0:34

Um, so, uh, before I show you the cases, I quickly,

0:38

uh, just wanted to, um, say that we started, uh,

0:43

we switched over from peer review to peer learning,

0:47

uh, about a year ago at our institution, and, uh,

0:50

this is a non-random case review where, um, the

0:53

radiologists and residents, um, submit cases in which

0:57

they think there have been oversights or

1:00

if there are unusual or great calls.

1:03

And today I will be showing some of those unusual

1:06

cases or, uh, subtle cases with great calls.

1:09

And, um, uh, hopefully you'll all find it interesting.

1:13

So let me start sharing my cases now.

1:17

Okay, so this is a 64-year-old

1:22

gentleman who presented with priapism.

1:27

He had, um, painful, almost permanent erections,

1:32

uh, which, uh, became kind of unbearable, so he

1:37

decided to present to the, present to urologists.

1:41

And the urologist ordered a, um, MRI, and,

1:45

um, um, starting with the T2-weighted images,

1:49

I'll scroll through the images slowly.

1:51

Um, if you think I'm too fast, please let me know.

1:55

Uh, starting with the sagittal images, which kind of,

1:58

uh, show the, um, penile profile, uh, well, um,

2:04

and, uh, maybe I'll show the coronal images too.

2:07

Um, there are two corpora cavernosa,

2:10

just to quickly update with anatomy,

2:12

corpus spongiosum more inferiorly here.

2:16

And on the T2-weighted images, frankly,

2:19

it kind of looks a little bulky, but otherwise,

2:24

um, also focus on the base of the penis here.

2:33

These are the axial images.

2:39

And then let me show you post-contrast images.

2:51

I'm scrolling down from the level of the bladder.

2:54

Ignore that arrow.

3:00

These images were obtained in the venous phase.

3:17

Out there again at the level of the bladder, prostate,

3:25

base of the penis, shaft of the penis,

3:32

and glans penis.

3:38

I'll quickly show you the coronal images,

3:40

and then we could, um, pull up the

3:44

first poll question as soon as I show the sequence.

3:54

Maybe sagittal too, because we saw the

3:57

initial images, um, in the sagittal plane.

4:03

Base of the penis, prostate, urinary bladder,

4:09

the shaft of the penis.

4:13

So let's pull up poll question number one.

4:17

What is the etiology for priapism in this gentleman?

4:22

He's about 65 years old.

4:24

Wow, great response.

4:27

So, to be honest, I think these are

4:30

the two most common etiologies, and I

4:34

completely understand the split response.

4:39

So, this was a great case.

4:41

Let me pull up the actual images.

4:43

To show, um, ischemia is actually the most

4:48

common cause for priapism in this person.

4:52

Um,

4:56

you may have noticed that, oh,

4:57

I'll send it to you right here.

4:59

Um, you may have noticed that there has,

5:03

there is heterogeneous enhancement of

5:04

the entire penile shaft also in the base.

5:09

And, um, in ischemia, and also in the tip. In ischemia,

5:14

there is hypo enhancement at the tip and enhancement

5:19

more in the shaft and at the base of the penis.

5:21

So that would be, uh, the kind of the main,

5:24

uh, reason which would, uh, our main finding

5:28

which would differentiate these two entities.

5:31

So, the answer here is tumor infiltration is

5:34

the etiology for this person's priapism.

5:37

Let's pull up the, uh, next poll question.

5:40

What is the etiology for, um,

5:43

So what does this person have?

5:45

Uh, we, I think in the first, uh, question we

5:49

figured out that this person does have cancer.

5:52

But what do you think could be the etiology?

5:55

There is, um, a structure which had

5:59

enhancements similar to the penis.

6:02

So the, um, on the initial review of the

6:05

images, very interesting response, and

6:09

thank you for, um, answering the questions.

6:13

So let me pull this image back, and,

6:17

uh, also the sagittal images, um.

6:22

So I see that metastasis was not

6:24

considered, and that this was a case,

6:28

uh, in fact of metastasis to the penis.

6:31

It is not common, it is unusual.

6:35

However, in this image, the prostate also

6:39

demonstrates heterogeneous enhancement.

6:42

And on these axial images as well, the prostate

6:45

is demonstrating heterogeneous enhancement.

6:48

So he had Gleason 5, uh, 4 plus 5, which

6:52

is high-grade prostate cancer, with

6:56

metastasis to the entire penis.

6:59

Um, and that was the etiology

7:01

for priapism in this person.

7:03

Now, I have to say, um, I kind of, um, also

7:09

to address the initial question about whether

7:13

this is indeed malignancy or, um, ischemia, we

7:17

can also look at the diffusion-weighted images.

7:21

Uh, the entire penis was intensely

7:24

restricting, another feature of malignancy.

7:28

And also, the prostate was also

7:32

demonstrating areas of restriction.

7:35

So this was a case of metastasis

7:38

to the penis from the prostate.

7:40

Now, um, we have a couple more quick poll questions.

7:46

Uh, so, uh, we just discussed that

7:48

the primary source for, uh, metastasis.

7:52

Oh, okay.

7:54

The next poll question.

7:55

I don't think we have discussed it.

7:56

What is the primary source of

7:57

metastasis in this patient?

7:59

Oh, which I just discussed.

8:01

Okay.

8:02

Sorry, Ryan.

8:03

We could, uh, I could just use this poll

8:05

question to, um, say that this is the order of

8:08

etiologies for, uh, um, metastasis in this order:

8:13

bladder is the most common, uh, organ of origin,

8:17

followed by prostate, rectum, sigmoid, and kidney.

8:21

That's 100 percent, yay.

8:23

So, moving on to the next question, uh, what is

8:27

the mechanism of spread of penile metastasis?

8:30

I only have three choices because these

8:32

are the only main three modes of, um,

8:36

um, modes of spread of metastasis.

8:40

Is it lymphatic, or is it via direct

8:42

invasion, or is it hematogenous?

8:45

Right.

8:46

Um, hematogenous.

8:48

So, the metastasis to the penis can spread both

8:52

by direct invasion and hematogenous spread.

8:55

In this case, it did look like it was

8:58

probably direct invasion just because there is

9:00

so much extensive tumor in the prostate as well.

9:02

However, this patient had a normal prostate, kind of

9:06

a routine, not normal, but a routine prostate MRI,

9:09

a year and a half ago.

9:11

And retrospectively, um, there were

9:16

a few foci of metastasis in the penile shaft.

9:21

So, in this patient, probably had maybe a combination

9:25

of both or maybe a hematogenous metastasis.

9:28

In fact, the commonest mode of metastasis to

9:30

the penis from prostate cancer is hematogenous.

9:33

And the metastasis is actually

9:36

seen in the penile shaft.

9:39

Uh, so, and then this patient, um, so that

9:42

was a prior MRI from a year and a half ago.

9:44

And then, um, I'll quickly finish up by

9:48

showing, um, just a couple of months later,

9:51

uh, the patient actually presented again.

9:55

Uh, this time, the

9:57

cancer was way more extensive.

9:59

Now it is more heterogeneous.

10:01

Um, it was, um, um, kind of, you know,

10:07

uh, more extensively involving the penis.

10:09

The patient also had bone metastasis and,

10:12

uh, uh, more disease in the prostate as well.

10:15

So, um, kind of, I, since this is such a rare tumor

10:19

and there is only so much, very little information

10:22

in the literature, I discussed this with the

10:23

urologist on the treatment for this extensive tumor.

10:26

Penile metastasis.

10:28

It's apparently radiation, just palliative,

10:31

or sometimes if the pain is pretty

10:33

excruciating, uh, they also do penectomy.

10:37

Moving on, let's go to, uh, the next case.

10:42

Okay, so this is, oh, sorry.

10:45

This is a, um, 30-year-old man who presented to ED

10:51

with, uh, kind of left flank pain.

10:56

And this CT was done in the ED setting.

11:03

Axial images.

11:04

I'll start from the top.

11:10

I'm scrolling down.

11:15

Towards the pelvis.

11:19

And now I'm scrolling back up.

11:25

I may pass at the areas of interest,

11:27

but I'm sure you've already noticed it.

11:30

Coronal images.

11:37

Okay, question number one.

11:40

Uh, which would be question five, Q5, yes.

11:43

What is the next, uh, or what is the next investigation

11:47

you would like to perform in this young gentleman?

11:51

Perfect.

11:52

Um, the answer is split between

11:53

CTA and scrotal ultrasound.

11:56

Um, so CTA can be useful to see the extent of vascular

12:01

involvement, but in this case, given this, um, Um,

12:05

extensive lymph node mass in the retroperitoneum,

12:12

which is compressing on the right left renal

12:16

artery and vein, almost obliterating the vessels.

12:21

Um, and also it has caused edema and

12:25

swelling of the left kidney from compression.

12:28

And also, um, there is all this

12:31

lymph node mass in the, uh, pelvis.

12:36

The top differential in this

12:37

case is a testicular malignancy.

12:40

So the next step would be to get a scrotal ultrasound.

12:45

And this patient did get a scrotal ultrasound.

12:47

In the interest of time, I'm going to show you,

12:50

um, the positive finding in the scrotal ultrasound.

12:55

It was actually a very subtle finding, uh,

12:57

but the sonographer was able to pick it up.

13:00

Um, this, um, there is this hypoechoic area,

13:06

which is kind of ill-defined in the left testicle.

13:10

So this person did have testicular malignancy and,

13:13

uh, the lymph node, uh, lymph nodes are presumed

13:17

to be from the, uh, testicular, the testicular

13:19

metastasis from the testicular malignancy.

13:22

Let's open the next question.

13:25

I do think I've been showing a lot of hints.

13:29

Very good.

13:30

So majority of the lymphadenopathy

13:33

is in the left retroperitoneum.

13:37

And also kind of if we look at the

13:39

lymphatic drainage of the left testicle.

13:42

Uh, and the lymphadenopathy here, it's

13:45

kind of around the left gonadal vein.

13:50

So with the right testicular malignancy, um,

13:54

the left gonadal vein drains into the left renal

13:57

vein and the right gonadal vein,

14:00

uh, drains into, uh, directly into the IVC.

14:05

So you don't see this amount of extensive,

14:08

um, involvement at the level of the renal

14:11

vein for the right testicular malignancies.

14:15

They terminate actually kind of inferior to the level

14:18

of the kidneys and they rarely ever cause, um, left

14:23

flank pain or involvement of the kidneys.

14:27

Um, with the left testicular malignancies

14:30

because they involve the left renal vein.

14:33

These patients present with symptoms early.

14:36

And, uh, we'll do the next question real quick.

14:40

What would be the histological

14:41

diagnosis in this young person?

14:45

Yes.

14:46

Um, seminoma, which is a germ cell tumor, is,

14:49

uh, the most common type of testicular malignancy.

14:53

Uh, testicular malignancies can be,

14:55

um, you know, the germ cell tumors can

14:57

be seminoma and non-seminoma germ cell tumors.

15:01

The non-seminomas include Embryonal Carcinoma, Yolk Sac Carcinoma,

15:06

Choriocarcinoma, and teratoma.

15:08

But sometimes you get mixed germ cell

15:10

tumors where you'll have a percentage

15:12

of these. Moving on to the next case.

15:16

So this person presented to ED, um,

15:19

post, uh, with a history of trauma.

15:24

Um, he is about 32. He presented with, uh,

15:29

um, his child sitting on his lap, who

15:33

kind of jumped on his lap, resulting in

15:36

severe and sudden pain in the left testicle.

15:41

And, uh, this study was done in the ED.

15:44

And just by looking at these

15:46

images, what is your diagnosis?

15:49

Only on ultrasound.

15:51

Great.

15:52

That was exactly the thinking on the

15:56

initial, um, interpretation of the study.

15:59

Uh, in fact, um, the thought process here was, um,

16:03

either testicular hematoma from trauma or testicular

16:07

infarct, except that because of the vascularity on

16:11

these dark blood images, infarct was considered less

16:14

likely, but there could be poor perfusion post-infarct.

16:18

So at this point in time, they asked for a

16:20

repeat ultrasound, sent the patient back home.

16:24

The patient came back after a month, and

16:27

the features were pretty similar.

16:29

Um, there was no change in the appearance

16:32

of this structure within the left testicle.

16:35

So at that point, it was decided to do an MRI on

16:39

this patient.

16:43

And

16:44

these, uh, are T2-weighted images.

16:47

As you can see, this is the right

16:50

testicle, and this is the left testicle.

16:52

The left testicle appears bigger.

16:55

I would say it's heterogeneous.

17:00

And these are the post-contrast images.

17:07

This is the enhancement within the right

17:10

testicle, and this is the extent of the

17:13

enhancement within the left testicle.

17:18

And, um, um, so let me give you another,

17:23

um, image, which is, um, subtraction images.

17:28

When in doubt, if the etiology is either a

17:32

hematoma or an infarct, subtraction images are

17:35

very helpful, uh, because there is not much

17:39

internal enhancement in hematoma or an infarct.

17:44

In this case, there is heterogeneous enhancement,

17:48

and this was a testicular malignancy based on the MRI.

17:53

So the patient did have a left orchiectomy.

17:57

And also in this case, I also wanted to

17:59

show you, um, a couple of other, um, uh,

18:03

sequences which we can use for diagnosis.

18:06

Diffusion-weighted images are not extremely

18:08

popular for the testicle, but they're very helpful.

18:12

Uh, when in doubt, so this patient had, um,

18:19

diffusion-weighted images done as well.

18:20

You can see there are some areas that restrict.

18:25

So this was called, um, there was a high

18:29

concern for testicular malignancy based on

18:31

the MR images, especially the enhancement,

18:34

which was seen on subtraction images.

18:36

The patient did get a CT scan.

18:42

and there was, um, lymphadenopathy

18:47

as well in the abdomen.

18:48

And, uh, this, histologically, this case

18:51

came back as a mixed germ cell tumor.

18:53

It predominantly had seminoma, but it also had about

18:57

5 percent of choriocarcinoma, 10 percent of teratoma.

19:01

Ryan, we can skip question nine.

19:04

Um, I'll be showing case four.

19:07

So, this is a young, um, she was about 27 years old.

19:14

She presented with pelvic pain, and she

19:19

got an ultrasound study done in the ER.

19:23

On the ultrasound, you can see the uterus.

19:27

This is the right ovary.

19:29

And there is this large cystic

19:30

structure within the pelvis.

19:33

What is the, we can put a poll up, uh, question 10.

19:38

What is the next step?

19:41

Great.

19:42

Both CT and MR are really good options.

19:46

Um, in our institution, in, uh, women with large

19:50

ovarian cysts, we, um, routinely get an MRI done.

19:55

Um, because these cysts, help the MRI gear has kind

20:00

of more, um, um, sequences in which we can actually

20:04

really characterize the, um, cystic structure.

20:09

This patient also got a CT then.

20:15

So let's look at the CT.

20:18

So this CT was done, uh, was performed, um, kind of

20:23

a few days before the, uh, ultrasound was performed,

20:27

uh, had presented with to the ED because she was

20:30

a young person, although the cyst is larger than

20:32

five centimeters, so it technically needed, um.

20:36

further evaluation with an MRI.

20:43

Um, at that point, a patient was sent back home.

20:46

She came back a couple of months later, got the

20:48

ultrasound that we just, that I just showed.

20:53

I don't think we need any more sequences.

20:55

Um, so this is the cystic structure that

21:00

we saw on the CT and on the ultrasound.

21:06

So based on these images, uh, let's get

21:10

question 11, which is what is your diagnosis?

21:15

Okay, that's okay.

21:16

It is kind of a complex case.

21:17

It's an unusual case.

21:19

So, on the ultrasound, this did

21:25

appear as a cystic structure, right?

21:27

And on the CT as well, it is

21:29

right next to the right ovary.

21:31

So, on the ultrasound, the differentials that were

21:33

given were peritoneal inclusion cyst, and just because

21:38

it appeared as if the ovary is right next to it.

21:42

Uh, not really coming, um, it didn't look

21:44

like the cyst was coming right off the ovary.

21:47

The patient only got, um, non-contrast

21:50

MR done and just a few sequences, but I

21:52

think that's all we need to diagnose this.

21:55

Okay, so let's go over the

21:57

CT again, and I, I apologize.

21:59

So this is the CT, the patient, um, which was performed

22:04

about two months before the ultrasound on your right.

22:09

On the CT, you see the cystic mass,

22:14

which is right next to the right ovary.

22:18

And MR was, let me scroll the CT up to

22:22

show the superior extent of the mass.

22:24

So it kind of starts from the right pelvis.

22:29

And then you kind of do see it in the retroperitoneum.

22:34

Keep scrolling up, you do see it.

22:37

Almost up until the upper abdomen and

22:43

that's why this person also got an MR done.

22:49

And on the MRI,

22:53

we can see the cystic mass.

22:56

She only got, um, a non-contrast MR.

22:58

So we only have T2 weighted images and

23:00

post-contrast and, uh, T1 weighted images.

23:04

Here is the cystic structure.

23:06

This is the bladder, which

23:08

extends along the retroperitoneum.

23:12

To, um, kind of, almost to

23:14

the level of the renal veins.

23:17

Let me show the abdomen, uh, axial images.

23:21

This is the superior extent of the cystic structure.

23:24

So this is lymphangioma.

23:28

And, uh, in this case, this was interesting

23:30

because had we only seen the cystic structure

23:33

in the retroperitoneum, lymphangioma

23:36

would have been our top differential.

23:39

The reason this is interesting is it was,

23:41

it started out with the pelvic ultrasound.

23:44

And I do feel like if we look at these images,

23:47

it's kind of easy to call this an ovarian cyst and

23:51

then, um, the GYN can get involved to kind of, you

23:55

know, because a cyst this size is prone to torsion.

23:58

And, uh, uh, every time we do mention a large cyst,

24:02

uh, GYN sometimes does either at least a diagnostic

24:05

laparoscopy to kind of, um, remove the cyst or, um,

24:10

kind of remove fluid from the cyst to prevent torsion.

24:12

But in this case, working this up further with MRI was

24:15

extremely helpful to say that this is a lymphangioma.

24:18

Um, so really the patient, uh, kind

24:21

of the patient's pain subsided.

24:23

Uh, they were hoping, thinking of aspirating

24:25

some of this fluid for symptomatic relief.

24:28

But, uh, she refused at the, um, at,

24:30

at least at the time of presentation.

24:31

She did not get any, uh, procedures done.

24:35

Let's, uh, move on to the next case.

24:38

So this is a case Great, a really good case, and I will

24:41

be focusing mainly on the important findings on this.

24:46

Um, so this patient actually came in

24:51

for, um, right upper quadrant pain.

24:55

So she got a CT scan done at an outpatient

24:59

setting, um, in a different hospital.

25:03

This is her CT.

25:05

In which, uh, we do see stone at the gallbladder

25:12

neck, some inflammation around the gallbladder.

25:16

And they wanted an MR done to

25:18

evaluate for any stones within the

25:21

CBD or, uh, within the common bile duct.

25:30

So she did get an MR.

25:31

And this is a T2 weighted

25:33

coronal images.

25:34

We, these, we do see the stone very well.

25:37

There was a gap of about three

25:38

days between the CT and the MRI.

25:40

And you can see the inflammation has really increased.

25:43

Um, the gallbladder.

25:46

Uh, we really didn't see any

25:47

obstructing stones, but I would like.

25:50

Uh, for you to spend a little

25:52

bit of time on these two images.

25:54

There was an incidental finding.

25:56

Uh, which retrospectively was also seen on the CT.

26:00

And it's also seen on this MR,

26:02

which was picked up by the.

26:04

Um, by the radiologist and it's in this image.

26:13

I will include a post contrast amount as well.

26:19

And, uh,

26:23

okay.

26:26

Um, Ryan, we can put up question 12.

26:29

Thank you.

26:30

I will minimize this.

26:32

What is your diagnosis?

26:35

So the answers are the hint.

26:37

This is something related.

26:38

It was an incidental finding seen on this

26:40

image, which kind of was we were hoping

26:44

will change the course of this patient

26:47

Great.

26:48

You all have really awesome.

26:50

I Um, so yes, this person indeed

26:54

has, um, the colon cancer here.

26:58

So this was actually picked up on the T2 weighted

27:02

coronal images, and among all the sequences in MR,

27:07

T2 weighted coronal images are my most favorite

27:09

because it has a larger field of view, kind of,

27:13

you know, just gives you a quick overview.

27:15

Overview and findings like this can be picked up.

27:18

Usually the cancers in this region are kind of missed

27:21

because there is a lot of stool in the region.

27:23

Um, and this was picked up fortunately before

27:26

the surgery and, um, patient was offered a,

27:31

you know, in the same setting to have the

27:33

cancer removed along with the gallbladder.

27:36

Uh, but she actually opted to

27:38

just get the gallbladder removed.

27:39

It was kind of overwhelming, uh, for

27:42

her, which is totally understandable.

27:44

Um, unfortunately she, um, was lost to follow-up

27:48

and, uh, she came back almost a year later with this.

27:55

extensive metastasis within the liver.

28:00

The malignancy had now grown

28:03

with local regional lymph nodes.

28:07

And also, diffusion weighted images are always another

28:11

of my favorite set of sequences because I'm pulling

28:16

back the prior MRI and I want to show how, um, Oh,

28:20

actually in the prior MRI, we did not go that far down.

28:24

Um, but there are cases where the only sequence

28:30

which shows any hint of malignancy is on diffusion

28:33

weighted images with these masses restricting.

28:35

So I always screen through the B-value 2 in

28:37

diffusion weighted images in this patient.

28:43

Apart from, um, you know, the

28:45

malignancy was also restricting.

28:49

Okay, moving on to the next case,

28:50

I'll put the windows back in.

28:55

This is a great case.

29:06

Let's start with the ultrasound.

29:11

This patient had, um, this is a young man in his

29:15

thirties who presented, who actually repeatedly

29:18

presented with right upper quadrant pain.

29:21

And this ultrasound was

29:22

performed in one of those visits.

29:25

And, um, he thought he may have hurt

29:27

his right flank, um, in the gym.

29:31

But we saw a structure right here, right

29:36

next to that patient's actual gallbladder.

29:40

The liver is slightly fatty.

29:44

Again, this is the structure,

29:47

and this is the gallbladder.

29:51

Again, this is the structure.

29:54

So I will quickly show it was not that vascular.

29:58

Um, I'll show a cine image on this patient.

30:04

So this is again the structure.

30:07

It was filled with what looked like debris and sludge.

30:13

And there is, it probably connects to this.

30:19

Okay, let's bring up question 13, which

30:22

is, What is your top differential?

30:25

Yes, uh, to be honest with you,

30:27

I called it choledochocele too.

30:29

I read the ultrasound and I thought this

30:31

must be choledochocele containing sludge.

30:33

Okay.

30:34

But I'm glad at least one person in this, in

30:36

the audience thought this was two gallbladders.

30:39

That was not in my initial diagnosis.

30:42

Um, I called this CHO seal and, um, or

30:47

it could be a gallbladder diverticulum.

30:49

It was like right next to the main gallbladder.

30:51

But anyway, uh, we got an MRI done.

30:56

T2 weighted images.

31:01

It looks like two gallbladders right on this image.

31:06

And, um,

31:09

the best sequence, which kind of, um,

31:13

nails this diagnosis, was actually

31:15

these thin, uh, MRCP images.

31:20

These really are not the prettiest images, but they

31:23

are one millimeter thick slices that heavily T2

31:26

weighted images, and they're excellent for any biliary

31:29

structure, uh, mainly for like IPMNs in the pancreas.

31:33

So if we follow these,

31:37

um, two cystic structures and try to, um, see

31:41

the relationship to each other after the CPD.

31:43

So this is, um, the more inferior structure.

31:47

And if you can see, there are two

31:51

cystic ducts and they join here.

31:58

Into one common cystic duct and drain into the CPD.

32:04

And it was, I thought it was an excellent

32:06

demonstration of these two, two separate gallbladders.

32:12

With two separate cystic ducts joining to form

32:15

a single cystic duct draining into the CBD.

32:18

So this was a really nice case

32:21

of duplicated gallbladder.

32:23

I'll show the images on axial, um, sequences as well.

32:26

It's kind of, to be honest, it's

32:29

really hard to interpret on axial.

32:31

The other cystic structure kind of just looks

32:33

like, um, you know, this was the other one.

32:36

Uh, but I think on the There was great visualization

32:40

and the structure inside this was just sludge.

32:46

So, um, I just wanted to like quickly share

32:49

one, um, like image of the type of, um,

32:55

duplication that you can see, um, which is,

32:58

um, you know, it could be either incomplete,

33:04

uh, with, you know, just

33:05

lobulated, um, gallbladder fundi.

33:09

They could be complete duplication with two

33:12

separate gallbladders to two separate cystic ducts.

33:15

Or they could be, still be complete, but they

33:18

drain through one cystic duct in this case.

33:20

I guess they both start, uh, they

33:22

eventually, they both are cystic ducts.

33:24

Joined.

33:25

Um, but they drain the two cystic ducts which

33:29

I showed kind of joined to form a single

33:30

cystic duct before draining into the CBD.

33:37

Sorry, I gotta like minimize this and this stuff.

33:41

Okay, I'll just move this out.

33:44

And we can skip question 14.

33:47

And, uh, let's move on to question, uh, case seven.

33:52

So this is a woman in her, um, early seventies

33:57

who presented to ED with right upper quadrant pain.

34:01

And this was an ultrasound performed.

34:03

Um, I think this key image is, uh, kind of all we need.

34:08

Um, can show you a couple more images.

34:10

Uh, this was an ultrasound performed in the ED setting.

34:14

Um, patient came back a couple of months

34:17

later, again with, um, right upper quadrant pain.

34:22

And she got a CT scan done.

34:31

Okay, great.

34:34

So on the CT,

34:38

look at the gallbladder

34:41

and also these structures in the hepatic hylum.

34:47

I'll also show the MR images.

34:59

These are T2 weighted axial images.

35:02

Again, we are focusing just on the gallbladder

35:09

and these structures in the hilum.

35:14

Coronal images.

35:19

And let me show you post-contrast images.

35:27

Those were arterial.

35:29

We had three months.

35:34

What are the images?

35:40

And subtraction images.

35:46

There is a little bit of

35:47

misregistration, but you can still

35:49

see these structures in the hilum.

35:53

And then the gallbladder itself.

35:57

Finally, I would like to show.

36:00

Diffusion.

36:09

Now I'd like to put the

36:12

T2 weighted images and the CT image back to back, and

36:17

um, let's pull up the first question, which is Q15.

36:22

What is your diagnosis?

36:25

Good answer.

36:25

On the initial diagnosis of the CT, the initial

36:30

interpreter actually put both these diagnoses as well:

36:33

Gallbladder cancer and chronic

36:36

cholecystitis diagnosis.

36:37

Now, before going over a few important features, I

36:40

would like to pull up the next poll question, please.

36:43

Q16.

36:44

What type of histology will you

36:46

expect with these imaging features?

36:49

A well-differentiated adenocarcinoma,

36:51

mucinous carcinoma, gallbladder

36:54

lymphoma, or gallbladder metastasis.

36:57

It's split up.

36:59

So there are two important, it, honestly, just

37:02

on the imaging, it could be anything, right?

37:04

But there are two distinct

37:06

features on these MR and CT scans,

37:09

which favor the diagnosis of

37:11

mucinous carcinoma in this patient.

37:14

And that was, that did come

37:15

back on the histology specimens.

37:18

Um, there are these calcifications.

37:23

Now again, the calcifications can be seen with

37:25

granulomatous diseases as well as something

37:27

chronic, but also these enlarged lymph nodes.

37:30

It's very unusual to see the significantly

37:34

enlarged lymph nodes in the hepatic

37:37

hila with just granulomatous disease.

37:41

These raise suspicion for malignancy and

37:43

also the lymph nodes also have calcification.

37:50

And on the MR, the lymph nodes are distinctly cystic.

37:55

It's, there are very few malignancies which

37:57

have, um, this, um, kind of, uh, cystic

38:01

lymph node metastasis, and mucinous carcinoma

38:04

of the gallbladder is one such etiology.

38:07

Um, so because of the cystic lymph node, uh,

38:11

morphology and on the MRI, and also comparison

38:14

with the CT, which showed calcifications, um, just

38:17

based on the MR itself, there was a high concern

38:20

for mucinous carcinoma of the gallbladder, which,

38:22

uh, and that was, uh, seen on histology as well.

38:27

I have a very interesting next case, um,

38:29

so I'll just show that one case and, um,

38:33

I think

38:34

that's, we should be able to, um, that's

38:37

kind of how much probably wrap it up.

38:41

Okay,

38:43

let me pull up the next case.

38:46

I'll show you a series of images

38:48

which kind of, um, show all the, um,

38:55

sorry, my, my screen is full

38:57

so which I can see it myself.

39:01

Okay, it came back up.

39:02

Perfect.

39:03

Okay.

39:05

Okay, so this is how this patient,

39:07

she is a 46-year-old woman.

39:11

She presented to the ED with, um, right upper quadrant pain.

39:16

So these are her initial sets

39:18

of images when she presented.

39:20

She has a history of multiple myeloma

39:23

and breast cancer, um, and, um.

39:27

She was, she had already

39:30

completed her breast cancer treatment years ago,

39:33

and her multiple myeloma was being monitored.

39:38

So this is the, let me put the liver, um, sure.

39:42

In the liver window.

39:45

So, right upper quadrant, she had

39:47

pleural effusion and that during the COVID

39:50

time, everything is attributed to COVID.

39:53

Um, she did have a few infectious, um,

39:56

etiologies in the lower lung as well.

39:58

So at this visit, they didn't

40:01

really see anything in the abdomen.

40:05

Seemed pretty clean.

40:07

She was sent home.

40:09

She comes back nine days later.

40:15

This CT was performed exactly nine

40:17

days after the initial diagnosis.

40:21

In this CT, do you notice these enhancing areas?

40:31

Several of these.

40:33

So, let's pull up the question number, uh,

40:37

Q17, which is, um, What is your diagnosis

40:41

just based on these two CTs which were done?

40:44

Nine days apart and with these

40:47

numerous, numerous lesions in the liver.

40:51

Great.

40:52

That is really awesome thinking.

40:53

It does look like metastasis.

40:55

It is avidly enhancing.

40:57

Although it was just nine days apart, we have to

41:00

start thinking about etiologies which can, um, kind

41:05

of cause the lesions, um, you know, in the liver,

41:10

um, kind of, you know, it could still be rapid,

41:13

but, you know, the appearance is well circumscribed.

41:15

Perfusion image would be like transient,

41:18

ill-defined areas of enhancement or

41:20

wedge-shaped areas of enhancement.

41:23

Abscesses would have almost like a rim-like appearance

41:26

with surrounding, um, reactive enhancement.

41:30

Uh, this kind of looks like, uh,

41:32

pretty much well-circumscribed lesions,

41:35

so there is concern for metastasis.

41:38

So, at that time, um, she kind of had more like

41:44

pulmonary symptoms, so this was noticed but not

41:47

a lot of emphasis was given to this finding.

41:50

She came back nine days later with more

41:53

of those lesions, and on the ultrasound,

41:57

you could see them everywhere.

41:59

So, based on the ultrasound, an MRI was ordered.

42:03

And she came back exactly nine

42:04

days later, and she got an MR done.

42:08

Let me show you all MR images.

42:10

So this is the lesion.

42:12

This is a T2-weighted sequence.

42:14

And you can see numerous lesions.

42:18

And

42:18

on, um, post-contrast images.

42:26

It is hypo-enhancing, but it's enhancing.

42:30

Subtraction images sometimes help us

42:32

to assess the extent of enhancement.

42:35

The lesions become more distinct.

42:37

Also, she does have fat in the liver, which

42:39

kind of alters the appearance of the lesions.

42:42

So, but what was interesting was comparing

42:45

this to the CT in which the lesions

42:48

were identified in the first setting.

42:51

Um, so let me pull up the CT.

42:58

And then look at the same lesion on, so these

43:03

lesions, these were exactly 18 days apart.

43:05

So this patient went from no lesions in, you know, 27

43:10

days before this particular MRI to this significantly

43:14

increase in these lesions, which are this big.

43:17

Just 18 days later.

43:18

So I kind of, um, quickly want to bring

43:21

up, or before I bring up my slide,

43:23

could we pull up question 19, please?

43:27

Q19.

43:28

What is your diagnosis now?

43:30

Remember, she has both breast cancer and another

43:33

hematologic malignancy, which I may have mentioned.

43:37

Yes, so hepatic adenoma is a good

43:41

consideration in a young female,

43:44

especially if there is a history of OCP use.

43:47

Um, so I did mention at the, uh, so I did

43:51

mention that she did have, uh, she has

43:53

multiple myeloma and she was being monitored.

43:57

Um, so let me just pull up these, um, a couple of

44:01

slides and I'll tell you what the final diagnosis was.

44:08

So we could, um, there are calculators which are used

44:12

to, uh, kind of calculate the tumor doubling rate.

44:15

In this case.

44:17

This is just an arbitrary date for the test.

44:20

This is just to pull up, just to

44:21

calculate the, um, doubling days.

44:24

This was not when the study was done.

44:26

So the tumor increased from 16 millimeters

44:30

to 23 millimeters in 18 days, which cause,

44:33

which brings a doubling time of 11 days.

44:36

And there are two malignancies

44:38

which have this rapid doubling time.

44:40

Which is lymphoma and myeloma.

44:43

So this was a case of myeloma metastasis to the liver.

44:47

This patient did have myeloma.

44:50

It is, it doesn't very commonly metastasize

44:52

to the liver, but in her she did.

44:54

And again, um, just like you, the responses,

44:58

you know, this could be breast cancer too.

45:00

Although for breast cancer from the slide,

45:02

the doubling time is around 80 days.

45:05

Kind of unusual for this rapid doubling.

45:07

And we should think more of hematological

45:10

malignancies such as lymphoma and myeloma.

45:12

And the, uh, tissue diagnosis was myeloma in this case.

45:17

Also, what may help us to differentiate this from

45:20

adenoma is, um, the, again, the diffusion-weighted images.

45:24

Uh, those are my second favorite, I would

45:26

say after the, uh, corona T2-weighted images.

45:30

She did have, um, It was dark on ADC and really, really

45:35

bright on, uh, uh, diffusion-weighted images, so it was

45:39

restricting, and this was concerning for malignancy.

45:42

Also, diffusion-weighted images are kind of helpful

45:45

to demonstrate that bone infiltration as well.

45:48

She had a lot of bone lesions from her myeloma, but,

45:53

um, we could see that on diffusion-weighted images.

45:56

So this was a case of multiple

45:57

myeloma infiltration to the liver.

46:00

I'll stop here.

46:01

Uh, but I can take any questions.

46:03

I don't know how long, how far along we can go, Ryan.

46:07

So that's a good question.

46:08

Uh, the first question is, uh, the diffusion-weighted

46:11

images in testicles for assessing the testicular tumor.

46:15

Um, how would we consider diffusion restriction

46:18

while the testicle, that's a very good question.

46:21

So I think in this, sometimes the

46:24

testicle can avidly restrict too.

46:26

I do agree with you.

46:28

That's why it's important to compare

46:29

it with the adjacent testicle.

46:32

And so, diffusion, as I said, diffusion-weighted images

46:36

for testicles are not as popular as it is, for example,

46:40

for liver masses, for FCC and other malignancies,

46:44

but it can be problem-solving when you are, when

46:47

there is no enough heterogeneous enhancement or, you

46:51

know, if there are no other features, then you could

46:53

Compare the extent of this diffusion restriction

46:57

in the tumor compared to the rest of the testicle or

47:01

the, uh, uh, kind of, you know, the other testicle,

47:04

uh, just for comparison, just for problem-solving,

47:07

but otherwise the normal testicle can restrict

47:10

too, and it also depends on the age of the patient.

47:12

So that's a good question.

47:15

Is there any radiological sign that could help us

47:18

differentiate metastatic penile lesion from ischemia?

47:21

Yes.

47:22

There is, and, uh, that, I’ll quickly go back

47:25

to the image, and I think this was a good, um,

47:29

good case which showed how we can differentiate it.

47:32

Um, so, I'll stop sharing real quick

47:36

just to make sure I have, um, okay.

47:39

So, as you can see on this

47:45

axial MR image, there is heterogeneous enhancement

47:50

in the tip of the penis, in the region of the glans.

47:55

So, in ischemia, there is kind

47:58

of hypo-enhancement of the tip.

48:00

And ischemia is a more diffuse process.

48:03

So if there are only focal one or two

48:07

metastases, as we saw in the patient like a year

48:09

and a half ago, when he only had like one lesion

48:12

in the shaft, one or two lesions, then we don't

48:15

really have to differentiate it between ischemia.

48:18

But in cases like this, when the metastasis is advanced

48:21

and has pretty much involved the entire penis, then

48:26

um, that's when we kind of have to differentiate it.

48:30

So, in that case, the, the, the

48:33

enhancement is heterogeneous.

48:34

In fact, it will be seen at the tip,

48:37

at the base, wherever the tumor is.

48:39

With ischemia, the shaft and the

48:42

base enhances, but the tip does not.

48:44

It is relatively hypo-enhancing

48:46

compared to the rest of the penis.

48:49

And also the second, of course, I always

48:52

look at the diffusion-weighted images.

48:55

Um, to, um, but he’s at the oldest older MRI, but in

49:00

this newer MRI, when he was diagnosed with extensive.

49:05

Um, okay.

49:07

So there is also restriction

49:09

of diffusion with, um, uh, penile

49:13

malignancies, which was seen on this image.

49:17

That's it, right?

49:18

I'm done with this case.

49:21

Thanks so much.