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Wk 3, Case 5 - Review

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0:04

Same thing.

0:05

And I don't know why didn't use one case for both staging

0:08

and treatment response assessment,

0:09

but give you the same flavor.

0:12

This is the same thing.

0:14

Um, baseline,

0:18

trying to see what kind of cancer was ba tho carcinoma.

0:24

This, this time is different.

0:25

Look at this big and speculated intensely hypermetabolic.

0:30

I'm not gonna change the color just

0:31

for you guys to see a different color.

0:34

This is the basic color that everyone usually like to use.

0:39

Mm-Hmm. Um, right. Look at this.

0:42

It's big intensely hypermetabolic

0:46

speculated I would describe it, I think, right?

0:50

This is the primary site. It's very hot this time.

0:54

Then there are multiple metastatic acceler lymph nodes,

0:58

level one, two.

1:03

I don't think there is level three,

1:09

but there is, let's see what is this?

1:13

There's super time

1:17

we talk about this.

1:18

So makes it N three B.

1:22

There is right

1:29

internal memory lymph node, right?

1:33

There's another, um, noal

1:38

reason that is known

1:41

for the breast cancer that lost to go to internal memory.

1:49

There's some hyder, some inflammatory hy

1:52

medicinal lymph node.

1:53

It looks like some

1:58

are ified like we talked about.

2:03

We have the OMA disease. We always have it here.

2:14

But you see here, these two,

2:21

this is internal memory.

2:26

This one here,

2:33

yeah, this one, two internal memory lymph nodes as well.

2:38

So multiple auxiliary scle and internal memory reports.

2:47

Okay? Now when we look at, um,

2:50

the treatment response assessment, then let's go

2:55

to here.

3:01

I like to usually, I,

3:03

I look at the only images all the time as you guys know it.

3:06

Just for the sake of time here,

3:08

because we're just looking at findings.

3:10

I, I know you already looked at the cases.

3:13

So you have to go from top again, all the way down

3:16

the top is the, of course, um, the,

3:20

the more recent image and the bottom is the baseline.

3:25

And just, just one second. They're not synced, right?

3:38

You realize that all the activity

3:40

that we see in the bottom is gone.

3:43

Nothing is above blood pool level, right?

3:47

And then I'll show you the fuse to look at the lesions.

3:53

Nothing is about blood pool right now.

3:58

Let's go back to the image. Go up here.

4:03

Here's the primary side. Look here.

4:05

It's the shrink

4:10

and there's no activity about blood

4:13

pool level in that there.

4:15

And all the lymph nodes, they decrease in number,

4:21

the, you know, metabolic activity is gone.

4:24

And even many of them I don't see at all.

4:28

And the ones I see, they are like extremely smaller, right?

4:32

Plus the most important thing is our most powerful thing is

4:36

that the, a DG uptake is gone.

4:38

It went down at least to this pool level, right?

4:43

And when you look here in the map, make map eight,

4:48

it just, you can see

4:51

that all these black dots are gone.

4:54

So this is completely in this patient.

4:59

After neoadjuvant therapy,

5:06

um, it was ER positive,

5:09

or sorry, er negative, uh,

5:14

ER v weekly positive

5:16

and cin, she had seven cycles of TCHP.

5:24

So she just had, um, chemo therapy, just

5:30

so this is of course, um, new adjuvant,

5:32

like we just were talking about.

5:34

This is just new adjuvant therapy

5:37

before they take her to surgery.

5:41

That's amazing response. Complete metabolic response.

5:44

And you can see here that see the bone marrow activation,

5:50

the bone marrow is hot, but it's homogenously hot.

5:52

So this is just bone marrow activation. That's it.

Report

Technique:
Preparation: Last oral intake (except water): ----- at -----.
Blood glucose at time of FDG administration: ----- mg/dL.
Radiopharmaceutical: ----- mCi of F-18 FDG administered IV at -- via ----.
Uptake time: ---minutes.
Oral contrast: -----.
Positioning: Arms raised.
PET/CT scanner: -----.
PET/CT acquisition: skull-base-to-mid-thighs.
PET reconstruction method: Point Spread Function-Time of Flight (PSF-TOF), 2 iterations, 21 subsets, with and without CT-based attenuation correction.
Standardized uptake value (SUV): Corrected for BW or LBM.
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.


Head and Neck:
Solitary intensely hypermetabolic 10 x 7 mm left supraclavicular lymph node, maximum SUV 6.2.
No other suspicious hypermetabolic lesions in the head or neck.
Unremarkable thyroid gland.


Breast:
Intensely hypermetabolic large lobulated infiltrative left upper outer quadrant breast mass measuring 6.6 x 3.5 x 5.2 cm with maximum SUV 18.6 consistent with biopsy proven invasive ductal carcinoma.
Multiple intensely hypermetabolic metastatic left axillary and left internal mammary lymph node. Examples are:

12 x 26 mm with maximum SUV 13.1.
10 x 13 cm sub-pectoral/level II axillary lymph node, maximum SUV 8.3.
Small 7 x 6 mm let internal mammary lymph node maximum SUV 4.3.
Chest:
No suspicious hypermetabolic lesions within the chest.
No suspicious pulmonary nodules or masses. No large areas of focal consolidation.
Dependent hypoventilatory changes.
Paraseptal emphysematous changes.
Stable heart size and caliber of the major vessels.
Mild aortic and multivessel coronary artery atherosclerotic calcification.


Abdomen and Pelvis:
No suspicious hypermetabolic activity in the abdomen or pelvis.
Solid Abdominal Organs:
Hepatic steatosis.
No focal hypermetabolic activity in the liver significantly greater than the heterogeneous physiologic uptake.
Unremarkable noncontrast appearance of the liver.
Normal gallbladder.
No hydronephrosis.
Unremarkable spleen.
No suspicious adrenal masses.
No suspicious pancreatic findings.
GI Tract/Mesentery/Peritoneum:
Physiologic bowel activity, without suspicious focal FDG uptake.
The large and small bowel appear normal in caliber.
Sigmoid diverticulosis.
No suspicious peritoneal/mesenteric findings.
Lymph Nodes: No pathologically enlarged or hypermetabolic lymph nodes in the abdomen or pelvis.
Pelvic Viscera: Unremarkable uterus and ovaries.
Vasculature: Extensive aortoiliac atherosclerotic calcification.
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.

Impression:
1. Intensely hypermetabolic large lobulated infiltrative left upper outer quadrant breast mass, consistent with biopsy proven invasive ductal carcinoma.
2. Multiple intensely hypermetabolic metastatic left axillary, left internal mammary and solitary left supraclavicular lymph nodes.
3. No convincing evidence of metabolically active distant metastatic disease.

Technique:
Preparation: Last oral intake (except water): ----- at -----.
Blood glucose at time of FDG administration: ----- mg/dL.
Radiopharmaceutical: ----- mCi of F-18 FDG administered IV at -- via ----.
Uptake time: ---minutes.
Oral contrast: -----.
Positioning: Arms raised.
PET/CT scanner: -----.
PET/CT acquisition: Vertex-to-mid-thighs.
PET reconstruction method: Point Spread Function-Time of Flight (PSF-TOF), 2 iterations, 21 subsets, with and without CT-based attenuation correction.
Standardized uptake value (SUV): Corrected for BW or LBM.
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.


Head and Neck:
No suspicious hypermetabolic lesions in the head or neck.
No suspicious cervical adenopathy.
Thyroid gland is unremarkable, without suspicious FDG uptake.


Breast:
Complete metabolic resolution with significant decrease in size of previously seen intensely hypermetabolic large lobulated infiltrative left upper outer quadrant breast mass, currently measuring 1.5 x 1.1 x 2.2 cm (AP x TRA x CC) with maximum SUV 1.7 (similar to background breast tissue), previously measuring approximately 6.6 x 3.5 x 5.2 cm with maximum SUV 18.6.
Complete metabolic resolution with significantly interval decreased number and size of previously seen numerous left axillary, left internal mammary and solitary left supraclavicular lymph node. For example:

Largest left axillary lymph node on comparison study measured 12 x 26 mm with maximum SUV 13.1, now measures 7 mm in maximal dimension without discernible FDG uptake.
Complete resolution of previously seen 1.3 x 1.0 cm sub-pectoral lymph node, previously showed maximum SUV 8.3 in prior scan.
Chest:
No suspicious hypermetabolic lesions within the chest.
Right middle lobe peri-fissural 5 mm nodule with trace FDG uptake likely infectious or inflammatory given absence on prior PET/CT.
No suspicious pulmonary nodules or masses.
No large areas of focal consolidation.
Dependent hypoventilatory changes.
Multiple new small to borderline mild to moderately hypermetabolic mediastinal and bilateral hilar lymph nodes, an example is the Subcarinal lymph node measuring 9 mm with maximum SUV 3.6.
Stable heart size and caliber of the major vessels.
Mild aortic and multivessel coronary artery atherosclerotic calcification. No abnormal esophageal activity.


Abdomen and Pelvis:
No suspicious hypermetabolic activity in the abdomen or pelvis.
Solid Abdominal Organs:
No focal hypermetabolic activity in the liver significantly greater than the heterogeneous physiologic uptake.
Unremarkable noncontrast appearance of the liver.
Normal gallbladder.
No hydronephrosis.
Unremarkable spleen.
No suspicious adrenal masses.
No suspicious pancreatic findings.
GI Tract/Mesentery/Peritoneum:
Physiologic bowel activity, without suspicious focal FDG uptake.
The large and small bowel appear normal in caliber.
No suspicious peritoneal/mesenteric findings.
Lymph Nodes: No pathologically enlarged or hypermetabolic lymph nodes in the abdomen or pelvis.
Pelvic Viscera: Unremarkable uterus and ovaries.
Vasculature: Extensive aortoiliac atherosclerotic calcification.
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.

Impression:
1. Complete metabolic resolution with significant decrease in size of previously seen intensely hypermetabolic large lobulated infiltrative left upper outer quadrant breast cancer with no residual FDG uptake above background breast tissue.
2. Complete metabolic resolution with significantly interval decreased number and size of previously seen numerous left axillary, left internal mammary and solitary left supraclavicular lymph node.
3. New mildly hypermetabolic mediastinal and bilateral hilar lymph nodes most consistent with sarcoid like reaction to immunotherapy.
4. No convincing evidence of new metabolically active 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

Tags

PET/CT FDG

PET

Nuclear Medicine

Female Breast

CT

Breast