10/31

1

Oncologic Emergencies in Body Imaging

Frederico Souza, M.D.Associate Professor in RadiologyFlorida International University - FIUBody and Oncologic ImagingRadiology Associates of South FloridaBaptist Health South Floridafsouza@rasf.net

Disclosure

• Nothing to disclose

• My presentation will not include discussion of off-label or unapproved usage.

Objectives • Case based image review of common

oncologic emergencies in the Chest, abdomen and pelvis.

• Discussion on the differential diagnosis of each entity.

• Typical and atypical presentation of acute findings in patients with known malignancies.

• Side effects and toxicity of new targeted therapies and local therapies in the oncologic population.

72-year-old female. Lung cancer. SOB, tachycardia, left upper extremity swelling.

Diagnosis: SVC syndrome and a “hot quadrate” lobe.Findings: Non-opacification of the SVC, right hilar/mediastinal mass anterior chest wall collaterals and enhancement of segment 4.

10/31

2

64 YO male with known NSCLC

Lymphangitic spread of tumor/Carcinomatosis Pattern: Interlobular septal thickening , effusion, mass in the right lung Differential for Carcinomatosis: Lymphoma, Pulmonary edema, sarcoidosisAcute interstitial pneumonitis secondary to drug reaction

Diagnosis: SCC of the trachea Narrowing of the trachea, widening of mediastinum and no abnormalities are seen in the lungs.DX: Mets, sarcoidosis, adenoid cystic carcinoma of the trachea, TBO, Wegners, lymphoma, amyloidosis

65-year-old male.

Hx: SOB, cough, tachycardia.

Diagnosis: Nerve sheath tumor (neurofibroma, schwannoma are he benign types of PNST)Schwanoma is the encapsulated form; Neurofibroma the non encapsulated form. Malignant type of peripheral nerve sheath tumor (spindle cell neoplasm.)Differential (on Xray): Neuroenteric cyst, Meningocele. Pancoast tumor would expect rib destruction

40 YO male with chest pain Side Effects in QT• Many types of lung toxicity have been reported in regular QT

– Interstitial pneumonitis/NSIP/fibrosis

– Hypersensitivity reactions

– Diffuse alveolar damage/ ARDS/ NCPE

– Cryptogenic organizing pneumonia• In targeted Therapy Drug targets specific cancer cells • Cancer cells express specific receptors (e.g. epidermal growth

factor receptor [EGFR] in a variety of solid tumors)• Benefits of targeted antineoplastic drugs

– Increased specificity– Decreased toxicity– Enhanced effect of conventional chemotherapy and radiation

10/31

3

Targeted Therapies Approved FDA

Bevacizumab Avastin Monoclonal Ab Hemorrhage, PE Metastatic Colorectal, NSCLC

Pembrolizumab Keytruda Monoclonal Ab Pneumonitis NSCLC

Iplimumab Yervoy Monoclonal Ab Sarcoid Like reaction Adenopathy

Melanoma

Nivolumab Opdivo Monoclonal Ab Sarcoid Like reaction, Adenopathy, Pneumonitis

NSCLC, Melanoma

Dasatinib Sprycel Small molecule Plural Effusion, edema CML, ALLErlotinib Tarceva Small molecule Pneumonitis Metastatic NSCLCImatinib Gleevec Small molecule Pleural effusion and

edemaCML, GIST, ALL,

DFSPTrastuzumab Herceptin Monoclonal Ab Pneumonitis HER2 +ve Metastatic

breastRituximab Rituxan Monoclonal Ab Pneumonitis CD20 +ve NHL

Sorafenib Nexavar Small molecule Hemorrhage Advanced RCCSunitinib Sutent Small molecule Hemorrhage GIST, Metastatic RCC

71 year old female with NSCLC on an erlotinib. SOB

Dx: Cavitational change with hemorrhage Initial CT : large left upper lobe mass. 2 months later, ct showed cavitation in the mass with surrounding ground glass attenuation secondary to hemorrhage

66 year old male with post transplant lymphoproliferative disorder on rituximab.

Dx ARDS induced by RituximabInitial CT: diffuse abnormality with bilateral effusions, ground glass attenuation, thickened interstitial Repeat CT after discontinuation of therapy shows some improvement. PET CT shows diffuse parenchymal uptake of FDG in keeping with a diffuse inflammatory process (arrow). Biopsy revealed diffuse alveolar damage.

73 year old female on bevacizumab for stage IV NSCLC. Worsening shortness of breath

Dx: Bevacizumab induced BP fistulaBevacizumab- Anti angiogenic drugCommon side effects: Tissue necrosis, thrombosis, and hemorrhage.

10/31

4

54 YO F, NSCLC on gefitinib. Initial CT showed

DX: acute Capillary syndrome Initial CT patchy opacification, septal thickening and groundglass attenuation. Repeat CT showed interval development of a right pleural effusion, and more coarse thickening of the interstitium. An atypical infection was suspected, but pathology revealed areas of pneumonitis

Initial CT Follow-up

58 year old male with NSCLC on bevacizumab. SOB

DX: NSIP Post treatment CT shows interval development of groundglass attenuation, interstitial thickening and parenchymal bands. Subpleura sparing . Biopsy showed NSIP.

54 YO F with ovarian cancer on Erlotinib, shortness of breath

54 year old female with ovarian cancer on Erlotinib. CT demonstrates new geographic groundglass attenuation in the right upper lobe, which was sub clinical.

85 year old male with NSCLC on Erlotinib. CT shows new onset right lower lobe groundglass attenuation

54 year old female with ovarian cancer on Erlotinib.

Cryptogenic Organizing Pneumonia Bronchovascular bundle thickening, peripheral consolidations No specific distribution.

10/31

5

24 YO male with abdominal Pain

Metastatic testicular cancer Mass in the retroperitoneum, testicular mass Retroperitoneal adenopathy in a young male: Mets from testicular cancer Differential; Retroperitoneal sarcoma, lymphoma, paraganglioma, etc..

60 YO Male with Abdominal pain, weight loss

Pancreatic Adenocarcinoma, Thrombosis of the main portal vein Transient Hypoperfusion in the liver Differential; Thrombosis due to other causes, pancreatitis,etc..

30 YO male with abdominal Pain

Metastatic testicular cancer Mass in the retroperitoneum, testicular mass Retroperitoneal adenopathy in a young male: Mets from testicular cancer Differential; Retroperitoneal sarcoma, lymphoma, paraganglioma, etc..

60 YO male. Rectal cancer, status post APR. Lower abdominal pain, blood in the stool. Status post partial colectomy for coloncancer.

Diagnosis: SVC syndrome and a “hot quadrate” lobe.Findings: Non-opacification of the SVC, right hilar/mediastinal massanterior chest wall collaterals and enhancement of segment 4.

10/31

6

60 YO male. Abdominal pain, distention, sx of bowel obstruction.

Diagnosis: Intraluminal mets from melanoma to the jejunum.Findings: Left upper quadrant jejunal intussusception fromintraluminal metastasis ; proximal short segment small boweldilatation. Associated mesenteric stranding and mets to the left adrenal

40 YO male, tachycardia and hypertension.

Diagnosis: Pheocromocytoma.Findings: Left flank mass , heterogeneous. Cystic components on CT. T2 Hyper SI , T1 hyper SI. Differential: Adrenal hemorrhage, ACC, Metastatic disease Clinical info needed for the Dx

65 YO female. Abdominal pain Primary cancer hx withheld

Diagnosis: Gastric adenocarcinomaFindings: Diffuse thickening of the stomach (linitis plastica)Differential: Mets from Breast cancer, lymphoma

40 YO status post BMT, 30 days before

Diagnosis: Neutropenic colitis/TyphitisFindings: Diffuse thickening of the colonic wall, strandingDifferential: Colitis due to other infection, inflammatory bowel disease, ischemic colitis

10/31

7

75 YO male, pelvic pain and fever in ER patient.

Diagnosis: Seminal vesicle abscess Status post pelvic radiation for prostate CA.fluid collection closely associated with the prostate, and sigmoid colon

Abdominal pain, fever, increased lipase/amylase

Diagnosis: Pancreatic LymphomaDiffuse gland enlargement, minimal strandingMaybe without LADDx: pancreatitis, sarcoma, adenoca (focal mass)

After 6 cycles of Chemo

65 YO F, abdominal distention, status post appendectomy 5 years ago

Diagnosis: Pseudomyxoma peritoneiBorderline epithelial cells or cells from low-grade mucinous carcinomas Majority of cases develop from low-grade mucinous carcinomas from appendix which rupture in the peritoneal cavityDifferential: Peritoneal carcinomatosis from GI, ovary, lymphoma and sarcomatosis

60 YO male abdominal pain

Dx: Lymphoma Omental and periportal involvement are rare forms of lymphomatous involvementCT: hypodense mass along the portal triad. Most common types to involve the peritoneum: NHL (large B-cell lymphoma), Burkitt lymphoma

10/31

8

40 YO male abdominal pain , diarrhea

DX: Lymphoma Segment of small bowel with typical aneurysmal dilatationDiff: adenocarcinoma, Mets Infection/ischemic colitis unlikely, lack of stranding

65 YO , elevated LFTs, Abdominal pain, weight loss

DX: Cholangio CaIntra and extra hepatic biliary dilatationDiff: other ampullary masses ( duodenal CA, Pancreatic CA) benign stricture, choledhocolithiasis

Colorectal Ca on Bevacizumab, weight gain, abdominal pain

Budd Chiari Syndrome. Bilateral PE Thrombosis of the hepatic veins from Bevacizumab.

65 YO increased LFTs

DX: Cholangiocarcinoma/Klatskin TumorIntra and extra hepatic biliary dilatationDiff: other ampullary masses (duodenal CA, Pancreatic CA) benign stricture

10/31

9

Bile Duct Stricture

60 YO male status post RFA for HCC 70 YO M, HCC, Status post RFA liver lesion

DX: Abscess after RFA for HCC Potential Complications after RFA, Cryo and MWA: Hepatic Abscess, Bilomaand Biliary Necrosis, Thrombosis

55 YO 4 months status post Trans arterial Radio embolization- yttrium 90 (Y90)

DX: Expected changes after TARE/SIRTRight lobe radiation effect with hyperenhancement, contralateral left liver lobe hypertrophyComplications: Hepatic Abscess, Radiation Hepatitis, Biliary Dyskinesia and Radiation-induced Cholecystitis, Biloma and Biliary Necrosis, Gastrointestinal Ulceration

Tumor Thrombus

54 YO HCC, new onset of abdominal pain

10/31

10

Other complications after directed Therapy

Hepatic Infarction

Hepatic artery pseudoaneurysm

Hepatic Hematoma

Mets with Hemorrhage Biloma

60 YO F with infiltrative HCC and left Hepatic adenoma

Rupture HCC with perihepatic hematoma

Thank You

Suggested Reading1. Imaging of Angiogenesis: Clinical Techniques and Novel Imaging

Methods. Provenzale J. AJR 2007; 188:11-23.2. Epidermal Growth Factor Receptor Mutations, Small Molecule

Kinase Inhibitors, and Non-Small Cell Lung Cancer. Pao W, Miller VA. JCO 2005; 23(11):2556-2568.

3. Inhibition of KIT Tyrosine Kinase Activity: A Novel Molecular Approach to the Treatment of KIT-positive Malignancies. B Heinrich et al JCO 2002; 20(6);1692-1703

4. The Present and Future of Angiogenesis Directed Treatments of Colorectal Cancer. The Oncologist 2005; 11(9): 992-998.

5. Bevacizumab, Bleeding, Thrombosis and Warfarin. Kilickap S et al. JCO 2003; 21(18): 3542.