The Role of Imaging for the Investigation, Staging and Follow-Up of Non-Hodgkins Lymphoma - Term Paper Example

Discuss the Role of Imaging for the Investigation, Staging and Follow-Up of Non-Hodgkins Lymphoma (Radiography Student) Table of Contents Introduction 2 A Brief Outline of Non-Hodgkins Lymphoma 2 Importance of Accurate Staging of NHL 3 Discussion of the Role of Imaging for Investigating NHL 6 Different Modalities 6 PET Imaging for Investigation of NHL 6 FDG-PET Scans for Investigation of NHL 8 MRI Scans for Investigation of NHL 9 Ultrasound for Investigation of NHL 11 X-ray for Investigation of NHL 12 Diagnostic Value of Imaging for Investigation of NHL 12 Current Guidelines of Imaging for Investigating NHL 13 RCR Guidelines for Investigating NHL 13 NICE Guidelines for Investigating NHL 13 Ionising Radiation (Medical Exposure) Regulation (IR(ME)R) (2000) 15 Patient Issues In Relation To the Imaging Investigations 16 Discussion on Appropriate Treatment Options for NHL 17 Conclusion 19 References 20 Introduction Non-Hodgkins Lymphoma (NHL) is a type of cancer which initiates in the white blood cell known as lymphocytes, a part of immune system. The immunity system assists in fighting infections and several other diseases. The disease is caused if the DNA of the lymphocytes parent cell is damaged. The damage of DNA is not inherent to birth but is obtained. The change in the DNA results in the overstated development of the lymphocytes. The cells and the lymphocytes accumulated together form a tumour, which is observed in the lymph nodes and other parts of the human body. NHL typically originates in several organs like the stomach along with the intestine. It is the main reason which causes diseases to spread (Leukemia & Lymphoma Society, 2013). The essay aims to evaluate the importance of staging of the NHL. It also evaluates the role of imaging and treatments for NHL. A Brief Outline of Non-Hodgkins Lymphoma NHL is a form cancer which damages the cells in the human body. The lymphatic system has lymph vessel which carries fluid that flows in the tissues before being emptied in the blood vessel. The B Cells and the T cells are the main forms of the lymphocytes which are created in the ‘bone marrow’. It is noticed that NHL is caused when the lymphocytes begin to act abnormally, these cells then form various other abnormal cells causing damage in the human body (National Institutes of Health, 2007). Also, the NHL has the tendency to disturb the non-lymphoid tissue comprising oral tissue. The NHL clinically is observed with regard to bone swelling and neurological disturbance (Cancer Council NSW, 2011; Buric & et. al., 2010). It is a slow as well as a fast growing disease which rests on the immunity system of the human body. Moreover, the main reason for the NHL is unknown but a few of the factors which might cause NHL entail the weakened immune system, exposure to high dosages of radiation and human immunodeficiency virus (HIV) Or Epstein–Barr virus (EBV) viruses. The treatment and the rate of survival depend mainly on the grade of the disease and the age of the person (F. Hoffmann-La Roche Ltd, 2010). The objective of the essay is to evaluate the imaging and investigation of the NHL to comprehend the symptoms, stages and treatments or follow-up of the individuals suffering from such disease. Importance of Accurate Staging of NHL Staging is the procedure which aids to determine the extent to which the disease has spread in the human body. Staging is important for the physicians to comprehend the extent of the disease spread and assists to provide a proper diagnosis in order to determine a set of proper treatment mechanism. Staging system helps in determining the distribution of lymphatic which facilitates in the treatment of the disease and the severity of it. It aids in developing the best therapy required by the patient and ascertaining the accuracy regarding the diagnosis. Staging for NHL is difficult and complex because of the varied nature of disease and symptoms. Once the disease is identified various imaging investigations are done to determine the extent of disease spread. The tests for staging contain the physical exam, biopsies of the lymph nodes, blood tests, CT scans and bone marrow biopsy. The NHL is also characterised on the basis of the tumour and hence one of the most important staging processes for NHL is the ‘Ann Arbor Staging System’. The staging process has several stages. In stage one, NHL is restricted to one Lymph node group which is either overhead or underneath the diaphragm, or it is an organ which has not yet spread to different parts of the body. The stage two of staging NHL depicts a growth of two lymph nodes on the same side of the diaphragm. Moreover, the third stage shows an involvement of the different lymph nodes on both the sides and the last stage evaluates the association of Extranodal organ (Armitage, 2009). Figure 1 demonstrates the stages of staging which is necessary for proper accurate treatment. Fig 1: Stages of Staging Source: (Cancer Council NSW, 2011) These stages of NHL help in assessing the grades of the disease which include "low" "intermediate" or "high". Figure 2 below depicts the location of diaphragm which works as a guide for the doctor to understand the stages of NHL as it is the lower part of the body. Fig 2: Location of Diaphragm Source: (1Cancer Research UK, 2012) The Tumour Nodes Metastasis (TNM) classification of staging is important for the diagnosis process of NHL. The two major stages of staging are ‘Clinical and Pathologic Stages’ for cancer determination, which is relevant for treating NHL. Clinical staging is used to evaluate the best treatment as it is based on the physical examination such as X-Ray. Pathological staging on the other hand is unusually associated with surgical treatment procedure that involves removal the lymph nodes and cancer. In the pathologic process, the tissues of the body are examined to get the accurate stage of the disease which makes it easier for the treatment (Takvorian & Dipiro, n.d.). Discussion of the Role of Imaging for Investigating NHL Imaging tests such as MRI, PET scan and CT scan among others are vital for diagnosis as well as to determine the stages of the NHL. These imaging practices play a vital part in management of patients with malignant diseases such as NHL and are used at every point along the treatment pathway for instance in the early analysis and staging of disease level, for observing reaction to the treatment of disease, for evaluating any residual form after treatment, for validating remission of disease and for identifying difficulties of treatment (Husband & et. al., 2006). Different Modalities There are several imaging techniques available in order to develop image for NHL. However, there is no consensus as to which diagnostic modality is appropriate in order to investigate NHL. In this regard, some reports favour the use of Positron Emission Tomography PET imaging in order to investigate NHL while others favour the use of Magnetic Resonance Imaging MRI scan in order to detect NHL (Hussain & et. al., 2008). Following are comprehensive review of certain imaging modalities used to investigate NHL. PET Imaging for Investigation of NHL Positron Emission Tomography (PET) and most currently the Computed Tomography (CT) imaging is the most delicate and specific imaging methods presently available for patients with NHL. PET/CT provides utmost medical advantages in the evaluation of NHL and support in dispersing large B-cell lymphoma. PET/CT has arisen as the most significant advancement in the evaluation of patients with NHL. It is a non-invasive, three dimensional and metabolic imaging method which applies a radiopharmaceutical technique in order to target glucose metabolism in blood cell. PET/CT has nearly swapped the independent PET scanner as it conglomerates a complete ring sensor with multiple CT sensors. In PET/CT imaging, the images are united in order to deliver accurate localisation of abnormal wounds in cells. PET/CT provides sensitive and precise imaging in comparison with modality alone and is significantly quicker than the blend of emission and transmission PET scans (Cheson, 2010). Figure 3 demonstrates an image developed by PET/CT imaging of lesions in midbrain and corpus callosum of old man with NHL. Fig 3: PET/CT Imaging of Lesions in Midbrain and Corpus Source: (Cheson, 2010) PET imaging has tremendously improved in recent times, however, PET/CT imaging is rather restricted in its capability to distinguish initial postoperative provocative changes in body. Thus, the utility and development of PET imaging is currently ongoing and is still regarded as an accurate method of discovering lymph node incursion. FDG-PET Scans for Investigation of NHL Fluoro Deoxyglucose (FDG-PET) is extensively applied in the supervision of patients with NHL. It is essentially a glucose correspondent which is vaccinated into patient’s body and afterwards transported in the cell tissue. The tumours are well visualised through FDG-PET imaging having higher glucose metabolic rates in comparison with normal cells. This tool has been confirmed as sensitive and precise in comparison with other CT technique, delivering more accurate distinction between wound, fibrosis and active tumour (Seam & et. al., 2007). FDG-PET provides functional and anatomic information regarding NHL. In traditional visual image fusion, FDG-PET and CT images were observed and compared with each other. Nevertheless, with the appearance of fusion, incorporation of FDG-PET and CT images has been set in single study by software fusion (Kwee & et. al., 2014). Figure 4 demonstrates an image developed by FDG-PET imaging on cervical lymph node of a patient having NHL. Fig 4: FDG-PET Imaging on Cervical Lymph Node Source: (Kwee & et. al., 2014) MRI Scans for Investigation of NHL MRI is an ultimate entire body imaging tool. It has high spatial resolution and excellent soft-tissue contrast which make MRI a perfect tool for the recognition of parenchymal and osseous lesions. MRI possesses high level of contrast and it is a key modality choice for investigating NHL. It provides information regarding tissue cellularity and cellular membranes. Nevertheless, due to long imaging time, restricted availability and extensive expenses, MRI was formerly utilised only as a technique in order to develop image for limited functional fields of body. Current development in MRI technology has resulted in the availability of sufficiently quick and analytical structures for MRI. Moreover, the introduction of rolling bed patient platform has overwhelmed the time consumption issue of MRI imaging by allowing data acquisition of diverse functional area of body. Thus, MRI has become a feasible imaging and investigating method for NHL (Kwee & et. al., 2014). Figure 5 demonstrates an image of cervical lymph nodes developed by MRI imagining of a female with NHL. Fig 5: Image of Cervical Lymph Nodes Developed by MRI Imagining Source: (Kwee & et. al., 2014) Ultrasound for Investigation of NHL Ultrasound is also regarded as one of the modern modalities accessible for doctors or physicians in order to investigate patients for NHL or for detecting tumour staging. Ultrasound has several benefits in comparison to other imaging techniques, for instance, ultrasound is able to demonstrate cross sectional structure of body without radiation in a non-invasive manner. Furthermore, ultrasound is fairly inexpensive in comparison with other imaging techniques and it also necessitates few provisions and generates little patient issues (Mittelstaedt, 1980). Ultrasound can reveal large masses of tumour in the body and therefore is helpful in rapid diagnosis and treatment of NHL. The following figure demonstrates images developed by ultrasound about hyperechoic mass of a woman. Fig 6: Images Developed By Ultrasound about Hyperechoic Mass of a Woman Source: (Crawshaw & et. al., 2006) X-ray for Investigation of NHL X-ray imaging is also used in order to investigate NHL, particularly to detect the type of lymphoma a patient is suffering from. The most common imaging used is chest x-ray which is conducted in order to investigate swollen lymph nodes of other indications of NHL in body. CT scan is another x-ray tool through which sequence of detailed pictures are made on areas of head, neck and stomach among others in order to diagnose any abnormalities. This scan assists in signifying if any lymph node or tissues of body are enlarged. However, one key concern for x-ray imaging is radiation which can damage DNA tissues and result in abnormality. Thus, x-ray imaging is only suggested if it is deemed essential for investigation of disease (National Cancer Institute, 2007). Diagnostic Value of Imaging for Investigation of NHL Patients with NHL commonly undergo routine imaging investigation. It has critical role in inhibition of disease, early recognition, diagnosis and treatment. When patients have access and obtain proper scan at the proper time, the outcome improves and the expenses minimise. Imaging is one of the key developments, which has transformed the face of clinical remedy for NHL (Akiyama & et. al., 2000). Imaging has considerable diagnostic value for investigation of NHL. Imaging can help to detect lymphoma as early as possible and avoid the risk of delayed treatment. Since the introduction of various imaging techniques, the reported occurrences of NHL have increased comprising those having AIDS, those who are experiencing chemotherapy and those who have transplanted organs. Due to the characteristics, appearance along with localisation of NHL on different imaging scans and images, its diagnosis has become more straightforward in recent times (Akiyama & et. al., 2000). Current Guidelines of Imaging for Investigating NHL RCR Guidelines for Investigating NHL Royal College of Radiologists (RCR) provides guidelines for best use of imaging services. The guidelines assist radiographers, clinicians and other medical care service providers to determine most appropriate imaging investigations for any health problem. The guidelines of RCR are based on proper indications and expert thoughts (The Royal College of Radiologists, 2014). For instance, RCR guideline provides guidance regarding the use of PET imaging in order to enhance the outcome. According to RCR guideline, PET imaging can be used where staging is clinically challenging for instance for patients with trismus or where indecision of other imaging would impede essential treatment of NHL (Royal College of Physicians, 2013). NICE Guidelines for Investigating NHL National Institute for Health and Cared Excellence (NICE) also provides guidance for imaging assessment for different diseases. It defines the best processes for imaging and rules for radiography in order to manage diseases. For instance, NICE recommends that CT imaging should be used as primary imaging modality for such patients having chronic disability and neural signs and symptoms. Furthermore, CT is also regarded as the most cost-effective imaging than other radiographs for several risk groups such as intubated patients. NICE also recommends MRI imaging to be used for investigation of ligamentous damages (Barry & et. al., 2006). Ionising Radiation (Medical Exposure) Regulation (IR(ME)R) (2000) IR(ME)R 2000 is a regulation that has been developed to safeguard the patients from hazards related with ionising radiation of imaging. The fundamental principle of IR(ME)R is that it permits extensive diversity of imaging practices to be undertaken with proper explanation. It provides guidelines regarding roles and responsibilities of different parties involved in imaging. This legislation has been originated from ‘European Council Medical Exposures Directive’ and has been implemented under section 2(2) of the ‘European Communities Act’ of 1972. The guidance includes clinical application of ‘Ionising Radiations Regulations’ (IRR). Figure 6 demonstrates the key components of IR(ME)R 2000. Fig 7: Key Components of IR(ME)R 2000 Source: (The Royal College of Radiologists, 2008) The imaging also must be undertaken strictly on the basis of the etiquette with well-documented quality control process and the images should be inferred according to transparent, simple and preferably constant principles (Hutchings, 2009). Patient Issues In Relation To the Imaging Investigations PET/CT is the imaging investigation technique which is used as an important form of diagnostic tool for the patients suffering from lymphoma. The investigation is done through Magnetic Resonance Imaging (MRI) which is scanning of the body via radio waves. The issues that patients might face when considering the imaging investigation such as MRI are varied. A patient with the ‘pacemaker, metal pins along with medication pump’ might face issues in the MRI scanner due to the magnetic field. It is suggested that people with pacemaker should not be scanned through MRI. Besides, pregnant women with NHL while diagnosis might face issues as the effect of the imaging using the techniques are unknown on fetus. Any person who had a food intake before 5 hours of the scan might face issues regarding the abdominal scan. The kidney patient are faced by certain issues during the cancer diagnose. In this regard, it has been ascertained that the normal scan are not effective while CT scan is often suggested as it provide clear view which is quite expensive. Besides, the key issue faced in relation to imaging by the people who have Claustrophobia is the problem associated with narrow space (State Government of Victoria, 2013). Also, children face issues regarding the fear generated through high level of anxiety. It is also observed that few patients undergoing imaging investigation might face difficulties associated with radiation dosimetry. The radiation causes various biological issues such as skin eruptions, fatigues and nausea. Moreover people with allergies such as skin might face issues regarding rashes and skin disease. It is also observed that patients face issues such as loss of hair, low blood cell counts and at times high skin infections. Another key issue that the patients might face is high form of ionizing radiation, which causes various ill-effects (American Cancer Society, 2013; Griffeth, 2005). Furthermore, imaging investigations such as CT and PET are expensive, which is another vital issue for the patients on the basis of affordability and easy diagnosis for treatment. The cost in relation to imaging is also a vital issue for patients who are under the Non-Hodgkins Lymphoma treatment (Elstrom & Leonard, 2008). Discussion on Appropriate Treatment Options for NHL Any patient with this disease requires a special care and for the best treatment the doctor depends upon various options which are best suited. The NHL treatment forms include chemotherapy, radiotherapy and biological therapy. It is often observed that various patients require any one of the treatments but few require more than two forms. The age of the patient, severity of the disease and the grade help in assessing the treatment options (2Cancer Research UK, 2012). Chemotherapy is a form of treatment which uses anti-cancer drugs through which the cells of the cancer are destroyed and it also disrupts the development of the cancer cells. Chemotherapy helps in aiding patients with the low grade and high grade. Chlorambucil is a drug which is provided by the physician for the low-grade patients and the recovery time is nearly 6 months. With regard to high-grade lymphoma, the doctor suggests high dosages of medication with a combination of drugs for the treatment of NHL (2Cancer Research UK, 2012). Radiotherapy takes into consideration the strong rays of energy to destroy the cancer cells in the body. It is one of the commonly used treatments when one or two lymph nodes have the lymphoma cells in a part of the body. Radiotherapy along with chemotherapy is the treatments which are majorly used to treat patients with high level of NHL. Radiography is a structured form of treatment with various steps and the duration of the treatment depends on the type of the lymphoma. The treatment is undertaken for few minutes where the radiographer makes the arrangement and takes care of the comfort level while treating. It is a safe method of treatment and in case of any issues during treatment the patient can connect with the radiographer through intercom (3Cancer Research UK, 2012). Monoclonal antibodies are a form of biological therapy which is used for the treatment of NHL. These are the proteins which are prepared in the laboratory from the humanised antibody. Rituximab is one of the antibodies, which is used for the treatment of different forms of NHL such as B cell lymphoma and follicular lymphoma, a general form of NHL (4Cancer Research UK, 2012). The treatment options in NHL are based on the staging done which is supported through the imaging. The most appropriate treatment option recommended is radiotherapy which is the use of radiation in order to treat NHL. It is the safest option of treatment as it can be both used in and outside the body in the form of radiation which is painless. The radiotherapy can alone work well as a form of treatment but it is at times shared with chemotherapy (Moreno & et. al., 2012). Conclusion The study comprises a review of different imaging modalities and their role in investigation of NHL. Various imaging modalities have been identified namely CT, PET, MRI and Ultrasound among others which are used for assessing NHL. In this context, it can be concluded that each modality has its unique characteristics and plays an essential role in staging of NHL. Furthermore, fusion of different imaging modalities is also performed in order to investigate patients with NHL, because no one imaging technique is sufficient for proper treatment of NHL. Besides, the study also reveals that there are several issues which are related with imaging and therefore various guidelines have been established in order to enhance the quality of radiography. References Akiyama, Y. & et. al., 2000. 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