Fact Sheet on Imaging Tests for Cancer

Cancer Association of South Africa (CANSA)

Introduction An imaging test is a way to let doctors see what’s going on inside one’s body. These tests send forms of energy (X-rays, sound waves, radioactive particles, or magnetic fields) through the patient’s body. The changes in energy patterns made by body tissues create an image or picture. These pictures can show normal body structures and functions as well as abnormal ones caused by diseases like cancer.

[Picture Credit: Imaging Tests]

Imaging tests are different from endoscopy (like a colonoscopy or bronchoscopy), which puts a flexible, lighted tube with a lens or a video camera inside the body. Endoscopy lets doctors see inside parts of the body as if they were looking with the naked eye – more like real pictures. These pictures are very different from the images that are made with imaging tests.

Lennon, A.M., Buchanan, A.H., Kinde, I., Warren, A., Honushefsky, A., Cohain, A.T., Ledbetter, D.H., Sanfilippo, F., Sheridan, K., Rosica, D., Adonizio, C.S., Hwang, H.J., Lahouel, K., Cohen, J.D., Douville, C., Patel, A.A., Hagmann, L.N., Rolston, D.D., Malani, N., Zhou, S., Bettegowda, C., Diehl, D.L., Urban, B., Still, C.D., Kann, L., Woods, J.I., Salvati, Z.M., Vadakara, J., Leeming, R., Bhattacharya, P., Walter, C., Parker, A., Lengauer, C., Klein, A., Tomasetti, C., Fishman, E.K., Hruban, R.H., Kinzler, K.W., Vogelstein, B. & Papadopoulos, N. 2020 “Cancer treatments are often more successful when the disease is detected early. We evaluated the feasibility and safety of multicancer blood testing coupled with positron emission tomography- computed tomography (PET-CT) imaging to detect cancer in a prospective, interventional study of 10,006 women not previously known to have cancer. Positive blood tests were independently confirmed by a diagnostic PET-CT, which also localized the cancer. Twenty-six cancers were detected by blood testing. Of these, 15 underwent PET-CT imaging and nine (60%) were surgically excised.

Twenty-four additional cancers were detected by standard-of-care screening and 46 by neither approach. One percent of participants underwent PET-CT imaging based on false-positive blood tests, and 0.22% underwent a futile invasive diagnostic procedure. These data demonstrate that multicancer blood testing combined with PET-CT can be safely incorporated into routine clinical care, in some cases leading to surgery with intent to cure.”

What are imaging tests used for? Imaging tests are used in cancer in many ways: • it is sometimes used to look for cancer in its early stages (when it is still small and has not spread), even though a person has no symptoms. When used in this way, it is called cancer screening. A mammogram is an example of an imaging test used for cancer screening • it can be used to look for a mass or lump (tumour) if a person has symptoms. It can also help determine if the symptoms are caused by a tumour or by some other type of disease • it can sometimes help predict whether a tumour is likely to be cancer. This can help doctors decide if a biopsy is needed. • it can show exactly where the tumour is, even deep inside the body. • it can help determine the stage of the cancer (how far the cancer has spread) • it can be used to plan treatment • it can show if a tumour has gotten smaller, stayed the same, or grown after treatment • it can help determine if a cancer has come back (recurred) after treatment

Limitations of imaging tests Imaging tests can find large collections of cancer cells, but no imaging test can show a single cancer cell or even a few cancer cells. It takes millions of cells to make a tumour big enough for an area to look abnormal on an imaging test

Imaging Tests Used in the Diagnosis of Cancer The following is a brief description of the most important imaging tests used in the diagnosis of cancer.

X-rays An X-ray is a way to create a picture of the structures inside of the body using a small amount of radiation. X- rays are a type of electromagnetic radiation, just like visible light.

[Picture Credit: X-Ray]

X-rays are painless. However, some body positions needed during an X-ray may cause temporary discomfort.

Risks - X-rays are monitored and regulated to ensure a minimum amount of radiation exposure needed to produce the image. Young children and babies in the womb are more sensitive to the risks of X-rays. Health care provider should be informed should one be pregnant.

Bone Scan A bone scan uses a radioactive tracer to look at the inside of the bones. The tracer is injected into a patient’s vein. It collects in areas of the bone and is detected by a special camera. Healthy bone appears grey to the camera, and areas of injury, such as those caused by cancer, appear dark.

[Picture Credit: Bone Scan]

Pregnant patients should consult with a physician before consenting to radioactive injections. Computed Tomography or Computer Axial Tomography (CT or CAT) Scan A CT scan creates a three-dimensional picture of the inside of the body with an X-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumours. Sometimes, a contrast medium (a special dye) is injected into a patient’s vein to provide better detail.

[Picture Credit: CT Scan]

The CT scanner uses digital geometry processing to generate a 3-dimensional (3-D) image of the inside of an object. The 3-D image is made after many 2- dimensional (2-D) X-ray images are taken around a single axis of rotation - in other words, many pictures of the same area are taken from many angles and then placed together to produce a 3-D image.

Any woman who suspects she may be pregnant should inform the doctor beforehand.

Positron Emission Tomography (PET) Scan A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive sugar or other substance is injected into a patient’s body and is absorbed mainly by organs and tissues that produce the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body. [Picture Credit: PET Scan 1]

Positron emission tomography (PET) scan is a medical imaging procedure. It helps in giving detailed images of all that is happening at the molecular and cellular level. Other diagnostic procedures like an X-ray, CT scans, etc. help in giving anatomical images of the body. A PET scan gives a detailed report of all the biological processes occurring within the body.

Magnetic Resonance Imaging Scan (MRI) An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. A contrast medium may be injected into a patient’s vein to create a clearer picture.

Magnetic resonance imaging (MRI), nuclear magnetic resonance imaging (NMRI), or magnetic resonance tomography (MRT) is a medical imaging technique used in radiology to visualise internal structures of the body in detail. MRI makes use of the property of nuclear magnetic resonance (NMR) to image nuclei of atoms inside the body. MRI can create more detailed images of the human body than are possible with X- rays. [Picture Credit: MRI Scan 1]

Ultrasound An ultrasound uses sound waves to create a picture of the internal organs. It is a painless test that uses sound waves to create images of organs and structures inside the body. It is a very commonly used test. As it uses sound waves and not radiation, it is thought to be harmless. Doppler and duplex scans are used to visualise blood or fluids flowing through the body. Ultrasound is a high-frequency sound that one cannot hear, but it can be emitted and detected by special machines.

As ultrasound 'hits' different structures of different density in the body, it sends back echoes of varying strength.

[Picture Credit: Ultrasound 1]

Angiogram An angiogram (angiography) is a procedure used to create an image of blood vessels, including those of the head, kidneys, heart or lungs. A contrast medium is injected into the artery so that the blood vessels can be seen.

Angiography can be performed using: o an X-ray with catheters o computed tomography (CT) o magnetic resonance imaging (MRI)

Angiography may also be called arteriography. Angiography may be done to find out how well the person’s blood is passing through the blood vessels.

Barium Enema Barium enema is a special X-ray of the large intestine, which includes the colon and rectum.

This test is done in a hospital radiology department. It is done after the patient’s colon is completely empty.

The bowels need to be completely empty before the examination. If the bowels are not empty, the test may miss a problem in the large intestine that needs to be treated. The bowels may be emptied using an enema or laxatives, along with a clear liquid diet. The patient will be asked to drink plenty of clear liquids for 1 to 3 days before the test. [Picture Credit: Barium Enema]

Barium Swallow A barium swallow is a radiographic (X-ray) examination of the upper gastrointestinal (GI) tract, specifically the pharynx (back of mouth and throat) and the oesophagus (the hollow tube of muscle extending from below the tongue to the stomach). The pharynx and oesophagus are made visible on

X-ray film by a liquid suspension called barium sulphate (barium). Barium highlights certain areas in the body to create a clear picture.

A barium swallow may be performed separately or as part of an upper gastrointestinal (UGI) series, which evaluates the oesophagus, stomach, and duodenum (first part of the small intestine).

X-rays use invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs on film. X-rays are made by using external radiation to produce images of the body, its organs, and other internal structures for diagnostic purposes. X-rays pass through body tissues onto specially-treated plates (similar to camera film) and a ‘negative’ type picture is made.

[Picture Credit: Barium Swallow 1]

Fluoroscopy is often used during a barium swallow. Fluoroscopy is a study of moving body structures—similar to an X-ray ‘movie’. A continuous X-ray beam is passed through the body part being examined, and is transmitted to a TV-like monitor so that the body part and its motion can be seen in detail. In barium X-rays, fluoroscopy allows the radiologist to see the movement of the barium through the pharynx and oesophagus as the person drinks.

Intravenous Pyelogram An intravenous pyelogram (IVP), also called an excretory urogram, is an X-ray examination of the urinary tract. An intravenous pyelogram lets the doctor view the kidneys, bladder and the tubes that carry urine from the kidneys to the bladder (ureters).

[Picture Credit: Urogram 1]

An intravenous pyelogram may be used to diagnose disorders that affect the urinary tract, such as kidney stones, bladder stones, enlarged prostate, kidney cysts or urinary tract tumours.

During an intravenous pyelogram, an X-ray dye (iodine contrast solution) is injected into a vein in the arm. The dye flows into the kidneys, ureters and bladder, outlining each of these structures. X-ray pictures are taken at specific times during the examination so the doctor can clearly see the urinary tract and assess how well it is working.

Nuclear scan Nuclear scanning (radionuclide scans) uses radioactive substances to see structures and functions inside the body. Nuclear scans involve a special camera that detects energy coming from the radioactive substance, called a tracer. Before the test, the patient receives the tracer, often by an injection. Although tracers are radioactive, the dosage is small.

[Picture Credit: Nuclear Scan]

During most nuclear scanning tests, the patient is asked to lie still on a scanning table while the camera makes images. Most scans take 20 to 45 minutes.

Mammogram An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and treat medical conditions. Imaging with x-rays involves exposing a part of the body to a small dose of ionizing radiation to produce pictures of the inside of the body. X-rays are the oldest and most frequently used form of medical imaging.

Three recent advances in mammography include digital mammography, computer-aided detection and breast tomosynthesis.

Digital mammography, also called full-field digital mammography (FFDM), is a mammography system in which the X-ray film is replaced by solid-state detectors that convert X-rays into electrical signals. These detectors are similar to those found in digital cameras. The electrical signals are used to produce images of the breast that can be seen on a computer screen or printed on special film similar to conventional mammograms. From the patient's point of view, having a digital mammogram is essentially the same as having a conventional film mammogram.

Computer-aided detection (CAD) systems use a digitised mammographic image that can be obtained from either a conventional film mammogram or a digitally acquired mammogram. The computer software then searches for abnormal areas of density, mass, or calcification that may indicate the presence of cancer. The CAD system highlights these areas on the images, alerting the radiologist to the need for further analysis.

Breast tomosynthesis, also called three-dimensional (3-D) breast imaging, is a mammography system where the X-ray tube moves in an arc over the breast during the exposure. It creates a series of thin slices through the breast that allow for improved detection of cancer. This results in fewer patients recalled for additional imaging.

Mammograms are used as a screening tool to detect early breast cancer in women experiencing no symptoms. It can also be used to detect and diagnose breast disease in women experiencing symptoms such as a lump, pain or nipple discharge.

Screening Mammography Mammography plays a central part in early detection of breast cancers because it can show changes in the breast up to two years before a patient or physician can feel them. Current guidelines recommend screening mammography at least every 3 years for women, beginning at age 35.

Diagnostic Mammography Diagnostic mammography is used to evaluate a patient with abnormal clinical findings—such as a breast lump or lumps—that have been found by the woman or his/her doctor. Diagnostic mammography may also be done after an abnormal screening mammogram in order to evaluate the area of concern on the screening examination.

[Picture Credit: Mammogram 1]

[Picture Credit: Male Mammogram]

Mammography is also performed on male patients with suspected breast cancer.

Fluoroscopy Fluoroscopy is an imaging technique that uses X-rays to obtain real-time moving images of the internal structures of a patient through the use of a fluoroscope. In its simplest form, a fluoroscope consists of an X-ray source and fluorescent screen between which a patient is placed. However, modern fluoroscopes couple the screen to an X-ray image intensifier and CCD video camera allowing the images to be recorded and played on a monitor.

The use of X-rays, a form of ionizing radiation, requires the potential risks from a procedure to be carefully balanced with the benefits of the procedure to the patient. While physicians always try to use low dose rates during fluoroscopic procedures, the length of a typical procedure often results in a relatively high absorbed dose to the patient. Recent advances include the digitisation of the images captured and flat panel detector systems which reduce the radiation dose to the patient still further.

[Picture Credit: Fluoroscopy]

lymphangiogram (LAG) Lymphangiogram is an imaging study that can detect cancer cells or abnormalities in the lymphatic system and structures. It involves a dye being injected into the lymph system.

A lymphangiogram is a special X-ray of the lymph nodes and lymph vessels. Lymph nodes produce white blood cells (lymphocytes) that help fight infections. The lymph nodes also filter and trap cancer cells.

The lymph nodes and vessels are not seen on a normal X-ray, so a dye or radioisotope (radioactive compound) is injected into the body to highlight the area being studied.

[Picture Credit: Lymphangiogram]

Reflection Imaging Reflection imaging refers to the type of imaging produced by sending high-frequency sounds to the body part or organ being studied.

[Picture Credit: Reflection Imaging]

These sound waves ‘bounce’ off of the various types of body tissues and structures at varying speeds, depending on the density of the tissues present. The bounced sound waves are sent to a computer that analyses the sound waves and produces a visual image of the body part or structure.

Endoscopic Retrograde Cholangiopancreatography (ERCP) Endoscopic retrograde cholangiopancreatograph y (ERCP) uses a dye to highlight the bile ducts in the pancreas.

[Picture Credit: ERCP]

During ERCP, an endoscope is passed down the throat of the patient, through the stomach and into the upper part of the small intestine. A dye is then injected into the pancreatic and bile ducts through a small hollow tube (catheter) that is passed through the endoscope. Finally, X-rays are taken of the ducts. A tissue or cell sample (biopsy) can also be collected during ERCP.

Elastography Elastography is a relatively new imaging modality that maps the elastic properties of soft tissue. This modality emerged in the last two decades.

Elastography is useful in medical diagnoses, as elasticity can discern healthy from unhealthy tissue for specific organs/growths. For example, cancerous tumours will often be harder than the surrounding tissue, and diseased livers are stiffer than healthy ones. There are a several elastographic techniques based on the use of ultrasound, magnetic resonance imaging and tactile imaging. The wide clinical use of ultrasound elastography is a result of the implementation of technology in clinical ultrasound machines.

[Picture Credit: Elastogram] Main branches of ultrasound elastography include Quasistatic Elastography/Strain Imaging, Shear Wave Elasticity Imaging (SWEI), Acoustic Radiation Force Impulse imaging (ARFI), Supersonic Shear Imaging (SSI), and Transient Elastography. In the last decade a steady increase of activities in the field of elastography is observed demonstrating successful application of the technology in various areas of medical diagnostics and treatment monitoring.

Tactile Imaging Tactile imaging is a medical imaging modality that translates the sense of touch into a digital image. The tactile image is a function of P(x,y,z), where P is the pressure on soft tissue surface under applied deformation and x,y,z are coordinates where pressure P was measured.

[Picture Credit: Tactile Imaging]

Tactile imaging closely mimics manual palpation, since the probe of the device with a pressure sensor array mounted on its face acts similar to human fingers during clinical examination, slightly deforming soft tissue by the probe and detecting resulting changes in the pressure pattern.

Photoacoustic Imaging Photoacoustic imaging is a recently developed hybrid biomedical imaging modality based on the photoacoustic effect. It combines the advantages of optical absorption contrast with ultrasonic spatial resolution for deep imaging in (optical) diffusive or quasi-diffusive regime. Recent studies have shown that photoacoustic imaging can be used in vivo for tumour angiogenesis monitoring, blood oxygenation mapping, functional brain imaging, and skin melanoma detection, etc.

[Picture Credit: Photoacoustic Imaging]

Echocardiography When ultrasound is used to image the heart it is referred to as an echocardiogram. Echocardiography allows detailed structures of the heart, including chamber size, heart function, the valves of the heart, as well as the pericardium (the sac around the heart) to be seen.

[Picture Credit: Echocardiogram]

Echocardiography uses 2D, 3D, and Doppler imaging to create

Researched and Authored by Prof Michael C Herbst [D Litt et Phil (Health Studies); D N Ed; M Art et Scien; B A Cur; Dip Occupational Health; Dip Genetic Counselling; Diagnostic Radiographer; Dip Audiometry and Noise Measurement; Medical Ethicist] Approved by Ms Elize Joubert, Chief Executive Officer [BA Social Work (cum laude); MA Social Work] March 2021 Page 11 pictures of the heart and visualize the blood flowing through each of the four heart valves. Echocardiography is widely used in an array of patients ranging from those experiencing symptoms, such as shortness of breath or chest pain, to those undergoing cancer treatments. Transthoracic ultrasound has been proven to be safe for patients of all ages, from infants to the elderly, without risk of harmful side effects or radiation, differentiating it from other imaging modalities.

Functional Near-Infrared Spectography Functional near-infrared spectography (FNIR) Is a relatively new non-invasive imaging technique. NIRS (near infrared spectroscopy) is used for the purpose of functional neuroimaging and has been widely accepted as a brain imaging technique. (Wikipedia).

[Picture Credit: Functional Near-Infrared Spectography]

Magnetic Particle Imaging

[Picture Credit: Magnetic Particle Imaging]

Using supermagnetic iron oxide nanoparticles, magnetic particle imaging (MPI) is a developing diagnostic imaging technique used for tracking superparamagnetic iron oxide nanoparticles. The primary advantage is the high sensitivity and specificity, along with the lack of signal decrease with tissue depth.

Medical Disclaimer This Fact Sheet is intended to provide general information only and, as such, should not be considered as a substitute for advice, medically or otherwise, covering any specific situation. Users should seek appropriate advice before taking or refraining from taking any action in reliance on any information contained in this Fact Sheet. So far as permissible by law, the Cancer Association of South Africa (CANSA) does not accept any liability to any person (or his/her dependants/ estate/heirs) relating to the use of any information contained in this Fact Sheet.

Whilst the Cancer Association of South Africa (CANSA) has taken every precaution in compiling this Fact Sheet, neither it, nor any contributor(s) to this Fact Sheet can be held responsible for any action (or the lack thereof) taken by any person or organisation wherever they shall be based, as a result, direct or otherwise, of information contained in, or accessed through, this Fact Sheet.

Sources and References Consulted or Utilised

American Cancer Society http://www.cancer.org/treatment/understandingyourdiagnosis/examsandtestdescriptions/imagingradiologytests/imaging -radiology-tests-what-are http://www.cancer.org/treatment/understandingyourdiagnosis/examsandtestdescriptions/imagingradiologytests/imaging -radiology-tests-toc http://www.cancer.org/treatment/understandingyourdiagnosis/examsandtestdescriptions/imagingradiologytests/imaging -radiology-tests-nuc-scan

Angiogram https://www.google.co.za/search?q=angiogram+cancer&source=lnms&tbm=isch&sa=X&ei=RdoRUufGOoS2hAeCq4HIDg&v ed=0CAcQ_AUoAQ&biw=1366&bih=614#facrc=_&imgdii=_&imgrc=CFmmJwWalWs_jM%3A%3BhI7CeyM2qj_O_M%3Bhttp %253A%252F%252F31.media.tumblr.com%252Ftumblr_lhm98owrYH1qz6pa5o1_500.jpg%3Bhttp%253A%252F%252Fwww .tumblr.com%252Ftagged%252Fangiogram%3B500%3B339

Ask.Com http://www.ask.com/web?am=broad&q=what+is+bone+scan&an=google_s&askid=62a2b2ba-dcaf-474e-af31- a552a2eb1c35-0-us_gsb&kv=sdb&gc=0&dqi=bone%2Bscan&qsrc=999&ad=semD&o=4807&l=dir http://www.ask.com/web?am=broad&q=what+is+a+mri+scan&an=google_s&askid=928bdc20-b921-4254-9a2c- 9775cf6e9c3f-0-us_gsb&kv=sdb&gc=0&dqi=mri%2Bscan&qsrc=999&ad=semD&o=4807&l=dir

Barium Enema https://www.google.co.za/search?q=barium+enema&source=lnms&tbm=isch&sa=X&ei=lPQRUs- UNcqmhAel74GQCQ&sqi=2&ved=0CAcQ_AUoAQ&biw=1366&bih=614#facrc=_&imgdii=_&imgrc=BP1QU4LyI9T0iM%3A%3 Bxoc54SjpjGJa7M%3Bhttp%253A%252F%252Fwww.hopkinscoloncancercenter.org%252FUpload%252F200811241353_222 86_000.jpg%3Bhttp%253A%252F%252Fwww.hopkinscoloncancercenter.org%252FCMS%252FCMS_Page.aspx%253FCurren tUDV%253D59%2526CMS_Page_ID%253D2AB211EA-18D0-40BB-A8E5-B4096012E444%3B410%3B313

Barium Swallow 1 https://www.google.co.za/search?q=barium+swallow&source=lnms&tbm=isch&sa=X&ei=2Q8SUt_OMZSLhQfO34GADg&sq i=2&ved=0CAcQ_AUoAQ&biw=1366&bih=614#facrc=_&imgdii=_&imgrc=FJFtGj91QwUE- M%3A%3BJUd52_a6Dvql3M%3Bhttp%253A%252F%252Fwww.aviva.co.uk%252Flibrary%252Fimages%252Fmed_encyclop edia%252Fcfhg589barswa_001.jpg%3Bhttp%253A%252F%252Fwww.aviva.co.uk%252Fhealth-insurance%252Fhome-of- health%252Fmedical-centre%252Fmedical-encyclopedia%252Fentry%252Ftest-barium-swallow%252F%3B400%3B360

Bone Scan https://www.google.co.za/search?q=bone+scan&source=lnms&tbm=isch&sa=X&ei=4csRUsm1HsSxhAeX- oHQCw&sqi=2&ved=0CAcQ_AUoAQ&biw=1366&bih=614#facrc=_&imgdii=_&imgrc=zdxLaMvfgAHMaM%3A%3BKmpKuaX HMcb10M%3Bhttp%253A%252F%252Ftomography.files.wordpress.com%252F2008%252F03%252Fbone_scan1.jpg%3Bhtt p%253A%252F%252Ftomographyblog.com%252Fcategory%252Fbone-scan%252F%3B958%3B826

Canadian Cancer Society\ http://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/tests-and-procedures/core-needle- biopsy/?region=on

Cancer.Net http://www.cancer.net/all-about-cancer/newly-diagnosed/tests-and-procedures http://www.cancer.net/cancer-news-and-meetings/expert-perspective-cancer-news/choosing-wisely%C2%AE-top-five- cancer-related-tests-procedures-and-treatments-many-patients-do-not-need/topic-3-imaging-tests-early-stage-breast- cancer http://www.cancer.net/cancer-types/brain-tumor/diagnosis

Cancer Research UK http://www.cancerresearchuk.org/cancer-info/cancerandresearch/all-about-cancer/what-is-cancer/detectingcancer/detectingcancer#Imaging

CT Scan https://www.google.co.za/search?q=ct+scan&source=lnms&tbm=isch&sa=X&ei=gs4RUoD1KqGe0QWwr4DIBA&ved=0CAc Q_AUoAQ&biw=1366&bih=614#facrc=_&imgdii=_&imgrc=KDzVc5HjeZsUNM%3A%3BY0dRMecm8BMkQM%3Bhttp%253A %252F%252Fwww.abujaclinics.com%252Fpixes%252FctScan.JPG%3Bhttp%253A%252F%252Fwww.abujaclinics.com%252F equipments.htm%3B3680%3B2070

Echocardiogram https://www.saintlukeshealthsystem.org/health-library/echocardiogram

Elastogram http://pbc-society.ca/blog/mre-magnetic-resonance-elastography/

ERCP https://www.google.co.za/search?q=Endoscopic+retrograde+cholangiopancreatography&source=lnms&tbm=isch&sa=X&e i=2KVTUsKLL8WQtAa7x4CwDQ&ved=0CAcQ_AUoAQ&biw=1366&bih=614&dpr=1#facrc=_&imgdii=_&imgrc=FqLyu5PscCk G3M%3A%3BEnE3ECVi- 8T6xM%3Bhttp%253A%252F%252Fdrjoycerichards.com%252Fimages%252Fercp.jpg%3Bhttp%253A%252F%252Fdrjoyceric hards.com%252Fercp.htm%3B611%3B328

Fluoroscopy https://www.google.co.za/search?q=fluoroscopy&source=lnms&tbm=isch&sa=X&ei=niASUsn7IJGIhQfPxIHIAg&sqi=2&ved= 0CAcQ_AUoAQ&biw=1366&bih=614#facrc=_&imgdii=_&imgrc=8ZUXcyRsAO_DZM%3A%3BEUMv1cZ32REg8M%3Bhttp%25 3A%252F%252Fwww.eorthopod.com%252Fsites%252Fdefault%252Ffiles%252Fimages%252Fpain_pumps_fluoro.jpg%3Bht tp%253A%252F%252Fwww.eorthopod.com%252Fcontent%252Fpain-pumps%3B400%3B400

Functional Near-Infrared Spectography http://www.eejecerc.usu.edu/nirs/background.php

HealthPlus24 http://www.healthplus24.com/diseases/cancer/pet-scan.aspx

Imaging Tests https://www.google.co.za/search?q=imaging+tests+for+cancer&source=lnms&tbm=isch&sa=X&ei=34YIUtraMdSHhQfGvo G4Dg&ved=0CAcQ_AUoAQ&biw=1366&bih=614#facrc=_&imgdii=_&imgrc=EHBweqVNsqV24M%3A%3BFhTRC3CDTdT7SM %3Bhttp%253A%252F%252Fwww.privatemdlabs.com%252Fnewsimages%252FX- ray_2248_19582686_0_0_8665_300.jpg%3Bhttp%253A%252F%252Fwww.privatemdlabs.com%252Fnews%252FProstate% 252FImaging-test-may-help-determine-treatment-options-for-prostate-cancer-%252419582686.php%3B300%3B300

Johns Hopkins Medicine http://www.hopkinsmedicine.org/healthlibrary/test_procedures/gastroenterology/barium_swallow_92,P07688/ http://www.hopkinsmedicine.org/healthlibrary/test_procedures/urology/retrograde_pyelogram_92,P07713/

Lymphangiogram https://www.google.co.za/search?q=lymphangiogram&source=lnms&tbm=isch&sa=X&ei=oCQSUtnfDJSKhQfKhoGADQ&sqi =2&ved=0CAcQ_AUoAQ&biw=1366&bih=614#facrc=_&imgdii=_&imgrc=MD7ih9ds0uDWNM%3A%3Ba4DJH6C_PQU- JM%3Bhttp%253A%252F%252Fwww.mediscan.co.uk%252Fimages%252Fbatch9%252F8405%252F8405w.jpg%3Bhttp%253 A%252F%252Fwww.mediscan.co.uk%252Fcfm%252FIm_info.cfm%253FImageID%253D008405%2526mediatype%253DIma ge%2526log%253Dnk%3B320%3B491

Lymphangiogram of Legs https://www.google.co.za/search?q=lymphangiogram&source=lnms&tbm=isch&sa=X&ei=oCQSUtnfDJSKhQfKhoGADQ&sqi =2&ved=0CAcQ_AUoAQ&biw=1366&bih=614#facrc=_&imgdii=_&imgrc=zlFTBeM1aYkW6M%3A%3BLkbw5r3FxjCkVM%3Bh ttp%253A%252F%252Fradiology.rsna.org%252Fcontent%252F220%252F3%252F816%252FF2.large.jpg%3Bhttp%253A%25

2F%252Fwww.lookfordiagnosis.com%252Fmesh_info.php%253Fterm%253DLymphography%2526lang%253D1%3B1506%3 B1710

Male Mammogram http://wommen.org.uk/male-breast-cancer/ Mammogram 1 https://www.google.co.za/search?q=mammogram&source=lnms&tbm=isch&sa=X&ei=- RsSUpUUk_CFB5PJgagO&sqi=2&ved=0CAcQ_AUoAQ&biw=1366&bih=614#facrc=_&imgdii=_&imgrc=Wm6oACTJSQ2eqM% 3A%3BTtW0q7WxPFFynM%3Bhttp%253A%252F%252Flissarankin.com%252Fwp- content%252Fuploads%252F2013%252F05%252FWoman_receives_mammogram.jpg%3Bhttp%253A%252F%252Flissarank in.com%252Fscreening-mammography-saving-lives-or-overdiagnosis-overkill%3B3000%3B2400

Mayo Clinic http://www.mayoclinic.com/health/intravenous-pyelogram/MY01204/DSECTION=why-its-done http://www.mayoclinic.com/health/pancreatic-cancer/DS00357/DSECTION=tests-and-diagnosis

Medical News Today http://www.medicalnewstoday.com/articles/153201.php

MedLine Plus http://www.nlm.nih.gov/medlineplus/ency/article/003337.htm http://www.nlm.nih.gov/medlineplus/ency/article/003817.htm http://www.nlm.nih.gov/medlineplus/mammography.html http://www.nlm.nih.gov/medlineplus/ency/article/003798.htm

MRI Scan 1 https://www.google.co.za/search?q=mri+scan&source=lnms&tbm=isch&sa=X&ei=o9MRUp- 5EqSn0QXIlYGwDw&ved=0CAcQ_AUoAQ&biw=1366&bih=614#facrc=_&imgdii=_&imgrc=FN9MBFxnOGU92M%3A%3Bwd0 ObhX1bXu2PM%3Bhttp%253A%252F%252Fwww.womens-health-advice.com%252Fassets%252Fimages%252Fmri- scan.jpg%3Bhttp%253A%252F%252Fwww.womens-health-advice.com%252Ftests%252Fmagnetic-resonance- imaging.html%3B274%3B236

National Cancer Institute http://www.cancer.gov/cancertopics/screening/types#Imaging+Tests http://www.cancer.gov/clinicaltrials/learningabout/what-are-clinical-trials

Nuclear Scan https://www.google.co.za/search?q=nuclear+scan&source=lnms&tbm=isch&sa=X&ei=9qtSUpSsA- XR7Ab3rICoDQ&sqi=2&ved=0CAcQ_AUoAQ&biw=1366&bih=614&dpr=1#facrc=_&imgdii=_&imgrc=I1LxF8Kb46_ycM%3A% 3B9eZW66gWqXWjbM%3Bhttp%253A%252F%252Fwww.kch.nhs.uk%252FImages%252FGet%252F1UYvv7%252Fradiograp her-prepares-patient-on-scanner-bed-for-nuclear-medicine- scan%3Bhttp%253A%252F%252Fwww.kch.nhs.uk%252Fservice%252Fcancer%252Ftests-and-investigations%252Fnuclear- medicine-scan%3B227%3B171

PET Scan 1 https://www.google.co.za/search?q=pet+scan&source=lnms&tbm=isch&sa=X&ei=ctARUo3mBZCKhQeFiIGgBw&ved=0CAc Q_AUoAQ&biw=1366&bih=614#facrc=_&imgdii=_&imgrc=wefTMk2OmWzHNM%3A%3BEyRQgvrTKN6QqM%3Bhttp%253A %252F%252Fhealthypattern.com%252Fwp-content%252Fuploads%252F2011%252F12%252FPET- Scans.gif%3Bhttp%253A%252F%252Fhealthypattern.com%252Fpet-scans.html%3B317%3B251

Photoacoustic Imaging http://www.cell.com/trends/biotechnology/fulltext/S0167-7799(16)00034-2

RadiologyInfo.org http://www.radiologyinfo.org/en/info.cfm?pg=mammo

Reflection Imaging https://www.google.co.za/search?q=reflection+imaging&source=lnms&tbm=isch&sa=X&ei=va5SUuLqHOfI0wW974GADg& ved=0CAcQ_AUoAQ&biw=1366&bih=614&dpr=1#q=reflection+imaging+cancer&tbm=isch&facrc=_&imgdii=_&imgrc=OioZ

045XD0ij5M%3A%3BCSXAmacyLiZBqM%3Bhttp%253A%252F%252Fsafetyca.info%252Fwp- content%252Fuploads%252F2013%252F06%252Fovarian-cancer-tumorimaging-of-pelvic-malignancies-with-in-line-fdg- pet---ct--case-e5xtrws8.jpg%3Bhttp%253A%252F%252Fsafetyca.info%252Fdiseases%252Fphiladelphia-reflections- favorites-ii%3B1800%3B1357

Retrograde Pyelogram https://www.google.co.za/search?q=retrograde+pyelogram&source=lnms&tbm=isch&sa=X&ei=a40EU4O9IYiSkQfb7IGgAQ &sqi=2&ved=0CAcQ_AUoAQ&biw=1517&bih=714&dpr=0.9#facrc=_&imgdii=_&imgrc=8fF3PFVpzw8dqM%253A%3BIPd_W HpEgYulYM%3Bhttp%253A%252F%252Fwww.comiterpa.com%252Fimages%252FP1270011a.JPG%3Bhttp%253A%252F%2 52Fwww.comiterpa.com%252Fhematuria_special_procedures.htm%3B1536%3B2048

Stanford Cancer Institute http://cancer.stanford.edu/information/cancerDiagnosis/diagnosticImaging.html

Tactile Imaging https://en.wikipedia.org/wiki/Tactile_imaging

Ultrasound 1 https://www.google.co.za/search?q=ultrasound+scan&biw=1366&bih=614&source=lnms&tbm=isch&sa=X&ei=6tgRUsL3DI iZ0QWUp4CgCg&ved=0CAcQ_AUoAQ#facrc=_&imgdii=_&imgrc=F5XdH68hLeBJSM%3A%3BqNXduJF4AT_kKM%3Bhttp%25 3A%252F%252Fwww.royalmarsden.nhs.uk%252FSiteCollectionImages%252F440x190%252Frdac-ultrasound- scan.jpg%3Bhttp%253A%252F%252Fwww.royalmarsden.nhs.uk%252Fdiagnosis-treatment%252Ftests- investigations%252Fultrasound%3B440%3B190

Urogram 1 https://www.google.co.za/search?q=intravenous+pyelogram&source=lnms&tbm=isch&sa=X&ei=BBMSUv- IAY2ShQfXiIGADA&sqi=2&ved=0CAcQ_AUoAQ&biw=1366&bih=614#facrc=_&imgdii=_&imgrc=QV3e91ejgjpLMM%3A%3BK Mkwke- kgK52UM%3Bhttp%253A%252F%252Fwww.healthcentral.com%252Fcommon%252Fimages%252F1%252F19245_8324_5.j pg%3Bhttp%253A%252F%252Fwww.healthcentral.com%252Fincontinence%252Fh%252Fivp- procedure.html%3B400%3B320

Wikipedia http://en.wikipedia.org/wiki/Fluoroscopy https://en.wikipedia.org/wiki/Medical_imaging

X-Ray https://www.google.co.za/search?q=x-ray&source=lnms&tbm=isch&sa=X&ei=v8gRUu- AMoqHhQeE8oDQBw&ved=0CAcQ_AUoAQ&biw=1366&bih=614#facrc=_&imgdii=_&imgrc=bygq7XdihBK3tM%3A%3B3oN ueYx13YngBM%3Bhttp%253A%252F%252Fwww.medicalradiation.com%252Fwp- content%252Fuploads%252Fx_ray.jpg%253Fa17713%3Bhttp%253A%252F%252Fwww.medicalradiation.com%252Ftypes- of-medical-imaging%252Fimaging-using-x-rays%252Fradiography-plain-x-rays%252F%3B633%3B633