Hello, I'm Kristin Dittmar, Assistant

Professor of Radiology at the Ohio State

University Comprehensive Cancer Center,
James Cancer Hospital and
Solove Research Institute.
I specialize in diagnostic imaging
of the abdomen and pelvis as well
as interventional radiology procedures for
the diagnosis and treatment of cancer.
Basically, I use imaging to diagnose and
treat cancers using minimally
invasive image guided techniques.
Today, I'm here to tell you
about imaging and cancer.
We will discuss the types of imaging tests
and procedures that oncologist might order
to help detect, diagnose and
treat cancer patients.
These images are read by physicians
like me, who are radiologists.
Imaging also plays an important role in
cancer research both in human trials,
to evaluate new,
innovative drug therapies and
in animal studies to help us learn
how cancer develops and progresses.
Imagine tests for cancer use different
forms of energy to evaluate what is
happening inside the body.
The science and practice of imaging
began with the discovery of X-rays in
1895 by Wilhelm Roentgen.
He used x to refer to these rays because
they were an unknown form of radiation.
Today, this radiation plays an essential
role in the detection, diagnosis, and
treatment of cancer.
We also use forms of energy
that are not as energetic
as ionizing radiation to diagnose and
treat cancer such as MRI and ultrasound.
Diagnostic imaging of cancer helps
physicians locate a tumor in a body
when a patient complains about
something like pain or fatigue.
Using imaging, we can learn
whether a malignancy is present,
where it may have originated and evaluate
whether the cancer has metastasized or
spread to other organs in the body.
In this presentation,
I'm going to introduce to use several
diagnostic imaging modalities and
help you to understand the role they
play in cancer diagnosis and treatment.
Modalities include X-rays and
mammograms, computer tomography or
CT scans, magnetic resonance imaging or
MRI scans, nuclear medicine scans,

specifically positron emission

tomography and ultrasound.
I'll begin with X-rays which
are useful for seeing bone and
joint problems, imaging of the lung,
bowel, bladder and kidneys.
In most circumstances however,
other imaging methods such as CT and
MRI Scans are far better at
showing details of soft tissues.
Here is an example of an X-ray that
was used to evaluate a patient with
right leg pain.
In this radiograph of the pelvis,
you can see numerous small,
metallic densities located
over the central pelvis.
The patient has a history of prostate
cancer and these are small brachytherapy
seeds used to deliver radiation to
the prostate to treat prostate cancer.
So we know that this patient has
a history of prostate malignancy.
You can see in the image
there are two arrows.
Notate that the left femur is normal
compared to the right femur which is
abnormal.
The arrow over the right femur points to a
halusinasi in the head of the Right femur.
Note the bony abnormality.
Given the presence of this abnormality and
knowing that the patient has a history of
prostate cancer we are concerned
about metastatic disease.
Therefore we decided to
advance to MRI imaging.
Here is the MRI image.
You see the tumor that occupies
the proximal femur and femoral head
as well as a soft tissue lymph node
located anterior to the bone tumor.
These findings strongly
suggest a malignancy.
To confirm this, the patient
underwent an image guided biopsy,
shown in this CT image.
We used a biopsy needle
to go into the leg and
extract tissue from the soft tissue for
diagnosis.
Here's a chest X-ray.
A patient presented with a cough.
Note the central venous catheter
is located over the right chest.
This catheter is used to
administer chemotherapy drugs
in a patient who has a history of cancer.
The soft tissue densities throughout
both lungs are called pulmonary nodules.

These lung nodules are very worrisome for

metastatic cancer therefore the patient
underwent a CT scan for better evaluation.
Here in the CT scan which was
taken in the coronal plane,
which shows the patient is basically
standing in the upright position.
Again, we can see the numerous
pulmonary nodules.
Given the history of malignancy and
potential need for a new drug or
clinical research trial,
the patient underwent a CT guided biopsy
of one of these pulmonary nodules.
This CT scan shows the use of
imaging guidance to obtain a biopsy
of one of the patient's nodules.
This tissue would be very important for
diagnosis and to test for
molecular markers that help
identify new patient therapies.
Mammography is a type of
imaging technique that uses
low energy X-rays to take
specialized images of the breast.
They show details of the breast tissue and
are used for
the evaluation of malignancies.
During the past ten years, older X-ray
machines that captured images on film have
been replaced with X-rays that
capture images in a digital format.
These digital images are cleaner,
clearer and capture more information.
They can also be exchanged more
easily by doctors in consultation.
There are two categories of mammography,
screening and diagnostic mammography.
Screening mammography is designed to
detect breast cancer in women who
have no signs or symptoms of the disease.
They can detect tumors that
are only a few millimeters in size.
Sometimes too small to otherwise to be
felt during a clinical self breast exam.
Diagnostic mammography is used to
show details of breast tissue and
help determine whether a breast
abnormality detected in a screen mammogram
or a lesion which is palpitated on
a clinical exam might be cancerous.
Here is an example of
a diagnostic mammogram.
The image demonstrates a nodular focus or
density located in the upper outer breast.
This lesion has speculated margins.
It was therefore worrisome for
primary breast malignancy.
A diagnostic mammogram
shows only one lesion

therefore a targeted ultrasound

was performed, shown here.
The targeted ultrasound
demonstrates a hypoechoic
stellate lesion located in the same region
which is also suspicious for malignancy.
Therefore, an ultrasound guided
biopsy was obtained of this lesion
which proved to be a malignancy.
The patient went on to
receive a curative surgery.
When performing breast imaging,
we use the Breast Imaging Reporting and
Data System or the BIRAD system.
The BIRADS system categorizes a possible
malignancy using a scale of one to five,
with one being benign and
five being very suggestive of malignancy.
This lesion we just discussed
was designated a BIRADS 5.
Therefore, a ultrasound
guided biopsy was obtained.
Computerized tomography scans which
are sometimes called CAT scans,
which is an acronym for
Computerized Axial Tomography
are X-ray like images of internal
organs and structures of the body.
CT scans record changes by
using low energy X-rays
as they pass through different organs
which all have different densities.
Computers compile that data and
produce scans that are cross
sectional slices through the body.
Computers also stack those slices to
produce 3D images that provide additional
information about some cancers.
Our newest CT scanners have focused
on reducing radiation doses that
are delivered during imaging.
These low dose CT scanners are helpful for
patients who are young or for
those undergoing screening studies such
as people who are suspected to have
kidney stones or cigarette smokers
that are at high risk for lung cancer.
CT scans can be used for
a number of reasons when evaluating
a patient's symptoms including
evaluation of a patient's organs which
are suspected to be abnormal based
on clinical history of physical exam
to help locate a tumor within the body.
To learn if a patient's cancer is
responding to the prescribed treatment and
follow up imaging and cancer patients to
exclude an early occurrence of disease.
Here is an example of the CT scan of
a patient who went to the emergency room,

complaining of blood in the urine or

what we call hematuria.
This exam is used to exclude
renal stones in renal cancer.
Here are two examples of delayed phase
imaging that show the IV contrast being
excreted in the collecting systems in the
kidneys such as the kerasys in ureters.
The collecting systems is well
opacified with excreted IV contrast
allowing you to see them clearly.
While these are only two
representative sizes,
you can see that when 3D information
is compiled by computers, we can
make beautiful reformats of the patient's
collecting systems in three dimensions.
So the doctors can better see and
find details of this.
Because CT scans emit radiation some
patients worry about whether repeated CT
scans are safe.
Whether they might cause
a second cancer later in life.
There are two ways to look at this.
As radiologists,
we prescribe radiation very judiciously.
We use doses of radiation
that are as low as possible,
after determining the benefit versus risk
of radiation exposure for the patient.
If the patient needs
ionizing radiation for
imaging, it is likely more important
to make an urgent diagnosis
than worry about the potential risk of
a theoretical malignancy later in life.
Sometimes, these decisions
are made by a group of physicians
especially in patients who are pregnant or
young like children.
Typically, people who are having imaging
performed are a much older age group or
people who are much less likely to
develop a secondary malignancy,
which can take 20 to 30 years to develop.
The amount of radiation that a patient
is exposed to during diagnostic imaging
is very small.
Some people say that you
can absorb more radiation
during a transcontinental flight
than you do from an imaging study.
MRI scan are extremely powerful magnets
that use radio waves rather than
ionizing radiation to create detailed
cross sectional images of the body.
These magnets induce hydrogen ions
in the body to respond to radio
waves which produce signals based

on the water content of the organ.

MRI scans are used for
many of the same reasons as CT scans,
although MRI is sometimes used
rather than CT scans because they can
produce better images of soft tissues.
Here are two examples of the brain.
One is a CT scan and
the other is an MRI scan.
You can see that the MRI shows
much great soft tissue details.
A trained radiologist can see details in
the CT scan, but it is more difficult.
Patients must be carefully screened for
MRI studies because of the strong
magnetic fields involved.
Certain implants,
medical devices and other objects
ranging from artificial joints and
pacemakers to shrapnel are certified
according to whether they are magnetic
resonance safe, conditional or unsafe.
MR unsafe devices contain iron and
present a clear danger to the patient.
Iron containing objects cannot be worn or
brought into the MRI scanner because
highly magnetic objects can become
dangerous projectiles in the presence
of a strong MRI magnetic field.
Nuclear medicine involves the injection
of radioactive tracers that release small
doses of radiation for a short time, for
the diagnosis and treatment of cancer and
other diseases.
Unlike the forms of imaging we discussed
earlier, nuclear medicine involves making
the patient radioactive then using
a crystal to detect the radiation.
When the photons emitted from
the patient interact with the crystal,
a small light is produced.
These flashes of light become data points
which a computer turns into images.
Examples of nuclear medicine imaging
include whole body bone scans which can
reveal the presence of cancer in
bones administering radioactive
phosphate molecules to patients
which are used in bone production.
Thyroid scans are obtained by using
radioactive iodine which the thyroid gland
normally absorbs and metabolizes.
Heart or cardiac scans are produced by
injecting small amounts of radiotracers
which also use naturally acquired
ions such as thallium and
potassium analog to detect
heart muscle damage.
Gallium imaging uses radioactive Gallium
salts, which are taken up by tumors and

areas of inflammation such as inflamed or

infected tissue.
This technique is used for
patients with fevers
where we cannot find an apparent origin or
in patients with lymphoma.
SPECT imaging stand for Single Photon
Emission Computerized Tomography.
SPECT imaging takes the information
from nuclear medicine scans and
makes a 360 degree image which
therefore comes together as a 3D image.
This provides information that can also
be used to help locate tumors that are in
the body in three dimensions.
In cancer imaging,
the most common nuclear medicine study is
Positron Emission Tomography or
PET imaging.
This is similar to other forms of nuclear
medicine in that a small amount of
radiation is administered
into the patient.
However PET imaging is different
than other nuclear medicine tests
in that it produces two photons which
emit in equal and opposite directions.
That is 180 degrees apart from each other.
Allow the crystals to rotate around the
patient taking a 180 degree picture and
produce the images.
The most common imaging agent in PET
imaging is FDG, Fluoro Deoxy Glucose.
For FDG imaging, the patient is injected
with a radioactive sugar that is taken up
by cells that are metabolically active.
The sugar is then trapped within the cell.
The theory is that the faster a cell is
growing, the more sugar it can take up.
Therefore, PET scans are used in the
detection of patients evaluated for cancer
because cancer cells tend to grow much
faster than other cells within the body.
PET scans can help stage diseases and
localize certain tumors within organs.
Here is a PET image that shows
multiple areas of normal uptake.
They include the brain which
is yellow in color and
tells us it is very metabolically active.
The heart muscle is also
metabolically active.
Some activity is shown in the bladder
because sugar is excreted by the kidneys.
Ultrasound uses high frequency sound
waves that bounce off organs and
tissues and are detected by probes and
produce images called sonograms.
Also special transducers can be used
to evaluate blood flow through vessels

called doppler flow.

As I mentioned earlier imaging plays
an important role in cancer research.
X-rays, CT scans and nuclear medicine
imaging can help provide critical
information to help understand how
cancer develops and progresses.
Micro imaging technologies
enable us to use CT and
PET to produce images of small
animals used in research.
The information obtained from these images
allows scientists to gain information
about how cancer develops and
spreads in animal models.
Animal research helps scientists
to study the safety and efficacy
of experimental new drugs in animals,
hopefully preventing harm in patients.
As you can see, imaging is
a multimodality area of healthcare.
We have seen examples of radiographs,
CT scans, thermography,
ultrasound, MRI,
nuclear medicine and PET imaging.
Most of these technologies
were discovered after 1975.
The rapid progression of scientific
advancements will only allow imaging to
become a more integral part of
patient diagnosis and treatment.