| See |  |
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| L. Cancer | |||||||
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CLINICAL/DIAGNOSTIC PROBLEM |
INVESTIGATION |
RECOMMENDATION (GRADE) |
COMMENT |
DOSE |
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| Many
of the clinical problems related to the diagnosis of cancer have already
been partly covered within the individual system sections. Brief
notes are provided here about the use of imaging in the diagnosis,
staging, and follow-up in some of the common primary malignancies.
Paediatric malignancies are not included as their management is always
at specialist level. (For breast cancer see also section J) |
A
CXR is necessary at presentation for most malignant lesions to identify
possible pulmonary metastases. CXR is also part of many follow-up protocols (e.g. testicular lesions). Follow-up investigations to monitor progress (e.g. post-chemotherapy) are often required. Some are driven by trial protocols rather than clinical nee and thus should be appropriately funded. Concern about radiation dose in diagnostic imaging is generally less relevant in this section. |
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| Mouth and pharynx | |||||||
| Diagnosis | MRI/CT | Indicated
(B)
|
Diagnosis is commonly by clinical examination, supported by MRI or CT when there is high suspicion of occult disease. | 0/II | |||
| Staging | MRI/CT | Indicated (B) | Imaging
is not commonly needed for diagnosis. Staging should include
cervical node groups; colour Doppler US may improve N staging.
Chest may be examined by XR or (preferably) CT, but clinical
effectiveness of M staging is unproven. |
0/II | |||
| PET | Specialised investigation (C) | To
identify recurrent disease in previously treated patients. |
IV | ||||
| Parotid | |||||||
| Diagnosis
|
US | Indicated (B) | Useful
for superficial lobe tumours. If FNAC (fine needle aspiration
cytology) is required, US can be used for guidance. If US is
unable to visualise the entire tumour, then MRI is the investigation of
choice for extent. |
0 | |||
| MRI/CT | Specialised investigation (B) | MRI
is preferred for the assessment of parotid masses. Limitations in
ability to identify calcification make CT better for inflammatory
disease. MRI cannot reliably differentiate benign from malignant
lesions and does not obviate the need for a tissue diagnosis in
indeterminate cases. However, MRI is better than CT for soft
tissue resolution. Dental amalgam may also be a problem on CT.
CT should be used if MRI is impracticable and for suspected inflammatory
disease. |
0/II | ||||
| PET | Not indicated (B) | PET is poor at differentiating benign from malignant lesions. | 0 | ||||
| Staging | MRI/CT | Indicated (B) | MRI should be used in preference to CT for the staging of parotid masses because of its superior soft tissue resolution, multiplanar capability, and ability to define both the extent of disease and any intracranial involvement. | 0/II | |||
| PET | Specialised investigation (C) | May have a role in staging tumours as it will identify metastases in normal-sized lymph nodes. | IV | ||||
| Larynx | |||||||
| Diagnosis | CT/MRI | Indicated only in specific circumstances (B) | Clinical endoscopy and biopsy for diagnosis | II/0 | |||
| Staging | CT/MRI | Indicated (B) | Where available, MRI is preferable to CT for T staging. Either can be used for N staging. | II/0 | |||
| US | Specialised investigation (B) | Can be used for T and N staging and follow-up in centres with appropriate expertise. | 0 | ||||
| Thyroid | |||||||
| Diagnosis | NM | Indicated (B) | For detection of residual/recurrent differentiated thyroid cancer after thyroidectomy. | II | |||
| US | Indicated (B) | Used in combination with or to guide FNAC. | 0 | ||||
| Staging | CT/MRI | Indicated (B) | To assess large primary tumours, detect distant metastases, and for medullary thyroid carcinoma in MEN syndromes. | II/0 | |||
| NM | Indicated (B | For detection of residual/recurrent differentiated thyroid cancer after thyroidectomy. | IV | ||||
| US | Indicated (B | Where appropriate expertise is available. | 0 | ||||
| Lung | |||||||
| Diagnosis | CXR | Indicated (A) | Lung cancer can have several different clinical presentations and, if it is suspected, CXR is indicated. A proportion of cancers will be radiographically occult despite the presence of malignant cells in the sputum. | I | |||
| CT | Indicated (B) | CT has not yet proven to be of benefit as a screening tool for lung cancer. CT will increase sensitivity of detection of early tumours. | II | ||||
| Staging | CT | Indicated (A) | When correlated with histological findings, CT has an overall accuracy of up to 80% in the detection of mediastinal adenopathy. Mediastinal lymph node biopsy will be required in some cases to confirm the CT findings prior to thoracotomy. PET is more accurate (see below). | I | |||
| MRI | Indicated only in specific circumstances (C) | In the majority of patients with lung cancer MRI does not offer any benefits over CT. However, it is of value in patients with superior pulmonary sulcus (Pancoast’s) tumours. MRI may also be of value in demonstrating the vascular anatomy of the mediastinum in those patients allergic to iodinated contrast media. Studies have shown MRI to be better than CT at differentiating tumour from distal atelectasis. | 0 | ||||
| PET | Indicated (B) | FDG-PET is significantly more accurate than CT or MRI in the staging of patients with non-small-cell lung cancer and has a high negative predictive value for nodal metastases. | IV | ||||
| Oesophagus | |||||||
| Diagnosis | Ba swallow | Indicated (B) | Before endoscopy in dysphagia, Ba studies are sensitive for the diagnosis of oesophageal cancer. | II | |||
| Staging | CT | Indicated (B) | Many patients present with advanced disease that is inoperable. CT can be used as the initial investigation to exclude these patients. Endoscopic US is needed for more accurate TNM staging, particularly if it will alter the surgical approach. | II | |||
| Endoscopic US | Indicated (B) | Requires expertise. If available, it can be the initial investigation. Often used if CT suggests patient is operable, to plan most appropriate surgery. | 0 | ||||
| PET | Specialized investigation (B) | PET is of use in the pre-surgical assessment of patients with oesophageal cancer in order to detect metastases. | IV | ||||
| Stomach | |||||||
| Diagnosis | Endoscopy/Ba meal | Indicated (B) | Endoscopy and double contrast Ba meal are equally sensitive in the diagnosis of advanced gastric cancer. Endoscopy allows biopsy for histology. | 0/II | |||
| Staging | CT | Indicated (B) | CT is currently the best staging investigation if active treatment is planned. Endoscopic US is useful for local staging. Laparoscopy is most sensitive for small peritoneal deposits. | III | |||
| Liver: primary lesion | |||||||
| Diagnosis | US | Indicated (B) | The majority of lesions will be identified by US. | 0 | |||
| MRI/CT | Specialized investigation (B) | Indicated if biochemical markers are elevated and US is negative or the liver is very cirrhotic. Enhanced MRI and arterial phase CT are the most accurate in delineating tumour extent. | 0/II | ||||
| Staging | MRI/CT | Indicated (B) | MRI is probably the optimal investigation for assessing the involved segments and lobes. CT arterial portography and intra-operative US are useful where available. | 0/II | |||
| Liver: secondary lesion | |||||||
| Diagnosis | US | Indicated (B) | US will reliably detect metastases >2 cm and can guide biopsy. | 0 | |||
| CT/MRI | Indicated (B) | Indicated when US findings are negative and clinical suspicion is high. MRI is better for characterising lesions. CT arterial portography is sensitive but not specific, but many now use triple-phase spiral CT techniques following IV enhancement. CT and MRI often form part of other staging and follow-up protocols. | III/0 | ||||
| PET | Specialized investigation (C) | Indicated when other imaging is equivocal, to exclude other metastatic disease prior to surgery. | IV | ||||
| Pancreas | |||||||
| Diagnosis | US/CT | Indicated (B) | Much depends on local expertise and the patient's body habitus. US is usually successful in thin patients; CT is better in more obese patient. Biopsy can be performed using US or CT. Endoscopic US is the most sensitive. | 0/III | |||
| MRI/MRCP/ERCP | Specialized investigation (C) | MRI for clarification of problems. MRCP or ERCP may also be needed. Interest in PET is increasing. | 0/0/II | ||||
| Staging | MRI/CT | Indicated (B) | Especially if radical surgery is contemplated. There is wide local variation: some centres use angiography; others, spiral CT. | 0/III | |||
| PET | Specialized investigation (B) | Of use in cases where there is a significant possibility of distant spread. | IV | ||||
| Endoscopic US | Specialized investigation (B) | Should be reserved for those patients in a tertiary referral centre whose disease is deemed resectable on the basis of CT/MRI. | 0 | ||||
| Colon and rectum | |||||||
| Diagnosis | Ba enema/colonoscopy | Indicated (B) | Much depends on local availability and expertise. | III/0 | |||
| CT | Specialized investigation (C) | Increasing interest in CT, particularly in the elderly and infirm. | III | ||||
| Staging | CXR, US | Indicated (B) | For pulmonary and liver metastases. Endoluminal US is useful for local rectal spread. | I,0 | |||
| CT, MRI | Indicated (B) | Local pre-operative staging to assess rectal lesions before pre-operative radiotherapy. Many centres now treat liver secondaries aggressively, which may necessitate MRI and/or detailed CT. MRI and CT are often complementary; both can assess other abdominal spread. Interest in PET is increasing. | III,0 | ||||
| Follow-up | US | Indicated (B) | For liver metastases. Preliminary evidence now supports routine imaging follow-up in asymptomatic patients. | 0 | |||
| CT/MRI | Indicated (B) | For liver metastases and local recurrence. | III/0 | ||||
| PET | Specialized investigation (A) | PET is the best imaging technique for the evaluation of suspected local recurrence in patients with colorectal cancer and is of use in the assessment of patients prior to hepatic resection for metastases. | IV | ||||
| Kidney | |||||||
| Diagnosis | CXR | Indicated (C) | To look for pulmonary metastases. | I | |||
| US | Indicated (B) | US is a sensitive detector of renal masses > 2 cm and accurately characterises masses as cystic or solid. US helps to characterise some masses indeterminate at CT. | 0 | ||||
| IVU | Not Indicated (B) | Less sensitive than US for the detection of renal masses. However, this is the method of choice for detecting transitional cell carcinoma of the pelvicalyceal system or ureters. | II | ||||
| CT | Indicated (B) | A sensitive detector of renal masses 1.0 - 1.5 cm and accurately characterises masses. | III | ||||
| MRI | Specialized investigation (B) | Contrast-enhanced MRI is as sensitive as CT for detecting and characterising renal masses. MRI should be used if the masses are not adequately characterised by CT and US or if iodinated contrast medium is contraindicated because of diminished renal function or allergy to iodinated contrast agents. | 0 | ||||
| Staging | CT/MRI | Indicated (B | MRI is better at detecting advanced stages, e.g. renal vein involvement. CT and MRI are equivalent at staging T1 disease. | III/0 | |||
| PET | Not Indicated (C) | Current evidence with PET demonstrates no advantage for staging or detection of renal carcinoma | IV | ||||
| Recurrence | CT | Indicated (B) | For symptoms suggesting relapse around nephrectomy bed. Routine follow-up is not recommended | III | |||
| Bladder | |||||||
| Diagnosis | IVU | Indicated only in specific circumstances (B) | Cystoscopy is the investigation of choice to diagnose bladder tumours. | II | |||
| US | Indicated only in specific circumstances (B) | Not sufficiently accurate to assess small (< 5 mm) bladder tumours, but enables assessment of upper tract. | 0 | ||||
| Staging | IVU | Indicated (B) | To assess kidneys and ureters for further urothelial tumours. | II | |||
| CXR | Indicated (C) | To look for pulmonary metastases | I | ||||
| MRI | Indicated (B) | Sensitive and specific and useful in invasive transitional cell carcinoma. CT is less specific than MRI, but of use if MRI is not practicable | 0 | ||||
| PET | Specialized investigation (C) | Role yet to be clarified | IV | ||||
| Prostate | |||||||
| Diagnosis | US | Indicated (B) | Some variation according to local availability and expertise. TRUS (transrectal ultrasonography) is widely used together with guided biopsies | 0 | |||
| Staging | MRI | Specialized investigation (B) | Some variation exists in the range of investigative and therapeutic policies. MRI with appropriate coils is sensitive for assessment before possible radical prostatectomy. Staging is continued into the abdomen when pelvic disease is found. CT is of no value for local staging. | 0 | |||
| NM | Indicated (B) | To assess skeletal metastases, when PSA (prostate specific antigen) is significantly elevated. | II | ||||
| Testicle | |||||||
| Diagnosis | US | Indicated (B) | In suspected testicular malignancy and when presumed inflammatory disease does not respond to treatment. | 0 | |||
| Staging | CT chest, abdomen and pelvis | Indicated (B) | CT is the mainstay of staging, and at initial diagnosis should include the chest, abdomen and pelvis. Pelvis can be omitted if all risk factors, including abdominal nodal disease, have been excluded. For non-seminomatous germ cell tumours, thoracic CT is more sensitive in the detection of pulmonary metastases than CXR. | III-IV | |||
| Follow-up | CT | Indicated (B) | If risk factors for pelvic nodal disease have been excluded, pelvic CT may be omitted. The appearance of residual masses may assist in decisions on whether to undertake surgery. MRI has no clear advantage over CT, apart from reducing radiation burden. CT of previously involved areas can demonstrate morphological evidence of enlargement of masses. | III-IV | |||
| PET | Specialized investigation (B) | When a marker rises following treatment, F-18 FDG-PET may be helpful in identifying the site of relapse. | IV | ||||
| Ovary | |||||||
| Diagnosis | US | Indicated (B) | Most ovarian lesions are initially identified on clinical examination or US. Transabdominal US supplemented by transvaginal US and colour Doppler are used in their evaluation. | 0 | |||
| MRI abdomen and pelvis | Specialized investigation (B) | MRI is useful for problem solving, as it is more accurate than US in determining the presence of malignancy. Surgery is still required in some cases to distinguish benign from malignant disease. | 0 | ||||
| Staging | CT abdomen and pelvis | Specialized investigation (B) | Many specialists request imaging in addition to staging by laparotomy | III | |||
| MRI abdomen and pelvis | Specialized investigation (B) | MRI is useful when enhanced CT is contraindicated, the patient is pregnant, or for problem solving. | 0 | ||||
| PET | Specialized investigation (C) | Indicated in difficult management situations to assess distant and local spread. | IV | ||||
| Follow-up | CT abdomen and pelvis | Specialized investigation (B) | CT/MRI defines extent, but normal findings do not exclude recurrence. CT is used to assess treatment response. | III | |||
| MRI abdomen and pelvis | Specialized investigation (B) | MRI is useful for surgical planning and problem solving. | 0 | ||||
| NM | Specialized investigation (C) | Clinical examination and the serum Ca-125 radio-immunoassay are used to detect recurrent disease. | II | ||||
| Uterus: cervix | |||||||
| Diagnosis | MRI | Indicated only in specific circumstances (B) | Usually a clinical diagnosis. MRI may assist in complex cases | 0 | |||
| Staging | MRI | Indicated (B) | MRI provides better demonstration of tumour and local extent than CT and is also better for pelvic nodes. Para-aortic nodes and ureters must also be examined. Some centres now use TRUS for local invasion | 0 | |||
| PET | Indicated only in specific circumstances (C) | PET is useful in difficult situations to define the extent of disease with accompanying image registration. | IV | ||||
| Relapse | MRI abdomen and pelvis | Specialized investigation (B) | MRI provides better information in the pelvis than CT. Biopsy (e.g. of nodal mass) is easier with CT. | 0 | |||
| Uterus: body | |||||||
| Diagnosis | US/MRI | Indicated (B) | MRI can give valuable information about benign and malignant lesions | 0/0 | |||
| Staging | MRI | Indicated (B) | MRI is the optimum technique for staging endometrial carcinoma | 0 | |||
| CT | Not indicated (B) | CT is of limited value for local staging and is therefore unlikely to affect management. | III | ||||
| Lymphoma | |||||||
| Diagnosis | CT | Indicated (B) | Diagnosis will usually be made by excision biopsy of a lymph node but CT demonstration of extensive nodal enlargement may strongly suggest the diagnosis of lymphoma. For disease confined to the torso it will also allow the selection of a site for image-guided biopsy. | III-IV | |||
| NM | Specialized investigation (B) | Ga-67 can show foci of occult disease (e.g. mediastinum). PET is used in some centres. | II | ||||
| Staging | CT | Indicated (B) | Depending on site of disease, the head and neck may also need to be examined. | III-IV | |||
| MRI | Indicated only in specific circumstances (B) | While MRI is not indicated routinely as an initial staging test, it shows nodal sites as well as CT and can image marrow burden of disease, which has prognostic implications. | 0 | ||||
| PET | Specialized investigation (B) | FDG-PET is as accurate as CT | IV | ||||
| Follow-up | CT | Indicated (B) | CT of areas affected at staging for Hodgkin's disease. If there is clinical suspicion of relapse or progression, it is appropriate to examine chest, abdomen and pelvis, especially for non-Hodgkin's lymphoma. | III-IV | |||
| MRI | Not indicated initially (B) | MRI may help assess the nature of a residual mass detected at CT. | 0 | ||||
| NM/PET | Specialized investigation (B) | Studies directly comparing Ga-67 and FDG-PET are limited. It is clear that FDG-PET is more sensitive and specific than Ga-67, especially for small masses and below the diaphragm. With Ga-67 a pre-treatment image must be obtained. | III/IV | ||||
| CXR | Indicated (B) | For initial assessment of response in overt thoracic disease the CXR is entirely appropriate. | I | ||||
| Musculoskeletal tumours | |||||||
| Diagnosis | XR and MRI | Indicated (B) | Imaging and histology are complementary. Best before biopsy | I + 0 | |||
| NM | Indicated (B) | To ensure that the lesion is solitary | III | ||||
| Staging | MRI and CT chest | Specialized investigation (C) | MRI is best for local spread and extent. CT is used to detect lung metastases. | 0 + III | |||
| PET | Specialized investigation (C) | PET is best imaging technique for detecting metastases from an unknown primary tumour. | IV | ||||
| Metastases from unknown primary tumour | |||||||
| Diagnosis
of primary lesion
'Carcinoma, unknown primary' is a diagnosis of exclusion and not a diagnosis in its own right. Histology review is key to identifying likely sites of primary tumours and treatable tumours, e.g. lymphomas, germ cell tumours, and head and neck primary tumours. The site of initially identified metastases determines the likely origin, e.g. disease in upper cervical lymph nodes is likely to come from head and neck primaries, disease in axilliary lymph nodes from breast carcinoma, and cancer cells in ascites from ovarian carcinoma in women. |
CXR | Indicated (B) | CXR can help to identify the source of the occult primary | I | |||
| CT chest, abdomen and pelvis | Specialized investigation (B) | CT is the most sensitive investigation in determining the primary site. This may allow effective treatment, e.g. for lung cancer, and palliation. It also allows entry into clinical trails and has unquantified psychological benefits to patient and doctor. | IV | ||||
| Mammography | Indicated only in specific circumstances (C) | Breast cancer survival is better from occult breast cancer metastases. Even in the presence of metastases, it is worthwhile to diagnose and treat cancer of the breast. | I | ||||
| MRI breast | Specialized investigation (B) | MRI may demonstrate a primary breast carcinoma with axilliary lymph node metastases despite a normal mammogram and US. | 0 | ||||
| PET head and neck, supradiaphragmatic or whole body | Specialized investigation (C) | After full work-up, including CT or MRI. | IV | ||||
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