Principles and Practice of Radiation Therapy Chapter 5 Detection and Diagnosis Copyright © 2010 by Mosby, Inc., an affiliate of Elsevier Inc

Principles and Practice of Principles and Practice of Radiation TherapyRadiation Therapy

Chapter 5Chapter 5

Detection and DiagnosisDetection and Diagnosis

Copyright © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.Copyright © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

22Copyright © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.Copyright © 2010 by Mosby, Inc., an affiliate of Elsevier Inc.

Statistics: CancerStatistics: Cancer

5-year survival rates:5-year survival rates: 1975-19771975-1977 50%50% 1996-20031996-2003 66%66% 20222022 ??


Early Detection and DiagnosisEarly Detection and Diagnosis

AwarenessAwareness Early detection (signs and symptoms)Early detection (signs and symptoms) PreventionPrevention

WellnessWellness Advanced knowledge of cancer behaviorAdvanced knowledge of cancer behavior Detection and diagnosisDetection and diagnosis

Radiology/pathologyRadiology/pathology New treatment methodsNew treatment methods


Three Fundamental QuestionsThree Fundamental Questions

What’s happening to me?What’s happening to me? What’s going to happen to me?What’s going to happen to me? What can be done to improve what happens What can be done to improve what happens

to me?to me?


American Cancer Society (ACS)American Cancer Society (ACS)

PreventionPrevention Measures that stop cancer from developingMeasures that stop cancer from developing

Early detectionEarly detection Tests and exams intended to find the disease as Tests and exams intended to find the disease as

early as possibleearly as possible Early detection (screening) exams recommended Early detection (screening) exams recommended

by ACSby ACS• Breast, colon, rectum, cervix, prostate, testes, skinBreast, colon, rectum, cervix, prostate, testes, skin


Cancer Education: Cancer Education: Less Cancer IncidenceLess Cancer Incidence

SunSun Limit exposure to harmful UV rays (prevent skin Limit exposure to harmful UV rays (prevent skin

cancer)cancer) SmokingSmoking

Most preventable cause of lung cancerMost preventable cause of lung cancer DietDiet

Prevention of colon cancerPrevention of colon cancer


Physical ExaminationPhysical Examination

SignSign SymptomSymptom SyndromeSyndrome


DiagnosisDiagnosis

Identification of disease or conditionIdentification of disease or condition Objective Objective

• Medical procedures and tests (biopsy and/or lab tests)Medical procedures and tests (biopsy and/or lab tests)

SubjectiveSubjective• Patient’s complaintsPatient’s complaints

• Medical historyMedical history

• Physician’s preliminary diagnosisPhysician’s preliminary diagnosis


Objective DiagnosisObjective Diagnosis

InterviewInterview Physical examPhysical exam


Interview: Diagnostic ToolInterview: Diagnostic Tool

Chronologic events of illnessChronologic events of illness SymptomsSymptoms Establish physician-patient relationshipEstablish physician-patient relationship Physician’s explanation (goals, benefits, Physician’s explanation (goals, benefits,

risks)risks) Patient communication (verbal and Patient communication (verbal and

nonverbal)nonverbal) Observation Observation


Medical Record and HistoryMedical Record and History

Patient’s past medical experiencePatient’s past medical experience Medical historyMedical history Results of lab testsResults of lab tests Medical proceduresMedical procedures Progress notesProgress notes Copies of consent formsCopies of consent forms CorrespondenceCorrespondence Images from radiology or radiation therapy Images from radiology or radiation therapy

departmentsdepartments


Privileged InformationPrivileged Information

Legal public document available toLegal public document available to Medical staffMedical staff Medical departments of hospitalMedical departments of hospital ClinicsClinics Insurance companiesInsurance companies Court of law by subpoenaCourt of law by subpoena Patient (may review or release copies to other Patient (may review or release copies to other

physicians)physicians)


Medical Record and HistoryMedical Record and History

Demographic dataDemographic data Chief complaintsChief complaints Medical historyMedical history Family historyFamily history Personal historyPersonal history


Demographic InformationDemographic Information

AgeAge GenderGender RaceRace Marital statusMarital status OccupationOccupation


Chief ComplaintsChief Complaints

SymptomsSymptoms Current illnessCurrent illness Current conditionsCurrent conditions


Medical HistoryMedical History

Childhood illnessesChildhood illnesses AllergiesAllergies ImmunizationsImmunizations InjuriesInjuries Prior hospitalizations or problemsPrior hospitalizations or problems

Premalignant conditions, paraneoplastic syndromePremalignant conditions, paraneoplastic syndrome Indigestion, gastric refluxIndigestion, gastric reflux

Psychological problemsPsychological problems Medications Medications


Family HistoryFamily History

IllnessesIllnesses Causes of deathCauses of death Genetic disordersGenetic disorders

MutationsMutations• Leukemia, breast, colonLeukemia, breast, colon

Mental disordersMental disorders


Personal HistoryPersonal History

OccupationOccupation Past and presentPast and present Exposure to asbestos, diseases, chemicalsExposure to asbestos, diseases, chemicals

LifestyleLifestyle Diet, exercise, alcohol, cigarettes, drugsDiet, exercise, alcohol, cigarettes, drugs

Sexual activity and preferencesSexual activity and preferences


Physical ExaminationPhysical Examination

InspectionInspection PalpationPalpation PercussionPercussion AuscultationAuscultation Vital signsVital signs


InspectionInspection Color of patient’s skinColor of patient’s skin

Dark, pale, gray, flushed, jaundice, cyanoticDark, pale, gray, flushed, jaundice, cyanotic Scarring or lesionsScarring or lesions AsymmetryAsymmetry EdemaEdema

Swelling, accumulation of fluidSwelling, accumulation of fluid Sense of smellSense of smell

Breath, urine, wound, sputumBreath, urine, wound, sputum


PalpationPalpation

Use of touchUse of touch Distinguish between hard and soft, rough and Distinguish between hard and soft, rough and

smooth, warm and drysmooth, warm and dry Tips of fingersTips of fingers SuperficiallySuperficially

LymphadenopathyLymphadenopathy DeepDeep VibrationsVibrations

Chest, abdomen, arteriesChest, abdomen, arteries


PercussionPercussion

Striking or tapping gentlyStriking or tapping gently Determine pain in underlying tissueDetermine pain in underlying tissue Cause vibrationsCause vibrations

Lung or abdomen percussionLung or abdomen percussion Sound dependent on locationSound dependent on location

Air-filled lung (resonant sound)Air-filled lung (resonant sound) Abdomen (duller sound)Abdomen (duller sound)


AuscultationAuscultation

Listening to sounds within the body with Listening to sounds within the body with stethoscopestethoscope Lungs (presence or absence of air or fluid and Lungs (presence or absence of air or fluid and

disease)disease) Heart (pumping heart sounds may be altered by Heart (pumping heart sounds may be altered by

changes or abnormalities)changes or abnormalities) ArteriesArteries StomachStomach BowelBowel


Vital SignsVital Signs TemperatureTemperature

Oral, rectal, in ear, on skin, axillaryOral, rectal, in ear, on skin, axillary PulsePulse

Rhythm, size, tensionRhythm, size, tension RespirationsRespirations

Rate, depth, rhythm, characterRate, depth, rhythm, character Blood pressureBlood pressure

Systolic, diastolicSystolic, diastolic PainPain

IntensityIntensity


Cancer PreventionCancer Prevention

EducationEducation Maintaining good health through education that Maintaining good health through education that

encourages changes in lifestyleencourages changes in lifestyle PreventionPrevention

Immunizations (if they exist)Immunizations (if they exist) ScreeningScreening

Early detection and conditions of the diseaseEarly detection and conditions of the disease


ScreeningScreening

Lab studiesLab studies Blood studies, blood chemistry, microbiologic studies, Blood studies, blood chemistry, microbiologic studies,

urine studies, fecal studies, immunologic studies, and urine studies, fecal studies, immunologic studies, and serologic studiesserologic studies

Normal ranges for complete blood countNormal ranges for complete blood count Medical imagingMedical imaging

Electrical imaging, nuclear medicine imaging, Electrical imaging, nuclear medicine imaging, radiography, computed tomography, magnetic radiography, computed tomography, magnetic resonance imaging, diagnostic ultrasoundresonance imaging, diagnostic ultrasound


Screening/Testing ResultsScreening/Testing Results

SensitivitySensitivity SpecificitySpecificity Predictive valuesPredictive values PrevalencePrevalence IncidenceIncidence


Common Sources of ErrorsCommon Sources of Errors

Timing of medical studiesTiming of medical studies Coordination of patient’s activitiesCoordination of patient’s activities


ACS Screening for ACS Screening for Early Detection of CancerEarly Detection of Cancer

BreastBreast Colon and rectumColon and rectum ProstateProstate CervixCervix UterusUterus Cancer-related checkupCancer-related checkup

Thyroid, oral cavity, skin, lymph nodes, testes, Thyroid, oral cavity, skin, lymph nodes, testes, ovariesovaries


Breast ScreeningBreast Screening

Mammogram Mammogram Recommended age to start: 40 Recommended age to start: 40 Family history may require early start ageFamily history may require early start age

Clinical breast examClinical breast exam Self-examSelf-exam MRI MRI Sentinel lymph node procedureSentinel lymph node procedure

Procedure focused on finding lymph nodes that Procedure focused on finding lymph nodes that are the first to receive draining fluid for breast are the first to receive draining fluid for breast tumors and, therefore, the first to collect cancer tumors and, therefore, the first to collect cancer cellscells


Colon/Rectum ScreeningColon/Rectum Screening

Beginning at age 50, men and womenBeginning at age 50, men and women Fecal occult blood test (FOBT) or fecal Fecal occult blood test (FOBT) or fecal

immunochemical test (FIT) every yearimmunochemical test (FIT) every year Flexible sigmoidoscopy (FSIG) every 5 yearsFlexible sigmoidoscopy (FSIG) every 5 years Annual FOBT or FIT and FSIG every 5 yearsAnnual FOBT or FIT and FSIG every 5 years Double-contrast barium enema every 5 yearsDouble-contrast barium enema every 5 years Colonoscopy every 10 yearsColonoscopy every 10 years


Prostate ScreeningProstate Screening

Beginning at age 50Beginning at age 50 Prostate-specific antigen (PSA) testProstate-specific antigen (PSA) test Digital rectal examDigital rectal exam

Beginning at age 45 if history existsBeginning at age 45 if history exists


Cervix/Uterus ScreeningCervix/Uterus Screening CervixCervix

Pap smear annuallyPap smear annually Age related to start of intercourse, no later than age Age related to start of intercourse, no later than age

2121 Uterus (Endometrium)Uterus (Endometrium)

Endometrial biopsyEndometrial biopsy Menopause (inform about risks and symptoms)Menopause (inform about risks and symptoms) Age 35 if high risk or hereditary Age 35 if high risk or hereditary


Cancer-Related CheckupCancer-Related Checkup

Periodic health exam may include:Periodic health exam may include: ThyroidThyroid Oral cavityOral cavity SkinSkin Lymph nodesLymph nodes TestesTestes OvariesOvaries


Cancer DiagnosisCancer Diagnosis

Histologic evidence of tissueHistologic evidence of tissue ScrapingScraping Needle aspirationNeedle aspiration Needle biopsyNeedle biopsy Incisional biopsyIncisional biopsy Excisional biopsyExcisional biopsy

Tumor markerTumor marker Detect widespread diseaseDetect widespread disease


StagingStaging Determine the anatomic extent of the diseaseDetermine the anatomic extent of the disease Treatment decision based on diagnosis and Treatment decision based on diagnosis and

extent of diseaseextent of disease Groups involved for stagingGroups involved for staging

International Union Against Cancer (UICC)International Union Against Cancer (UICC) International Federation of Gynecology and Obstetrics International Federation of Gynecology and Obstetrics

(FIGO)(FIGO) American Joint Committee on Cancer (AJCC)American Joint Committee on Cancer (AJCC)

Grading (differentiation of cells)Grading (differentiation of cells)


TNM Clinical ClassificationTNM Clinical Classification

T = Primary TumorT = Primary Tumor N = Regional Lymph NodesN = Regional Lymph Nodes M = Distant MetastasisM = Distant Metastasis


Primary Tumor (T)Primary Tumor (T)

TxTx Primary tumor not assessablePrimary tumor not assessable

T0T0 No evidence of primary tumorNo evidence of primary tumor

TisTis Carcinoma in situCarcinoma in situ

T1, T2, T3, T4T1, T2, T3, T4 Increasing size and/or local extent of the primary Increasing size and/or local extent of the primary

tumortumor


Regional Lymph Nodes (N)Regional Lymph Nodes (N)

NxNx Regional lymph nodes not assessableRegional lymph nodes not assessable

N0N0 No regional lymph node metastasisNo regional lymph node metastasis

N1, N2, N3N1, N2, N3 Increasing involvement of regional lymph nodesIncreasing involvement of regional lymph nodes


Distant Metastasis (M)Distant Metastasis (M)

MxMx Presence of distant metastasis not assessablePresence of distant metastasis not assessable

M0M0 No distance metastasisNo distance metastasis

M1M1 Distant metastasisDistant metastasis


GradingGrading GxGx

Grade not assessableGrade not assessable G1G1

Well differentiatedWell differentiated G2G2

Moderately differentiatModerately differentiateded G3G3

Poorly differentiatedPoorly differentiated G4G4

Very poorly differentiatedVery poorly differentiated


Reasons for Precise Reasons for Precise Staging/GradingStaging/Grading

Aids physician in radiation treatment planningAids physician in radiation treatment planning Gives some indication of prognosisGives some indication of prognosis Assists in evaluation of resultsAssists in evaluation of results Assists in exchange of information from Assists in exchange of information from

center to center (national registry)center to center (national registry)


Medical ImagingMedical Imaging

Electrical impulsesElectrical impulses Nuclear medicine imagingNuclear medicine imaging Routine radiographyRoutine radiography Computed tomographyComputed tomography Magnetic resonance imagingMagnetic resonance imaging Diagnostic ultrasoundDiagnostic ultrasound


Electrical ImpulsesElectrical Impulses ECGECG

Demonstrates the electrical conductivity of the heart, Demonstrates the electrical conductivity of the heart, detection and diagnosis of heart diseasedetection and diagnosis of heart disease

EEGEEG Records brain-wave activity; aids in the detection and Records brain-wave activity; aids in the detection and

diagnosis of seizure disorders, brainstem disorders, diagnosis of seizure disorders, brainstem disorders, brain lesions, and states of consciousness brain lesions, and states of consciousness

EMGEMG Measures the electrical conductivity of the muscle, Measures the electrical conductivity of the muscle,

aiding in detection and diagnosis of neuromuscular aiding in detection and diagnosis of neuromuscular problemsproblems


Nuclear Medicine ImagingNuclear Medicine Imaging

Nuclear medicine studiesNuclear medicine studies Require the administration of a radioactive Require the administration of a radioactive

chemical compound, known as chemical compound, known as radiopharmaceutical, to patients before imaging radiopharmaceutical, to patients before imaging proceduresprocedures

Evaluate organ function by visualizing the Evaluate organ function by visualizing the metabolic patterns associated with disease metabolic patterns associated with disease

PETPET


Routine Radiography X-RaysRoutine Radiography X-Rays

Noncontrast studiesNoncontrast studies Chest x-rayChest x-ray AbdomenAbdomen KUBKUB BonesBones

Contrast studiesContrast studies IVPIVP GI system (upper and lower)GI system (upper and lower) Blood vesselsBlood vessels CT/MRICT/MRI


Computed Tomography (CT)Computed Tomography (CT)

Ionizing radiationIonizing radiation Cross-sectional studiesCross-sectional studies

HeadHead ChestChest AbdomenAbdomen PelvisPelvis


Magnetic Resonance Imaging Magnetic Resonance Imaging (MRI)(MRI)

Radiofrequency wave and a strong magnetic Radiofrequency wave and a strong magnetic fieldfield

Anatomic images in transverse, sagittal, and Anatomic images in transverse, sagittal, and coronal planescoronal planes

Demonstrates soft tissue to a much greater Demonstrates soft tissue to a much greater degree than CTdegree than CT


Diagnostic UltrasoundDiagnostic UltrasoundSonographySonography

Diagnostic ultrasound uses sound waves to Diagnostic ultrasound uses sound waves to evaluate anatomy and blood flow throughout evaluate anatomy and blood flow throughout the bodythe body

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Principles and Practice of Radiation Therapy Chapter 5 Detection and Diagnosis Copyright © 2010 by Mosby, Inc., an affiliate of Elsevier Inc