0:00

This is a patient who has presented

0:03

with a biochemical recurrence.

0:06

And so this is again, a patient who has had treatment

0:10

and they were being treated and managed with a DT

0:13

and then ended up with, um,

0:15

a rising PSA despite androgen deprivation therapy.

0:18

So this patient here, we will again start

0:21

with our rotating MIP beneath the bladder.

0:23

There's not too much going on with the prostate,

0:25

but you will see that there are multiple focal areas

0:27

of increased trace accumulation,

0:29

which are distinct from the ureters,

0:31

which are really beautifully delineated on this case,

0:33

I think with the kind of the wavy look

0:34

and it's tracking up

0:35

through the retroperitoneum all the way up

0:38

into the upper abdomen.

0:39

So let's have a look at what

0:40

that looks like on our fused imaging.

0:43

Come all the way to the bottom, check our prostate.

0:46

Yes, it's enlarged,

0:47

but there's no focal abnormal uptake in it.

0:50

Then incidental sigmoid diverticulosis we're noting.

0:53

But following our nodal groups

0:56

and starting at the left pelvic sidewall orator station,

1:00

there is focal uptake.

1:01

This is the ureter.

1:02

Um, so when you see them on the same slice,

1:04

you're very concerned.

1:05

And similarly on the other side, we've got ureter as well

1:09

as an involved lymph node in

1:11

that right external ILI ex station.

1:13

And then following them up through the retroperitoneum,

1:16

the more you look, the more you see.

1:18

This is ureter here, ureter

1:19

and a lymph node, adjacently aorta

1:21

or the aortic bifurcation on that left hand side.

1:24

And then coming up multiple small

1:28

but definitively PSMA expressing lymph nodes

1:31

and even kind of up here, retro aortic and retro caral.

1:36

So now we're above the diaphragm patient's,

1:40

got some bystander kind of lesions as well.

1:43

And incidental findings, which show i,

1:45

I would put in my report.

1:46

So I'm just gonna pop on my CT window here, which shows

1:52

multiple calcified lymph nodes in the mediastinum.

1:54

So we're thinking silicosis like occupation exposure

1:57

or maybe sarcoidosis, um,

1:59

which can have a little bit of uptake.

2:00

They can be mildly avid.

2:01

And then checking the patient's lungs as well.

2:06

Not too bad coming through.

2:10

So in a patient like this where there is

2:15

multiple lymph nodes

2:16

and we've got a disease above the diaphragm, you have

2:18

to look really closely for metastatic disease.

2:20

So I'm interrogating those bones as we're coming through.

2:25

So we haven't talked about this already,

2:26

but there is one thing that I do like to do in terms

2:28

of my regular reporting when I am reviewing the skeleton.

2:32

Yes, I will go through on the gray scale data, um,

2:35

and in my regular practice with my own viewer, I will go

2:38

through and scroll through the black

2:39

and white data on its own,

2:41

and then I will go through the fusion data.

2:42

But I'll always check the low dose CT

2:45

and, you know, that's, you know, good practice

2:47

because not everything that we see

2:49

and we talk about is going to be PSMA expressing.

2:52

So if there's a big lytic lesion

2:54

that you know is differenti, doesn't have the uptake,

2:57

then you may miss it on the fusion

2:58

And on the gray scales.

2:59

So I like to always look to make sure that there are no, um,

3:02

aggressive skeletal lesions similar to

3:04

how I would go reviewing a CT in my radiology practice.

3:07

So scrolling through, but this is

3:09

looking, not looking too bad.

3:10

And in this case as well, scrolling through the fusion,

3:12

really paying attention to the lumbar spine

3:15

and then scrolling through that rotating mip

3:17

or rotating the rotating MIP to um, see if there's any dots

3:21

that there, that I have not accounted for

3:23

as a review area as well.

3:25

But this patient did have biochemical recurrence

3:27

with extensive lymphadenopathy.