option for patients is : to discuss all these issues directly with their

Doctors, who should inform them of all thepossible risks, as well as the benefits, beforedeciding to undergo screening tests.

Patients should know that :Screening is not perfect ; it may not detect Every Cancer,but it can detect Cancer Early Enough to

achieve Remission.

FUTURE DEVELOPMENTS

Technological Improvement. Computer-aided detection and diagnosis systems New ways to identify High-risk Subjects, based on

Molecular or Genetic studies Multidisciplinary Teamwork (Radiologists,

Biologists, Physicists and Doctors of NuclearBiologists, Physicists and Doctors of NuclearMedicine )

Personalisation for the Screening , to find out theindividual’s risk of cancer, based on Very SpecificBiological Tests

o Diet and Obesity management,o Environmental and Lifestyle Modifications, may also help to prevent cancer in the future.

A 3D image from a neurosurgical navigationalsystem, which allows the Neurosurgeon to seefunctional information during the operation.

The Tumor yellow. The Motor Cortex red.indicates the large Veins overlying the brainPurple.

Detection

1. Medical Imaging in the detection ofcancer

2. The role and skills of the radiologist 2. The role and skills of the radiologist 3. The communication flow 4. Informing the public 5. Future developments

MEDICAL IMAGING IN THE DETECTION OF CANCER

Imaging plays a Major Role in the Detectionof Cancer

It shows : the Exact Location and Extent of the the Exact Location and Extent of the

disease.Structural or Cancer-related Changes. Molecular imaging, (Traditional imaging +

Nuclear medicine ) ,to detect Anatomic andMetabolic Changes.

Various ways to Detect cancer usingImaging Methods :

IncidentallyAccording to Symptoms ( to confirm, locate,

and determine the extent of the disease ).Screening programme.

Imaging Methods : Modern medical technology offers a Wide Range of

Imaging Methods . Well known methods for the detection of cancer are : Ultrasound (US), Computed tomography (CT), Magnetic resonance imaging (MRI) Magnetic resonance imaging (MRI) Mammography, (specifically to detect breast cancer). Functional Imaging techniques, ( physiological or

functional changes , such as specific changes in BloodFlow , that can also signify the presence of cancer).

“The technique of choice depends on the type and site of the cancer.”

Imaging Methods … PET (Positron Emission Tomography ) PET-CT ( the Most Promising Imaging Technique

in cancer Patients ) In these methods Biomarkers are used, to Target

specific areas or suspicious findings. a Biomarker is anything that can be used as an

indicator of disease or changes in the human body,a Biomarker is anything that can be used as anindicator of disease or changes in the human body,

This interacts Chemically with its surroundings toproduce an effect that can be seen on the screen.

These methods help to get, Earlier Detection andBetter Understanding of Tumor development.

In other methods changes in size, density or watercontent, are evaluated

Imaging Methods …

Tumor Characterization ( Malignant orBenign)

By, a comparison of various images,By, a comparison of various images,obtained with different methods

o Biopsy : If a definite Diagnosis still cannotbe made, is necessary.

THE ROLE AND THE SKILLS OF THE RADIOLOGIST

The radiologist is likely to be the First Personto Detect a Tumor.

Imaging Specialists detect cancer duringroutine screening and are the MostExperienced Physicians in choosing from awide range of available imaging techniques inwide range of available imaging techniques inorder to get the best results.

After the detection of cancer, the radiologistinterprets the cross-sectional images of thepatient, makes the Diagnosis and determinesthe Stage and Extent of the disease based ontheir findings.

Prof. Hiroshi Honda, Japan

“Image interpretation is the Most VisibleContribution of Radiologists.

Diagnosis by Expert Radiologists is basedDiagnosis by Expert Radiologists is basedon the Extensive knowledge of Anatomy,Normal Variations, Pathology and TechnicalPrinciples of the Imaging Modality.”

In case of cancer, Patient Care is a TeamEffort.

A Multidisciplinary Approach and goodTeamwork between the Various Physiciansare crucial to the successful care of cancerpatients from Detection to Treatment andFollow-up.patients from Detection to Treatment andFollow-up.

The role of the Radiologist is not limited tothe phase between Detection and Diagnosisbut extends further, by involving in theChoice of Therapy, its Monitoring, Delivery,and Follow-up.

Staging

1. The importance of staging 2. The Radiologist takes Centre Stage 3. The communication Chain 4. Looking forward

THE IMPORTANCE OF STAGING

In addition to Detection and Characterizationthe Tumors,

Imaging is , Extremely Useful in taking the NextStep (Staging).

Exact localization of the tumor, Exact localization of the tumor, Define the surrounding area, Any Cancer spread ; if so, How far.Where the Best point for the Biopsy is, Which provides the first hints as to the

‘Staging’ .

Staging is , the most important thing todetermine the first steps of treatment – ifnot the Entire Treatment Plan

In this sense, Staging is essentially theReconnaissance, for the ‘Battle Plan’ ofTreatment will be drawn up.Treatment will be drawn up.

Imaging is by far the Most Effective Methodto Accurately Stage Cancer, and;

the Radiologist’s Skill and Experience, ofmedical images, plays a very important part.

Prof. Anno Graser, Germany “Accurate staging is widely based on

Imaging.No other Test allows for the depiction of

both the Primary Tumor and its Potentialboth the Primary Tumor and its PotentialMetastases.

The Prognosis of any Malignant Conditiondepends on the Initial Stage at the time ofDiagnosis.”

THE RADIOLOGIST TAKES CENTRE STAGE

With a broad range of Radiological Tools andTechniques, Radiologists can Choose :

How to Examine the body for Staging cancer. every Method is influenced by various factors,

such as :such as : the Location of Body where the Primary Tumor is The Areas to which cancer is most likely to Spread, The Sensitivity of the patient to Radiation ( age,

physical condition, pregnancy, etc.) and, in some cases, the Cost of the Examination.

The Most Commonly used methods for staging:

CT , PET-CT and, increasingly, MRI ,particularly where a Whole-body exam isrequired,

but other techniques such as Ultrasound, X-ray, but other techniques such as Ultrasound, X-ray,and Mammography are also commonly used.

Endoscopy in Some cases. No single method is Guaranteed to spot

everything, But a Combination can be used to provide a

more comprehensive picture.

Prof. Yves Menu, France

“ To answer different questions, theRadiologist can use all imaging techniques.

But it is important to understand that there But it is important to understand that thereis no single perfect examination.

In most cases, a Combination ofexaminations is the appropriate strategy,even if CT is the usual starting point.”

Treatment & Therapy

1. Treatment Monitoring with Imaging(saving time)

2. The growing use of Image-guidedTherapies

3. Interventional Radiology and MinimallyInvasive Treatments

4. Future developments

TREATMENT MONITORING WITHIMAGING: SAVING TIME

Once Cancer has been Localized and Staged,the Next Step is Treatment.

Here, as in every stage of oncologic care, Here, as in every stage of oncologic care,Imaging is of Fundamental Importance.

Imaging Techniques are used to MonitorTherapy, which allows doctors to Gauge theSuccess of the Therapeutic Plan from thebeginning.

TREATMENT MONITORING …

By checking up the Effectiveness of aTreatment one can :

Changing the therapy as soon as it becomesnecessary (Crucial timesaving )necessary (Crucial timesaving )

And improving quality of life during andafter treatment.

Imaging techniques Can Measure theEffectiveness of Treatment by showing howthe tumor responds to the selected therapy

TREATMENT MONITORING … Response Criteria Models (Various ) the most commonly used is the RECIST Model

(Response Evaluation Criteria In Solid Tumors) a set of Rules that Define whether the Patients : Improve (response) Stay the same (stabilization) Stay the same (stabilization) Or Worsen (progression) Monitoring includes :

1-An initial Scan (Various imaging techniques),before the Treatment2-Later Scans , to assess the Response (Complete,Partial or Stable)

TREATMENT MONITORING … Treatment response is Traditionally monitored

by :Measuring the Dimensions of the Primary

Tumor the Dimensions of a number of Lymph nodes the Dimensions of a number of Lymph nodes

and Abnormalities, and : Comparing with the original Pre-treatment

Images. In addition, certain Imaging Tools can show

Tumor Metabolism, increasingly importantinformation in Treatment Planning.

TREATMENT MONITORING … Functional and Molecular Imaging are

increasingly popular in cancer management. These techniques use Contrast Products or

Biomarkers, (swallowed or injected), To Highlight Certain Body Tissues or Biological

Molecules.Which in CT, MRI PET, they can show Cellular Which in CT, MRI PET, they can show CellularActivity and Molecular Processes in Organisms,including Tumors.

By Knowing the nature of a tumor and itsInteractions with the rest of the body,

One can more easily define which Therapy ismost likely to be Effective.

.”Dr. Jean de Villiers, South Africa

“Imaging is used to assess Response to Treatmentlargely using Tumor Size and/or Recurrence.

It is also used to monitor possible Side Effects oftherapy and therapeutic interventions.

Conventional imaging, such as x-ray, US , CT andMRI utilize Measurements to assess Response orMRI utilize Measurements to assess Response orProgression.

Response is typically classified as being : Progressive - Stable – Partial Response – or

Complete Response to Treatment. Functional and Molecular Imaging will include : assessment of Tumor Metabolism and there by

predict Response to a particular therapy

Follow-up Care

1. The importance of follow-up care 2. Tools of the trade2. Tools of the trade 3. The radiologist’s role 4. What the public should know about

imaging in follow-up care

THE IMPORTANCE OF FOLLOW-UP CARE

Cancer can be a particularly Resilient disease. Cure ? most medical professionals avoid using

this term (Recurrence Capability). Instead, physicians prefer to talk of ‘Remission’

(Reduced the Spread of the disease)(Reduced the Spread of the disease) Partial Remission,( a 50% reduction in tumor

growth Complete Remission, ( the Tumor and all

manifestations of the cancer havedisappeared).

THE IMPORTANCE OF FOLLOW-UP CARE …

So , patients should undergo Regular Checkupsafter declared to be in Remission.

Follow-up care involves a Series of RegularExaminations in order to monitor :

Remission or any possible Recurrence. (the Earlier Recurrence is spotted, the Better the (the Earlier Recurrence is spotted, the Better the

Prognosis) This is where Imaging plays one of its Most

Important Functions, (non-invasively Detects : the State of the Disease or

its Recurrence before symptoms appear). It is a Cornerstone of follow-up cancer care.

TOOLS OF THE TRADE

Much like other stages of Cancer Care, Patients undergo follow-up by : CT, MRI or US US : to detect occurrence of Lymph node and

Liver metastasis. CT : to detect CT : to detect Local Recurrence, as well as Metastases to

lymph nodes and distant Organs. Late Complications of Chemotherapy and

Radiotherapy. MRI : for similar purposes, but is more useful

in detecting Brain and Bone metastasis.”

THE RADIOLOGIST’S ROLE

Radiologists contribute to post-cancer careby :

Detecting RecurrenceDiagnosing Complications as a result of

treatment (often difficult to distinguishtreatment (often difficult to distinguishfrom Recurrence)

Early detection of Recurrence requires deepknowledge about Patterns of Recurrence ineach type of cancer.

WHAT THE PUBLIC SHOULD KNOW ABOUT IMAGING IN FOLLOW-UP CANCER CARE “They should know that : Imaging is the Most Important Reference

for the Follow-up of Treatment.Clinical Information and, in some cases,Clinical Information and, in some cases,

Biological Data are important.The medical decision always relies on a

Multidisciplinary Approach.”

Thanks for your attention