European Society of Radiology

European Society of Radiology
MIKING CNCER VISIBLE
the roleof imagingin
INTERNATI ONAL DAYOF RADIOLOG
u!li"hed !y the ESR # European Society of Radiology In
cooperation with ES$I # European Society of $ncologic Imaging $cto!er %&'% Coordination( ESR $ffice) Neutorga""e *)'&'& Vienna) +u"tria hone( ,- ./'0 1// .& 2.#& 3a4( ,-./'0 1//.&2.# ..' E#Mail( communication"5myESR6org 7776 myE SR6org Managing Editor: 8ulia atu99i Editors: Sim:n Lee) Michael Crean Contributing Writers: Michael Crean ,Chapter 10) Sim:n Lee ,Chapter /0) M;li"ande Rouger ,Chapter '-.0) <a=id >i9?a ,Chapter %0 Art Direction & Layout: Ro!ert un9 Photo Credits: "ee page *.
@he logo for the International <ay of Radiology 7a" !een created 7ith the help of the MR Center of E4cellence in Vienna) +u"tria6 Ae 7ould li?e to than? rof6 Siegfried @rattnig and M"6 Claudia Kronner7etter for their =alua!le help6
An Introduction Prevention B creening

'6@he =alu; of "creening in cCncer care %6 National "creening programme"( o!Decti=e" and reality /6 atient information .6 @hing" to ?eep in mind !efore an e4amination i" carried out 16 3uture de=elopment" age E age'F
Page 4 Page !
age '' age'% age'.
Detection
'6 Medical imaging in the detection of cCncer age %' age /& %6 @he role and "?ill" of the radiologi"t /6 @he communication flo7 .6 Informing the pu!lic 16 3uture de=elopment"
Page"#
age %. age %F age %E
taging
'6@he importance of "taging %6 @he radiologi"t ta?e" centre "tage /6 @he communication chain .6 Loo?ing for7ard
Page $$
age /. age /2 age /E age .&
%reat&ent & %herapy

'6@reatment monitoring 7ith imaging( "a=ing time %6 @he gro7ing u"e of image#guided therapie" /6 Inter=entional radiology and minimally in=a"i=e treatment" .6 3uture de=elopment"
Page 4$
age .. age .2 age .E age 1&
'o((ow)up Care
'6@he importance of follo7#up care %6 @ool" of the trade /6 @he radiologi"tG" role .6 Ahat the pu!lic "hould ?no7 a!out imaging in follo7#up care
Page *$
age 1. age 12 age 1* age 2&
About the Interviewees ,(ossary
Page +$ Page +#
Ma?ing CCncer Vi"i!le( the Role of Imaging in $ncology +n Introduction

CCncer) in all of it" more#than#%&& form") i" one of the leading cau"e" of death 7orld7ide6 +ccord# ing to the a =ery large proportion of thi" progre"" i" !eing made in the field of medical imaging6 Aorld Health $rgani"ation) the di"ea"e accounted for around '/I of all death" in %&&E6 <ue to it" high incidence) mo"t people ?no7 "ome# thing a!out the di"ea"e and) ine=ita!ly) the maDor# ity al"o ?no7 "omeone 7ho ha" !een afflicted !y it6 But it" +lthough oncology i" the !ranch of medicine that traditionally deal" 7ith cancer) modern cancer care i" a multidi"ciplinary underta?ing) and "pe# ciali"t" in medical imaging # 7hether they are radiologi"t" or practitioner" of nuclear medicine # are e""ential pre=alence al"o ma?e" cancer a =ery high priority for re"earch and healthcare in=e"tment6 +"ide from the continuing "earch for a cure) huge glo!al effort" are mem!er" of the team6 @he techno# logical ad=ance" made in imaging eJuipment and the de=elopment of "pecific techniJue" for e=ery "tage of cancer care mean that the contri!ution of
ing) from e=ery continent) each of 7hom ha" pro# medical imaging) a" 7ell a" the e4perti"e of tho"e 7ho =ided it) their =alua!le input =ia "hort inter=ie7"6 @hi" practi"e i" indi"pen"a!le6 material ha" !een put together 7ith the lay# per"on in @hi" !oo?let) 7hich ha" produced to e"pecially for mind) !ut a" an aid to!een the ne7comer radiology and themedical fir"t International <ay included of Radiology) aim" to imaging) 7e ha=e a glo""ary of term" highlight the e""ential contri!ution imaging ma?e" to at the !ac? of the !oo?let6 fi=e maDor "tep" in the cancer care chain( "creening and pre=entionK detectionK "tagingK treatment Ae hope that thi" pu!lication 7ill pro=ide "ome and u"eful therapyK and follo7#up6 in"ight" into the role of radiology and medical imaging in cancer care) and 7e "incerely hope it pro=ide" a fe7 @he 7hole to !oo?let ha" !een 7ritten 7ith the gen# rea"on" cele!rate the International <ay of Radiology erou" a""i"tance of '1 e4pert" in oncologic imag 7ith u" on No=em!er E6
!eing made to impro=e the pre# =ention) detection) and treatment of cancer) and
re=end:n B
1. THE VALUE OF SCREENING IN CANCER CARE 2. NATIONAL SCREENING PROGRAMMES: OBJECTIVES AND REALITY 3. PATIENT INFORMATION 4. THINGS TO KEEP IN MIND BEFORE AN EXAMINATION IS CARRIED OUT
THE VALUE OF
and "mall clinically
SCREENING IN
Early detection RadiologyG" role i" central to cCncer man# and pre=ention of di"ea"e ha" crucial agement) 7ith a 7ide choice!ecome of tool" and in the fight again"t cCncer) e"pecially in people techniJue" a=aila!le for the detection) "taging at higher ri"? of de=eloping malignancy) a part of the general and treatment of the di"ea"e6 But 7hat i" le"" population that 7ell ?no7n i" the =alu; of medical imaging in 7ill continu; to gro7 7orld7ide in theof decade" recogni"ing early man# ife"tation" cCncerto come6 undetecta!le tumour" <ynamic Contra"t# !efore they !ecome clinically apparentK a Enhanced MR capacity that pu"he" radiology to the fore of L$f cour"e) there i" no image of !rea"t guarantee that radiology oncologic care6 cCncer can pre=ent cCncer !efore
@here identify
are the
many early
7ay" "ign" $f
for of the
radiologi"t" an
to
indi=idual tool"
de=eloping
cCncer6
=ariou"
a=aila!le) tho"e that u"e 4#ray technology) "uch a" mammography are for !rea"t cCncer
"creening) Recently)
"tandard
e4amination"6 tomo#
multidetector
computed
graphy ,C@0) a computeri"ed imaging tool 7hich i" u"ed to create /< image" !a"ed on 4# ray") ha" "ho7n it" "trength in applica# tion" "uch a" colorectal cCncer "creening6
it i" there) !ut it i" of tremendou" help in detecting precancerou" "ituation" li?e colonic polyp" and li=er cirrhotic cCncer care team" ha=e at their di"po"al6 In + recent National Lung Screening @rial ,NLS@0 nodule"6 If 7e detect a particular) different radio# logical te"t" ha=e in the Pnited State" "ho7ed a reduc# tion of tumour early) it may ma?e !ecome =ery helpful in "creening a" they can %&I in lung cCncer mortality among hea=y treatment much "impler "ho7 precancerou" le"ion" !efore they !ecome "mo?er" 7ho 7ere "creened 7ith lo7#do"e and cheaper and may e=en malignant and cau"e "ymptom"6 "a=e li=e" M "piral C@ =er"u" tho"e "creened 7ith traditional
che"t 4#ray6
mography "creening ha" helped reduce !rea"t Medical e4pert" agree that mo"t cancer" can cCncer mortality !y /&I) according to a recent !e dealt 7ith effecti=ely if detected early In "tudy) 7hich 7a" conducted o=er almo"t three thi" re"pect) imaging i") "econd only to la! decade"'6 te"t") 7hen it come" to the mo"t =alua!le tool"
rof6 N=e" MenO) 3rance
Multidetector C@ i" no7 !eing u"ed much more freJuently in the detection of pre# malignant le"ion") "o#called polyp") in the large !o7el) the di"co=ery # follo7ed !y endo"copic
re"ection # of 7hich may "ig# nificantly impro=e patient progno"i" !y prompting appropriate management6
@he !enefit" of "creening ha=e !een pro=en repeatedly "ince it" introduction6 Mam
L@hi" add" to e4i"ting "ucce""ful imaging "creening "tudie" "uch a" !rea"t and colon6 Aithout Jue"tion) early detection of di"ea"e i" greatly impro=ed 7ith imaging6M
<r6 Reginald Munden) PS+
Q@he "tudy QS7edi"h @7o#County @rialG 7a" pu!li"hed in %&'' in Radiologyby <r6 LC"9l: @a!Cr et al6 @he longe"t "tudy e=er conducted) it demon"trated that) %* year" after their fir"t mammogram) 7omen 7ho 7ere in=ited to get routine "creening had a "ignificant reduction in !rea"t cCncer mortality compared to tho"e 7ho recei=ed u"ual care6
MAKING CANCER VISIBLE PREVENTION THE ROLE OF IMAGING IN ONCOLOGY AND SCREENING
Mo"t countrie" ac?no7ledge the importance of running national "creening pro# gramme" for
NATIONAL SCREENING PROGRAMMES:

"creening programme" for !rea"t and cer=ical cCncer) and many of tho"e 7ho ha=e not already launched nation7ide programme" for colorectal cCncer are plan# ning to introduce them "oon6 Lung cCncer i" al"o under e=aluation a" a po""i!le "u!# Dect of "creening in many countrie"6 Setting up a national "creening pro# gramme i" a comple4 ta"?) partly !ecau"e it i" difficult to define preci"e target group" 7ith age limit") "imilar clinical hi"torie") and =ariou" other characteri"tic"6 Guide# line" for "creening are determined locally and !a"ed on the re"ource" of healthcare "y"tem") the health concern" of the population) and cultural attitude" and prioritie"6
OBJECTIVES AND REALITY
dence i" e4pected to increa"e !y a" much a" *&I !y %&/&) according to a recent "tudy %6
certain group" of patient"6 Ho7e=er) today) the only 7ide"pread "creening programme" are for !rea"t cCncer in 7omen u"ually aged roughly !et7een .& and F.) 7ho repre"ent the group 7ith the highe"t ri"? of de=eloping cCncer6
LLarge "erie" "eem to pro=e the !enefit of "uch a "creening) at lea"t in a carefully "elected population6M
Screening practice" =ary con"idera!ly from one country to another6 Ahile Korea offer" "creening on a national le=el for "tom# ach) li=er) colorectal) !rea"t and uterine cer=i4 cCncer) the mo"t common type" in that High rate" of under#reported di"ea"e pre"# ent another challenge in collecting clear and
relia!le figure") 7hile re"tricted acce"" to the late"t technology remain" a pro!lem in many part" of the 7orld6 @he a!"ence of adeJuate tool" for detecting early or pre# cancerou" condition" i" all the more alarm# ing in poorer countrie") 7here cCncer inci#
LIn mo"t de=eloping countrie") acce"" to "creening i" e4tremely limited or e=en non# e4i"tent6 Gi=en that cCncer incidence i" e4pected to ri"e dramatically in "ome of the"e countrie" in the coming decade") the glo!al medical community "hould 7or? together to define minimum "creening recommendation" for all countrie" and to pro=ide the nece""ary re"ource" # including eJuipment and training # for e""ential "creening programme"6M
rof6 Hed=ig Hrica?) PS+
%
country) China and South +frica) for e4ample) do not yet ha=e any e"ta!li"hed national "creening programme"6 Mo"t countrie" in
+merica and Europe operate
@he "tudy QGlo!al cCncer tran"ition" according to the Human <e=elopment Inde4 ,%&&E#%&/&0( a population# !a"ed "tudyG 7a" led !y <r6 3reddie Bray of the International +gency for Re"earch on CCncer ,I+RC0 and pu!li"hed in The LancetOncologyin 8une %&'%6
PATIENT
Aithout "uch glo!al guideline" or nation# 7ide "creening programme") it i" all the more important to pro=ide clear recom# mendation" to patient"6 Some people are more at ri"? than other" due to their clini# cal hi"tory or family !ac?ground) and doc# tor" can ad=i"e them on ho7 to proceed to a=oid any future complication"6 cancer6
INFORMATION
"hould !e "creened for lung cancer6 3or 7omen 7ith a lifetime cancer ri"? of %&I or greater) for in"tance 7omen 7ith a genetic ri"?) a !rea"t e4amination 7ith magnetic re"onance imaging ,MRI0 i" recommended6 eople 7ith
li=er cirrho"i" andRor hepatiti" B or C =iru" "hould !e "creened to detect any "ign" of li=er
L ro=iding the pu!lic 7ith complete information i" really a ?ey i""ue for the "ucce"" of a "creening campaign6 Ha=ing the patient a" a partner ma?e" e=erything ea"ier M
eople can o!tain information a!out "creening
L eople 7ho ha=e high ri"? factor") "uch a" a family hi"tory of particular cancer" and "ome related gene carrier") "hould !e "creened M
rof6 3eng 3eng) China
It i" generally accepted that people aged o=er 11) 7ith a "mo?ing hi"tory of one pac? per day o=er /& year") and former "mo?# er") 7ho ha=e Juit 7ithin the la"t '1 year")
from
their
general urologi"t") and
practitioner") any other
u!lic a7arene"" campaign" play a maDor role in thi" dialogue) and the participation of
gynaecologi"t")
"peciali"t) 7ho "hould !e a!le to ad=i"e 7hen to "creen and for 7hat6 Some patient" may al"o !enefit from their companie"G medical in"urance) 7hich in "ome coun# trie" may co=er the annual health#chec? for their
in"titutional
partner"
i" highly de"ir#
a!le6
Healthcare "ta?eholder" and cancer patient "ocietie" "hould !e incorporated into the"e campaign"6
employee" o=er a certain age6 @he "ucce"" of "creening depend" entirely on ho7 7ell#
Information i" al"o ?ey to impro=ing pu!lic healthcare6 @he more informed the pu!lic i") the li?elier they are to pu"h their go=#
informed the pu!lic i" and on the health policie" of each country6
ernment" to ta?e action6
THINGS TO KEEP IN MIND

L+ lot depend" on the educational le=el of the population6 Pnfortunately) in de=eloping countrie") there are "till great challenge" to achie=ing a "ati"factory le=el of under"tanding of the"e i""ue"6 @he population need" to !e informed a!out the importance of imaging in cancer "creening programme") in order for them to !e a!le to demand health authoritie" to "et up "uch programme"6M CCncer "creening undou!tedly !ring" !en# rof6 Marco" <uarte Guimarae") Bra9il L<i"ad=antage" are minor efit") 7hen it lead" to the identification of compared to the li=e" cCncer !efore it po"e" a real danger and "a=ed !y the technology6 reJuire" inten"i=e and often e4pen"i=e Mo"t radiological te"t" treatment6 But one "hould al"o !e a7are of the u"ed for early detection of ri"?" that are a""ociated 7ith imaging di"ea"e ha=e no or minimal e4amination"6 "ide effect" that are greatly out7eighed !y the Mammography) for in"tance) in=ol=e" a "mall !enefit"6M amount of ioni"ing radiation) 7hich can ha=e a
rof6 +nno Gra"er) Germany
potentially carcinogenic effect6 Becau"e it al"o u"e" 4#ray technology) C@ i" not a ri"? free procedure either6 Ho7e=er) radiation ri"?" Some e4amination") li?e mammography) may al"o cau"e di"comfort to patient") !ecau"e they 7ill ha=e a de=ice pre""ed firmly again"t their !odie"6 @he u"e of con# tra"t producS") media "7allo7ed or inDected into the !ody to enhance the contra"t of an effect" at
<iffu"ion cellularity map reflect" the pro!a!ility of cancer in the central pro"tate gland6
BEFORE AN EXAMINATION IS CARRIED OUT

image) may al"o cau"e allergie" and ?idney dy"function in "en"iti=e patient"6 $n the other hand) ultra"ound e4amination" u"ed in o=arSan cCncer "creening) for e4ample) ha=e no "ide all6 +" for multide# tector C@
colonography) it cau"e" much le"" di"comfort than con=entional colono"copy in "creening for colon cCncer) and can !e carried out much more rapidly6
3inally) one "hould not undere"timate the ri"? of fal"e po"iti=e diagno"i" and the "erie" of co"tly e4amination" it can trigger6 + fal"e po"iti=e re"ult indicate" that a per"on ha" a gi=en condition 7hen they do not6 3or in"tance) a cCncer te"t might return po"iti=e 7hen the per"on i" actually healthy6
remain =ery lo7 and mu"t !e 7eighed again"t the !enefit" !rought !y the e4amination6
lE
3#fluorodeo4ygluco"e ,3<G0 E@#C@ of lung cCncer 7ith media"tinal lymph node meta"ta"e"
L3al"e po"iti=e diagno"i" may re"ult in o=er# in=e"tigation of 7hat ultimately turn" out to !e a !enign condition6 @hi" can in turn re"ult in unnece""ary an4iety in the patient and unnece""ary co"t" M
@he !e"t option for patient" i" to di"cu"" all the"e i""ue" directly 7ith their doctor") 7ho "hould inform them of all the po""i!le ri"?") a" 7ell a" the !enefit") !efore deciding to
undergo "creening te"t"6
atient" "hould ?no7
that "creening i" not perfectK it may not detect e=ery cCncer) !ut it can detect cCncer early enough to achie=e remi""ion6
FUTURE
Imaging techniJue" ha=e "ignificantly impro=ed in recent decade"6 +" technolo# gie" are con"tantly !eing refined) imaging potential imaging modalitie" 7ill !ecome e=en more accurate and relia!le in the future6 Lo7# do"e che"t "piral C@ in lung cCncer "creening i" =ery promi"ing6 challenge" But and there are to "till !e enormou" an"7ered mi""ed
DEVELOPMENTS
Radiologi"t" are increa"ingly u"ing radia# tion do"e reduction "trategie") 7hich min# imi"e the ri"?" of radiation 7ithout in 4#ray#!a"ed rent trend in "creening i" to7ard per"on# ali"ation) to find out the indi=idualG" ri"? of cCncer) !a"ed on =ery "pecific !iological te"t"6 modalitie" compromi"ing
image Juality6 Computer# aided detection and diagno"i" "y"tem" can reduce the rate of cancer" and may al"o help to
Jue"tion"
characteri"e early le"ion"6 Re"earcher" are al"o 7or?ing on 7ay" to identify high#ri"? "u!Dect") !a"ed on molecular or genetic "tudie") 7hich may enhance "creening effecti=ene""6
!efore thi" techniJue can !e appro=ed for u"e around the 7orld6 $ne of the main pro!lem" remain" the "ig# nificant di"parity in acce"" to and u"e of tool" for pre=ention and early detection of cCncer6
Cooperation 7ith other medical "pecialtie" i" ?ey to the"e achie=ement"6 Radiologi"t"
already 7or? in multidi"ciplinary team" to treat cCncer patient"6 Ci:"e colla!oration 7ith other
LAe all ?no7 that "ome people are more predi"po"ed to "ome cancer") and 7e "hould maintain our progre"" in the a!ility to propo"e to the indi=idual a "creening programme that i" tailored) rather than a Qma"" productG6M
+ i" /#dimen"ional image from aforneuro"urgical na=igational "peciali"t") in"tance !iolo# gi"t") phy"ici"t" LIt de"ira!le to de=elop andneuro"urgeon doctor" of nuclear medicine i" fundamental "y"tem) to 7hich allo7" to "ee functional "trategie" ena!le ne7 the In addition to the !enefit" !rought !y imaging) to the de=elop# ment of ne7 "creening tool"6 technologie" to !e the operation6 @he tumour i" in information during yello76 diet and o!e"ity @he management) a" 7ell a" +" i" the ca"e in many other area" of medicine) implemented uni=er"ally in motor corte4 ,the part of the !rain that Control" motor en=ironmental and life"tyle modi# fication") the cur# order to reduce mortality6M may al"o help to pre=ent cCncer in the future6 function0 i" in red6 urple indicate" the large =ein" o=erlying the <r6 +driana <iegue9) +rgentina "urface of the !rain6
etection
1. MEDICAL IMAGING IN THE DETECTION OF CANCER 2. THE ROLE AND SKILLS OF THE RADIOLOGIST 3. THE COMMUNICATION FLO! 4. INFORMING THE PUBLIC
Imaging play" a maDor role in the detection of cancer a" it pro=ide" a detailed in"ight into the e4act location and e4tent of the di"ea"e6 It can al"o pro=ide detailed information
MEDICAL IMAGING IN THE DETECTION OF

tion of a malignancy 7hile participating in a "creening programme6 cancer6 a!out more detailed including information their a!out di"tinct
onance imaging ,MRI0 and mammography) the latter !eing u"ed "pecifically to detect !rea"t
"tructural or cancer#related change"6 Emerging method" of molecular imaging) 7hich com!ine traditional imaging technology and nuclear medicine tech# niJue") can al"o !e u"ed to o!tain
a!normalitie") meta!oli"m6
@here are =ariou" 7ay" to detect cancer u"ing imaging method"6 Cancer may !e detected incidentally) 7hen an e4amina# tion i" carried out for other rea"on") or there may !e clear "ymptom" and the patient may undergo
LCertainly radiology i" !y far the !e"t method for cancer detection in the maDority of cancer"6 Ho7e=er) the =a"t maDority of tumour" are only apparent 7ith an ad=anced te"t) e"pecially at the initial "tage) and radiology i" certainly the maDor player6M
Modern medical technology offer" a 7ide range of imaging method" to imaging "pe# ciali"t"6 Aell ?no7n method" u"ed for the detection of cancer are ultra"ound ,PS0)
L@he techniJue of choice depend" on the type and "ite of the cancer6 +ll of the"e modalitie" pro=ide cro""# "ectional anatomical image"6 PS and C@ are generally le"" e4pen"i=e and more 7idely a=aila!le than MRI and are therefore u"ed more freJuently around the 7orld6M
imaging to confirm) l:cate) and determine the e4tent of the di"ea"e6 +nother po""i!ility i" of cour"e the detec
In many ca"e" cancer i" identified !a"ed on the di"co=ery of a!normalitie" in the
computed tomography ,C@0) magnetic re"#
appearance of "oft ti""ue and !one6 But there are al"o functional imaging tech# niJue") 7hich detect phy"iological or functional change") "uch a" "pecific change" in !lood flo7 that can al"o "ignify the pre"# ence of cCncer6
change") 7hich open" up a completely ne7 field of po""i!ilitie" "uch a" earlier detec# tion and !etter under"tanding $ne of the of tumour promi"ing po"itron
de=elopment6 molecular
mo"t i"
imaging
techniJue"
emi""ion tomography , E@0) 7hich i" mo"t + =ery promi"ing "et of imaging techniJue" are a=aila!le to radiologi"t" through the method" of molecular imaging) 7hich dif# fer" from traditional imaging in that !io# mar?er pro!e" are u"ed to target "pecific area" or "u"piciou" finding"6 In general) a !iomar?er i" anything that can !e u"ed a" an indicator of di"ea"e or change" in the human !ody) 7hich interact" chemi# cally 7ith it" "urrounding" to produce an effect that can then !e "een on the "creen6 In compari"on to other method" 7hich "ho7 change" in "i9e) den"ity or 7ater contenS) the radiologi"t can o!"er=e molecular Ahen it come" to the characteri"ation of a finding) or the or differentiation !enign !et7een it a i" often com!ined 7ith C@ , E@#C@0 and u"ed to trac? pro!e" in order to detect meta# "tatic di"ea"e6
malignant
a!normality)
"ometime" difficult to reach a final diagno"i"6 @o a=oid unnece""ary in=a"i=e pro# cedure" and "a=e the patient further di"comfort) a compari"on of =ariou" image") often o!tained through different method") i" the fir"t "tep to7ard" a final diagno"i"6 If a definite diagno"i" "till cannot !e made) a !iop"y) 7here "mall part" of the a!normal#
ity are collected for further e4amination) i" nece""ary6
impro=ed to generate higher re"olution image" 7hile "ignificantly decrea"ing the amount of radiation and e4po"ure time6
Side#effect" may occur and =ary depend# ing on the method u"ed and the area of the !ody to !e e4amined6 @he u"e of con# tra"t agent" may cau"e allergie" and may po"e ri"?" to patient" 7ith renal in"uf# ficiency6 @echniJue" "uch a" PS and MRI do not entail any radiation e4po"ure and are generally con"idered to !e =ery "afe6 In "ome "ituation" ho7e=er) MRI i" not recommended) for in"tance in patient" 7ith a pacema?er or other metallic implant)
!ecau"e of the magnetic field u"ed during the e4amination6 Method" li?e 4#ray and C@) on the other hand) e4po"e the patient to ioni"ing radiation6 Radiologi"t" al7ay" u"e the lo7e"t radiation do"e po"# "i!le to get the de"ired re"ult" and mod# ern imaging de=ice" are con"tantly !eing
LEffect" on the patient can !e con"idered a" related to di"comfort during the te"t) u"e of contra"t agent") irradiation and directly in=a"i=e te"t" "uch a" !iop"ie"6 Radiation effect" are from ioni"ing radiation from 4#ray and C@6 Effect" are proportional to the do"e of radiation and cumulati=e effect" of mOltiple e4amination" although the"e are "eldom rele=ant in daily practice6M
<r6 8ean de Villier") South +frica
THE ROLE AND THE SKILLS
OF THE
@he radiologi"t i" li?ely to !e the fir"t per# "on to detect a tumour !a"ed on either clear "ymptom" or pre=iou" "u"picion"6 Imaging "peciali"t" al"o detect cCncer during routine "creening and are the mo"t e4perienced phy"ician" in choo"# ing from a 7ide range of a=aila!le imaging techniJue" in order to get the !e"t re"ult"6 Ahen a tumour or an a!normal# ity i" detected) the fir"t ta"? of the radiologi"t i" to identify the e4act location of the tumour and the e4tent of the di"ea"e6 +fter the detection of cCncer) the radiologi"t
LImage interpretation i" the mo"t =i"i!le contri!ution of radiologi"t"6 <iagno"i" !y e4pert radiologi"t" i" !a"ed on the e4ten"i=e ?no7ledge of anatomy) normal =ariation") pathology and technical principie" of the imaging modality6M
+ radiologi"t i" not only an e4pert in the field of imaging techniJue") !ut al"o an e4pert in under"tanding the pattern" and appearance of cCncer in =ariou" !ody part" and organ" a" 7ell a" 7ay" of local and di"tant "pread of different tumour") "o#called meta"ta"e"6
Ahen it come" to cCncer) patient care i" a team effort and not the 7or? of a "ingle doctor6 + multidi"ciplinary approach and good
team7or? !et7een the =ariou" phy"ician" are crucial to the "ucce""ful care of cCncer patient" from detection to treatment and follo7#up6 @he role of the radiologi"t i" not limited to the pha"e !et7een detection and diagno"i" !ut e4tend" further) a" radiology 7ill al"o !e in=ol=ed in the choice of therapy) it"
monitoring) deli=ery) and follo7#up6 In ho"pital" e"pecially) a multidi"ciplinary approach to the fight again"t cCncer i" =ery common and radiologi"t" freJuently 7or? in a team together 7ith other "peciali"t"6
interpret" the cro""#"ectional image" of the patient) ma?e" the diagno"i" and determine" the "tage and e4tent of the di"ea"e !a"ed on their finding"6
<etection of hepatocellular carcinoma
L+ lot of communication ta?e" place 7ith the clinical oncologi"t" and "urgeon") u"ually in the conte4t of regular multidi"ciplinary committee meeting"6 Ho7e=er) it i" good practice to communicate 7ith colleague" 7ho ha=e referred patient" for e4amination" and) o!=iou"ly) are in charge of the patient6 @hi" communication can !e !y telephone) e#mail or =ideoconference6M
Characteri"ation of eJui=ocal ultra"ound finding" ,not "ho7n0 7ith C@6 C@ of the ?idney "ho7" a cy"tic "tructure in the left ?idney ,7hite arro706 Ho7e=er)thi" i" not a "imple cy"t6 C@ demon"trate" a "olid nodule ,green arro70) 7hich i" "u"piciou" for a cy"tic cancer6
THE
Ahen the final diagno"i" i"
COMMUNICATION FLOW
reached and more in=ol=ed6 Ahen 7or?ing in multidi"# clarified) the ne4t "tep i" to inform the patient of their condition and the further "tep" and treatment option" a=aila!le6 +t thi" "tage) the role and the in=ol=ement of the radiologi"t =ary and are "trongly depen# dent upon the local "ituation6 In mo"t ca"e" it i" referring @he radiologi"t i" in many ca"e" the fir"t per"on to detect a tumour) !ut rarely the one 7ho inform" the patient6 But the radiologi"t i" "till left 7ith a degree of per"onal ciplinary team") the attending phy"ician often reJue"t" that the radiologi"t !e pre"# ent 7hen the patient i" informed of a find# ing) "o that "pecific Jue"tion" regarding imaging can !e an"7ered !y a "peciali"t6
phy"ician" 7ho 7ill inform the patient a!out the re"ult") a" they are generally the people 7ho ha=e the mo"t detailed ?no7ledge of the patientG" medical hi"tory6 @here are al"o ca"e") 7here the final diagno"i" can only !e reached !y performing a pathological te"t) 7hich
re"pon"i!ility a" the patient ha" to !e ad=i"ed to "ee their attending phy"ician Juic?ly to di"cu"" their diagno"i" and further option"6 He "hould ma?e it clear to the patient that they "hould "ee? further treatment and "ee their doctor6 In the"e "itua# tion") patient" might al"o a"? the radiologi"t directly for clear information6
e4elude" the participation of a radiologi"t6 But the con=entional i" !ac?ground role of a" the the
radiologi"t
changing approach
"lightly and
multidi"ciplinary
patient"G
demand" ma?e the radiologi"t more and
L3or in"tance) if a cCncer i" detected) the patient "hould !e =ery clearly encouraged to con"ult hi" referring clinician =ery "oon in order to organi"e the medical "trategy6 More and more the patient" a"? for clearly "hared comprehen"i=e information6 Ho7e=er) thi" i" not a "imple "ituation) !ecau"e it may change the patientG" life) "o the 7ay the information i" communicated "hould !e con"idered =ery
INFOR MING
Aith imaging !eing one of the maDor play# er" in the fight again"t cancer) it i" impera# ti=e that the pu!lic !e 7ell informed a!out it" !enefit" and po""i!ilitie"6 @he early detection of cancer) it" progno"i" and detailed information a!out the e4tent of the di"ea"e 7ouldnGt medical !e a=aila!le +ll to patient" 7ithout imaging6 further treatment deci"ion" are !a"ed on the"e finding"6
THE PUBLIC
undergo a "pecific procedure6 It i" al"o in the pu!licG" !e"t intere"t" to !e a7are of the "pe# cific co"t" of imaging and 7hether a referral i" needed if they 7ant to "ee a "peciali"t or undergo a "pecific imaging e4amination6 Be"ide" all the information on the !enefit" of modern imaging) the pu!lic "hould al"o !e made a7are of the po""i!le di"ad=an# tage" and "ide effect" 7hich go hand in hand 7ith
Computed tomography image of the che"t u"ing lo7 radiation do "e
@here i" al"o a need to inform the pu!lic a!out the 7ide range of imaging tech# niJue"
"ome techniJue"6 Some method" e4po"e the human !ody to larger amount" of radiation than other" and "ome "uch a" ultra"ound and MRI u"e no radiation at all6 It i" important for patient" to !e a7are of tho"e fact" in order to under"tand 7hy the radiologi"t ha" to decide in each indi=idual ca"e 7hich method i" the mo"t appro# priate6 @hi" i" particularly important for patient" 7ith "pecial condition") 7ho may for
a=aila!le and 7hich are the !e"t diagno"tic te"t" for a "pecific cancer or condition6 More recently de=eloped method" "uch a" E@#C@
are not 7ell ?no7n to patient") !ut !ring crucial !enefit" to the field of oncologic
imaging6
Information on the a=aila!ility of the dif# ferent method") 7hether they are a=aila!le at all or only in "peciali"ed ho"pital depart# ment") 7ould ma?e it ea"ier for patient" to con"ider their option" 7hen they ha=e to
in"tance !e allergic to contra"t agent" or ha=e metal implant") in the ca"e of MRI
e4amination6
regnancy al"o limit" the u"e of
"ome method"6
L@he population "hould !e informed a!out the importance of imaging in cCncer detection6 @hu" the population 7ill !e a!Se to reJuire that health DEVELOPMENTS authoritie" ta?e action aimed at implementing cCncer detection6M
FUTURE
.& year") there ha=e !een maDor
Medical imaging "trongly depend" on tech# nology) "o progre"" and further de=elop# ment"
E@) 7hich i" a!le to produce a /< image of a
functional proce"" in the !ody) ha" !ecome an integral part of cCncer diagno"i"6 +" tumour" or
in the field of imaging technology are =ital to
the progre"" of the di"cipline it"elf6 $=er the la"t
inflammation u"e up high le=el" of gluco"e) the
radiologi"t can ea"ily trac? the location and "pread of the di"ea"e6
inno=ation" in the field of medical imaging) "uch a" C@ and MRI) 7hich currently achie=e a
high le=el of diagno"# tic accuracy and "patial re"olution 7hen com!ined 7ith the method" of molecular imaging) 7hich i" for many
But it i" not only ne7ly de=eloped method" that !ring a!out impro=ement" in cCncer
detectionK e"ta!li"hed method" "uch a" MRI al"o ha=e a lot to offer6 +t the moment mo"t MR de=ice" operate at a magnetic field#
radiologi"t" the mo"t promi"ing tool for the future6
"trength of '61 and / @e"la) !ut in e4periment" @he =ery early "tage" of cCncer and other ill# ne""e" "hould then !ecome detecta!le u"ing cu"tomi"ed !iomar?er" 7hich can detect the "malle"t trace" of the di"ea"e6 @he u"e of radiola!elled gluco"e in com!ination 7ith "trength" of up to '' @e"la ha=e !een achie=ed and pro=ide e4tremely high Juality image"6 <iffu"ion#7eighted imaging) 7hich allo7" the mapping of the diffu"ion proce"" of mol# ecule") ha" already "ho7n "ome =ery po"iti=e
Brea"t MR image of In=a"i=e Lo!ular Carcinoma

L E@#MR i" a cutting#edge imaging modality and ha" !een relea"ed !y "ome =endor" =ery recently6 Compared to E@#C@) E@#MR pro=ide" a !etter !ac?ground image 7ith impro=ed "oft ti""ue contra"t 7ithout radiation e4po"ure6 Moreo=er) integration of molecular and functional information generated from E@ and MR could pro=ide u"eful information in characteri"ing the cCncer6M
rof6 Hiro"hi Honda) 8apan
re"ult") and 7ill certainly "ee further de=el# opment" that 7ill aid under"tanding of the function) "tructure and e=olution of ti""ue" li?e cCncer 7hen treatment i" admini"tered6
logic imaging and 7hen patient" 7ill !en# efit from it6 Ahat can !e "aid for "ure i" that imaging 7ill !ecome an e=en more po7er# ful cCncer detection tool in the future e"pe# cially 7hen !iomar?er" and molecular method" ha=e
It i" of cour"e hard to predict ho7 ne7 method" or de=ice" 7ill influence onco#
!een de=eloped to their full potential6
C@ for tumour "taging C@ in a patient 7ith long#"tanding upper a!dominal pain "ho7" a large) ad=anced pancreatic cancer ,arro7"0) 7hich infiltrate" the "urrounding =e""el"6 @he cancer 7a" found to !e unre"ecta!le !ecau"e of the ad=anced "tage at the time
taging
1. THE IMPORTANCE OF STAGING 2. THE RADIOLOGIST TAKES CENTRE STAGE 3. THE COMMUNICATION
THE IMPORTAN CE OF STAGING

@here are many clinical factor" that might rai"e the initial "u"picion of cCncer) and there are =ariou" method" u"ed to con# firm it" pre"ence in one form or another6 @he actual diagno"i" of cCncer i" generally made through la!oratory te"t" of a ti""ue "ample collected through !iop"y or "ur# gery) the need for 7hich i" u"ually deter# mined !y !lood te"t") imaging) or !oth6 So) imaging alone cannot pro=ide definite diagno"i") !ut it =ery often help" doctor" to reach their conclu"i:n6 characteri"ing tumour" that ha=e !een e=idenced =ia other method") !ut it i" al"o e4tremely u"eful in ta?ing the ne4t "tep6 Being a!le to =i"uali"e the e4act location of a "u"pected tumour allo7" doctor" to clo"ely e4amine the "urrounding area) pro=iding a fir"t impre""ion of 7hether or not any potential cCncer may ha=e "pread) and if "o) ho7 far6 Not only doe" thi" mean doctor" can =i"ually pic? the !e"t point in that area for the !iop"y "ample to !e ta?en from) !ut it al"o pro=ide" the fir"t hint" a" to the Q"tageG of 7hat may +" the pre=iou" chapter e4plained) radiol# ogy pro=ide" =ital tool" for detecting and later !e con# firmed a" cCncer6
L$nce a hi"tologic diagno"i" i" made) imaging i" the ?ey diagno"tic tool u"ed to "tage the cCncer # that i") to determine e4actly 7here the primary tumour i" located and ho7 far the cCncer ha" "pread6 3or "ome tumour") imaging finding" are "till "upplemented !y finding" from "urgery # !ut 7ith the continuou" ad=ancement of cro""#"ectional imaging and the de=elopment of molecular imaging) "taging laparotomy i" !ecoming o!"olete6 +ccurate "taging i" e""ential in order to "elect the appropriate treatment6 @hu") !y "taging cCncer) radiologi"t" and other imaging "peciali"t" "ignificantly influence
Chemical e4change "aturation tran"fer ,CES@0 imaging of a malignant !rain tumor

+" rof6 Hrica? "ay") a" "oon a" cCncer i" diag# i" 7here the radiologi"tG" "?ill) and e4peri# ence of medical image") play" a =ery important part6 no"ed) the mo"t important thing to e"ta!li"h) 7hich 7ill determine the fir"t "tep" of treat# ment # if not the entire treatment plan # i" the preci"e e4tent of the cCncer6 <octor" 7ill only ?no7 ho7 to proceed !y finding out e4actly 7here cCncer i" in the original "ite ,the primary tumour0) 7hether it ha" "pread to other part" of the !ody ,the proce"" ?no7n a"
QmetC"ta"i"G0) and ho7 large any tumour" are6 In thi" "en"e) "taging i" e""entially the
reconnai""ance) 7hich inform" e4actly ho7 the Q!attle planG of treatment 7ill !e dra7n up6 Imaging i" !y far the mo"t effecti=e method to accurately "tage cCncer) and thi"
L+ccurate "taging i" 7idely !a"ed on imaging6 No other te"t allo7" for the depiction of !oth the primary tumour and it" potential meta"ta"e"6 @he progno"i" of any gi=en malignant condition depend" on the initial "tage at the time of diagno"i"6G
THE RADIOLOGIST
Ahile complete "taging relie" on a com# @he !road range of radiological tool" and !ination of clinical finding") including !lood te"t") radiology pro=ide" the central and pi=otal "taging proce"") "o the radiologi"tG" role at thi" point in the cCncer care continuum i" a!"olutely e""en# tial6 +" 7ell a" managing and operating the eJuipment u"ed for "taging and diagno"i") and "electing the method" u"ed to carry out the e4amination") the radiologi"t i" al"o the per"on 7ho 7ill analy"e and interpret the re"ulting image") 7ith reference a!out to the
TAKES CENTRE STAGE

"cope ,a =ery tu!e containing a light ciplinary team"mall of doctor") re"pon"i!le for and the camera0 into the management of !ody6 each cCncer patient6 Image" o!tained in the e4amination" 7ill !e pre"ented No commented "ingle method i" the guaranteed to !efore "pot and on !y radiologi"t) e=erything) !ut the !ig team) ad=antage of including ha=# ing !eing di"cu""ed !y the u"ually "o many option" to choo"e from i" that they oncologi"t" and pathologi"t"6 3reJuently) ne7 can often may !e u"ed in com!ination to pro=ide a Jue"tion" !e rai"ed) due to ne7 e=ent" or more comprehen"i=e picture6 !io# logical finding") and =ery commonly) the radiologi"t 7ill return to pre=iou" e4amination" 7ith the "ame or another imaging tool) in order to
important patientG"
clinical current
?no7l# condi#
edge tion
and
medical
hi"tory6 @he radiologi"t i" therefore relied upon not only to detect already e=ident finding") !ut to ?no7 to 7here a gi=en tumour may "pread
Chemical and di"tant meta"ta"e" ,the ne7 "ite" of e4change "pread0 through detailed analy"i" of the"e "aturation location"6 tran"fer ,CES@0 imaging of a
and to confirm or e4elude the pre"ence of local
L@he radiologi"t ha" a choo"e ho7 to e4amine the !ody 7hen "tag ing fundamental under"tanding theto u"e cancer6 @he deci"i:n of 7hich of method "trength" 7ea?ne""e" can !e influencedand !y =ariou" factor") "uch a" of the imaging the area of the !ody 7here tool" the pri# mary a=aila!le and 7hich tumour i" located) the area" to 7hich cancer i" imaging modalitie" are mo"t li?ely to "pread) the "en"iti=# ity of the !e"t "uited for the patient to radiation ,influenced !y age) in=e"tigation of particular phy"ical condition) pregnancy) etc60 and) in tumour type"6 articular "ome ca"e") the co"t of the e4amination6 cancer" are !e"t appreciated 7ith certain C@) E@#C@ and) increa"ingly) MRI are perhap" type" of in=e"tigation" and the mo"t commonly u"ed method" employed in a radiologi"t i" !e"t "taging) particularly 7here a 7hole#!ody e4am "ituated to ?no7 7hich i" i" reJuired) !ut other techniJue" "uch a" the mo"t appropriate ultra"ound) 4#ray) and mammography are al"o in=e"tigation to u"e6M
techniJue" a=aila!le mean" radiologi"t" can commonly u"ed6 +"ide from the"e method") all of 7hich are u"ed to loo? in"ide the !ody from @he radiologi"tG" e4pert analy"i" 7ill !e an out"ide) doctor" may al"o occa# "ionally u"e integral factor in the deci"i:n a!out the cour"e endo"copy in the cour"e of "taging) 7hich of action to !e ta?en) !ut the deci"ion" are in=ol=e" the in"ertion of an endo# u"ually made !y a multidi"
LIn order characteri"e image" to or to an"7er en"ure that different Jue"tion") the nothing 7a" mi""ed6 radiologi"t can u"e all imaging techniJue"6 But it i" important to under"tand that there i" no "ingle perfect e4amination6 In mo"t ca"e") a com!ination of e4amination" i" the appropriate "trategy) e=en if computed tomography i" the u"ual "tarting point6M
THE
COMMUNICATION CHAIN
@here are u"ually many people in=ol=ed in the management of an indi=idual ca"e of cCncer) "ome of 7hom the patient 7ill ha=e ci:"e contact 7ith and "ome of 7hom remain =ery much Q!ehind the "cene"G6 Mo"t healthcare in"titution" ta?e a mul# tidi"ciplinary approach to cCncer care) meaning that the management of each patient i" the re"pon"i!ility of a team of doctor" from =ariou" !ranche" of medicine) all of 7hom 7or? together clo"ely to achie=e the !e"t po""i!le re"ult"6 +t e=ery "tage of a patientG" progre"") meeting" u"ually ta?e place that dra7 on the e4perti"e of oncologi"t" ,cCncer "peciali"t"0) patholo# gi"t" ,"peciali"t" in di"ea"e proce""e"0) radiation oncologi"t" ,"peciali"t" in treating cCncer 7ith radiation0) and radiologi"t") a"
L+t a local le=el good communication 7ith all mem!er" of the multidi"ciplinary team managing a patient i" ?ey to Juality care6 It i" no7 routine in many countrie" for the initial diagno"i") imaging "taging and potential management "trategie" for cCncer patient" to !e di"cu""ed in a multidi"ciplinary team meeting6 @hi" en"ure" that there i" good communication !et7een all partie"6M
rof6 Vic?y Goh) Pnited Kingdom
STAGING
7ell
a"
numerou"
other
phy"ician")
tion finding" for the team) a" 7ell a" pro# =iding recommendation" and coordination of follo7#up ,co=ered in chapter fi=e of thi" !oo?let06 +lthough patient" may not nece"# "arily hear directly from in radiologi"t") meeting") their and in=ol=ement
Ahen it come" to informing the patient of the actual diagno"i") thi" i" done !y the oncologi"t or referring phy"ician in the maDority the of ca"e") radiologi"t although 7ill !e occa"ionally
includ# ing tho"e 7ho "peciali"e in the particular !ody region" affected6 Indi=idual team mem!er" are in=ol=ed to =arying degree" in the different "tep" of cancer care) !ut communication i" "till =ital6 3or the radiologi"t) thi" mean" compiling clear) detailed and accurate report" on e4amina
in=ol=ed6 @hi" =arSe" from country to country) !ut in general the radiologi"t 7ill only !e con"ulted 7hen the patient ha" a particular Jue"tion6
particularly through freJuent contad 7ith the referring clinician) i" an important factor in cancer management6
-In China. patients receive their &edica( i&aging reports /ro& the depart&ent o/ radio(ogy. and they wi(( see their physicians0surgeons with the reports1 2ccasiona((y. the patient wi(( consu(t the radio(ogist direct(y and the radio(ogist wi(( provide the necessary e3p(anations14
-Depending on (oca( c(inica( practice. the radio(ogist either ta(5s to the patient direct(y. or to the re/erring physician1 In ,er&any. /or e3a&p(e. &ost private radio(ogy centres o//er direct patient interviews and discussion o/ /indings a/ter the i&aging1 In &ost hospita(s. however. that is i&possib(e to provide and /indings wi(( be co&&unicated to the patient during c(inica( rounds on the ward14
rof6 +nno Gra"er) Germany
STAGING
<ue to the nature of the ta"?" in=ol=ed) radiol# ogy to !enefit cCncer "taging are the "ame a") or "imilar to) in tho"e !enefitting characteri"ation ment" in the detection ,de"cri!ed many
many of the ad=ance" !eing made in
LOOKIN G
imaging) and and the technical MR
+rgua!ly) the mo"t "ignificant ad=ance" !eing made are related to molecular 7hich i" u"ed to o!"er=e emi""ion molecular change" on a cellular le=el) "pecifi# cally po"itron tomography , E@0) 7hich i" u"ually u"ed in com!ination 7ith high Juality C@ or "can"6 E@ i" an e"pe# cially "en"iti=e imaging tool) 7hich relie" on the unu"ually high rate of meta!olic acti=ity that occur" in cCncer ti""ue to produce three#dimen"ional image" of particular functional proce""e"6 @he com!ination of E@ 7ith C@ or MR
Molecular e4tremely !enefit" in=ol=ed)
imaging all the
in
general field) of image"
i"
an
promi"ing 7here
7hich cCncer are "taging)
"tage" diagno"i")
management i6e6
treatment e=aluation) and follo7#up6 @he mo"t important feature of the"e te"t" i" that they com!ine) in a "ingle "ean) morphologi# cal ,anatomical0) phy"iological ,functional0 and meta!olic information6 @hi" mean" that doctor" can o!tain an unprecedented le=el of detail a!out the nature of cCncer ti""ue) e=en to the e4tent that fine difference" can !e detected !et7een indi=idual tumour" in a "ingle patient) 7hich could pro=e to !e in=alua!le 7hen it come" to planning
pre=iou" chapter06 Incremental impro=e# component" of todayG" common imaging eJuipment mean that progre"" i" al7ay" !eing made and that the re"olution and clarity of image" are on the ri"e6 But ne7 de=elopment" al"o include the additional feature" that are !eing added to e4i"ting technology) "uch a" functional imaging( the a!ility to =i"uali"e proce""e" in the !ody) "uch a" !lood flo7 and other
pro=ide" far "uperior image") 7hich help the radiologi"t to accu# rately locali"e the acti=e cCncer ti""ue to a particular
LNot only can the "ame type of cCncer !eha=e differently in different patient") !ut e=en 7ithin a "ingle patient) meta"tatic tumour" ari"ing from the "ame cCncer may !eha=e differently6 In fact) e=en different region" 7ithin a "ingle tumour may ha=e their o7n di"tinct molecular characteri"tic"6 Becau"e molecular imaging can di"tingui"h difference" in the"e characteri"tic" 7ithin and !et7een tumour") the role of imaging "peciali"t" in diagno"ing) characteri"ing) and "taging cCncer) a" 7ell a" determining the appropriate treatment) i" li?ely to !ecome e=en more pronounced 7ith progre"" in molecular imaging and
reatment B erapy
1. TREATMENT MONITORING !ITH IMAGING: SAVING TIME 2. THE GRO!ING USE OF IMAGE"GUIDED THERAPIES 3. INTERVENTIONAL RADIOLOGY AND
TREATMENT MONITORING !ITH IMAGING:

$nce cCncer ha" !een locali"ed and "taged) oncologic fundamental doctor" care) can proceed i" 7ith of treatment6 Here) a" in e=ery "tage of imaging importance6 Imaging in a patient and) if not) can help doctor" to choo"e a more "uita!le "trategy6 Ahether radiation therapy) chemotherapy) or !oth) are carried out) imaging can mea"ure their effecti=ene"" !y "ho7ing ho7 the tumour re"pond" to them6 Variou" re"pon"e criteria model" ha=e !een de=eloped for thi" purpo"e) of Being a!le to chec? the effecti=ene"" of a treatment early on mean" a change in cour"e can !e made a" "oon a" it !ecome" nece""ary) 7hich i" a crucial time"a=er in the !attle again"t cCncer and a factor in impro=ing Juality of life during and after treatment6 Imaging techniJue" can "ho7 if the "elected 7hich the mo"t commonly u"ed i" the RECIS@ ,Re"pon"e E=aluation Criteria In Solid @umour"0 modelK a "et of pu!li"hed rule" that define 7hen cCncer patient" impro=e ,re"pon"e0) "tay the "ame @reatment moni# re"pon"e !y i" traditionally the ,"ta!ili"ation0 or 7or"en ,progre""ion06 +n initial "ean i" ta?en !efore the treatment "tart") again"t 7hich later tored mea"uring ou" imaging techniJue" are then u"ed once therapy commence") to determine it" effect6 Ahen the cour"e of treatment end") a final e4amination i" performed to a""e"" 7hether the re"pon"e of the cCncer to treatment ha" !een complete) partial or "ta!le6 Information i" a!out for treatment re"pon"e crucial techniJue" can !e u"ed to monitor therapy) 7hich allo7" doctor" to gauge the "ucce"" of the therapeutic plan from the !egin# ning6 doctor") a" they can u"e it to plan the ne4t "tep") i6e6 7hether the patient need" further treatment or) in the !e"t ca"e") follo7#up care) if tumour" ha=e !een de"troyed6
dimen"ion" of the primary tumour and the dimen"ion" of a num!er of lymph
-I&aging is used to assess response to treat&ent (arge(y using tu&our si6e and0or recurrence1 It is a(so used to &onitor possib(e side e//ects o/ therapy and therapeutic interventions1 Conventiona( i&aging. such as 3)ray. u(trasound 78 9. co&puted to&ography 7C%9 and &agnetic resonance i&aging 7M:I9 uti(ise &easure&ents to assess response or progression1 :esponse is typica((y c(assi/ied as being ;progressive disease<. ;stab(e disease<. ;partia( response< or ;co&p(ete response< to treat&ent1 'unctiona( and &o(ecu(ar i&aging wi(( inc(ude assess&ent o/ tu&our &etabo(is& and thereby predict response to a particu(ar therapy14
and comparing tho"e dimen"ion" 7ith the original pre#treatment image"6 In addition) certain imaging tool" can "ho7 tumour planning6 3unctional and molecular imaging are increa"ingly popular in cCncer manage# meta!oli"m) increa"ingly important infor# mation in treatment ment6 @he"e techniJue" u"e contra"t producS" or !iomar?er") 7hich are "u!"tance" that are u"ually "7allo7ed or inDected and u"ed to highlight certain !ody ti""ue" or !iological molecule"6 Ahen =ie7ed 7ith imaging tool" "uch a" C@) MRI and , E@0) po"itron they emi""ion can "ho7 tomography in organi"m") including tumour"6 $nce doctor" ?no7 the nature of a tumour and ho7 it interact" 7ith the re"t of the !ody) they can more ea"ily define 7hich therapy i" mo"t li?ely to !e effecti=e6
cellular acti=ity and molecular proce""e"
THE GROWING USE OF IMAGE+nother role of imaging in cCncer treat# ment i" to facilitate the deli=ery of therapy6 chemical Radiation agent" ,radiotherapy0 or are ,chemotherapy0 =ery freJuently u"ed in treatment) and the medical team 7ant" to !e a" "ure a" po""i!le that they hit their target" 7ithout harming the "urrounding organ" or ti""ue"6 @he"e treatment" u"ed to !e applied to the 7hole !ody) !ut many are no7 performed locally) to de"troy Du"t the tumour and minimi"e any complica# tion"6 @he"e therapie" reJuire a =ery high le=el of preci"i:n) and oncologic
GUIDED THERAPIES
-I&aging is used to guide the treat&ent o/ c=ncer in a variety o/ ways1 :adiation onco(ogists use i&aging to deter&ine the (ocation o/ the c=ncer and proper(y position the radiation bea&1 >uc(ear &edicine physicians use i&aging to trac5 the activity o/ radiophar&aceutica(s in the body and deter&ine whether they are reaching their target accurate(y and in su//icient ?uantity1 A(so. i&aging e?uip&ent is now insta((ed in &any surgica( operating roo&s14
7hether they are radiotherapi"t") "urgeon" ing "?ill" to guide them during their inter# or nuclear medicine phy"ician") increa"# =ention"6 ingly rely on per"onnel 7ith "pecific imag#
-I&age)guided surgery based on preoperative C% and M:I has beco&e popu(ar especia((y in brain surgery. and is wide(y used /or the resection o/ brain tu&ours1 P(anning o/ radiation therapy is a(so based on C% i&ages. so that the tu&our receives su//icient doses o/ radiation whi(e contro((ing the dosage to preserve critica( organs1 I&age)guided therapy can i&prove treat&ent outco&e and reduce the ris5 o/ co&p(ications4
"urgery C@ image" ena!le phy"ician" to ma?e "ure that the tumour i" gone6 In radiation therapy image guidance i" al"o more and more commonly u"ed to impro=e "afety6 So radiologi"t" are re"pon"i!le for treat# ment monitoring and they help deli=er therapy a" accurately and "afely a" po""i!le6 In addition) they "ometime" perform to a the 7hole treatment !ranch of them"el=e"6 radiology( @he"e acti=itie" ha=e actually gi=en ri"e
@here are many e4ample" of ho7 C@ or MRI can !e u"ed to guide treatment6 Neu# ro"urgeon" commonly u"e 7hole# !rain /<
image" to plan "urgery in detail) and "ur# geon" increa"ingly u"e /< image" during their inter=ention" in li=er "urgery6 +fter
In recent year") a gro7ing num!er of image#guided therapie" ha=e 7idened the range of cancer treatment option"6 Inter=entional radiology) a "u!"pecialty of radiology) ha" !een de=eloping "ince the early '*F&S and many inno=ati=e image# guided techniJue" ha=e !een e"ta!li"hed) e"pecially 7ith regard to cancer treatment6 @he"e techniJue" are minimally in=a"i=e) meaning that they can !e per# formed through a tiny
time image") to de"troy the tumour 7ith# out damaging the "urrounding ti""ue"6 Image#guided lung or renal therapeutic cancer procedure" are +"
rial directly into the arterie" that "upply the tumour6 Radiologi"t" al"o commonly perform radiofreJuency a!lation) 7hich u"e" electromagnetic ,radio0 7a=e" com# !ined 7ith PS or 4#ray) to a!late lung and li=er meta"ta"e" a" 7ell a" primary renal cancer"6 @he ad=antage of minimally in=a"i=e image#guided therapie" i" that they can reduce the ri"? of complication" and "horten in#patient "tay"6 @hey are al"o an e4cellent alternati=e to "urgery for patient" 7ho are "e=erely ill) refu"e to ha=e "urgery) or 7ho"e cancer cannot !e "urgically remo=ed6 hy# "ician" can recommend to patient" 7hich treatment they "hould undergo after con# "idering all the information and gathering all the e4perti"e on a ca"e#!y#ca"e !a"i"6 @he type of cancer) clinical hi"tory of the patient) and a=aila!ility of re"ource" 7ill determine the choice of therapy6
may !e u"ed in many ca"e"( !rain) li=er) patient" thi" 7ay6 increa"# ingly treated
INTERVENTIO NAL RADIOLOGY AND

inci"i:n and there# fore in=ol=e minimal phy"ical "tre""6 @he ad=antage of the"e techniJue" i" that they po"e little ri"? to the patientK much le"" than con=entional cancer"6 tumour until it "urgery) 7hich u"ually reJuire" larger ultra"ound) 4#ray) C@ or MRI to guide the inci"ion"6 @he"e techniJue" typically u"e
rofe""or Hri# ca? point" out) there are
many different po""i!le option") all of 7hich may !e u"ed to treat different Em!oli"a# tion "hrin?" con"i"t" and of o!"tructing !lood =e""el" that feed a die"6 Em!oli"ation i" u"ed to treat not only li=er) !ut al"o !one and lung cancer6 Catheter" can al"o tran"port chemi# cal agent" to the "ite of the tumour) and relea"e agent" 7hich 7ill eat up the tumour6 Radiologi"t" may al"o admin# i"ter radiation them"el=e") for in"tance in a treatment called "electi=e infernal radiation therapy ,SIR@0) !y inDecting
MINIMALLYINVASIVE
e4treme temperature") 7hich cau"e the tumour to "hrin?6 @he treatment tu!e !y i" deli=ered catheter) through 7hich a "mall or a i" guided
application of radiofreJuencie" ,R30 or
-Instead o/ &a5ing a (arge incisi@n. an interventiona( radio(ogist wi(( typica((y use i&aging to guide a catheter or need(e to the treat&ent site to de(iver a therapeutic agent1 'or e3a&p(e. in an approach ca((ed ther&a( ab(ation. i&aging is used to guide a need(e to a tu&our and then e3tre&e te&peratures are app(ied via the need(e to + %#dimen"ional image destroy the tu&our1 %her&a( ab(ation &ay be used to treat cancers in the 5idney. (iver of or (ung. a&ong other sites1 In hepatic artery e&bo(isation. a treat&ent /or (iver a !rain tumour ,circled0 tu&ours. i&aging is used to guide a catheter to the hepatic artery. and partic(es are and the part" of thenthe inAected to b(oc5 the /(ow o/ b(ood /ro& the artery into the tu&ourB so&e doctors &ay a(so choose to inAect a che&otherapeutic agent or partic(es that e&it radiation14 !rain
that control motion of the hand ,"een in yello7 and orange06 @hi" information
FUTURE
includ# monitor# the "urgical
DEVELOPMENTS
Re"earch i" !ooming in many area" of cCncer imaging) ing treatment imaging) and thi" "hould re"ult in !etter ing option" and more refined image#guided therapie" 7ithin ne4t ten year") according to e4pert"6 Radiotherapy and techniJue" are currently under the "cope of re"earcher") a" 7ell a" ne7 chemotherapeutic agent" and Qintelligent drug"G de"igned to
-%he pro&ising deve(op&ents in c=ncer treat&ent that invo(ve radio(ogists inc(ude the abi(ity to se(ective(y de(iver therapeutic agents to target tissues and thereby reduce syste&ic to3icity1 Patients with c=ncer wi(( bene/it /ro& the new PE% &etabo(ites that target speci/ic tissue and wi(( i&prove the sensitivity and speci/icity o/ c=ncer detection and treat&ent response14
rof6 +ndre7 Little) +u"tralia
3urther ad=ance" "hould al"o !e e4pected in phy"ical a!lation and electroporation) a treatment that facilitate" the introduction of a drug or a piece of coded#<N+ into a cancerou" cell !y increa"ing the electrical conducti=ity andpermea!ility of the cell mem!rane6 Electroporation i" typically guided !y imaging techniJue" "uch a" C@ or MRI) fir"t to create /< image" of the tumour !efore treatment and then to place the electrode" during the procedure6 In addition) the de=elopment of "ophi"ticated nano#particle" and pro!e" "hould and pu"h the 7ith accuracy imaging of treatment further6 monitoring guidance e=en
@reatment" "hould continu; to !e refined) a" they ha=e !een in recent year") impro=ing !oth life e4pectancy and Juality of
-In genera(. current treat&ents are sa/er and &ore e//ective than in the past1 %he &agnitude o/ bene/its varies /ro& tu&our to tu&our. but overa((. stage by stage. patients are (iving (onger today than in the past. in &ost (ocations1 A(so. ?ua(ity o/ (i/e has i&proved so &uch through the deve(op&ent o/ strategies that a((ow (ess aggressive treat&ents and e3tensive deve(op&ent o/ pa((iative therapies to contro( sy&pto&s 4 <r6 +driana <iegue9) +rgentina
I'
ollo7#up are
M T i
>
1.THE IMPORTANCE OF FOLLO!"UP CARE 2.TOOLS OF THE TRADE 3.THE RADIOLOGISTS ROLE 4.!HAT THE PUBLIC SHOULD KNO! ABOUT IMAGING IN FOLLO!"UP CARE 5.FUTURE DEVELOPMENTS IN FOLLO!"UP CANCER IMAGING
PfD
# i
Cancer can !e a particularly re"ilient di"ea"e6 In fact) mo"t fact that many cancer" are capa!le of recurring later on in life6 In"tead) phy"ician" in=ol=ed in cancer care prefer to tal? of Qremi""ionG) ha=ing halted or reduced the "pread of the di"ea"e6 Some patient" may e4peri# ence partial remi""ion) 7here there i" a 1&I reduction in tumour gro7th) or e=en
medical profe""ional" a=oid u"ing the term QcureG) due to the
THE IMPORTANCE OF FOLLOW-UP

follo7# up cancer care6
recurrence !efore "ymptom" appear6 It i" a corner"tone of
complete remi""ion) 7here the tumour and all manife"tation" of the cancer ha=e di"appeared6 @hough there i" no definite cure) patient" can) and often do) "ur=i=e cancer and it i" not al7ay" the ca"e that the cancer remerge"6 Becau"e of the re"ilient and per=a"i=e nature of cancer cell" it i" important that patient" undergo regular chec?up" after they ha=e !een declared to !e in remi""ion6 3ollo7#up care in=ol=e" a "erie" of regular e4amination" in order to monitor cancer remi""ion and pinpoint any po""i!le recurrence6 atient" "hould undergo follo7# up chec?" to en"ure their cancer remain" in remi""ion !ecau"e the earlier recurrence i" "potted) the !etter the progno"i"6 @hi" i" 7here imaging play" one of it" mo"t important function") a" it can help phy"ician" to non#in=a"i=ely
-Medica( i&aging is vita((y i&portant to &onitoring therapy response and /o((ow)up care o/ cancer patients1 I&aging provides a non)invasive outpatient assess&ent /or patients. which is accessib(e to the genera( co&&unity not on(y in &aAor urban centres. but a(so in re&@te and rura( co&&unities1 %he digitisation o/ &edica( i&aging e3a&inations per&its re&@te diagnosis and e3pert second opinions0
rof6 +ndre7 Little) +u"tralia
Medical imaging allo7" oncologi"t" to ma?e follo7#up chec?" le"" uncomforta!le or intru"i=e to patient" and it" efficiency en"ure" that patient" can !e monitored and informed of any
TOOLS OF
Much li?e during the preceding "tage" of cCncer care) radiologi"t" ha=e an array di"# po"al6 up
THETR ADE
atient" 7ho undergo follo7# are mo"t li?ely to e4amination" of tech# nology) allo7ing the
cific cCncer) patient" may encounter other techniJue" "uch a" MRI and ultra"ound6 hy"ician" and radiologi"t" 7or?
of techniJue" and eJuipment at their
encounter computed tomography ,C@0) magnetic re"# onance imaging ,MRI0 or ultra"ound ,PS06 Each techniJue i" "uited to a""e""ing different form" of cCncer6 C@ i" pro!a!ly the mo"t common techniJue u"ed for follo7# up e4amination"6 It i" Juite a =er"atile radiologi"t to image mo"t part" of the !ody Juic?ly and 7ith a high le=el of
together to decide on the mo"t "uita!le techniJue) and factor" "uch a" the type cCncer) loca# tion) and pre=iou" of treatment influence the choice
procedure6 Many patient" may ha=e had C@ or other ioni"ing radiation "can" duringthe detection) "taging) ortreat# ment "tage") and in "uch ca"e" the medical team may 7ant to limit the patientG" e4po"ure to further radiation do"e"6 Ho7e=er) the !enefit of ha=ing
LPltra"onography i" 7idely u"ed to detect occurrence of lymph node and li=er metC"ta"i"6 C@ i" u"ed to detect local recurrence) a" 7ell a" meta"ta"e" in lymph node" and di"tant organ"6 It i" al"o u"ed to detect late complication" of chemotherapy and radiotherapy6 MRI i" u"ed for "imilar purpo"e") '!ut i" more u"eful in detecting !rain and !one metC"ta"i"M
@he
THE RADIOLOGI STS

ROLE
radiologi"t ing i" the their phy"ician6 re"pon"i!le for image" analy"i" @hi" acJuired to the the ma?# ing their role pi=otal effecti=ene"" of follo7#up care6 mean" prompt mean" detection u"ed to of any detect are complication"6 atient"
the early "ign" of cCncer recurrence) to the
had during the "taging of their di"ea"e) "uch a" !iop"ie" mean") or !lood te"t"6 Ho7e=er) radiologi"t" pro=ide a non# in=a"i=e 7ith minimum di"comfort to the patient) of a""e""ing the need to carry out more in=a"i=e or uncomforta!le procedure" and can thu" "a=e patient" a great deal of "tre""6 @he radiologi"t 7or?" !ehind the "cene" to pro=ide treating phy"ician" 7ith indi"pen"a!le information) helping them to ma?e crucial deci"ion" on further treatment or te"t"6
interpret#
through a range of techniJue" and then communicating patientG"
+gain) a" i" the ca"e at earlier "tage" of cCncer care) the radiologi"t operate" a" part of a medical team to gi=e patient" the !e"t follo7#up care and to en"ure po""i!le po""i!le li?ely to complication"6 Imaging i" not the only
radiologi"t need" to under"tand more than Du"t image"K they mu"t !e familiar 7ith oncologic medicine in order to di"# tingui"h the appearance of cCncer from other di"ea"e" or anomalie"6 Gi=en the radiologi"tG" ?no7ledge and e4perience of the imaging feature" of cCncer and it" recurrence) they are often the fir"t to
undergo other e4am") "imilar to tho"e
-:adio(ogists contribute to post)cancer care by detecting recurrence1 Ear(y detection o/ recurrence re?uires deep 5now(edge about patterns o/ recurrence in each type o/ c=ncer1 Another ro(e o/ the radio(ogist is to diagnose co&p(ications as a resu(t o/ treat&ent. which are o/ten di//icu(t to distinguish /ro& recurrence14
-A &u(tidiscip(inary approach and the Aoint participation o/ other e3perts with the radio(ogist are essentia(14
rof6 Marco" <uarte Guimarae") Bra9il
WHAT THE PUBLIC SHOULD KNOW
ABOUT IMAGING IN FOLLO!"UP CANCER CARE

-%hey shou(d 5now that i&aging is the &ost i&portant re/erence /or the /o((ow)up o/ treat&ent1 At the sa&e ti&e. c(inica( in/or&ation and. in so&e cases. bio(ogica( data are i&portant1 %he &edica( decisi@n a(ways re(ies on a &u(tidiscip(inary approach14
rence6 @he freJuency of "uch chec?up" =arie" depending upon the type of cCn# cer in Jue"tion) the health of the are four patient) and their cour"e of treatment6 Generally "cheduled "pea?ing) for e=ery chec?up" three to
month" for the fir"t t7o to three year" follo7ing treatmentK after that) patient" u"ually ha=e appointment" imaging once or
@he
general of
pu!lic
are
often
made for
change") other" may not !e fully a7are of 7hat come" <uring after the initial care) treatment6 follo7#up
t7ice a year6 e""arily undergo
atient" 7ill not nec# procedure"
a7are) through campaign" of =ariou" ?ind") "creening programme" certain can# cer"6 Ahile many people may ha=e "ome idea of 7hat an actual cCncer diagno"i" entail" in term" of treatment and life"tyle
during all of the"e appointment") !ut it i" an option for the treating phy"ician 7ho can then con"ult or 7ith "ign" the of radiologi"t a" to the nature of any remaining tumour"
patient" often need to undergo "imilar e4am" to tho"e they e4perienced during diagno"i" and "tag# ing in order to chec? for po""i!le recur#
FUTURE DEVELOPMENTS
re"earch) many and ca"e" thi" i" due to normal factor" de=eloping method" of detection rently po""i!le6 treatment6 Ho7e=er)
tumour" 7ithin a patient through "uch atient" "hould al7ay"time report pain!y pinpointing hand) can help detect recurrence potential or complication" a" early a" po"# CCncer i" the "u!Dect of a great deal of =alua!le for any patient" much of 7hich or "ymptom" to their phy"icianK 7hile in than complication" goe" into a po""i!le recurrence earlier i" cur# !efore they"i!le) !ecome helping to en"ure the =ery !e"t "ymptomatic6 Mo"t techniJue" are"i!le Juic? -In the /uture. po"# progno"i"6
IN FOLLO!"
other tumour" treatment6 and
-During re&ission. patients are e3a&ined chap# ter" of &ore thi" !oo?let) ha=e "ome of regu(ar(y in the ear(y period a/ter thi" co&p(etion o/ potential6 Molecular imaging and therapy and then &uch (ess /re?uent(y when technology li?e po"itron emi""ion disease re&ission has been con/ir&ed1 tomography , E@0 could !e u"ed more 'or e3a&p(e. patients in estab(ished re&ission 7idely to di"cern the preci"e meta!oli"m a/ter breast cancer or so&e testicu(ar cancers are of cCncer tumour") gi=ing oncologi"t" usua((y on(y i&aged on an annua( basis 4
rof6 +ndre7 Little) +u"tralia more detailed information regarding the
Some
ermea!ility map of malignant li=er tumour" relate" to aggre""i=ene""6 imaging tool") di"cu""ed in other
nature of the cCncer6 @reating phy"ician" 7ill !e a!le to monitor indi=idual
&o(ecu(ar i&aging it can prompt the oncologi"t to in=e"tS# and can detect complication") allo7ing many wi(( be i" concerned) "ooner i" to 7or? 7ith gate further6 Ahere MedicalcCncer imaging on the phy"ician" the(i5e(y radiologi"t to used de=elopment" can al"o !en# efit patient"
already !attling the di"ea"e6 al7ay" !etter and thi" i" particularly true identify any in term" of the initial detection of Impro=ement" 7ithin the field of medical imaging could ha=e the potential to !uy recurrence follo7ing
-%his is an i&portant issue1 Even i/ i&aging provides use/u( in/or&ation as it is. we wou(d (i5e it to be better1 We are (oo5ing /or &ethods that wou(d not on(y te(( us that the treat&ent is e//ective or not. but a(so te(( us &ore ?uic5(y. and. i/ possib(e. even to predict it /ro& the beginning1 I&aging and other sciences are wor5ing hard on this issue. because it wou(d save ti&e and i&prove treat&ent e//ectiveness1 A(though not possib(e today. we 5now that so&e i&aging &ethods have the potentia( to provide this in/or&ation1<
to assess di//erences in treat&ent response within and between di//erent tu&our sites in individua(
@he !enefit" imaging !ring" to cCncer care at pre"ent are clear6 It allo7" the phy"ician) in cooperation 7ith the radiologi"t) to di"cern "ign" of cCncer) non#in=a"i=ely and efficiently6 Ahile thi" a!ility !y it"elf ma?e" a huge impact on cCncer care) it i" con"tantly de=eloping and ne7 techniJue" to impro=e patient care "hould emerge in the year" ahead6
!outthe nter=ie7ee"
3ergu" V6 Coa?ley ortlandR$R) Pnited State"
8ean# ierre de Villier" Cape @o7n) South +frica
+driana <iegue9 Bueno" +ire") +rgentina
3er gu" Coa?ley 7a" recently appointed a" chair of radiology at $regon Health and Science Pni=er"ity in ortland6 He pre=iou"ly "er=ed a" chief of a!dominal imaging and =ice# chair for clinical "er=ice" in the department of radiology and !iomedical imaging) the Pni=er"ity of California) San 3ranci"co6 fel# lo7"hip and a year a" faculty in Body Imag# ing at Memorial Sloan#Kettering CCncer Center) Ne7 Nor?6 <r6 Coa?ley i" in=ol=ed in the teaching of radiology at all le=el") from medical trainee"6 +t PCS3) he o!tained a @/% @raining "tudent" to po"tgraduate a"t e4perience include" a n ierre de Villier"
8ea na <iegue9 i" a i" a radiologi"t "pe# ciali"ing in onco# logic imaging and inter=entional radiol# ogy) 7or?ing in pri=ate practice in Cape @o7n) South +frica6 He recei=ed hi" undergraduate training at the Pni=er"ity of '*EF) and "pent t7o year" in general practice6 He then completed hi" radiology re"idency at Grootte Schuur Ho"pital) Cape @o7n) fol# lo7ed !y a fello7"hip at the Pni=er"ity retoria) from '*E% to "peciali"ed currently coordinator magnetic of the in
+dria practicing phy"ician at the Pni=er"ity of Bueno" +ire") +rgen# tina) 7here "he gradu# ated 7ith honour" and radiology6 She i" of
department
re"onance and computed tomography in oncologic di"ea"e" and the department of teaching <iagn:"tico M;dico medical centre) Bueno" +ire") +rgentina6 <r6 <iegue9 i" a mem!er of the e4ecuti=e committee of the +rgentine Society of Radiology and coordinator of and re"earch at the
Marco" Sao Bra9il
<uarte aulo)
'eng 'eng CeiAing. China

Mar 3e ng 3eng i" profe""or of radiology at e?ing Pnion Medical College , PMC0) chair of the department of radiology) PMC Ho"pital6 She at the com# mittee @umour Imaging) 7hich i" affiliated 7ith the Chi# ne"e +nti#Cancer +""ociation6 She "er=e" a" a mem!er of the editorial !oard of the mem!er of the Society of i" al"o phy"ician#in#chief of radiology PMCH) a" 7ell a" a "tanding and =ice#
Vic?y Goh London) Pnited Kingdom
Vic?y Goh i" profe""or of clinical cancer imag# ing at KingG" College London) and honorary con"ultant at GuyG" and St @homa"G Ho"# pital") London6 She i" currently =ice# pre"i# dent of the European Society of $ncologic Imaging) a mem!er of the European Society of Radiology Re"earch Committee Board) a mem!er of the European Society of Radiol# ogy Leader"hip In"titute) a mem!er of the European School of Radiology faculty and a mem!er of the Her editorial re"earch of !oard of radiologi"t
co" <uarte Guima# rae" practi# tioner 7ith a ma"terG" degree He al"o contri!ute" to the h< programme of the +C Camargo Cancer Ho"pital) in Sao aulo) Bra# 9il6 He i" a mem!er and coordinator of the cancer imaging "ection of the Bra9ilian Col# lege of Radiology 7ith ,CBR06 He ha" e4perience 7or?ing modali# tie" including C@) E@#C@) thoracic and 7hole#!ody percu# taneou" procedure"6 <r6 <uarteG" MRI) and image#guided "e=eral radiological in oncology6 i" a medical
Journal of Cancer Research, and a" a

peer# re=ie7er for "e=eral Chine"e medical Dour# nal") "uch a" the Chinese Medical
European Radiology
include the impro=ement tumour intere"t"
Journal,
Din Mo ,oo eou(.

8in Mo Goo i" profe"# "or of radiology and director of the che"t 4#ray "ection at Seoul National Pni=er"ity Ho"pital) Seoul) Korea6 He recei=ed hi" M< and from Seoul National Pni=er"ity6 He "er=e" on the editorial !oard" of the Korean Journal h< degree"
+nno Gra"er Munich) Germany
Eiroshi Eonda 'u5uo5a.

Hiro "hi Honda i" pro# of fe""or of radiology and chairman of the department of radi# ology at the GradOate School of Medical Sci# ence") Kyu"hu Pni=er"ity) 8apan6 He 7ill al"o !e pre"ident of the 8apan Radiologi# cal SocietyG" Congre"" in %&'/6 <r6 Honda recei=ed Kyu"hu Pni=er"ity) radiology 8apan) re"idency in '*F*6 at He completed hi" Kyu"hu in Pni=er"ity and recei=ed !oard#certification radiol# ogy6 +fter 7or?ing a" an a!dominal radiol# hi" medical degree from
+n no Gra"er i" a""oci# ate clinical radiology and direc# tor of oncologic imag# ing at the Pni=er"ity of Munich Medical Centre6 He recei=ed hi" initial undergraduate train# ing at the Pni=er"ity of Munich) !ut he al"o "tudied at the Memorial Sloan#Kettering CCncer Center) Ne7 Nor?) and the Pni=er"ity of California) San 3ranci"co6 He then 7ent on to of complete Munich hi" re"idency mo=ing at on to the a Pni=er"ity !efore profe""or
of Radiology, Investigative Radiology,

and the
American Journal of Roentgenology,

and ha" !een a mem!er of the 3lei"chner Soci# ety "ince %&'%6 Hi" main re"earch
Hed=ig Hrica? Ne7 Nor?RNN) Pnited State"
+ndre7 Little Mel!ourne) +u"tralia
Lui" MartS#BonmatS Valencia) Spain
He d=ig Hrica? i" chair# per"on of the depart# ment of radiology at the Sloan#Kettering CCncer Center in Ne7 Nor?) and profe""or of radi# ology at Aeill Medical College) Cornell Pni# =er"ity) Ne7 Nor?6 She ha" pu!li"hed o=er .E& re"earch report") re=ie7" and article") plu" 'E !oo?" and '// !oo? chapter"6 In total) her 7or? ha" !een cited o=er '2)&&& time"6 She ha" !een honoured a7ard" including European Society of Radiology) the B;cl;re Medal from the International Society of Radiology) the Moroccan Merit Medal from the Interna# tional Society of Radiology) an honorary doc# t:rate in medicine from the Lud7ig Ma4i# the Gold Medal of the 7ith numerou"
+n dre7 Little i" a""oci# ate profe""or of radi# ology at St6 VincentG" Ho"pital) Mel!ourne) +u"tralia and a fello7 of the Royal +u"tralian B Ne7 >ealand College of Radiologi"t" ,R+N>CR0 and the Royal College of Radi# ologi"t") PK6 He graduated from the Pni# =er"ity of Mel!ourne 7ith a doctorate in medicine and a ma"terG" degree in "urgery6 He completed hi" po"tgraduate fello7"hip training in !ody imaging) non#=a"cular inter=ention and =a"cularRinter=entional radiology at @he Middle"e4 Ho"pital) Lon# don and the Pni=er"ity of Medi# cal Center6 <r6 Little "peciali"e" in oncologic imaging and oncologic inter=ention) 7ith re"earch hepato!iliary inter=ention and hepatic MR imaging6 He intere"t" including itt"!urgh ology Spain6 at MartS#BonmatS i"
Lui" head of the MRI) C@ and a!dominal "ec# tion of <octor e"et Pni=er"ity Ho"pital) Valencia and chief of radi# $uir:n Ho"pital) Valencia)
Hi" re"earch intere"t" include MR and C@ of the li=er) clinical application" of MRI) contra"t agent") and image proce""ing6 He al"o "er=e" a" =ice#pre"ident of the Span# i"h Society of Radiology ,SER+M0 and) in addition to hi" pu!lication") he ha" "er=ed
Fves MenG Paris.

N=e " MenO i" profe""or of radiology and chair# man of the department of radiology at Saint +ntoine Ho"pital) ari" and head of the depart# ment of radiology and nuclear medicine at the ari" VI Pni=er"ity Ho"pital"6 + "pecial# i"t in a!dominal and oncologic imaging) he ha" lectured on ga"trointe"tinal di"ea"e and the e=aluation of tumour re"pon"e at many international conference"6 He i" pa"t pre"ident of the European Society for Ga"# trointe"tinal and +!dominal Radiology ,ESG+R0 and 7ill !e pre"ident of the %&'1
Reginald 36 Munden Hou"tonR@U) Pnited State"
Aolfgang Schima Vienna) +u"tria

Aolf gang Schima i" head of radiology at the Goettlicher Hei# land) Barmher9ige Sch7e"tern and San?t 8o"ef Ho"pital") Vienna) +u"tria6 He "tudied medicine at the Pni# =er"ity hi" of Vienna) in 7here he He al"o ha" completed re"idency radiology6 7ritten
Re ginald 36 Munden i" profe""or of diagno"# tic radiology at the M< +nder"on Cancer Center) Pni=er"ity of @e4a"6 He initially "tudied !iology at the Pni=er"ity of South Caro# lina) !efore mo=ing on to "tudy medicine and denti"try at the Medical Pni=er"ity of South Carolina) 7here he later completed hi" re"idency in diagno"tic radiology6 He recei=ed a fello7"hip in thoracic radiol# ogy from Har=ard Pni=er"ity) Bo"ton) and earned a degree in !u"ine"" admini"tra# tion from +u!urn Pni=er"ity) +la!ama6 <r6 Munden ha" !een acti=ely in=ol=ed
a num!er of peer#re=ie7ed article" and i" an acti=e mem!er of many international "cientific re"earch intere"t" include oncologic imaging and C@ "ocietie"6 <r6 SchimaG"
lo""ary
+!lation
Biop"y
Contra"t m;dium
+ techniJue u"ed to de"troy or remo=e any a!nor# mal ti""ue gro7th"6

+denoma
+ medical te"t) in 7hich a "ample of cell" or ti""ue i" ta?en6 @here are a num!er of different !iop"y procedure" 7hich are u"ually performed under optical guidance ,li?e endo"copy or direct "?in "ample0) imaging or "urgical guidance) depending on the locali"ation of the ti""ue to !e "ampled6 It may reJuire a local or general anae"the"ia6 @he ti""ue "ample i" then e4amined !y a pathologi"t to determine the pre"ence of di"ea"e6
+n agent or "u!"tance introduced into the !ody ,=e"# "ei" or ca=ity0 to enhance the contra"t of fluid" or "tructure" 7ithin the !ody for imaging6 Iodine ,for C@ and angiography0 and gadolinium chelate" ,for MRI0 are the t7o mo"t common contra"t media u"ed in imaging6 Contra"t media are "ometime" in"erted into the dige"ti=e tract ,oral or rectal admini"tra# tion06 Barium and iodine are the mo"t common dige"ti=e contra"t media6 In rare in"tance") contra"t media can ha=e ad=er"e effect") li?e an allergic reac# tion6 Renal damage can al"o occur) !ut only in ca"e" of pre#e4i"ting ?idney di"ea"e6 3or thi" rea"on) renal function "ometime" need" to !e e=aluated !efore contra"t media i" inDected6
Computed tomography ,C@0
Benign tumour" of glandular ti""ue "uch a" colon muco"a ,al"o ?no7n a" colonic polyp"0) li=er or thy# roid6 @hey can) in rare ca"e") !ecome malignant o=er time) in 7hich ca"e they are referred to a" adenocar# cinoma"6
Benign tumour
+ tumour 7hich lac?" the a!ility to "pread ,meta"# ta"i"e0 or in=ade the contiguou" organ"6 In other 7ord") it lac?" the propertie" indicati=e of cCncer6
Biomar?er"(
Catheter
+tu!e that can !e in"erted into a !ody ca=ity) duct or =e""el6 It facilitate" the drainage or introduction of fluid" or ga"e"6 It can al"o pro=ide acce"" for "urgical in"trument"6
+n indicator of the pre"ence) a!"ence or progre"# "ion of a "pecific di"ea"e6 It can !e identified through !lood or uriVe "ample") li?e anti!odie" for infection" or gluco"e rate for dia!ete"6 It can al"o !e identified =ia imaging) li?e the le=el of enhancement of a tumour after intra=enou" inDection of contra"t media6 + relia!le !iomar?er i" u"eful for e=aluating the pre"ence) recurrence or re"pon"e to treatment in ca"e" of cCncer6
Contraindication
+l"o commonly referred to a" 4#ray computed tomography or computed a4ial tomography ,C+@0 and often 7rongly called a W"eanG or W"cannerG6 @he term WtomographyG mean" W"lice"G and refer" to the acJui"i# tion and pre"entation of image" a" contiguou" "lice" of ti""ue6 @hi" applie" to C@ and al"o ultra"ound) MRI and nuclear medicine6 In the ca"e of C@) the attenu# ation of 4#ray" !y the ti""ue i" mea"ured6 Becau"e more than one million calculation" are made in le"" than a "econd) a =ery po7erful Computer i" nece"# "ary to manage thi" information immediately6 @he"e %X image") can !e put together to pro=ide /< image"6 @hi" i"
+ condition or factor 7hich ma?e" it inad=i"a!le to carry out a "pecific medical treatment6 @here are a!"olute and relati=e there contraindication"( are ne=er any a!"olute meaning
circum"tance" to Du"# tify the treatment) and relati=e meaning that in "ome circum"tance" the !enefit of the treatment may out7eigh the con"eJuence"6 + penicillin allergy i" an e4ample of an a!"olute contraindication to the u"e of penicillinK 7hile pregnancy i" a relati=e con# traindication to the u"e of ioni"ing radiation "can") ho7e=er in "ome ca"e" the !enefit" of
C@ colonographyR=irtual colono"copy
Em!oli"ation
Ioni"ing radiation
+ con=entional colono"copy in=ol=e" the u"e of an endo"cope to e4amine the large !o7el and di"tal part of the "mall !o7l6 @he endo"cope i" a fle4i!le tu!e 7ith a camera 7hich i" then) for the purpo"e" of a colono"copy) in"erted =ia the anu"6 + =irtual a colono"copy to /< thi" image of i" a the non#in=a"i=e u"ing !o7el6 C@ It to i" alternati=e produce procedure)
+ techniJue 7hich principie i" u"ed to o!"truct =e"# "ei" that are !leeding ,for in"tance after a trauma or feeding a tumour06 In ca"e" of cCncer) em!oli"ation reduce" the Juantity of !lood and therefore o4ygen 7ithin the tumour) 7hich halt" it" gro7th and of may =e""el" e=en i" de"troy it6 @he o!"truction u"ually performed
Radiation i" a proce"" 7here energetic particle" or 7a=e" tra=el through "pace or a m;dium6 @here are t7o main type" of radiationK ioni"ing ,radiography) MRI06 U#ray" are C@) nuclear radiation medicine) u"ed in radiotherapy0 and non#ioni"# ing ,ultra"ound) ioni"ing radiography and C@6 It i" intere"ting to ?no7 that 7e are all e4po"ed to ioni"ing radiation from the atmo"phere) higher for in"tance 7hen tra=el# ling in the mountain"6 Becau"e ioni"ing radiation can !e harmful) the do"e" u"ed in radiological procedure" are ?ept a" lo7 a" po""i!le) and any ri"?" the from radiation In e4po"ure are carefully ioni"ing 7eighed again"t the !enefit" of the "ean !efore e4amination6 radiotherapy) radiation i" u"ed to de"troy tumour"6 Lo7 po7er) non#ioni"ing radiation i" gen# erally harmle"" and i" 7idely u"ed in telecommuni# cation"6
Inter=entional Radiology
through a catheter in"erted =ia the femoral artery under local anae"the"ia6 Em!oli"ation i" commonly a""ociated 7ith local admini"tration of particle are !earing called antitumoural agent" li?e or chemo# therapy or radiotherapeutic component"6 @he"e Wchemoem!oli"ationG Wradioem!oli"ationG) re"pecti=ely6
con"idera!ly more comforta!le for the patient) !ecau"e it doe" not reJuire any anae"# the"ia6 Ho7e=er) good preparation ,colon clean"ing0 i" nece""ary to o!tain rele=ant image"6
<iffu"ion#7eighted imaging ,<AI0
@hi" It i"
MRI u"eful
techniJue in of many
identifie" ca"e") "tro?e)
the the or
micro# early the
Endo"copy
mo=ement" of 7ater molecule" 7ithin the !ody6 li?e detection
+ procedure 7hich allo7" phy"ician" to "ee in"ide the patient6 Pnli?e radiological procedure") endo"copy i" an in=a"i=e procedure 7hich in=ol=e" in"ert# ing a fi!re optic ca!le 7ith a camera) =ia a ca=ity6 It "ometime" reJuire" general anae"the"ia6 It allo7" for the direct in"ertion of inter=entional tool" in order to
detectionRcharacteri"ation of tumour" in =ariou" area" of the !ody6

Electroporation
medical
"u!"pecialty
7ithin
radiology6
Inter=en# tional radiology compri"e" all in=a"i=e diagno"tic andRor therapeutic approache"6 P"ing imaging guid# ance) the inter=entional radiologi"t perform" !iop# "ie"K in"ert" "tent" or pro"the"e") to re#e"ta!li"h flo7 in o!"tructed =e""el" !odie") Inter=en# or li?e !ile duet"K treat" tumour" for often 7ith a!lation or em!oli"ationK and remo=e" foreign !ro?en catheter" in"tance6 perform tional radiologi"t"
techniJue
that
increa"e"
the
electrical
perform a !iop"y or e=en the re"ection of "mall
conducti=# ity and permea!ility of a cell pla"ma
Laparotomy
Malignant tumour
Medical Imaging
+ "urgical procedure that in=ol=e" ma?ing an inci"i:n in the a!dominal 7all in order to gain acce"" to the a!dominal ca=ity6
Laparo"copy
tumour
7hich
ha"
the
a!ility
to
"pread
Refer" to any proce"" u"ed to create image" of the human !ody for medical techniJue" a" purpo"e"6 u"ing It encompa""e" of di"cipline" imaging "uch !oth
,meta"ta# "i"e0 andRor to in=ade the contiguou" organ"6 Ho7e=er) in=a"i=ene"" i" =ery different from one tumour to another6 Some tumour" de=elop mainly locally) 7hile "ome other" are often multifocal from the !eginning6 E=en 7ithin the "ame organ) there might !e =ery different type" of malignant tumour6 @here# fore) the e=olution o!"er=ed in one per"on i" u"ually not applica!le to another) e=en if the "ame organ i" in=ol=ed6 Malignant tumour i" a "ynonym for cancer6
Mammography
=i"i!le and in=i"i!le light and "o co=er" a range radiology) nuclear medicine) endo"copy) thermogra# phy) medical photography and micro"copy6
Multi#<etector C@
+ "urgical procedure that allo7" acce"" to the a!dominal ca=ity 7ithout an inci"i:n6 @hree hole" are made in order to in"ufflate ga") in"ert a =ideo camera and "urgical tool"6 @hi" techniJue i" u"ed for many "urgical procedure" today6 Ho7e=er) !ecau"e of more limited acce"") pre# "urgical e=aluation of di"ea"e i" crucial and "o imaging i" in"trumental 7ith regard to "urgical planning6
Li=er cirrhotic nodule"
+l"o ?no7n a" multi#"lice computed tomography) thi" method u"e" a t7o dimen"ional array of detec# tor" to create image" of mOltiple "ection" "imultane# ou"ly) 7hich greatly increa"e" the "peed of image acJui"ition6
Nano#particle"
+ proce"" that u"e" lo7 energy 4#ray" to image the human !rea"t6 @he aim i" to detect !rea"t cancer a" early a" po""i!le !y detecting ma""e" or microcalci# fication"6
MetC"ta"i" Magnetic re"onance imaging ,MRI0
Nodule" or lump" that are "ymptomatic of li=er cir# rho"i" and are formed 7hen damaged ti""ue in the li=er regenerate"6
+term u"ed in nanotechnology) it refer" to an o!Dect 7ith a "i9e !et7een '&& and i nanometre"6 $ne nanometre i" eJual to one !illionth of a metre6
Nuclear Medicine
Refer" to the "pread of a di"ea"e from one part of the !ody to another6 Ahen a cancer ha" "pread) it i" "aid to ha=e meta"ta"i"ed6 @he ne7 tumour" are referred to a" meta"ta"e"6
Modality
+ techniJue 7hich u"e" a magnetic field to con# "truct an image of a "pecific area of the !ody6 @hi" techniJue i" particularly good for imaging the !rain) !one") mu"cle") li=er and !ile duct") pancrea") heart) and =e""el"6 It pro=ide" high contra"t !et7een the different "oft ti""ue"6 Pnli?e C@ and 4#ray") MRI doe" not u"e ioni"ing
+ medical "pecialty in=ol=ing the u"e of radio# acti=e "u!"tance" to diagno"e and treat di"ea"e6 Nuclear medicine "peciali"t" u"e the"e radioacti=e "u!"tance" or Wradiopharmaceutical"G to gauge the e4tent of a di"ea"e !a"ed on cellular function and meta!oli"m) rather than on
+term u"ed 7ithin medical imaging to refer to particular imaging eJuipment or e4amination
$ptical imaging
remalignant le"i:n
Selecti=e Internal Radiation @herapy ,SIR@0
+n
imaging
techniJue
7hich
u"e"
=i"i!le)
Refer" to altered ti""ue 7here there i" a greater chance of cCncer de=eloping than in the unaltered form6 Identification of "uch a le"i:n allo7" pre=en# ti=e treatment6
Radiola!elling
+ type of radiation therapy for cCncer that in=ol=e" inDecting tiny amount" of radioacti=e "u!"tance into the arterie" 7hich "upply the tumour6
Serum alpha#fetoprotein
infrared or ultra=iolet light6 Inference" can then !e made !a"ed on the a!"orption or "cattering of light 7ithin the !ody6
$=er#in=e"tigation
In "ome ca"e" patient" may !e referred for more e4amination" than i" ultimately nece""ary6 @hi" can re"ult from o=erly !road "creening programme" leading to "ome patient" !eing e4amined for condi# tion" that may ne=er cau"e any "ymptom" or complication"6
o"itron emi""ion tomography , E@0
+l"o ?no7n a" i"otopic la!elling) thi" refer" to the introduction of a radioacti=e "u!"tance into the !ody and trac?ing it through a meta!olic path7ay or cell6
+ pla"ma protein found 7ithin the human !ody6 It i" u"ed a" a !iomar?er to detect the pre"ence of certain tumour"6
Spiral C@
Radiology
+ type of computed tomography) 7here the 4#ray "peciality "uch E@) a" and 7hich 4#ray MRI to u"e" imaging C@) and "ource and detector" mo=e in a helical ,"piral0 pat# tern around the patient in order to increa"e re"olu# tion6
Pltra"ound
+ @hi" imaging techniJue create" /< image" of func# tional proce""e" ta?ing place in the !ody !y detect # ing the ray" emitted !y a po"itron emitting "u!# "tance) 7hich ha" !een placed in the !ody6 It and i" mo"t commonly imaging) u"ed "o in the com!ination 7ith C@ , E@#C@0 7hich allo7" for anatomical meta!olic radiologi"t can "ee 7hat the "tructure loo?" li?e and 7hat it i" doing6
olyp" ,colorectal0
medical
techniJue" ultra"ound)
radiography) =i"uali"e
identify di"ea"e 7ithin the !ody6

RECIS@
+n imaging modality that u"e" ultra"onic 7a=e"6 @he"e 7a=e" are a!o=e the audi!le range of human") !ut can !e u"ed to image tendon") mu"cle") Doint") =e""el" and e=en organ" for any "ign" of le"ion"6
U#ray
Re"pon"e E=aluation Criteria in Solid @umour" i" a "et of pu!li"hed guideline" to help phy"ician" define a cCncer patientG" "tatu"6 It i" u"ed to indScate if a patient ha" impro=ed ,re"ponded0) "tayed the "ame ,"ta!ili"ed0 or 7or"ened ,progre""ed06
@he
Renal in"ufficiency
olde"t
and
mo"t
7ell
?no7n
imaging
+ fle"hy gro7th 7hich de=elop" on the lining of the colon or rectum6 @hey are u"ually !enign) !ut "ome type" can !ecome malignant6 See the term WadenomaG6 Not all colonic polyp" are adenoma6 $nly adenoma" can de=elop into cCncer o=er
modality) 7hich u"e" 4#ray" to produce image" of the !ody6 It i" a particularly u"eful techniJue a"
+ condition al"o ?no7n a" renal failure or ?idney failure6 It i" a condition in 7hich the ?idney" fail to adeJuately filter to4in" and 7a"te producS"
European
BKIGV
Society of
Radiology
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European Society of Radiology

MIKING CNCER VISIBLE

the roleof imagingin

INTERNATI ONAL DAYOF RADIOLOG

u!li"hed !y the ESR # European Society of Radiology In

An Introduction Prevention B creening

%reat&ent & %herapy

About the Interviewees ,(ossary

Ma?ing CCncer Vi"i!le( the Role of Imaging in $ncology +n Introduction

rof6 N=e" MenO) 3rance

NATIONAL SCREENING PROGRAMMES:

OBJECTIVES AND REALITY

+merica and Europe operate

eople can o!tain information a!out "creening

general urologi"t") and

practitioner") any other

i" highly de"ir#

ernment" to ta?e action6

THINGS TO KEEP IN MIND

BEFORE AN EXAMINATION IS CARRIED OUT

undergo "creening te"t"6

atient" "hould ?no7

MEDICAL IMAGING IN THE DETECTION OF

computed tomography ,C@0) magnetic re"#

ity are collected for further e4amination) i" nece""ary6

THE ROLE AND THE SKILLS

<etection of hepatocellular carcinoma

demand" ma?e the radiologi"t more and

Computed tomography image of the che"t u"ing lo7 radiation do "e

regnancy al"o limit" the u"e of

E@) 7hich i" a!le to produce a /< image of a

in the field of imaging technology are =ital to

the progre"" of the di"cipline it"elf6 $=er the la"t

inflammation u"e up high le=el" of gluco"e) the

radiologi"t" the mo"t promi"ing tool for the future6

Brea"t MR image of In=a"i=e Lo!ular Carcinoma

!een de=eloped to their full potential6

THE IMPORTAN CE OF STAGING

Chemical e4change "aturation tran"fer ,CES@0 imaging of a malignant !rain tumor

TAKES CENTRE STAGE

many of the ad=ance" !eing made in

Molecular e4tremely !enefit" in=ol=ed)

imaging all the

general field) of image"

7hich cCncer are "taging)

TREATMENT MONITORING !ITH IMAGING:

dimen"ion" of the primary tumour and the dimen"ion" of a num!er of lymph

cellular acti=ity and molecular proce""e"

INTERVENTIO NAL RADIOLOGY AND

rofe""or Hri# ca? point" out) there are

application of radiofreJuencie" ,R30 or

rof6 Hed=ig Hrica?) PS+

medical profe""ional" a=oid u"ing the term QcureG) due to the

THE IMPORTANCE OF FOLLOW-UP

recurrence !efore "ymptom" appear6 It i" a corner"tone of

of techniJue" and eJuipment at their

THE RADIOLOGI STS

the early "ign" of cCncer recurrence) to the

through a range of techniJue" and then communicating patientG"

undergo other e4am") "imilar to tho"e

WHAT THE PUBLIC SHOULD KNOW

ABOUT IMAGING IN FOLLO!"UP CANCER CARE

t7ice a year6 e""arily undergo

atient" 7ill not nec# procedure"