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CT Techniques and Principles, Including Mpr and 3D: Oncology Patients Imaging Pearls - Educational Tools | CT Scanning | CT Imaging | CT Scan Protocols - CTisus
Imaging Pearls ❯ CT Techniques and Principles, including MPR and 3D ❯ Oncology Patients

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  • “Lymphoma comprises a heterogeneous group of diseases; remarkable advances have been made in diagnosis and treatment. Diagnostic imaging provides important information for staging and response assessment in patients with lymphoma. Over the years, staging systems have been refined, and dedicated criteria have been developed for evaluating response to therapy with both computed tomography (CT) and fluorine-18 fluorodeoxyglucose positron emission tomography (PET)/CT. The most recent system proposed for staging and response assessment, known as the Lugano classification, applies to both Hodgkin and non-Hodgkin lymphoma. The use of standardized criteria for staging and response assessment is important for making accurate treatment decisions and for determining the direction of further research. This review provides an overview of the updated CT and PET response criteria to familiarize the radiologist with the most important and clinically relevant aspects of lymphoma imaging. It also provides a short clinical update on lymphoma and the associated spectrum of imaging findings.”


    Imaging for Staging and Response Assessment in Lymphoma.
Johnson SA et al.
Radiology. 2015 Aug;276(2):323-38
  • “Lymphoma comprises a heterogeneous group of diseases; remarkable advances have been made in diagnosis and treatment. Diagnostic imaging provides important information for staging and response assessment in patients with lymphoma. Over the years, staging systems have been refined, and dedicated criteria have been developed for evaluating response to therapy with both computed tomography (CT) and fluorine-18 fluorodeoxyglucose positron emission tomography (PET)/CT. The most recent system proposed for staging and response assessment, known as the Lugano classification, applies to both Hodgkin and non-Hodgkin lymphoma. The use of standardized criteria for staging and response assessment is important for making accurate treatment decisions and for determining the direction of further research.”
Imaging for Staging and Response Assessment in Lymphoma.
Johnson SA et al.
Radiology. 2015 Aug;276(2):323-38
  • “Splenic involvement in lymphoma is common, with most cases representing diffuse large B-cell lymphoma, Hodgkin lymphoma , or indolent B-cell lymphomas such as splenic marginal zone lymphoma, chronic lymphocytic leukemia, mantle cell lymphoma, or hairy cell leukemia. Imaging findings vary. Splenomegaly is common but neither sensitive nor specific for lymphoma involvement; no size criterion has been widely accepted . The following observations strongly suggest splenic involvement with lymphoma: (a) massive splenomegaly, (b) focal or multifocal solid masses or multiple, tiny nodules, (c) adenopathy in the splenic hilum.”

    Imaging for Staging and Response Assessment in Lymphoma.
Johnson SA et al.
Radiology. 2015 Aug;276(2):323-38
  • “Gastrointestinal tract lymphoma is common in non-Hodgkin lymphoma and has variable appearances on CT images. The stomach is most commonly affected, followed by the small bowel and colon; esophageal involvement is rare. Gastric involvement with mucosa-associated lymphoid tissue is hypothesized to be particularly prevalent secondary to chronic inflammation in patients harboring H. pylori. Small bowel lymphoma has a predilection for the terminal ileum, likely secondary to the high volume of lymphoid tissue at this site. On CT images, findings include focal or multifocal bowel wall or fold thickening (characteristically without causing upstream obstruction), polyps, ulcers, and aneurysmal dilatation.”


    Imaging for Staging and Response Assessment in Lymphoma.
Johnson SA et al.
Radiology. 2015 Aug;276(2):323-38
  • “Primary lymphoma of bone is uncommon and is typically either diffuse large B-cell lymphoma or follicular lymphoma . This entity was described as “reticulum cell sarcoma” before the introduction of newer immunohistochemical markers. The CT appearance of osseous lymphoma is variable; focal lesions are typically lytic but may be sclerotic, as seen with a classic “ivory vertebra,” or may demonstrate a mixed lytic/sclerotic appearance. Sclerosis may also develop after chemo- or radiation therapy in treated lesions . Either focal bone lesions or diffuse bone marrow involvement may occur in advanced-stage lymphoma. Bone marrow involvement is often assessed with bone marrow biopsy (typically of the posterior iliac crest) but can be diagnosed in the presence of focal or multifocal increased FDG uptake in bone marrow on pretreatment FDG PET/CT images.”


    Imaging for Staging and Response Assessment in Lymphoma.
Johnson SA et al.
Radiology. 2015 Aug;276(2):323-38
  • “Currently, functional imaging with FDG PET/CT is often obtained in FDG-avid lymphoma, but indications depend on specific diagnosis and presentation. A baseline pretreatment scan is always recommended to allow meaningful comparison later . Combined FDG PET/CT has been found to be more accurate than CT alone for response assessment. For example, one analysis showed that in identifying lymph node involvement, FDG PET/CT was 94% sensitive and 100% specific, while contrast-enhanced CT alone was 88% sensitive and 86% specific. For organ involvement, FDG PET/CT showed sensitivity of 88% and specificity of 100%, whereas contrast-enhanced CT alone had sensitivity of 50% and specificity of 90% ”


    Imaging for Staging and Response Assessment in Lymphoma.
Johnson SA et al.
Radiology. 2015 Aug;276(2):323-38
  • “With FDG PET/CT, non-Hodgkin lymphoma will be upstaged in 31% and downstaged in 1% of patients relative to CT (usually patients with stage I or II disease), thereby potentially changing treatment in 25%. Hodgkin lymphoma will be upstaged in 32% and downstaged in 15% of patients with FDG PET/CT, thus possibly leading to treatment change in up to 33%.”


    Imaging for Staging and Response Assessment in Lymphoma.
Johnson SA et al.
Radiology. 2015 Aug;276(2):323-38
  • “Among patients with early-stage Hodgkin lymphoma, the cornerstone of therapy is chemotherapy, most commonly with the ABVD regimen (consisting of doxorubicin, bleomycin, vinblastine, and dacarbazine) with or without consolidative radiation therapy. For advanced-stage Hodgkin lymphoma, combination chemotherapy is the standard of care, in the United States usually with the ABVD regimen. In select higher-risk scenarios, the BEACOPP regimen (consisting of bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone) may be chosen. Consolidative radiation therapy may be considered for initially bulky disease.”

    Imaging for Staging and Response Assessment in Lymphoma.
Johnson SA et al.
Radiology. 2015 Aug;276(2):323-38
  • “Cure can be achieved in the majority of patients with the most common type of aggressive non-Hodgkin lymphoma (diffuse large B-cell lymphoma) with combination chemotherapy-immunotherapy or combined-modality therapy. A standard regimen in patients with advanced-stage disease is six cycles of R-CHOP (the anti-CD20 antibody rituximab in combination with cyclophosphamide, vincristine, doxorubicin, and prednisone). Patients with limited-stage disease can be treated with an abbreviated course of R-CHOP (three to four cycles) followed by involved-field radiation therapy with similar outcomes to full-course chemotherapy. Bulky disease at any stage is typically treated with six cycles of R-CHOP with or without radiation therapy.”


    Imaging for Staging and Response Assessment in Lymphoma.
Johnson SA et al.
Radiology. 2015 Aug;276(2):323-38
  • “In the ongoing clinical effort to optimize outcomes while minimizing toxicity in the treatment of lymphoma, early response assessment with an interim FDG PET/CT scan is often performed. Interim FDG PET/CT scans are those completed after initiation but before completion of therapy, often after either the second or fourth cycle of a standard six-cycle course. Reduction in lesion size and metabolic activity are indicative of response and interim FDG PET/CT negativity is associated with improved outcomes. The greatest potential benefit of interim FDG PET/CT evaluation is the potential to inform “response-adapted therapy,” whereby treatment could be de-escalated in intensity in the setting of a satisfactory early response or escalated if early response is inadequate.”

    Imaging for Staging and Response Assessment in Lymphoma.
Johnson SA et al.
Radiology. 2015 Aug;276(2):323-38
  • ■ "At CT, response is categorized as complete radiologic response (all nodes ≤ 1.5 cm in longest diameter, disappearance of all CT findings of lymphoma), partial remission (≥50% reduction in disease burden), stable disease (<50% decrease in disease burden), or progressive disease (new or increased adenopathy or new extranodal lymphoma)."
    ■ "At FDG PET/CT, response is graded on the five-point scale and categorized as complete metabolic response (score 1, 2, 3), partial metabolic response (score 4 or 5 with reduced FDG uptake), no metabolic response (score 4 or 5 with no significant change in FDG uptake), or progressive metabolic disease (score 4 or 5 with increased FDG uptake or new lesions compared to previous scan).”

    Imaging for Staging and Response Assessment in Lymphoma.
Johnson SA et al.
Radiology. 2015 Aug;276(2):323-38
  • “ In addition to diagnosis and follow-up assessment of disease response, the radiologist should be familiar with the imaging findings of acute conditions affecting the oncologic patient to optimize patient care.”
    Cross-sectional imaging of acute abdominal conditions in the oncologic patient
    Heller MT, Khanna V
    Emerg Radiol (2011) 18;417-428
  • “ In addition to the commonly encountered acute conditions found in the general population, the oncologic patient is at increased risk to develop an acute condition due to local effects of the primary tumor and metastases, untoward effects of treatment, and potential altered immune response.”
    Cross-sectional imaging of acute abdominal conditions in the oncologic patient
    Heller MT, Khanna V
    Emerg Radiol (2011) 18;417-428
  • Tumor Related Complications
    - Acute vascular complications
    - Gastrointestinal complications
    - Hepatobiliary complications
    - Genitourinary complications
  • Tumor Related Complications
    - Acute vascular complications
    - Vessel invasion or occlusion (Budd Chiari syndrome)
    - Organ infarction due to vessel invasion (splenic infarction)
    - Organ abscess (splenic abscess)
    - Spontaneous hemorrhage (renal cell carcinoma)
  • Tumors with Spontaneous Hemorrhage
    - Hepatoma
    - Renal cell carcinoma
    - Melanoma
  • Tumor Related Complications
    - Acute vascular complications
    - Gastrointestinal complications
    - Hepatobiliary complications
    - Genitourinary complications
  • Tumor Related Complications
    Gastrointestinal complications
    - Obstruction
    - Perforation
    - Intussusception
    - Ischemia
  • Treatment Related Complications
    Complications of immunosuppression include
    - Typhlitis
    - Acute graft versus host disease
    - infection
  • Treatment Related Complications
    Complications of TACE include
    - Mild post procedure symptoms like abdominal pain, nausea and vomiting, increased LFTs and leukocytopenia
    - Hepatic artery spasm or occlusion
    - Tumor rupture
    - Duodenal perforation
    - Acute cholecystitis
    - Liver abscess
    - Biliary necrosis

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