L. Cancer

L. Cancer

CLINICAL PROBLEM		INVESTIGATION	RECOMMENDATION {GRADE}		COMMENT
Many of the clinical problems related to the diagnosis of cancer have already partly been covered within the individual system sections. Brief notes are provided here about the use of imaging in the diagnosis, staging and follow-up of some of the common primary malignancies. Paediatric malignancies are not included as their management is always at specialist level. For breast cancer see Section J. A CXR is necessary at presentaion 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 reuired; some are driven by trial protocols rather than clinical need and thus should be appropiately funded.
Parotid
Diagnosis	L1	US	Indicated	[B]	To establish presence of a mass, particularly in superficial lesions.
Diagnosis	L1	MRI or CT	Indicated	[B]	Useful in the deep portion of the gland and before complex surgery.
Staging	L2	MRI or CT	Indicated	[B]	Especially when complex surgery contemplated; to see relations and involvement of deep lobe.
Larynx
Diagnosis	L3	Imaging	Not indicated	[B]	This is a clinical diagnosis.
Staging	L4	CT or MRI	Indicated	[B]	MRI has the advantage of direct coronal imaging. MRI will eventually supersede.
*Thyroid*
Diagnosis	L5	US and NM	Indicated	[B]	See Neck Section B1. US guided core biopsy is increasingly being used.
Staging	L6	CT or MRI	Indicated	[B]	To assess local extent (e.g. retrosternal extension and nodes).
Staging	L6	NM	Indicated	[B]	After thyroidectomy.
*Lung*
Diagnosis	L7	CXR PA and Lat	Indicated	[B]	But can be normal, particularly with central tumours.
Diagnosis	L7	CT	Specialised investigation	[B]	Many centres proceed directly to bronchoscopy which allows biopsy. CT is superior in identifying lesions responsible for haemoptysis.
Staging	L8	CT chest, upper abdomen	Indicated	[B]	Despite limitations in specificity of nodal involvement, etc. Some centres perform NM for possible skeletal metastases.
		MRI	Specialised investigation	[B]	Assists in estimating local invasion of chest wall, particularly for apical and peripheral lesions and mediastinal invasion. Helps distinguish adrenal adenoma from metastasis.
		PET	Specialised investigation	[B]	A single expensive investigation to identify small metastatic foci may save a lot of other investigations and inappropriate surgery.
*Oesophagus*
Diagnosis	L9	Barium swallow	Indicated	[B]	Before endoscopy in dysphagia.
Staging	L10	CT	Indicated	[B]	Despite limitations in sensitivity and specificity of nodal involvement. Simpler than MRI for lung, liver and intra-abdominal nodes.
Staging	L10	Transoeso- phageal US	Indicated	[B]	Increasing use of transoesophageal US for local staging where available.
*Liver: Primary Lesion*
Diagnosis	L11	US	Indicated	[B]	The majority of lesions will be identified.
Diagnosis	L11	MRI or CT	Indicated	[B]	If biochemical markers elevated and US negative or liver very cirrhotic. Enhanced MRI and arterial phase CT most accurate in delineating tumour extent.
Staging	L12	MRI or CT	Indicated	[B]	MRI probably the optimal investigation in assessing involved segments and lobes. CT arterial portography and intra-operative US useful where available.
*Liver: Secondary Lesion*
Diagnosis	L13	US	Indicated	[B]	US will show the majority of metastases and guides biopsy.
Diagnosis	L13	CT or MRI	Indicated	[B]	When US negative and clinical suspicion high. MRI better for characterising lesions. CT arterial portography is sensitive but not specific, but many now use triple phase spiral CT techniques following intravenous enhancement. CT and MRI often part of other staging and follow-up protocols.
*Pancreas*
Diagnosis	L14	US or CT or MRI	Indicated	[B]	Much depends on body habitus. US usually successful in thin patients; CT better in the more obese. MRI for clarification of problems. Biopsy using US or CT. ERCP or MRCP may also be needed. Endoscopic US, where available, most sensitive.
Staging	L15	CT or MRI abdomen	Indicated	[B]	Especially if radical surgery contemplated. Wide local variation: some centres use angiography, others spiral CT; laparoscopic US also used.
*Colon and Rectum*
Diagnosis	L16	Ba enema or colonoscopy	Indicated	[B]	Much depends on local policy, expertise and availability. See Section G. Increasing interest in CT of the colon.
Staging	L17	US	Indicated	[B]	For liver metastases. Endoluminal US useful for local rectal spread.
Staging	L17	CT or MRI abdomen, pelvis	Indicated	[B]	Local pre-operative staging to assess rectal lesions before pre-operative radiotherapy. Many centres now treat liver secondaries very aggressively, which may necessitate MRI and/or detailed CT. MRI and CT often complementary; both can assess other abdominal spread. Increasing interest in PET here.
?Recurrence	L18	US liver	Indicated	[B]	For liver metastases. Some debate about the value of routine US follow-up in asymptomatic patients.
?Recurrence	L18	CT or MRI abdomen, pelvis	Indicated	[B]	For liver metastases and local recurrence. Increasing interest in PET here.
*Kidney*
Diagnosis	L19	US	Indicated	[B]	See Renal Mass H7.
Staging	L20	CT or MRI abdomen	Indicated	[B]	For local extent, venous, nodal and ureteric involvement, opposite kidney etc.
Staging	L20	CT Chest	Not indicated routinely	[B]	The presence of lung metastases does not usually influence management. Increasing interest in PET.
?Recurrence	L21	CT abdomen	Indicated	[B]	For symptoms suggesting relapse around nephrectomy bed. Routine follow-up not recommended.
*Bladder*
Diagnosis	L22	Imaging	Not indicated	[B]	Cystoscopy is the optimal (although not infallible, e.g. diverticulum) investigation.
Staging	L23	IVU	Indicated	[B]	To assess kidneys and ureters for further urothelial tumours.
Staging	L23	CT or MRI abdomen and pelvis	Indicated	[B]	When radical therapy contemplated. MRI is probably more sensitive. CT widely used for radiotherapy planning.
*Prostate*
Diagnosis	L24	Transrectal US	Indicated	[B]	Some variation according to local availability and expertise. Transrectal US is widely used together with guided biopsies. Some interest in MRI and PET here.
Staging	L25	MRI/CT pelvis	Specialised investigation	[B]	Some variation in range of investigative and therapeutic policies. MRI with appropriate coils is sensitive for assessment before possible radical prostatectomy. Staging continued into the abdomen when pelvic disease found.
Staging	L25	NM	Indicated	[B]	To assess skeletal metastases, when PSA is significantly elevated.
*Testicle*
Diagnosis	L26	US	Indicated	[B]	Especially when clinical findings equivocal or normal.
Staging	L27	CT chest, abdomen, pelvis	Indicated	[B]	Management now depends heavily on accurate radiological staging.
Follow-up	L28	CT abdomen	Indicated	[B]	Some centres still routinely examine the chest as well, especially for patients without biochemical evidence of disease. Some debate as to whether whole pelvis is needed at follow-up unless there are identified risk factors.
*Ovary*
Diagnosis	L29	US	Indicated	[B]	The majority of lesions are diagnosed by US (including TV with Doppler), laparoscopy or laparotomy. Some are identified by CT/MRI investigations for abdominal symptoms. MRI useful for elucidating problems.
Staging	L30	CT/MRI abdomen, pelvis	Specialised investigation	[B]	Many specialists require CT or MRI in addition to staging by laparotomy. CT is still more widely available.
Follow-up	L31	CT abdomen, pelvis	Specialised investigation	[B]	Usually to assess response to adjuvant therapy. Also use, along with markers, to detect relapse.
*Uterus: Cervix*
Diagnosis	L32	Imaging	Not indicated routinely	[B]	Usually a clinical diagnosis. MRI may assist in complex cases.
Staging	L33	MRI or CT abdomen and pelvis	Indicated	[B]	MRI provides better demonstration of tumour and local extent. Also better for pelvic nodes. Para-aortic nodes and ureters must also be examined. Some centres now use transrectal US for local invasion.
?Relapse	L34	MRI or CT abdomen and pelvis	Specialised investigation	[B]	MRI provides better information in the pelvis. Biopsy (e.g. of nodal mass) easier with CT.
*Uterus: Body*
Diagnosis	L35	US or MRI	Indicated	[B]	MRI can give valuable information about benign and malignant lesions.
Staging	L36	MRI or CT investigation	Specialised	[B]	Both CT and MRI can show extra-uterine disease. But MRI can also demonstrate intra-uterine anatomy.
*Lymphoma*
Diagnosis	L37	CT	Indicated	[B]	CT good at evaluating nodal sites throughout the body. Also allows biopsy although excision of whole node preferable where possible.
Diagnosis	L37	NM	Specialised investigation	[B]	NM (gallium) can show foci of occult disease (e.g. mediastinum). PET used in some centres.
Staging	L38	CT chest, abdomen, pelvis	Indicated	[B]	Depending on site of disease, head and neck may also need to be examined. Increasing interest in PET here.
Follow-up	L39	CT or MRI	Indicated	[B]	Increasing role for MRI in long term follow-up and residual masses.
Follow-up	L39	NM	Specialised investigation	[B]	Consider NM for gallium positive disease. Some centres use PET.
*Musculoskeletal Tumours*
Diagnosis	L40	XR + MRI	Indicated	[B]	Imaging and histology complementary. Best before biopsy: See Musculoskeletal Section D.
Staging	L41	MRI local disease + CT chest	Specialised investigation	[C]	See Musculoskeletal Section D. CT for lung metastases.
*Metastases from Unknown Primary Tumour*
Diagnosis of primary lesion	L42	Imaging	Not indicated routinely	[C]	Rarely beneficial. Some exceptions for specialists, younger patients or favourable histology.

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