This video features Maruti Kumaran, MD, MBBS, FRCR presenting on Radiological Evaluation of the Surgical Patient with CT/PET. This presentation was given at our October 20th Management of Early Stage Non-Small Cell Lung Cancer event in 2022.
I thought I would start with clearing the air a little. I'm not an imposter, I just had my stash removed. I'm the same guy like you see on the pictures and just without the mustache. Um, so I'm really glad that I chose to do classic ideology and a lot of my colleagues, I do remember, I didn't really want to do throw six, but over the years we've become literally the heart of whatever we do with lung cancer. Right? From detection, staging. Obviously image guided procedures like biopsies and treatment. And then obviously follow up this was meant to be just a quick review of what we're doing and you know, what's in the offing. Just as a review of imaging in lung cancer, especially in early stage cancer next like this, Right? And so seti obviously remains the mainstay of what we do in terms of detection and early detection at least. And then obviously staging and then follow up and and also procedures like we talked about some of the major advancements in CT technology at least has made made sure that, you know, a we do these cans in a much better way better resolution and also it's more prevalent available. And also the relation does has come down almost a quarter of lung cancer patients probably would have had a negative chest x ray, which is very hardly sensitive in picking up lung cancer unless it's fairly advanced. So city remains the mainstream of early detection of lung cancer, which is obviously the main premise of lung cancer screening, which we seem to be doing more and more of which I'm very happy and proud about. Um it has obviously survival benefits and also in case you know you're wondering about radiation it's going down as we speak on on on a kind of regular basis and we give almost a third of what an individual receives as background radiation in the US. So just around one million. So it's negligible considering you know the advantages we have in picking up early stage lung cancer. Next slide please. And some of the incidental findings obviously like I. And D. Or areas disease which can help them in that kind of journey with smoking. Um Next slide please. So these are some examples of you know what I was talking about. So we have a case on the upper left corner which basically is a large tumor invading the media stand literally invading the left atrium as we can see. But M. R. Has much better sensitivity in the other images as you can see where we have a large tumor surrounded by electricity. So you can clearly tell which part of the tumor and which is the electors are surrounding that. And clearly that helps the surgeons to decide whether the lesion right at the apex is tumor or not. Pan costumer has traditionally been one of the major areas where M. R. Scores over C. T. Because of its multi plane or abilities and also the soft tissue capabilities of whether there is invasion of the chest wall or break plexus involvement. So if you selectively I think M. R. Is excellent is, and as an added value to staging ct assess for respectability of lesions. So non small cell lung cancer obviously is one of the primary lung cancers that we see. And then a lot of the new definitions that we have are basically nicely brought out on CT. So if it's a small ground glass, not consider that to be uh matters hyperplasia. If it's slightly larger in size less than three cm then it becomes a. M. I. A. Or minimally invasive adenocarcinoma. If there's a solid component then obviously we characterize that as invasive costumers and not just that depending on the size progression and the temporal growth. The linearity of these lesions helps us decide whether this is an invasive or non invasive adenocarcinoma that can either be watched or should be treated. So radiology plays a huge pivotal role in deciding based on the morphology as to what should be done with these. These are some of the examples of the arrow basically points to a small less than five minutes and audio which is obviously no matter what a pleasure and that some of the larger lesion on the top to bottom left is a minimally invasive and then if you have a solid confident then it becomes an invasive adenocarcinoma. So there are some new techniques that are basically being introduced and how better kind of feasibility as well as sensitivity in characterizing nodules. So if you give contrast you can actually tell whether a lesion is benign or not by its contrast enhancement characteristics. If there's a 10 millimeter Nadia which we can actually do a dynamic control sort of contrast enhanced can either with a CT or NMR. I benign lesions tend to not enhance as much as the malignant ones and the malignant ones not only do they enhance, they try to retain the contrast. So those are the characteristics we can use to characterize no deals if you're just intending to follow those up. And and also with the dual energy scan which is again something that we have a temple and we can use to our advantage, benign nodules tend to be slightly more dense. They have this kind of a small amount of calcium which human I may not be able to detect. But with the dual energy scan they may have higher attenuation values that can give us higher confidence in watching these nodules which are considered to be knowing. So these are some of the new things that we can and we will be doing in the future. And as we develop these imaging strategies to support lung cancer or an audio characterization and any talk about lung cancer will not be complete without Pet City obviously which has become again a pivotal kind of in in terms of staging the moment we see an audio and if they think it's lung cancer. The next step that we do recommend that we do is Pet City obviously, which basically relies on F. D. G. Uptake by these metabolically active cancer cells which gets trapped in them. And empirically we use 2.5 S. U. V. Max and as a kind of a cut off for malignancy, although we know that, you know, the benign and cancer sort of radiologist lie on either side. Um it is it is a semi quantitative way, so it's rather crude and but the combination of Pet and CT, which is a pet ct and with the low resolution of pet and a higher resolution of CT, we are able to now anatomically characterized and localize these lesions much better. Unlike in the past. Um it has its limitations, you know, and its resolution is poor and it obviously hasn't got the kind of sensitive and the lesion is small or not as metabolically active as some of the other lesions. But regardless, Pet remains one of the first staging techniques that we do. Once we pick up a lesion that is suspicious on CT, some of the examples that we have is actually from our own center where we have a large invasive mass right in the center of the media stand, which has higher uptake and the whole body. Pet cT clearly also demonstrates a few northern areas of taking the left neck, which turned out to be metastatic nodes. So that's where I think pet scores hugely over cT where CT is great in local staging of the lesions. You know for distant metastases. Pet a huge advantage over C. T. These are some other examples. So these are two scans from nearly 18 months apart where you had a tiny ground glass nodules in the right lung apex. I don't know what happened to those arrows and it obviously grew and had a higher soft tissue component on the follow up city. The city because of the size has very low uptake. But fortunately I think the whole body ct Pet ct basically show didn't didn't show any metastases and this patient was treated radically. So this is a part solid audio which is a right a pickle lesion which has an eccentric ground glass component and a more sort of medial solid component. And the clearly issues FDD ability in the solid component, confirming that that is invasive component of the customer that we have. So this again, can be used if it is not treated surgically. It's BRT and again, there is some evidence coming out that used suv in these lesions can be a sign of response to treatment. So those are evidence as it comes out. We probably will be using those eventually in the future. So that elegantly shows the combination of CT and Pet city and characterizing as well as confidently calling this aetna carcinoma with a solid component. So clearly Pet city has an advantage for distant metastases and also incidental malignancies that maybe coexistence with the lesion, which is something that we probably won't be able to do with ct alone. And we do have nodal disease which is a major area where pet scores over cT because CT basically relies on size criteria. So we still use the 10 millimeters short exercise criteria for cT but we as we all know smaller notes can be metastatic and pet cT scores on that. It may have some false positives because of other other co morbid conditions like Grand matters disease or precocious. But regardless the poor sensitivity specificity of pet ct over C. T. Is much higher for nodal disease. So this was a case of a small right typical long ordeal which is not shown on the ct. But Pet ct obviously she picked up all these activity in the lymph nodes and the distribution kind of suggests very symmetric, bilateral Hyler and some central nodes. And the suggestion at the time was this is probably benign. Either sark oid or some exposure related Neil nodal activity. But regardless it helps the surgeon to decide whether they need to do a sampling of the notes before radically treating the tiny long audio is another case where Pet city struggles to pick up brain metastases because of the intense ability of the cerebrum for F. D. J. Just just like glucose. But if the brain metastases is larger, it tends to stand out like in this case fortunately we were able to pick up brain metastases straight away on the pet city. Although the lesion of the city and the city in the chest kind of looks respectable and the larger lesions in the brain kind of shown through and immediately you're able to triage these patients as to what needs to be done next. So still some of the new advancements around the corner which I'm pretty sure over the next decade will become the norm rather than a bit of a novelty. So instead of using C. T. As a combination with pet, there are pet M. R. S, which obviously will have the advantage of better soft resolution and better anatomical divination as we talked about radio mixes ai and data driven algorithms being developed rather sort of furiously with so many companies which extracts a lot of information about these nodules in terms of the internal heterogeneity. Their surface modularity which is a better kind of a predictor of them being malignant or benign and eventually I think they will be integrated into our regular work stream maybe in the next 5 to 10 years I'm hoping. Which will be much more specific in diagnosing benign versus malignant lesions. Right at the outset a lot of SCP driven data is also being tested these days. SCP max is a rather crude assessment of metabolic activities. So things like metabolic tumor volume or normalizes quantification is again something that the city will be able to afford uh in a more kind of an effective manner that we will be able to use on a regular basis. And so those are exciting times in terms of being more specific and more sort of in terms of helping the clinical team a bit more effective in terms of not just telling them that there is a lesion, but we should be able to tell them this is likely to be benign or malignant. And in terms of post treatment follow up, we should be able to tell whether these are responding to treatment or not more confidently. So, I mean, those are the just main things that I want to talk about and Realogy, as I said, you know, still remains pivotal in pretty much everything that we do. And it's exciting to see that there are more kind of advancements around the corner that that will help the difficulty manage these patients in a much more effective way. And that's all I had. I was told not to talk a lot, sorry if I did. But I'm happy to take any questions if any of you have any questions. Thank you. Thank you. Yeah, Thank you all great. Thank you. Rudy