0:00

Thank you very much, Ashley Paul Ben and

0:03

the entire MRI online group. It's a pleasure to

0:06

join you guys today here.

0:08

And I'm going to share some interesting cardiothoracic cases

0:11

that I encountered in practice.

0:14

I also want to extend a welcome to all the participants looks

0:17

like it's a small intimate group. So that

0:20

should free us time to ask any questions and I'll

0:23

try my best to answer these.

0:30

I have no disclosures.

0:32

And I'm going to share with you cases that

0:35

taught me in one way or another whether it

0:38

was in terms of perception and picking up the

0:41

findings or it was an aspect of interpretation that

0:44

was interesting in you.

0:46

So let's start off with the very first case and I

0:49

called it the case of mysterious bone lesions. So

0:52

to give you a little history. This was a 75 year

0:55

old female known history of lung cancer.

0:58

And came up for a follow-up surveillance CT

1:01

scan.

1:03

So I'll share with you a scroll of CT images,

1:06

and I'm going to scroll from the top to the bottom.

1:09

So here is an axial contrast enhanced CT.

1:15

As I'm scrolling. I just would like you to make the

1:18

pertinent findings that you are gathering in

1:21

the very first scroll and I'll do this a few

1:24

times because it's a lot harder when somebody else is crawling to

1:27

really pick up the findings.

1:29

As I mentioned this patient had a history of lung cancers.

1:32

So you're looking very carefully at the abdominal organs. The

1:35

liver has the small hypogensulation here,

1:38

which was indeterminate and happens stable on multiple

1:41

exams. The adrenal glands were normal.

1:44

As you go higher up in the chest, you can see

1:47

clearly there is volume loss on the right side and

1:50

the media's time is shifted over to the same side.

1:54

and in fact here is the

1:56

let's bring it up. Here is the right bronchial stump.

1:59

So this patients had a new minectomy

2:02

and you're seeing all these pneumonectomy related changes

2:05

the pluralism what thickened and there's

2:08

a small amount of loculated plural fluid

2:11

Now let's look at some other aspects of

2:14

the scan whenever we have an oncology patients.

2:17

It's always a good idea to look at the pulmonary arteries to

2:20

look for any incidental filling defects. This

2:23

patient really had no incidental pe's

2:26

Again, there weren't any suspicious or big

2:29

lymph nodes. You can see this patient has a left

2:32

ionic Arch. So here is the left auric Arch. There's a

2:35

variant of branching anatomy where

2:38

the rights of clayven artery is retro esophageal and

2:41

courses over behind the esophagus.

2:44

So just an incidental finding this is not really a

2:47

vascular ring, but you have a left Arch within a parent rights of

2:50

cave in artery.

2:53

Another thing we notice is a lot of contrast in the veins.

2:56

So the timing of the scan is such that there is significant

2:59

venous enhancement the contrast as

3:02

you can see has been administered on the left side. So

3:05

the left brake is cephalic veins of caving veins are opacified.

3:10

You also notice that the left Breakers cephaloquine as its coursing

3:13

anterior to the aorta is fairly narrowed.

3:17

And again as we scroll for the down you

3:20

get to the SVC SVC itself looks quite patent.

3:24

And it was to the right SVC right

3:27

atrial Junction. I'm not showing you

3:30

the lung windows in this particular patient because they were not very helpful

3:33

or contributory to the diagnosis. So there

3:36

wasn't any suspicious or new or growing lung nodules.

3:40

As I mentioned the case is the case of mysterious bone

3:43

lesions. So let's look at the bone Windows now.

3:46

And again, I'll do the same thing. I'll scroll from the

3:49

top to the bottom and what you're starting to see right away

3:52

is

3:54

some kind of what looks like sclerotic RCS

3:57

lesions involving multiple vertebrates. So

4:00

here is one for instance.

4:02

You scroll down further. You see another one right here.

4:06

And there were several such lesions another one

4:09

here.

4:11

And so on.

4:13

So the question is and I would like you to think about

4:16

it for a minute. So you've seen the media channel

4:19

windows and you've seen this finding on the bone windows.

4:23

It's obvious helpful to look at another plane. So here is a sagittal

4:26

bone winter for the same patient again, you're

4:29

seeing this is what the what evil bodies look like. These

4:32

are the lesions we are talking about today.

4:36

So as I mentioned, this is a surveillance CT scan

4:39

so we had prior Imaging for comparison and just for reference

4:42

here is the scan. We just looked at so you

4:45

can see this where these were the vertebral body lesions that

4:48

we have seen in the current scan.

4:50

We had a scan from four years ago six years

4:53

ago as well as six and a half years prior to this current

4:56

study.

4:57

In the scan which was done four years ago, and I've

5:00

tried and linked these images at

5:03

a very similar corresponding level.

5:05

You notice that you don't really identify anything

5:08

wrong with the vertebral bodies at this point.

5:11

However on a scanned on six years ago you again

5:14

see these sclerotic appearing lesions though.

5:17

They have a slightly different morphology than the

5:20

current exam.

5:22

And again, if you just went six months further back

5:25

in time, so six and a half years from the index scan you again

5:28

don't identify these lesions.

5:31

so

5:33

If you think yourself as interpreting the study, I

5:36

would like you to consider as what do

5:39

you think are the likely possibilities for the Arceus lesions?

5:43

Would it be sclerotic metastases that are

5:46

perhaps waxing and reigning with treatment?

5:49

Is it radiation changes?

5:51

Are you thinking of collaterals or are

5:54

there intrinsic bone abnormalities like bone Islands or

5:57

bone-infox?

5:59

So

6:01

Just go ahead and give your word

6:04

as the most likely possibility for these obvious

6:07

lesions.

6:11

So I noticed that nobody really

6:14

thought of sclerotic metastasis which is indeed great

6:17

because that is an incorrect response.

6:20

25% people thought of radiation changes and

6:23

a similar percentage of people considered collaterals.

6:27

But more people considered born in

6:30

France.

6:31

So let's look at the correct answer. I'm going to close this

6:34

falling window for a minute.

6:36

The correct response in this case is actually collaterals and

6:39

let's see why and how can we come to this conclusion?

6:43

So incidentally this patient here is the current scan

6:46

that we had done with contrast incidentally this patient

6:49

received a non-contract CT just a few days after

6:52

this indic study and what you notice is that

6:55

there is absolutely none of those chlorotic lesions

6:58

that we are seeing in the non contrast scan.

7:01

And we could imagine I mean as you can see this really

7:04

points to us that all of these lesions are

7:07

in some way related to contrast Administration or

7:10

giving contrast.

7:13

So this is what's been termed as Vanishing and

7:16

I would say quote and quote osteoblastic metastases because that's

7:19

not what they are. These are pseudo lesions.

7:22

So these are pseudoslerotic appearing lesions and

7:25

they have been described in some kind

7:28

of venous obstruction. Whether that Venus obstruction happens at

7:31

the SVC level. It could also happen at

7:34

the breaker cephalic vein level where either both or

7:37

a single breaker cephalic vein or occluded or obstructed.

7:41

If you remember when we were going over this stack of

7:44

CTE images in this current case.

7:46

You might remember we had looked at the left previous

7:49

narrowing.

7:52

And what happens with this kind of Venus obstruction is we know about

7:55

the collaterals that open up in the media's tynem. They may open

7:58

up in the chest. But apart from these well-known collateral

8:01

channels. There are also prominent vertebral Venus

8:05

taxes that are dilated and they start

8:08

fooling with contrast when you have this kind of central venous obstruction.

8:13

So it is the opacification of these prominent part

8:16

of vertebral veins as well as the

8:19

enhancement Within These Central in these venous

8:22

plexuses that leads to this illusion of sclerotic

8:25

lesions. This is in fact just contrast enhancement

8:28

and not truly a sclerotic RC isolation.

8:32

So now let's revisit the case. Once again, this was

8:35

a current scan as I showed you. This was a

8:38

scan from four years ago, six years ago and six and a

8:41

half years ago.

8:42

And interestingly you don't see it in six and a half years ago,

8:45

but you see it in six years ago scan and then it

8:48

again disappears. So what could possibly explain this?

8:52

You do notice that all these scans are contrast in hands.

8:55

So it's not just the fact that we did

8:58

not give contrast which led to these lesions disappearing.

9:01

rather the important thing to note here is

9:05

the site of administration of contrast as you can see in

9:08

the scans from the current study as well as the six year

9:11

ago study contrast has been given on the left side. So

9:14

on the side where you have that unilateral Breakers

9:17

of aloequain obstruction, when you

9:20

have that you're a pacifying the collateral channels and

9:23

hence the vertebral venous plexuses are getting enhanced and

9:26

you're curing as chlerotic lesions on the

9:29

other hand the other study from six and a half years ago and

9:32

four years ago. You can nicely see that the contrast has

9:35

been given on the right side which is why these collateral

9:38

channels have not a pacified and hence you

9:41

do not see these were people body lesions.

9:45

In fact, this is another follow-up scan done a year later. This was

9:48

a total non-contrast CT and again those lesions do not appear

9:51

if it's non-contrast.

9:53

So I found this to be a very interesting scan. I

9:56

think it teaches us some very important points particularly

9:59

when we are looking at oncologic surveillance

10:02

studies. This is an important bitfall and

10:05

how do we really come to the possibility that this

10:08

is not a metastasis, but this

10:11

is related to the Venus obstruction. Make sure

10:14

that you look for the wings. Is there central

10:17

venous obstruction?

10:19

If there is if there is either SVC or there is

10:22

precise Valley Queen obstruction.

10:24

You can consider this as one of the possibilities or

10:27

differentials to think about.

10:30

The other thing you will notice is these patients will often have very dilated

10:33

periodiveral veins as you can see in this particular image

10:36

of the same patient all the

10:39

venous structures. The Venus plexuses are quite dilated and

10:42

prominent.

10:44

Also, it's a good idea to compare with iopraya scans

10:47

that have non-contract CT or sometimes if

10:50

they have unilateral venous obstruction then paying attention

10:53

to which side we give contrast can be very very important.