0:00

68-year-old male that was found incidentally,

0:05

a pulmonary nodule on a CT of the neck

0:09

that was done for dysphagia and working up that

0:14

and they found that right acal SPD pulmonary mass

0:18

and a separate nodule slightly lower down in

0:22

the right upper lobe.

0:24

And therefore, because these were suspicious for malignancy

0:29

and possible satellite nodule,

0:32

they recommended an FDG pit for staging

0:36

and to help guide tissue sampling.

0:40

So here we have the FDG PET CT in which we see

0:43

that there is abnormal tracer uptick in the right apex.

0:49

And these corresponded to that right optical lesion.

0:55

You can see the extension of the speculations

0:59

to the pleural surface

1:01

and the soft tissue component of the lesion itself.

1:06

Uh, the degree of uptake is mild with an SUV max

1:11

of 3.5, mild to moderate

1:15

and lower down.

1:16

There was a second lag nodule that was solid and more round.

1:20

That also shows mild tracer uptake

1:24

with an SUV max of 2.6.

1:27

There were additional small lag noles

1:30

that were not included in that CT neck.

1:32

And we are now seeing on the CT portion of the PET ct,

1:37

these are too small for us to characterize.

1:40

These are below the size resolution for PET

1:45

that we uh, mentioned earlier.

1:47

It's one of our limitations,

1:50

but you can see that there are several small pulmonary no,

1:54

like this one on the right lower lobe.

1:56

Unfortunately this patient didn't have a prior,

1:58

so we cannot establish chronicity

2:00

of these, uh, lung nodules.

2:03

Now looking at the findings on the mediastinum, you can see

2:07

that there are several areas of increased tracer uptake,

2:10

bilateral mediastinum and bilateral hila.

2:14

In these correspond to lymph nodes.

2:19

On the CT portion, you can see

2:20

that these lymph nodes are enlarged.

2:22

For instance, this one in the right lower parital station

2:25

measures one centimeter ensure axis.

2:28

Uh, we have another one that is quite prominent superiorly

2:33

at the tracheoesophageal groove measuring 0.6 centimeter.

2:39

Also left a lower parital alsation is involved

2:43

SubCal station and bilateral hila.

2:48

In addition to those findings, there was no evidence of

2:52

a disease outside of the chest.

2:55

So we didn't suspect the presence

2:57

of distant metastatic disease.

3:00

So how to interpret this case in which we have two

3:03

abnormalities in the lung

3:05

and multiple mediastinal lymph nodes.

3:09

Well, the pattern is important here

3:11

and the morphology of the lesions is also important.

3:15

I think no one could argue that the morphology

3:18

of this right optical lesion is, uh,

3:22

suspicious for malignancy.

3:24

We should prove if this is or isn't malignancy

3:29

before we can move on and say this.

3:32

This is something else, particularly in the context

3:35

of additional lung nodules.

3:39

The pattern of uptake in the mediastinum

3:42

however, appears very symmetric

3:46

and the degree of uptake is relatively low.

3:49

So in this case, uh, we've raised the concern

3:53

for malignancy in the right upper lobe

3:55

with satellite nodules in the lung.

3:57

But we mentioned that the pattern

4:00

of no disease in the mediastinum

4:02

and hila favored to be something else such

4:06

as sarcoidosis

4:07

because it was so symmetric, this patient underwent a biopsy

4:12

and uh, the biopsy revealed adenocarcinoma

4:16

and they sampled multiple of these, uh,

4:20

metastatic lymph nodes, which all came back

4:23

as non necrotizing sarcoid li granulomas.

4:27

So with the FDGP ct, we've been able to accurately

4:33

describe where the disease was located,

4:37

and we've been able to say that the presence

4:40

of all this adenopathy was not related

4:44

to the primary malignancy.

4:46

I.