Multi Detector Computed Tomography in Oncology CT
Perfusion Imaging - 1st Edition
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To Elizabeth, Matthew, Benjamin, and Samuel …
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Contents
List of contributors ix
Foreword xiii
Preface xv
1 Computed tomography perfusion: a historical perspective 1
Anne E Miles and Kenneth A Miles
2 Scientific basis and validation 15
Ting-Yim Lee and Errol Stewart
3 Image acquisition and contrast enhancement 47
protocols for perfusion CT
Kenneth A Miles
4 Image processing 61
Ting-Yim Lee, Xiaogang Chen, and Kenneth A Miles
5 Angiogenesis, tumor perfusion, and cancer management 73
William W Li, Aliya Jiwani, and Michelle Hutnik
6 Tumors of the brain, head, and neck 89
Part A: Perfusion CT imaging in cerebral neoplasms
Karim Samji and Kenneth A Miles
Part B: Perfusion CT in head and neck cancer
Robert Hermans
7 Perfusion CT applications in lung cancer 111
Kwun M Fong, Rayleen V Bowman, Ian A Yang,
and Kenneth A Miles
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viii Contents
8 Tumors of the gastro-intestinal tract 129
Part A: Rectal cancer
Massimo Bellomi and Giuseppe Petralia
Part B: Other gastrointestinal tumors
Kenneth A Miles
9 Tumors of the urogenital tract 147
Elizabeth P Ives and Ethan J Halpern
10 CT perfusion of lympth nodes 163
Kenneth A Miles
11 CT perfusion of liver metastases and early 173
detection of micrometastases
Charles-André Cuenod, Laure Fournier,
Daniel Balvay, and Kenneth A Miles
12 Beyond RECIST: perfusion CT in evaluating 197
treatment response and complications
Natalie Charnley and Kenneth A Miles
13 Perfusion CT–PET: opportunities for combined 215
assessment of tumor vascularity and metabolism
Kenneth A Miles
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Contributors
Daniel Balvay PhD Xiaogang Chen PhD
Laboratoire de Recherche Radiology and Nuclear Medicine
en Imagerie Department
Université Paris V The University of Western
Paris Ontario
France London, ON
Canada
Massimo Bellomi MD
School of Medicine Charles-André Cuenod MD PhD
University of Milan Laboratoire de Recherche en
and Imagerie
Department of Radiology Université Paris V
European Institute of Oncology Paris
Milan France
Italy
Kwun M Fong MBBS FRACP PhD
Rayleen V Bowman MBBS PhD Department of Thoracic Medicine
FRACP The Prince Charles Hospital
The University of Queenland Brisbane
Brisbane Australia
Australia
Laure Fournier MD PhD
Natalie Charnley MBChB MRCP Laboratoire de Recherche
FRCR en Imagerie
The University of Manchester Université Paris V
Wolfson Molecular Imaging Paris
Centre France
Manchester
UK
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x Contributors
Ethan J Halpern MD William W Li
Department of Radiology The Angiogenesis Foundation
Thomas Jefferson University Cambridge, MA
Jefferson Medical College USA
Philadelphia, PA
USA Anne E Miles BSc PGCE MA
University of London
Robert Hermans MD PhD London
Department of Radiology UK
University Hospitals Leuven
Leuven Kenneth A Miles MBBS FRCR MSc
Belgium MD FCRP
Brighton and Sussex Medical
Michelle Hutnik School
The Angiogenesis Foundation Brighton
Cambridge, MA UK
USA
Blake Murphy BSC
Elizabeth P Ives MD Radiology and Nuclear Medicine
Department of Radiology Department
Thomas Jefferson University The University of Western
Philadelphia, PA Ontario
USA London, ON
Canada
Aliya Jiwani
The Angiogenesis Foundation Giuseppe Petralia MD
Cambridge, MA Department of Radiology
USA European Institute of Oncology
Milan
Ting-Yim Lee PhD FCCPM Italy
Radiology and Nuclear Medicine
Department Karim Samji MBBS BSc
The University of Western Brighton and Sussex University
Ontario Hospitals NHS Trust
London, ON Brighton
Canada UK
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Contributors xi
Errol Stewart BSC Ian A Yang MBBS PhD FRACP
Radiology and Nuclear Medicine Department of Thoracic
Department Medicine
The University of Western The Prince Charles Hospital
Ontario Brisbane
London, ON Australia
Canada
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Foreword
The extraordinary advances in medical technology over recent years
have placed imaging at the center of cancer diagnosis and assessment
but today the information used to direct patient management is based
almost entirely on morphological assessment. However, we are now at
the brink of a new and exciting era in which functional data will
become an integral component of routine tumor imaging.
It is well recognized that a tumor cannot grow beyond the size of
1mm3 without a blood supply and that assessment of tumor vasculature
provides a measure of tumour aggressiveness as well as insight into
other factors related to prognosis, prediction of response to treatment
and risk of recurrence.
This text brings imaging of tumor vasculature into the domain of
leading edge clinical practice and describes the added value and limita-
tions of current perfusion techniques in individual tumor types. While
Magnetic Resonance Imaging (MRI) provides a unique tool for assess-
ing tumors using a multifunctional approach, multidetector CT (MDCT)
is more widely available for staging tumors and indeed remains the
workhorse of cancer imaging today. It is appropriate therefore that
MDCT should be exploited to provide both morphological and func-
tional measurements of tumor vasculature in the routine assessment of
patients with cancer.
This approach is a welcome step forward in striving to reach the goal
of providing a detailed portrait of the morphological and functional
aspects of a tumor prior to therapy. Opportunities for developing
multifunctional assessment of tumors by a combination of PET and CT
data will take us further down this road, particularly as we look forward
to the introduction of new tracers which will allow interrogation of
multiple biological processes.
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xiv Foreword
Professor Miles has undertaken pioneering work in the development
of perfusion imaging with CT and here he brings together the views of
a team of highly regarded world experts. Together they present a con-
temporary analysis of the current evidence of the role of perfusion
MDCT in cancer medicine thus providing the foundation on which to
build a robust framework for the future.
It is hoped that in the not too distant future these techniques will be
applied to patients with cancer routinely and that this will lead to
improved survival and better patient outcomes.
Professor Dame Janet Husband DBE FMedSci PRCR FRCP
The Institute of Cancer Research
Royal Marsden NHS Trust
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Preface
It is now more than 25 years since Leon Axel proposed a method for
determination of cerebral blood flow from rapid-sequence contrast-
enhanced computed tomography (CT). Today, the availability of rapid
imaging with multidetector CT systems and commercial analysis soft-
ware has made perfusion imaging with CT an everyday technique for
clinical practice.
CT remains an essential tool in the assessment of patients with
cancer, not only for diagnosis but also for assessment of disease extent
and severity, and for the evaluation of response to treatment. Perfusion
CT is readily performed as an adjunct to conventional CT, providing
valuable information about tumor vascularity. In many ways, perfusion
CT is not unlike CT angiography, but depicts the functional status of the
tumor circulation at tissue level rather than visualizing the morphology
of discrete vessels. By reflecting the processes of tumor angiogenesis,
this additional information can aid in diagnosis, assess tumor aggres-
sion, and help to overcome some of the limitations associated with
morphological criteria for evaluation of tumor response.
The development of perfusion CT also links with another recent
advance in cancer imaging, the introduction of integrated positron
emission tomography (PET)–CT systems. The increasing use of intra-
venous contrast material during PET–CT can be extended to include a
CT perfusion study. In this way, it is now possible to depict tumor mor-
phology, perfusion, and glucose metabolism to provide an exceptionally
detailed assessment of tumor biology in a single examination.
This book is the first to be dedicated solely to the application of
perfusion CT in oncology. The aim is to provide the technical knowledge
required to reliably obtain CT perfusion images of tumors, to give an
understanding of the pathophysiology of tumor angiogenesis and its
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xvi Preface
relationship to contrast enhancement on CT, and to outline the ability
of perfusion CT to enhance diagnosis, prognosis, and therapy monitoring
for patients with cancer. The technique is also portrayed in its historical
context. The book will therefore be of interest to radiologists and radi-
ographers currently using perfusion CT or considering its introduction
to their institution. The information will also be valuable to clinicians
treating patients with cancer and to researchers involved in the devel-
opment of new cancer therapies.
Ken Miles MD
Brighton and Sussex Medical School
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1
Perfusion computed
tomography: a historical
perspective
Anne E Miles and Kenneth A Miles
Perfusion computed tomography (CT) has been made possible by the
joining together of two great medical specialities: anatomy and physi-
ology. It is important for us today as doctors and scientists to look back
into history and to our predecessors, at the state of knowledge from
ancient up to modern times, as well as looking forward to the possibil-
ities and dreams to which we aspire. J B Thornton wrote: ‘The more we
treat the theories of our predecessors as myths, the more inclined we
shall be to treat our own theories as dogmas.1 By looking back through
history, we are able to see the grand schemes and ideas developing
over time, and the continuity of ideas from great thinkers which can be
added to and extended to attain new levels of knowledge by our own
thinkers today. This chapter does not attempt to mention all the impor-
tant thinkers and achievers who have helped anatomy and physiology
become what they are together. It would be an impossible task. Rather,
by dipping in and out of history, we will attempt to cover some of
the more major scientists, philosophers, and physicians who have
contributed to making CT perfusion what it is today.
ANATOMICAL AND PHYSIOLOGICAL KNOWLEDGE
IN ANCIENT CIVILIZATIONS
Many of the medical accomplishments of the great civilizations of
antiquity have been sadly ignored in the West because of the lack of
accurate records, and problems with deciphering material that has been,
and still is being, discovered. One of the earliest Egyptian papyruses
