0:04

Let's start with the first case.

0:05

It's a multiple myeloma patient.

0:07

You already saw the cases, so there's nothing blinded

0:09

Or anything.

0:10

Um, this is, um, this was a multiple myeloma patient

0:13

coming for, um, initial staging.

0:16

Um, as you see here in this patient, um, I,

0:19

as I always tell my, um,

0:21

and again, I'm not gonna go through my search pattern today.

0:25

Um, we're just going through the findings.

0:27

Uh, so I'm not gonna go systematically,

0:29

although I always go systematically when I, when

0:31

I look at my cases, um, as you see here,

0:35

we starting there is finding here for collectivity

0:39

and, um, I'll put it in a, in a bone window.

0:43

There's a litic lesion here in the skull.

0:48

And if I put it in a soft tissue window,

0:50

you can obviously see that there is a soft tissue component

0:53

that is extending out to thecal,

0:56

but also it has, um, an extra axial

1:00

and intercranial, extra AAL extension.

1:03

I will put it in a brain window.

1:08

It's not the best brain window you can have.

1:11

'cause the CT here is like a one kernel ct.

1:15

So it's not the best CT for the brain, right?

1:19

It's trying to manually make it there.

1:21

It's not helping much. This is the best I can show you.

1:26

But see there is here a soft tissue component

1:29

that is extending intracranial,

1:31

but I think it's, look, it's obviously extra axial, right?

1:35

So there's a soft tissue component of that lytic lesion,

1:38

which, which is typical for multiple myeloma, right?

1:41

This is the first one,

1:42

and I can show you the, let's put the volume of interest

1:47

here, right?

1:54

Like I told you before, for clinical use,

1:56

you wanna make your volume of interest the biggest you can,

2:00

but make sure that you're not including something

2:02

that might be hotter than your lesion.

2:03

Because we report the max UV, right? The SUV max.

2:06

So I'm gonna take it away from the cortex

2:08

because the cortex might be hotter than my

2:10

lesion, although I don't think so.

2:11

But see, I'm scrolling up

2:13

and down, making sure that I'm not touching the cortex

2:18

and oh, I always can go corona

2:19

and to make sure that I'm out.

2:21

It's kind of 7.9 near the max SUV, right?

2:25

You, you notice that I have in mind I can display more.

2:28

I have the peak, the means and the vision.

2:30

I have others, but we report in the clinical report,

2:33

the max, the SUV max, right?

2:36

I'll go down more in the axi.

2:39

You always have to look at the brain.

2:41

Like I said, I'm not gonna go systematically,

2:43

but quickly through

2:48

the pet only image, which I always depend on a lot,

2:56

all you see is basically

2:59

skeletal findings.

3:01

See here and this rep, right?

3:07

Yeah. So you guys can see it.

3:10

I, I know that you guys went through these cases.

3:12

These were last weak cases.

3:15

Again, it's a,

3:19

it's a bone lesion with a soft tissue component.

3:23

Ative, some areas it's a,

3:25

it's an obvious litic destructive lesion

3:27

of the soft tissue component.

3:29

In other areas, it's more of permi, right?

3:32

This most eaten how you describe it.

3:35

See here, you have to zoom in to be able

3:37

to see the abnormality, the bone abnormality you see here,

3:41

it's not the obvious litic destructive,

3:43

but it's obvious that the bone is abnormal, right?

3:46

So really this is a bone lesion

3:47

with a soft tissue component.

3:49

It's not a subpleural or pleura based, um, lesion.

3:53

It's not a long lesion. Let me put it in a long window here.

3:57

So look here. See, it's not a long nodule. It is not.

4:02

It is actually a bone lesion with soft tissue component.

4:07

And this is important to determine in a multiple myeloma.

4:11

Why? Because multiple myeloma lesions are either middle

4:15

or extramedullary lesion.

4:17

And it's important to decide on this patient,

4:19

are all these lesions gonna be middle only or there is mid

4:23

and extra medullary?

4:25

This is important in their staging.

4:27

And it's, so Im important to emphasize this

4:29

and I, I always tell that to my president

4:33

'cause they always do this mistake.

4:34

They still use primary

4:36

and metastatic terms in, um,

4:39

myeloma and in lymphoma.

4:41

And these are the two that we see a lot.

4:43

We don't see leukemia a lot in our, uh, pet suite

4:46

because leukemia is considered low grade for us.

4:49

So re rarely we would see them coming through our suite.

4:53

Um, so what is the point I'm making here?

4:56

I'm making the point that

4:59

primary metastatic disease are not valid terms

5:02

in lymphoma and myeloma.

5:05

And you have to think about it for a second.

5:07

If you think about myeloma, what is the primary site?

5:10

And if you tell me, well,

5:12

bone marrow is the primary site, okay?

5:14

Bone marrow is the primary site.

5:15

What is the metastatic site? In the myeloma disease?

5:20

There's no metastatic, right?

5:21

Because hematologic malignancies are different than

5:25

the rest of malignancies.

5:26

There's no primary metastatic.

5:27

So they have, we, we have our own terms when we talk about

5:31

hematologic cancers.

5:32

So we need to use their terms, right?

5:35

So the terms we use here in myeloma is medullary, intary,

5:40

and extramedullary, right?

5:41

Or medullary and extramedullary patients.

5:44

Um, in lymphoma we use nodal and extra nodal disease, right?

5:47

So just use their terms in your reports.

5:51

Never say primary metastatic disease.

5:53

When you talk about, um, a myeloma patient,

5:56

a lymphoma patients, even if it's a negative scan,

5:58

don't say, okay, there is no f dg avid primary metastatic

6:02

disease in the myeloma or lymphoma patients.

6:04

It just doesn't look right

6:07

and it makes you look like you

6:08

don't understand what you're talking about.

6:10

This is my advice, okay? So coming back to the patients.

6:14

So in, in a, in a lesion like this, it's easy

6:17

for you when you're looking like on, on, um,

6:20

on the point in the long window

6:22

or the soft tissue window to say, okay,

6:23

is this a pleural based nodule?

6:26

Don't look carefully

6:27

because this will put it in an extra medullary lesion

6:31

category and this will stage the patient differently.

6:34

So make sure, and in this lesion too, make sure that,

6:37

is this a bone lesion or is this really a long lesion?

6:41

Okay? Again, this is another

6:45

litic lesion, right?

6:49

And like I said

6:50

before, you already went through this whole patient,

6:53

the whole case,

6:55

and you just figured out that all these lesions are

7:00

just here.

7:02

Look how here, put this one here. TIC lesion here.

7:05

That is ly active. This is the uter.

7:12

You have to make sure it is the uter. Just follow it up.

7:16

This there, right? So this isn't, there's no problem.

7:19

It's not a lymph, it's just David.

7:22

So all the lesions in these patients are,

7:29

um, bone lesions, right?

7:31

I'm looking at bladder

7:33

and there's nothing suspicious here.

7:37

It's just like some, um, bladder neck funneling

7:40

that we sometimes see or there's maybe, I don't remember.

7:44

There's something in this.

7:56

I'll just go slowly and make sure what are we seeing?

7:58

Because there's some budding here

8:00

and the, it's just how the most probably it's how the

8:06

bowel is sitting on the semi empty bladder.

8:10

Just put it in a different orientation and go there.

8:16

I'm sorry it's a little bit slow

8:17

because I have like four cases open.

8:20

So single here is gonna be slower than normal.

8:23

See how, how it is looking in the sagittal, see this

8:29

here, the in the bowel is sitting on the bladder,

8:34

making the bladder look kind of concave, right?

8:37

This one, this is why when you look axial,

8:40

it looks like there's focal connectivity here,

8:42

but it's not focal connectivity, it's just

8:43

the bladder, right?

8:44

You just confirm that this is what it's, okay.

8:47

So this lesion, this patient has numerous metabolically

8:50

active medullary,

8:51

but plate lesions with soft tissue,

8:53

some are some which is the larger,

8:54

larger ones have soft tissue components.

8:57

All this has been lower disease, right?

9:01

And then some incidental findings, right?

9:04

And I'm not gonna go over the incidental findings.

9:06

You know how to report incidental CT findings

9:08

and we do report the CT findings, of course.

9:10

Um, the important other point I always make in these cases

9:14

is that there's no evidence

9:17

of metabolically active extramedullary disease.

9:20

This is it because this is important in the stage.

9:24

That's it for this multiple myeloma patient

9:26

because this was an interest staging, um, patient.

9:29

And of course if you look here at the map,

9:33

although there is diffuse in this patient,

9:35

there is diffuse bone marrow activation as you see here.

9:37

There's diffuse homogenous bone marrow activation,

9:39

but it's obvious that is in the, there's a background

9:43

of bone marrow activation, but there's also disease, right?

9:48

It's obvious. This is what we always say.

9:50

We can tell when there is a bone marrow involvement on top

9:55

of the bone marrow activation, right?

9:59

So there's a difference between the look of involvement

10:02

or infiltration and activation.

10:04

There's a difference. And we can tell when there is

10:07

both in the same patient.

10:08

And you can see here how there is bone marrow activation

10:12

and infiltration in the same time, right?

10:15

It's obvious in this patient, right? It's beautiful, right?

10:20

I don't think there's anything else in this patient that is,

10:22

um, significant.