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Wk 1, Case 5 - Review

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0:04

So this is the, the lymphoma patient.

0:07

There was nothing up there.

0:11

There's small lymph node here,

0:13

but then there's this large mediastinal mass

0:16

that is necrotic.

0:17

So obviously large nodal mass here.

0:20

Intense labor metabolic, so obviously high grade lymphoma.

0:23

And then there's this also

0:28

lymph node, intensive metabolic node,

0:30

but both are above diaphragm.

0:32

This is so important because we're talking about

0:36

nodal disease above diaphragm, right?

0:43

And then there is pleural effusion.

0:53

There was some, um, mild metabolic

0:57

To mild metabolic.

0:59

What is this? Is this or these nodules here?

1:09

Patient just had, I think, um, subpleural nodule, yeah,

1:13

subpleural nodules

1:18

and some effusion, antis

1:20

and some post-surgical changes from biopsy.

1:32

And we have the

1:33

Nodes here, paral lymph nodes.

1:42

The huge necrotic mass is the dominant mass.

1:48

See the from the tho thoracotomy,

1:52

the post-surgical changes.

1:55

Other than that, I think this is why we had, okay,

1:58

let me stop this 'cause this's gonna be easier to see.

2:03

So this nodularity is at the end of the thoraco thoracotomy.

2:08

See this one here is at the end

2:11

of this tho thoracotomy, see here and here,

2:18

but it's these hot nodules

2:21

or nodes that are lymphomas.

2:29

So nodal disease above dran, basically, right?

2:33

But, and there's no nodal disease below the fram

2:35

and there's no external nodal disease.

2:37

So this will affect the staging of that patient.

2:41

And there's blur effusion.

2:45

The blur effusion. See how it's totally photogenic here?

2:50

So it doesn't look like this is really, um,

2:53

malignant blue effusion.

2:57

It doesn't look like even exudate.

2:59

It looks like transudate because it's totally photogenic.

3:02

This is the atelectatic lung,

3:05

which is here, this one here.

3:14

Rather than that, I don't think there

3:15

was anything else in that patient.

3:19

So in lymphoma, you need to

3:22

decide what you see.

3:25

Is nodal disease external?

3:26

Do you have nodal disease and external disease?

3:29

One of them or both of them?

3:31

Is it one sided diaphragm or both?

3:34

Side of the, of course we're talking about initial staging.

3:37

Treatment response assessment is gonna be a different, um,

3:41

well, not different, but I mean you will have to look at

3:44

pre-treatment, post-treatment.

3:46

What is the residual disease?

3:47

I think we have other cases that we talk about treatment

3:49

response assessment, but now we're talking only about

3:53

baseline, nodal and external disease.

3:56

Uh, and above and below diaphragm

4:00

or both, right?

4:02

And then if it's one side of the diaphragm is,

4:05

is it one region or multiple regions?

4:08

Um, and then, um,

4:11

the other thing I I wanna talk about is spleen.

4:15

Is spleen nole or external nole? Spleen is nole.

4:18

Like, think of it as a big node, right? Uh, marrow is it?

4:22

No external. External marrow is considered

4:25

external in this patient.

4:26

Here, again, the marrow is hotter than norm.

4:30

A little, a little hotter than normal,

4:33

but here again, it's diffusely nicely hot.

4:37

So again, it's the marrow activation, not infiltration.

4:41

Okay? And you have my report, this is

4:44

how I say like nodal mass in this area,

4:47

and no other smaller nodes, no nodal disease

4:50

below diaphragm, no external nodal disease.

4:52

So this is when they read it, they know how,

4:55

what is the staging of that patient?

Report

Please note: Items with dashed lines (--) are information withheld as it is not relevant for you to arrive at the correct findings and impression for the report and/or it was withheld for privacy information. The items were left in to show you the typical information documented in a PET report.

Clinical Indication:
18-year-old male presented with a large mediastinal mass, status right VATS with mediastinal mass biopsy revealing diffuse large B-cell lymphoma. PET/CT performed for initial staging and treatment planning.

Technique:
Preparation: Last oral intake (except water) on ----- at ----- AM/PM.
Diabetic: -----.
Blood glucose at time of FDG administration: --- mg/dL.
Radiopharmaceutical: ----- mCi of F-18 FDG administered IV at --- at AM/PM.
Incubation interval: -- minutes.
Oral contrast: ----.
Positioning: Arms raised.
PET/CT scanner: -------.
PET/CT acquisition: Vertex-to-mid-thighs.
Standardized uptake value (SUV): Corrected for ------.
CT: Low-dose, non-breath-hold, without intravenous contrast.
TOTAL DLP (Dose Length Product): -- mGy cm.

Comparison/Correlation:
No prior PET/CT comparison. No correlative imaging.

Findings:
Technical quality: Diagnostic.
Measurements: Unless otherwise specified, all SUVs refer to maximum value in the target.
Mean SUV liver: ---.


Head and Neck:
No suspicious hypermetabolic lesions in the head or neck.
No suspicious hypermetabolic cervical adenopathy.
Unremarkable thyroid gland.


Chest:
Large intensely hypermetabolic centrally necrotic anterior mediastinal mass with invasion of the pericardium and adjacent middle lobe lung parenchyma, with maximum SUV 19.0, measuring approximately 10.6 x 7.4 cm.
The mediastinal mass is causing narrowing of the medial right upper and middle lobes bronchi with associated collapse of the right upper and middle lobe and small non-FDG-avid ground-glass opacities in the aerated right upper lobe.
Few additional hypermetabolic paratracheal and para-esophageal lymph nodes. Examples are:

10 x 7 mm right upper paratracheal node, maximum SUV 3.6.
11 x 10 mm para-esophageal lymph node, maximum SUV 11.6.
Small to moderate non-FDG avid right pleural effusion with associated compressive atelectasis of the dependent right lung.
No left pleural effusion.


Abdomen and Pelvis:
No suspicious hypermetabolic lesions in the abdomen or pelvis.
Solid Abdominal Organs:
No suspicious focal hypermetabolic activity in the liver significantly greater than the heterogeneous physiologic uptake.
Unremarkable non-contrast appearance of the liver.
Normal gallbladder.
No hydronephrosis.
Unremarkable spleen.
No suspicious adrenal masses.
No suspicious pancreatic findings.


GI Tract/Mesentery/Peritoneum:
Physiologic bowel activity, without suspicious focal FDG uptake.
The large and small bowel appear normal in caliber.
No suspicious peritoneal/mesenteric findings.
Lymph Nodes: No suspicious hypermetabolic or pathologically enlarged lymph nodes in the abdomen or pelvis.
Pelvic Viscera: No suspicious findings.
Vasculature: Normal caliber of the abdominal aorta.
Free Fluid: No ascites or drainable fluid collection.


Skeleton and Soft Tissues:
No suspicious hypermetabolic osseous or soft tissue lesions.
No aggressive osseous lesions.
Moderate FDG activity fusing to the right chest wall soft tissue and intercostal space is likely secondary to recent thoracotomy, maximum SUV 4.0.

Impression:
1. Metabolically active nodal disease above diaphragm, predominantly a large intensely hypermetabolic centrally necrotic anterior mediastinal mass with invasion/involvement of multiple mediastinal structures and compression of the right upper and right middle lobe bronchi and associated atelectasis.
2. No metabolically active nodal disease below diaphragm.
3. No metabolically active extra-nodal disease.

Case Discussion

Faculty

Riham El Khouli, MD

Associate Professor of Radiology, Chief, Division of Nuclear Medicine/Molecular Imaging & Radiotheranostics

University of Kentucky

Michael F. Shriver, MD

Director of Nuclear Medicine

Proscan-NCH Imaging

Tags

PET/CT FDG

PET

Nuclear Medicine

Hematologic

CT