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This is a patient with melanoma that we have looked at

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in the video, but we're gonna now look at the entire study

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and follow ups more in detail.

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He initially presented with a seizure

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and was found to have a metastatic brain lesion.

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As you can see here in the dicom.

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As you can see here in the mi, there's a focal uptake

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in the left, uh, frontal parietal region.

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And, uh, this was biopsied

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and confirmed metastatic melanoma.

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In addition, we have several other findings,

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including the axial.

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We have soft tissue nodules, uh, here in the

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left aspect of the jaw and also in the back.

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This patient also had a lung metastasis with very intense

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NDG uptake and multiple lesions in the liver.

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If we look at this closer, we'll see that the majority

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of these lesions do not have a CT correlate.

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If I scroll through up

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and down, there's only a faint correlation with this one,

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but the majority of the other lesions really don't show up

1:22

on the CT indicating that the disease is truly metabolic

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and, uh, microscopic difficult for us

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to see unconventional imaging.

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Aside from that, the patient had several areas

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of disease in the abdomen, including this lymph node,

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but also a focus

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of uptake in the descending colon in the abdomen.

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There was an abnormal area of uptake in the mid body

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of the stomach as well as, uh, intensely

1:56

mein lymph node.

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Patient also had several sites of o osteos disease,

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for instance, this one in the left iliac bone without CT

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correlate also in the sacrum bilaterally.

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And these were consistent with metastatic disease.

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Patient underwent immunotherapy and I have the follow ups.

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So the first follow up of this patient,

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we can see the meep images alone.

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You can appreciate the tremendous response that he had

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with majority of the, of the GI lesions.

2:31

Uh, nearly resolved, uh, if not completely.

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Now let's look at it more in detail.

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In this view, I'm showing you the baseline at the bottom,

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the first follow up

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and then the subsequent follow up on top.

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So, as I said earlier, the

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lesions had nearly resolved.

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For instance, the left

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lung metastasis had decreased both in size

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and degree of FDG uptake.

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The soft tissue lesions have resolved.

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This one in the left back is no longer appreciated.

3:09

The hepatic lesions that were numerous

3:14

now are no longer evident on the ct,

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though we see new appearance of multiple lesions

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that are hypodense but not FDG avid.

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The response in the liver was very positive.

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The majority of these FDG AVID lesions have resolved.

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Now we do see new hypodense lesions at sites of prior

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uh, metabolism, but this is part of the treatment response

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In the subsequent pit.

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We can see that the majority

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of those hypodense lesions are now less obvious

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indicating continuous treatment response.

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And there were no new lesions at the end, uh,

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when patient was on maintenance, uh, nivolumab

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looking at the chest, we can appreciate that.

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In the first follow up, we have new findings.

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These were FDG Avid lymph nodes in the mediastinum

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and bilateral hila.

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If we look closer, we appreciate the symmetry,

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but also the lymph nodes themselves

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and the CT portion of the exam look a little prominent

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but not dramatically enlarged.

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On the next follow up, the lymph nodes continue to be there,

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but this is the classic sarcoid like reaction

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seen in immunotherapy patients.

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Once patient was on nivolumab maintenance, he came

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for follow-up and he was found to have

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new findings in the chest.

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And these were demonstrated as

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diffuse grand glass opacities in the, in the lungs.

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And look at the diffuse FDG uptake.

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Know we should expect no uptake

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or very little in normal lung parenchyma in this case.

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It is hard to depict those lymph nodes in the mediastinum

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because there is background lung uptake.

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And this is one of the things we have to recognize

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and communicate to the clinician to make sure

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that the patient is appropriately treated and evaluated.

5:29

Often these patients will require steroid treatments

5:33

until a resolution of symptoms

5:35

and CT findings at the end.

5:39

Once the patient was on, uh, maintenance, nivo nivolumab,

5:43

he continues to have a good metabolic response

5:46

and no new site of disease.

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Let's look at one more thing and ease the brain.

5:54

This patient had that

5:57

Metastasis, uh, resected.

6:00

The edema that was seen initially

6:02

as decreased tracer uptake in the cortex resolved as well as

6:07

that crossed clar diasis that we saw initially

6:12

is now resolved.