0:04

Okay, so the next

0:05

Case is, it was the Sotal monitory nodule case.

0:10

It's one, it's one of the first indication that

0:12

PET was approved for it.

0:15

The sotal mono nodule. Again, the brain was negative.

0:18

Here I'm just showing you have to get your eye used

0:20

to how to look at the brain.

0:22

You are looking quickly through the brain, brain mass,

0:25

symmetric, no high focal, um, hypermetabolic

0:28

or hypermetabolic activity.

0:30

And then you increase the intensity

0:32

and go through it, look forward the scalp

0:34

and the skull, um, go down.

0:38

There was nothing really attracting our attention

0:43

here till you see this

0:47

Here.

0:48

And actually this patient is referred to us for, um,

0:51

This nodule.

0:53

So, um, you are, um, you have to,

0:57

you already know this nodule.

0:58

So, um, usually actually,

1:02

and I'm sure you already saw by now, uh,

1:06

saw my report, right?

1:09

And you saw how I, I usually start with the questionable,

1:13

um, nodule.

1:15

This is how I start. Because usually the patient is sent

1:18

to you with, um, a nodule workup.

1:23

Uh, this is a very valid, legitimate indication.

1:27

Look at this, uh, p monitoring nodule.

1:30

And usually you have, um, uh, the agnostic CT chest

1:33

with full inspiration, thin, thinner slices, different,

1:37

um, kernel.

1:39

So you can see, have a better look at the nodule

1:43

than our tidal volume.

1:45

And we have to do tidal volume ct.

1:47

It's not that we don't have the capability

1:49

of doing a diagnostic ct.

1:50

We can do a diagnostic ct,

1:52

but remember that you, you

1:53

to acquire the pet table position, you need three, four, uh,

1:58

minutes for each table position.

2:00

Um, and to register this pet to this ct, you cannot have,

2:04

uh, this the, for example, if the initial time with the pet

2:10

time, they, we used to do a full inspiration ct

2:13

and then you do this, the pet

2:14

and you have to do, have the pet on the tidal volume

2:16

because you can't ask the patient to keep his, uh, uh,

2:21

breath for three minutes, right?

2:24

But then try to register a title volume PET

2:27

to a full inspiration, um, city

2:31

total misregistration.

2:33

So the only way to do this

2:35

and have a decent registration between the PET

2:37

and a CT is to have both of them done

2:41

with a patient breathing quietly.

2:43

This is why we cannot

2:44

Do a full inspiration CT in our PET ct.

2:48

Um, but

2:49

otherwise we have the capability of of getting,

2:51

doing a diagnostic CT

2:52

In our scanners, Right?

2:55

So bottom line is you have the diagnostic CT already

2:58

Available to you to review while looking at your pet ct.

3:01

And you look at this, but you are doing this to look

3:04

for the metabolic activity.

3:06

Now this usually this, um, nodule is when

3:11

by the time they send this to you, a lot

3:13

of time it's like eight millimeter, nine millimeter nodule.

3:16

A lot of times not even a centimeter, which is usually

3:20

below our, um, pet resolution.

3:22

The pet resolution is usually a centimeter.

3:26

So you have, um, a nodule that is below your PET resolution

3:30

or within, like just add the pet resolution border,

3:33

which is a centimeter.

3:34

And then you're looking for activity.

3:36

And you look at this activity, it's

3:38

above the liver parenchyma, right?

3:41

So it's not only above the blood pools,

3:42

above the liver parenchyma.

3:43

So this is sus suspicious enough, right?

3:46

So you have the imaging feature that is suspicious

3:48

and you have the, there is there,

3:50

it's exhibiting metabolic uptake.

3:54

So you are gonna say it is suspicious for malignancy

3:58

and you will ask for tissue sampling for sure.

4:01

But this is not only your job here, your job is not done.

4:05

You still have to look for lymph nodes.

4:08

Do you think there is lymph nodes?

4:09

You look at the ipsilateral hilar region, right?

4:13

You look at the epi medias no lesion.

4:16

I'm looking at the peton. There is nothing

4:17

that is suspicious to me.

4:20

Right? And then you look retro choal,

4:26

of course you'll look for other nodules in the

4:28

lung very carefully.

4:30

Make sure there's nothing else.

4:31

You are either are incidental findings, of course scarring.

4:34

If emus changes all this you'll mention.

4:37

But, and we do look at the ct.

4:40

There's nothing like CT is for the,

4:42

for attenuation correction

4:43

and low resolution CT for attenuation correction.

4:46

This is, I'm sorry, but this is nonsense.

4:47

You have a decent ct, not bad ct. Yes.

4:50

It's not a, it's not like the same quality

4:52

as the full inspiration diagnostic city,

4:54

but you can draw a lot of information outta the city.

4:57

So you have to read it.

4:58

You cannot just like, dismiss it totally

5:00

and say, okay, this is nothing.

5:01

I'm just have this nodule

5:03

that is hot and you're just like done.

5:04

And your, your report is done.

5:05

You have to do a good job and get as much information

5:08

as you can from this, right?

5:11

And so nothing, no nodules, no other nodules, no,

5:15

definitely not, no hypermetabolic nodules, no other nodules,

5:19

no lymph nodes, no metastatic lymph nodes, right?

5:22

Then you will go and look for the other sides of meds.

5:26

Adrenal the lung, you know that the,

5:31

um, adrenals, um,

5:35

do you guys still hear me?

5:40

Yes, we can hear you. Um,

5:41

'cause I, it's gave me a message that something like, um,

5:44

the microphone was changed or something.

5:47

So, and then the adrenals, for example,

5:49

is very important for the lung.

5:50

For the lung cancer. You look this, this fatty liver.

5:52

There is gold stones.

5:54

You will mention all these incidentals in your report,

5:56

but you're looking at the pet.

5:58

There is no other metastatic disease.

6:00

You will look in sagittal coronal.

6:03

There is no bone mets, no liver mets, no nothing else.

6:06

So the conclusion is that this nodule,

6:08

this small nodule exhibits mild, um, metabolic active, mild,

6:13

moderate metabolic activity, suspicious for malignancy, um,

6:18

tissue sampling is recommended.

6:20

And then you will say you are not done.

6:22

There's no suspicious, um, hy mein lymphadenopathy.

6:25

There is no evidence of meta hypermetabolic

6:28

or metabolically active

6:29

metastatic distant metastatic disease.

6:31

So you had the t you,

6:33

you said that the nodule is suspicious.

6:35

You said that there is no the n there's no no,

6:37

there's no suspicious lymph node.

6:39

You hit the m there is no

6:41

suspicious systemic metastatic disease.

6:42

So here you would not, not only told them

6:44

that this nodule is suspicious,

6:46

but you told them also

6:47

that the N is is most probably zero now,

6:50

and the M is most probably zero now.

6:52

So this is, you also stage the patient for them

6:56

once they get the pathology.

6:58

So then you concluded the case.

7:00

So you have significantly in this case.