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Hello and welcome to noom Conference, hosted by MRI Online

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Noon Conference connects the global radiology community

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through free live educational webinars that are accessible

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for all and is an opportunity

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to learn alongside top radiologists from around the world.

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You can access a recording of today's conference

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and previous noom conferences

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by creating a free MRI online account.

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Today we are honored to welcome Dr.

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Mahan Mather for a GI G case review. Since 2013, Dr.

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Mather has served his faculty at the Yale School

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of Medicine, where he's an associate professor of radiology

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and biomedical imaging and vice chair of education.

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He's passionate about radiology education and mentorship,

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and has been the recipient of the RSNA Honored Educator

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Award in 2017

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and 2021, as well as numerous departmental teacher

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and mentor of the year awards.

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We're also thankful for his supportive MRI align

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and for serving as our body imaging advisor.

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In this interactive session, Dr.

0:57

Mather will show key images along

0:59

with a multiple choice question,

1:00

and you'll respond with your best answer via

1:02

the live polling feature.

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After a quick answer explanation, it's onto the next case.

1:08

If there's time at the end of this case review,

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please join him in a q

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and a session where he will address questions you

1:13

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

1:18

as many as we can before our time is up.

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

1:24

Mather, please take it from here.

1:27

Thank you very much. Uh, good afternoon to everyone.

1:30

It's an afternoon here in New Haven, Connecticut.

1:32

Um, not sure where people are joining from,

1:33

from across the world, but, uh, good afternoon to all.

1:36

I'm delighted to be here.

1:37

Truly an honor to be here

1:39

and, uh, excited to be able to share some cases with you,

1:42

uh, for the next hour or so.

1:44

So with that, I will share my screen.

1:47

So this is gonna be a GI GU case conference.

1:50

This is a snapshot of some of our, uh, trainees

1:53

and our program with some of the education leadership.

1:55

This is our, um, uh, our Yale mascot, handsome Dan, a big,

1:59

uh, this one is an inflatable dog,

2:01

and this is of course our Yale Medical School, um, uh,

2:04

picture of our Yale Med School.

2:05

And so today's gonna be GI G cases.

2:07

And the way I, uh, plan this out, there's gonna be 20 cases

2:11

and 20 GI ca uh, 10 GI cases.

2:13

10 GU cases, and they're gonna be

2:16

sort of interspersed throughout.

2:17

So it's not gonna be the first 10 or GI

2:19

and the, the second 10 or gu.

2:21

And we're gonna cover a bunch of different organs within,

2:23

uh, within those sections.

2:25

And, uh, as I said, there'll be, um,

2:27

an image or two that I'll show up.

2:29

We'll follow that up with a multiple choice question.

2:31

We'll have you guys, um, respond to that

2:34

and, uh, we'll go through the case together

2:36

and maybe I'll have some follow up questions as well, which,

2:38

uh, I'm happy for the audience to, to type in,

2:40

um, into the chat box.

2:42

So with that, let's go to our first case. Here we go.

2:50

I'm just gonna leave this up here for a few seconds.

2:52

Have a look at the case. What do we think is going

2:56

on as we go through this?

3:04

All right, now I'm gonna go

3:07

and provide you with the multiple choice options.

3:12

Over here. Should have a popup box.

3:21

What is the most appropriate initial treatment cystectomy

3:23

with ileal conduit creation, antibiotics

3:25

and Foley catheter drainage.

3:27

So is hitch sup pubic catheter placement.

3:36

All right, so we

3:41

see top answer antibiotics and Foley catheter.

3:44

And 68% no one picked a so

3:46

as hip, so people didn't like that.

3:47

Um, and then there was an even split between, uh,

3:50

some surgical options, cystectomy and, and aloc, conation

3:53

and SUP catheter replacement.

3:54

Perfect. So let's have a look at this case.

3:56

And, uh, the right answer is antibiotics

3:58

and Foley catheter drainage highlighted here in purple.

4:01

And so if we just look at this case, this is a plain film

4:03

of the, of the abdomen.

4:04

We can see, uh, an enteric tube over here.

4:06

And the real finding is centered around the pelvis.

4:08

You can see that there's almost this ring

4:10

of lucency around the pelvis.

4:11

And the question is, you know, what is that?

4:13

Um, and is that a normal finding? Is an abnormal finding.

4:16

If it's an abnormal finding, where is this located?

4:19

And this can be tough, you know, one can look at this

4:21

and think it's related to, um, a loop of bowel

4:24

and potentially air inside a loop of bowel,

4:26

which is called pneumatosis.

4:27

But the thing that lives down here in the midline

4:29

that has the shape, of course, is the bladder.

4:31

And when you see lucency surrounding the periphery

4:33

of the bladder like that, we need

4:35

to be worried about emphysema cystitis.

4:37

And, um, this is, uh,

4:39

and the treatment for emphysema cystitis is antibiotics.

4:42

Foley catheter drain, at least the initial treatment for it.

4:44

And so who gets emphysema

4:46

cystitis or what are the risk factors?

4:47

Diabetes is certainly one of them.

4:49

Anything that, uh, promotes urinary stasis,

4:51

whether it's a bladder outlet obstruction

4:53

or patients who can't, um, empty their bladder, say, uh,

5:00

am prone to getting emphysema cystitis,

5:02

there are certain bugs, the common bugs that cause

5:04

UTIs are the ones that can cause emphysema, cystitis.

5:07

You treat it with antibiotics, you try to drain it.

5:09

And, um, the key is to always, you know, sort

5:12

of differentiate this in your mind from emphysema pilon

5:14

nephritis, where you have this gas forming infection

5:17

of the renal parenchyma eating up the renal parenchyma

5:19

that often requires surgery, uh,

5:21

taking an, you know, the kidney out.

5:22

But this can be treated conservatively

5:25

with this sort of treatment.

5:26

And the other options, uh, that we talked about over here,

5:29

uh, you know, we, I haven't seen patients do cystectomy

5:32

or a supra pubic catheter placement for these.

5:34

Typically, uh, we'll do a Foley catheter

5:36

and just give antibiotics.

5:38

Um, certainly you can do, you know,

5:40

supra pubic catheter placement

5:41

for whatever reason if you can't do a Foley catheter.

5:43

But doing that as the first initial step

5:45

deemed a little bit too aggressive.

5:46

And then the so is hitch is sort of a procedure that's gone

5:50

to sort of re um, implant the ureters onto the so small, uh,

5:53

onto the bladder, which is, uh, sort of taken

5:56

and attached a little bit more

5:57

cephalad than it normally lives in.

5:59

So those are all surgical options wherein this needs

6:01

to be treated conservatively with the antibiotics

6:03

and Foley catheter drainage.

6:06

Perfect. And so with that, we'll move on to the next case.

6:13

Here we go.

6:22

So have a look. What sequence is this?

6:26

What modality is this? What plane are you looking at?

6:30

What organ are you looking at? What's the abnormality?

6:33

What do we think is going on over here?

6:40

For this one, I'm just asking you for the best diagnosis.

6:45

I've given you some mouthfuls there.

6:46

Adenomyosis, leiomyoma, adenomyosis,

6:51

intravenous leiomyoma, leiomyomatosis.

6:55

There you go.

7:07

All right, I love this.

7:08

So no one thought it was intravenous

7:10

leiomyomatosis, so that's good.

7:12

Somebody put myoma, maybe there's a, a fibroid in there.

7:14

Uh, but that's not probably the best diagnosis.

7:16

And then we got almost a 50 50 split between the two words

7:19

that sound very similar to one another.

7:21

So maybe the teaching point in this case is

7:23

how do we remember which one it is

7:24

when we look at it in real life?

7:25

So let's have a look. So, uh,

7:27

the answer is adenomyosis in this case.

7:30

And so the image

7:31

of course here is this al T two image of the pelvis.

7:33

We're looking at the uterus,

7:35

but we can see that the junctional cell looks very

7:37

indistinct, certainly looks indistinct posteriorly,

7:39

but anteriorly you can't even delineate it from

7:41

the adjacent myometrium.

7:42

So it's enlarged.

7:44

It looks indistinct to these tiny foci

7:46

hyperintensity T two signal within it.

7:48

This is a great look for adenomyosis, um, fibroids

7:52

that have more discreet discrete borders to it,

7:54

where you can actually take a, you know, uh, like a,

7:57

a pencil and sort of trace the, the outer border of it.

7:59

But you don't see that in this case.

8:01

Um, this is a good look for adenomyosis.

8:03

And so what do we need to know about adenomyosis?

8:05

It's the presence of endometrial clans

8:07

and stroma within the myometrium.

8:09

I sometimes think of this like endometriosis,

8:11

but involving the uterus itself.

8:13

And uh, you'll see a thickened

8:15

and lde defined junctional zone.

8:16

The number to remember is 12 millimeters in size when you

8:20

measure it, and you'll see hyperintense T two foci

8:23

that represents the endometrial glands

8:25

and sometimes the endometrial

8:26

glands could have hemorrhage in them.

8:27

So you'll see T one hyperintense foci in it as well.

8:29

In this case, I'm just showing you a T two weighted image.

8:32

And then how do you differentiate this word from adeno?

8:35

Mytosis? Adeno mytosis occurs in the gallbladder

8:39

and the one somebody taught me this many years ago,

8:42

and, uh, it always somehow stuck with me.

8:45

Gallbladder as a word, is a longer word than uterus.

8:48

Uterus is a shorter word, just like adenomyosis is a shorter

8:52

word than adeno mytosis.

8:54

And so somebody told me that one day about 15 years ago

8:57

and stuck with me and I've been, uh,

9:00

pretty good with remembering it.

9:01

Um, with that,

9:04

I think there is DIE case two,

9:09

oh, I don't know if I know what DIED

9:12

infiltrating endometriosis.

9:13

Is that what you're referring to?

9:15

That's 1D IE that I can think of.

9:17

If you wanna clarify that, that would be great.

9:19

Before I move on, you can do that in the chat

9:20

or, um, uh, or otherwise.

9:25

Oh yes. Okay. Yeah, it's possible. It's present.

9:27

Lemme just have a look. Um,

9:29

lemme just have a look over here.

9:32

I think based on these images,

9:33

it's really, it's tough to say.

9:34

I think what you could be referring to is this sort

9:36

of T two hypo intense signal there.

9:38

And I think absolutely that may, you know,

9:39

that's a good look for what, um, you know,

9:42

endometriosis could look like.

9:43

Uh, certainly in the, uh, in the,

9:45

in the cul-de-sac over there.

9:47

Um, I don't recall this patient had deep

9:49

infiltrating endometriosis.

9:50

That's a good observation. And,

9:52

and certainly one you'd have to sort

9:53

of see in different planes to, to figure out.

9:56

Perfect. So we answered that, answered that,

10:01

and we'll move on to our next mystery case,

10:17

the T two way image.

10:18

Do you wanna post contrast?

10:21

Hopefully we get a chance to look at it, figure out

10:24

what this abnormality is, where it's located.

10:26

And the question will be,

10:28

what do you wanna do next about this one?

10:31

Giving you mu multiple options to get a Whipples.

10:35

You can do a pet ct, you can do an endoscopic ultrasound,

10:39

and our facility, uh, GI docs end up doing that,

10:42

or you may be so confident to think that this is benign

10:46

and I could call it as such and no follow up needed.

10:48

So what does the group think about this?

10:58

Uh, this is, this is good.

11:00

I'm I, you know, listen, I, my ideally I'd have, you know,

11:03

I'm not somebody who wants to trick anybody.

11:05

I want everyone to get a hundred percent the right answer.

11:07

But it's also interesting to have a, a spread of answers to

11:09

so we can sort of understand what's going on.

11:11

I think this is a challenging case.

11:13

And so let's look at, see, uh, in this case, uh,

11:15

the right answer, um, uh, would be an endoscopic ultrasound.

11:18

Let's have a look and, and why that would be.

11:20

And so you look at this case, a T two 80 image.

11:22

We see a mass at the head of the pancreas.

11:24

It has lobulated borders

11:25

and internally it looks like it's composed of multiple,

11:29

multiple small cysts.

11:31

And, uh, we, we let post contrast image,

11:34

there are these thin septa that separate some of these cysts

11:37

and those end up enhancing

11:38

and it's located at the head of the pancreas over there.

11:41

And so what do we think is the best diagnosis?

11:43

Anybody can, uh, pop it up in the chat if they want to type

11:45

and, uh, flex their knowledge on what they think this is,

11:48

uh, given the imaging appears and what I've described.

11:55

Yeah, sist adenoma agree with, uh, uh, our, our,

11:59

our, our colleague there.

12:00

And so I think this is a great look for cyst adenoma

12:02

and I think that's probably what a lot of folks, um,

12:05

thought about exactly.

12:06

Pancreatic, scy, adenoma.

12:08

Um, the question then, uh, becomes, uh,

12:11

what do you do when you have something

12:13

that looks really classic for a sist adenoma?

12:16

And so we'll go through that in a second.

12:18

Let's talk a little bit about sist adenoma for those

12:20

who perhaps are struggling to understand

12:22

what this is in the first place.

12:24

This is a benign neoplasm that's seen, uh,

12:26

a little bit more often in females and,

12:28

and is often sort of used.

12:30

Uh, it is often, it, it can be challenging

12:33

to distinguish it from a munos adenoma,

12:36

both occur in females.

12:37

But remember that muus occurs a lot more commonly in females

12:40

at a ratio of six to one, whereas

12:42

serous is just a little bit more sys Adenomas tend

12:45

to occur in patients, um, who, uh,

12:48

are more than 60 years of age.

12:49

The majority of them, whilst musos adenoma a little bit

12:52

younger, 40 to 60 serous can occur anywhere.

12:54

But, um, some reports say it occurs preferentially in the

12:57

head, but I think the latest literature shows

12:59

that it really can occur anywhere.

13:00

Where am muus is generally body

13:01

and tail imaging appearance tends to be different.

13:05

S cystadenoma has a lobulated border multiple small cyst

13:08

that make it up, but 20% will have a central scar

13:11

muus the border will be nice and round.

13:13

Fewer cysts that look larger.

13:15

There is malignant potential fram malignant fra mucinous

13:19

or cys sist adenomas are benign.

13:22

And so the question becomes, what do you do with somebody

13:24

who has a, something that looks like a sist adenoma,

13:27

even though we know it's benign.

13:29

If you look at the guidelines, it turns out

13:31

that there is a lot of overlap between

13:34

what a serres adenoma can look like

13:36

and what some other pancreatic cystic lesions can be.

13:38

And so the best thing to do when you see somebody who has a

13:43

pancreatic cystic lesion that has high, you know,

13:46

the imaging period is a highly suggestive adenoma still need

13:49

to do the endoscopic ultrasound at least initially

13:51

to confirm that that's what you're dealing with.

13:53

Once you know that's what you're dealing with, you know,

13:55

you don't really need to do any further follow up

13:57

unless the patient is symptomatic,

13:59

in which case you can do an imaging follow-up

14:01

and potentially talk about reception.

14:02

But, uh, you do need to confirm it,

14:04

even though the imaging appearance can be classic.

14:06

There's a lot of overlap until that endoscopic ultrasound,

14:10

um, is critical in sort of, uh, cinching that diagnosis

14:13

of cy a no, let me just, uh, look at the chat box

14:17

and the quest q and a to make sure

14:18

that I've cleared everything.

14:20

Um, somebody said I'm not audible.

14:22

Hopefully I'm audible right now.

14:25

Um, and uh, you're good. Okay, perfect.

14:30

Maybe I, I, I, I muted out for a bit. I apologize for that.

14:34

Okay. And let me just see the other questions.

14:39

Did it show fat suppression?

14:42

I'm assuming that meant somebody's asking that.

14:44

I'm not sure which case that was.

14:46

It's referring to the pancreas case

14:48

and this, if it was that, you know, this, this, this,

14:51

this mass did not suppress with fat.

14:52

It does not contain any fat.

14:56

Alright, let's go to our fourth case.

14:59

Remember we got 20 cases, so we're, uh,

15:01

about a fifth way through this.

15:02

Now

15:08

for this one showing you a single image,

15:15

conventional radiograph.

15:16

Conventional radiographs are very tough.

15:18

It's hard to know what's going on.

15:28

And this one I'm asking the best diagnosis.

15:31

A couple of options here. SQL ulu, sigmoid ulu.

15:35

So Valase syndrome,

15:39

one of my favorite syndromes.

15:40

I haven't seen too many cases of that though.

15:41

Gallstone ileus,

15:49

what do we think?

15:50

Yeah, so this is good.

15:52

So I think, uh, most at sigmoid volvulus,

15:55

some said SQL ulu

15:57

and not too many were, um, enticed by the other options.

16:01

And so let me just look at, uh, the chat box to make sure

16:07

that, uh, we are good.

16:08

And so there was just some option, um, uh, chat about

16:11

what the diagnosis is.

16:13

And so this was, uh, a sigmoid vulu, which is, uh, uh,

16:18

the top answer, uh, that was suggested in this case.

16:20

And so what do we see over here?

16:21

So we're seeing basically, you know,

16:23

I say a conventional radiograph.

16:24

This really is a, a scout from a CT scan

16:27

that we eventually ended up doing on this patient.

16:29

And what we can see is that there's a large, uh, sort

16:32

of gas containing structure

16:34

that occupies much of the abdomen.

16:36

It has that classic coffee Bain appearance.

16:38

And if you look at sort of, you know, where it's pointing

16:41

to, it almost looks like it's pointing

16:42

to the right upper quadrant.

16:44

These are signs that are highly suggestive of sigmoid vis.

16:47

In this case, you can actually, uh, kind

16:50

of see the seum over here

16:51

and you can see the ileum over here

16:52

and you can see that that actually looks okay.

16:54

And so, um, you know, that's one way to exclude SQL vous.

16:58

SQL VOUSs, when it does occur,

17:00

often flips in the opposite direction so that most

17:02

of this occupies the left upper quadrant and the, you know,

17:06

and the, uh, sort of point of, um, direction the vector so

17:10

to speak, is sort of that left upper quadrant space.

17:13

Um, uh,

17:14

and it typically happens in younger patients as well.

17:17

Sigmoid vous on the other hand, older patients.

17:20

And, uh, there's all these signs that you can look for, um,

17:23

and you have this beak sign, this swirl sign

17:26

of the actual area of transition.

17:27

And remember, sigmoid VUL is in both sigmoid and SQL vs.

17:31

Are a type of large bowel obstruction.

17:32

And so you have twisting

17:34

of the mesentery resulting in that obstruction.

17:36

And, um, uh, you know,

17:39

I would say in real life it's sometimes challenging just on

17:41

x-rays to differentiate which one it is.

17:42

I think the important thing would be to figure out

17:45

that you're dealing with a ulous potentially

17:47

type configuration of the bowel.

17:49

You can always do a CAT scan to,

17:50

to sort out which one it is.

17:54

Uh, so let me just make sure

17:56

that we are clearing the chat box as we go along.

17:58

Perfect. Excuse me.

18:03

Let's go on to our next case.

18:11

We're shifting gears a little bit.

18:12

We saw a couple of conventional radiographs, we saw an MRIs,

18:15

now we move on to ultrasound of the right testicle,

18:21

gray scale image colored Doppler image.

18:23

We're seeing something there. Not subtle.

18:28

The question is, what do you wanna do about this

18:35

in your, in nucleation

18:38

orchiectomy biopsy?

18:43

Ablation?

18:57

Yeah, good.

18:58

So most people said nucleation,

19:00

which in this case is the right answer.

19:01

A few said orchiectomy, a few people said biopsy, um,

19:04

and some said ablation as well.

19:06

So let's just see, um, nucleation over here.

19:10

And so the key thing, this is sort of a, a two step, uh,

19:13

question in a sense in that.

19:14

Um, and the first thing is to, to understand

19:17

what diagnosis you're dealing with.

19:18

And you see this mass in the testicle.

19:20

It's clearly in particular mass,

19:22

but it has this classic appearance of, you know, sort

19:25

of onion, um, skinning

19:27

and, uh, sort of concentric circles

19:30

that are within this lesion is pretty well defined.

19:32

There's no flow within this,

19:33

just we couldn't detect it on color, color doppler imaging.

19:36

Uh, but certainly, uh, this is a classic appearance

19:39

for an epidermoid cyst.

19:41

This is a benign lesion

19:42

and, uh, it's essentially a cyst

19:44

that contains multiple layers of keratin

19:46

and the treatment is actually in nucleation.

19:48

And so the key thing in this case is to

19:51

identify prospectively that you're dealing

19:53

with a potential epidermoid cyst based

19:55

on this imaging appearance.

19:57

You relate that to urologists.

19:59

They do need to go to the operating room to take it out.

20:01

And once they confirm indeed

20:04

that this is an epidermoid cyst,

20:05

they do an nucleus just scoop it out.

20:08

Um, and that, uh,

20:09

prevents the patients from getting an orchiectomy,

20:11

which is a much more invasive treatment,

20:13

obviously taking out the testicle.

20:14

As far as I know, there's no rule for abl, there's no rule

20:17

for ablation, and this is not something

20:19

that we do a percutaneous biopsy on prior to that.

20:21

We actually do take into the operating room

20:22

and, uh, it is sampled in the operating room,

20:26

and if it comes back as epidermoids,

20:27

you scoop it out with an a nucleation.

20:29

If it comes back as, uh, a potential germ cell tumor, in

20:33

that case you'll do an orchiectomy.

20:34

And so they can only be alerted to

20:36

that possibility based on the read from the radiologist,

20:40

which is why it's really important to be able

20:41

to recognize this, um, when you're, uh, reading these cases.

20:47

Perfect. All right, case number six.

20:58

So CT scan, non-contrast.

21:04

Think about what we're seeing.

21:09

Excuse me,

21:15

what's the best diagnosis here?

21:18

Oh, we love these syndromes, don't we on hippo.

21:20

Linda, I'm giving you it all on hipa,

21:22

Linda neurofibromatosis, tuberous sclerosis.

21:26

Bert, uh, dubay, I forgot the accent on the e I'm sorry,

21:31

but I think it's dubay with the accent.

21:33

So what do we think is the best diagnosis

21:34

based on the images that we're seeing?

21:39

Good. So most people,

21:41

but two thirds thought it was tuberous sclerosis.

21:43

Uh, uh, uh, you know, there was, um, the folks,

21:46

some people thought it was Von Ilin, then there was a few,

21:49

uh, offerings for neurovirus and bird hog tope as well.

21:53

Uh, let me see the answer.

21:54

In the ua, someone wrote ms, which I'm not sure if

21:58

that's referring to, but I'll move on for the moment

22:00

and I'll, I'll go back to that at the end.

22:02

The answer this case is to scle. Good.

22:06

And so let's have a look at the images themselves.

22:08

So we have a non-contrast ct,

22:10

and if you haven't seen what the, you know, case of this

22:12

before, it can look really bizarre.

22:13

And so for junior trainees, you know,

22:16

I think a case like this can be quite challenging,

22:17

but if you've seen it, this is what they look like.

22:19

These are the kidneys and they are replaced

22:21

by multiple fat containing masses.

22:24

We can see that the containing macroscopic lipid,

22:26

it's almost hard to see any normal

22:27

renal parenchyma over here.

22:28

And when you see, um, kidneys that are replaced

22:31

with these types of masses, you really need to think of, uh,

22:34

uh, tuber sclerosis.

22:35

There's really almost nothing else

22:37

that can give you disappearance.

22:39

Uh, in this case. We can also see very subtly some tubing

22:42

that's coursing through portions

22:43

of the subcutaneous fat and peritoneum.

22:46

It's probably a VP shunt, as you know, patient

22:48

with supras sclerosis get

22:49

additional findings that we'll talk about.

22:52

And so what's, uh, we'll talk a little bit about an angio,

22:54

my lipomas first, these are fat continuing masses.

22:56

If you measure the house, phs usually be less than 20.

22:59

Uh, they don't calcify, they do calcify.

23:01

Uh, one would need to be suspicious that they potentially,

23:04

uh, are a fairly rare fat containing renal cell carcinoma.

23:08

It can happen, but those usually have fat

23:10

and calcium as opposed to AMLs which just have fat.

23:12

Most AMLs contain fat.

23:14

There'll be very small

23:15

percentage that are a little bit poor.

23:18

Mostl are just sporadic.

23:19

But when you have multiple bilateral, they're almost, uh,

23:22

always associated with the tuberous sclerosis.

23:24

They can rupture particularly when

23:25

they're more than four centimeters.

23:27

So we try to preemptively embolize them.

23:30

Now for tuberous sclerosis, what do they get in the kidneys?

23:33

The big flagship mass

23:35

that they get in the kidneys is the angiomyolipoma.

23:38

They can get cyst, they can get rccs

23:41

and that's fine to remember,

23:42

but just understand that the majority of them will get AMLs.

23:45

That's what you need to be worried about.

23:46

I'm not really looking for these other things in patients

23:48

with tuberous sclerosis, I'm looking for angio.

23:51

My lipomas von Hippel Linde on the other hand,

23:54

are the patients who get rccs.

23:56

They don't get angio.

23:58

My lipomas bird hog dubay, one

24:00

of the other options really rare,

24:01

but those patients end up getting rccs with lung cysts.

24:06

And so it's sort of a combination of, uh, of v hippo lindo

24:10

and, and, and tuberous sclerosis.

24:11

In terms of what things it, it gets

24:14

for tuberous sclerosis in the CN s they get cortical tube

24:16

subc, cortical appendamoma

24:17

that can sometimes cause hydrocephalus.

24:19

So you may see VP shunts in these patients heart

24:21

to get RDO myomas.

24:23

They get lung cysts, uh, called lamb abbreviation in,

24:26

in the lungs and bone islands.

24:28

Uh, they often get area bone islands in the bones.

24:30

And that's how I remember the sclerosis

24:33

part of tuberous sclerosis.

24:34

I don't think that's why it's called tuber sclerosis,

24:35

but I think it's an easy way to remember.

24:37

Look at the bones in patients tube sclerosis,

24:39

they'll often end up seeing these areas

24:40

of sclerosis, uh, bone islands.

24:42

Um, you know, in in their, in their, um, osteo structures

24:47

clinically, these patients present

24:49

with intellectual disability, seizures

24:52

and skin findings, the adenoma ation or the segre patches.

24:56

And if you present earlier on,

24:57

they end up doing poor prognosis

24:59

that if they present or oral prognosis than 3% later on.

25:01

So a bunch of things here about tubular sclerosis,

25:03

it's an important thing to know about.

25:04

It can come up in multiple organ systems

25:07

and one needs to really know this inside out

25:08

and be able to differentiate it from on HIPA Linde

25:11

and the more rare bird hog bay

25:13

neurofibromatosis doesn't get any of these things.

25:15

They just get these skin lesions

25:16

and neurofibromas elsewhere in the abdomen and pelvis.

25:20

So let me just make sure that everything has been answered.

25:26

Uh, some. Okay.

25:28

And someone still said ms, I wasn't sure what

25:33

that's referring to, but I will, uh,

25:36

unless you wanna put it in the chat box, I will move on.

25:39

Maybe it's multiple sclerosis.

25:40

If it is, this is not

25:42

what multiple sclerosis would look like.

25:44

Um, there's really not many abdominal findings that I know

25:47

of with multiple sclerosis,

25:48

unless they have secondary effects of uh,

25:50

say bladder dysfunction, you get a large bladder.

25:54

Okay, so move on

25:57

to our next case group is doing very well so far here.

26:02

I'm giving you some Mr images

26:04

T two T one post in different phases

26:08

and I want you to focus on this thing over here.

26:09

That's what I'm trying to show you.

26:16

Course. So

26:23

What do we think? This is

26:24

giving you some benign options,

26:27

giving you some malignant options.

26:29

I think it's important to, to be able to

26:35

diagnose this and be confident when you're diagnosing this.

26:37

So let's see, the group thinks,

26:42

let's see what the group group answers.

26:48

Yeah, 79% said hemangioma. Few people said others.

26:52

And, uh, let's talk a little bit about, uh, why those,

26:55

um, correct.

26:57

This is a angio, a nice example of I angio.

26:59

And so let's look at this lesion.

27:00

This is one we're gonna focus on here.

27:02

One of the key things in this case, it's

27:04

to look at the T two signal of the mass.

27:07

It's rather bright, right? It looks similar to CSF.

27:10

Whenever you see a mass that has signal,

27:11

that looks pretty similar to

27:13

CSF on the T two related images.

27:15

For the most part you're dealing with something benign

27:17

and you're really gonna be dealing

27:18

with other hemangioma or a cyst.

27:20

How do you differentiate between a hemangioma or cyst?

27:22

You give contrast cyst will not enhance hemangiomas.

27:26

Have a classic peripheral discontinuous areas of enhancement

27:30

that fill in as you go

27:31

through the different post contrast phases.

27:35

Now, on the other hand, if you see a mass in the liver

27:37

and it has the T two signal that's closer to say

27:39

what the spleen looks like, that's sort of evil gray look.

27:42

In that case, you're probably dealing

27:44

with maybe a primary tumor such as an HCC

27:46

or cholangio, maybe a met,

27:48

but potentially also things like FNHN, um, and adenoma.

27:52

So point is there that you could be dealing

27:54

with something benign or malignant,

27:55

but when you see something this, right,

27:56

you're almost always dealing with something benign.

28:00

Somebody says that the cases are easy.

28:03

Well, uh, I'm glad you find them easy,

28:05

but I think, uh, for some like

28:07

there are maybe learning opportunities.

28:08

So, uh, I'm glad to share those with the group.

28:12

And, um, uh, the only other

28:16

potentially malignant thing that can look this ttu right,

28:19

is a mucinous metastasis.

28:21

Metastasis from a primary mucinous neo, such as a mucinous

28:26

adenocarcinoma of the colon or the rectum.

28:29

Those can often have this T two bright signal,

28:31

but of course they won't have this sort of classic area

28:33

of enhancement and fill in like this.

28:36

And so what do we need to know about angios?

28:38

Well, we need to know what they look like for sure.

28:40

And this is a classic hemangiomas.

28:42

They can also be flash filling hemangiomas when they're

28:44

small because they're very common.

28:46

They're more often seen in females and they're benign.

28:49

And this is one of those things that we can say confidently

28:51

that this is benign and we don't need to worry about it.

28:53

Occasionally they can grow, uh,

28:55

but sometimes they can regress with, uh, with, in patients

28:58

who have cirrhosis and they can get a little bit smaller.

29:01

Bleeding for them is so, so rare.

29:02

There is a very rare syndrome called CAA backer syndrome

29:05

where hemangiomas, if they get really large

29:08

and in pediatric patients can sort

29:09

of cause a consumptive coagulopathy resulting

29:12

in thrombocytopenia.

29:13

And having patients prone

29:14

to bleeding can also cause high output,

29:17

high output cardiac layer.

29:18

In pediatric patients when they're very, very large

29:21

imaging findings can be diagnostic

29:22

to the point where no biopsies needed.

29:24

If imaging findings are classic,

29:27

somebody's asking about a sclerosis angio.

29:29

Now those sclerosis angios I'll answer right now,

29:31

are very, very tough to diagnose.

29:33

Sclerosis angios are gonna be those lesions that have sort

29:36

of slightly a, they kind of have some imaging features

29:38

of the hemangioma, but not all of them.

29:41

For example, you kind of T two bright,

29:43

but they won't have a classic peripheral discontinuous

29:45

enhancement in fillin.

29:46

They may have rim enhancement and some fillin

29:49

and you're really gonna be thinking about them in the

29:51

context of patients who have that bright T two signal.

29:53

Uh, with a little bit more atypical features.

29:56

The only way you diagnose it is sort of one of two ways.

29:59

Best way is that you have prior studies

30:02

from maybe many years ago showing

30:04

that in the same location there was a hemangioma

30:06

and now, uh, it, it sort of has this atypical feature.

30:09

So then you can call it sclerosis angioma.

30:12

The other way you do it is either just suspect it

30:14

and follow it up or you end up having a biopsy.

30:16

That's one of those things that is very tough

30:18

to call prospectively unless you haveli that showed an angio

30:21

with classic imaging features.

30:27

Alright,

30:35

two CT images, coronal, axial

30:38

and coronal in this patient who has a finding

30:57

best diagnosis.

31:05

Not sure if the, uh, answer has gone, uh,

31:08

the question has gone up for the group.

31:12

Yeah, it's launched. Okay, don't see it on my screen,

31:16

but that's perfectly fine.

31:24

Can you see are the results Dr. Mather?

31:27

I can't see the results. Mm-Hmm? Are they up?

31:29

They are up. Okay. Oh, I wonder where they went.

31:32

Let me see.

31:38

Hmm. Disappeared from my screen.

31:44

I can stop sharing. I can tell you I can stop sharing

31:46

and and sharing again. Maybe that'll help or

31:48

That, yeah, let's give that a try.

31:50

Okay, so let me do that again.

31:52

Sometimes these things happen.

31:54

Let me do one last thing before I share. Let me just,

32:08

okay, let's see.

32:10

I don't still see the answers up.

32:15

I will let you know the results of this one.

32:17

Yeah, and then maybe it'll correct for the next one.

32:19

That sounds great. So 26% pick the first option.

32:22

41% picked the second option,

32:25

31% picked the third option and 2% picked the last option.

32:30

Perfect. So we're really, you know, struggling

32:32

to an A, B, and C.

32:34

And so I think somebody

32:36

liked the last case 'cause it was a little bit too easy.

32:38

And hopefully they like this

32:39

case 'cause a little bit too hard.

32:40

This happens to be one of my favorite cases.

32:43

Um, and uh, I think somebody, uh, uh, yeah, so that's great.

32:47

So the answer over here is TREM roll desmoid tumor.

32:52

This is one of my favorite cases.

32:53

Now I actually think you can make this diagnosis

32:54

prospective, which is why it's one of my favorite cases.

32:57

Okay, talk a little bit about this case.

32:59

So everyone actually, um, correctly identified, uh,

33:03

the abnormality, right?

33:04

This is, uh, your mesenteric mass differential diagnosis.

33:08

We can see it over here, soft tissue attenuation

33:10

and has some ill-defined borders, maybe some speculations.

33:13

It's sort of centered in the mesentery.

33:15

And the question is, you know, you have this differential,

33:17

which I put up there, a desmoid tumor.

33:19

You have a carcinoid, nodal met, um,

33:22

retract on ENT neuritis, gossi oma sort of put in there.

33:25

Sometimes if you have routine surgical sponge,

33:26

it can cause this sort of reaction,

33:28

but nobody really thought that was the answer.

33:29

So let's put that aside. So

33:31

how are we gonna differentiate between these three?

33:33

That's sort of the, the, the crux of this question.

33:36

Well, maybe some observers noted

33:38

that there was something else missing in this case, right?

33:42

That's why I'm showing you the crawls.

33:44

I'm showing you the axial cts.

33:46

I don't see a colon over here.

33:48

Uh, maybe you say it's outta the field of view,

33:49

but I gotta tell you, you know, you're gonna have

33:51

to see a little bit of colon at this image.

33:53

You know, whether it goes in and outta the imaging.

33:55

I don't see anything here, nor do you see it here.

33:57

So this is a patient who's had a colectomy.

34:00

So patients who have colectomies, who gets colectomies,

34:03

sometimes patients with the ulcerative colitis

34:05

and also patients with familial adenos polyposis syndrome.

34:09

And, uh, that's part of the syndrome.

34:12

Um, patients in Gardner syndrome,

34:14

patients can't get desmoid tumors.

34:16

And so this is why, um, I think

34:18

potentially could get desmoid based on

34:20

the other ancillary features.

34:22

So, um, this is your differential for potential speculative,

34:24

esoteric mass desmoid happen post-surgery potentially.

34:27

Um, and also can be seen in the context of Gardner syndrome.

34:31

Carcinoid tumors tend to have, uh,

34:33

sometimes a few more flexive calcium,

34:36

a little bit more hyper enhancement associated with it.

34:38

Often it, you know, the primary tumor will be in the bowel.

34:41

So look at the adjacent lips of bowel,

34:42

see if there's any ileal, um, uh, primary tumors

34:45

retract mesenteries tends

34:46

to be a little bit more heavily calcified,

34:49

whereas this had no calc.

34:51

This is just a soft tissue mass.

34:52

And so, um, you know, there is sort of an overlap

34:55

of imaging appearance, but the key thing is to recognize

34:57

that colon is missing.

35:00

Um, uh, and when, and, and,

35:02

and those who, who were able to answer this, uh, correctly,

35:05

uh, may have seen that clue.

35:06

And, and, and kudos to you for doing so.

35:10

Alright, move on to our next case.

35:17

CT scan. I'm not sure if this is in the graphic phase,

35:22

it looks like it's probably a portals phase,

35:23

but we happen to end up having some contrast in the bladder.

35:25

But you know, there's a finding there and

35:36

I know we're radiologists,

35:37

but I'm gonna ask you for the histological diagnosis

35:39

of this finding and good.

35:41

I can see the case, the polls now, so

35:43

that, that ended up working.

35:44

So squamous cell adenocarcinoma, urothelial carcinoma,

35:47

small cell carcinoma.

36:08

One person said it, some people thought of squamous cell

36:12

and then most people urothelial carcinoma

36:13

and adenocarcinoma.

36:15

And you know, this is a tough one.

36:16

You know, maybe, maybe this, this question's a tough one

36:18

because, you know, common things being common,

36:20

this will probably end up being a urothelial carcinoma,

36:22

but the key is to recognize the location of this mass

36:27

and, um, and the internet.

36:31

Can, can you everyone hear me okay?

36:32

My internet connection said it was unstable Briefly.

36:35

Yeah, you were a little choppy. Okay,

36:37

But We hear you good now. Yeah.

36:39

Okay, good. So as I said, you know,

36:41

most people pick urothelial carcinoma and,

36:43

and you're right, in some sense statistically

36:45

that's probably the right answer.

36:46

But given the location of this mass

36:49

and the sort of appearance, one really needs

36:50

to think about adenocarcinoma, um, involving the UCUs.

36:55

And so let's have a look at this case itself.

36:57

So here we have a massive sort of the anterior aspect

36:59

of the bladder sort of situated in the bladder.

37:01

Do we actually see probably UCal diverticulum over here?

37:03

And this mass is sort of surrounding the

37:05

base of that diverticulum.

37:06

And when you look at that, you really need

37:08

to think of an adenocarcinoma.

37:09

There's really very few other contacts in which an

37:12

is gonna occur in the bladder.

37:14

Um, the other thing in this case you end up seeing is

37:16

actually carcinomatosis on some of these images.

37:19

Remember that adenocarcinomas in the ureas are very,

37:21

very aggressive tumors.

37:22

So, um, you may end up seeing, uh, you know,

37:25

widespread disease at the time with the diagnosis.

37:27

And so, which you do see in this case, often don't see

37:30

that in urothelial carcinomas,

37:31

even though there may be large masses in the bladder.

37:35

And so there's a bunch of, you know, uh,

37:37

range iCal abnormalities, whether it's a patent UCUs cyst,

37:40

diverticular, the sinus can get complications

37:43

with the diverticula including stone formation infection

37:46

and adenocarcinomas as well.

37:47

These tend to be a progressive aggressive tumors.

37:49

And so I think, uh, if I'd read this, I'd probably think

37:52

that that would be my favorite diagnosis,

37:54

this end up being an adenocarcinoma.

37:56

But to those who said urothelial, yeah, statistically,

37:59

you know, anything occurs on the bladders end up gonna be a,

38:01

it's probably gonna end up being a urothelial carcinoma.

38:03

And a question to the group

38:04

and you can feel free to chime in the chat box.

38:06

What are some risk factors, uh,

38:08

for getting squamous cell carcinoma of the bladder?

38:11

We get squamous cell carcinoma of the bladder.

38:14

Yeah, it's just a surmise.

38:15

So if someone, uh, answered that correctly,

38:18

and I think somebody, um, on the prior question,

38:20

how can we rule out carcinoma?

38:21

Hopefully I answered that correctly,

38:22

so I'm gonna say answered it live

38:24

and somebody's writing ra potentially

38:29

as an answer for something,

38:30

but I'm not sure if that's a abbreviation for something

38:33

that I don't know about four S's.

38:35

Okay, somebody wrote four S's, so probably smoking ESIS

38:40

and a couple of other S's there that, uh, to make up the,

38:43

um, the risk factors for for developing

38:47

squamous cell carcinoma, both SAP pubic catheter,

38:49

potentially SAP pubic catheter.

38:51

I, I would call this that as a, um, definite risk factor,

38:55

but I can imagine that a chronic indwelling supra pubic

38:58

catheter can cause enough irritation over a period of time,

39:01

uh, can develop squamous cell carcinoma.

39:03

You know, TB is not something I've typically heard

39:05

associated with squamous cell carcinomas though.

39:07

Um, I'm sure I, it's, it may be a possibility

39:11

and it's out there in the literature,

39:13

but that's, uh, I really do think it's just

39:14

a CIN is the big one.

39:15

That and smoking for squamous cell carcinoma. Good.

39:19

I think we're about halfway through,

39:20

so let's go move on to our next case.

39:23

There we go. CT scan, coronal axial,

39:28

hopefully a mass, not too subtle now we'll look,

39:33

think about what it is, think about where it is,

39:41

then ask yourself what is the best diagnosis.

39:46

I'm giving you some benign masses, some malignant masses,

39:50

some non masses hemorrhage and pseudocyst.

40:05

Yeah, general cortical carcinoma. Good.

40:07

Um, it probably this one may

40:09

have some areas of hemorrhage in it.

40:10

Uh, not a great look for pseudos.

40:12

We'll talk a little bit why I wouldn't

40:14

like this for adrenal adenoma.

40:15

I think, you know, again,

40:16

statistically any adrenal mass is gonna

40:18

end up being an adrenal adenoma.

40:19

But there's a couple of things here

40:20

that would sway me against that.

40:21

So let's have a look at this case a little bit more closely.

40:23

Answer adrenal cortical carcinoma

40:26

and even a large mass, right?

40:28

Very heterogeneous adenomas tend

40:30

not to be that heterogeneous, right?

40:31

They a little more homogeneous,

40:32

whether they're low intensity or higher intensity,

40:35

but very heterogeneous here.

40:36

High areas, low density areas.

40:38

I think the key thing is to look at the axials over here.

40:40

Look what this mass is doing.

40:41

This is the IVC, this is the left adrenal vein.

40:43

There's tumor that's eating away into this IVC.

40:45

There's tumor thrombus. Adenomas not gonna do that.

40:48

Certainly a pseudocyst is just a simple appearing syst in

40:51

the adrenal adrenal gland.

40:52

So that's not gonna be a hemorrhage.

40:54

Um, you know, our, you know, high density adrenal mass

40:58

that is often in the same shape as the adrenal gland,

41:00

but this you have a large mass heterogeneous innovating.

41:02

The IC this is gonna be an adrenal caral carcinoma.

41:07

And so that's what, uh,

41:08

I've mentioned here in some of the teaching points.

41:10

Most of these end up being non-functioning,

41:12

but if small proportion will be functioning

41:14

and those that are functioning a general cortical

41:16

carcinomas, they almost often present with Cushing syndrome,

41:19

Cushing syndrome that, uh, something that um, people like

41:24

to, uh, ask about.

41:27

And so that's something that the back of your, you know,

41:29

somewhere in the back of your mind

41:30

as you go through these cases.

41:37

Next case, single axial CT scan,

41:44

bizarre looking findings in the liver.

41:46

But it is what it is.

41:55

Here are your options. Best diagnosis.

41:59

I don't see, by the way, I'm not seeing the, um,

42:01

pole at this point, but I'm assuming it's launched.

42:04

Yes. Okay.

42:12

All the cystic liver disease s disease,

42:14

recurrent genic cholangitis and sclerosing cholangitis.

42:22

21% answered for the first one.

42:24

74% answered for the second option.

42:27

Um, and then 1% and 4% answered for the last two options.

42:33

Very good. I'm just gonna mute myself for two seconds.

42:44

Okay. There's a announcement overhead

42:46

and I didn't want that to, um, to, to get in the way of, uh,

42:49

of what I wanted to chat about.

42:51

So, great. So the top answer is Carli said, listen,

42:53

this is a very tough case, so I'm

42:54

really happy that everyone got this one.

42:55

Uh, the majority got it correctly.

42:57

And so this is coli's disease.

42:59

And um, so you notice a couple of things.

43:01

Uh, this happens to be a pediatric patient.

43:03

Look how small the C is.

43:04

The body's also quite small

43:06

and we're seeing multiple, um, low densities,

43:08

almost cystic appearing mass in the liver with, uh,

43:11

a beautiful thing right in the mineral.

43:13

What's the sign called?

43:14

You wanna chime in in the chat box of what the sign is,

43:16

what we're seeing in the middle

43:24

central dot sign.

43:25

Perfect. Yeah, it's exactly what it is. Central dot sign.

43:27

And that's classy for carles disease.

43:29

Uh, this is, uh, a ute in utero malformation of the ductal,

43:33

uh, of the ductal plate.

43:35

Um, these patients are at increased risk

43:37

for cholangiocarcinoma or just generally cholangitis

43:39

and infections within the biliary tree.

43:42

And you're end gonna end up seeing dilated intrahepatic bile

43:45

ducts, uh, which look very, very pronounced.

43:47

They manifest as the cystic spaces that surround

43:50

the, uh, portal vein.

43:51

So you get that central dot sign.

43:53

And so you can see that here on the

43:55

CT scan on this MIP image.

43:56

You can see how central portion

43:57

of the portal veins are going, you know, uh,

44:00

or the portal veins are going

44:01

to the central portions of this mass.

44:03

You can see beautifully here on this ultrasound.

44:05

And I also put this CT image here

44:06

because it has some associations with choal disease,

44:08

with abnormalities of the kidney.

44:10

So once you've seen

44:13

and suspected the patient has choal disease, you know,

44:15

to sort of finish off the case, look at the kidneys

44:17

and see if there's any cystic disease of the kidneys,

44:19

whether it's infantile, polycystic kidney disease,

44:21

or sometimes even mentally sponge kidney.

44:24

Uh, but this is a classic example

44:25

of cruelly disease target sign.

44:27

Somebody else said, yeah, central.target sign is, uh,

44:30

pretty much equivalent in my, uh, in my, my book

44:33

and somebody else has said central.in their webinar chat.

44:36

Perfect. Those are the cases of caroli disease.

44:38

The other options in this case, um, you know,

44:41

polycystic liver disease know you can think about that,

44:43

but they won't have that central dot sign.

44:45

Recurrent biogenic cholangitis is a disease

44:47

that preferentially occur, uh,

44:49

affects the left sided ducts causing ductal dilatation.

44:52

Um, and the next most common side

44:54

is the posterior right ducts.

44:55

And so that's sort of the distribution that we see

44:57

and sclero and cholangitis multifocal areas of beating

45:01

and uh, and dilatation, stricturing dilatation

45:04

of the intra extra patag bi tree.

45:06

They don't have this nice round cystic appearance in the

45:09

intrahepatic bile ducts.

45:12

Alright, and next case,

45:35

best diagnosis for this diver I'm giving you.

45:37

This is a diverticulum sanker killing Jameson

45:43

traction schizophrenic.

45:44

I don't see the answer box, so

45:46

I'm assuming the answers have launched.

45:49

Yes,

46:01

72% answered the first option

46:04

with 21% answering the second option.

46:07

Okay, so that makes up an even uh, 100. Very good.

46:10

The answer of course here is this sinkers dive reticulum.

46:13

Very, very good. And so, um, we look at this, this is, uh,

46:18

esophagus, we're looking at the, uh, top of the esophagus.

46:20

We see this sort of, um, contained collection of contrasts,

46:24

uh, rising on the cervical esophagus.

46:26

We could see on the AP view sort

46:28

of projects over the esophagus on the lateral view projects.

46:30

Posteriorly classic appearance of a sanker is diverticulum.

46:34

It's a type of pulsion diverticulum

46:37

and uh, there are several types of pul

46:38

and diverticulum anchors being one of them,

46:40

killing Jameson being the other one of them.

46:43

Zenker's his, you know, histologically goes

46:45

above the cricos line

46:46

through the killing dehiscence while killing Jameson occurs

46:49

below the killing dehiscence.

46:51

And when you look at killing Jameson diverticulum,

46:53

remember you're gonna best see it on the AP view

46:55

as something projecting laterally as opposed

46:57

to the zenker's diverticulum, which you see best on.

47:00

The lateral view is something projecting posteriorly

47:03

epi phrenic, which is one of the options of one

47:05

that occurs in the distal esophagus.

47:07

So we're really not dealing with that over here.

47:09

And then, uh, you can see

47:10

that the epi phrenic diverticulum here,

47:11

beautiful zenker's diverticulum over here killing Jameson

47:15

diverticulum projecting out laterally.

47:17

And then there's the traction diverticulum as well,

47:20

which is our fourth option, occurs at the meta esophagus.

47:23

And it's usually the setting of prior infection,

47:25

inflammation, surgery.

47:26

Often granuloma is disease in the mediastinum

47:28

that tugs the esophagus over a period of time

47:31

to create little focal out pouching.

47:33

So that's one that occurs in the mid esophagus.

47:35

So mid esophagus is traction in the context

47:37

of some mediastinal abnormality.

47:39

Distal esophagus is epi phrenic up

47:41

above his anchors and Killian Jameson.

47:43

And one needs to be able to differentiate them based on

47:47

where they project on, on ap uh, views.

47:50

And um, patient with zenker's can, for example,

47:52

with dysphagia, uh,

47:54

classic presentation is osis or bad breath.

47:57

And so that's another thing that, uh, patients are referred

48:00

to in the context when they're looking

48:03

for zenker's hyper reticulum.

48:07

All right, next case I've labeled these images for you.

48:11

T two, T one, pre T one fat s post

48:15

subtraction image down

48:21

Have a look.

48:29

Perfect. I can see case that's good.

48:31

It's case number 13, MHIC cyst endometrioma, two ovarian

48:36

germ and all things that can occur in the ovaries.

48:38

And that nexa, what do we think is the best diagnosis?

48:52

Yeah, so really, um, majority is endometrioma.

48:55

Uh, some, uh, next majority is the hemorrhagic cyst.

48:58

Dermoid is a possibility. That's a, a tricky one

49:00

for a dermoid actually, just based on the images I've given

49:02

you in then tube, ovarian aps correct answer

49:04

is endometrioma.

49:06

So here we see on the T two eight images bilateral, uh,

49:08

ovarian and nal masses, classic appearance FT two shading

49:12

as you go from top to bottom it gets darker.

49:15

T one pre fats that image, they look very bright,

49:18

not a good look for a dermoid, um,

49:20

because if it was, uh, fats that image over here,

49:23

these should be dark, but yet these are very, very bright.

49:25

So it's telling us it contains hemorrhagic content

49:27

and there's no enhancement over here.

49:29

Some people may argue there's something here

49:30

and you would be correct in that observation,

49:32

but I'll tell you, um, this panned out to be nothing.

49:35

I think it was just volume averaging of something like that.

49:37

So this is no essentially no enhancement within this lesion.

49:40

There's no inflammatory change around this suggests tube.

49:43

Ovarian abscess and hemorrhagic cyst is a possibility,

49:45

but you seldom see that beautiful T two shading

49:48

because um, you know the, the reason you see T two shading

49:52

of course is because you have repeated bouts of hemorrhage

49:54

that give you different gradations of blood within that,

49:57

you know, within that mass as opposed

49:58

to hemorrhagic cysts which just comes

49:59

and goes over a period of time.

50:01

So you don't have that classic T two shading.

50:04

Bonus question for the group.

50:05

What are the cancers that are most classic associated

50:08

with endometriomas?

50:10

Type it in the chat box if you want.

50:22

Endometrioid. Yep. Love that one.

50:23

There's another one that's also classic for it.

50:25

If anybody knows

50:31

someone said a, so maybe prematurely type

50:34

that in, but let's go through it.

50:36

Um, and so this is a case of endometriosis.

50:39

Yeah, clear cell. Perfect, perfect.

50:40

And so endometriosis, we've talked a little bit about some

50:43

of the imaging signs that we look for.

50:44

We also look for adhesions by the way

50:46

that can occur in endometriosis.

50:47

It can occur to deposition

50:49

of the stromal tissue in the a nexa

50:51

and uh, sometimes their scarring

50:52

as a reaction to some of that.

50:53

So look for adhesions,

50:55

you have the classic kissing ovary sign

50:56

that pull the ovaries together.

50:58

Um, somebody also talked about endometriosis, one

51:00

of our prior cases with adenomyosis, uh,

51:03

where we saw some stuff in the cul-de-sac.

51:04

That was T two IBO intensive. Of course these are the

51:06

associated tumors that one needs to look for.

51:09

Recently we've seen cases of tumors associated with these

51:11

and all you're looking for is soft tissue enhancement

51:13

associated with something that otherwise looks like

51:15

it endometrioma.

51:17

Somebody said chocolate. That's the classic thing you see on

51:19

uh, on laparoscopy and um,

51:22

and others have answered in the chat

51:23

box in terms of the, the cancer.

51:25

So perfect.

51:29

Next case, HSG.

51:45

Which of the followings are risk factor for developing

51:49

whatever disease you thought about

51:50

that I showed you on the prior prior C-section?

51:53

Endometriosis, PID

51:55

or just getting a, excuse me, getting a prior HSGI

51:59

don't see the answer options, but I'm assuming they're up.

52:04

Oh, there we are. Now they're gone again. Oh, here we go.

52:09

Perfect. Pelvic inflammatories. Okay, perfect.

52:11

So, um, a few people said some other things,

52:14

but vast majority of pelvic inflammatory.

52:15

So before I give away, uh,

52:18

talk a little bit more about this,

52:19

what disease are we actually dealing with?

52:20

Just wanna make sure we're all on the same page.

52:22

So you can put in the chat box or in the q and a

52:35

perfect sin.

52:36

That's good enough. It's too long

52:38

to type out in its entirety.

52:39

This is a case of uh, a rare thing.

52:41

I haven't seen too many cases Sal meningitis, ISA and OSA

52:45

and um, this really amounts to,

52:48

well the imaging appearance is really these small

52:50

diverticula, these outpouching

52:52

that extension from the fallopian tubes typically in the

52:54

proximal portion of the fallopian tubes, um, can

52:58

and uh, it is often bilateral seen up to 80%

53:02

of patients and one clear association of the history

53:04

of prior pelvic inflammatory disease.

53:07

Clinically, these patients may manifest with, uh,

53:10

infertility or ectopic pregnancies

53:12

and there is a differential for this,

53:14

but you know, I don't think one needs

53:16

to remember this disease are so rare,

53:17

including this disease, which is very rare.

53:20

But um, I have this image from STAT dx,

53:22

which I thought was really nice that really show why you

53:25

know, what happens from a, from a sort

53:27

of a drawing perspective to have

53:28

that translates to what you're seeing.

53:30

So because of the PID as one of the prime risk factors,

53:33

you get thickening of the fallopian tube

53:34

and you get these little out pouching that sort of form

53:36

inside this area of thickened fallopian tube.

53:38

And these are the ones that fill with contrast

53:40

manifesting in these diverticula.

53:41

Uh, in some sense this is um,

53:44

almost looks like adeno mytosis in the gallbladder

53:46

fundus right that we see.

53:47

But this is actually in the a fallopian tubes

53:49

and it's called esophagitis ISA osa.

53:52

Perfect. And so I'm just looking at the chat box

53:54

to make sure that we are on top of that.

53:59

So good on the group for getting that move on

54:02

to case number 15,

54:10

Yellow arrow in this case.

54:12

'cause as I realized as I put this together

54:14

that you may be looking at other things over here,

54:16

so I wanted to make sure

54:17

that you were looking at the right finding.

54:18

And the question is, in this case,

54:22

what's the next best step?

54:24

So this obviously requires you to make the finding,

54:26

figure out what it is and then give an option.

54:30

So you have options including pet ct ultrasound,

54:34

surgical resection where you can be bold,

54:38

say no further follow up.

54:44

So I don't see the answer options

54:47

nor the answers for what it's worth. So

54:51

Nine, three, uh, excuse me, 9% answered PET ct 39%.

54:55

Okay, perfect. Answered I see ultrasound,

54:57

I'm seeing that, I'm seeing them now, so that's great.

54:59

Okay, perfect. Thank you so much.

55:00

Yeah, maybe this just bit of a delay.

55:02

I apologize maybe on my end. It's okay.

55:04

So there's a bit even between

55:05

ultrasound no further their follow up.

55:06

Yeah, so you know,

55:08

question really is what is this represented?

55:09

Somebody had already, uh, kindly uh, put in the chat box,

55:12

adeno mytosis, we know how

55:13

to differentiate it on adenomyosis.

55:15

Now another a case that we saw earlier today.

55:18

Um, and so this one I'd say no further follow up.

55:22

I feel pretty good that this is adeno mytosis.

55:24

I know these are benign things and

55:25

I really don't wanna do anything else.

55:27

And so adeno mytosis is benign, but it's important uh,

55:31

because it's common and sometimes if it looks

55:33

atypical may mimic cancer.

55:35

But what ends up happening, um,

55:37

I suppose I didn't realize I put this right

55:38

after my uh, celling isma osis slide,

55:41

but you get hyperplasia at the epithelium in these little

55:43

um, uh, mucosal imaginations that sort

55:46

of protruded into that area.

55:48

These perform these diverticula

55:50

that called world ash cuff sinuses.

55:52

And you may have, you know,

55:53

because of the stasis here, biliary crystals that deposit,

55:56

um, it can be focal segmental,

55:58

diffuse often it can be, uh, focal.

56:01

And it has this classic appearance on Mr,

56:03

where you have a string of pearls, T two hypertensive foa

56:05

that are just clustered next to each other on the uh,

56:08

gallbladder fundus.

56:09

When I see this, I don't need an ultrasound to prove it.

56:12

In fact, to me it's easier to call on these MR than it

56:14

is on the ultrasound at times.

56:15

You know, this is not a good look

56:17

for a malignancy of any sort.

56:19

And so, you know, you see this

56:21

not uncommonly I I mentioned in my report.

56:24

I wouldn't recommend further follow up if there are any

56:27

atypical features which are often, by the way, sometimes,

56:32

uh, seen on CT scans where

56:34

you don't see the actual cystic foci.

56:36

It just looks like soft tissue thickening.

56:37

In that case I would maybe get an MRI or an ultrasound.

56:39

But on MRI now if it looks like this, it's quite clear

56:42

that you're dealing with adenomyosis

56:44

and you would need a follow up for it.

56:50

Okay, wrapping up last couple of cases here.

56:58

I dunno if I have another image over here,

57:00

but I'll just keep with that for the

57:02

moment and maybe I have another image.

57:04

May have a misplaced animation.

57:11

There we go. Coronal CT as well.

57:17

Axial ct.

57:23

Best diagnosis for this case please.

57:26

Mucosal infected mesh plug diverticulitis. Lymphocy.

57:46

Yeah, 66% said mucosal.

57:48

A few others said other things, but looks like uh,

57:50

the goop knows what they're dealing with over here.

57:53

Um, let, just see.

57:55

Make sure 13 millimeters with cancer

57:58

and PMP.

58:01

I'm not what that's referring to,

58:03

but we can certainly go back to that.

58:05

So the answer here is in muco cell.

58:06

So what are we actually looking at here?

58:08

Abnormal in the right lower quadrant, a tubular mass,

58:11

low in density, peripheral calcifications,

58:13

you know this is gonna be a mucosal, uh, mesh.

58:16

Plugs can be placed for inguinal hernia.

58:17

Appears they're gonna occur more triangular in shape.

58:20

And right in the inguinal canal.

58:21

Um, you know, diverticulitis, uh, you know,

58:24

I don't see any inflamm diverticular area on lymphic seals

58:27

or lymphatic malformations can look fluid in density,

58:30

but, uh, usually not mass like,

58:31

and, um, don't often have

58:33

that classic peripheral calcifications.

58:36

Um, oh yeah, pseudo oma. Yes, uh, that's what somebody said.

58:39

Now and certainly when these things pop

58:41

or they spill over, they get pseudo oma peritonitis,

58:43

which you get this gelatinous mucin appearing

58:45

ascites all over the body.

58:47

Um, in this case, is there a mass?

58:48

Tough to say, I don't see a mass in this case, but, um,

58:52

but certainly, uh, one thing to look out for is the mass.

58:55

What we can say with confidence that

58:57

what you're dealing with is a mucosal.

58:58

Uh, there's a number of things that can cause it

59:00

to become a mucosal, including a mass.

59:02

And you really need to look carefully with a panic, scenic,

59:04

soft tissue nodules to suggest, uh, the presence of a mass.

59:08

When you see this, this does need surgical resection,

59:10

often more than just appendectomy, right?

59:12

Hemic colectomy. Um,

59:14

and so that's the importance of being able to diagnose this,

59:17

uh, prospectively to guide our, our surgical colleagues.

59:23

Right? Next case I'm showing you Mr.

59:27

Images T two weighted

59:32

post contrast image

59:37

abnormalities in the right kidney.

59:47

And I'm asking you, 'cause you did so well last time,

59:50

figure out the histology for this neoplasm.

59:54

Clear cell papillary

59:58

medullary squamous cell.

60:10

So I'm not seeing the popup box,

60:13

so I'm not sure if it's been answered already,

60:14

but you can guide me to, to let me know when that's,

60:16

that's been answered.

60:18

Sure. 33% said clear cell.

60:20

Okay, 47% said papillary, 16% said manary. Okay.

60:25

And 4% said squamous cell.

60:27

Perfect. Thank you very much.

60:29

And to the majority I think got this answer correctly,

60:31

but there was a bit of a spread

60:33

and to the correct answer in this case

60:35

that's I would say was a papillary renal neoplasm.

60:37

Um, and somebody asked something about the

60:40

mucus, answer that in a second.

60:42

And so what are we actually seeing over here?

60:44

And so here we're seeing a mass in the right kidney,

60:47

relatively T two hypo hypo intense and there is enhancement,

60:52

but it's not very brisk enhancement.

60:53

This is what we call low level enhancement.

60:55

Most clear cell carcinomas will have much brighter T two

60:58

signal and much more brisk enhancement.

61:00

And whereas it is the most common histology,

61:03

this is not a great look for it papillary on the other hand,

61:06

this is a great look for it.

61:07

It has that low T two signal low level enhancement

61:09

and so I would favor that medullary.

61:12

Not a great look for medullary by the way.

61:14

Who gets medullary carcinomas of the kidney.

61:16

People can chime in the chat box.

61:17

There's certain demographic factors

61:19

that make patients at risk for that.

61:21

Does anybody know?

61:26

Yeah, sickle cell trait make sickle cell trait.

61:30

Sickle cell trait. Exactly.

61:31

And so, um, uh,

61:35

and so in this case, uh, uh, you know, there's,

61:38

I didn't give you the history of sickle cell trait.

61:39

You really do need to have that history of it.

61:40

By the way, patient in a couple of cases,

61:43

they have very aggressive tumors.

61:45

They're young patients with very aggressive tumors

61:47

that are very infiltrative in their appearance.

61:49

Don't have these nice around borders like this

61:51

and often have widespread metastasis.

61:53

A time of diagnosis including adenopathy liver mets.

61:56

Um, so this is not a great look for it.

61:58

Squamous cell carcinoma of the kidney, very, very rare.

62:00

There is one condition that I know of

62:03

which is associated squamous cell carcinoma with a kidney.

62:05

Anybody know what that is? Chime in the chat box.

62:20

Somebody's putting it in. Yeah, very good.

62:22

I think you spelt that a little incorrectly,

62:23

but you are correct Exis, Carbin is pyelonephritis.

62:26

And so that's the only one that I know of that as,

62:28

as an associated with squamous cell caroma.

62:29

Very, very rare. So

62:31

as I talked about, there's different subtypes.

62:33

These are the three most common clear cell

62:34

and papillary could potentially diagnose prospectively.

62:37

Um, in general, when you see a mass in the kidney's,

62:40

T two hypot intenses, your options are papillary cyst debris

62:44

or Lipitor ml cystic debris has no enhancement.

62:47

Papillary is low level enhancement.

62:49

Lipitor AMLs, what we've talked about AMLs

62:50

before, only about 5% are lipid poor.

62:53

They can look quite T two hypot intenses,

62:55

but they tend to have avid, avid enhancement,

62:57

whereas this doesn't.

62:58

And so that's one way to potentially differentiate it.

63:00

Sometimes it's tough for me to biopsy it,

63:02

but those are some clues we can look at to figure that out.

63:06

Somebody asked about percentage of calcification mucus cell.

63:08

You know, I don't have the uh, answer to that.

63:10

Um, but um, you know, I I certainly not all

63:14

of them do calcify, but it's a classic sign of,

63:16

of a mucus seal that when they do have some peripheral

63:18

calcifications, how can we differentiate from a hemorrhagic

63:21

cyst presence or absence of enhancement?

63:23

And in terms of enhancement, uh,

63:26

when something does not enhance, it looks black,

63:28

it looks dark, it looks like the stuff over here,

63:30

completely black over here,

63:31

but this has a little gray

63:33

enhancement, low level enhancement.

63:35

So even that little amount tells us that it's enhancing

63:37

and that it represents a papillary RCC as opposed

63:40

to a hemorrhagic cyst.

63:45

Next case over here, I think we are almost done.

63:47

We have one or two more cases to go

63:52

gray scale and colored doppler image.

64:02

We have repeated some slides here. I apologize.

64:05

Next best step. So giving you

64:10

some benign options, antibiotics,

64:12

giving you some more aggressive options,

64:13

giving you some imaging, follow-up options,

64:15

which is always a possibility.

64:24

Perfect. 88%. Yeah.

64:26

So what we're dealing here, clearly the group knows

64:29

is EPI ide.

64:30

So we see the tail of the epidem here, enlarged,

64:33

heterogeneous, vascular, um, you know, there's a couple

64:37

of clinical signs that can be associated with it

64:39

and the bugs you're dealing with when it's above the age

64:40

of 35, typically e coli, uh, due

64:43

to retrograde infection from the bladder when it's less than

64:45

35 to sexually transmitted infections

64:47

tend to be a little bit more common.

64:48

Regardless, you need to be treating it with antibiotics.

64:50

There are some non-infectious etiologies, um, much,

64:54

much less common such that it's not even worth, you know,

64:57

really remembering these, these things being so common.

65:00

Uh, you're dealing with epi, somebody asked about the prior

65:04

case, but T one hypertense content

65:06

and hemorrhagic is certainly,

65:07

if you see T one hypertense content,

65:09

highly suggest hemorrhagic is,

65:10

I find it's variable sometimes can be T two hypo

65:13

right on one weighted images.

65:14

So just having that is not a great clue.

65:17

I think it's the, the lack of enhancement

65:19

that to me that helps the most.

65:27

Next case,

65:36

CT scan.

65:37

Hopefully the finding is not subtle.

65:41

What are we dealing with here?

65:45

Clearly a fat containing thing,

65:47

but which version of a lipos sarcoma?

65:50

An A MLA myeloid lipoma or a lip best diagnosis?

66:01

Yeah, lipos sarcoma.

66:02

So I'm liking the way we're ending here

66:04

with people all on the same page as being a lipo sarcoma.

66:07

Listen, this is a, a large fat,

66:09

fat containing masses in the retro repair

66:10

and look out to pushing the kidney upwards.

66:12

Um, and the well differentiate ones will have some septal

66:15

which are thinner minimally, uh, thickened,

66:17

minimal nodular components.

66:19

Um, I think there should be less than one centimeter

66:21

as opposed to greater than one centimeter,

66:22

but it does have mass effect.

66:24

Well, differentiated ones are low grade, no metastases,

66:27

but if you do resect them, they can have local recurrence.

66:29

Um, angio my lipomas.

66:31

You know, you know, in theory it can look like this,

66:33

but you want to see sort of a claw sign of,

66:35

or um, a sign any sign that it's sort

66:37

of arising from the kidney, in which case you don't.

66:40

My lipomas occur in your adrenalin gland.

66:42

This is not super renal and lipomas, by the way,

66:44

in the retroperitoneum are so rare such

66:46

that even if you see a beautiful FatCat contain mass without

66:48

any complexity, you're still gonna be thinking

66:50

that I'm dealing with a well differentiated lipo sarcoma

66:53

as opposed to a plain old lipoma.

66:57

In the last case, I believe

67:03

give you 10 gi 10 G wanted to cover as many organs

67:07

as I could and I had to give you one spleen, one to end.

67:09

So here we have a splenic mass, you see it here,

67:15

post contrast image out of phase image

67:17

and endphase image trying to show you something here

67:30

as diagnosis

67:35

lymphomas sent

67:37

hematoma splenic infarcts.

67:50

And so, so this is a tough one.

67:52

I I found it very difficult to write the question

67:54

for this one because, um, you know, uh, you know,

67:59

s san even if you don't know what it is,

68:00

if you look at these other options, you may pick it out

68:02

of a, you know, of exclusion

68:03

and this turns out to be a, a santi was resected.

68:05

Lemme see what the question is here San, somebody answered

68:07

that, that perspective really good for you.

68:09

Um, and so what's a san,

68:11

so san sclerosing angio oid nodular transformation

68:15

of the spleen is rare, sort of recently described.

68:18

Uh, lesion often is incidental.

68:20

And what are the imaging features that you're gonna clue you

68:23

and that you may be dealing with ascent?

68:24

Well, first of all, you're gonna be dealing

68:25

with an isolated splenic mass pretty well circum,

68:28

so nice uh, definable border

68:31

often has hypo intense T two signal

68:34

because it's a relatively vascular lesion

68:36

and that can undergo internal bleeding.

68:38

When it does enhance, it has, uh,

68:41

spoke wheel type enhancement within it.

68:43

And what I was trying to show, core example

68:46

of it in this case was in the in

68:48

and out phase images was, um, hemo,

68:50

citrin deposition a little bit on the endphase image.

68:53

It's a little bit dark over there

68:54

because of that uh, uh, presence of hemorrhage.

68:57

This is not a great look for lymphoma.

68:58

Lymphomas without treatment don't really have this

69:00

heterogeneous signal heterogeneous enhancement.

69:03

Um, although lymphomas can occur in the spleen,

69:05

this is just not a great look for it.

69:07

Infarcts don't enhance, hematomas don't enhance.

69:10

And so those would not be a good look for that.

69:12

The other thing that comes up, it's a rare tumor

69:14

that sometimes can be, you know, miscon confused

69:17

with this one is, uh, literal cell angioma

69:20

and the one key differentiating feature

69:22

that I always remember, literal cell angioma versus ascentis

69:24

sans are isolated, tend to be solitary.

69:27

As for solitary razan, literal cell cell angios tend

69:30

to be more multiple and smaller in size.

69:34

Hematoma could look similar, you know,

69:36

'cause these things, you know, in spleen it's, it's not

69:38

as easy as other organs, um, to,

69:40

to call things prospectively.

69:42

But I would say that the T two signal generally is

69:43

not as dark at a hematoma.

69:45

Usually more intermediate looks similar to the spleen.

69:48

Hemangioma tend to be brighter.

69:50

What's I think, unique about this is

69:51

that relatively dark T two signal spoke wheel enhancement

69:54

and hemo citrine deposition.

70:00

How is sand managed? That's a great question.

70:01

It's benign things. You could potentially just follow it.

70:04

Um, but sometimes, uh, you know, certain patients, uh,

70:07

because you can't call it prospectively what you know,

70:10

we don't know prospectively what it ends up being.

70:12

They may need to do a splenectomy,

70:13

but it's reasonable to follow it over a period of time,

70:15

maybe for six months for a while, then yearly just

70:18

to make sure that it doesn't grow.

70:20

Certainly the symptomatic you're gonna have to take it out.

70:25

I haven't heard of cases someone's asking if San can rupture

70:28

spontaneous cause placebo, peritoneum.

70:29

I haven't heard, um, of, of, of it doing that.

70:33

There may be case reports, but that's not something

70:34

that's really associated with, with sand tumors.

70:37

Uh, in terms of endometriomas the best treatment,

70:39

I mean not much to do.

70:41

Uh, you know, if the patient has a lot of symptoms,

70:43

I know they can sometimes go in and,

70:45

and sort of do an ovarian cystectomy

70:47

and take out the endometriomas,

70:48

but uh, it's usually just hormonal treatment

70:51

and symptomatic treatment.

70:52

Um, oftentimes they don't wanna do much surgery

70:54

with endometriomas 'cause already

70:55

so many adhesions if you go in there,

70:57

it's gonna cause more damage.

71:01

Perfect. And threw out the chat box and q and a.

71:04

I know I kept you the group a little bit over,

71:05

so I apologize for that, but hopefully this was useful.

71:08

Um, personally I'm not used to doing a lot

71:10

of multiple choice type of conferences.

71:12

I, I love the sort of the oral format where you can engage

71:15

with an audience, uh, in that manner.

71:16

But I really appreciate the engagement in this matter.

71:19

All the questions and I'm happy to sit around

71:21

for a few more minutes, uh, if anyone needs

71:23

to, to reach out to me.

71:29

Thank you so much Dr. Mather for that great case review.

71:32

Even though you don't do multiple choice questions a lot.

71:33

That went great. Appreciate it.

71:37

I'm quickly looking through the chat

71:38

to see if there's any other questions that came up.

71:41

Lots of thank yous.

71:45

Lots of, yeah, I think you covered everything.

71:48

Somebody asked about mucinous mets on liver.

71:50

MRI uh, mucinous liver mets on TW.

71:52

Yeah, mucinous lesions tend to not have that.

71:55

Nice um, beautiful restricted diffusion can, you know,

71:59

it's good to sort of pick up on the

72:01

lesions 'cause they'll all appear bright.

72:02

But if you look at the A DC, you may not end up seeing, um,

72:05

the dark, uh, thing on a DC images.

72:08

And so you really have to deal with, you have to interpret

72:11

that image in the context of the tumor that you're dealing

72:13

with, which is the mucinous primary as well

72:15

as the T two image appearance

72:16

and the post contrast appearance.

72:19

Well, I think we will wrap things up.

72:21

Thank you so much again Dr.

72:22

Mather, for this great case review

72:24

and for everyone else for participating today.

72:27

Wonderful. Thank you everybody.

72:29

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72:31

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72:33

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72:36

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72:38

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72:41

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72:45

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72:48

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72:50

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72:54

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