0:00

So our next case is another case

0:02

of biochemical recurrence.

0:04

So post-treatment, the patient's got a rising PSA

0:07

and they are referred to us to re-image

0:09

to see if we can find the sites.

0:11

And you may encounter something like this.

0:13

And unfortunately in this case you can see

0:15

that there are multiple areas

0:16

of PSMA expression throughout the body.

0:19

Um, and with this distribution it seems very peripheral

0:22

and we're very concerned for skeletal metastatic disease.

0:26

Um, so unfortunately I don't have a fused axial floor review

0:29

in this case, but we will use our fused sagittal,

0:34

which is great for looking at the spine.

0:36

I think this demonstrates it really well.

0:37

Can see there's multifocal

0:39

and multi vertebral level areas

0:41

of increased tracer accumulation.

0:44

And if we were to go to, we'll pick this,

0:47

we'll pick this pubic synthesis lesion here,

0:49

pop on our bone window as well.

0:52

And you can, it's interesting that looking at that

0:57

lesion here, we know

0:59

that it's in the right anterior pubic bone.

1:03

There's really no sclerotic eant lesions here.

1:05

And this is a great example of where

1:08

PSMA PET performs really well over ct.

1:12

So here we know that there's a metastasis in there.

1:15

I'll just go down a smidge. There we go.

1:17

But we can't really see it.

1:18

Um, but interestingly we've got these tiny foci

1:22

of sclerosis in the left isum there, which are not

1:27

PSMA expressing.

1:28

So they, we can confidently call them as bone islands here.

1:31

Whereas in addition, this lesion here is avid.

1:34

Even though there are small sclerotic lesions in the pelvis,

1:36

they're not the ones that are accounting

1:38

for this patient's biochemical

1:39

recurrence in sites of disease.

1:41

Um, and it's a great example of

1:43

how this particular modality is really changing,

1:45

how much we can see and how management decisions are made.

1:49

Really cool. So yeah, there's another one,

1:51

a bone island non avid, whereas you know, multiple sites

1:54

of skeletal disease which are okay.

1:57

So on these patients as always we'd be going through looking

2:00

for lymph nodes, um, and correlating with our rotating nip.

2:04

Um, and on this case, let's just kind of bring through,

2:07

I know that we would always assess these on axial

2:09

for a moment we'll just work with

2:11

what we have on the screen.

2:14

So coming up through this region here, anterior

2:17

to the L three four invertible junction, there

2:22

are some avid lymph nodes.

2:26

We are noting that there's some bowel as well.

2:28

So just underneath the Georgina as it's coming in,

2:31

there's going to be an avid lymph node in here in probably

2:33

the aorta cable region.

2:35

Just there, that little node.

2:38

And then as we saw with the extensive case,

2:41

I always wanna speak, especially when we've got multifocal

2:43

bone disease, is I really wanna look for complications

2:45

or things that could potentially cause the patient trouble.

2:49

So is there anything that we can do to help And

2:53

with this patient, there's actually quite a dominant lesion

2:55

here centered on the cl, maybe even a little bit of early

2:59

Extra skeletal soft tissue extension.

3:01

So I would mention this probably in my body of report

3:03

as a in particular lesion

3:05

and maybe even in the conclusion going, you know,

3:08

multifocal PSMA expressing skeletal metastatic disease in

3:12

particular, there is a dominant lesion based on the

3:13

cliver and base of skull.

3:15

Just so they know about this

3:16

because if this gets larger in size,

3:18

if it starts encroaching on cranial nerves or getting

3:20

or invading through the base of skull,

3:22

this can be quite problematic for the patient.

3:25

And then I'll run the spine as well to make sure

3:27

that there's no evidence of pending cord compression

3:29

or something that we can do before the cord compression

3:31

occurs.