0:04

So first thing you do is you have to,

0:06

and again, it's, uh, it's gonna be,

0:08

but this is in one case, it's, it is, um, both

0:13

baseline and treatment response, I think.

0:16

And the first thing I like to do is

0:18

to adjust my setting the way I like to look at it.

0:22

So what's the intensity? I like to look at

0:24

what is the color lookup table I like to look at.

0:28

A lot of people like to look at this hot metal

0:29

or hot iron, whatever, every software call it differently.

0:32

The the one that was there, this is what I like to look at.

0:35

It's just, it's gonna be your preference.

0:37

As long as it's, I don't like the steps,

0:39

so don't use the steps because it does exist.

0:41

Read differences sometimes to be careful.

0:44

Um, this is the baseline I will, um,

0:53

quickly, there's nothing in the brain,

0:55

so I'm not gonna go systematically.

0:56

Like I said, I'm just showing the findings.

0:58

I don't wanna take a lot of your time

0:59

because you already, we already are took a lot

1:03

of time in the lymphoma because lymphoma, there's a lot

1:04

of things to say about the lymphoma.

1:06

So this is ahead head and neck cancer patients, right?

1:09

Patient comes usually with big mass. It's the cervical mass.

1:13

Cervical node usually is the presenting, which is this one.

1:16

See, how big is this big necrotic lymph node here, right?

1:21

Here's the, here's damage. Big necrotic lymph node.

1:24

That is palpable, right?

1:25

This is the presenting usually,

1:27

um, symptom.

1:31

But then they look for primary side.

1:34

A lot of time we can find the primary side

1:36

here is the tonsor mass.

1:38

Beautifully seen here in the,

1:39

but only fo intensely hypermetabolic,

1:44

tonsor mass right here.

1:52

And then few smaller lymph node that are not

1:56

horribly directly active.

1:58

You'll talk about it.

2:01

Um, it's just one big intense level node.

2:04

This is, this is the sure metastatic noal

2:06

mass and then few other.

2:09

Remember these patients comes to us after biopsy already.

2:12

So maybe these lymph, this for example here,

2:17

it's mildly hypermetabolic has, has a fatty high oxide.

2:20

It may be just like reactive.

2:22

If no patient just went through biopsy,

2:23

you'll still mention it, but

2:25

you're not gonna go strong on it, right?

2:26

Other patients comes with, with multiple big,

2:30

obviously metastatic lymph node

2:32

and some of them comes with bilateral metastatic

2:34

lymph nodes, right?

2:38

This is the head and neck part.

2:45

And then you want to do,

2:48

and do you notice here toward the end of the,

2:53

um, volume, you have noisy, you,

2:55

you don't call anything at the last few frames here.

2:59

Why? Because it's the crystal, the end of the crystals.

3:02

That's it. It's not, it, it's very noisy.

3:04

It's very, these images are not,

3:06

you don't count on these images for diagnosis, right?

3:09

So be careful with this. Now let me, of course, don't forget

3:13

to look at the coronary and sagittal, you know,

3:16

I'm gonna gonna look at them just

3:17

because, um, the sixth time

3:22

I will just pull quickly the torso

3:35

for both studies.

3:50

That's obviously, there's nothing torso, right?

3:52

Just looking at the map again, you,

3:54

I you took your time looking at this case.

3:57

Nothing in the meb. This is a ureter.

4:00

This is your activity in the ureter

4:03

in both in the baseline and the post-treatment.

4:07

This, see this is, um, me again,

4:10

neuroactivation, you see that?

4:12

So this is miral activation.

4:26

This is just activity in activity.

4:28

You see that sometimes it's variable

4:30

how much inactivity even some patients have spares.

4:34

So we don't call it just

4:36

because we, you see a lot, a lot of inactivity in patients.

4:39

This is physiologic, this is not

4:41

worrisome, so don't worry about it.

4:44

And don't, don't over call the inactivity, right?

4:46

We have, I didn't, let me put back the,

4:51

because um, we have

4:55

to talk about the treatment response, right?

4:56

Patient had chemo radiation therapy, which most

5:00

of them do before surgery.

5:03

Even if they're planning for surgery.

5:05

Do chemo radiation first, right? And you see here,

5:12

see complete metabolic response.

5:14

Again, where is the activity?

5:17

Anything that goes to the level of the blood pool.

5:20

This is called complete metabolic response.

5:22

See the tonsil here, consular activity is gone.

5:25

Totally gone, right?

5:28

And even the node, the big node,

5:30

necrotic node is not activity.

5:32

The activity is similar to blood pool.

5:33

Here's where's the blood pool is the carotid

5:35

and jugular, right?

5:37

And here was where the necrotic node was. It's similar here.

5:41

If, if even this is the node, right? Here's the node.

5:45

It's similar to the carotid activity.

5:47

So it's similar to blood pool. Now let me put, uh, here,

5:51

here is the node similar.

5:53

There's no activity above the node.

5:56

So it's complete metabolic response in this patient right

6:00

after, um, accumulation.

6:02

Another point that is important

6:04

after radiation therapy, how much we recommend

6:07

that they wait three months.

6:09

We want 'em to wait three months

6:10

because radiation was a lot of inflammation.

6:13

And the inflammation, when they send them early,

6:16

sometimes you are flipping a coin.

6:18

Some patients will be able to assess response like this one.

6:22

But some patients, a lot of res, a lot

6:24

of inflammation, a lot of activity.

6:27

And when it's too close to radiation, completion

6:29

of radiation, I can't tell them whether this,

6:31

this activity is inflammation or residual disease.

6:35

So, I'm sorry, I say there's a lot of activity giving

6:39

that the patient recently completed a

6:41

radiation, I cannot tell.

6:43

And you have to repeat, you have

6:45

to do a short-term follow up

6:46

after proper period of, uh, time after completion.

6:52

So we still do it. Why we still do it?

6:55

Because sometimes they are taking the patient to the OR

6:57

and they want to see and they know

6:59

that in some patients they're not gonna be able to see.

7:01

But in other patients they will,

7:02

we will be able to tell them something.

7:04

So they are taking their chances.

7:06

So we still do it when they send the patient early,

7:08

but they know and we know

7:09

that sometimes we're not gonna be able to give them um,

7:12

a good opinion, right?

Wk 2, Case 3 - Review

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Interactive Transcript

Pro Tip: Click on a word in the transcript to jump to that point in the video

0:04

So first thing you do is you have to,

0:06

and again, it's, uh, it's gonna be,

0:08

but this is in one case, it's, it is, um, both

0:13

baseline and treatment response, I think.

0:16

And the first thing I like to do is

0:18

to adjust my setting the way I like to look at it.

0:22

So what's the intensity? I like to look at

0:24

what is the color lookup table I like to look at.

0:28

A lot of people like to look at this hot metal

0:29

or hot iron, whatever, every software call it differently.

0:32

The the one that was there, this is what I like to look at.

0:35

It's just, it's gonna be your preference.

0:37

As long as it's, I don't like the steps,

0:39

so don't use the steps because it does exist.

0:41

Read differences sometimes to be careful.

0:44

Um, this is the baseline I will, um,

0:53

quickly, there's nothing in the brain,

0:55

so I'm not gonna go systematically.

0:56

Like I said, I'm just showing the findings.

0:58

I don't wanna take a lot of your time

0:59

because you already, we already are took a lot

1:03

of time in the lymphoma because lymphoma, there's a lot

1:04

of things to say about the lymphoma.

1:06

So this is ahead head and neck cancer patients, right?

1:09

Patient comes usually with big mass. It's the cervical mass.

1:13

Cervical node usually is the presenting, which is this one.

1:16

See, how big is this big necrotic lymph node here, right?

1:21

Here's the, here's damage. Big necrotic lymph node.

1:24

That is palpable, right?

1:25

This is the presenting usually,

1:27

um, symptom.

1:31

But then they look for primary side.

1:34

A lot of time we can find the primary side

1:36

here is the tonsor mass.

1:38

Beautifully seen here in the,

1:39

but only fo intensely hypermetabolic,

1:44

tonsor mass right here.

1:52

And then few smaller lymph node that are not

1:56

horribly directly active.

1:58

You'll talk about it.

2:01

Um, it's just one big intense level node.

2:04

This is, this is the sure metastatic noal

2:06

mass and then few other.

2:09

Remember these patients comes to us after biopsy already.

2:12

So maybe these lymph, this for example here,

2:17

it's mildly hypermetabolic has, has a fatty high oxide.

2:20

It may be just like reactive.

2:22

If no patient just went through biopsy,

2:23

you'll still mention it, but

2:25

you're not gonna go strong on it, right?

2:26

Other patients comes with, with multiple big,

2:30

obviously metastatic lymph node

2:32

and some of them comes with bilateral metastatic

2:34

lymph nodes, right?

2:38

This is the head and neck part.

2:45

And then you want to do,

2:48

and do you notice here toward the end of the,

2:53

um, volume, you have noisy, you,

2:55

you don't call anything at the last few frames here.

2:59

Why? Because it's the crystal, the end of the crystals.

3:02

That's it. It's not, it, it's very noisy.

3:04

It's very, these images are not,

3:06

you don't count on these images for diagnosis, right?

3:09

So be careful with this. Now let me, of course, don't forget

3:13

to look at the coronary and sagittal, you know,

3:16

I'm gonna gonna look at them just

3:17

because, um, the sixth time

3:22

I will just pull quickly the torso

3:35

for both studies.

3:50

That's obviously, there's nothing torso, right?

3:52

Just looking at the map again, you,

3:54

I you took your time looking at this case.

3:57

Nothing in the meb. This is a ureter.

4:00

This is your activity in the ureter

4:03

in both in the baseline and the post-treatment.

4:07

This, see this is, um, me again,

4:10

neuroactivation, you see that?

4:12

So this is miral activation.

4:26

This is just activity in activity.

4:28

You see that sometimes it's variable

4:30

how much inactivity even some patients have spares.

4:34

So we don't call it just

4:36

because we, you see a lot, a lot of inactivity in patients.

4:39

This is physiologic, this is not

4:41

worrisome, so don't worry about it.

4:44

And don't, don't over call the inactivity, right?

4:46

We have, I didn't, let me put back the,

4:51

because um, we have

4:55

to talk about the treatment response, right?

4:56

Patient had chemo radiation therapy, which most

5:00

of them do before surgery.

5:03

Even if they're planning for surgery.

5:05

Do chemo radiation first, right? And you see here,

5:12

see complete metabolic response.

5:14

Again, where is the activity?

5:17

Anything that goes to the level of the blood pool.

5:20

This is called complete metabolic response.

5:22

See the tonsil here, consular activity is gone.

5:25

Totally gone, right?

5:28

And even the node, the big node,

5:30

necrotic node is not activity.

5:32

The activity is similar to blood pool.

5:33

Here's where's the blood pool is the carotid

5:35

and jugular, right?

5:37

And here was where the necrotic node was. It's similar here.

5:41

If, if even this is the node, right? Here's the node.

5:45

It's similar to the carotid activity.

5:47

So it's similar to blood pool. Now let me put, uh, here,

5:51

here is the node similar.

5:53

There's no activity above the node.

5:56

So it's complete metabolic response in this patient right

6:00

after, um, accumulation.

6:02

Another point that is important

6:04

after radiation therapy, how much we recommend

6:07

that they wait three months.

6:09

We want 'em to wait three months

6:10

because radiation was a lot of inflammation.

6:13

And the inflammation, when they send them early,

6:16

sometimes you are flipping a coin.

6:18

Some patients will be able to assess response like this one.

6:22

But some patients, a lot of res, a lot

6:24

of inflammation, a lot of activity.

6:27

And when it's too close to radiation, completion

6:29

of radiation, I can't tell them whether this,

6:31

this activity is inflammation or residual disease.

6:35

So, I'm sorry, I say there's a lot of activity giving

6:39

that the patient recently completed a

6:41

radiation, I cannot tell.

6:43

And you have to repeat, you have

6:45

to do a short-term follow up

6:46

after proper period of, uh, time after completion.

6:52

So we still do it. Why we still do it?

6:55

Because sometimes they are taking the patient to the OR

6:57

and they want to see and they know

6:59

that in some patients they're not gonna be able to see.

7:01

But in other patients they will,

7:02

we will be able to tell them something.

7:04

So they are taking their chances.

7:06

So we still do it when they send the patient early,

7:08

but they know and we know

7:09

that sometimes we're not gonna be able to give them um,

7:12

a good opinion, right?

Report

Clinical Indication:
Recently diagnosed right tonsillar invasive squamous cell carcinoma P 16 positive. Presenting for staging and initial treatment planning.

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

Comparison/Correlation:
--

Findings:
Technical quality: -------.
Measurements: Unless otherwise specified, all SUVs refer to maximum value in the target and all CT linear measurements are performed on axial.
Reference: mean SUV liver: ----

Head and Neck:
Intensely hypermetabolic right tonsillar mass without significant contralateral extension, poorly delineated on non-contrast images with maximum SUV 16.2, extend superiorly close to the soft palate.
No evidence of significant base of tongue invasion.
Intensely hypermetabolic right level II and III cervical adenopathy, including partially necrotic lymph nodes, consistent with biopsy proven metastatic squamous cell carcinoma. Index nodes are:

Right level II cystic or necrotic nodal mass measuring approximately 4.2 x 3.6 cm with maximum SUV 13.5.
7 mm right level III lymph node with suspicious FDG uptake for size, maximum SUV 2.7.
Sub-centimeter contralateral left lymph nodes without significant FDG uptake, likely reactive.

Chest:
No suspicious hypermetabolic lesions in the chest.
No suspicious pulmonary nodules or masses.
No suspicious focal consolidation. Benign calcified granulomas.
No FDG avid mediastinal or hilar lymph nodes.
No pleural or pericardial effusion.
Sequela of prior granulomatous disease.
No suspicious esophageal activity.
Normal caliber of the thoracic aorta.
Three-vessel coronary artery atherosclerotic calcification.

Abdomen and Pelvis:
No suspicious hypermetabolic activity 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.
Cholelithiasis.
No hydronephrosis.
FDG non-avid exophytic hypodense left renal lesion incompletely evaluated on this study. Nonspecific perinephric stranding.
Unremarkable spleen.
No suspicious adrenal masses.
No suspicious pancreatic findings.
GI Tract/Mesentery/Peritoneum:
Postsurgical changes from bariatric surgery.
Physiologic bowel activity, without suspicious focal FDG uptake. The large and small bowel appear normal in caliber.
Colonic diverticulosis.
No suspicious peritoneal/mesenteric findings.
Lymph Nodes: No pathologically enlarged or hypermetabolic lymph nodes in the abdomen or pelvis.
Pelvic Viscera: Unremarkable.
Vasculature: Normal caliber of the abdominal aorta.
Free Fluid: No ascites or drainable fluid collection.

Skeleton and Soft Tissues:
No suspicious hypermetabolic activity in the visualized osseous structures.
No aggressive osseous lesions.
Degenerative changes throughout the spine.
Straightening of the cervical, thoracic, and lumbar spine. Anterior bridging osteophytes throughout the thoracic spine.
Bone-on-bone endplate changes and vacuum phenomena at all 3-L4 and L4-L5.
No suspicious FDG avid soft tissue nodules.
No axillary or inguinal adenopathy.

Impression:
1. Intensely hypermetabolic right tonsillar mass consistent with biopsy proven squamous cell carcinoma. No evidence of significant contralateral extension.
2. Intensely hypermetabolic right level II and III lymph metastatic adenopathy, including lymph nodes with central necrosis or cystic transformation.
3. No evidence of metabolically active distant metastatic disease.

Clinical Indication:
Head/neck cancer, assess treatment response. 57-year-old male with history of Stage I (cT2, cN1, cM0, p16+) status post right partial tonsillectomy (September 21, 2021) and adjuvant chemoradiation completed 3 months prior

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

Comparison/Correlation:
--

Findings:
Technical quality: -------.
Measurements: Unless otherwise specified, all SUVs refer to maximum value in the target.
CT linear measurements performed on axial images.
Reference: mean SUV liver: ----; previously: ----.

Head and Neck:
No suspicious hypermetabolic activity in the head or neck.
Postsurgical treatment changes of post right partial tonsillectomy and chemoradiation. No suspicious FDG uptake within the surgical bed.
Interval complete metabolic resolution with significant decrease in size of the previously seen intensely hypermetabolic necrotic right cervical level IIA lymph node, which measures 20 x 8 mm, compared to 50 x 35 mm.
Complete resolution of previously seen hypermetabolic level III lymph nodes.
Ventricles and sulci are normal in size.
No acute large cortical infarct, intracranial hemorrhage or large mass on this noncontrast study.
No significant soft tissue swelling is present.
No calvarial destructive lesion or fractures.
Bilateral maxillary sinus retention cysts.
Mastoid air cells are clear.

Chest:
No suspicious hypermetabolic activity in the chest.
Central airways are patent.
Heart normal in size. Mitral annulus calcification.
Three-vessel calcified coronary sclerosis.
Aorta is normal in caliber and course. Main pulmonary aorta is normal in caliber.
Calcified left hilar lymph nodes.
No suspicious pulmonary nodules.
Small subcentimeter right fissural nodules.
Bilateral dependent atelectasis.
Patulous fluid-filled upper and mid esophagus.
Small sliding hiatal hernia.

Abdomen and Pelvis:
No suspicious hypermetabolic activity in the abdomen or pelvis.
No focal hypermetabolic activity in the liver significantly greater than the heterogeneous physiologic uptake.
Physiologic bowel activity, without suspicious focal FDG uptake.
Prior gastric bypass surgery.
Gallbladder contracted.
Normal liver, spleen, pancreas, adrenal glands, and kidneys.
Nondilated small and large bowel. Normal appendix.
Nondistended urinary bladder.

Skeleton and Soft Tissues:
No suspicious hypermetabolic activity in the visualized osseous structures.
No aggressive osseous lesions.
Reversal of the cervical spinal lordosis with apex at C5.
Mild thoracic dextroscoliosis with apex at T5.
Lumbar levoscoliosis with apex at L2.
Multilevel spondylotic disease with degenerative disc space narrowing, endplate sclerosis, vacuum phenomenon, Schmorl's nodes, and marginal osteophytosis.

Impression:
Findings consistent with complete metabolic response:

1. Posttreatment changes post right partial tonsillectomy and chemoradiation with no suspicious FDG uptake within the surgical bed.
2. Interval complete metabolic resolution with significant decrease in size of previously seen hypermetabolic metastatic right cervical level II and III lymph nodes.
3. No evidence of metabolically active distant metastatic 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

Course

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Wk 2, Case 3 - Review