0:04

So the next one was the sarcoma,

0:06

the pediatric sarcoma patient.

0:08

And there are so many sarcomas.

0:10

All of them are usually aggressive, high grade,

0:14

which means they are usually, uh, a t

0:18

Here's the sarcoma patient, um, pediatric patient.

0:23

Um, I think this patient was like 16, 17-year-old.

0:27

Um, again, he, they come with not always, a lot

0:30

of times they already are.

0:33

Um, have the diagnosis. Okay?

0:35

You will look through, look through the map. Of course.

0:37

What are these? These are the seal plates, right?

0:40

These are the growth plates.

0:41

We know that if you don't know it, fine.

0:45

Anytime you have something nice, nice zoom in, bilateral

0:50

symmetrical, this cannot be cancer.

0:53

First of all, you have to think to yourself that this, some,

0:56

this is something that has to be physiologic, right?

1:00

Or uh, least inflammatory, right?

1:03

This cancer is not that beautiful and not that symmetric.

1:06

There's no way cancer can, can look like that.

1:08

So this is growth plate. We know that.

1:10

Then the next thing is here, let's, let's move.

1:13

I'll talk about the pitfalls first,

1:15

and then we'll talk at the cancer.

1:16

About the cancer. Lets look at this.

1:18

You have this, and this is something you would see a lot in

1:23

pet and especially we're starting winter,

1:27

like starting cold weather.

1:29

We, we already started seeing that in our pet suites,

1:31

and there are ways to deal with this,

1:34

but we usually do it for PS patient.

1:36

PS meaning like you're talking about a five-year-old

1:39

six-year-old, 7-year-old usually don't do it

1:42

for somebody who's like older, uh, like 19, 18,

1:46

we don't do it for them, right?

1:48

Which we give petta blockers most of the time.

1:50

Most places give petta blockers, right?

1:52

To control what this is.

1:53

An activated brown fat having antabolic brown fat, right?

1:57

This is your, again, you look at this, you know,

2:01

people will think lymph nodes, come on, look at this.

2:04

How beautiful is that? It's bilateral, symmetric.

2:07

It's like a meta image. It's gonna be cancer, right?

2:11

But cancer, even when it's bilateral,

2:13

it's not that symmetric.

2:14

It's never not that nice symmetric

2:16

and, you know, going smooth.

2:18

So you have to think about something else.

2:20

And this pattern, like bilateral neck, tubular region,

2:25

accelerated lesion region.

2:26

And then you see this, this is in the intercostal space.

2:30

This is not in the ribs.

2:31

This is the inter, the, the medial intercostal space.

2:34

And then these, especially

2:37

because it's very extensive in p you'll see it in the sup in

2:40

the media, severe mediastinal region.

2:42

You will see it here in the cost, cost of, uh, cost of, um,

2:46

cardio schizophrenic region.

2:47

You will see it in the senal, even like,

2:49

I think this patient have it in cd focal activity.

2:52

This is not meds. This is activated brown fat.

2:56

And the ine lesion also in the cross section. All

2:58

This, all these likestyle activity are

3:01

Actually activated brown fat.

3:03

So this is old seed. This is all brown fat.

3:07

All these activity are brown fat.

3:09

And you can just confirm that through going through the

3:13

cross-sectional images.

3:15

And it's all fat.

3:16

It's challenging in a lot, in a lot of patients,

3:19

especially when you have a lymphoma patient

3:21

and you wanna assess the lymph nodes.

3:23

And then the lymph nodes is, is living

3:24

where the brown fat activation is,

3:26

and then you can't, you know, differentiate the activities.

3:29

This brown fat activity or this lymph node.

3:31

It's, it becomes sometimes challenging.

3:33

So, and, but know that there are a way

3:35

to suppress the brown fat activation, which is the,

3:37

it's, the technique is very easy.

3:38

You just give petta blockers the day off,

3:40

you bring the patient an hour earlier,

3:42

give petta blocker, warm the patient.

3:45

And um, of course you have to keep your eye on the,

3:48

the heart rate of blood pressure

3:50

because you know,

3:51

petta blockers can get the patient into Brady.

3:53

Uh, Brady can easy, uh, ready bradycardia.

3:58

So, because when I used to do this, we used

4:01

to do it in pediatric patient also.

4:02

So we, we have to, to have, uh, uh, close,

4:05

they are under observation

4:07

and we look at their heart rates, uh, frequently, make sure

4:12

that they're not getting into bradycardia And look at

4:15

their blood pressure.

4:16

But we were doing it and we didn't have any

4:18

problems with it.

4:21

Um, so know that you can do that.

4:23

Now, let's go back to the,

4:24

and of course, and we talked about this.

4:26

This is infiltration. Look, this is, well, it doesn't have

4:28

to be like, it's not significant infiltration

4:30

because we all know how, how much the

4:35

activity blooms, right?

4:36

So even a little bit of activity can look like a lot, a lot

4:39

of this activity is actually not in the patient.

4:41

A lot is in the tubing.

4:42

And I can show you, let me take this out.

4:45

I like to put it in a long window

4:47

so you can see what's going on.

4:48

See, like there is like a cannula and the tubing out

4:51

and the activity is activity.

4:53

A lot of it is outside the patient.

4:55

It's not really infiltration in the patient.

4:58

It's more of activity in the tubing.

5:01

And some of it is in the cannula, like in the patient.

5:04

But anyway, this activity is not worrisome or anything. Now,

5:09

Let's go back to the even

5:14

sarma patient has even sarcoma here.

5:17

This thing is to look at the patient in, um,

5:23

here, of course the

5:28

sarcoma is like we said, aggressive high

5:30

Grade tumor that would Have, um,

5:35

it would be hypermetabolic course.

5:37

And this is a typical, really a typical, um,

5:40

ing sarcoma patient that you can see here.

5:45

Oh, I didn't give you the age of that patient, right?

5:47

So it's intensely hypermetabolic.

5:49

You can see here the aggressive, how aggressive is the, the,

5:53

even in the bone window here that I

5:57

ol I hopefully ol ct

6:02

I didn't because we usually have a reconstruction.

6:05

You see the co triangle,

6:06

you see the aggressive, which is the aggressive.

6:08

Um, but if I have theit ct, you see better than that.

6:12

But the, um, the typical, um,

6:18

it's not showing unfortunately in the

6:22

see is it showing, well, in the axi

6:28

the typical appearance of the, uh,

6:39

of the perio reaction, I mean of the O Ewing sarma, right?

6:44

Well, this one has the sunburst, which is more, we see

6:46

that more with the ooma,

6:49

but it can be seen also with the sarcoma, right?

6:51

Usually the sarcoma is described

6:54

to show more the onion view, um,

6:58

uh, OSI reaction.

6:59

But both of them can show either,

7:02

both these osi reactions are aggressive ones, right?

7:05

So anyway, it's a, it's non-cancer,

7:06

but the location, the physio is more, uh, I sarcoma than,

7:11

uh, osteosarcoma age of the patient also is, is a factor.

7:17

So anyway, like I said,

7:18

this patient is coming to us with a diagnosis.

7:20

We are not putting differential diagnosis.

7:22

But if you see this pa this patient with the location,

7:24

you would think in the age of the patient, maybe you would,

7:27

you would think, I dunno,

7:31

ICOM I think it's more the, it's more the physio than

7:34

with the physio and, um, the look

7:38

of it maybe I would think in sarma more than, uh,

7:43

ocom, right?

7:44

So what's the question? The question is, is there other

7:48

satellite lesions in the skeleton?

7:51

Is the, is their exoskeletal uh, lesions

7:54

And in this patient there was not, this was the only site

7:57

of disease and that's what's important.

8:00

And then they do send these patients for follow-up to us

8:03

as well, to see the, when they do, um,

8:07

new adjuvant therapy prior to surgery and

8:09

after surgery, we do look at them.

8:12

Um, there was nothing in this patient that were, uh,

8:16

explaining.