Subject: Surgery Topic: Principles of Cancer DiagnosisRadiologic Lecturer: Mateo T.

Ilano, MD, FPCR Date of Lecture: July 19, 2011 Transcriptionist: Jan Eric Editor: Hanna Morcilla Pages: 10

PART I: RADIOLOGIC MODALITIES USED IN CANCER DIAGNOSIS 1. X-ray (Radiography) y Examination of any part of the body for diagnostic purposes by means of x-rays with the record of the findings usually impressed upon a photographic film.

attenuation(absorption) of different body parts: Appearance Termed as: Degree of on X-ray Attenuation (absorption) Black Radiolucent Air, Lungs, Sinuses Gray Muscles, Fats, Soft Tissues, Fluids White Radiodense Bone, Metal, Contrast Media **
X-rays are attenuated (absorbed) depending on the atomic number of the medium, the higher the atomic number of the substance, the more x-rays will be absorbed, the whiter it would appear on the radiograph (ex. Bones, metal). Air on the other hand (being low in atomic number) will appear Black.

y 2 dimensional only, needs at least 2 views in order to check the exact location of the lesion:  AP/PA & Lateral View  AP/PA & Oblique view
**Example may nakita kang calcification sa AP/PA na Radiograph, hindi mo madi-distinguish agad yung location niya kung sa anterior ba siya or bandang posterior, kaya kailangan tingan mo yung side view(Oblique/Lateral View)

B C
y Radiation is produced thru an X-ray tube (A) which has two basic parts:  Cathode  Anode- which emits the x-rays y The Medium (B) is the anatomic part of interest being x-rayed. The intensity of x-rays will be attenuated depending on the atomic number of the substance y Image Receptor/Film (C) is where the image is formed
** Analogy: Turn on a desk lamp (A) and hold your finger(B) under it. The light bulb represents the x-ray tube while the desk(C) is analogous to the film.

1.a Plain X-ray y X-ray procedure that does not utilize contrast media y Not a good diagnostic tool for tumors, (in contrast to CT Scan/MRI) y Some tumors may exhibit radiolucency: Multiple myeloma exhibits lytic lesions on Radiography (Radiolucent)

y Nowadays, we have what we call Computed/Digital Radiography wherein images are seen in a computer monitor instead of on film
**Same lang siya ng principle sa conventional x-rays, yun nga lang instead of films, we have what we call image receptors that will be processed by the computer, so you can view it on the computer monitor. ** Lateral view of a skull with Multiple Myeloma: In a normal radiograph of the skull, the cranium appears homogenous, in this case of multiple myeloma, we can observe mottled black, Radiolucent lesions (parang nasisira kaya madali siyang mapenetrate ng x-rays, therefore magiging dark)

y In X-ray, there are differences in densities produced, depending on the

y Some may exhibit radiodensity: Osteoma an example of calcification (Radiodense) 1

SY 2011-2012

y Images formed in the computer will be termed as: Appearance Termed as: Degree of on CT Scan Attenuation(absorptio n) Black Hypodense Air, Lungs, Sinuses Gray Isodense Muscles, Fats, Soft Tissues, Fluids White Hyperdens Bone, Metal, Contrast e Media Hounsfield Units/Attenuation Coefficient: y Determines the degree of attenuation y Coefficient number used in determining the density of the tissue Tissue Type CT Number Appearance Bone +1000 White Blood +100 Brain +30 CSF +5 Water 0 Gray Fat -100 Air -1000 Black
**This is used as a guide, for example gusto mong malaman kung anong composition ng tumor, i-point mo lang yung cursor dun sa tumor may lalabas na value dun ex. around +1000 yung lumabas, therefore calcified yung tumor mo, pag naman around -100 yung lumabas, medyo fatty yung composition ng tumor.

1.b Contrast Aided X-ray y X-ray procedure that utilizes contrast media:  An internally administered substance that has a different opacity from soft tissue in xray, CT Scan & MRI, used to opacify GIT blood vessels and genitourinary tract.  Attenuates x-rays therefore, would appear white  Ex. Barium Sulfate, Iodine y Below: An example of contrast aided x-ray, blood vessels of the head are opacified with the use of contrast media:

Contrast Media in CT Scan y There is a need to check for BUN/Creatinine levels first because of toxicity (should be within normal range) y Check for any allergies first before introduction (ex. In seafoods) Types y Ionic: commonly used but high incidence of allergic reaction y Non-ionic: More expensive, less allergic reaction Types of CT Scan: 2.a. 4th Generation CT Scan

2. Computerized Tomography Scan (CT Scan) y Imaging anatomical information from a crosssectional plane of the body. Each image is generated by a computer through synthesis of x-ray transmission data obtained in many different directions in a given plane. y Determines the exact location of the tumor, sensitive for bone imaging or calcifications y Compared with x-ray, the film is replaced by a bank of electronic detectors mounted directly opposite to the x-ray tube but on a rotating assembly. These detectors convert high intensity x-rays into electrical signals which are processed by the computer.

y y

y y

use of ring of detectors fixed around the entire periphery of the gantry x-ray beam rotates around the patient and always radiates a freshly calibrated detector. Does axial cuts only Longer scanning time, may skip/miss lesions within the slice (example if the lesion is inside the 10mm slice, it will not be shown on the monitor) 1 Slice, patient moves inside the machine, 1 slice, patient moves inside the machine sequence

** Analogy: Bread is to Px Body: Raisins is to tumors. Nag slice ka ng raisin bread na tig 10mm thick, possible na may hindi ka makitang

raisins sa bread na ini-slice mo kasi hindi siya na-daanan ng knife (raisins na nasa loob nung hiniwa mong part).

MRI Sequence: Sequence Appearance Tissues that will appear hyperintense Fat, Skin, Highly protienacious fluids Fat, CSF, Majority of Tumors, edema

2.b. Spiral/Helical CT Scan

y y

Developed in the late 1980 s and was 1st commercially available in 1990. In helical CT, the x-ray tube and detector array rotates continuously about the patient collecting view data. The patient table is moved at constant speed.

**Analogy Potato is to Px. Body: Tumor is to rotten areas within the potato. Bumili ka nung spiral na potato chips na nasa BBQ Stick sa SM, parang ganun. Kita mo agad kung may rotten areas yung potato kasi thin cuts.

T1 Weighted CSF is Black Images (T1WI) T2 Weighted CSF is White Images (T2WI) T2 Flair Same as T2WI but CSF is nullified

T1WI

T2WI

2.C. Multidetector CT scan (MDCT)

T2 Flair
y y Ability of CT scanner to acquire more than one slice simultaneously Advantages of MDCT (RSVP)  R Resolution (higher)  S Speed (less patient motion)  V Volume (increased length that can be scanned)  P Power (increased usage of x-ray tube power) In 2007 (256-slice was developed, latest of its kind) Faster gantry rotations Faster reconstruction 3D volume rendering images (axial, coronal, sagittal and 3D images)

y y y y

Contrast Media in MRI y Gadolinium y Meglumine Advantage of MRI: y Does NOT utilize ionizing radiation y Can do direct axial, coronal, sagittal images y More sensitive in imaging:  Posterior fossa  Pituitary tumors  Spinal Cord  Minute tumors in the brain  Demyelinating diseases y Bone blind -Not good in imaging bones, calcifications (appears black) y Long scanning time(cannot be used for trauma and restless/moving patient) y Expensive procedure 4. Ultrasound y Utilizes very high frequency sound waves y Electrical Signals will go to the transducer where soundwaves would be emitted y Echoes will bounce back from the structures and go back to the transducer, then to the computer and convert it to images. y Uses Probes:  Linear Probe  Superficial Probe(for thyroid, breast)  Sector Probe (for cardiac imaging) 3

**Same lang din ng principle ng Spiral CT, yun nga lang mas marami yung slices na nagagawa niya ng sabay-sabay kaya mas mabilis.

3. Magnetic Resonance Imaging (MRI) y Based on the principle of nuclear magnetic resonance (NMR), in which signals emitted by Hydrogen nuclei in a strong magnetic field are measured Principle is based on the change of polarity of hydrogen atoms in the body through the use of magnets:  Permanent Magnets(0.2-0.4 Tesla)  Super Conducting Magnets (1.5-3 Tesla)
Magnet strength, resolution of images & speed

** Tesla,

y Images formed in the computer will be termed as: Appearance on MRI Termed as: Black Hypointense Gray White Hyperintense

Convex Probe (for majority of solid organs) y Images formed in the computer will be termed as: Appearance Termed as: Structures: on Ultrasound Black Hypoechoic Gray Isoechoic White Hyperechoic/echogenic Fat, stones, gas  Sound frequencies used by ultrasound (in Megaherstz) Frequecy Used for imaging: 3.5-5 mHz Deep organs: (liver, kidney pancreas) 7.5-10 mHz Superficial organs: (Thyroid, breast) Advantage: y Does not utilize ionizing radiation y Can determine whether the tumor is solid or fluid filled y Used in Ultrasound guided biopsy Disadvantage y Hollow organs with gas/air (stomach, intestines, colon) cannot be efficiently imaged y Air may interfere 5. Positron Emission Tomography Scan (PET Scan) y Nuclear medicine imaging procedure y Instead of detecting changes in the physical size or structure of internal organs, as other traditional imaging technologies do, PET detects changes in the cellular function/metabolic function. (Remember Cancer elicits change in metabolism)

y Radioisotope is short-lived and has less radiation equivalent to two chest X-rays. y Determines if the cancer has spread to other parts of the body, so that appropriate treatment can be started y Monitors recurrence of disease, for primary tumors that cannot be detected by other imaging modalities(X-ray, CT, MRI) y Cancer cells are highly metabolic, therefore utilizes the radioactive glucose (sugar) that is injected in the patient prior to the exam. The areas of high glucose uptake are dramatically displayed in the scan imagery will appear bright. y A value of  SUV >2.5: is regarded as consistent with malignancy  SUV <2.5: as inflammatory  However, in a minority of patients, higher SUV may be seen in non-malignant diseases such as granulomatous infections, sarcoidosis, bacterial infections, etc. Low grade tumors may have SUV less than 2.5 Used in diagnosis of: y Cardiovascular diseases y Early brain changes/diseases y Tumors or anatomical abnormalities y The cause of mental disorders y Areas affected by a clot or stroke Role in Cancer Diagnosis: y Diagnosis (PET does not have so much role) y Staging y Restaging y Response to treatment Disadvantage y Inflammatory diseases(arthritis) will appear bright (may erratically be suspected as malignant) y PET scan cannot clearly visualize the anatomy involved that s why PET-CT is developed: combination of PET Scan and CT Scan in order to locate the exact location.

y Radiotracer is administered intravenously.  FDG (fluorine-18-2-fluoro-2deoxyglucose), which includes both sugar (glucose) and a radionuclide (a radioactive element) with a half life of 110 minutes

1. Nervous System (brain, skull)

PART II: BODY SYSTEMS Primary Brain Tumor (2/3) Occurence 40-50% Tumor Gliomas(Most common intra-axial brain tumor) y Glioblastoma Multiforme y Astrocytoma y Ependymoma y Oligodendroglioma Meningioma Pituitary Adenoma Schwannoma

Brain Tumors y 80% of CNS tumors occur intracranially y tumor is initially detected by associated edema
*Edema is associated with most tumors, except in low-grade tumors, Contrast material is needed in order to enhance its visualizing properties.

y CT description of brain tumors should include:  tumor location and extent  tumor characterization  mass effect and edema  brain herniation

15% 5-6% 6%

Type Glioblastoma Multiforme

Medulloblastom a

Pilocystic Astrocytoma

Characteristics y Most common primary brain tumor y 12-15% of all intracranial tumors y 60-75% of astrocytomas y Multifocal in up to 20% y Supratentorial white matter is most common location (frontal, temporal, parietal, occipital) y Basal ganglia and thalamus less common y Brainstem and cerebellum common in children y Typically crosses white matter tracts to involve contralateral hemisphere y Corpus callosum (butterfly glioma) y Anterior and posterior commissures y 15-20% of pediatric brain tumors y 30-40% of posterior fossa tumors in children y 75% occurs in < 10 y/o y 4th ventricular tumor (arises from the roof) y It may also arise from the cerebellar hemisphere y Hydrocepalus is common (95%) y Most common primary brain tumor in children (up to 25%) y 5-15 y/o (older age range than medulloblastoma) y Cystic cerebellar mass with enhancing mural nodule y Location: cerebellum(60%), optic nerve/chiasm(25-30%), adjacent to 3rd ventricle, brainstem

CT Scan Findings NECT y Irregular iso or hypodense mass with central hypodensity representing necrosis y Marked mass effect and surrounding EDEMA y Hemorrhage not uncommon y Calcifications are rare CECT y Strong, heterogeneous irregular rim of enhancement

MRI Findings T1WI y Irregular iso to hypointense white matter mass T1 with contrast y Thick, irregular ring of enhancement surrounding central necrosis T2WI y Heterogeneous, hyperintense mass

NECT y Solid hyperdense mass in the 4th ventricle y Calcification in 20% y Intratumoral cysts in 40-50% CECT y 90% homogeneous enhancement NECT y Discrete solid/cystic mass y Little or no surrounding edema y Calcification 20% CECT y >95% enhance

T1WI y Hypointense with gray matter T1 with contrast y Heterogeneous enhancement T2W1 y Slightly hyperintense to gray matter

T1WI y Iso to hypointese to gray matter T1 with contrast y Intense but heterogeneous enhancement T2 WI y Solid portions hyperintense to gray matter

Sella & Pituitary Tumors Type Characteristics Pituitary y < 10 mm in diameter Microadenoma y Intrapituitary lesion that enhances but less rapidly than surrounding normal gland y Circumscribed, welldemarcated mass

Pituitary Macroadenoma

y Most common intra or combined intra/suprasellar mass y Figure of eight or snowman configuration y > 10 mm in size y 20-40 yrs of age

Craniopharyngio y Benign often partially cystic ma sellar region tumor derived y Adamantinoma from Rathke pouch tous epithelium y Papillary y Multilobulated and often large (> 5cm) y Peak is 5-15 y/o and > 50 y/o y Most common pediatric intracranial tumor of nonglial origin y Imaging locations:  Suprasellar 75%  Suprasellar + intrasellar 21%  Entirely intrasellar 4% y - Rare ectopic location are optic chiasm, 3rd ventricle Cerebello-Pontine Angle(CPA) Lesion Type Characteristics Epidermoid cyst y 90% intradural, 10% extradural y 40% CP angle, 20% 4th ventricle y Insinuating mass with scalloped margins y Cauliflower like margins y Engulfs 7th and 8th cranial nerves y 3rd most common CPA mass

MRI Findings T1 and T2 y Isointense with normal pituitary gland T1 with contrast y 70-90% hypointense to intensely enhancing pituitary gland NECT T1 and T2 y 15-20% have cysts or y isointense with gray necrosis matter T1 with contrast y 10% hemorrhage y 1-2% have y Intense inhomogeneous calcification enhancement CECT y inhomogeneous enhancement NECT T1 (adamantinomatous y heterogeneous type) nodule with hypo to y 90% mixed solid, hyperintense cyst cystic T2 y 90% calcify y hyperintense cyst with hypointense y 90% enhance calcifications ( papillary type) y Often solid, isodense and rarely calcify

CT Scan Findings NECT y Isodense if no hemorrhage or cyst CECT y 2/3 appear hypodense on dynamic scans

CT Scan Findings NECT y Same density with CSF y Calcification in 20% mostly in margins y Pressure erosion of temporal/skull base CECT y no enhancement(as most of the cyst during contrast stage) CECT y well-delineated enhancing mass of CPA-Internal Acoustic Canal cistern y May flare IAC when large

MRI Findings T1WI y Isointense to slightly hyperintense to CSF y Rare of white epidermoid with high T1 T2WI y Hyperintense DWI y Hyperintense

Vestibular Schwannoma/ Acoustic neuroma

y Adults with unilateral sensorineural hearing loss y Most common CPA mass (8590%) y 2nd most common extra-axial neoplasm in adults y Avidly enhancing cylindrical or ice-cream on cone mass

T2WI y Filling defect in CSF signal in CPA-IAC cistern T1 with contrast y Focal, enhancing mass of CPA-IAC cistern 6

y Small lesions: Intracanalicular y Large lesions: Intracanalicular with CPA cistern extension Meningioma y Benign, unencapsulated neoplasm arising from meningothelial arachnoid cells of CPA-IAC dura y 2nd most common CPA-IAC mass y 10% are multiple y If found in children, consider NF2 y <10% are symptomatic y Compresses rather than invades structures NECT T1 with contrast Isodense 25%, y Enhancing dural Hyperdense based mass with 75% dural tail centered 25% calcified along posterior petrous wall >90% strong T2WI enhancement y Iso to hypointense

CECT -

Brain Metastases increasingly common, affecting 20% 40% of cancer patients predominant presenting symptom in brain metastasis is headache 50% of patients with brain metastasis have motor or language deficits, and 10% 15% present with seizures the distribution of primary cancers:  48% lung  15% breast  11% genitourinary (21% kidney, 46% testes, 5% cervix, 5% ovary)  10% osteosarcoma  9% melanoma  6% head and neck tumor  5% neuroblastoma  3% GI (3% colon and 2% pancreatic)  1% lymphoma (mainly non-Hodgkin)
*Of note, renal, GI, and pelvic cancers tend to metastasize to the cerebellum, whereas breast cancer most commonly affects the posterior pituitary.

 Images produced by T2 weighted MRI are more sensitive to smaller lesions  up to 15% of patients diagnosed with brain metastasis, the primary cancer site will remain unknown despite thorough investigation  Positron-emission tomography imaging is a good tool for detecting an unknown primary CA site when brain metastasis is suspected y Gadolinium-enhanced MRI has the following advantages:  Useful for detecting smaller lesions  Provides better soft tissue contrast  Provides relatively stronger enhancement with paramagnetic contrast agents  No bone artifacts in the images  Provides less partial-volume effects, particularly for lesions adjacent to bones  Provides direct multiplanar imaging

Imaging Brain Metastases: Type CT Scan Findings Brain Metastases NCCT y the mass may be iso to hypodense, surrounded by variable amounts of vasogenic edema. CECT y enhancement is also variable and can be intense, punctate, nodular or ringenhancing if the tumour has outgrown it's blood supply

MRI Findings T1 y typically iso to hypointense y if haemorrhagic may have intrinsic high signal y melanoma metastases also hyperintense due to the paramagnetic properties of melanin y enhancement pattern can be uniform, punctate, or ring-enhancing, but it is usually intense. Delayed sequences may show additional lesions, therefore contrast-enhanced MRI is the current standard for small metastases detection. T2 y typically hyperintense y haemorrhage may alter this y FLAIR : typically hyperintense with hyperintense peri-tumoural oedema 7

y DWI : edema is out of proportion with tumour size and appears dark on trace-weighted DWI.

Differential diagnoses of Brain Metastases y abscess : typically hypermetabolic with central area of necrosis y stroke y primary brain neoplasm y lymphoma y post-treatment effects (post-surgical or postradiation): hypermetabolic acutely progressing to hypometabolic over time (Radiation Necrosis)

Intraspinal tumors y Intramedullary tumor (Within the spinal cord) 1. Ependymoma (adults) 2. Astrocytoma (children) y Intradural extramedullary tumor (Outside the spinal cord but within the dura mater) *2/3 (majority of intraspinal tumors) 1. Neurofibroma 2. Meningioma y Extradural tumor (Purely outside the dura, most likely metastatic) 1. Metastases

Intramedullary tumor Type Characteristics Ependymomas y most common intramedullary neoplasm in adults y typically have a central location in the spinal cord. y occur throughout the spinal axis. y well delineated from the surrounding spinal cord and have rostral and caudal cysts which cap the tumor poles. They are histologically benign. Hemangioblasto mas y 3 to 7% of all intramedullary spinal cord tumors, rare in children y occur throughout the spinal canal. y 25% of patients will have von Hippel-Lindau disease. y most common intramedullary tumor in children y The majority of these neoplasms are benign y benign neoplasms common in children and young adults y consist of well-differentiated neoplastic neurons and astrocytes y Most gangliogliomas grow slowly and have an indolent course. y most common primary malignant bone tumor to affect children and adolescents. y The intraosseous and extraosseous extent of the tumor must be assessed. y Important features of intraosseous disease are the longitudinal distance of bone containing tumor, the involvement of adjacent epiphyses, and the presence or absence of skip metastases.

Astrocytomas Gangliogliomas

Osteosarcoma

2. Chest y Plain x-ray is commonly requested y CT-Scan is the modality of choice for tumor localization y CT Scan guided biopsy- uses CT Scan in locating the parenchyma of the tumor before biopsy Two settings in CT of the Chest: 1. Mediastinal Setting- for visualizing the vascular structures, bones, soft tissues and muscles of the thorax. 2. Lung Setting- for viewing the lung parenchyma

*Retrocardiac tumor is hard to see in plain x-rays because it is obstructed by the heart. CT scan is the modality of choice

y MRI is NOT the modality of choice in imaging the lungs because of long scanning time. Brochogenic carcinoma y Lung cancer is the most common fatal malignancy worldwide y Approximately 80 to 90% of cases involve nonsmall cell carcinoma:

Type Adenocarcinoma

Non-small Cell Carcinoma Characteristics y accounts for 25 to 30% of NSCLC and is the most common type y It is typically classified as acinar, papillary, solid, and bronchioloalveolar varieties y Typically presents as a small (often < 4 cm), peripheral, round or oval, smoothly 8

Squamous cell carcinoma

Large Cell Carcinoma

Small Cell Lung Carcinoma

marginated, solitary pulmonary nodule y has decreased in frequency and now comprises 25% of lung cancers y usually slow growing, with late metastasis predominately to the liver, adrenal glands, kidneys, and bones y Tumors usually range in size from 1 to 10 cm. They are typically found in the central bronchi, although one third occur beyond the segmental bronchi y cavitates in 10 to 20% of cases, particularly in large peripheral lesions y most common type to prove Pancoast or superior sulcus tumors y is approximately 10 to 20% of all lung cancers y Majority present as a large (average size > 7 cm), peripheral mass, with poorly defined margins y Cavitation and calcification are uncommon (6%). Hilar and mediastinal adenopathy are seen in 30% and 10% of cases, respectively y 20 to 25% of all lung cancers y The tumors are usually located centrally (75 to 90% of cases) and mediastinal extension is common and often extensive with encasement of mediastinal structures and tracheobronchial compression -replaced, nowadays, by endoscopy because they can do biopsy at the same time, unless there is an obstruction then UGIS or CT Scan will be the modality of choice. Barium Enema- Radiographic study of the Large Intestine. Requires the use of contrast media to demonstrate the large intestine and its components -retrograde procedure (starts in the anus -cannot clearly demonstrate the tumor, just the narrowing/widening of the involved structures Virtual Colonoscopy  Uses CT Scan  Fast scanning (about 5 mins only)  No scope is introduced, but instead air  Polyps and tumor is visualized but cannot do biopsy

Type Nodule y Well defined y Lobulated y Spiculated Calcifications y Central y Eccentric

Pulmonary Nodule/Calcification Diagnosis(most likely) Benign In between Malignant

Benign Malignant

3. Abdomen y Plain X-ray for determination of displacement of hollow organs y Contrast aided ( to determine if there is a presence of strictures, thickening of walls, irregularities in rugal folds, ulcers, abdominal narrowing of the passages)  Esophagogram- also known as barium swallow, is the radiographic procedure/examination of the pharynx and esophagus, utilizing a radiopaque (appears white in the radiograph) contrast medium. Upper Gastro-intestinal Series (UGIS)Same as esophagogram, but small intestines are also examined using a radiopaque contrast medium -widened c-loop would indicate compression due to pancreatic tumor

Hepatocellular carcinoma y most common primary hepatic tumor y Risk factors include cirrhosis, chronic hepatitis, carcinogens, and errors of metabolism y can be solitary, multicentric, diffuse, and infiltrating y may invade adjacent vascular structures and metastasize to the lung(s), adrenal gland(s), lymph nodes, or bone.

Imaging Hepatocellular carcinoma Ultrasound Findings y Small HCCs can be homogeneously hyperechoic and can mimic hemangioma. This can result from a large proportion of fat being present in the tumor y Small HCCs also can appear hypoechoic, with larger HCCs frequently mixed in echogenicity CT Scan Findings y CT appearance of HCC varies depending on tumor size and the imaging phase. The most common attenuation pattern is isohyper-isoattenuation on prephase, arterial phase, and venous phase, respectively MRI Findings y HCC on T1-weighted images may be isointense, hypointense, or hyperintense relative to the liver. On T2weighted images, HCC is usually hyperintense

Renal cell carcinoma approximately 3% of adult malignancies and 9095% of neoplasms arising from the kidney Angiomyolipoma composed of varying amounts of blood vessels, smooth muscle, and fat Calcification and necrosis are rare, hemorrhage is frequent Ultrasound shows echogenic renal mass but also seen in 32% of small (less than 3 cm in diameter) renal cell carcinomas MR imaging, most angiomyolipomas can be clearly characterized because of the depiction of intratumoral fat 4. Breast 4.a. Mammogram y Used for routine screening of breasts y Painful procedure, but nowadays digital mammogram features less painful procedure. y 2 Views in mammogram:  Craniocaudal projection(CC)-compression is usually applied from the top of the breast. Whenever possible, the nipple should be projected in profile  Mediolateral-oblique projection(MLO)single most useful mammographic projection of the breast. A properly positioned MLO shows tissues extending from axillary tail to the upper abdominal wall 4.b. Ultrasound

y y y y

not as a replacement for x-ray mammography differentiation from solid or cystic mass guide for aspiration and biopsy Modality of choice for very dense breast

Location of Breast Cancer y cancer can occur anywhere in the breast or indeed wherever the breast tissue is found y Cancer can develop anywhere along the milk line where the embryologic structure was not resorbed. y Most common location is in the upper outer quadrant y Develops at the periphery of the glandular tissue just beneath the subcutaneous fat or anterior to the retromammary fat Mammographic Appearance of Breast Cancer y Spiculated lesions-dense irregular mass with a spiculated margin that is not related to prior surgery is the only combination of features that is virtually diagnostic of malignancy y Fine, linear, irregular branching calcifications are practically always due to malignancy Findings that should arouse suspicion malignancy y Lesion with ill-defined margins y Lesion with a microlobulated margin y Architectural distortion y Distorted parenchymal edge y Density increasing over time y Clustered microcalcifications y Changing calcifications of

___________________________________END OF TRANSCRIPTION____________________________________
NOTE: MEMORIZE THOSE HIGHLIGHTED TEXTS, most likely yun yung lalabas sa exam kasi inemphasize niya yun. Hindi dinefine ni Doc yung mga basics like: What is CT scan? Contrast media? Etc nung college, wala kasi sa PPT, baka magtaka kayo. Yung ibang definitions na nandyan ay galing sa mga textbooks ko

Legend: *Doc Ilano s explanation **Simplification ko lang sana maintindihan niyo. Sorry Phil-Am batch mates for using vernacular, I tried my best to explain it so that everyone can grasp those highly technical terms. Sources: Doc Ilano s PPT, voice recording, past trascriptions & my college textbooks. Hello Ellynel! =) Di ko sure kung same tayo ng lecture dyan sa school niyo, gusto lang kita i-greet ulit dito kahit hindi mo magamit to... Hehe ;-P

Finally, brothers, whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable- if anything is excellent or praiseworthy-think about such things Philippians 4:8

10