0:04

This patient.

0:05

I didn't read this patient clinically, so I actually,

0:08

I updated the report and the slides

0:10

because, um, there was, um, again, um,

0:15

a mening that I didn't talk about in the report.

0:17

So Shriver mentioned to us, here it is.

0:23

Let me pull the ct, the access

0:29

to the difference solution.

0:31

Yeah, here you go. Okay, so we have here the,

0:35

this is the twittery, this theologic twittery activity

0:40

that we are used to, right?

0:42

And there's this focal activity,

0:43

focal intense activity in the LAR region, right?

0:47

This is men of course, we all know that mening,

0:49

we mening gmas express our receptor

0:51

receptors and we see it all the time.

0:53

And usually like brain mass from neuroendocrin tumor is

0:56

super duper rare.

0:58

So this is, this is much,

1:01

much more likely to be a mening gma.

1:02

We see mening GMA all the time.

1:03

Actually, I have cases where we saw Mening, we did MRI,

1:08

it was too small for even MRIs to see it, believe it or not.

1:12

MRI couldn't see it, but it wasn't mening.

1:14

It was not metastatic. So this is,

1:16

look, look at the location.

1:18

Oh, it's obviously extra axi, right? And it's hot here.

1:23

We used to see it on ultra scan.

1:24

If you guys remember even core exam used to, uh,

1:27

I mean our radiology exam, um, used to ask about it.

1:31

They would tell you an oxygen scan

1:32

with a focal activity in the head

1:33

and to ask, what is this Oma?

1:36

It is known, right? So one of the non neuroendocrin tumors

1:40

that expressed smart statin receptors, other than

1:43

that is the primary being pancreatic mass here.

1:47

That is intensely SA avid,

1:53

very hot pancreatic mass, right?

1:57

And um,

2:01

and the same concept, you have to look carefully around it

2:05

for the regional lymph nodes.

2:07

Is there any aortic?

2:10

My experience with the,

2:11

and we do a lot of neuroendocrin tumors, pancreatic mass,

2:15

pancreat, uh, masses usually love to go

2:18

to the al lymph nodes.

2:19

Med gut, neuroendocrin tumor, love to go to the mesenteric.

2:23

Later on you can have,

2:25

for the med gut you can have metastatic and al,

2:28

but usually, predominantly med gut will be mesenteric.

2:32

Pancreatic will be tronia. This is usually the pattern.

2:36

So when you have mesenteric nodes, a lot of mesenteric nodes

2:41

and you don't see the primary me enteric is 99%

2:45

of the time it's gonna be med gut, which means small bowel.

2:48

Look carefully at the small bowel.

2:50

And usually it's gonna be in, in the vicinity

2:53

of the mesenteric nodes.

2:56

So see, where is your bulk of mesenteric? The

2:58

Largest mesenteric node.

3:00

And look closer to it.

3:04

You will find focal activity.

3:06

It's not gonna be as prominent.

3:08

It's gonna be smaller

3:10

and less hot than the mesenteric node itself.

3:14

Fussing to a gut, fusing to a small bowel.

3:16

This is gonna be your primary side. I'll show you.

3:18

The next case is a small bowel.

3:20

This case doesn't have anything. A

3:21

necrotic obviously necrotic, right?

3:23

You see the central Nia intensely, CC avid,

3:27

pancreatic head mass, nothing else, no lymph nodes.

3:31

And then you go up, you have to decrease the intensity

3:33

because still this is still too hot

3:38

and will make you feel that everything is like popping up.

3:41

So this a little bit more. And then look through the liver.

3:43

The liver is like really this is, this is,

3:46

this is a little more lighter than it would like.

3:50

And then anyway, so nothing the liver you already got looked

3:53

at, this liver was clean

3:57

also and nothing else.

4:00

And you always look at the map.

4:01

Don't forget to look at the map.

4:07

So this is just pancreatic.

4:08

And I did put the staging,

4:12

the a g CCC eighth edition

4:14

because in the eighth edition there was significant change.

4:18

It was for the first time ever

4:20

that they separated the pancreatic neuro, the consumer.

4:22

Then the regular till that addition,

4:24

till the seventh edition pancreatic neuroendocrin tumor were

4:28

staged similar to the pancreat, uh, exocrine

4:30

or adenocarcinoma, which was not fair

4:34

because adenocarcinoma is very aggressive tumor.

4:37

Why neuroendocrin tumor is not have very two or not.

4:41

Um, so the staging was not working.

4:45

But then in the eighth edition, finally they recognized

4:48

that neuro pancreatic neuroendocrin tumor should have their

4:51

own staging, right?

4:52

Because this is linked to survivals.

4:55

So they separated them and we had, uh, a separate staging.

5:00

So this is why I included this in your, uh, the slides.