0:04

Which is the Hodgkin's lymphoma baseline.

0:07

And then I will show you the treatment response, which is,

0:09

which is the next case, which is the same

0:10

patient after treatment.

0:13

Uh, you, you're supposed to be seeing my screen right now.

0:16

Um, this is usually what, how you display.

0:18

I have another monitor. So usually my, um,

0:22

PET software is two monitor.

0:24

Most, I wanna say all, but I cannot say all.

0:28

But most pet softwares will at least have two monitors

0:32

displayed on two monitors.

0:33

So one monitor. Usually you want to have your pet only

0:38

axial CT infuse image and you wanna see your map, right?

0:42

And then the other monitor will have,

0:43

because this is, I'm showing you one time point.

0:46

This is one, uh, study, uh, for the patient.

0:49

And the other monitor for me has the coronal

0:52

and the sagittal reconstruction.

0:55

Um, so, but

0:56

because I can show you one monitor,

0:58

I'm showing you this one right now

1:00

and I can change the orientation while, while we're talking.

1:03

And we already have a session.

1:06

The first session was going through the search pattern.

1:08

So I'm not going through this again.

1:10

Um, I'm just showing today,

1:11

I'm showing just the findings in this case.

1:14

Um, last session we talked about lymphoma staging

1:17

because we had an lymphoma case.

1:19

So it's, you know, nodal,

1:21

external nodal disease is important to dec uh,

1:23

to decide in your patient is there metabolically active

1:26

nodal disease, only external, external disease only,

1:29

or both, right?

1:31

And this is a Hodgkin disease patient, right?

1:33

I'll go up from, there's a lot of motion.

1:35

You can see that right? When I go here,

1:38

patient has two noses, right?

1:40

One here and a little bit of nose here,

1:42

which means this patient did move through the scan

1:45

so you know that there's some motion.

1:46

This is why you see this like doubling in some of the areas.

1:50

You realize that which means there will be mis restoration

1:53

and there will be some artifacts.

1:54

Don't let this confuse you for some disease.

1:57

'cause you know that this is there.

1:59

This, this study is suboptimal, right?

2:02

This is something we deal with. Our scans takes time.

2:05

It's not like CTV done. Some patients will have some motion.

2:08

Sometimes the motion's too much that it will, uh,

2:12

limit your evaluation

2:13

and you will tell your, uh, tech, okay, hey,

2:16

repeat the head part.

2:19

He will, they will go back and they will do,

2:21

they should repeat that part.

2:22

Sometimes the motion is so trivial in an area

2:25

that you don't see any disease

2:26

and you'll say, you know what, I don't mind.

2:28

I don't wanna, you know, trouble the patient and,

2:30

and keep them in the scanner longer than they should.

2:33

And do you know,

2:34

and this patient will delay the next patient

2:37

that should be in the scanner.

2:38

So it's always your decision. Does it, is does it worth it?

2:42

Do you really need to repeat this part or no? Right?

2:45

So like, like I said, in this patient here, there is motion.

2:48

I'm telling you there's motion. Did I repeat it?

2:49

No, I didn't because it's not affecting my diagnosis.

2:53

It's an I can look here

2:55

and I can tell all this artifact, it's not bothering me.

2:58

I can't decide whether this is a,

3:00

there's a problem here or not.

3:02

Okay? It's not affecting my decision.

3:05

So I let it go in other patients.

3:07

No, I say no, I wanna repeat this part

3:10

because this is really an area that I care about.

3:12

There's disease here. It, this is knocking my activity,

3:16

it's gonna affect my decision on whether this

3:19

is, how hot is this lesion?

3:20

Is it hot or not hot? The SUVs.

3:23

So no, I need this part to be repeated and we repeat it.

3:26

So it's always your decision.

3:28

And it's not only, okay, because I want at

3:29

the prettiest scan ever.

3:31

No, it's usually for diagnostic value of the scan, right?

3:35

So I'm going down there is,

3:37

and then you start seeing, I'm looking

3:39

and you guys, I'm, I'm looking here,

3:41

I'm looking at the pet only image.

3:42

So you start seeing disease here, right?

3:46

Predominantly left sided,

3:47

but there are right sided as well,

3:48

right from the cervical region.

3:51

Um, then I start looking at the CT only and diffused image.

3:55

This, these are cervical nodes.

3:57

I can zoom in and we can start seeing

4:00

that they are cervical nodes.

4:01

So there are metabolically active or hypermetabolic, right?

4:07

And uh, I did you have the report? I did the SUVs.

4:11

How we do, you have to do a volume

4:13

of interest in our word and pet.

4:15

We don't do region of interest, we do volumes of interest.

4:18

Why? Because you report the maximum SUV, right?

4:22

So you, you have to encompass the whole lesion.

4:25

You have to go beyond the lesion, right?

4:28

Not, don't go, like some of my, my resident will go

4:30

to a lesion like this one for example,

4:33

and go here, do this wrong.

4:36

This vol, this volume of interest is not sufficient.

4:39

'cause you might be missing the hottest vox cell in

4:42

that lesion, right?

4:44

This is not the right way to draw a volume of interest.

4:47

Your volume of interest has to encompass the whole lesion.

4:50

See, go beyond it.

4:52

I don't care that it's, it's having some outside in the air

4:56

or in the soft tissue or in the muscle.

4:58

As long as it's not hitting a structure

5:01

that is hotter than my lesion.

5:04

So when you are close to the urinary pla, for example, close

5:07

to a ureter or a collecting system,

5:09

or if you are close to the myocardium

5:11

and the myocardium, that patient is very hot

5:14

and you think that that is gonna be hotter in than

5:16

in than your lesion.

5:18

You have to be cautious

5:20

because then this will shoot your s maximum SUV higher

5:24

than the lesion, right?

5:26

But in this case, there's nothing around my lesion that is,

5:30

sorry, I mean I did the fast scroll.

5:33

Nothing around this node that is hotter than it, right?

5:37

So I'm fine.

5:40

And then you scroll up

5:41

and down, make sure if you are not sure, you can always go

5:45

and do the coronal

5:49

and sagittal right?

5:52

To see

6:00

And, and you can see

6:05

where you are, right?

6:09

Here's that. And if you feel it's too big

6:12

or it's like not centered, you just like move it more

6:15

and just, and then this, this is your issue max.

6:19

So this is important.

6:20

I I'm, I'm glad that I remember to talk to you about that,

6:23

how to draw the regional interest

6:24

because it's one of the, even our resident all the time

6:28

I see the re volume of interest

6:29

and I tell them this is not, this is not sufficient volume

6:32

of interest, right?

6:33

And I measure because I ha I see what they reported

6:36

and I measure the UV myself and it's not right.

6:40

The number, the number is usually not sufficient.

6:42

So here is 4.5, for example, maximum CB, okay,

6:47

my way of reporting,

6:49

I'm not gonna hunt all these and report all these.

6:51

This is not right. Even when we do re uh,

6:56

for treatment response, you do two lesions per organs,

6:59

five lesions in the whole patient, right?

7:01

This is how you do racist or persist for pet.

7:05

Um, you don't hunt everything.

7:07

So what I say is you have to say, um, a sentence.

7:11

You, we we section neck, chest, abdomen, bel vest, right?

7:15

So you will, and then musculo skeleton

7:18

and our pet, uh, report.

7:20

So you will say a sentence about the cerv

7:23

cervical nodes to their arm.

7:25

Like let's say multiple, um, moderate

7:28

to intensely hypermetabolic.

7:31

I don't know how we um, how the depends,

7:33

I look more careful.

7:35

May maybe multiple line and large in the cer in the necks.

7:39

They're not really horribly enlarged in the neck.

7:42

Um, predominantly like maybe lift more than right?

7:46

If you wanna say it like that.

7:48

Lower cervical and ular lymph nodes, right?

7:52

And index nodes are, or examples are

7:54

whatever you, you prefer to say.

7:56

And then pick the hottest and the largest, right?

8:01

And if the hottest is the largest,

8:04

pick this one and pick the next one.

8:06

Two per section is more than enough

8:09

because if you do two per section, you will end up

8:12

with more than even what they need to know.

8:15

And then, so there are cervical bilateral, okay?

8:19

And so there are subra lab and there's infraclavicular

8:22

and going to the medias stem.

8:23

So there are, if you guys remember the um,

8:27

staging, okay, let me switch, um, zoom

8:33

'cause this is important for the lymphoma, the staging.

8:40

Okay, here's the staging

8:41

and this is in your slide, in your po the,

8:43

the slides I sent you, the work point I sent you.

8:46

Uh, this is the staging. If it's nodal only, right?

8:50

One nodal region and the nodal region is very specific.

8:54

What is the another region in lymphoma there is,

8:57

if you Google, um, I'm surprised I didn't include

9:00

that in the PowerPoint.

9:03

Another regions in lymphoma are very specific.

9:05

The the working group, the lymphoma work group.

9:08

Specify what, what do they, um, let me show you.

9:13

There are so many diagrams.

9:16

If you just Googled, I will show you one of them.

9:18

There are so many of them.

9:21

See this is the, another, another regions defined by the,

9:25

um, working group, informal working group.

9:28

Uh, this is the National Cancer Institute.

9:30

There is also the, um, uh,

9:35

my god, what is, what is it called?

9:37

The, um, cancer, oh my god.

9:39

The, the, uh, the big cancer situation that we always go,

9:42

uh, with their recommendations,

9:45

the you will have it everywhere, this different look,

9:49

but it's the same, um,

9:50

region showing you the same different diagrams.

9:53

So you will notice that the bul dire ring is one region.

9:58

The cervical node nodes are one region,

10:01

but till the sbra clef,

10:03

once it's into the infra clef infraclavicular,

10:07

it's a different region, right?

10:09

So sometimes I have nodes all the way to this area

10:13

and I start looking carefully,

10:15

is it including the infraclavicular region or not?

10:18

Because then it we're jumping into a different region.

10:21

And this why is it, why is it important? I'll show you.

10:25

Why is it important? Accelerate is

10:26

a different region, right?

10:28

Mid is the region, higher is a different region.

10:31

You'll notice that, right? Right.

10:34

Eular, um, is a region.

10:37

And then you like, you have to look at this

10:39

and this is available in,

10:40

like I said, lemme show you what I mean.

10:42

You go to the know the regions here just,

10:44

I just put in look what I put in the search.

10:45

Know the regions inform look how many,

10:56

see how many national, yeah, see

11:00

how many things you can see different

11:02

iation of the same diagram.

11:05

Okay, let's go back. Why is it important?

11:07

Because the staging one region is stage one.

11:11

We're talking about nodal only lymphoma, which is a lot,

11:14

most of the, most of the time it's gonna

11:15

be nodal only lymphoma.

11:17

No, the, not the disease.

11:19

Um, two, two regions at, no sorry,

11:22

any like multiple regions on one side of the diaphragm,

11:25

either above diaphragm only or

11:26

below diaphragm only is gonna be stage two, right?

11:31

No, the disease above and below diaphragm

11:33

becomes stage three.

11:35

And then disseminated disease is stage four.

11:37

This is how you stage lymphoma. It's as simple as this.

11:40

This is why defining the nodal region is important.

11:43

Because once you go beyond one region,

11:46

you jump from stage one to stage two.

11:48

Okay? Um, external nodal disease is different.

11:51

Once it's external nodal disease, you add add an E

11:53

to the stage to it's gonna be stage one E.

11:56

This means that you're defining

11:57

that this is external nodal lymphoma, not nodal.

12:00

And then one external,

12:02

one external site is gonna be stage one, meaning

12:05

that if you have, um, gastric lymphoma

12:07

and it's one gastric mass and this proven to be lymphoma

12:11

and there's nothing else,

12:13

this is gonna be a stage one external nodal,

12:14

like stage one E.

12:16

That's it. If it's a nodal disease

12:19

with extra nodal extinction, the disease extending into an,

12:23

um, external nodal site.

12:25

So a big nodal mass that is extending beyond the,

12:28

beyond the node into an external.

12:30

This is a stage two e rather than that it's called, it's,

12:34

it's considered ex disseminated disease.

12:36

If it's noted an external, it's considered dis stage four.

12:40

Okay? It's this, this is how simple is, is it

12:44

to stage lymphoma, right?

12:46

Let's go back to our case.

12:50

Um, okay,

12:54

now you're seeing the case again.

12:56

So these are, this is another nodal disease here in the

13:01

right here.

13:05

So what's happening here?

13:07

Nodal disease, multiple nodes, hypermetabolic,

13:11

definitely no nodal lymphoma, right?

13:17

Definitely multiple regions, right?

13:21

Let me go down quickly.

13:23

So these, what about this, this is important.

13:26

She is, let me tell you, give you some history

13:28

because I did include the history.

13:32

Where is it lymphoma? Is this the baseline?

13:39

Yeah, here, I think the age, she's young.

13:43

She's a young, um, female, obviously a young female.

13:47

Look at this, look at this here. This is physiologic, right?

13:52

What is it? Let me increase the map to look at it.

13:56

This is a memory gland uptake.

13:57

This is physiologic memory gland uptake in a young

14:00

female, right?

14:03

It's nice, it's beautiful, right?

14:05

I'm sure I included for you also, um,

14:07

because I see something here in the pelvis.

14:11

I didn't review this patient, but

14:13

before I, I talk to you guys quickly,

14:15

but I can, I can tell that this patient has,

14:17

this is a corpus UTM look at how beautiful is that?

14:21

These are all pitfalls.

14:22

These are, I have a dedicated lecture for my resident

14:25

that I only talk about PET pitfalls,

14:30

a dedicated lecture about this.

14:33

Why? Because you can call this cancer. Look how hot is this?

14:36

How is this? It's harder than the lymphoma looking

14:40

at the map, right?

14:45

No, this is the, no, this is, yeah.

14:47

You see what I was telling you

14:48

because my volume of interest is too big.

14:50

It hit the bladder. Look how hot is the maximum UV 165.

14:54

Come on F DG 1 65.

14:57

Yes, it goes that high, but FG never goes that high.

15:00

So it's obviously that my, um, volume

15:03

of interest is, is nonsense.

15:11

Do another more reasonable one.

15:16

It's 8.4, right? 8.4. It's hotter.

15:20

I showed you how hot was the volume.

15:22

But anyway, so this is a corpus ut right?

15:26

Because she's a young female.

15:28

And look at the endometrium, endometrial cavity I showed you

15:33

where it's

15:39

here.

15:40

See how beautiful see here in the pit only how it looks.

15:44

Nice here, look here.

15:50

So this patient is um, this is just, um,

15:55

no physiology, uh, um, activity in the, um,

16:02

um, endometrial cavity.

16:04

And there's a corpus based on the, um, depending on what,

16:09

what phase is this patient on in her menstrual cycle.

16:12

We see that in young patients.

16:14

When we get young patients in our suite, um, we are used

16:17

to see it and we don't over call it as cancer.

16:19

So you have to be aware of these pitfalls in, in, in bed.

16:22

And this is, I think what's really important is not

16:25

to call cancer cancer

16:26

because it's, everyone will call,

16:27

will call a hot lesion cancer.

16:30

It's important to recognize what is not cancer

16:34

and not over call it, right?

16:35

Okay. Um, the other thing is

16:37

that Hodgkin's lymphoma usually is a continuous disease.

16:40

So the disease here is in the mast.

16:41

It's not gonna have a mastin disease and boom, jump

16:43

and have a lymph node in the vis nonsense.

16:45

Hodgkin's disease doesn't work like that, right?

16:48

We know, we know that. We know

16:49

that Hodgkin's disease doesn't work like that.

16:52

Then, uh, the other thing I, I always comment, okay,

16:55

is there a, okay, let me open the chat box

16:59

because I don't have it open.

17:02

Oh, just not for you guys, it's not from me. But,

17:10

um, so the other thing I always tell my, my, um,

17:15

resident about is that, um, with lymphoma,

17:20

with hematology, cancers in general, uh,

17:23

don't use the word the term primary and metastatic

17:26

because I always tell them, okay, in lymphoma,

17:30

what is the primary side?

17:31

They say lymph nodes. Okay, what is the metastatic side?

17:35

Uh, lymph nodes already.

17:36

So lymph nodes are the primary AM metastatic side, right?

17:39

Okay, what about myeloma? What is the primary side?

17:41

What is the metastatic side?

17:43

So the, the, the thing is

17:45

that in hematology cancers there is no primary

17:47

with metastatic sites it's different.

17:49

So this is why the,

17:51

the hematologic cancers have their own terms,

17:53

so we should use their own terms.

17:55

So in lymphoma, there is no that an external nodal disease.

17:59

In myeloma there's medullary and extra medo disease.

18:02

We don't see a lot of leukemias,

18:04

but when we see them, usually they're looking into,

18:07

um, uh, transformation.

18:10

So we, again, we look in into middle

18:11

and extra disease as well.

18:13

So please be careful

18:15

and remember that when you see a hematologic cancer patient

18:19

in your suite, don't use primary the static

18:23

because this is the wrong term.

18:24

This means that you don't know what you're talking about.

18:26

It just gives the long impression

18:28

because, uh, this is another important thing,

18:32

just the terms you use.

18:34

And this is like you have to do homework, whatever you,

18:38

whatever cancer you're working with, okay?

18:39

So simply, I just, I don't wanna talk anymore.

18:41

In this case, I think this is the

18:44

getaway things you have to talk about.

18:46

Yeah, the other thing here is the bone marrow, right?

18:49

The last thing I wanna talk about here is the bone marrow.

18:51

Before you decide what is the stage of this patient,

18:53

you have to decide the bone marrow.

18:55

Remember, we, we talk, I i

18:58

I think we talked last time about that.

18:59

The two, the two parts that are

19:02

confusing is the spleen in the bone marrow.

19:05

Are they nodal or external?

19:06

Nodal, because the other sites are,

19:08

are known like lymph nodes or lymph nodes, right?

19:11

Liver is not extra nodal, stomach is extra nodal.

19:14

All the other sites are kidney.

19:16

Kidney is extra nodal, right? But what about the spleen?

19:19

Is it no external node? Spleen is a node

19:21

is a nodal disease side.

19:22

What about the bone marrow? Bone marrow is external.

19:25

So spleen is a big note, but bone marrow is external side.

19:29

Now if you look at the map here, you will de you'll re um,

19:34

notice that the bone marrow is hot, right?

19:37

But then let me lodge this, okay?

19:43

Now look here at the bone marrow,

19:50

it is,

19:58

and this is also in the slides I sent you guys.

20:01

There is diffuse uptake of the bone marrow.

20:05

This is bone marrow activation. This is physiology, Carla.

20:07

Why? Because usually these patients are on colon stimulating

20:11

factors, right?

20:12

To reserve their marrow

20:13

because the, the chemotherapy they get is very cytotoxic

20:16

and it, it really hurt the marrow part.

20:19

So they give, we give them,

20:20

they give them colon stimulating factors,

20:22

which cause marrow activation.

20:24

A lot of times it's even much hotter than that.

20:26

And you see that in the post-treatment scan.

20:30

And sometimes even they become upfront with this matter.

20:32

Like this patient is, this is a baseline scan.

20:34

He's not even an a colon stimulating factor yet.

20:38

Uh, but there is matter why,

20:39

because the patient is maybe anemic.

20:41

There's, there is any, any reason that have the marrow

20:46

work hard, hard will cause this diffuse

20:50

because the f DG is very sensitive.

20:52

It will will show you this diffuse uptake.

20:54

What is your clue? This this is the clue.

20:56

The diffuse homogenous uptake in the marrow means

21:00

that this is not infiltration.

21:02

This is activation.

21:03

See how beautiful is the marrow cancer is never

21:05

beautiful, right?

21:07

Can cancer is always ous and ugly?

21:09

This is a marrow activation.

21:11

So this is not marrow involvement. So what does that mean?

21:14

Does this is mean? This is why I look at the melot.

21:17

This means when you look here, you will realize

21:19

that all the size of disease are

21:22

multiple hypermetabolic nodes in the lower cervical

21:26

and mediastinal region, which means multiple regions

21:30

on one side of the diaphragm,

21:31

which make this a stage two nodal disease, right?

21:34

That's it. So this is the baseline.