0:00

So really warm, welcome to everybody here.

0:03

I'm always so humbled by how many

0:07

people take the time they're busy days to come and spend

0:10

an hour, you know with with

0:13

any sort of lecture, but

0:16

certainly with me and as I was sort of scrolling through some of the participants

0:19

there's one or two that names that I recognize so special greetings

0:23

to those who have crossed paths

0:26

within the past. It's so nice to see you here. And so as I

0:29

said today, I'll be doing something a little bit different.

0:33

From some of the other conferences we've done for the new noon hour

0:36

where we're going to go through some uncommon disorders

0:39

and body Imaging problem. So some gastrointestinal

0:42

related some do you related and we're going to go through cases.

0:45

I'll be scrolling through them. And you know, I I'm not

0:48

going to use poll everywhere. I know probably majority

0:51

of the world likes it. I I find it.

0:54

I'm not very good at multiple choice. And so I don't

0:57

like doing that stuff but I love sort of interacting and so type in

1:00

your thoughts as we go through it and the idea here would

1:03

just be to engage with each other and with all of us so we can learn together and

1:06

get something out of this. And so this is a group

1:09

of that we work with at Yale. This is a handsome

1:12

Dan or you'll mascot and the outline

1:15

is really what we're going to do is really take cases

1:18

out of this National Organization

1:21

of rare disorder database called Nord. This

1:24

is something I didn't really know about and so this was

1:27

Brought to my attention at this exists. This is

1:30

the link over here. I have no affiliation with this and just

1:33

sort of providing you the link and and there's over

1:36

a thousand entries in this database and you may

1:39

be wondering what a rare disorder is because you

1:42

know, what may be rare for me may not

1:45

be aware for somebody else in the audience and vice versa. There's a

1:48

definition and these are these are cases this databases sort of

1:53

Takes into account the disease that we see the

1:56

United States. So it's just sort of rare disease is

1:59

something that affects your 200,000 Americans but you

2:02

know and and so some may be very rare maybe

2:05

case reports right? But but a lot of the stuff that we'll see

2:08

will be things that we don't see every day, but depending on

2:11

the practice you or maybe you'll see a little bit more than others. Okay, and

2:14

the way they sort of have the database if you go to that

2:17

website, they have it alphabetically and they have some that

2:20

start with the numbers and so you can click on anything they'll list

2:23

of diseases there. And so

2:25

Maybe somebody in the audience is wondering how

2:28

did I go about picking some cases? I thought

2:31

about that myself and the way I went about

2:34

doing it was I looked at my family members got

2:37

their initials first name and I

2:40

just picked those letters and so I'll be presenting you cases

2:43

based on that. So if I don't know

2:46

if that helps anybody in the audience, but certainly that

2:49

was my process and there's a lot of cases here. And obviously they want to

2:52

I want them to be pertinent to body Imaging there's a lot of stuff here

2:55

with neuro and msk. It's really interesting resource that that

2:58

they have. Okay, that's enough of me sort of

3:01

giving rambling. I know you're here to see cases and so I have

3:04

about seven today. We'll see if we can get through them. Maybe we get through them

3:07

all in 30 minutes and and we'll have a you know some engagement

3:10

after that, but if we don't we'll see what we

3:13

can get through in the next 15 minutes or so.

3:16

So these are all anonymized and so the

3:19

ages gender all that stuff is all

3:22

sort of, you know modified a little

3:25

bit. But here we go. Not gonna give you much history, but we'll work

3:28

through it together 37 year old male.

3:32

Right, it comes with renal failure got an ultrasound saw something. They want

3:35

to get a CT scan to further evaluate this

3:39

And so I don't know about your institutions but our

3:42

institutions.

3:44

Anything to do with the kidneys?

3:47

Are urologists if they get involved love doing hematuria protocols,

3:50

and so I'm going to give you a humaterial protocol today.

3:53

It's all so let's start up with the non-contract like how you would evaluate any material protocol.

3:58

I'll sort of scroll through it and at any

4:01

time if people

4:03

Want to chime in on things feel free to use the

4:06

chat box. I'll try to

4:09

be respectful of scrolling through going through things

4:12

and addressing some of the comments.

4:15

perhaps focus on the pelvis

4:28

we'll scroll back upwards.

4:32

And I'll tell you that the ultrasound saw they couldn't

4:35

find the left kidney and they saw a mass in the pelvis and

4:38

they thought that was the kidney and so it was sort of looking at this

4:41

immature protocol to help them figure out

4:44

what's going on.

4:46

And so this is the epigraphic face we do

4:49

this at about 90 seconds after giving contrast at our institution. I

4:52

need 100 seconds. We just go through the abdomen.

4:59

and finally

5:03

We'll have the excretory phase over here.

5:11

So we do this at about 8 to 10 minutes after giving

5:14

contrast.

5:16

We hope that our ureters are filled with contrast in this

5:19

case. They are built.

5:24

Let's go all the way down here.

5:27

down to the bladder

5:37

And just for the sake of completion, I'm going to put this.

5:41

sort of on modified

5:44

bone Windows here a little

5:46

so you can kind of see through the contrast because I know that we're doing

5:49

this as a hematuria, even though that's not what the

5:52

patient presented with you want to make sure you look at the collecting systems and the bladder

5:55

for any filling defects. And so

6:01

there you have it.

6:04

so

6:06

what do we think this mass in the pelvis is?

6:13

And if anybody wants to see any other of the sequences, feel free to say that

6:17

in the chat box. I'm happy to

6:20

to sort of put up any other sequences. We

6:23

have some reformats some may find that useful.

6:27

so young patient

6:29

reading issues couldn't find the kidney.

6:33

on the ultrasound

6:35

found something in the pelvis.

6:37

Thought it was a mass.

6:40

We have it on the immature protocol here.

6:44

Certainly is a mass and they thought that was a kidney actually on the ultrasound but

6:47

is it is it the kidney? Is it a weird? Kidney? Is it something

6:50

else?

6:51

How can we what's the approach here? So let's

6:54

see sad sage and misin come on neoplasmo

6:57

car. So here we getting I appreciate you know, by the way. I always

7:00

appreciate the first two or three people. Well, I appreciate everybody

7:03

but the first two three people chiming in is it often

7:06

takes the first couple to get the ball rolling and so I'm

7:09

off to not one of those people who chime initially. So I'm

7:12

very appreciative of the few that have chimed in already. So let's

7:15

see. This is the satchelory formats.

7:18

It's a very reasonable ask.

7:22

Perhaps you can see the relationship of what this thing is

7:25

to the bladder on that and to the ureter see

7:28

if it's a rising from it.

7:32

The other chat box.

7:35

Okay, cuz I come on neoplasm. Okay, some thought

7:38

I call neoplasm we have seminoma up there a multisy

7:42

stick dysplastic kidney like

7:45

topical that's an interesting thought so maybe the kidneys down there and that it looks

7:48

and it's really abnormal pelvic gist. I think it's a very

7:51

good thought and stick our seasoning topic

7:54

Oracle cancer. Yeah. So these are all really really good thoughts enter. Oh my

7:57

goodness. I think I saw cases in or the other day. I've been

8:01

looking for a good one. So let's these are

8:04

some really good thoughts over here.

8:06

And we have somebody as well on the other

8:09

Q&A feature midline Mass. Duramoid left kidneys at trophy urical cyst.

8:12

Okay, so I'm just reading stuff out now and we

8:15

will go through this but I really appreciate the engagement.

8:19

And what else do we have her left? Atrophic?

8:22

Kidney? Yeah. I'll say that.

8:26

Yeah, summative. Ethical someone's asking as well. It's a good thought

8:29

so I'll say you know.

8:31

There is one person in the chat box who actually is I

8:34

would say on the right track one person.

8:38

I'm not going to reveal who that is yet.

8:41

There's others who are getting close.

8:43

And and why don't

8:46

we start going through the case together? And as I go

8:49

through it feel free to chime in so you can

8:52

you can always see the the answer the final

8:55

answer before the final answer is revealed. Right? And so one of

8:58

the correct things I think a few people have noticed. I know it's tough when

9:01

I'm scrolling is that the left kidneys at trophic Heritage

9:04

you can actually see right over there. Right so very very

9:07

trophic left kidney. And so I think

9:11

some people talked about maybe a kidney that was a pelvic kidney

9:14

or something. That was an ectopic kidney and it's

9:17

a good thought. But in this case, you know, if

9:20

you if you had missed the initial few slices, you can see that kidneys actually

9:23

present but very very trophic and

9:26

it is enhancing a little bit but really not excreting anything. So really not

9:29

functioning any very well.

9:31

The other thing that a common theme that

9:34

has been brought up I think is it just tumor. I think it's

9:37

a very reasonable thing. So I'm going to put that aside for the moment as perhaps

9:40

a differential like, you know, like a pelvic gist.

9:43

It doesn't really seem to be a rising for

9:46

any bowel Loops, but just can arise within the mesentery as

9:49

well very so that's a possibility another common theme that's

9:52

come up with some of the comments.

9:54

Has been things arising from the salmon, Nebraska. I think it's a

9:57

really good thought. So let's look at the Seminary vesicles

10:00

here and certainly

10:03

We can see the right sum of ethical. Maybe I'll put up the non-contrast is

10:06

all because that goes down to the pelvis we can see the right feminine of

10:09

vesicle reasonably. Well one thing

10:12

that I don't see very well and maybe this is why someone went down

10:15

that pathway.

10:17

Not quite seeing the left Summit of us go very well. Maybe it's absent.

10:21

And maybe it's a trophic.

10:24

Certainly in the cases of seminal vesicle masses the

10:27

couple that have seen or zinner syndrome. The one that

10:30

I've seen in the books and stuff. Usually the mass is

10:33

sort of broadly in the shape of the Seminole vesicle. Usually

10:36

it's more sort of towards the left Hemi pelvis. This is a

10:39

little bit towards the midline. And so I

10:42

think it's a good thought to see if it's something arising the summit of ethical but not

10:45

quite in this case another couple of thoughts that

10:48

came up. Is this arising me you're right case. I like that thought. I think it's always a

10:51

good thing to think about when you see a mask sort of the lying atop the bladder, you know,

10:54

it doesn't really look like it's a

10:57

rising from the bladder looks like it always has mass effect and may even

11:00

see a thin fat plane over there. So what else so we have here your

11:03

AKO complex paragonally. I'm adding to differential. Yeah good thought,

11:06

you know can't forget a pair of gangliona, right or Rising for

11:09

me organizer gandal in particular. You see that's what we're on the

11:12

Ima take off. So I would expect that to be a little bit over here.

11:15

but

11:17

ovarian pseudos pseudo h

11:21

Yper. Oh pseudos pseudo wants feel

11:24

so bad. I don't know the eight stands for off the

11:27

top of my head. It does more tumors also possibility. We tend

11:30

to see desmoids and patients who are you know,

11:33

Gardener syndrome or a fat prior surgery this person

11:36

had a prior surgery and so all good thoughts and I don't mean to sort

11:39

of push away comments. I just want to try to work through why you

11:42

know, they're reasonable but not but there is

11:45

a way to get the right diagnosis in this case. So one clue

11:48

that I mentioned is that the Seminole on the left side is

11:52

how to get a trophic to absent okay the

11:55

other clue

11:57

I haven't seen in the chat box yet, but I'm going to start to

12:00

scroll down a little bit.

12:02

Now we're starting. Okay. Somebody wants to see something that I'm about

12:05

to say. So you got in just in the nick of time. Let's look

12:08

at this dramaticord.

12:10

What's missing over here?

12:12

At the right side you can see very nicely over here. You don't

12:15

see this dramatic chord on the left. Okay. Now can

12:18

we start putting things together? I think people have started putting

12:21

things together a little bit whenever you don't see this dramatic chords

12:24

young patient hasn't had an orchiectomy gotta think

12:27

of the possibility of an undescended testicle, correct fair

12:30

enough, and we've seen our share of undescent to testicles not

12:33

very common.

12:35

What's the next step to figure out this is the undescended testicle

12:38

or not? You got to look at the testicular veins and

12:41

the testicular veins on the left side typically will drain

12:44

into the left renal vein and so we can go upwards again.

12:47

Now that left a kidney is quite a trophic, but it

12:50

does have a renal vein.

12:51

And it's going to come out.

12:53

Right around here.

12:55

Going down going down.

12:58

Going down along the top of the left. So it's muscle coming

13:01

down here coming down here all going

13:04

a little bit more medially now.

13:05

And going right to this Mass. Right? So

13:08

this is certainly a mass. That's a rising in and

13:11

an undesendable undescended or in fact, maybe even ectopic

13:14

test will give them a location and it looks really heterogeneous. It

13:17

looks like it has enhancing components. This is a

13:20

neoplasm that's a rising in an undescended testicle and

13:25

And so I think somebody in the beginning had talked

13:28

about and people are trying to chime in. This could be

13:31

a seminoma. I find that very difficult to call perspectively whether to

13:34

seminoa, but all we all I can say is you know is a testicular neoplasm. And

13:37

in this case, we're rising and a in

13:40

an ectopic and undescented testicle and

13:43

so good on the group for

13:46

kind of going through that systematically and let's have a

13:49

few a few bullet points

13:52

on this and so, you know, we see

13:55

these undescended testicles from from time to time and we

13:58

know that there's some risk factors associated with

14:01

them most worrisome of courses that

14:04

risk and malignant transformation and malignancy and

14:07

it turns out that that risk is present both in that understand

14:10

a testicle as well as the contralateral testes and it

14:13

may be do to some underlying abnormal embryogenesis that

14:16

in some way affects both testicles, even though one is

14:19

actually quite a topic. And of course the other risk is the

14:22

increased risk of in fertility.

14:25

so

14:26

I remember looking at this case a couple years ago and you

14:29

know went through so much of the same

14:32

process that I think everyone in the group has gone

14:35

through and right as I

14:38

was about to close even as one of those things and we've all been through there you drive

14:41

right is about your clothes you start to notice. Hey, something's missing here.

14:44

Oh, this is also a trophic and that's something that's associated with

14:47

crypto coordinate and restivals. Then you look at the model veins reading right to

14:50

it. And I remember having this Eureka moment where I'm like wow, this is

14:53

this may be the first really, you know,

14:58

exciting kind of wacky call rare call,

15:01

whatever you want to call that I make as a

15:04

junior attending and so I never forgot that and so I wanted to share that with the group and certainly

15:08

appreciate the groups engagement and dialogue and

15:11

working through that. So I'm just gonna answer these questions

15:14

live and my Q&A feature so I can clear the box and

15:17

if it's okay with a group, we'll move on to our next case.

15:20

I don't promise they're all gonna be as exciting as this, but but hopefully

15:23

we'll be exciting for some people.