0:04

So this patient is history who recently diagnosed

0:08

with colon cancer and, um, coming for staging.

0:13

Okay, so let's start with the primary side.

0:18

I just agree the transparency of pet

0:20

because I don't like, um, background, my background to be,

0:23

um, colorful.

0:25

I don't like that. This

0:30

so nice mass.

0:31

Look at that. See how focal connectivity look at,

0:36

even in the, in the map, that's why we,

0:39

when we see focal connectivity in the bowel, it's always,

0:41

even if I don't, we don't see mass, most of them.

0:43

We don't see a mass in the ct,

0:46

but doesn't matter, we don't have to see a in the ct.

0:48

This is extremely suspicious for cancer

0:51

and we ask for a colonoscopy all the time in this patient.

0:54

Actually I can see Ms. Look at that. How beautiful is this?

0:59

It's a large colon cancer here.

1:03

Our value is not the T classification.

1:05

This is not what we do. Our value is the n

1:07

and n classification.

1:09

This is why they send these patient to us.

1:11

And in this patient we see ver lymph node, right?

1:18

And me enteric actually also see

1:21

what about this here?

1:26

Yeah, one, two.

1:28

And in the GI system you will realize that um,

1:32

in the staging of the GI system, number

1:34

of lymph nodes is important.

1:36

They like to stage the patient

1:37

with a lymph node number, interestingly, right?

1:42

So the three and the seven is always playing a good role on,

1:45

uh, the staging.

1:47

Let me show you this. So how many can we count

1:51

with this patient

2:04

from least like maybe three at least a month?

2:08

I think more than three. Looking here in the map,

2:13

you have to make sure that none, none of this is the ureter

2:16

of course, but look at this, you have this

2:19

and you have another one above it.

2:20

So these are two, not one.

2:21

And you have like this, maybe this and this.

2:24

See all these, but also look at this and look at this.

2:28

So this is muscle of course,

2:29

nicely see shown mu muscle uptake.

2:32

But what about these two? So let's go there.

2:39

The cover is that, okay?

2:44

This is a left supraclavicular lymph node,

2:46

the vecal node, right?

2:49

This is the metastatic for sure

2:51

because we know that the GI likes to go

2:53

to the metastatic.

3:00

This is one and there's another one here. Okay?

3:03

Why is this important? This is important

3:05

because there is something called regional

3:07

and non regional lymph nodes,

3:08

nodal metastasis in any cancer.

3:11

And this is an important concept I want you guys to,

3:13

um, know about.

3:15

Let me minimize this

3:17

because I wanna bring something else in here.

3:23

This is a lecture I give to my president.

3:27

So staging in pet, our value oncology,

3:31

of course I talking about oncology,

3:33

our value is always, uh, staging, right?

3:36

T we really have a revalue in the T part of the

3:40

classification, but in the n and m we are very valuable.

3:42

So it's always important to have our eyes on the, the n

3:46

and m part of the classification.

3:48

Um, I never really sit and memorize them,

3:52

but I repeatedly bring them up and look at them.

3:55

And when you look at them multiple times,

3:56

you start remembering them important parts of them.

3:59

And this isn't the colon cancer,

4:00

the colorectal cancer classification.

4:03

Um, right?

4:04

So, and and like I told you in the,

4:07

generally in the elementary tract,

4:09

it's the number of lymph nodes, right?

4:11

So three and seven are the two numbers I remember.

4:14

So N one is 1, 2, 3, regional, you will,

4:18

you will recognize the word regional lymph nodes, right?

4:22

N one is one to three, um, regional lymph nodes, right?

4:26

And they would give you an exceptions, right?

4:28

And then in two is four, right?

4:32

Um, just into four or more regional lymph nodes.

4:36

Uh, and then they, they do put um, into A and into B. Okay?

4:41

But there's something else

4:42

that is more imp that is very important.

4:45

We're talking about regional lymph nodes, right?

4:47

But then what I want you to look at is this.

4:53

Uh, where is next one here? M1 B.

4:58

So sorry, M1 A, M1 a.

5:00

What qualifies somebody to M1 A?

5:04

Um, where did it go?

5:12

Thats it says here the star. You see the star, okay.

5:17

Non regional lymph, okay,

5:19

this is what I want you to look at.

5:21

So anytime there is metastas to non regional lymph node,

5:25

although it's still a lymph node, it becomes an M1, A M1 a,

5:29

which is stage four, right?

5:31

So what's the non-original lymph

5:32

or basically what's the regional lymph node?

5:34

So then we know what's a non here is the regional lymph node

5:37

or colorectal cancer, right?

5:40

Okay. It describes it, right?

5:42

Um, outside of the drainage area of the tumor,

5:46

which is not found along the vascular arcade

5:48

of the marginal artery preco lon per recal me rectal nodes

5:53

should be considered the stems.

5:55

Here's the, here's the, the diagram.

5:58

Just we are, we are images, we are radiologists, right?

6:01

We're more visual people.

6:03

For me, I see it, I know it keep putting like paragraphs

6:08

of of text, it just doesn't stick to my head.

6:10

Show me a picture. I know it. Here's the picture.

6:13

See here it outside of this,

6:19

it is non regional,

6:20

which makes the supraclavicular node non regional,

6:24

which brings us to our case here.

6:27

Let us go back to our case here.

6:31

So this patient, although all we see in this patient is a

6:34

primary site and metastatic lymph node, he's a stage four

6:39

just because of the scl.

6:41

See, okay, this is what I wanna make sure.

6:44

So in each cancer there are regional nodes

6:47

and there are non regional nodes.

6:48

So just keep in mind that you need to be aware of

6:51

what is regional and what's non regional nodes

6:54

to this specific cancer

6:55

because it's important

6:57

to tell them when there is metastatic node in the non

6:59

regional area, it's important

7:01

to them in the staging of the patient.

7:06

Yeah, there is absolutely, absolutely. The I agree.

7:08

The, um, I see in this,

7:10

in the said you all use the term oli metastas as referred

7:13

to in the discussion of this case

7:15

as we don't find the type No, no, it is who who, why do you,

7:19

why do you think it's not helpful oligo metastasis?

7:21

It is, it's been around for more than 10 years I think now

7:23

and we recognize the oligo metastasis

7:25

and there are patients with actually not only, no,

7:28

there are patients with distant metastasis

7:30

and we do surgical, uh, intervention to them, right?

7:33

The re what is the value of oligo metastasis?

7:35

The value of oligo metastasis previously when,

7:37

whenever we say stage four, this means this patient is non

7:41

uh, surgical, right?

7:42

Isn't this the old, um,

7:46

the old school thinking anytime a patient is stage four,

7:50

this means this patient is nonsurgical, right?

7:52

This is what we used to say this,

7:54

this patient is non-surgical, not anymore.

7:57

It's been around for a long time now.

7:59

Um, oligo metastasis means that

8:07

we yeah, yeah, yeah, yeah, yeah.

8:09

We do, we do see, yeah, we do see SBR lymph nodes

8:12

with no liver, with no dis mets.

8:14

Yes we do. Absolutely.

8:16

Absolutely because it's known especially for GI mes

8:19

and not only gi for other meds, this is a draining node,

8:23

a draining, uh, site, uh, lymphatic site.

8:26

So we see that often.

8:28

Um, and it doesn't mean

8:29

that this patient is on surgical, it doesn't.

8:31

Plus now there is new adjuvant therapy.

8:33

You start with the new adjuvant therapy

8:36

and then you turn a patient into a surgical picture

8:39

and there are patients with liver met with one

8:41

or two ary metastatic, metastatic lesions of the liver.

8:44

We do micro uh, we do uh, micro ablations

8:47

for example, right?

8:49

You do you we do directed therapy to the liver

8:52

and then they do, uh, debulking.

8:54

There are so many, there's a lot of patients now

8:57

that are uh, metastatic and we do, um, they go go in

9:01

and do surgery and during the surgery they do treat

9:05

directed therapy to the liver mets during the surgery.

9:10

Uh, no, this is definitely metastatic.

9:12

Do you have any doubt that this per clavicular lymph node,

9:15

you, you, you're asking would you biopsy

9:17

that rac clavicular node?

9:19

The question means that you're not sure

9:21

that the supraclavicular node is metastatic.

9:23

Am I correct? Is is, isn't this what you're asking about?

9:26

Would you biopsy it because you're not sure

9:27

it's metastatic or not correct?

9:30

This is your question, correct. Do you, do you doubt

9:33

that this RAC node is metastatic?

9:41

I would biopsy if I'm not sure, but I'm not sure.

9:43

I'm sure this is the study.

9:45

Okay, so why would you biopsy

9:46

it? What's the reason to biopsy?

9:50

Uh, high prof? Yeah, thank you so much.

9:52

Um, sometimes the oncologists, uh, might not be convinced

9:56

that, uh, we've often been caught out

9:58

with the dual pathology, especially head

10:00

and neck tumors, uh, uh,

10:05

that are sub centimeter in size,

10:07

especially squamous cell carcinoma.

10:09

Uh, and then, uh, in event of the probability

10:14

of it is keeping the livers, keeping the lung

10:16

and then finding a SEP rhythm lymph, no,

10:18

then generally the drainage of the head

10:20

and neck tumors will go there.

10:21

So sometimes they're often asked to to biopsy it.

10:24

That's the only reason why I asked that question.

10:27

And then in terms of oligo metastasis,

10:28

the oncologists don't like that term

10:31

because it just means little metastasis

10:33

and when it comes time for, for funding, um,

10:36

for a review pet, then, uh, it doesn't help,

10:40

uh, their cause. Thank you.

10:42

Alright, so two, you,

10:44

you mentioned two things, two separate things.

10:45

First, this is an expected metastas

10:47

for this, for this patient.

10:49

I agree with what you're saying when I, I myself, okay.

10:52

I have other cases where, um, the,

10:55

the pattern doesn't match, for example, interpreted, uh,

10:59

hot interpreted nodule, right?

11:01

In a patients with gynecological cancer, right?

11:04

For like, um, cervical cancer

11:07

and maybe like whether there is nodes in the pelvis or not,

11:10

and nothing that interprets me, right?

11:13

Do do you do, can you picture this right?

11:16

Uh, cervical cancer, maybe pelvic lymph nodes,

11:20

no ilia cor aortic lymph nodes, right?

11:23

Not, it's not, I'm not talking about tub clavicular even I'm

11:25

talking about intra nodes.

11:27

Cool. You did you, can you picture this?

11:31

Alright, I personally wouldn't call this

11:35

intra a metastatic.

11:37

I wouldn't, I would call this favors introverted blsm such

11:42

as polymorphic, um, adenoma.

11:46

Right? Why? Because like what you're saying,

11:48

this pattern doesn't match, it doesn't make sense that this,

11:53

that the, that the cervical cancer would jump

11:56

to the intra lymph node without tracking all the way.

12:01

I agree. We are the doctors of patterns.

12:05

I don't wait for the surgeons to tell me that

12:07

what you're saying doesn't make sense.

12:08

I make sense of my image before he says it.

12:12

I even, I'm the one who always in the tumor board tell them,

12:15

well guys, wait a minute, this doesn't make sense.

12:18

This node doesn't make sense

12:20

to be metastatic from this cancer.

12:23

When, when there is no intervening nodes, I am the one

12:26

who says that, I don't wait for him to say that,

12:29

but this node makes sense to be metastatic

12:32

because the, this is called the node.

12:34

No, this is a known drainage nodes

12:38

for the GI cancers.

12:40

It makes sense. Look at the map, right?

12:44

So this is, this is a different situation, right?

12:47

You have a colon cancer with metastatic retro al

12:51

and mesenteric nodes and the supraclavicular node.

12:53

This is absolutely a log, a logic situation.

12:59

It's different than what we're de what you're describing.

13:03

And lymphatic metastasis is a root

13:06

and hematogenous metas metastasis is a different root.

13:10

I don't need, uh, lung

13:12

and liver metastasis to see lymphatic metastasis.

13:15

These are two different root of metastasis, right?

13:17

Hematogenous versus lymphatic. These, these are not linked.

13:21

Sometimes I have a primary cancers with liver mets

13:25

and not a single lymph node.

13:28

They don't come sequential.

13:30

The patient doesn't have to have lymphatic metastasis

13:32

before he has hematogenous metastasis.

13:35

Nope, he doesn't because sometimes the primary sites start,

13:39

um, invading and um, uh, eroding capillaries

13:43

and hit the bloodstream

13:45

and boom, he goes to the, to the, you know, organs

13:50

before even he hits the lymphatics, right?

13:55

Okay, perfect. Exactly The colon cancer.

13:58

And you don't have to have lymphatic metastasis

14:00

before you have hematogenous metastasis.

14:02

You don't have to have that. I, I really do have patients

14:06

with primary side liver mets and maybe sometimes lung

14:10

or bone mets without lymphatic metastasis.

14:13

You do, you can have that because these are two separate

14:15

routes of metastasis.

14:17

They happen independently, right?

14:20

But lymphatic metastasis are predictable except in one

14:25

situation, if there is violation of the meta

14:27

of the lymphatics, meaning if this patient had uh,

14:30

lymph lymphatic dissection, they did surgery

14:34

and they did lymphatic dissection, once they do that,

14:37

they violated the lymphatic system.

14:39

Then eight, we see atypical lymphatic, uh,

14:42

metastasis happening.

14:44

Then we see like lymphatic mes going to weird locations

14:48

and you cannot say, oh, this doesn't make sense anymore

14:51

because they violated the lymphatic system.

14:53

Then it can throw mes somewhere that you don't expect.

14:56

But as long as this is a native lymphatic system

14:59

that wasn't touched, it's predictable

15:02

where it should go first before it goes next.

15:04

And the sub lab clavicular node,

15:06

node is an expected metastatic, uh, site for this cancer.

15:12

So this makes sense. It's not unpredictable.

15:15

The nobody, a GI oncologist is not gonna object to you

15:18

and say, okay, it doesn't make sense.

15:19

No, they won't ask for biopsy, I promise.

15:21

We have tumor boards too. We discuss these cases.

15:24

So they don't only, only look at our report,

15:26

plus they call us on our reading rooms

15:28

and they discuss these cases with us

15:29

and they come to our reading rooms.

15:31

So we're not hiding in, um, in rooms anymore.

15:34

They don't only see our reports, they know us

15:36

and they call us all the time we discuss these patients.

15:38

Nobody will ask for biosis for this

15:40

and this, uh, the look of this node, see

15:42

how it's surrounded, how hot it is.

15:45

There is no need for biopsy. This is assure metastatic node.

15:50

I don't need to biopsy this node. No, it doesn't matter.

15:54

Five. I don't have myself,

15:56

I don't like even when resident ask me these questions,

15:59

I don't like this threshold for SUVs, right?

16:01

Because SUVs is different. You use, if you use,

16:04

do you use body weight normalize SUV V

16:06

or do you use limb body mass?

16:07

Normalized SUV. The is the, the level

16:10

of SUV is gonna be different based on that, right?

16:12

The scanner, like how, how do you like, you know, the,

16:15

the techniques, do you weigh your patient

16:18

or do you ask the patient you shouldn't ask your patient The

16:20

weight should weigh your patient, right?

16:21

Technical. Yeah. Uh, yeah, exactly.

16:24

So I'm not asking you specifically,

16:26

but what I'm trying to say is that lean body mass,

16:29

normalized SUVs are lower than body weight

16:31

and I believe, I believe they are the better ones.

16:34

Although, although I couldn't move us to them yet.

16:37

I still, we still use the body weight

16:38

normalized, although I hate it.

16:40

Um, but lean body mass normalized, uh, SUVs are better.

16:45

Um, and we can have another session just to talk about that.

16:49

Um, but what I'm trying to say is that it's the,

16:52

it's the context, right?

16:54

SUVs just crude UV is not numbers, is not,

16:58

how big is this node?

16:59

If the node is, um,

17:02

five millimeter node, right?

17:05

But it's rounded, it's, it's in the right location

17:07

and it's, it's 2.5, right?

17:11

I might call it suspicious node. I don't care.

17:14

It didn't hit your threshold, right?

17:17

So it's, it's the context.

17:19

I don't, I'm not a big believer of a an SUV threshold

17:23

and I don't, I never give an SUV threshold to anyone.

17:26

It's a context of what are you looking at?

17:29

What type of cancer are we talking about?

17:32

What pharmaceutical are we talking about?

17:34

There's a lot of factors that feed into the SUV, right?

17:38

So you're talking about

17:43

SUV we less than five and background of previous,

17:48

what is CBNA?

17:49

I'm not previous tb.

17:53

What's cb what, what is that?

17:57

Which is prevalent in,

18:04

I'm sorry.

18:04

I'm not the best person with acronyms,

18:07

so I'm not sure what I understand.

18:08

What is this cubicle which is prevalent

18:12

in, is it Saudi Arabia?

18:14

sa South Africa? Okay. No, no, no, no, no. Please.

18:20

Um, no tuber closes is is still prevalent in many places.

18:24

Um, this is what I'm saying.

18:26

This is what I'm saying exactly.

18:28

Um, all your concerned

18:32

that this is infection just one lymph node in the sub

18:35

clavicular and the lungs is clean and nothing in the hilum

18:38

and nothing in, you know what I mean?

18:39

Again, the context, this is what I'm saying.

18:42

No calcification, nothing in the lungs,

18:45

nothing in the hilum, just one

18:48

s supraclavicular lymph node in the context of a, um,

18:50

metastatic colon cancer into the,

18:53

to the, you know what I mean?

18:55

Wouldn't this be unlikely to be tb? What do you think?

19:01

Okay. Yes. But why would be this supraclavicular node hot

19:05

from TB while everything else is called the,

19:10

the context would be this is a metastatic lymph node with

19:14

a patient with old heeled TB

19:20

or old, um, granulomatous disease.

19:23

We, what we have here in, in the states more is, um,

19:26

histoplasmosis for example, we have a lot of patients

19:29

with tr uh, granulomatous disease.

19:32

Histoplasmosis is one of them.

19:33

Sarcoidosis is more prevalent than TB here, for example.

19:37

And we have a lot of patients, I have a lot, many

19:39

of my patients have calcified, um, lung modules, uh,

19:43

I mean calcified to um, granulomas

19:46

and um, calcified, uh, lymph nodes as well.

19:49

But these are burned out lymph

19:50

nodes and they have their patterns.

19:52

Okay? Okay. We agree.