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Today we are honored to welcome Dr.

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Ssh Harrison Gani

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for a case-based lecture entitled Cases for ACEs.

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Dr. Harrison Gani completed his radiology residency

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and abdominal imaging subspecialty training at

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Massachusetts General Hospital.

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He is on the abdominal imaging staff at Massachusetts

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General Hospital, where he specializes in body MRI

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and translational imaging.

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At the end of the lecture,

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please join Dr. Harrison Gani in a q

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and a session where he will address questions you

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may have on today's topic.

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Please remember to use the q

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and a feature to submit your questions so we can get to

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as many as we can before our time is up.

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With that, we are ready to begin today's lecture. Dr.

1:02

Ani, please take it from here.

1:05

Good afternoon if you're in this part of the world,

1:07

or you know, good evening, good morning, wherever you are.

1:09

Just let me make sure I could you confirm, Ashley,

1:12

if you can hear me and can see my screen well?

1:15

Yes, we can. Perfect. Thank you so much.

1:18

Uh, so again, uh, a warm welcome to everybody

1:21

and, uh, what we are trying to do today

1:24

with the cases is it's a very practical, um, overview

1:28

of some very interesting cases.

1:30

And, and the points that we, we are trying to emphasize is

1:33

that, you know, pathology doesn't read textbooks.

1:36

What does, what that means is things that we believe

1:40

to have very specific imaging appearances may not

1:43

necessarily have that.

1:44

And so common conditions can present in uncommon ways

1:48

and uncommon locations.

1:49

So we always have to sort of keep our, uh, you know, we need

1:53

to sort of have a, uh, a standardized approach to things so

1:58

that, um, we are not always hitting home runs,

2:01

in other words, going for the actual diagnosis,

2:03

but we are trying to, uh, lean one way

2:07

or the other so that our referring, um, uh,

2:10

colleagues know exactly what to do with the patient in terms

2:14

of how we phrase things.

2:15

So that's what we will do is, you know, the goal is not

2:18

to get the diagnosis,

2:19

but to sort of have an approach to the finding that we see.

2:23

And then as we go along,

2:25

if there are some important take home points,

2:27

I'll be mentioning those.

2:28

So we'll start with our first case.

2:30

This is a, um, a 66-year-old, um, patient

2:35

who presents with hematuria.

2:37

And so, you know, depending on, uh,

2:40

the institution you are at many a times when patients do

2:43

present with hematuria, they may start

2:45

by getting an ultrasound of the kidneys

2:46

or the, um, and the bladder.

2:48

At our institution. When somebody presents

2:50

with Frank Hematuria,

2:52

we typically get a hematuria protocol ct,

2:54

and that's what this patient ended up having.

2:56

And I'm gonna show you the, um, uh, the corona images

2:59

of the early and the sort of the delayed, um, phase of the,

3:03

uh, hemato protocol scan.

3:05

So as I scroll through, uh, as you can see, there appears

3:08

to be compared to the left side, there is a fair amount

3:11

of fat stranding on the right side, you can see that the,

3:14

uh, on the, uh, uh, nephro graphic phase

3:19

and on the delayed phase that there is excretion on the

3:22

normal side, uh, or on the left side.

3:24

But on the right side, there appears

3:26

to be a delay in function,

3:27

and that's where the stranding is.

3:29

And compared to the left, there appears to be, um, uh,

3:33

dilatation of the right side.

3:35

And then in addition to that, what you see here is there is,

3:38

um, marked thickening of the wall of the, uh,

3:41

renal pelvis extending into the, uh,

3:44

minor CAEs in, in the kidney.

3:46

And that is essentially what is causing the

3:48

hydronephrosis and the d delayed function.

3:50

In addition to the, uh, marked perinephric stranding

3:53

that is, uh, seen,

3:56

you do see contrast making its way in the right rera,

3:59

as you can see right here.

4:00

Um, a little bit

4:02

of thickening also extending along the right rera.

4:04

And then you can see as we get down to the bladder,

4:06

there is both the ureters are seen distally, uh,

4:10

extending into the bladder.

4:11

So, uh, the, you know, the, the, um, uh,

4:16

the findings are pretty flagrant and obvious.

4:18

And so the question is, um, what are some

4:21

of the diagnostic considerations given, uh, just to again,

4:25

summarize the findings here are that, uh, there is, um,

4:29

delayed function of the right kidney.

4:30

There is hydronephrosis, there appears to be, um,

4:34

circumferential thickening, um,

4:37

which is a little bit asymmetric

4:38

and irregular of the renal pelvis extending into the, um,

4:42

uh, CAEs, uh, which is causing the obstruction.

4:45

We don't see any filling defect per se in the

4:47

opacified system.

4:49

And then the distal tors are visualized

4:51

extending into the bladder.

4:54

So I think when you look at something like this,

4:56

the first thing that comes to your mind, uh,

4:59

there are about five or six differential considerations.

5:01

And the usual suspect,

5:03

the first thing you worry about is urothelial cancer.

5:06

Uh, and, you know,

5:08

there are various ways in it in which it can present.

5:11

One way is the way we solve it.

5:12

There can be thickening, it can be irregular filling defect

5:16

as you see in this, uh, different patient.

5:18

Here is another patient where you can see

5:20

that there is a mass, uh, that is emanating from the, uh,

5:24

uh, penal parenchyma extending into the collecting system

5:28

and in the renal pelvis.

5:29

And these are two examples of urothelial carcinoma.

5:33

The other differential is some kind of inflammatory

5:35

or infectious etiology.

5:36

And one common one we see is IgG four, where, you know,

5:41

they typically present as focal masses,

5:43

but sometimes can present as circumferential thickening.

5:45

This can also be seen in some kind of granuloma disease,

5:49

like, you know, tb, et cetera.

5:50

So it can be some infection, can be some kind

5:53

of chronic inflammation.

5:55

And then the last one is lymphoma,

5:56

which we should never forget.

5:58

There is, as you can see here,

5:59

there is circumferential thickening, uh, that is present

6:02

and, uh, extending along the, uh,

6:04

renal pelvis into the collecting system.

6:07

So those are sort of the usual, uh,

6:09

suspects and differential.

6:11

Now, before we talk about this specific case, just a couple

6:14

of pointers about the common, uh, disease entity,

6:17

which is urothelial cancer.

6:19

One thing that is very, uh, unique, uh,

6:22

and you must have all heard the term field effect,

6:24

which means that you know, these tumors, um, owing

6:29

to certain, um, uh, predisposing factors, there is a large,

6:33

uh, area of urothelium that can be exposed to those in,

6:37

in enticing insults.

6:39

And so these tumors can be multifocal.

6:41

And this is one such example where you can see that there is

6:45

on the right side, there are multiple, um, lesions as, uh,

6:49

pointed out in the same patient.

6:51

So urothelial tumors can be multifocal.

6:54

And so there is two terms that we use.

6:57

One is what we call a synchronous,

6:58

and the other is what is called as synchronous.

7:01

And what are these two terms when you correlate them

7:04

with urothelial tumors?

7:06

So synchronous means they're occurring at the same time.

7:08

So ss is easy to remember

7:11

or within a very short period of time,

7:13

but typically, usually at the same time,

7:15

meta chronus is when it occurs

7:17

after a significant amount of time.

7:19

So again, just to remember, uh, what synchronous means

7:23

and what, uh, you know, meta chronus means in terms

7:25

of making it easy to understand.

7:28

And so when you look at the urothelial cancers,

7:31

the incidence of, uh, concomitant bladder

7:34

or upper urothelial tract tumor is about eight to seven

7:37

17%, or eight to 20%.

7:38

So if you have a lesion somewhere,

7:40

that's why we look very closely at the rest

7:42

of the collecting system, the

7:43

contralateral collecting system.

7:45

We look at the bladder. The other important number

7:48

to keep in mind is the contralateral

7:50

occurrence of upper tract.

7:52

Uh, urothelial cancer has been reported up to 6%, uh,

7:56

with multifocal, you know, u uh, upper tract in,

7:58

in about one third of the cases.

8:00

So the bottom line is that if you see a lesion

8:03

that looks like a urothelial cancer, you want to make sure

8:06

that you look at the rest

8:07

of the collecting system very closely,

8:10

including the bladder, so

8:11

that you're not missing a synchronous lesion.

8:15

As far as metre as, like we said, it come, it happens

8:18

after a certain amount

8:19

or, you know, amount of time that is,

8:21

they don't occur simultaneously.

8:23

The incidences of upper tract urothelial cancer ranges from,

8:26

you know, about zero to 2% with,

8:29

and the median is about four years.

8:31

So even after,

8:33

so let's say you have a cancer in the bladder urothelial,

8:35

cancer in the bladder, we still, uh,

8:37

monitor these patients very closely with hematuria protocol

8:40

because of this small, you know, increased number of cases,

8:44

even up to four years out that you can get a synchronous,

8:48

uh, lesion if you have an upper tract disease, you know,

8:51

you also monitor the bladder

8:53

and you do, um, uh, cystoscopies or, or hema mature protocol

8:56

because the incidence is relatively higher compared to

8:59

with the, with a bladder of upper tract, it's about 2%

9:02

with upper tract, the incidence in bladder is about 50%.

9:06

And so just keep these two, um, you know, things in mind

9:10

as far as urothelial cancers are concerned.

9:13

So now coming back to our case, uh, which was, you know,

9:17

just to, again, uh, the finding was this, where

9:20

we were had asymmetric functioning, we have a little bit

9:23

of thickening, and

9:24

so clearly the same differentials were

9:27

given as I showed you.

9:28

You know, the question was, is it some

9:29

kind of urothelial tumor?

9:31

Is it some kind of inflammation or is it some kind of,

9:34

or is it, uh, uh, lymphoma?

9:37

And it turns out the patient actually got a, um, cystoscopy

9:41

and they did, they went up with and did otoscopy

9:44

and they didn't see anything,

9:45

and so they decided to follow the patient.

9:48

And a scan done three months later, you can see

9:51

as I'm scrolling through the same, it's a mature protocol

9:54

with the, um, nephro graphic phase and the delayed phase,

9:57

and now it's absolutely normal.

10:00

And so there is absolutely no telltale, uh, sign of

10:03

that thickening that was present.

10:05

And, and so the question is, what is this entity

10:08

of the common differentials We discussed clearly,

10:11

urothelial cancer is not gonna go away.

10:13

Clearly lymphoma is not gonna go away.

10:15

So this is some kind of, is this some kind of inflammation?

10:18

The patient did not get any, you know, treatment.

10:21

And like I said, when they did a

10:23

otoscopy, they didn't see much.

10:24

Uh, so what is this entity, uh, that, uh,

10:28

was present in this specific individual?

10:30

And this is what is called a spontaneous subepithelial

10:33

hemorrhage in the renal pelvis,

10:35

it's also called Pol Goldman lesion.

10:38

It's usually localized in the upper renal pelvis and,

10:41

and in the upper ureter.

10:43

And you know, there have been, uh, etiologies

10:46

that have been postulated trauma,

10:48

anticoagulation hypertension,

10:50

but no one really knows why this happens.

10:53

It typically happens in the, uh, fourth

10:55

to the sixth decade of life.

10:57

So at the elderly patients

10:59

and the treatment is, uh, conservative,

11:01

you don't have to do anything.

11:02

So again, the goal of the case was not specifically

11:05

to talk about this entity,

11:07

but sort of the approach to these, uh, cases

11:10

and how do you look at it,

11:11

what the common differentials are.

11:13

And also you need to be aware of this rare entity that can,

11:16

uh, and, and we have seen, you know,

11:18

quite a few cases can happen and present as he maturity.

11:22

So that was the first case.

11:23

Now moving on to the next case, uh,

11:26

this is a 76-year-old male patient, has a PSA

11:31

of 3.99,

11:33

and, um, goes to see, uh, his, uh, primary care physician

11:37

who does a digital rectal exam

11:39

and fields, uh, an abnormal prostate.

11:42

So there is an abnormal digital rectal exam.

11:45

He has lower unit tract symptoms

11:47

and has occasional hematuria.

11:50

Now, um, before they decided to do something about the, um,

11:55

abnormal DRE, clearly the prostate,

11:57

the PSA is less than four.

11:59

So the question is, you know, is, is there, uh,

12:02

reason to be concerned?

12:03

And the, the previous year it was three point, you know,

12:07

five, and the year

12:08

before that it was three point something,

12:10

so it's not going up.

12:11

Uh, the velocity is not very rapid in terms of rise.

12:16

So they decided to do a, you know, a stone protocol CT

12:20

to see if there was any reason.

12:21

And the patient did have a small stone non obstructing stone

12:24

in the left collecting system.

12:26

And you can see the prostate on the CT

12:27

appears to be enlarged.

12:30

And so they, um,

12:31

attributed the occasional hematuria to the stone.

12:34

The question was the,

12:36

this problem abnormal digital rectal exam.

12:39

And clearly the, you know, the, uh, physician wanted

12:42

to make sure that, uh, um, uh, wanted to make sure

12:47

that there was nothing going on in the, uh, in the prostate,

12:49

so they decided to get a prostate, mr.

12:52

So these are images from the prostate, mr.

12:54

And so here is the, I'm gonna scroll through.

12:57

This is the A DC dynamic contrast enhanced series.

13:00

This is the T two, and this is the high B value of 2000.

13:04

So as I'm scrolling through, um,

13:07

and as we come up, you can see that right about here,

13:11

this is the normal signal intensity

13:13

of the left peripheral zone.

13:14

On the right side, there is a large area which is D two dark

13:18

showing restricted diffusion, as you can see here.

13:20

And it's dark on the A DC,

13:22

clearly showing early enhancement,

13:24

and it seems to be extending

13:26

beyond the margin of the prostate.

13:28

So as you can see on the left side,

13:31

this is the neurovascular bundle.

13:32

Clearly there is soft tissue extending all the way out from

13:36

the peripheral zone involving the neurovascular bundle.

13:38

And you can see there is enhancement, there is, uh,

13:41

dark signal on the A DC and on the high B value.

13:44

So there clearly is, uh, a abnormal, um,

13:49

uh, you know, lesion that is present on the right side,

13:53

which is fairly large.

13:54

There is clearly extra capsular extension

13:57

as we are seeing right here can see.

13:59

And the, it meets all the criteria that one would.

14:02

Uh, so remember it's in the peripheral zone.

14:04

So in the peripheral zone,

14:05

the dominant sequence is diffusion.

14:07

It clearly is a restricting in diffusion showing early

14:10

enhancement dark on T two, and it's clearly more than one

14:14

and a half centimeters with extra abstract extension.

14:16

Those clearly is a pyres five lesion on the right side.

14:20

And so it begs the course.

14:22

So as you can see here, the patient's PSA was 3.99,

14:26

and based on the volume of the gland that was measured,

14:29

which was around 44 ml, the PSA density was less than 0.15.

14:33

It was 0.09.

14:36

Uh, and despite the volume of the lesion

14:38

or the size of the lesion that you're seeing the patient's,

14:41

PSA is not very high.

14:42

And the PSA density certainly is not, uh, not abnormal.

14:46

And so the question is, you know, are we dealing

14:48

with prostate cancer here?

14:50

Are we dealing with something else?

14:52

There can be disease entities that may call be, uh,

14:55

may give rise to false positives.

14:58

And so when you are looking at something like this, one

15:01

of the things that you will always look in the charts

15:03

or the patient's, uh, history,

15:05

did the patient had history of bladder cancer?

15:07

Did they get BCG therapy

15:09

because BCG therapy can cause granulomatous prostatitis

15:12

that can look, you know, just like cancer, maybe look very,

15:15

uh, ugly looking cancer

15:17

that turns out the patient had no such history.

15:19

There was no history of any, um, uh, uh, uh, BCG therapy

15:24

or no bladder cancer.

15:26

The patient does not have any other histories, is

15:28

otherwise relatively fit, uh, you know, no chronic, uh,

15:32

debilitating condition.

15:33

So, uh, the patient also got A-P-S-M-A scan,

15:38

uh, because of the, uh, uh, extent of the abnormality

15:42

that was seen on the, uh, MRI, the question was, you know,

15:46

does the patient have distant metastasis?

15:48

And so you can see on this fused PSMA PET images that

15:52

that primary lesion also is not very PSMA habit

15:55

and obviously nothing else was seen.

15:57

So, you know, a couple of, uh, interesting, um,

16:02

observations here from an imaging perspective.

16:04

The question is, um, is, uh, before we,

16:08

before I show you the pathology, is that

16:10

clearly the patient's PSA is not very high.

16:13

The PSA density is low,

16:15

and also the PSMA scan is not, uh, in sync with

16:19

what we see on mr on the mr.

16:21

There's high volume disease, a lot of restricted diffusion,

16:24

early enhancement abnormality to signal extending into the

16:29

extracapsular, uh, uh, ex, uh, going beyond the, uh,

16:33

capsule into the neurovascular bundle.

16:35

And so the patient ended up getting a effusion biopsy,

16:38

and this was the final pathology.

16:39

It was prostate adenocarcinoma four plus five, which is,

16:42

you know, um, uh, Gleason, um, uh, grade group five

16:46

because of the, um, uh, the, uh, Gleason score of five,

16:50

the dominant being five,

16:51

and then a small percentage was grade group four,

16:54

cribriform pattern was present.

16:56

And, you know, vast majority of the course

16:58

that were sampled were involved.

17:00

So clearly this pathology report, uh,

17:04

is in sync with what was seen on mr.

17:07

Uh, you know, we saw large volume disease, we saw, uh,

17:11

marker restricted diffusion,

17:12

clearly extending into the extra capsular, uh,

17:15

having a extra capsular extent.

17:17

So this begs the two, two questions with low PSA

17:21

and PSA density and R is positive, what does that mean?

17:24

And when is positive?

17:25

And p SMA is relatively negative, what does that mean?

17:28

And in the, it's important for us

17:30

to understand these two issues

17:31

because as we are doing, um, more number of, uh, you know,

17:36

multiparametric ms it's not infrequent

17:39

that we encounter these two scenarios.

17:41

So what does the published body

17:43

of literature tell us about these two scenarios?

17:45

So I just, you know, in terms of take home points, so when

17:49

this was, uh, two studies, there are two studies, you know,

17:53

recently published looking at low PSA and a PSA density

17:56

and MR being positive.

17:57

And when you use a cutoff of four PS, a cutoff of four,

18:01

it turns out based on these two studies, the, uh, the,

18:05

the gist or the conclusion was if the PY RAD score is four

18:09

or five is a strong predictor of malignancy,

18:12

even when the PSA is low, what does this mean to us?

18:15

It means that you rely on what you see on mr,

18:18

even if the PSA value is, is, uh, is is not in sync with

18:22

what you're seeing on mr

18:23

or the PSA density is low, clearly what they say saw was,

18:27

you know, PSA density is a better,

18:29

a real more reliable indicator just, just as, uh,

18:32

purely looking at the PSA.

18:34

But as you saw in this case,

18:35

sometimes even the PSA density is not high.

18:38

So the, the, the bottom line is when you have this scenario,

18:41

when you have a low PSA, uh, and a low PSA density,

18:45

but you have a RADS four

18:47

or five, stick to that so that you know, it gets biopsied

18:49

and we know what's going on.

18:52

This was, um, uh, a large study of 17,000 patients,

18:56

and it was this DENBERG trial screening study where again,

19:00

here they looked at A PSA of less than three,

19:03

and they found that prostate cancer was seen in about 41.

19:08

And in, in these patients who had low PSA

19:10

and those who had a positive mr, they found that, um, uh,

19:15

on biopsying, those patients are doing fusion biopsy

19:17

of those patients, a vast majority, about 40, 41%

19:21

of those patients had, uh, prostate cancer that was found.

19:24

And of these, uh, 41% of the patients, nearly, uh,

19:29

you know, uh, 20% had Gleason seven or higher.

19:32

So that what, again, it reiterates the same, same message.

19:35

If you have low PSA

19:36

and you have a positive MR with a RADS of four

19:39

or five, rely on the, on the MR so that they can biopsy

19:43

and find a clinically significant cancer.

19:46

What about the second question?

19:47

If it's a low p, SA and PSA density and, and you know, am I,

19:52

and in this scenario, the question is what are the types

19:55

of tumors that we see?

19:57

So, you know, the most common, uh,

19:59

pathologic subtype is the aser subtype.

20:02

Uh, when you have this scenario, you can think about some,

20:06

uh, or you may envision that when they biopsy,

20:08

they may get some variance.

20:09

And one, one common,

20:11

maybe there's a small volume, high grade tumor.

20:13

This is less common scenario.

20:14

It can be ductal adenocarcinoma

20:16

and sort of ASIN adeno carcinoma

20:18

and sort of asinine adenocarcinoma and ductal

20:19

adenocarcinomas have less PSA production per cell, and

20:22

therefore the P overall PSA, uh, value is less.

20:25

And then you can have neuroendocrine variants that may, um,

20:29

contribute to the low PSA

20:30

and the PSA density, even though the R is

20:32

flagrantly abnormal.

20:34

So keep this in mind that you may have path variance,

20:37

pathologic variance,

20:38

especially the ductal adenocarcinoma sort.

20:42

So now let's look at the next, uh, um, sorry,

20:46

I'm just looking at the chat.

20:47

The next, uh, um, uh, question

20:50

or point that we were talking about, which is discordance

20:53

between MR and PSMA.

20:54

And again, this was a recent study that came out

20:57

and a couple of months ago

20:59

where they looked at 309 patients,

21:01

and what they found was MR

21:04

and PSMA PET can be discordant in about half 50%

21:08

of the cases, MR Unique lesions,

21:12

or in other words, those that were only seen on MR had

21:14

clinically significant cancer in, in about 85% of the cases.

21:18

And those that were unique by PSMA were high in about 78%.

21:23

And, um, if you look at, if you compare the MRI

21:27

and PSMA, it turns out

21:28

that they detected different index lesion in

21:31

about 7% of the cases.

21:32

So what does this tell you?

21:33

This tell you that they're truly complimentary tools,

21:36

and, you know, uh, one ought to, uh,

21:40

if either one is positive, one ought to focus on that lesion

21:43

and, and targeted, because as you can see here,

21:46

that you know, it meant it,

21:47

they may be harboring clinically significant cancer.

21:50

There again, this is not an uncommon occurrence.

21:52

We are seeing this more and more commonly,

21:54

just like we have false positives on, uh, on mr,

21:57

they are false positives on PSMA as well

22:00

as false negatives on PSMA.

22:01

So you have to, uh, keep this in mind.

22:03

So the take home here is low PSA does not exclude aggressive

22:07

or clinically significant prostate cancer.

22:09

Think of rare pathologic subtypes.

22:12

And if, and, and if you have a pyres four

22:15

or greater, it should prompt you consideration for biopsy,

22:18

even though the PSA or the uh, PSA density is low, and PSMA

22:22

and MR can be discordant in about 50% of the cases,

22:25

and one needs to take a closed look at, you know, both

22:28

to in order to, um, uh, in order to make sure

22:31

that you don't miss the clinically significant cancer

22:34

if you end up doing both.

22:35

So that's the second case. Now, moving on to the next case.

22:38

This is a, uh, recent, uh, patient

22:41

that we saw in our institution.

22:43

22-year-old woman, a three month history

22:46

of productive cough, expect she was coughing up mucus

22:50

with a metallic taste

22:51

and occasional shortness of breath

22:53

given the fact she was young, you know, they decided

22:55

to get a, um, chest x-ray, and these are the, the frontal

22:59

and the lateral radiograph.

23:01

And as you can see in this instance,

23:04

there is this ill-defined area that is present posteriorly,

23:08

uh, in the, uh, right lower lobe.

23:10

And so given her symptoms, it was thought

23:12

that this probably some kind of, you know, pneumonia

23:15

or pneumonitis, and they decided to empirically treat her,

23:18

uh, for the pneumonia with antibiotics.

23:22

Uh, despite being on the therapy for about, uh, two

23:25

to four weeks, she was still not getting better.

23:28

And during this time, she was complaining that occasionally

23:32

as she's coughing up, you know, she's going into spasms

23:35

where she feels a tightness in her throat.

23:37

She has difficulty in breathing, almost similar to

23:40

what you would see with anaphylaxis or laryngeal spasm.

23:44

And she also said that when she, uh, coughs up

23:48

or she's coughing up, this is, she brought in these,

23:51

you know what, she was coughing up

23:53

and this is what they look like.

23:54

Um, and you know, there were pictures taken.

23:57

So because she was not getting better

23:59

and, you know, not sure what was going on, they decided

24:01

to do a chest ct.

24:03

And so these are the lung windows.

24:04

Here is the coronal soft tissue and lung window.

24:06

And as I scroll through, you can see that there is a,

24:11

indeed an area of, um, airspace, uh,

24:14

disease on in the right lo lobe.

24:16

And you can see maybe a patch in

24:18

the right middle lobe as well.

24:19

The left lung looks relatively clear,

24:22

and if you now look on the coronal, uh, soft tissue

24:25

and lung windows, you'll see that as we scroll through,

24:29

there actually is a lesion in the dome of the liver.

24:31

And, uh, and as we go through, you can see

24:35

that there appears to be a communication to that area of,

24:38

uh, uh, airspace or ification seen in the right lower lobe.

24:43

So, you know, given the appearance on the ct, given

24:48

what she was coughing up, um,

24:50

and also the fact that something was seen in the liver,

24:52

a mr was done of the liver,

24:54

and let me show you the coronal, so

24:57

I much better delineation of what you see is, you know,

25:00

it looks like there is a multiloculated cystic lesion in the

25:04

dome of the liver that is clearly communicating across the

25:07

diaphragm into the lung, which is what the cause of her, um,

25:11

uh, uh, lung finding is.

25:13

Here's the communication right here, you can see,

25:15

and that's probably what, what she's coughing up.

25:18

And you know, those, and here is the early and the delayed.

25:21

Uh, this is the true fist kind

25:23

of showing the same appearance.

25:25

And then here is the enhanced images showing

25:31

what you know, that, uh, area

25:33

of air special specification enhancing,

25:34

and then the multilocular appearance of the, uh, uh, of the,

25:39

um, liver lesion.

25:42

And so it, so they questioned her more,

25:45

and it turns out she had extensive travel

25:47

history, including the sub.

25:48

She was, she had lived in the Sub-Saharan Africa

25:51

for about a couple of years

25:52

or two years owning multiple dogs.

25:55

And so based on, you know, uh, analysis of that cough up,

25:59

uh, material as well as the symptoms, you know, diagnosis

26:04

of hepatic cys rupturing into the lungs was made.

26:07

And this was, you know, is surgically resected as well.

26:11

And so rupture of the cyst can be spontaneous, can occur,

26:14

you know, due to increase in pressure

26:16

of the growing cyst can sometimes be hydrogen or traumatic.

26:20

So an interesting segue into discussion

26:23

of cystic lesions in the liver.

26:25

And so this clearly was a classic highlighted cyst

26:27

with the history and, you know, the clinical picture kind

26:30

of confirming what we see.

26:31

And in this case, the, in this case,

26:33

the high cyst had ruptured through the lung,

26:35

and clearly she was coughing up some of the scs

26:38

or the daughter cyst as we saw in those pictures.

26:42

So in terms of cystic lesions in the liver, you know,

26:45

this is sort of the broad differential

26:47

and you know, hers was a infectious etiology, a kind

26:51

of cocal, but you can see that these are the differentials

26:54

for the various, um, uh, cystic lesions.

26:57

And it's important to keep in mind that, you know,

26:59

having a list is good to understand what some

27:02

of the common entities are,

27:03

but how do we narrow the differential down?

27:06

One approach would be is to try

27:07

and think of the cystic lesions from a

27:10

embryologic perspective.

27:12

And you may have heard the term ductal plate malformations.

27:16

So this is, um, how the, uh, hepatocytes, uh,

27:21

ultimately form the liver parenchyma.

27:24

Uh, you know, based on that,

27:25

there can be certain congenital malformations that give rise

27:28

to cystic disease.

27:29

And, and this is a nice diagrammatic depiction of some

27:32

of those cystic lesions that are associated

27:34

with the ductal plate malformation.

27:37

And so a lot of these entities, you know,

27:39

you have commonly seen, I want to just emphasize two

27:42

that are, uh, clearly important

27:43

and, uh, to know, one is Carly disease.

27:47

And so Carly disease is sort of along the larger ducks

27:50

and it can come in two flavors.

27:53

One is the classic sort of multi multiple cy in the, um,

27:57

parenchyma where you have the central dot sign.

27:59

So essentially what it is, is there is a malformation

28:02

around the portal vein,

28:04

and that's what you're seeing as a flow wide in the center

28:06

and surrounding that is a cystic lesion.

28:09

So this is the classic Carly disease we see.

28:11

Now, it's important to keep in mind

28:13

that Carly disease can be, um, focal

28:16

as you're seeing in this case.

28:17

Oops, sorry. And so, you know, it doesn't have

28:20

to have this sort of flaw classic picture

28:23

with the central dot sign.

28:24

It can have this sort of a pattern where it appears

28:26

to be mullock red centered around that radical.

28:29

So this was path proven focal carol release disease.

28:33

The other common one we see is bi hamartoma.

28:36

And again, here's a CT appearance

28:38

where you are all familiar.

28:39

These are very scattered, you know, cyst up, uh, up

28:43

to a certain, uh, you know, they say up

28:45

to five millimeters in size, they are low density,

28:48

and they may show delayed enhancement on the, uh, you know,

28:53

if you run in the equilibrium phase images.

28:55

So, so that's sort of the, uh, one, one approaches.

28:59

And there are two other entities

29:01

that you have to be aware of.

29:02

One is, uh, what is referred to

29:04

as the intraductal papillary mucinous neoplasm

29:07

of the bile duct, which is the IPM

29:10

and equivalent in the liver.

29:12

And along the same, uh, spectrum is what is referred to

29:16

as the, uh, mucinous, um, cystic neoplasm of the liver.

29:20

Now they seem they, the, uh, description seems more

29:24

or less similar, but there are two very distinct entities,

29:26

the mucinous cystic neoplasm of the liver,

29:29

which this is an example of,

29:30

and you can see this is a CT right here in the center.

29:34

Here is a T two, and this is a gadolinium enhanced.

29:36

You can see that there is a large cystic lesion,

29:39

which on the T two you can actually see the peripheral, um,

29:43

uh, sort of smaller, uh, septated cystine along the edges

29:47

of the, uh, larger cystic lesion predominantly,

29:50

and it's just in the left lobe of the liver.

29:53

And so this, uh, what we call as MCNL

29:55

or mucin cystic neoplasm of the liver is characterized

29:59

by the presence of ovarian like trauma on, on pathology.

30:04

It, there is a risk of malignancy

30:05

associated with this lesion.

30:07

That's why they need to be resected.

30:09

And the other, um, important thing about, um, uh,

30:14

this lesion is how do you distinguish it from an I-P-M-N-B

30:19

or intra ductal pap?

30:21

Mucinous neoplasm or the bile duct is you try

30:23

and look for, uh, its relationship to the bile duct.

30:26

If it does not communicate with the bile duct,

30:28

it's com it's a cystic neoplasm of the liver.

30:31

So that's what this was pathologically receptor.

30:33

You can see on ct there is some peripheral calcification

30:36

as well, which these lesions, uh, can, uh,

30:39

depict and exhibit.

30:41

So that's what, uh, ml, uh, or MCNL, uh, looks like.

30:44

And now let's look at the example of, uh,

30:47

the intraductal papillary, uh, mucinous neoplasm

30:50

of the bile duct.

30:51

So this is, uh, a path proven case,

30:54

and what you see here is there is expansion

30:56

of the bile duct filling defect.

30:58

And you can see there is distal ductal dilatation.

31:00

So this clearly is communicating with the bile duct,

31:02

unlike the one we saw.

31:04

And what ends up happening is it produces mucin,

31:06

and this mucin is, uh,

31:08

slowly flowing within this dilated bile ducts

31:10

and can have, uh, flow voids or signal loss.

31:14

And, and there are various terms that describe that,

31:16

but the bottom line is it's mucin

31:18

that is free flowing in this lesion that appears as,

31:21

uh, filling defect.

31:22

So that's what it looks like on the coronal.

31:24

This is it on axial, again, showing the mark dilatation

31:27

and the lesion filling up the, um, dilated duct.

31:31

And as we come down, this is the early enhanced image,

31:35

and this is the d

31:37

enhanced image nicely showing the

31:39

dilatation of the bile duct.

31:40

So this was a path proven IPM and uh, b

31:43

or intra intra ductal papillary muus

31:46

neoplasm of the bile duct.

31:47

Again, like I said, both the cystic neoplasm

31:51

and this entity have a predisposition to malignancy,

31:53

and so they need to be, um, uh, resected.

31:58

So that's sort of, uh, a segue into cystic lesions.

32:00

You know, you need to look at the communication

32:02

to the bile duct relationship to the bile duct.

32:05

I look at symptoms and morphology of the cystic lesions

32:07

to come to a narrow differential, uh, diagnosis.

32:11

Okay, moving on to the next case.

32:13

This is a patient who presents to the emergency room

32:16

with abdominal pain.

32:18

And so I'm gonna walk you through the axial images.

32:22

Uh, this was a, um, adrenal lesion

32:25

that was present on prior studies, so nothing, uh, uh,

32:30

so something that will be relevant in this specific

32:33

instance, but let's go down

32:37

and see what is the cause of her pain.

32:46

So again, oral contrast has been given here.

32:49

And you know, I know that some institutions don't like

32:51

to give oral contrast, but in this case

32:52

it definitely did help.

32:54

Um, and here is the coronal.

33:02

So, um, the question is what is the finding?

33:05

The finding are, you are seeing multiple polypoidal lesions

33:09

seen within the, um, uh, opacified, uh, small bowel,

33:14

uh, loops, going all the way from the deum to the Im,

33:18

we saw a left adrenal lesion, uh, that was present as well,

33:23

and nothing else that is present.

33:26

So the question is, what is the differential

33:28

of multiple filling defects within, uh, pacified bowels?

33:33

And there are varying sizes.

33:34

They're not, uh, uniform in size.

33:36

Some of them are smaller, some of them are larger.

33:39

Uh, you know, some of them, uh, most

33:41

of them are pedunculated.

33:42

Some of them, uh, appear to be, um,

33:45

but there is no, uh, accompanying wall thickening.

33:48

There is no obstruction, there is no int interception.

33:50

So those are sort of pertinent negatives that you will, uh,

33:53

uh, like to mention in this, uh, in this case.

33:57

And so the question is, what are some

33:58

of the differential considerations?

34:00

So, you know, the differential consideration in this case.

34:03

Uh, so again, just to show you where the multiple, multiple,

34:08

uh, lesions are are.

34:10

So the differential considerations are,

34:12

can this be some kind of hereditary polyposis syndrome?

34:16

You know, in which case you can get multiple hematomas

34:18

that are present, you know, pure Jagger.

34:20

Uh, there are other familial polyposis

34:23

syndromes that can do this.

34:25

Uh, and pure checkers will have multiple hematomas

34:28

or multiple vascular malformations.

34:30

You can have multiple, um, gastrointestinal stromal tumors

34:34

that can happen in, uh, patients with neurofibromatosis.

34:37

These suddenly don't fit the picture of

34:38

what gist would look like.

34:41

And then they, you know,

34:42

always keep in mind when you have multiple, uh, uh,

34:46

lesions within the small bowel loop, you think in terms

34:48

of metastasis, the common one being melanoma,

34:51

you can also get mets to the bowel from lung and breast.

34:55

Now, in this case, you know, the fact

34:57

that patient has an adrenal lesion, patient has multiple,

35:01

uh, filling defects.

35:02

The question is what is the, uh, diagnosis?

35:05

And this was a patient who had metastasis from, uh,

35:08

lung cancer and the adrenal was adrenal lesion, was, uh,

35:12

also met a non met in a patient with lung cancer.

35:15

So keep that in mind. These are the, some

35:16

of the differentials for multiple filling defects.

35:19

Um, uh, you know, just as a point of note, uh, in terms of,

35:25

uh, somebody who would ask is, why are you, you know,

35:27

why was oral contrast given?

35:29

So at our institution with the history

35:32

of prior malignancies,

35:33

or when we're doing cancer staging, we like

35:35

to give oral contrast because of, of this very reason,

35:38

it makes identification of, uh, intraluminal, um,

35:42

filling defects a little bit easier.

35:44

Uh, also if you opacify the bowel loops,

35:47

o mental metastases are relatively easy to detect.

35:51

And so those are some key things to,

35:53

you know, to keep in mind.

35:54

Obviously, patient is coming to the emergency room, then,

35:57

uh, we don't typically give because that kind of waste time,

36:00

but, uh, uh, clearly in the oncology population,

36:03

it may be beneficial to, um, uh, you know, to, uh, to give,

36:07

um, uh, uh, oral contrast.

36:11

Okay, so that was, this can. Now moving on to the next case.

36:13

This is a 45-year-old, uh, who has never been,

36:18

um, pregnant before.

36:19

She, uh, is referred with pelvic pain pressure

36:22

and having irregular periods.

36:25

Her ca 1 25 is normal.

36:27

And so, um, you know, she comes and gets an ultrasound.

36:31

So I'm gonna walk you through some of the static images.

36:33

I don't have the, um, uh, the cine loops, uh,

36:37

but uh, I'm gonna show you.

36:38

So here is a ovary that you see, uh, sagittal leftover.

36:42

You can see there is a little bit

36:43

of free fluid surrounding the ovary.

36:46

And as I keep scrolling, this is

36:48

what is seen in the right at Nexa.

36:51

Uh, the right ovary was not, uh, visualized separate from,

36:55

you know, this was just seen in the right head nexa.

36:58

And so one thing to keep in mind is, you know, when you are

37:01

reading, uh, pelvic ultrasound or pelvic mrs, you try

37:05

and refrain from using the term complex

37:07

because that really doesn't

37:09

communicate any kind of information.

37:11

It's better to be descriptive.

37:13

And so, you know, the question is, is this some kind

37:15

of a multilocular lesion with what there appears to be?

37:19

Um, some of the molecules appear to show internal echos.

37:22

We haven't really seen any frank Nodularity

37:25

or, um, so this is what it looks like.

37:28

Um, again, you can see the septation present in the right

37:32

and neck and the technologist was not sure if she's looking

37:35

at the ary in this case here,

37:38

or is it just part of the larger lesion.

37:40

Her uterus was very large, as you can see.

37:42

And, uh, she had, uh, uh, fibroids arising,

37:47

as you can see, subserosal intramural.

37:49

And this was a large fibroid projecting from the

37:54

uterus into the ad nexa.

37:56

And so, um,

38:00

just keep going here.

38:01

So here's sort of, again, looking at the endometrium,

38:04

this is where the right adnexal lesion is

38:06

and what it looks like on, as you can see, this is a large,

38:09

uh, you know, mul multilocular cystic lesion

38:12

in the right and next up.

38:15

So that's was in a nutshell what it was not an acute pain,

38:18

it was, you know, just presenting with pain.

38:20

And, uh, the question was, any irregular periods, obviously,

38:24

given the fact that she had a large fibroids,

38:26

that may explain what's going on with the uterus.

38:29

So given this, the,

38:31

and the question was what was going on on the right side

38:33

and a pelvic MR was recommended?

38:35

So let me show you, uh, selected images from the pelvic mr.

38:39

So here's the axial T two edit sequence.

38:42

So as I come down, we can start seeing

38:46

that multilocular cystic lesion, uh, on the right side

38:50

that is extending, here's the go vein that is sort of

38:54

meandering along and you see the flow wide.

38:57

And, um, so that was the upper abdomen.

39:00

Now we are going into the pelvis.

39:03

So here it is, you can see it's coming in,

39:06

and again, you're seeing the multilocular lesion.

39:10

And here is the right ovary right here.

39:12

You can nicely see because there are follicles within it.

39:15

And, uh, you know, the gonadal vein tracks right into it.

39:18

So this, whatever this multilocular cystic lesion is,

39:22

is surrounding the right ov.

39:24

The leftover is also seen,

39:26

and it's in this location right here,

39:29

there you can see it right there.

39:31

And as you can see in the uterus, it's fairly vascular

39:35

and there's large fibroids that are arising, uh,

39:38

parasitizing, you know, vessels.

39:40

There's posterior subserosal, anterior subserosal,

39:43

intramural fibroids.

39:45

Um, so

39:47

that's the axial here is the post galin enhanced image, uh,

39:51

just to show you what the fibroid looks like

39:53

and what this multilocular cystic lesion looks like.

39:57

And you can see the septations that are enhancing, again,

40:00

no discrete ular component.

40:02

And the ovary, uh, as we saw earlier, shows, uh,

40:06

symmetric enhancement to what we see on the left side.

40:10

And let me show the SAG T two just

40:12

to show you what it looks like.

40:18

So very bulky fibroid uterus, uh, multiple oma.

40:22

And then we saw the multilocular cystic lesion

40:26

with really no solid component.

40:27

And, um,

40:29

and so the question is

40:31

what is clearly there are fibroids in the uterus.

40:34

The question is what is this large, uh,

40:36

multilocular cystic lesion

40:38

that is in the right nexus surrounding the right ovary

40:42

with no clear, uh, nodular component?

40:45

Uh, there are enhancing septations,

40:47

and you know, if one was to assign an OR category, it's said

40:51

that, you know, most of the multilocular cystic lesions are,

40:54

or at three with a very low percentage of, of malignancy.

40:58

And so the question is, what is this lesion?

41:00

And starting in the pelvis and,

41:02

and sort of extending into the retroperitonium along

41:04

with the fibroid.

41:05

And so obviously the patient was exceedingly symptomatic,

41:09

so patient ended up going to surgery

41:11

and this was the final pathology.

41:14

So the, uh, left side was fine.

41:16

The uterus had, uh, as you can see, multiple ERs

41:19

or fibroids, but in the right of way,

41:22

the right at nexel lesion was a lymph angioma.

41:24

So that multilocular cystic lesion

41:26

that we saw was a lymph angioma

41:27

and the ovaries did not show any abnormality.

41:31

So why am I showing you this case?

41:32

The reason, reason for showing this case is

41:34

that there is actually a known association with ERs

41:37

and lymphangion, especially when the ERs are very large.

41:40

So if the fibroid burden of the uterus is fairly large,

41:44

you can see these multi, uh, ated, uh, cystic lesions

41:48

that can start in the pelvis, go into the retroperitonium.

41:50

And some have postulated that these are owing to disruption

41:54

of lymphatic circulation leading to formation of the cystic,

41:57

uh, lymph angioma.

41:59

The larger the uterine fibroid burden,

42:01

the higher is the risk of the cystic lymph lymph angioma.

42:05

And when they do go in, they have to make sure

42:07

that they resect them completely.

42:09

Uh, if they end up leaving a part of it behind,

42:13

then it can grow.

42:14

And, uh, you know, also it,

42:16

it typically they're not symptomatic,

42:18

but again, they may grow and, you know, enlarge in size

42:21

and may produce symptoms in the near future.

42:23

Therefore, when they do take it out, they have to be sure

42:26

that there is a near complete excision.

42:28

So that's sort of a interesting, uh, um, uh,

42:33

you know, observation in terms of correlation.

42:37

Okay, moving on to the next case.

42:38

This is a 60-year-old woman who is complaining

42:40

of feeling something like a ball in her stomach.

42:44

And let's start with the axial, uh, uh, CT image.

42:49

And as we go down, you can see as we are coming,

42:51

there's probably a cyst in the liver.

42:53

There is some, um, stranding you're seeing in the omentum,

42:57

you know, maybe some nodularity right there.

42:59

Again, as we come down, it'll fairly nodular appearing, um,

43:03

o mental stranding.

43:06

And as this is the reason why this is the cause of

43:10

what she's feeling, there is a soft tissue mass per

43:12

umbilical in location

43:14

and we come down to the pelvis and looks pretty.

43:18

Here's the SAG image

43:23

Again showing that abnormality, periumbilical

43:25

or in location where there is clearly a soft tissue along

43:28

with the changes in the omentum that, uh, we spoke about.

43:39

So this is sort of the summation of, um, uh,

43:42

you know, of our findings.

43:44

You can see that there is stranding

43:46

and nodularity in the omentum

43:49

and then large soft tissue nodule periumbilical in location.

43:52

So the question is, you know, what are the findings

43:54

and what is your differential?

43:56

We talked about the finding is primarily in the o mentum

43:58

and what is the differential.

44:01

And so this sort of soft tissue nodule, uh, some people have

44:05

described it as a what is referred to

44:08

as a sister Mary Josephs nole.

44:10

And it is, uh, owing

44:13

to metastatic tumor deposit in the per

44:15

umbilical, uh, location.

44:17

And typically it is associated with cancers

44:19

of the GI tract and the ovarian.

44:21

Just to kind of, uh, in terms of reference,

44:24

why is it called Sister Mary Josephs?

44:26

Because you know,

44:27

sister Mary Joseph was a surgical assistant to the, uh,

44:30

Dr. William Mayo of the Mayo Clinic,

44:33

and she was the one who saw, saw the association

44:35

between these para iCal nodules

44:37

and metastatic intrabdominal cancer while they were prepping

44:41

the patient's skin for surgery.

44:42

And this was published and that's

44:44

how the EPI acronym was, uh, coined.

44:46

And so when you see this kind of soft tissue nodule

44:51

and you see this kind of omental stranding,

44:54

you immediately assume that this is owing to,

44:57

uh, metastasis.

44:59

But there is a differential.

45:00

You have to keep in mind that there are certain entities

45:03

that can mimic omental, uh, tumor deposits

45:07

and what other the usual suspects are.

45:09

Clearly, you know, you can have GI

45:11

or ovarian, um, source spreading

45:14

to the omentum, which is the case here.

45:16

In this case it is ovarian lymphoma is the other big one,

45:19

which can look just like, um, uh, the, uh,

45:23

metastatic spread from GI or ovarian primary

45:27

and then infection TB can sometimes what is referred

45:30

as a dry TB can, you know, where there is not a lot

45:32

of AEs can, um, can uh, look like, um, uh, uh,

45:37

metastatic tumor deposit.

45:39

But there is one other entity that we tend not to, uh,

45:42

talk about or we forget in the differential.

45:46

And that entity is malignant mesothelioma.

45:49

So this is malignancy of the peritoneal, uh, uh, you know,

45:53

reflection just like it happens in the ple can also happen

45:57

in the, uh, peritoneal cavity.

45:59

And this current case was actually a malignant mesothelioma.

46:02

It was not a metastatic deposit from either the GI

46:06

or the ovarian or an ovarian primary.

46:08

And so, uh, this is from an a JR article, you know,

46:12

talking about different types of mesotheliomas,

46:15

primary peritoneal mesotheliomas.

46:17

But the bottom line, the take home message is that

46:20

malignant mesotheliomas can mimic omental tumor deposit.

46:24

So along with the differential of MET lymphoma

46:27

and infection, keep primary malignant mesothelioma also in

46:31

your mind, because there are two reasons for that.

46:34

One is the treatment may vary, you know, it, it's um,

46:38

it's not the same as uh, treating a patient

46:41

with omental metastasis.

46:42

These patients require more aggressive line of therapy

46:46

and there are different, um, regimens that are used.

46:49

So knowing or at least suggesting this, can I tell you,

46:53

can I tell you all features

46:55

that are different from the others?

46:57

No, but you have to keep it in the differential.

46:59

And when they do the biopsy and find this, you know,

47:01

then they obviously have to appropriately treat the patient.

47:06

So moving on to the next case.

47:07

This is a 30 5-year-old woman who is pregnant at 25 weeks.

47:13

She comes with acute sharp, right upper quadrant pain

47:17

and gets an emergent ultrasound.

47:19

Now based just on the symptoms, you know, uh, pregnant, uh,

47:24

women can, uh, they can develop acute appendicitis,

47:28

which typically will be lower,

47:29

but this is upper quadrant, they can get cholecystitis.

47:32

If they had gallstones in the past, that would be one.

47:36

They can also get renal calculate that can present as, uh,

47:39

right upper quadrant pain.

47:41

And so those are some of the entities that you're thinking.

47:43

So starting with an ultrasound as a good option.

47:45

And you can see as I'm, again, I have static images here

47:48

as I'm scrolling through.

47:50

This is the kidney, the liver.

47:52

And in the senal region of the kidney, uh,

47:56

above the kidney there was this, uh, soft tissue lesion

48:00

that was seen and was measured.

48:02

It was about five and a half centimeters in size.

48:05

So as I keep going, you can see right, that's,

48:08

that's here is the kidney, this is the liver,

48:09

and this is above, uh, the kidney.

48:11

The left kidney was normal as we keep going.

48:20

So the gallbladder was, uh, you know, there was gallstones

48:23

that were seen, but there was clearly no sign

48:25

of cholecystitis, uh, that was, uh, present.

48:30

And so here's the findings on ultrasound cosis

48:33

with no Murphy sign or focal tenderness

48:35

this size sineal lesion, ISO EQU to the liver.

48:39

And the question is, what are the differential

48:41

diagnosis and what will you do next?

48:44

And you know, it was a conundrum what was going on?

48:47

Remember, you know, you can get sometimes if the patient has

48:50

a, a feel, you know, the fuel can bleed in in pregnancy.

48:54

That's one thing that you have to keep in mind.

48:55

So the question was what was going on?

48:57

And so an MR was ordered. So let's look at the MR now.

49:01

So what you're looking at here is a fat

49:03

saturated T two added image.

49:04

This is a non-fat saturated, uh, T two variant image.

49:08

So as we scroll through, you can see

49:09

that the gallstones are nicely seen.

49:11

And this is this lesion right here,

49:13

which is very bright on the fat saturated T two,

49:17

also bright on the non-fat SAT T two.

49:19

Again, nicely seen the gallstones as well.

49:22

So let's keep going.

49:24

So that's what on T two, this is the in phase

49:27

and the outer phase images.

49:30

So the lesion is uh, doesn't show any drop.

49:33

In fact, there are some subtle areas

49:35

of T one bright signal within it,

49:38

but again, not, not something that looks very hemorrhagic.

49:40

These are the, the low B value, the the B value of 800,

49:45

the a DC from that, and again the T two edit sequence.

49:48

And you can see that the lesion is, uh,

49:50

bright on the high B value

49:52

and relatively dark on the A DC, right?

49:58

A little bit, uh, in out of sync here,

50:00

but that's how you get the gist in terms of, so just

50:03

show there is no T two shine through.

50:05

In fact, there is, if anything,

50:06

restricted diffusion that is present.

50:08

Obviously contrast could not be given since you know she

50:11

was, uh, pregnant.

50:12

So this is the MR finding have kind

50:15

of laid out all the sequences for you.

50:17

So T two hyperintense lesion

50:18

with within the right adrenal gland measuring this

50:21

with subtle internal debris, rim of T two,

50:23

high point intensity, minimal T one, uh, high, high,

50:27

you know, signal intensity, peripherally

50:29

restricted diffusion, no signal dropout on

50:31

the auto phase to suggest.

50:33

And so the question is what are your differentials?

50:37

So as we al always do is we pull up the old, um, you know,

50:42

old images and it turns out the patient did have a CT scan

50:46

from before she was pregnant

50:48

and that did not show any adrenal mass.

50:51

So it becomes exceedingly unlikely that this is some kind

50:53

of a, you know, like we said,

50:55

it could be a few that has bled.

50:56

The question is, she didn't have anything on the CT scan

50:59

before her pregnancy.

51:00

So clearly it is something that is new.

51:03

And the question is what is the, the diagnosis?

51:06

And again, this is something that you have to be aware of,

51:08

can happen in pregnancy,

51:10

and this was unilateral adrenal hemorrhage.

51:12

Uh, unilateral adrenal hemorrhage can be, you know, trauma.

51:16

It can also because an underlying neoplasm

51:18

or in this case spontaneous.

51:20

So then you may ask me, well if it is hemorrhage,

51:22

why is it not bright on T one?

51:24

You're not seeing any bright signal on T one.

51:26

And so this is a very important point to keep in mind.

51:29

Going back to, you know, the experience from neuro, uh,

51:33

our neuroradiology colleagues when they have looked at

51:35

hemorrhage in the brain, it turns out when the hemorrhage is

51:38

less than 24 hours,

51:40

it can be T one iso intense T two, uh, hyperintense

51:44

and it can show restricted diffusion.

51:46

Once it goes beyond that,

51:48

that's when you start seeing the classic changes

51:50

where it becomes T one bright but

51:52

before in less than 24 hours.

51:53

And remember it was a very acute finding in this case.

51:56

And so she probably presented just right when she got the

51:58

hemorrhage, which was less than 24 hours.

52:00

That's the reason why. Oops.

52:02

It was, um, bright on T two

52:04

and was showing restricted diffusion.

52:06

So what is this entity?

52:08

Spontaneous unilateral adrenal hemorrhage in pregnancy?

52:10

It can occur in the absence of trauma

52:12

or anticoagulants, unclear etiology.

52:14

Some people say it's because of spasm of the adrenal vein.

52:19

It's fairly rare. It's usually on the right side can present

52:22

with sym, you know, acute symptoms of pain and fatigue

52:26

and it's conservative management, fluid resuscitation

52:28

and some, some give steroid therapy

52:31

and you know, if there is any kind of coagulopathy

52:33

of pregnancy underlying, they'll correct for that.

52:35

And so this patient was treated conservatively and this is

52:38

after, uh, four months

52:40

after her pregnancy she got an uh, mr.

52:42

You can see gadolinium was given

52:44

because obviously she's no longer pregnant

52:46

and you can see the right adrenal gland

52:48

is absolutely normal.

52:49

There is nothing there in the right adrenal.

52:51

So it was a spontaneous hemorrhage in this case, which, uh,

52:55

has resolved, uh, uh, you know, without any, with just

52:59

with conservative management.

53:00

She's starting to see, you're starting to see some changes

53:03

of, you know, chole status developed because of her stones.

53:05

But, uh, clearly the adrenal, uh, issue has,

53:08

uh, totally resolved.

53:11

So I think in the interest of time it is 1253.

53:14

I'll stop here.

53:15

You know, we have additional cases

53:16

but I don't think I'll complete the next one if we start.

53:19

And, um, I'm happy to answer any questions if you want

53:22

to unmute yourself or put any questions in the q

53:25

and a chat, I'm happy to, you know, take those and answer.

53:29

Yeah. Thank you so much for this case review, Dr. Ani.

53:32

Um, yes, at this time we'll open the floor

53:34

for any questions from our audience

53:36

and you may submit your questions

53:37

through the q and a feature.

53:39

Have you seen cases of pelvic and ovarian highlighted?

53:42

No, I have not.

53:44

Uh, it's not very common in this part of the world,

53:46

so you know, we don't see as many.

53:48

And so, uh,

53:50

so somebody said they have a question about

53:52

mucinous cystic neoplasma.

53:53

Yes, go ahead. If you wanna unmute and ask, that's fine.

53:56

Or if you wanna type it, please do that.

53:58

What would be the differential

53:59

for the right senal mass on ultrasound?

54:02

Yeah, so that's a good, you know, so remember uh,

54:05

as I mentioned on the prior ct, she didn't have any lesion

54:08

and so it would be very unusual for something

54:10

to develop in this shorter duration besides a hemorrhage.

54:14

Uh, so it really, it cannot be any kind of focal mass.

54:17

Um, so that essentially is the only possibility,

54:21

um, you know, that is present.

54:22

Now obviously what you wanna make sure is

54:26

that it is indeed arising in the adrenal

54:27

and that is one other re um, reason why Mr was done

54:30

to confirm theat location.

54:33

'cause you could have something that is sitting very close

54:35

to the, um, adrenal

54:37

and, you know, uh, mimic an adrenal mass.

54:39

So that's was something that we wanted to make sure that,

54:41

uh, uh, you know, it wasn't the case there,

54:44

so you could have something extra adrenal sitting next

54:47

to the, uh, you know, uh,

54:49

it could be a spontaneous perinephric hemorrhage

54:52

or something like that, that may mimic, but, uh,

54:54

but in terms of the adrenal, if their prior scan

54:57

in short order was negative,

54:59

then it would be very little except a hemorrhage.

55:04

Can we do differential diagnosis, adema, adenoma, poor, uh,

55:07

uh, lipid, poor adenoma?

55:09

Well again, but for that it should be present.

55:12

Um, on the prior study, which was not the case.

55:15

Uh, how do you distinguish, um, how,

55:20

so let's see, how do you distinguish, uh, IP, m and B?

55:25

And like I said, i, p, M

55:26

and B is usually in a, within the duct.

55:28

And so you will see dilatation of the duct

55:30

and communication to the duct.

55:32

Uh, how common are these cystic neoplasms

55:34

or liver as well as IP, M and B?

55:36

So, you know, I would say they're not as common

55:39

as a routine cyst with bleed or, you know,

55:42

but, uh, ours being a tertiary care center,

55:46

we see them fairly often.

55:48

So, uh, I, I can't give you a percentage in terms of

55:51

how many, you know, but it's not that uncommon.

55:54

And especially the ip ip, the, in the, uh, I-P-M-N-B is,

55:59

uh, we are seeing it increasing frequency, uh, nowadays.

56:03

So for the Carli disease, do we get

56:06

to see the central dot sign on all the lesion,

56:08

or is possible a combination

56:09

of the Carole and other cystic lesions?

56:10

So typically Caris doesn't, you know, you don't,

56:13

you don't see two, uh,

56:15

bi plate malformations coexist in the same individual.

56:18

So it, not all the lesions in Caroles will show

56:22

the central dot sign.

56:23

So that doesn't mean it's a different entity, it just means

56:26

that you're not, you know, seeing it as well in that, uh,

56:30

cystic lesion as you're seeing in the other, uh,

56:34

I've seen hepatic mucinous.

56:35

But yes, you can see biliary dilatation

56:37

with muus lesion when it obstructs the duct.

56:40

Uh, again, I'm, what I mentioned and emphasized was the ip.

56:44

The I-P-M-N-B is the one that communicates with the duct

56:48

obstruction of the duct can happen

56:49

because of the mass effect.

56:50

Even with, uh, simple cyst

56:52

that bleed can sometimes cause obstruction to the ducts.

56:55

It's the communication of the duct, uh,

56:58

uh, that makes it different.

57:00

Uh, are there any other locations other than the liver? Yes.

57:03

I mean, you know, the, where it is endemic,

57:05

you probably see it in multiple organs.

57:07

We have seen it in the liver, the lung, uh,

57:10

even in the kidneys.

57:11

Uh, I'm sure those who live in that part of the, uh,

57:14

you know, where it's common, they probably have seen

57:15

it in multiple organs.

57:18

What do we do? If you don't have the old CT in the adrenal

57:21

case, then yes, then the differential widens a little bit.

57:24

Obviously you will have to think about an adenoma,

57:27

uh, lipid, poor adenoma.

57:28

Yes, absolutely.

57:32

How do we differentiate muus and scy adenoma of the ovary?

57:35

Well, we didn't, we didn't quite cover that topic,

57:37

but, so remember, it's in the spectrum

57:40

of epithelial lesions.

57:41

One of the specific features with mucin is, you know,

57:45

they have that what is called as a stained glass appearance,

57:47

because there is varying components of mucin in the cyst,

57:50

which is not typically seen with the, um,

57:53

the cs, uh, type of tumor.

57:54

So there is one way of, uh,

57:56

but apart from that, it can sometimes be a challenge.

57:59

All you can say it's a cystic lesion, give the, uh, chances

58:03

of it being malignant with the rads, uh, criteria.

58:06

Uh, and then, you know, uh, the commonest being epithelial,

58:09

which basically encompasses s

58:11

and muus, uh, lesions, uh, how

58:15

to differentiate peritoneal mets versus

58:17

stranding in cirrhosis.

58:19

So that's actually a good point, uh, on Mr and,

58:22

and you are right sometimes on mr, it can be a challenge.

58:25

Uh, uh, what I'll tell you is obviously if there is

58:27

cirrhosis and just simple stranding

58:29

with no discreet nodularity, then it's more likely

58:31

to be congestion rather than, um, rather than true, uh,

58:36

peritoneal deposits.

58:38

So peritoneal inclusions, how

58:40

to differentiate peritoneal inclusion system

58:42

and lymph angioma, that's a, a good, uh, good question.

58:46

So the two, uh, things

58:47

that peritoneal inclusion cys require is, um,

58:51

functioning ovarian stroma and adhesions.

58:52

Now, those are adhesions are typically post-surgical.

58:55

So obviously there'll be a history of surgery, uh, with,

58:58

you know, residual ovarian from my left behind, which kind

59:01

of is causing the fluid to form.

59:03

And then the adhesions are one ones that cause a loculation.

59:06

Those typically are, again, confined to the pelvis.

59:08

Lymph angiomas, like in this case, extends all the way

59:11

to the retroperitoneum, as you saw.

59:13

So lymph angiomas are, are more conforming lesions.

59:17

So they conform to the anatomy

59:18

and extend along the vessels, uh, into the retroperitoneum,

59:21

which, uh, the, um, inclusion system typically don't do.

59:25

Again, you know, at the, at the onset I said that, uh,

59:28

these are merely, you know, criteria that you can apply,

59:32

but, uh, there are no absolute uh, imaging, uh, findings.

59:38

Well, awesome. I think you got 'em all.

59:39

Dr. Harrison Gotti, thank you so much.

59:44

Yeah, thanks a lot. Thanks.

59:45

Thank, thank you to all the

59:47

attendees as well. Thanks, Ashley.

59:49

Yes, and thank you for everyone participating today

59:52

and asking such great questions.

59:54

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59:56

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59:59

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60:03

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60:06

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60:08

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60:12

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60:14

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