0:04

So the first case was a, a guest case or just case.

0:08

Um, and it was biopsy proven.

0:10

So it's as usual for pet coming for staging.

0:14

Uh, so you know, the type,

0:16

but sometimes we get cases where, uh, there's a mass, um,

0:20

they know or they think it's malignant, sending it for, um,

0:24

further characterization and staging.

0:27

And we get the chance to, you know, pro brainstorm

0:31

and give the French shell.

0:33

And we usually have fun with these cases,

0:36

but this is not the, the case most

0:38

of the time, uh, as you know.

0:41

So, um, as we always say, I'm not gonna go

0:46

with my regular standard, uh, search,

0:49

but I never look my, at my cases like this.

0:52

I always go systematic. I always go the way I do it.

0:55

This is so important in the geology.

0:57

I cannot emphasize it enough.

1:00

You have to always follow your system.

1:02

All you will, you will miss a finding.

1:05

Uh, if you don't go systematic, uh, especially we in pet,

1:10

we have sometime a lot of times cases with so many findings

1:13

that lights up like a Christmas tree and you get excited

1:16

and you go after, oh, look at this.

1:18

Oh, look at that. Oh, look at this.

1:19

And then, um, the satisfaction of the search kicks in

1:25

and you feel, okay, I find

1:27

I found enough findings in this patient and you conclude

1:31

and then, um, you missed findings

1:33

and sometimes, uh, findings

1:34

that you missed are really, really important.

1:37

Uh, so, um, you have to go systematic.

1:40

But these sessions are sessions just

1:44

to show you the findings

1:45

and explain it and answer your questions.

1:47

So, um, I'm not going systematic in my, in these cases,

1:51

so I don't want to give you the wrong impression

1:52

that this is how I look at my case.

1:54

This is not how I look at my case, right?

1:57

So, um, this, there is here the primary lesion, an ex vedic

2:02

mass, which is typical for G it's usually, um,

2:05

solid or necrotic.

2:06

Um, not, that's not what I mean,

2:08

but they are usually mass arising from the stomach.

2:11

Um, hypermetabolic, a lot of times they are exo,

2:15

um, uh, masses.

2:18

And then, um, in this case, this is a really necrotic, um,

2:23

uh, mass as you see,

2:25

but the, the viable peripheral part

2:27

is really intensely hypermetabolic, right?

2:30

Uh, it's not scrolling easily, I dunno why.

2:34

Um, and that's it, right?

2:39

For it. Another finding you see in here is when you scroll

2:43

through the, okay, you have to look,

2:44

okay, this is a gastric mass.

2:46

So the, the next thing I look at,

2:48

I look carefully at not only the per aortic

2:51

or two cable, you know, lymph nodes in the al

2:54

that we will always look at.

2:55

I look carefully around the stomach, right?

2:58

Because this is regional for this area.

3:01

I look at also the gastro hepatic area here.

3:03

Is there a small lymph node that might be hypermetabolic

3:06

but maybe not intensely hyperbolic, maybe still small,

3:09

too tiny below bit resolution.

3:11

So it's really mildly avid, which would be significant.

3:14

So I zoom in, I look at bit only carefully,

3:17

but I also look at the fuse damage.

3:19

So I'm looking for a lymph node in this region here, right?

3:24

Very carefully. Is there something I might miss if I look

3:26

like, you know, superficially

3:28

and go over it, you have to look carefully

3:32

for these lymph nodes, right?

3:34

There's a lymph node that passed

3:35

but it didn't look suspicious.

3:36

There's no activity whatsoever, right?

3:40

So you go carefully around these areas.

3:43

So always depending on where is the cancer, you have you,

3:47

you do your first look, but then you go back

3:49

and look carefully at the regional lymph node for this area.

3:53

Make sure that you're not missing a lymph node, right?

3:57

And then in the pre aortic area, there is nothing,

4:00

there's nothing, the mis enteric nodes,

4:04

there's nothing suspicious.

4:06

Neither hypermetabolic

4:08

nor uh, anatomically right in the city.

4:11

'cause we read the city too. There's nothing there, right?

4:15

Then let's go back because

4:17

after I look at this, I look at the liver.

4:19

Now looking at the pit only you will notice first the

4:23

patient had her arms down,

4:25

which we usually like the arms up.

4:28

This causes a lot of problem to us, right?

4:31

As you see, this is a noisy liver.

4:33

There's a lot of, um, noise signal

4:36

to noise ratio is not good.

4:39

What this is causing, this is causing that.

4:41

You see all these flicks here, look, this, what is this?

4:44

Is this a lesion or this is just noise? I dunno.

4:49

'cause you go like this and there's many of them.

4:52

Am I, am I gonna call all these

4:54

the static disease in the liver?

4:56

I can't 'cause this can be simply just noise, nothing.

5:01

But when I blow up this, uh, me image

5:06

and scroll, some of them really stand out.

5:09

Like this one here, it stands out.

5:12

I can see it and appreciate it. I cannot ignore it.

5:15

So, so I mentioned it in the report.

5:18

I say there are few scattered, subtle focal, uh, FDG

5:24

activity or uptake through the liver, similar to,

5:29

uh, the level of the, you know, noise.

5:33

What, just where I'm attention followup exams.

5:36

I don't call it metastatic disease yet,

5:38

but I bring it to the attention.

5:41

So next time this patient will get a PET scan,

5:45

my colleague will see my, my command

5:48

and look at this area very well.

5:51

Hopefully next time the patient will bring the arm up

5:55

and either

5:56

This will go away because this was noise, nothing.

5:59

And next time my colleague will look and see nothing

6:01

and say, well, the usually like if I'm reading the next

6:05

scan, what I would say is that what I would say?

6:08

It's not that. We'll ignore it. Ignore it totally.

6:10

Even if I see it, I will still talk about it

6:11

because it was mentioned in the prior report.

6:14

So you have to address it in the the next report.

6:18

You have to say, well,

6:19

or this is my opinion at least I'm just presenting

6:22

to you my, um, professional opinion.

6:25

I would say the, the scattered FCI

6:28

of activity described in the previous report are not

6:31

appreciated in the current report, likely represented, um,

6:35

technical image noise or something like that.

6:37

An artifact or an artifact. And I move on.

6:40

So why are we, why am I doing this first?

6:43

Because I am telling who, like the referring physician that

6:48

I know that there were foci that were mentioned before.

6:53

Because simply you might, didn't you,

6:56

you might ignore the prior report.

6:58

You were busy, you had a busy list,

7:00

and you just didn't look at the prior scan

7:02

or the prior report and you looked at this, right?

7:05

If you don't mention it, most time, most

7:08

of the time people think you don't know about it, right?

7:12

People, you, you don't assume that if you don't mention it,

7:14

it means that it's not there.

7:17

Not necessarily. Maybe you don't know about it,

7:19

maybe you didn't know that they saw it,

7:21

so you didn't look for it.

7:22

So you have to mention it.

7:24

So you tell them, I know about it.

7:26

I saw the Briar report, I saw the briar, um,

7:29

you know, documentation of it.

7:31

I look for them, they are not there. They were our artifact.

7:35

Have a peace of mind. This is nothing. The liver is clean.

7:38

So this is my approach.

7:40

So anything that was mentioned in the previous report,

7:44

I address it in my report and tell them what was it, right?

7:47

It resolved.

7:49

And this means that it was an infection

7:52

or it was a, it doesn't have, doesn't mean it'll make it

7:55

to my impression even if it wasn't the impression last time,

7:58

because last time they were worried about it.

8:00

This time it's not in my impression,

8:02

but it's in the body of my report.

8:04

So if the re referring physician was worried about this foy

8:07

last time, this time in the follow

8:09

up, he's not gonna find it.

8:10

In my impression. He will dig in my report

8:13

and find that I talked about it in the liver, right?

8:16

This is my, um, opinion. Um, that's it.

8:20

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

8:22

that worth incidental findings.

8:25

You have to talk about it of course

8:28

because we report everything with radiologist

8:31

and nothing else I think in this patient.

8:34

Um, worth discussing.