0:04

Now let's look at the post treatment, which is case,

0:08

the second case today.

0:11

And to look at the BA post treatment, you have

0:13

to look at them side by side.

0:15

You can't look at post-treatment alone.

0:16

You have to look at them in comparison.

0:20

And this is what we are doing now, see what I told you, the,

0:24

the baseline now is in the bottom

0:26

and that post-treatment treatment scan is in the top right.

0:30

And I think this was a mid,

0:32

this was even a mid treatment, not a post treatment.

0:36

One second, let me,

0:42

um, I think it was a mid treatment scan,

0:44

if I'm not mistaken.

0:47

I can, I can't tell you exactly what was it

0:51

after just two, two cycles of, uh, chemotherapy

0:55

and see how beautiful is that the treatment?

0:57

Let me go back up. You have to go up

0:59

and I will put it on bit only.

1:03

Of course, you look at the bit only image

1:06

and show you the

1:11

ano first, where we talk about

1:16

ve the five scale, VE or I call it Lugano just

1:19

because they met again in Logano

1:21

and they had a new, they had a new, um, release

1:24

of updating the, the staging and everything.

1:26

And they, it, they call it Luo

1:28

because it's, it's the updated version.

1:30

So you can call it VE or logano, whatever you call it.

1:32

It's the, it's the same scale.

1:34

So let me show you,

1:36

and again, it's in your syllabus, it's very easy.

1:40

Um, I will show you the scale

1:43

and I will show you, I'll tell you how simple it is

1:46

to remember it.

1:48

So see, this is it. So basically what are the reference?

1:51

This is important. The background.

1:52

The background is the background muscle, the background, um,

1:56

fat, the background, okay?

1:58

And then you have the medicinal plot.

2:01

Pool is the second, and then you have the liver.

2:06

Okay, so you compare the site

2:10

of disease to the, at the baseline,

2:14

to the post-treatment scan.

2:15

And then the hottest residual activity,

2:19

is it up to background?

2:21

If it's up to background, it went down to that.

2:25

It's just nothing up to background. So it's a one.

2:27

If it's up to the blood pool, it's two.

2:31

If it's up to the liver, it's a three, right? That's easy.

2:36

If it's above the liver, it's gonna be four or five. Okay?

2:41

What is, what decide four

2:42

or five, four is just mild to moderately above the liver.

2:46

Five is basically plaque intensely hot, right?

2:50

Then it,

2:51

it will be depending on are we mid treatment or end of treatment.

2:55

So 1, 2, 3 is considered complete metabolic response, right?

2:59

Four five are gonna be depending on are we met treatment

3:03

or end of treatment.

3:04

If we are met treatment

3:06

and there was significant decrease in f DG uptake,

3:09

but there's still residual disease that is hot, we know

3:12

that this is a chemosensitive, um, tumor lymphoma.

3:15

And by the end of treatment, hopefully it will be gone.

3:20

If we are at the end of treatment, it's not the case.

3:23

This means this is a refractory disease and,

3:25

and the patient will need to have another,

3:27

a second line treatment, right?

3:29

So it, the, the four five is usually depending on

3:31

where are we in the treatment.

3:33

Okay? So you guys, I wanted to show the slides,

3:37

which is this one here when I was talking, but, so,

3:42

but you have it in your, all this is in,

3:44

in your syllabus already.

3:45

Uh, these are sent to you.

3:47

So you have this, this is what I was talking about. Okay.

3:52

All right. Now let's go from top again.

3:54

So baseline is the bottom

3:56

and post-treatment scan is the top right.

3:59

And I'm going slowly

4:00

and I'm looking at the size of, um, disease in the prior

4:05

and looking in

4:07

the post-treatment.

4:11

And whenever I am not sure, I said, well,

4:14

you are seeing only one monitor,

4:16

but I have two monitors, right?

4:17

I have, so I can see the, when I see something here

4:20

and here, and I can see is this a lymph node

4:22

that would happen to the lymph node.

4:23

I can show you also what I can do is I can do this

4:27

and we can see what is the side of disease.

4:29

But to really judge, is it similar to Blackpool liver?

4:33

You have to look at the pit only.

4:35

You have to look at the pit only, right?

4:37

Um, and looking through the disease,

4:47

going slowly here.

4:52

See, how beautiful is that?

4:54

And I'll show the, the city and the fuse after,

4:56

after we go through the peton.

4:58

See, see how much disease was here?

4:59

And look here you have thesal blood pool

5:03

and look, nothing above them, just no blood pool.

5:06

And when you look on the bottom, these were sites

5:08

of disease, right?

5:10

By the way, some of this was thymus like this, this,

5:13

you see this smooth wing gly, this is the thymus.

5:17

So above these nitrogenous heart, this are,

5:21

this is disease, right?

5:24

But when I go down here, this is the ths.

5:27

But anyway, I didn't wanna confuse you

5:29

because it's too hard to see for you.

5:31

And it doesn't matter the baseline

5:33

because the baseline, there's, there was disease already, so

5:36

it didn't matter to anyone

5:37

that the ths was also a little bit hypermetabolic.

5:40

But see, all the disease compared the bottom, I'm going up

5:44

and down for you guys to see that all the disease,

5:47

the bottom is gone.

5:48

Now let show you.

5:57

Now look, look here for example, in the salary notes,

6:02

look here, some of them are totally gone, some

6:05

of them shrink and it's not activity.

6:11

Look at that. Look at the, so

6:14

how I de describe its complete metabolic resolution

6:17

with significant decrease in number and size, right?

6:20

So how we, how I

6:21

and all they care about in the lymphoma, um,

6:26

oncology people, the medical, the medical oncology people,

6:28

they care about the metabolic activity

6:29

because some of this disease, the in the city,

6:32

the the no are gonna stay there.

6:34

There you, there will be always disease to measure on city.

6:39

But the FDG pet

6:41

what will tell them whether this disease is gone

6:43

or not really, it's okay.

6:46

Um, so and then if I zoom in here,

6:49

and then the other thing that is important is,

6:51

is there any new sites

6:53

of metabolically active disease in this scan?

6:55

Because anytime there's a new site of metabolically disease

6:59

that you think it is lymphoma, this is a five.

7:01

It doesn't matter how hard it's as, as long as it's f dg,

7:05

avid side that is new in this scan

7:08

and you believe it is a lymphoma, this is a five, right?

7:11

If it's a new site, you don't know what it is.

7:14

You are not sure it's lymphoma

7:15

or not lymphoma, maybe infection,

7:16

maybe lymphoma, I don't know.

7:18

You give it an x, X means I don't know, right?

7:23

And you need to follow this up or you know, watch it

7:26

or something, right?

7:27

Because there's an X also in the,

7:29

in the dove slash ano, right?

7:32

So in this patient, there's nothing,

7:33

and you'll notice that this is also gone the physiologic

7:36

because it depends, this corpus tmm is, is,

7:39

is depends on the phase, which phase we were in the

7:42

menstrual cycle and even the endometrial activity

7:45

cooled down, right?

7:46

You see, because it depends on the phase.

7:49

Like this one was in um, November 11th.

7:53

This is, it depends on the face

7:55

of the, of her menstrual cycle.

7:57

The other thing is look how much hotter is the bone marrow?

8:02

Because this was a baseline prior to treatment.

8:05

Now she's on treatment and they are giving her

8:07

the colon stimulating factor.

8:08

So now the marrow is much more stimulated, right?

8:12

But still it is marrow activation,

8:15

it is not infiltration.

8:18

And this is of course, um, injection side activity.

8:22

All this, you have to know

8:24

that this is nothing to worry about.

8:27

And this is, um, complete me

8:29

of response case And the mid treatment

8:32

after two cycles by the fourth cycle patient was complet

8:35

public response.