 Thank you very much for having me at this meeting. It's one of my favorite meetings that I get to go to because it's really with the Patients and that was such a great story, but you'll notice how the see how the cancer was found CT scan You know CT scan and that's how virtually every person who goes through the ER now gets a CT scan it's become a really I think almost indispensable diagnostic test and Unfortunately, there is a serendipitous finding but in this case hopefully everything will go well so I Work and UNC also and I work in abdominal imaging which I Predominantly everything below the diaphragm and above the hips a specialized in oncology and particularly gynecology and urology so I work in that area and So how do I try and help out the doctors? Well, the first thing you're gonna see here is our cancer board or tumor board So almost every major hospital will have a multidisciplinary conference and this brings all the doctors together So anyone who might be involved in patient care together and this includes the pathologists who look at the cells And you saw from dr. Kim and it calls including the radiologists who look at the cancers from that point of view and All of these people get together We get a consensus sort of agreement on how things are looking because we really learn from each other And we also yell at each other sometimes Because not everything has a single answer. There are often multiple ways to deal with something Oh, I think we have a picture of dr. Kim right here conference and We have to go through that and that way also you don't have to run around all different hospitals Right, you have one space and you get an opinion now when you get the opinion There you're gonna go over it with your physician team and I decide do I like this? Do I not like this but this gives you one place to go and so if I had a tumor I want to go someplace that has a multidisciplinary team So the goals for this lecture are really to describe the use of radiology in screening staging and planning therapy Treatment and follow-up because we're sort of involved in all of those areas and you're a very very organized audience But whenever I do a lecture, I was like to define what we're talking about So tumor equals mass equals cancer to me and in an oncology So we use these terms you might see them in your radiology reports So unless you know you have a benign disease Mass is always something to think about right tumor mass cancer an image just a picture, right? Cat scans are CT scans those are the ones that you go through you get the injection and they only take like I can do the whole body now in 19 seconds So very very fast. So it's a really fast thing regarding people sometimes say they have an allergy to the dye that we use It's pretty it's very uncommon now and when people ask me what the death rate is from the from an allergy It's the same as for penicillin. It's about one in a hundred thousand. So you shouldn't be worried about it Unless you know you've had a serious reaction in the past Then ultrasound is I think the easiest to undergo no dye no nothing you get to sit on the table and have a massage So that's good And then magnetic resonance imaging that has the scariest name we call it MRI but it's also another tube and you get to lie in the tube and It takes longer and it it sounds louder and we still usually give you dye Okay, why would I choose CT versus MRI and we'll go a little bit more into that But in general all of the literature supports that we have previously supports CT scanning So this goes back a long way, right? And so we have many many studies demonstrating exactly what each finding means Now during the last 10 years, which is as long as I think we've had good MRI imaging and it really changes almost every week practically I think you can use similar findings with MR It's particularly useful for certain kinds of tumors and also of course for the occasional patient who already has renal failure MR is a great option because when it still see a lot with patients with renal failure So renal obviously equals kidney and you also always gonna want to get reformatted images This is state-of-the-art now. It should be everywhere So that's when all the axial pictures little pictures are stacked up On top of each other and then we can cut it any way so we can look from the front which is a coronal or from the side Okay, which is a sagittal that's extremely helpful. So we get reformatted images on everyone So this is the renal mass, okay So this person unfortunately had already had a kidney out because I noticed it was done for a right lower quadrant transplant And so we take a look at the left kidney I always tell people ultrasound you're allowed to use the the labels because it's it's all looks kind of gray and this Ovoid thing is the kidney this whole ovoid thing and then there's a dark thing in the middle of it So the dark thing doesn't look like a cyst to me It looks like it's going to be solid and so it's actually a nice picture of a mass So we're seeing the word mass. I think it's most likely gonna be a cancer and then This person ended up getting an MRI and I'll show you why in a moment, but a lot of when we asked to say to that when you Last speaker said they want to see you from neck to pelvis It's because we find this kind of stuff too one We want to see if there are any metastasis anywhere else, but also we want to see if there's any other disease going on So in this patient, here's the cancer that we're looking at before But you see how the aorta which is the main aorta to main Supply to your body is split in half It's called a an aortic dissection So there's blood supply comes from the front aspect to the left and from the post your aspect to the right So we need to be able to know where that blood is going to come from so that when you have your surgery We know exactly what they're going to cut and where they're going to go Especially when they said the laparoscopic hand assisted Remember that when you're using that type of surgery the surgeons are going in through little tubes, right? Little little tubes and they're looking through the tubes and I got to tell them in advance. Whoa That that aorta split so we need to consider if it needs treatment before after and what we're going to do about it and This is what the chest X-ray looked on this patient So another thing that most people of renal cell carcinoma get at the very beginning is a chest X-ray and This thing up here. You're looking kind of sticks out, right? This is the right shoulder and the left shoulder This is the neck and this is where the abdomen starts There's the heart and there's this thing and that's the aorta That's where the dissection or the split starts so the order split in half very high up here and went down So looking at all the pictures together. We now have a Dissection we would call it that started at the top. We need to think about whether that needs to be Fixed before after dealing with the kidney. Okay, and then we have the kidney lesion and we know now which side the blood comes from So sometimes people we see lots and lots of you know, pretty healthy baby boomers But maybe they've got another disease We don't know about and even though we get there's a lot of discussion from Washington about Imaging and Lord knows I've been on the phone trying to get imaging agreed to in many many cases it is absolutely essential prior to surgery and last year because the government does things in such a wise way We got what's called a haircut in imaging. We got a 50% reduction in payment for all readings and all hardware costs Wham across the board. So they're obviously careful thoughts occurred in that and that's why we have to spend so much time on the phone Right the goal of insurance companies is not to make sure you're healthy Goal of insurance companies right now is to make sure they're making money for their stockholders And also the government is not really a thoughtful group right now and everything is changing all the time So I would also advise all these other things that you get an advocate for yourself in the financial realm too and that you make sure What how things are going to go and ahead of time? And I think that there's usually a financial services person at the hospital You may also want to network and talk with other people who've been through it because you don't want to get a $10,000 bill If it could have been handled earlier. I know you're scared I know things are rough, but the last thing you're going to need is a $10,000 bill when you have things to do So make sure you know what's going to happen But literally we took the haircut as we said last year and we have not decreased our services at all But that's you know, that's not going to happen forever So we'll have to see how that works out Okay renal cell carcinoma everybody's telling you okay, there's so many of them. What's going on? I don't know some of them are increasing for some reason maybe in our environment But a lot of it is that everybody gets a CT scan and it turns out I find one centimeter or two centimeter tiny CT tiny renal cell carcinomas all the time and Then there comes up later on which is the whole teams decision out there what to do about it Some people like choose to hang out with it. Some people say whoo, it's cancer. I want it out of me and Some people are sort of in between they'll watch it for a little while and there are some Rules and guidelines, but this is the case where you're making the decision on this the final call will be yours And so it's good to know what the guidelines are and your physicians can go over that with you And that's why I advise having the team approach with high quality physicians who do this all the time Because they will know what the current guidelines are So is there a screening test for kidney cancer? No, I don't have the silver bullet You know and there are some that are coming up now in imaging We're finally there where we're doing molecular imaging and Dr. Rathmell and I have done some work combining some of the medications with some findings on there, but Ultrasound or CT we do those patients with the genetic disorders like we talked about von Hippel-Lindau and other family syndromes We're gonna be screening those people so we're gonna see that and overall ultrasound is great for detection So a lot of people will have that early on we saw the black thing usually you can see it But CT is good for treatment planning. So you'll probably have those along the way How is CT done you've all had this okay every place is kind of different, but I usually obtain three sets of pictures The first two sets are basically used to determine the cancer how vascular is it versus how not how other things And then finally when I stack them all together I talked about making reformats That's when I decide on how many arteries there are how many veins there are is there any Complicating factor are there lymph nodes is there anything in the liver or is there a secondary lesion that I need to see Can MR be used instead? Yeah, if you're at a place where people read MR all the time so again Our hospital happens to have a very strong MR section that may not be true everywhere But CT is a really good test and I use only MR as a second choice test So what about pet and kidney cancer dr. Rathmill and I were talking about that and it's always been like no no no But now I think it's like soon, you know, and you're going to be hearing later on I think from a speaker specifically about that Right now we don't use it as a routine Okay, but I think pretty soon things will be changing But this is just a patient that I've treated not I've treated I've seen who has vulvar cancer and metastatic disease to the left chest wall and so We have the vulvar we have the bladder here actually the vulvar cancer has been removed These are the kidneys and you see how you're looking from the front now So this is right left superior inferior and this would be under the arm axilla and The chest wall so now the patient gets some therapy and This looks better But we have a new site in the spine So Pet CT or any pet relies on a snapshot of glucose in your body So if there's someplace that's very active with blood and sugar, okay, which tends to be most cancers It takes a snapshot of that location. And so that's really what you're looking at So pet is a nice whole body scan It doesn't really focus on little pieces and you also can't measure the size of the patient So sometimes we have to do two things or one thing one time in the CT the other time But pet is very useful for identifying you can see those bright things you could really see that but you can't measure the size Which is also critical for making a decision This is new technology. Dr. Rathbell and I will be publishing some work on this soon And we happen to have a combination of a hybrid pet and MR scanner So we're using the MR underneath in here. This is a normal kidney There we saw some blood supply there. This kidney is obviously abnormal much larger This particular case has a tumor in it and what we do is put the pet scan over it So we always put pet scans over CT scan That's how we started out that you still couldn't measure things the concept here is I can use this part of the scan Do all the accurate measurements and stuff and then we could use this part of the scan to see which parts of the tumor are active So we're trying now to put those two together. We have one of these machines There's now I don't know 30 or something like that. I still don't know if it's going to be a clinical Tool, but for certain people for children. I use it all the time There's a little book up there that said Wilms tumors really at the beginning. That's a special cancer of children It's a great tool. No radiation So you have a child who's going to live a long long life from a Wilms tumor. You don't want to rate You don't want to radiate that child So reading the scan I try to tell their your doctor is what they want to know how big the tumor is where it is How many there are and sometimes patients have a familial story? the relationship to the Arteries and veins and ureters how many there are where they come off again for the surgeons who are look going to be looking through those little tubes the presence or absence of enlarged lymph nodes measure those and find them and All distant disease I'm going to take a look at the liver and the bones and those kind of things So it really has a big sort of shopping center list for that So I just wanted to show you a couple pictures This is one of the very first patients I saw 12 years ago when I came to UNC 44 years old with a large mass and we needed to do some good Staging on this person and we I just got the right equipment for it at that time So this is the normal kidney here. This is the right kidney and this is the left And that's a big tumor right so quite a good size But hard to see where everything went I knew what where most of the vessels were but I really wanted to see the pancreas and some other things over it So here this is when I told you I stacked them up together all the pictures and now we're looking from the front Okay, and I can see that actually this tumors just in the upper half of the kidney And I can see that this arrow points to a piece of the pancreas so I can tell the surgeons It's right on it so when you're going to go in there watch out for the pancreatic tail And I can say oh here are the adrenal gland that's that little upside-down Y thing it's not involved So these are sort of just different things and over the years. I've learned to what people want to know I Don't use the the ones from the side as much, but it's really critical for me to get the ones from the front and How about what kind of cancer it is sometimes I can be helpful sometimes So here I know there's something wrong if you pick it pick a kidney that's wrong This looks like the good one looks like the abnormal kidney something's going on here But it looks like there might be a little clot in there Here's a more tumor and I was deciding which kind of kidney cancer it was there's certain, you know signals that I'm looking at but the presence of The clot was what really made the difference for me and that's where I saw it the best So this is the big vein coming from the the bad kidney and there is the clot inside it And that only happens with your standard renal cell carcinoma. There's another type of cancer called transitional cell carcinoma Also occurs in the kidney doesn't make clots And then also I wanted to tell like where the lymph node was oh here it is look It's at the lower pole of the kidney This is where the big vessel is and it looks like we can figure that out nicely and This one is where we learned a little bit about again other things This time the kidney was Here this one's a little bit smoother and denser, but I couldn't tell what cell type it is from looking that I don't have that magic glasses All I can do is tell you where it is and kind of what it's going to be but then this is important stuff How many vessels so if you're going to have your kidney removed that surgeon wants to know how many vessels and where are they? so usually I mean they're supposed to be one 25 percent of patients have two and Most of the time actually they go to the superior inferior poles We call it of the kidney, but these are all right in the middle It's gonna be a tough if you're gonna remove tough part of it and then while I was there I found out they had a kidney stone on the right Which doesn't seem like a huge yield that was why they came in pain You know on one side and find this other thing on the other side So another patient remember our dr. Kim was talking about dialysis patients who get cysts on their kidneys This patient we did a CT scan on and we had this thing is let's kind of solid kind of hard to tell This is how we measure the density 35 is about soft tissue is like oh might be and then it needs to assess what happens to it when we add Contrast material so now all of these dark things are cysts But look at this thing and when I measured it it doubled in density when you increase the density It's a cancer. It's a tumor and so I was able to find the one this that was problematic versus all the other ones So that's also trying to help out on what to do next and then just a couple other things that we can help out with This is a cancer. That's posteriorly high up here We do percutaneous therapy at our hospital where what we do is Put probes Right here hot probes cold probes in kill off the tumor There it is dead. It's pretty good the it's about 90% rate of Cure with this type of tumor compared with the surgical Approach, but we use this on particularly difficult cases very obese patients that sort of thing and as I said with dr. Rath mal and her colleagues We looked at some of these drugs that dr. Kim was talking about Sinitinib and seraphinib and those kind of things and when the patients got this This drug it's kind of interesting We've always used size as a very important indicator of whether the kidney is getting better or not, right? So this patient this is their kidney with the tumor in it and this is after they got The Sinitinib so there's all this dead tumor in there, but it's not very much decreased in size Even though there's been a really good response. So that's where radiology is changing in this area we have the Same type of thing going on, but this guy is A non-responder no real change in density or size Non-responder and this patient has plenty of tissue here complete very good response on this patient very dark so even though the size is the same the density is different and that may eventually come into staging and And you saw this from dr. Kim earlier We had different types of tumors and he showed you these different types of cells One of the things dr. Rathmell and dr. Kim work on is deciding which drug works for which Tell cell type because not everything is everybody. So thank you so much for listening and I'll be happy to talk with you Okay, thank you