About Scans Compiled by doctordee, with the help of Roger, Neil, Glenn, Ro, Lynette, Jim, Dick and Richard

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A Word About Surveillance What to Wear, Eat, and Drink How to get your Reports Promptly Scans: To Have and To Hold and to Copy Learn to Read Your Scans Imaging Errors CT Radiation and CT Contrast Are Not Without Risk Imaging Choices X-rays CT Scans Bone Isotope Scans Bone Density Scans MRI Scans PET Scans Mammography Ultrasound Scans Comparison of MRI and CT scans for Liver Imaging Surveillance Schedules and Discussion Uterine LMS Gastrointestinal LMS Retroperitoneal LMS Extremity LMS Skin Which Scan is Best for Which Organ?

A Word About Surveillance

Leiomyosarcoma, once removed, has an alarming tendency to return. Surveillance is necessary so as to identify recurrences when they are small and surgically resectable. Scans therefore become a very important part of living with LMS. What is surveillance? It means watching. It means regular scans, usually every three months for the first two years, then every six months for the next three years, then yearly, so that any returning LMS is picked up early and small. Dealing with recurrences when they are small is easier, and they are more often surgically removed. If each recurrence can be dealt with appropriately, remissions [when there is No Evidence of Disease, NED,] will be achieved, prolonging survival time. With high grade LMS, a majority of LMS recurrences happen by two years. And it would make sense also, that the tumors that recur earlier are the more aggressive, higher mitotic index tumors that are reproducing faster. So close surveillance for the first two years is important. And it is every three months because the tumors that recur earlier also grow faster, and might easily get inoperable if you wait six months between scans. After two years, there is still a recurrence rate, although much lower. And these tumors might grow more slowly as well. So the scan interval is lengthened to six months. After five years there is still a recurrence rate, but low. And again, the probability is that the tumor would be slower growing. So yearly scans are done. It is not known how long one must do these; there are reports of LMS lung metastases discovered at 10 to 20 years after initial diagnosis.

What to Wear, Eat, and Drink

What to Wear You should wear comfortable, loose-fitting clothing for your imaging exams. Metal objects can affect some images, or be affected by the MRI magnetic field. Avoid any metal on your person, including clothing with zippers and snaps and metal trims and underwired bras. You may be asked to remove hairpins, jewelry, eyeglasses, hearing aids and any removable dental work. Women should always inform their doctor or x-ray technologist if there is any possibility that they are pregnant. What to Eat and Drink Ask the radiology department about what to do for the specific imaging process. You might be asked to refrain from eating or drinking anything for up to four hours before the exam. For examinations that require an intravenous injection of "contrast" or a radioisotope, tank up on fluids, including salty fluids* like broth or bouillon, prior to the Oral Intake Cut Off. This will help expand your blood volume, and make it easier for them to stick needles in your veins successfully the FIRST time. [*If allowed by your other health conditions.] If you are not on chemotherapy, and the imaging exam involves X-rays or isotopes, you might want to have a fair amount of anti-oxidant in your pre-exam meals [perhaps a liberal dosing of olive oil]. If you are taking treatment with chemotherapy or radiation, ask your treating doctor about this, because it might interfere with the treatment. The CT scans often require an hour beforehand of drinking 'Sunny Delight', a contrast agent [barium suspension] which helps to indicate bowel on the scan. Sunny Delight is generally acknowledged to be both disgusting in texture and disgustingly flavored. We have been toying with the possibility of spiking the stuff with vodka or gin. [Just kidding.] You have to be there for the scans. Why not enjoy it?

How to get your Reports Promptly

"Is it okay to bombard (or just call) your doctor to get info after the scans and before your next appointment, because you're going bonkers wanting to know? " Be pro-active and avoid the post-scan battle for your report and films. Train your doctors. Make sure that every written order for a scan includes instructions to the radiology department to "give the films and a copy of the Report to the Patient". Get a copy of your doctor's written order to take with you when you go for the scan or X-ray. In many cases you will be able to pick up your copy of the report after waiting just a few hours or you may have to come back to pick it up the next morning. Depending upon the efficiency of the radiology department, your scans will have been read and typed within 1 to 24 hours after you returned to the waiting room. The reason they may not want to give you the report before you see your doctor is because they think you will be all upset, and it is better to have the doctor break the news to you. This is known as Professional Ethics. As the clerk who refuses you the information will tell you: We Only Send Information To The Doctor Who Requested The Scan. This is actually nonsense. Read the AMA Patient's Bill of Rights. Legally, the information on that report BELONGS to you. Furthermore, there is the point that the bad news reaction is maybe best dealt with at home, and having time to review the report before meeting with your doctor will allow you to prepare a list of questions to make better use of that appointment. If your doctor refuses to instruct the radiologists to "give the films and a copy of the Report to the Patient", here are some other ways that might get your scan results quickly: 1. You can explain that you need the report results now, and are quite stable and can manage bad news. Further, you would not like to lose the time waiting until the next oncologist's appointment, when you could be finding out about treatment and arranging it. 2. Put your GP's name and address down as one of the doctors to receive the faxed report, but put YOUR FAX number on the sheet. [See below about getting free FAX service online.] 3. Ask when the report will be ready, and where you can pick up your copy. Do not volunteer further information. If they refuse, tell them, in measured, pleasant, droning tones: "That is not acceptable. I have a legal right to access to this information in a timely fashion, when will the report be ready, and where can I pick up my copy?" If they refuse again, tell them again, in measured, pleasant, droning tones: "That is not acceptable. I have a legal right to access to this information in a timely fashion, when will the report be ready, and where can I pick up my copy?" If they say they cannot get it for you, tell them, in measured, pleasant, droning tones: "Well, who can get it for me? I have a legal right to access to this information in a timely fashion, when will the report be ready, and where can I pick up my copy?" Speak slowly, distinctly, and in dulcet tones. Repeated, this is called "The Broken Record" and is an assertiveness training technique guaranteed to keep you cool and drive them crazy, while getting you what you want. 4. General rules for dealing with refusals: a. Be calm. But you may have to be very persistent -- quietly and politely obdurate. Do not make a disturbance. Do not nag. b. Ask for a deadline for results -- when you should get back to them if something doesn't happen. Then if it doesn't happen, you are calling as per the agreement. Following up. Don't let them get away with forgetting about you. c. Have copies of your legal rights or the bylaws or laws governing the situation. A copy of the AMA patient's bill of rights, and/or your state's legal position on patient's rights to information, may be very helpful. d. ALWAYS get the person who is refusing ON YOUR SIDE. NOTICE them as people, not as automatons. Assume that they REALLY want to help, but are bound by the rules. Ask them what you need to do to get what you want. REWARD them with gratitude. The easiest way to get a person on your side is to simply assume that they are. Working from that assumption usually gets you the furthest with the least friction. e. Your oncologist is a valuable resource in getting your results more quickly. If you would prefer seeing him/her for the results, arrange for appointments the day after the scans are scheduled, and have the radiology department notified that you must take the scans and report to the doctor yourself. How to get a Free Fax number online Look up the services on the comprehensive list. Most of them will provide you a free fax number and free RECEIVING of faxes. Some of them have conditions. Comprehensive List Of Free Fax Services online OR do a GOOGLE or other search engine search for FREE FAX fax4free is one site. eFax Free is another. It is an easy-to-use service that lets you receive faxes by email. look carefully for the free receiving of faxes, not the free TRIAL offer efax sitemap efax signup efax registration

Scans: To Have and To Hold and to Copy

Take over the scans yourself. "My oncologist informed me that the chemo didn't work, but today I found out the radiologist is missing my September scans. So instead of comparing my November scans to ones I had in September, the radiologist was comparing them to scans I had in June. It seems my oncologist had the September scans in his office and didn't tell anyone." "I brought the September scans over to the radiologist tonight, and asked him to reread the scans based on the new info. So maybe the chemotherapy DID do something? I have my fingers crossed! I really feel so much better! Cathie " Legally, besides the information in the report, the scans THEMSELVES also belong to you. It would be a good idea to get control of their physical existence. You will take better care of them than any institution or any other person. Often, the radiology department themselves will give you the scans and the report after they have been read. Sometimes this will be on "loan", but the "loan" is never followed up. It is a good rule of thumb to take physical possession of the scans yourself. Get an artist's portfolio to carry them in, with protection from inclement weather. Eventually, as the scans accumulate, one of those portable aluminum luggage racks on wheels will move them around easily. COPIES can be made at the same time as the original scans are done. This is useful if there is a possibility that you will be sending the scans to surgeons or oncologists or radiation facilities across the country for their opinions on treatment. Some departments can also copy CT scan sheets later on, as well. Ask how much copying would cost. You might only need to copy a certain part of the scan if the problem is localized. SCANS ON CD are the wave of the future. Currently, some of the facilities doing CT scans can put these scans on Compact Disc [CDs]. It needs special software to read, which is usually placed on the CD as well as the images and the report. Having your scans on CD allows for making multiple copies of the scans by having someone copy the CDs, and for sending them to many people for consultation, cheaply. Some facilities also have the equipment to take regular Xray sheets of scans, and convert them to digital format and put them on the computer database at the institution, as well as creating a CD of the scan for you. This allows them to keep a full record of your scans, and allows you to hold three years worth of scans in one hand. CDs are much easier to handle than the heavy Xray CT scan films. The software to view the images on the CD is actually ON the CD, and they self-play.

Learn to Read Your Scans

If you do this, you will understand why radiologists need to be given more clinical information than they often get, and why they need to compare and contrast not only serial CT scans, but also may need to correlate ALL scans that were done, whether they were CT, Ultrasound, MRI, or PET. A common situation is the ambiguity created when the MRI scan interpreter is not given the previous week's CT scan. You then get ONE radiologist seeing a lesion, and the other missing it. It is actually not terribly difficult to understand X-rays and Scans. First, you need some knowledge of anatomy. It doesn't have to be comprehensive knowledge, but you should know the location, appearance and function of major organs in basic terms. Like: your liver is on your right side, just below the diaphragm. The spleen is on the left side, just below the diaphragm. The stomach is in the middle, just below the diaphragm. The gall bladder is tucked under the liver. This is not major genius work, and will help you immeasurably in understanding and feeling comfortable with your body. There are online anatomy sites that can help, one of which is: Medline Anatomy Site Also useful: GRAY'S Anatomy of the Human Body (20th edition) featuring 1,247 vibrant engravings from the classic 1918 publication. Gray's Anatomy and another Anatomy Site Two online medical dictionaries. The first one gives terms in the language(s) of your choice. medical dictionary another medical dictionary Secondly, you need to know how the dark and light parts of the scan are interpreted. For X-rays and CT scans, a dark color means that radiation reached the film/detector array, and a white color means that the radiation was blocked on its way through the body. The more dense the tissue, the more it will block the radiation. So bones would be white, and lungs [which are mostly air] would be dark, and other tissues would be shades of grey, darker for less dense tissue, lighter for more dense tissue. If contrast is used, this is a very dense liquid injected into a vein, which then makes blood and organs which are highly vascular, much more dense. LMS and many cancer tumors are highly vascular, and they will "light up", become more white [radio-opaque] than surrounding tissue, because of the presence of increased amount of blood-borne-contrast. The picture of the tumor's increased blood supply is called a "tumor blush". If you are looking at a bone isotope scan, or a PET scan, these are scans where radioisotopes are taken up preferentially in high grade cancers or inflammations. So the films will show DARK spots where the isotope was taken up. None of this is difficult. Some of it is amazing. Most of it is rewarding. Take every chance to ask radiologists and your doctors to explain the scans to you. Take a look at libraries and bookstores and see if there is a simple book explaining how to read X-rays. You can do this. Always go over each reading either with the radiologist or your oncologist. Ask if you have questions. You will learn. You will also be a double check to make sure that the right scans are being read, because you will check that the name of the patient and the date of the scan are correct for each sheet. This benefit will occur from the FIRST time you look.

Imaging Errors

Comment from DIck: As a caveat, I must mention that a CT missed a 1.6x1.6x1.6 cm mass in Regina's pelvis. The PET missed the one in her shoulder. X-ray didn't show either the tumor or the small fracture in her femur. Both PET and bone scan had areas that were suspicious, but by MRI "unremarkable." None of them are perfect. Comment from Jim: I should also throw in that when the surgeon ordered an MRI prior to operating second time it came back that there was no [abdominopelvic] mass there. He wasn't very happy as he could feel it! I gather they locked the CT scan person and the MRI scan person into a room until they agreed on their interpretation. Comment from doctordee: One radiologist missed reporting on my LMS in a CXR when it was 1 cm and stage 1. Another radiologist missed reporting on my Adrenocortical Carcinoma on a routine CT abdomen when it was 1 cm and stage 1. Both cancers went to stage 3 before being officially reported upon. Even when the imaging is technically good, the human error boggles the mind.

CT Radiation and CT Contrast Are Not Without Risk

Radiation Exposure "One thing that I think about a LOT is that if you do all the scans that seem "reasonable" that the accumulated radiation dose could easily become a factor." Comment from Neil: "On the matter of X-ray exposure I'm relying on Bev's [his wife's] age as a counterbalancing factor. In his book, "X-Rays, Health Effects of Common Exams" (Sierra Club, 1985), Gofman has a table (Table 2) titled "Sensitivity Factors, by Ages Compared with Newborn, for Cancer-Induction by Ionizing Radiation" in which each entry denotes how many times less sensitive is that age than the newborn age. " "In case it's of interest here's the table:"

Age Yrs Males Females Newborn - - 1 1.01 1.01 5 1.11 1.16 10 1.39 1.52 15 2.80 3.18 20 3.14 3.64 30 3.68 4.17 40 8.44 9.31 50 210.89 213.98 55 307.53 306.88

"The values in the table are referenced to the ratios of whole-body cancer doses from "Radiation and Human Health," (Gofman, Sierra Club, 1981) Tables 21 and 22. Why the table stops at age 55 I don't know, but it certainly suggests that, at age 72, Bev's sensitivity to ionizing is relatively low. But I guess that, like everything else in treatment decisions, it's a tradeoff of information vs. risk." Contrast Can Be Dangerous IF contrast medium is a problem because of allergy or potential kidney problems, surveillance could be done with ultrasound or MRI of abdomen, and Chest X-ray for the lung. Alternatively, one could do the CT without contrast. Allergic reaction to intravenous contrast medium The iodinated dye that is injected into patients can cause anaphylactic shock, if the patient is or has suddenly become allergic to it. Allergy to seafood [also containing organic iodine compounds] is a warning clue. It is for this reason that THERE MUST ALWAYS BE A DOCTOR IN ATTENDANCE whenever an injection of contrast material is given. Kidney risk association with intravenous contrast medium Neil commented: "Joan wrote about "contrast scans after nephrectomy". I thought there might be some interest in the following information." Prevention of Contrast-Induced Kidney Failure One of the limitations of contrast studies such as cardiac catheterization and CT scanning is decrease in kidney function resulting from exposure to radiographic agents. Most patients do not experience worsening of their kidney function. For those who do, it can be a serious problem. It is frequently possible to identify patients at risk. Those with pre-existing kidney disease, diabetes, dehydration, and prior problems when exposed to x-ray dye are usually at risk for transient decreases in kidney function as are patients on certain types of drugs (eg, ACE inhibitors) and those given large volumes of radiographic contrast. Some patients with moderate to severe kidney disease before exposure to contrast will risk the need for temporary or even permanent dialysis. One of the better deterrents against this problem is adequate hydration with intravenous saline prior to the dye study. One thing that you can do is drink at least two quarts of clear liquids on the day of the scan. Fetch Article Recent evidence has suggested that the antioxidant, acetylcysteine [n-acetyl cysteine], administered before and after dye exposure significantly reduces the risk. This drug is traditionally used to treat Tylenol overdoses. Tepel and associates (N Engl J Med 2000;343:180) studied 83 patients with modest chronic renal insufficiency (baseline creatinine 2.4 mg/dl) who underwent CT scanning with radiographic contrast. Patients were treated with oral acetylcysteine 600 mg twice daily before and after contrast exposure. Compared to placebo, administration of Acetylcysteine significantly prevented worsening kidney function by 48 hours after contrast administration (2% vs 21% had a creatinine increase of > 0.5mg/dl). Also, patients given the drug actually had a significant decrease in their baseline creatinine at 48 hours.] Another discussion of the same study can be found at kidney contrast agents. This site contains additional information provided to the site by the authors of the referenced study.

Imaging Choices

Basic information about each type of scan is given at the following sites. NIH/Medline Site gives information on all choices. Diagnostic Imaging Information on Imaging of the body, also gives information on all choices. Diagnostic Imaging

X-RAYS are the least expensive, but are not the best diagnostically. However, if you have a lesion that does show on plain X-ray films, this is the cheapest and easiest way to follow treatment progress of that lesion. Some surveillance protocols replace Chest CT scans with Chest X-rays, or alternating one with the other. X-rays are good for showing lung metastases, but CT is better. X-rays will show up bone metastases, but only when half the bone has been destroyed.

Spiral CT Scans are very sophisticated X-ray examinations. They support faster, higher-quality image acquisition with less radiation exposure, typically eight to 10 times faster than conventional CT scans, and can usually be obtained during a single breath hold, and increase the rate of lesion detection. CT [Computerized Tomography] scanning works very much like other x-ray examinations in that controlled amounts of x-ray radiation are passed through the body, and different tissues absorb the radiation at different rates. With CT, X-ray film is replaced by an array of detectors, which measure the x-ray profile emerging from the body that is being scanned. When the computer reassembles the image slices, the result is a very detailed, multidimensional view of the body's interior. You might think of it like looking into a loaf of bread by cutting it into thin slices. CT scans are very good for lung metastases. CT is used as an overall screener, and is probably more cost effective than MRI for that purpose. Since the two most worrisome places are liver and lungs for metastases, and CT performs excellently for lungs and reasonably well for the liver, it is a good choice. CT scans picked up adrenal tumors, and they will show problems in pancreas, spleen, kidneys, and bowel. If lesions are small, CT can miss them. The size of the smallest tumor picked up by CT varies with the machine...later models do 1/2 cm cuts instead of 1 cm cuts, but tumors of up to a centimeter can be missed if they happen to fall between the cuts. CT can miss a lot of pelvic pathology. If your pelvis is a primary site, you might want to use ultrasound scans as well, and MRI if there are any suspicious lesions. CT scans are not good for bone, nor are they good for brain imaging. MRI is preferred for suspected brain and bone lesions. MRI is also the scan of choice for extremity lesions. CT is generally better for things that move, like lungs and bowel. See the section below comparing CT and MRI scans of the liver. There are higher resolution, swifter scanning multi-slice CTs being developed. The use of a four row scanner offers various options -- a large volume can be scanned quickly (e.g. chest, abdomen, and pelvis in a trauma patient in 20 seconds) OR a smaller volume can be examined with much finer slices (e.g. 1 mm slices through the chest in 20 seconds, with much more detail.) CT scans are reaching towards the ultimate they can achieve - better resolution, increased speed, and lower power consumption are areas under development. They are often the imaging tool that gave the primary cancer diagnosis, and often the main tool for surveillance for recurrence. CT limiting factors for patient exposure remain radiation dose, and potential kidney toxicity from the injected iodinated contrast medium. A new combination of PET and CT scan, done at one sitting, will allow for correlation between metabolic activity [PET scan] and the more exact physical picture of a lesion [CT scan]. However, some of the early combination scanners may have reduced resolution compared to their single-purpose counterparts. British researchers announced that they have combined CT scans and magnetic resonance imaging (MRI) to help better identify cancerous tumors. Dr. Peter Hoskin, a clinical oncologist at Mount Vernon Hospital in Middlesex, southern England, who helped to develop the technique, said it will initially be used in prostate cancer patients, but it could be helpful in treating other tumors, particularly those in the pelvis, head and neck. Combination scanners are not yet widely available. EXCELLENT British Medical Journal Article on Computed Tomography in Clinical Practice CT Article About CT Scans

Bone Isotope Scans are done to screen for bone tumors, or to get a baseline so that tumor changes can be picked up at a later time. A radioisotope is injected into a vein, and an hour or so later, the scan is done. Only bone cells that are very active pick up this radioisotope. The films will show dark "hot spots" superimposed on a skeleton. It is a screening method for bone metastases, useful when X-rays are negative. Hotspots can be high grade tumors, inflammation [like arthritis], or infection and would require an Xray first and then possibly an MRI follow up to get exact information. Again, smaller tumors might be missed. And low grade tumors may not pick up enough radioisotope to be stand out from the background count. Bone scans are easy to read and relatively quick to do. If something shows up, then it's followed by Xrays, and possibly MRI. If nothing shows up, then there is probably nothing there of significant size, or the tumor is low grade. NIH/Medline Site Diagnostic Imaging Information on Imaging of the body Diagnostic Imaging

Bone Density Scans are specialized X-rays that check bone strength in the hip and spine. Because osteoporosis can occur from radiation, chemotherapy, invalidism, menopause/andropause, or poor diet, cancer patients are at risk. Discuss with your doctor. There is treatment for osteoporosis. NIH/Medline Site Diagnostic Imaging Information on Imaging of the body Diagnostic Imaging

MRI Imaging is not a good choice for organs that move, like lungs and bowel, but very good for anything else. MRI scans are often done pre-operatively, as a better idea of what is going on is obtained. Images of the soft-tissue structures of the body are clearer and more detailed than with other imaging methods. The detail of MRI images makes MRI an invaluable tool in early diagnosis and evaluation of tumors. MRI enables the detection of abnormalities that might be obscured by bone with other imaging methods. MRI provides a fast, noninvasive alternative to x-ray angiography for diagnosing problems of the heart and cardiovascular system. MRI images can help physicians evaluate the function as well as the structure of many organs. MRI contrast material is less likely to produce an allergic reaction than the iodine-based materials used for conventional x-rays and CT scanning. Exposure to radiation is avoided. However MRI examinations do take longer than the newer CT scanners, and some people do become too claustrophobic to complete the exam. MRI scans are the scan of choice for bone, brain, cardiac lesions, and tumors of the extremity. Its excellent resolution makes it either first or second choice in imaging any lesion, and it is often done pre-operatively for the best visual resolution of the tumor. Not good for lung visualization, but excellent for tissues around the lungs. CT scans and MRI scans are both used for the scanning of liver, spleen, kidneys, and possibly pancreas. CT is better for lung and bowel. MRI is better for pelvis, brain, bone, soft tissues, and extremities. See the section below on Comparison of hepatic MRI and CT scans. British researchers announced that they have combined CT scans and magnetic resonance imaging (MRI) to help better identify cancerous tumors. MRIs MRI Information Comparison of MRI and CT scanners: British Medical Journal Article on Computed Tomography in Clinical Practice link to article

PET Scans [Positron Emission Tomography ] are useful for identifying metastases across most of the body, as well as for differentiating between local recurrence of high grade tumors and scar tissue, and can be used in certain situations to examine the impact of chemotherapy on an active tumor. PET scans will highlight a high grade, active metabolizing tumor, that is 7mm or larger. Low grade tumors will not pick up enough radioisotope to distinguish themselves against background, nor will very small tumors. Sites of inflammation or infection will also pick up extra radioactively tagged glucose, and will highlight areas which may not be cancerous. It is always necessary to correlate a PET scan with another imaging method, like CT or MRI or ultrasound, to determine what the PET scan has actually found. PET scans are the result of an intravenous injection of a solution of radioisotope-tagged glucose molecules, waiting for the molecules to be picked up by highly active cells in the body, and then taking a picture of the resulting "hot spots". The completed scans look similar to Bone Isotope scans, with dark "hotspots" superimposed upon a small skeleton, with resolution on about the same level. PET scans are measurements of the metabolic activity of lesions, and screen for metastases that are asymptomatic and still small. They also can help differentiate a high grade tumor from other lesions that are not cancerous. They can also be used to discover quickly if there is a response to a chemotherapy agent, e.g. during trials of Gleevec on GIST sarcomas, tumor necrosis could be seen on a PET scan within 8 to 10 days after treatment was begun - but the same tumors didn't shrink enough to be measurable on CT scans until 3 to 4 months later "My onc told me about the first time he used PET to examine the before-and-after impact of Gleevec on a GIST patient - 'it was like an aerial view of a city at night, and all the lights had gone out - it was the most exciting thing I have ever seen. The tumors were still there but we could see they had stopped working.' " PET is expensive (as much as $5000), has frequent false positives, and even false negatives. The parts of the body that can be scanned vary with the equipment available. It should be treated as a screening test. IF something shows up, then you'd have to do an MRI of the area to actually determine if it was something to be concerned with. A new combination of PET and CT scan, done at one sitting, will allow for correlation between metabolic activity [PET scan] and the more exact resolution of the lesion and its location [CT scan]. This combination scan is available at a few centers only at this time. The method combines computed tomography (CT) and positron emission tomography (PET) to create computer-generated images of cancerous tumors. A CT scan shows precise anatomical detail. A PET scan is sensitive enough to reveal even very small, high-grade tumors, but its fuzzy image is poorly correlated with a tumor's exact size and precise anatomic location. The combination of the two scans pinpoints even small deposits of cancer cells and gives the exact location. Exploitation of PET technology is also involved in: a. Techniques for adding radioactive ions to chemo are now allowing injection of drugs directly into tumors, while the doctors watch on the PET scanner to see whether the drugs are having an effect. This is being done clinically in trials in the UK. b. New materials that carry radioactivity and can bind to cells with specific DNA characteristics are also being developed. There is a clinical trial due to start in the UK with high risk breast cancer patients to see whether metastases can be identified before they become tumors. Exploiting PET technology involves chemists, physicists, and pharmacologists, as well as the electronics wizards, radiologists and other doctors. New skills are being learned, new materials are being created, new treatments are being developed, and new hope too. NIH/Medline Site Diagnostic Imaging Information on Imaging of the body Diagnostic Imaging

Mammography is a special X-ray technique used for detecting breast lesions. LMS can metastasize to breast tissue, or appear there as a primary tumor. Mammography is the imaging of choice for breast lesions, with ultrasound an additional choice if abnormality is found. Even though the breasts may be included in a chest CT, CT is not the preferred choice for imaging in soft tissues because it doesn't show up the tumors well. Even if you are clear of LMS tumor on scans, do not forget to have your scheduled mammograms. 7.5% of LMS patients develop a second primary cancer. Fetch PMID: 11283938 NIH/Medline Site Diagnostic Imaging Information on Imaging of the body Diagnostic Imaging

Ultrasound Scans which bounce sound waves off structures, seem to work best in picturing cystic type structures. Those are things that are like water balloons, skins filled with fluid or homogeneous tissue. Ultrasound is good for imaging uterus and ovaries, kidneys, liver, spleen, and cardiac structures. It is inexpensive, and free of radiation exposure. It can be better than CT at picking up pelvic lesions. It can pick up LMS lesions that are embedded in muscle. As a cardiac echo exam it can be used to calculate an ejection fraction before, during, and after doxorubicin or other anthracycline chemotherapy treatment. Ultrasound is interactive. While doing the scan, if the technician is uncertain about an element in the image, the probe or the patient can be repositioned, or displacement pressure can be provided, to provide a more definitive image. It is not good for visualization of the lung. NIH/Medline Site Diagnostic Imaging Information on Imaging of the body Diagnostic Imaging

Comparison of MRI and CT scans for liver imaging from ONCOLOGY 14(Suppl 3): 21-28, 2000. CT and MRI scans are the most common scans for imaging the liver in cancer patients. Both have undergone major improvements, and it is often not clear which technique is better suited to specific clinical situations. "The spatial resolution of CT scans remains superior, but MRI has better contrast resolution and has repeatedly been proven to detect and characterize focal liver lesions with greater accuracy than CT. Despite this obvious advantage, CT remains the primary tool for routine diagnostic evaluation of patients with known or suspected liver malignancies in most centers. The relative underutilization of MRI may be due, at least in part, to a lack of understanding of the advantages and disadvantages of each technique."[1] CT is cheaper than MRI: the equipment and its upkeep cost less, and scan time is shorter, so there is not such a backlog of patients. CT scans are widely available, and physicians feel comfortable with evaluating the images. CT scans have the disadvantages of nephrotoxic contrast agents, and adverse reactions to the iodinated contrast agents, and exposure to ionizing radiation. CT scans are less sensitive and specific than MRI scans in imaging hepatic foci of disease. "Magnetic resonance imaging provides excellent contrast that can reveal subtle variations in tissues of differing histology."[1] There is no ionizing radiation or nephrotoxicity, and the usual contrast agent [gadolinium chelates] has a good safety profile. The scan can be done in any direction, not just axially like CT scans. MRI has better detection and descriptive powers than does CT. MRI is usually a more expensive scan, is not so widely available, takes longer, and has more contraindications [e.g. implanted metal like: pacemakers, aneurysm clips, heart valves, vascular stents] than CT scans do. "Dual-phase contrast-enhanced CT is a recently developed improvement in liver imaging. In this technique, a complete set of images is obtained during the hepatic-arterial dominant phase of liver perfusion, followed by a second set obtained during the portal-venous phase." [1] Those lesions whose blood supply comes from the hepatic artery, like LMS, will show a different appearance during the arterial phase, than from the portal venous phase. The lesions are detected as well as the source of their blood supply, which helps determine the nature of the lesion. Dual-phase scans need higher injection rates of nonionic contrast. For CT Angiography, a catheter is placed in an appropriate artery and a rapid injection of contrast results in a large contrast load reaching the liver. It is more sensitive than noninvasive CT, but is invasive and not routinely used. Fast MRI sequencing has reduced scanning time for the entire liver to 15 to 30 seconds-a single breath holding. Specific lesions appear distinctively different, e.g. hemangiomas are distinctive. CT-MRI Comparison Studies Many of the initial comparison studies between MRI and CT were done using early technology and found no significant difference between the two. With further technological developments, this is no longer true. MRI With RES-Specific Agents New contrast agents are being designed for liver imaging; they target the cells of the reticuloendothelial system [RES], so that the contrast accumulates and remains within the liver. These agents allow longer imaging periods after administration, and increase the detection and characterization of focal liver lesions. The RES agents are composed of iron oxide [ferumoxide] particles, which are not taken up by the metastases. The difference in enhancement increases the sensitivity of the examination for lesions by making the focal liver lesions conspicuous. Many well-controlled studies support the superiority of a ferumoxide-enhanced liver MRI over CT or unenhanced MRI, but not over intraoperative ultrasound or pathological examination. Ferumoxide-enhanced MRI scans are statistically superior to other noninvasive liver scans. "Economic factors also play an important role in determining which imaging modality will be used... In one study, in 95% of the patients imaged preoperatively with ferumoxides-enhanced MRI, there were no additional lesions detected using IOUS. Compared to contrast-enhanced CT, ferumoxides-enhanced MRI altered the clinical management in 67% of patients. These management changes corresponded to an overall net cost savings of $108,368 ($1,901 per patient). The authors concluded that ferumoxides-enhanced MRI is an economically feasible imaging method that will alter the clinical management in a substantial number of patients as compared with contrast-enhanced CT."[1] MRI vs CT Angiography CT Angiography had been considered the most sensitive exams for investigation of liver lesions. Several studies have shown that noninvasive ferumoxides-enhanced MRI is at least as accurate as CT angiography, and could probably replace the invasive procedure. However, several authors have concluded that spiral CTAP is more sensitive than ferumoxides-enhanced MRI in patients who are to undergo liver resection, on a lesion-by-lesion analysis. Conclusions "Dual-phase spiral CT, CT angiography, ultrafast MRI, and MRI enhanced with liver-specific contrast agents have allowed for better detection and characterization of focal hepatic neoplasms."[1] "Direct comparison studies have repeatedly confirmed that MRI has greater accuracy for detecting hepatic lesions, especially when the targeted contrast agents are employed. Angiographically assisted CT and MRI appear to have similar sensitivity for detecting hepatic neoplasms; however, MRI has greater specificity and the advantage of being noninvasive. Liver CT is most commonly employed as a routine screening tool because it is somewhat less costly and is more widely available"[1] "State-of-the-art spiral CT and MRI are each highly accurate in detecting focal hepatic neoplasms. Magnetic resonance imaging has clear advantages when the highest possible accuracy is desired, such as when imaging patients prior to hepatic resection or intervention, or when the CT result is either inconclusive or conflicts with other clinical data."[1] 1. ONCOLOGY 14(Suppl 3): 21-28, 2000 Comparison studies of CT and MRI in patients with hepatic metastases. Earls JP. Inova Fairfax Hospital Center, Falls Church, Virginia, USA. The Johns Hopkins University School of Medicine, Baltimore, Maryland

Surveillance Schedules and Discussion

The surveillance schedules below are offered as a guide. The SARCOMA ONCOLOGIST who is following you should be the actual expert on the most current and cost effective care for you, as are the NCCN guidelines NCCN Website Here are two statements made by sarcoma oncologists about surveillance, in response to the following questionnaire: Questions For Physicians On behalf of the many LMS survivors who were diagnosed at a medical institution that did not have a sarcoma center, please answer the following questions related to the guidelines for LMS medical follow up. The questions are not directed to chemotherapy and/or radiation therapy, as each treatment is individualized. 1. Immediately after surgery and/or treatment, what are the guidelines for (A) CT Scans, (B) Bone Scans, and (C) other tests? 2. Are scans/tests administered on a schedule or only when symptoms are present? 3. How do guidelines change after a period of years? 4. Is it ever safe to stop all scans/tests? If yes, after how many years? A Doctor at MD Anderson Answers Unfortunately, there are no clear guidelines (based on published data) available to make specific recommendations for follow-up of sarcoma patients. We have published our follow-up strategy for extremity sarcoma recently in the Annals of Surgical Oncology (Vol 5, pp 464-472, 1998 ). A few generalizations are possible: 1) Follow-up should be most frequent in the first 3 years after completion of treatment since 80% of those who recur will do so in the first 36 months. 2) Follow-up should continue longer than 5 years since perhaps as many as 10% of patients who have no sign of recurrence at 5 years will recur between the 6 and 10th post-treatment years. 3) We don't know if patients should be followed longer than 10 years. 4) Chest X-ray at regular intervals (every 3 to 6 months during the first 3 years) is a reasonable strategy for detection of lung metastases. There is no evidence that earlier detection of lung metastases using more sensitive and expensive techniques like serial CT scans of the chest is helpful. 5) Imaging of the primary tumor site for detection of local recurrence is dependent on anatomic site. Our strategy for extremity tumors is detailed in the above reference and utilizes physical exam with high quality ultrasound (with one post treatment MRI). For tumors of the thorax, intraabdominal sarcomas, retroperitoneal sarcomas, and pelvic sarcomas serial CT scanning is optimal because physical examination is unreliable for detection of early recurrence in these sites. The optimal frequency of CT scanning is not known. Given the high risk for recurrence of many (but not all) sarcomas in these sites, it may be optimal to repeat CT scans frequently in the first 3 post-treatment years - perhaps as often as every 3 to 6 months. 6) Bone scans are not usually indicated for any form of follow-up or initial staging unless there is new bone pain or other bone symptoms. 7) Routine blood tests are of no benefit in long-term follow-up. Exceptions to this would include follow-up of blood counts previously noted to be abnormal secondary to chemotherapy and/or a BUN and creatinine blood test to confirm normal kidney function prior to contrast enhanced CT scans. A Doctor at Dana Farber Answers 1. Immediately after surgery and/or treatment, what are the guidelines for (A) CT Scans, (B) Bone Scans, and (C) other tests? ANSWER: This really depends upon the grade, size, and histology of the tumor -- in brief the "risk factors" for recurrence should drive subsequent testing and surveillance. One national group, called the NCCN, recently published a set of practice guidelines for sarcoma that are based on consensus -- as imperfect as these may be -- and they are in continual refinement and revision. These help to provide some structure and guidance to care. But thee is no substitute for getting expert advice at a center at least to help the local docs plan how to implement subsequent care. One important point -- routine blood testing has very little, if any, role in follow-up screening and surveillance. The roles of CT, MRI, and bone scanning are more controversial, with some centers tending to use these scans a lot in order to detect any recurrences early and be able to intervene more effectively with minimal disease size. There have been no randomized studies to show how frequently scans should be done... 2. Are scans/tests administered on a schedule or only when symptoms are present? ANSWER: See above. Certainly, symptoms should trigger surveillance and evaluation in detail with a low threshold. 3. How do guidelines change after a period of years? ANSWER: We tend to stretch out the intervals between scans -- often this is judged as reasonable to perform surveillance scanning, say, every 3 months for 3 years, then if no recurrence, stretch it out ot every 6 months for a few years, then every year. But clearly this is based more on practice patterns than on actual data showing that this is the "right" thing to do. 4. Is it ever safe to stop all scans/tests? If yes, after how many years? ANSWER: Excellent question -- and the answer is probably dependent on the type of sarcoma. For low grade disease, if no recurrence after 10 years, if the primary were small, it might indeed be reasonable -- but for higher grade or very large primary lesions, this might be ill advised. This too is a matter more of opinion and practice pattern difference than of data. General Health Care Surveillance Seven and a half percent of people with LMS will develop a second, different, primary cancer. Mammograms, breast and/or testicular self exams, stool for occult blood, physical exams, and various blood tests are necessary screeners. Routine Surveillance Against LMS Recurrence Leiomyosarcoma has an alarming tendency to return either locally or as a metastasis or both. Surveillance is necessary so as to identify recurrences when they are small and surgically resectable. What is done for surveillance, and for how long, may depend very much on the primary site of the LMS, as well as the country of residence of the patient. Generally surveillance is more frequent, usually every 3 months, in the first two years, when most of the recurrences appear, becoming less frequent in the subsequent three years [every 6 months], and then remaining yearly. Of course, if there is abnormality, the appropriate scans would be used. If disease becomes active, and is treated, surveillance reverts to the pattern of the first two years. The surveillance patterns on this web page are for high grade tumors. "It is most important that new list members know that they should be scanned routinely and over their full body. I had no scans until I had a chest X-ray 11 yrs after my hyst and discovered mets in both lungs. I had NO pelvic or abdominal scans until last year. They thought I was cured after not having a recurrence for 11 yrs. Ha! Do I fool everyone who knows my history? I had a recurrence to the primary area after 19 yrs. If I had pelvic scans all along, even at intervals of 1 yr, it would have been discovered when it was smaller and not almost 7 cm." "I had to insist on abdominal scans because I have problems with my stomach and intestines. I had to argue that I needed it. Speak up and be assertive with your doctors. It is important and it is your life that you may be saving. Early detection is important. It determines your treatment." "The value of surveillance for detection of recurrences in patients with soft tissue sarcoma (STS) after definitive surgical resection of the primary tumor is based on the premise that early recognition and treatment of local or distant recurrence can prolong survival. Surveillance strategies should meet the criteria of easy implementation, accuracy, and cost-effectiveness. Although guidelines have been proposed for follow-up of patients with STS, there are few data in the medical literature on the effectiveness of these recommendations. The role of specific surveillance strategies for recurrence detection for sarcomas of the trunk, head and neck, retroperitoneum, and viscera has yet to be defined." Semin. Surg. Oncol. 17:83-87, 1999 Personal Examination Once a person has lung metastases, it is possible that metastases will develop peripherally as well. It might be useful to feel for lumps in areas not routinely scanned [scalp, skin, breasts, tongue, extremities, neck].

Uterine LMS Uterine LMS tends to recur locally, and to metastasize to the lungs. There are several "packages" of routine surveillance on offer: The SARCOMA ONCOLOGIST who is following you should be the actual expert on the most current and cost effective care for you, as are the NCCN guidelines. All essentially agree that attention must be paid every three months for the first two years, then every six months for the next three years, then, after 5 years, yearly. 1. Generally in the US, the "attention paid" consists of routine spiral CT scans, with contrast, of chest, abdomen and pelvis. Coupled with the scans are a physical exam, an interim history, and blood and urine tests. 2. MD Anderson has begun recommending the replacement of routine chest CT with a Chest X Ray, but keeping the rest of the protocol the same. A chest CT scan would be done before any chemotherapy was given. 3. European standards tend to use Ultrasound of Pelvis and Abdomen instead of routine CT scans of these areas, and routine Chest X-rays, with six monthly CT scans of the chest. [The standard monitoring approach in Europe is chest x-ray every three months, with chest CT scan every six months. I was told (though I haven't been able to find a research abstract) that there was no traceable benefit in quarterly chest CT scans. Their reason is that anything which escaped the chest Xray would be so small that doctors would probably leave it to the next scan to see whether it grew if found on a scan. From Roger]

GI LMS The most important thing for any GI soft tissue tumor is to make sure it is or isn't GIST. This may involve a second opinion on the tumor by a sarcoma pathologist AND a test for Ckit. GI LMS tends to recur locally, and to metastasize to the liver first, before the lungs. The SARCOMA ONCOLOGIST who is following you should be the actual expert on the most current and cost effective care for you, as are the NCCN guidelines. Depending upon the country and the person's resources, this surveillance might be as follows: In the US, the protocol is usually: Spiral CT scan of Chest, Abdomen, Pelvis with contrast, plus usual interim history, physical exam, urine and blood tests. Surveillance is every three months for two years, every 6 months for the next three years, and then yearly. In other countries, the "economy" alternative might be substituting ultrasound of abdomen and pelvis for routine CT scan, and substituting the CXR every three months, with the CT chest done only six monthly, plus usual interim history, physical exam, urine and blood tests.

Retroperitoneal Retroperitoneal LMS tends to recur locally, and can metastasize to liver and lungs. The SARCOMA ONCOLOGIST who is following you should be the actual expert on the most current and cost effective care for you, as are the NCCN guidelines. Surveillance is every three months for two years, every 6 months for the next three years, and then yearly. Depending upon the country and the person's resources, surveillance might be as follows: In the US, the protocol is usually: Spiral CT scan of Chest, Abdomen, Pelvis with contrast, plus usual interim history, physical exam, urine and blood tests. Other countries might favor the 'economy' route: substitution of ultrasound of abdomen and pelvis for routine abdominopelvic CT, and substituting Chest X-rays for the routine chest CT, with a CT chest six monthly, plus usual interim history, physical exam, urine and blood tests.

Extremity A good complete physical exam and an initial CT scan of chest and abdomen/pelvis would be wise to rule out the possibility that this tumor is actually a metastasis from a primary at another site. Extremity LMS can recur locally, and can metastasize to the lungs. The SARCOMA ONCOLOGIST who is following you should be the actual expert on the most current and cost effective care for you, as are the NCCN guidelines. The usual intervals of three monthly for two years then six monthly for the next three years then yearly would generally also apply. Attention paid would be interim history, physical exam, and chest X-ray at each appointment. A yearly scan of the primary site is still recommended. However, CT scans of chest, and/or MRI scans of extremity, might be laid on should there be any question of abnormality or symptoms. See the quote below, which is Roswell Park's experience: "We reviewed the effectiveness of a surveillance program for primary extremity STS in an effort to provide an evidence-based rationale for follow-up of STS. We concluded that clinical assessment of patient symptoms, chest X-ray imaging, and physical examination are effective strategies for follow-up of extremity STS." "Chest X-ray imaging also appears to be cost-effective, at least for high-grade extremity STS. Imaging of the primary extremity site by computed tomography (CT) scan or magnetic resonance imaging (MRI) on an annual basis and routine laboratory blood tests were ineffective strategies for recurrence detection. However, certain patient characteristics such as body habitus, previous radiation therapy, and location of the primary tumor site may require the use of CT scans and MRI for adequate clinical assessment." [1] And MD Anderson's Experience: Cost-effectiveness of staging computed tomography of the chest in patients with T2 soft tissue sarcomas "Six hundred consecutive patients with primary, nonthoracic, T2 (> 5 cm) STS underwent both chest X-ray (CXR) and chest CT scanning to evaluate the presence of pulmonary metastatic disease (M1). The authors constructed a decision tree that modeled the outcomes of diagnostic testing for two hypothetical diagnostic strategies: 1) routine chest CT (rCT) or 2) CXR and selective chest CT (sCT). " [2] "For patients with T2 STS, ROUTINE Chest CT scan was most cost-effective in patients with high-grade lesions or extremity lesions. The findings of this study do not support the routine use of chest CT scanning in all patients with T2 STS." [2] ______________________________________ 1. Semin. Surg. Oncol. 17:83-87, 1999. [Effective follow-up strategies in soft tissue sarcoma. (Special Issue: Soft Tissue Sarcoma . Issue Edited by Raphael E. Pollock.) Published Online: 30 Jun 1999 Copyright (c) 1999 Wiley-Liss, Inc. Online ISSN: 1098-2388 Print ISSN: 8756-0437 email: William G. Kraybill (kraybill@sc3103.med.buffalo.edu) *Correspondence to William G. Kraybill, Chief of Soft Tissue-Melanoma and Bone Department, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263 2. Cancer 2002;94:197-204. (c) 2002 American Cancer Society. Cost-effectiveness of staging computed tomography of the chest in patients with T2 soft tissue sarcomas Geoffrey A. Porter, M.D. 1, Scott B. Cantor, Ph.D. 1, Syed A. Ahmad, M.D., et.al. Multidisciplinary Sarcoma Center, The University of Texas M. D. Anderson Cancer Center, Houston, Texas email: Peter W. T. Pisters (ppisters@mdanderson.org) *Correspondence to Peter W. T. Pisters, Department of Surgical Oncology, Box 444, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, TX 77030-4009 Conference: 36th American Society of Clinical Oncology, Louisiana, 20 May 2000 to 23 May 2000.

Skin A good complete physical exam and an initial CT scan of chest and abdomen/pelvis would be wise to rule out the possibility that this tumor is actually a metastasis from a primary at another site. The SARCOMA ONCOLOGIST who is following you should be the actual expert on the most current and cost effective care for you, as are the NCCN guidelines. Cutaneous LMS rarely, if ever, metastasizes. It can, however, return locally. Surveillance for Cutaneous LMS is simply physical inspection, if the pathology on the tumor is unequivocally cutaneous LMS. Subcutaneous LMS, can recur locally, but also can and does metastasize, often to lungs. Surveillance for Subcutaneous LMS would be physical inspection, and either Chest X-rays or CT Scans of the chest, or some combination of the two, as the usual time intervals [every 3 months for two years, then every 6 months for another 3 years, then yearly.]

Which Scan is Best for Which Organ?

Specific Organ Imaging Prim Care 1992 Dec;19(4):677-713 Diagnostic imaging in cancer. Berman CG, Clark RA. Department of Radiology, University of South Florida, Tampa. Screening chest radiographs do not reduce mortality from lung cancer. Should an incidental noncalcified pulmonary parenchymal nodule be discovered, chest CT will demonstrate one third of such patients to, in fact, have the multiple nodules of metastatic disease. CT is very helpful to guide fine needle aspiration biopsy of lung lesions and to assist in evaluation for resectability. MR can be helpful in special circumstances, including the definition of the extent of paravertebral, superior sulcus, and diaphragmatic lesions. Endorectal ultrasound is not sensitive enough to function as a screening tool for prostate cancer but is used routinely to guide biopsies. CT and MR are rarely helpful in staging this disease. Given the highly characteristic trait of bone metastasis in prostate cancer, a bone scan is mandatory in all patients. Double contrast barium enema can be used as an adjunct or alternative to sigmoidoscopy for colorectal cancer screening, in the preoperative evaluation of patients, and in postoperative surveillance. CT and MR can detect macroscopic adenopathy and liver metastases; CT is generally the preferred study. Screening mammography can have a major impact in reducing breast cancer mortality. It is recommended that a baseline study be obtained at age 35. Annual or biannual examinations should commence at age 40. Any palpable lesion, whether or not it is demonstrated mammographically, must be subjected to biopsy. Ultrasound is the most useful initial imaging study for evaluating pelvic masses. MR will, on occasion, identify the origin of a mass not determinable from ultrasound scan. MR is particularly valuable to identify parametrial spread (inoperability) of cervical cancer, and has been underused for this purpose. Surgery remains the mainstay for the staging of ovarian and endometrial cancer, although CT can be helpful to identify macroscopic relapse, ascites, or liver metastases. Bone scan and liver CT remain the standard procedures for detecting metastases in these respective organ systems. MR can be invaluable in the imaging of epidural metastasis and spinal cord compression in patients with vertebral metastatic disease. Contrast-enhanced MR is more sensitive than contrast-enhanced CT for detecting brain metastases, but the latter remains a useful tool. Chest CT can improve the detection of pulmonary metastases when this is of crucial importance. Fetch PMID: 1465483 Liver/Spleen/Kidney Ultrasound, CT scan, and MRI can all visualize these organs well. Preoperatively, MRI is probably preferred. Female Organs Ultrasound is a good first choice. Then CT or MRI. MRI will sometimes show pelvic pathology that the CT missed. Pelvis Pelvis and abdominal and chest walls can be shown well by Ultrasound, perhaps CT, but sometimes lesions show up best on MRI. Extremity MRI scans are best for delineation of any abnormality. Ultrasound will sometimes show the presence of a metastasis within muscle. Lungs Chest X-rays are good for lung lesions, but CT scans are excellent. MRI might be useful for adjacent soft tissues of the mediastinem, chest wall, and in and around the spine and head and neck. Brain MRI scans are best for picking up brain lesions. Bone Imaging Techniques: The main imaging techniques used to diagnose bone tumors are conventional radiography, CT, MRI, and isotope bone scan. Angiography is rarely used, but is helpful when a preoperative selective embolization is needed, or when complex vertebral surgery or vascular surgery is planned. X-rays: Lytic lesions appear as dark 'holes' in bones. For a lytic lesion to show on X-ray, 50% of the bone matrix must be destroyed. X-rays will not show early stage disease. Conventional radiography is the screening examination of choice and is sufficient in several benign lesions not requiring treatment. Supplementary imaging studies are usually needed when radiographic findings are questionable and/or the lesion requires treatment. Bone Isotope Scan: will show areas of increased bone activity-including inflammation, arthritis, and infection. It can be thus useful to depict lesion quiescence or activity and to stage any tumor that can metastasize to the skeleton. Bone scan is also helpful to show bone lesions when they are not visible on plain radiographs and can indicate the tumor response to preoperative chemotherapy. High grade lesions show up best on bone isotope scans. MRI scan: MRI is the scan of choice for depicting any bone tumor. MRI beautifully shows the different tissues and compartments and it is particularly sensitive in depicting fat. Moreover, it can be repeated many times, even in pregnant women, because it needs no ionizing radiations and iodinated contrast; it is also free of artifacts in the patients with orthopedic devices that are usually nonferromagnetic. However, the execution of an adequate MRI requires experience and knowledge of bone pathologic conditions. While Bone Isotope Scans and PET scans are useful adjuncts to indicate strong suspicious of metastases to bone, it is the MRI which is the definitive examination to give clear delineation of the bone tumor and its extent. No imaging method is without its difficulties, however, and sometimes the MRI cannot distinguish between different types of lesions; one notable situation is between a hemangioma [a noncancerous tumor of twisted blood vessels] and some neoplasms [often also highly vascular]. [Repeatedly on the LMS ACOR List, the MRI has shown the bone mets, despite negative X-rays and negative bone scans. The scan of choice for detecting bone tumors is MRI. Ed.] PET scan: will show areas of increased metabolic rate, in bone and other organs, including inflammation, arthritis, and infection. It is a new technique, and its specificity and reliability are still open to interpretation. This technique is also best for finding high grade tumors. By CT scan: CT best shows mineralized tissues and pulmonary metastases. It is also frequently used as a guide for needle biopsies. Not a good choice for bone studies. Compiled by doctordee, with the help of Roger, Neil, Glenn, Ro, Lynette, Jim, Dick and Richard. last updated January 2004

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