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In this case, this 25-year-old male presented

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with back pain

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and had a spine MRI that showed

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diffusely abnormal bone marrow signal concerning

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for an infiltrative disease.

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Clinically patient presented with night sweats

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and was concerning for lymphoma.

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So this PET CT with FDG was performed

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For initial staging.

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As we can see in the meep, there are numerous areas

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of abnormal trace or uptake.

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There's fuse disease in the bones

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of the extremities but also in the axial skeleton,

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but there's also disease uh, within the mediastinum.

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So we're gonna go through the

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findings starting from the top.

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And as we have mentioned previously,

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looking at the pit alone, we can see

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that there are multiple areas of uptake.

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Now, when cases are complex and

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and there's a lot of abnormality, it's very important

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to correlate with the CT and the fued images.

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Uh, as you scroll through in this case,

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even looking at the neck, we can see

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that there's already an osseous lesion,

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but I want to see what's happening in the soft tissues.

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Are there abnormal lymph nodes?

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And uh, scrolling lower down we can see

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that there are bilateral lymph nodes

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that have abnormal tracer uptake.

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Some are larger like these one on the left,

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some are small like this one on the right.

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But regardless, this is abnormal.

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We can see that there are multiple stations in the neck

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that are involved and they show intense tracer uptake

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with an SUV max for instance of 8.1.

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Here on the left.

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Aside from the novel disease

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and what we can already know, OSCEs disease,

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there are no other structures that are involved in the neck.

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The thyroid looks normal on pit and on ct.

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The airway is patent disease is not

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bulky on the neck.

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Scrolling down to the mediastinum,

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there are multiple stations of the no disease as well,

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but there is a larger

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nodal mass in the anterior mediastinum that is heterogeneous

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with central relative nia.

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These may indicate necrosis, so

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in this case the novel mass but the heart

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but it's not infiltrative.

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There's also disease in other areas of the mediastinum,

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including the right parital noles station

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and bilateral hial su carinal station.

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The heart otherwise has, you know, physiologic uptake.

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In this case for instance, I would provide

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for sure the measurement of the largest novel mass,

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which would be the anterior mediastinum

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and maybe we can also add measurements of the highest

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or most FDG avid lymph nodes in the neck.

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Always thinking about what would be best target

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for biopsies.

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Another trick that I use when I'm reading cases with a lot

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of disease is change the color scale.

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It is hard for me sometimes to identify what is the area

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of highest uptake when there is so much going on.

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If I want to provide a number of the area

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that has higher FDG uptake, I can manually

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go through each area

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or I can select a scale that allows me

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to separate the colors better

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and I usually change it to rainbow.

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That's a trick that I use, but it works great for me

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and I change it so I can identify the areas.

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In this case, it's red, so it's very easy to see.

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In this case, it's obvious this mass has a lot of uptake.

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Even if I change it very low, there is still some red

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and this is an SUV max of 13.6,

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but let's go to the neck to identify which would be the,

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the one with highest uptake.

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For instance, these lymph node on the left base

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of the neck, this one has a 6.3

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and this other one has 8.1.

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So I would be probably providing this one as an example.

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There's also axillary involvement.

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Uh, we can see it on the right there.

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The lungs were clear on this patient.

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There was no abnormality within the lung parenchyma

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going down to the abdomen, one of the things to

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report is obviously adenopathy,

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but also mentioned the spleen, if it's normal in size

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and normal in intensity of uptake.

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So in this case the size is normal

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but we can see that the uptake is greater than the liver.

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This would be something to mention

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and then once we have the overall picture, we'll be able

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to better interpret these particular finding.

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This patient had multi-stage noal disease

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with very intensely FDG added lymph nodes in the upper

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abdomen, periportal location

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and retroperitoneum as well

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as bilateral pelvis.

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On the right external iliac, it's a very bulky adenopathy

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that measures 2.4 centimeters insured taxes

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and has an SUV max of 12.

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These other one more anteriorly is also

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quite enlarged.

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It measures 1.9 10 with an SUV max of 10.7.

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Additional findings in the inguinal region.

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I would mention that there is bilateral involvement,

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but I will also describe these as an example

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because I think these are

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becoming really good targets for tissue sampling.

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They are very superficial

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and very FDG avid,

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so I think this would be a fine place to biopsy.

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I changed the display to have a better visualization

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of the entire skeleton.

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As I have mentioned in earlier details in this case,

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we can see that there is diffusely patchy uptake in the

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spine with areas that have intense uptake.

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Some of them actually don't have a CT correlate, such

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as in this one where there is FDG uptake,

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but really not a lot of morphologic changes.

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So once I have gone through the skeleton

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and described the bones that are involved,

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I will particularly mention those bones that have

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large involvement and are prone to pathological fractures.

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All of the bones can fracture,

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but areas of weight bearing are ones that are more prone.

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So these would be good for the clinician to know

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and for the patient to know as well.

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Once I have finished reading the case, I'm going to go back

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to the MIP and make sure that everything that I have seen

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on the axial Coronas or sagal have been uh, described

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and I am not missing anything on the edges of the film.

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In this case, we have extensive

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multi multistage nodal disease above

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and below the diaphragm

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with no mass in the anterior mediastinum.

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There's also extra nodal involvement in the

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bones of the axial and appendicular skeleton.

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We mentioned that there was abnormal splenic uptake

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and I think in this case now

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that we put everything together,

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the spleen may be also involved.

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Now remember that the spleen is a novel organ,

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so when I say that there is novel disease,

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I am including the spleen,

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but I will specifically say that in the impression

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if they don't have tissue sampling,

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which was the case for this patient.

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I will repeat in my impression that the right inguinal

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and external iliac bulky lymph nodes are amenable

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for image guided biopsy.