0:04

This patient here had a history of, of lung cancer,

0:10

uh, with stage one B, non-small cell lung cancer

0:14

and had fats, the left lower lobectomy.

0:17

Um, and she also had a topic duct hyperplasia

0:21

of the left wrist, and she had concern

0:26

for recurrent lung cancer.

0:28

And obviously when you look here,

0:30

it's obviously intensely metabolic recurrent disease.

0:34

But not only that, at the surgical bed, right,

0:37

when you look here in the, in the meb,

0:39

we in bed love the MEB because you see how it looks.

0:44

You have a curve in your recurrence,

0:46

but there's a lymph node here, right?

0:50

You can easily see it in the map,

0:53

but if you depend only in Thele image,

0:57

you might not see it, right?

0:59

So you have a recurrent disease,

1:00

but you have also, um, lymph node,

1:03

metastatic lymph node with it.

1:06

Um, in the same time there's effusion

1:11

and of course ECTs.

1:30

And I think in this patient there are,

1:38

there are multiple cysts here.

1:41

If I look at the, see here where the cysts are, see

1:46

how it's photonic a bit only, which tells you

1:51

that these are cysts.

1:53

If they are even in zumas, they will not be photo,

1:59

they'll have similar activity as the liver parenchyma.

2:01

So these are really cysts.

2:04

Rather than that, there's just some incidental findings.

2:06

Nothing really stands out.

2:14

So this is this regional recurrent dd.

2:17

How and where do you measure the medicinal blood

2:20

pool and reference liver?

2:22

Okay, this is a good question. I have a question.

2:24

Um, saying, um, okay, everyone see the, so the

2:28

Noel is asking about the medicinal and liver reference.

2:32

And this is a great question and I see

2:34

that everyone can see it, not only me.

2:35

So you guys can, um, okay, so I will put this

2:40

to PET only.

2:45

This is the importance of using, um, PET software

2:49

because the reference, whether it's a level reference

2:52

or a medicinal blood pool reference has a specific, first

2:56

of all, in pet we use volume of interest, nutrition

2:59

of interest, which is like a ball, right?

3:01

The sphere, um, is 3D structure.

3:05

Then usually when you draw a of interest, a volume

3:08

of interest to get, um, SUV max,

3:12

you freely free hand draw it.

3:14

But when you are measuring a reference, you cannot do that

3:19

because it's a specific volume.

3:22

It's not arbitrary, it's not any volume you wanna throw in.

3:27

Why? Because when we dictate ans UV of any lesion,

3:30

it's the max, it's the maximums UV, it's the SUV max.

3:34

While the reference UV is the mains UV, it's,

3:38

this is the mean UV of that sphere.

3:42

So let me show you here, I go here,

3:45

and this is, this is, this is a Siemens,

3:48

but any pet software will have, have this capability.

3:54

Not only this. I'll go here

3:57

and when I, okay, I come here,

4:03

this one here, see I have a, a lever reference

4:07

and I have an aorta reference.

4:09

If I click deliver reference,

4:12

it'll throw a volume of interest.

4:14

See? And then I'll just put it where I want.

4:17

I just wanna put it in the lever in

4:18

the little bit posterior.

4:20

And then this is the number I'll dictate.

4:22

2.9 the mean SUV of the liver.

4:25

And it, it's called reference lever. Why?

4:28

Because, because it has a specific volume.

4:33

That's it. It's just, it's not, I don't free hand draw it.

4:38

It has to ha it has to be one cubic centimeter volume

4:42

of interest in the liver, right?

4:45

I cannot just free hand draw it.

4:48

Now let me do the same.

4:51

I will go here and say I want the reference aorta,

4:55

which is the medicinal blood code.

4:57

See here you go and throw it in the aorta.

5:03

And here is the 2.7 is the main SUV of the aorta.

5:07

This is how you get the reference lever

5:09

and the reference mediastinal blood post.

5:12

Any pet software has this capability

5:16

because this is important in our work.

5:20

I hope I answered your question, okay.

5:23

After I talked about this, there's another important thing,

5:26

although we do have these numbers

5:28

and we put them in our reports,

5:30

we dictate them in our reports when we use them for our,

5:35

um, reporting.

5:37

When I say like this lesion is above liver parenchymal level

5:41

or above the thing, absolutely my pleasure.

5:44

Above the blood pool level, this is, um,

5:47

this is a qualitative assessment.

5:49

This is a judgment. It's, well,

5:51

sometimes we call it eyeballing, right?

5:53

So when I say for example, this lesion here

5:56

Is above blood pool level

5:58

or above the liver parenchymal level.

6:00

This is not based on quantification.

6:02

This is based on my eyes looking at the lesion

6:07

and judging that the lesion is hotter.

6:09

Of course the lesion is very intense,

6:10

but let's look at something else.

6:12

For example, let's look, let's see this.

6:14

See this something here. Do you see this?

6:16

I don't know what is this? Maybe this is the esophagus.

6:19

I think maybe whatever you see this,

6:22

but let's, let's just assume this is the lesion.

6:24

This is a nodule. Let's just consider this a game.

6:28

Let's consider this a nodule, right?

6:31

And then, I mean, I wanna say is this nodule hot or not?

6:36

This nodule is mildly avid, mild

6:40

to moderately hypermetabolic with FDG uptake

6:43

above blood pool level.

6:45

See, this is eyeballing, I'm not measuring anything.

6:47

It's not based on SUV, just based on eyeballing why

6:51

I'm looking, I'm comparing it to this

6:54

and I'm comparing it to the blood inside the, my

6:56

inside the heart chamber.

6:58

In the cardiac chamber, it looks like it's hotter than the

7:04

blood inside the cardiac chamber, right?

7:07

And then let's say I wanna compare it to the liver.

7:11

I try to go to the liver and see,

7:14

or sometimes I put it in coronal.

7:15

I try to put it in the same brain as the liver

7:18

and see is it hotter than the liver?

7:20

I think it's hotter than, so it is

7:22

judgment, it's qualitative.

7:24

The ve or lugano, sometimes we call it lugano.

7:27

'cause the more, the more, uh, dated is in lugano.

7:34

It's, it is they specifically say this is a qualitative

7:37

assessment, not quantitative.

7:40

And lymphoma, you should judge the uptake compared

7:45

to the background or blood mastin, blood pool or liver.

7:49

Qualitative eyeballing not based on numbers.

7:54

Okay? So this is so important.

7:56

Why is the reference, why do we

7:57

get the numbers in the reference?

7:58

Because in such a case, for example, let's,

8:02

let's throw in the liver reference here.

8:04

For here in this patient,

8:08

he has two time points, right?

8:10

A prior scan 2.3 in the prior

8:15

liver today, or the current is 2.9, right?

8:20

The mean SUV of the liver was 2.3, last time.

8:23

This time is 2.9.

8:25

So I know that the, the, the current scan,

8:29

the SUVs are gonna be higher than the prior scans.

8:32

'cause there are so many factors that affect SUV.

8:35

So many factors, including factors related to the patient.

8:38

How long did the patient fast?

8:39

Like I said, like we talked about how, what,

8:41

how is the hydration of the patient?

8:43

Um, the, a lot of, a lot of factors.

8:46

How much disease is in the patient.

8:49

Um, this time, um,

8:52

how much activity was injected to the patient?

8:54

How much the, how long did the uptake time?

8:56

The uptake time, maybe this time was 60 minutes.

8:59

Last time it was 75 minutes.

9:01

All these factors affect the scanner settings.

9:04

A lot, a lot of things affect the SUV measurements, right?

9:08

Um, so when I look at the, the reference,

9:12

I can in my head know that the SUVs

9:16

of the lesions this time are gonna be technically higher

9:20

than the SUVs of the lesions last time.

9:23

Just technically not related to the biology

9:25

or the treatment response or whatever.

9:27

So this is the value of the reference.

9:30

You know, you try

9:31

to normalize the technical factor in your head.

9:35

Okay? So I think this case is, there's nothing, no,

9:39

no other finding in this case.