0:00

so let's move on to our next case, which is

0:06

41 year old female with a right upper quadrant pain

0:09

okay, 41 year old female right upper quadrant pain

0:17

I'll show you some of these images here.

0:21

So T2 will start off with the t2 image. So let's just

0:24

scroll all the way from the top.

0:40

t2s

0:49

There's a lot going on here. So.

0:53

hopefully just focus on

0:56

some things in the right upper quadrant and

0:58

as you once you figure that out.

1:01

Try to put other things together. See if you come up the specific diagnosis

1:04

here. I think it's going to be tough. But this is

1:07

a good group. We have about 254 now and so

1:11

See if we can potentially suggest a specific

1:14

diagnosis here.

1:16

So again 41 you're female right upper quadrant pain.

1:21

Showing you some post contrast sequences.

1:30

So curious to see what people are seeing in the chat box. Let me finish scrolling

1:33

a little bit and I'll

1:34

have a look. Let's put up a more delayed three minutes

1:37

sequence here.

1:48

I think that's sufficient. I think that's

1:52

it's reasonably sufficient for the moment. So, let's see what

1:55

the chat box says.

1:56

Okay, okay a lot. We're all over the place which is

1:59

just great. We're gonna sort this out. So history was 41

2:02

year people write up a quadrant pain right real math. So that's absolutely

2:05

correct X GP. Okay and abscess,

2:08

that's a good thought xgp, or your

2:11

last liver lung mats. So pretty young sort of

2:15

when a step further and saw that there were some lesions in the

2:18

liver and lungs a good on you for recognizing that if only

2:21

thrombosis RCC with metatrcc never renal vein.

2:24

Okay, somebody thought a real thrombos has been out take that back. That's fine all

2:27

letters telling TCC. Yeah all

2:30

over the place. This is tough. Okay. Somebody asked an

2:33

interesting patient is sick, Colorado. I don't know. I don't know what

2:36

Harish Patel is getting at but if they

2:39

were to elaborate on that, I'm happy to.

2:42

Entertain that comment can't see the right adrenal gland.

2:47

And so we really just see a very aggressive looking

2:50

Mass right in the right kidney here.

2:53

Everyone's heterogeneous enhancement. Okay, you see

2:56

a chat box one more time. Let's see with Mets.

2:59

Okay. So again, I think we're on

3:02

the right track. And I think one person at least is on the right track, perhaps

3:05

a tiny tiny tiny bit more than others.

3:08

And so let's go to the case. So

3:11

You know, listen, if all of

3:14

you have this case and we interpret it

3:17

as a, you know, a very correct, you know, a heterogeneous

3:20

right renal mass. And there's all this adenopathy here.

3:23

Look there's even retrocrial notes. I want the last times your retrocruel mode

3:26

from a big RCC. I don't know I've seen big rcc's. I

3:29

don't quite Seattle all the way up there quite extensive at an

3:32

apathy here as well. Somebody pointed out there was

3:35

lung mats. You can see one right over there.

3:37

And you don't see it on all sequences really nicely and

3:40

there are liver mats, and there's one over here. For example.

3:43

And there's one over there.

3:45

And you know one over there. There's a whole bunch of

3:48

them and they're not all that easy to see on the post contrast sequences. But at least on the

3:51

t2 stay there.

3:52

A renal vein looks okay actually surprisingly. It looks

3:55

pretty okay in this instance though admittedly tough to see

3:58

in a few areas the collecting system looks a little bit abnormal in

4:01

the sense that there's a little bit of homage in it.

4:04

Okay, but you know if I were to look

4:07

at this, I don't feel that the mass is centered.

4:11

In the collecting system per se. It looks

4:14

like it's renal, Mass. But it also doesn't look like it's a

4:17

big, you know, like, you know, big ball like mass

4:20

that sort of sticking out of the kidney. It almost is ready for

4:23

him cheap. It's almost this infiltrative heterogeneous aggressive looking thing that's

4:26

almost in the shape of the kidney itself, which is

4:29

I think a little bit unusual like it's not quite

4:32

what you're used to seeing these aggressive clear Soul rcc's

4:35

or other tumors like that. So maybe that's a clue

4:38

as to what's going on. Now certainly it has some effect on the collecting

4:41

system and it's Hemorrhage. There's all this enhancement. I think

4:44

all that's probably secondary.

4:46

And it's very aggressive right? There's always at an apathy. There's all

4:49

these lung mats and liver mats.

4:51

And so can we come up with a type of

4:54

renal neoplasm? That could look like this?

4:56

That is really aggressive.

5:01

Renal lymphoma, that's a possibility. I find lymphoma though.

5:04

One thing I feel to mention.

5:07

You don't quite see I mean there's areas that look frankly necrotic,

5:10

you know, they're look like they're bright and they're not enhancing too.

5:13

Well, not quite used to seeing that with lymphoma unless there's

5:16

been some sort of treatment. But so if I had a more

5:19

homogeneous relatively homogeneous looking mess I would think of maybe lymphoma but

5:22

these nodes and everything just don't look like it's a run of

5:25

the middle of lymphoma. I think Von lippel

5:28

hindau was something that

5:32

With someone mentioned, you know you you know for that I'm

5:35

gonna look at also. I'm gonna look at you know, bilateral neoplasms adrenal

5:38

cortical carcinomas things in the pancreas. And so I'm looking

5:41

at those primary organs. I will say that somebody's asked

5:44

this twice now and I yeah, okay

5:47

fine. So now we finally have a few

5:50

people who are getting at what

5:52

I

5:54

I connecting the question that was

5:57

asked in the group with what I think the diagnosis this person is

6:00

not a sickler but it has sickle cell trait as

6:04

sickle cell trait and so this is a Metroid renal

6:07

cell carcinoma and I'll say that I've seen I don't

6:10

know. I've only seen two or three cases of this.

6:13

but

6:14

every time I've seen it it happens, you know, I think about

6:17

it when I see a young patient. It's a 41 year old female.

6:21

Who has a very aggressive looking Mass but it's

6:24

still sort of almost confined in a weird way to the kidney met

6:27

with a kidney maintaining. So any form shape and it's super aggressive.

6:30

I'm seeing talking about quite a lot of adenopathy livermets

6:33

and lung mats at the

6:36

time that you see it and I'm not saying that's all

6:39

specific for for medullary the ideas

6:42

that think about in that instance and that's

6:46

Was the thought process I went into this. They didn't tell

6:49

us the patient had sickle cell trade, but once we sort

6:52

of mentioned that possibility it worked them up in this indeed had

6:55

patient at Sickle Cell trade this turned out to be a

6:58

he imaginary RCC and so let's talk a little

7:01

bit about this entity.

7:03

Because we don't see it from time to time. It's really rare. But a

7:06

lot of the patients will have sickle cell trait in

7:09

particular. So that's the key differentiation sickle cell trait not sickle cell

7:12

disease itself and it happens

7:15

in young adults.

7:16

They can present with humaturity that comes out with pain and unfortunately

7:19

to very very poor prognosis. You do chemotherapy. You

7:22

didn't effective chemotherapy, but

7:25

You know.

7:26

It's always hard to see these cases because they happen to be

7:29

young patients in and what we know about it is that patients don't

7:32

do well and so on Imaging you'll see

7:35

a mass that inferior rises from the medulla extends

7:38

to the cortex the kidney maintains. It's raining formship, which is

7:41

what I'm trying to show you here can cause Hydro they tend to be large Mets

7:44

are common. In this case. It's sort of read the book and quite

7:47

heterogeneous enhancement. It can mimic an

7:50

abscess and that's one thing I didn't address with the group that a lot of people thought of xgp.

7:54

I think an xgp, you know, you're getting that sort of

7:57

Bearpaw appearance. You're getting that stag one calculation not

8:00

seeing heterogeneous soft tissue and the next GP couldn't necessarily account

8:03

for all the adenopathy a lung

8:06

medicine one potential complications the

8:09

group by Novak's GP that's really rare squamous cell

8:12

cancer. So maybe if you spun it saying xgp, what's

8:15

going to sell cancer and that's that's possibility. But in

8:18

and of itself this doesn't have that classic SGP look

8:21

and if I told you the patient, you know, urinary tract

8:24

infection symptoms of that maybe you could go along that pathway, but

8:27

this was not quite the case in this instance.

8:32

Oh, no, no one needs to apologize for any of

8:35

the diagnosis. He's made I appreciate it because I think it's part of the the dialogue

8:38

that we have about these cases in the

8:41

thought process. That's the most important they can we consistently have the right

8:44

thought process to get us hopefully to a diagnosis that's

8:47

a reasonable and a lot of the diagnosis that we're mentioned are very

8:50

very reasonable.