0:00

So our next set of cases is going

0:01

to be looking at patients who have had treatment

0:03

and they've come back to us with rising PSA

0:06

or concerns that there are new sites of disease.

0:09

And in this first patient, this is a patient

0:11

who has been image post prostate directed radiotherapy.

0:14

And you can see on this rotating map

0:16

that there are a few things going on.

0:19

So let's stop it in the middle.

0:21

So we are seeing

0:23

that there's a few things we need to look at.

0:25

Bladder ureter.

0:27

Firstly we can see that there's something another dot kind

0:30

of protruding out here from the bladder.

0:32

We've got some focal areas of uptake down here, lower down.

0:36

We expect the prostate to be in this region here,

0:38

so this is a bit low.

0:40

We've also seen a couple of spots in the thorax.

0:44

Yes, there are some bilateral lymph nos

0:46

but these are, you know, don't have too

0:48

much intensity of uptake.

0:49

Even on the mip I can see that there's a kidney bean shape,

0:52

but here looks a bit more focal than I would like.

0:54

So already there's a few spots I wanna check out.

0:57

So we'll start with the prostate

0:58

because with our tumor nodes metastasis approach,

1:01

that always um, is where we start.

1:04

And interestingly like we've got this almost butterfly

1:06

pattern, but lucky

1:08

for us the patient has had some iodine contrast.

1:10

And so you can see that as we go down the bladder's kind

1:13

of almost got this like U-shaped pattern here.

1:15

So that's gonna be radio urine which is nice and reassuring.

1:18

Um, even kind of extending more down on that other side.

1:21

So that's okay, we will pass the prostate

1:24

but we did see that there are a couple of other dots

1:26

and we'll start with this more superior one.

1:28

Is this a node or is this, you know,

1:30

potentially local recurrence adjacent to the bladder.

1:32

And you can see here we've got ureter here

1:34

and something anterior to this.

1:36

But again it is lucky that we gave the patient intravenous

1:39

contrast because this is just a diverticulum, see

1:42

how it's high density coming off.

1:44

So that's just gonna be radio urine within

1:46

that bladder diverticulum common in patients

1:49

with prostate disease because of features of previous

1:52

or ongoing bladder outlet obstruction.

1:55

But coming down and these are these

1:57

two dots here at the bottom.

1:58

What is this? And is this urine as well?

2:02

It's not quite where I would expect.

2:04

So we would expect the ureter to be tracking kind

2:06

of more anteriorly to this as it goes out

2:08

through the the penis.

2:10

So this is where at the bulb of the penis here

2:12

and on the left hand side there are these two foci

2:15

of uptake, abnormal focal intense uptake.

2:19

And let's have a look on our ct, see if we can correlate

2:22

that area and I would be doing that side by side.

2:25

But here it goes here. So you can see there's asymmetric

2:29

soft tissue nodule density

2:30

and let's see if we can really put them side by side

2:33

to show you what I'm talking about.

2:36

So here it is here, asymmetric soft tissue

2:38

and then another small nodule more posteriorly here.

2:41

Um, just at the anterior aspect of the anorectal junction.

2:44

So this is unfortunately, um, local recurrent disease

2:48

and the prostate has been treated

2:50

so their thing has come back

2:51

but some cells have managed to come down here into the bulb

2:54

of the penis and recur with disease.

2:57

But as we saw there

2:58

Is more going on.

2:59

And so as with any case, we go

3:01

through our systematic review looking at the local regional

3:04

lymph nodes being guided by the vessels going up

3:06

and down through the obturator stations

3:08

or pelvic sidewalls looking for sites of um, nodal disease.

3:11

And these were not too bad,

3:13

but then coming up to those dots

3:15

that we saw in the mediastinum, Sam, the celiac ganglia

3:19

symmetrical normal retro choral space looks okay,

3:23

but as we come up to just inferior to the arch of the aorta

3:28

intense uptake.

3:29

So we are in kind of like left lower para trache

3:31

but also in the AP window here we've got probably three

3:35

lymph nodes which are intensely PSMA expressing coming again

3:39

up to on our low dose CT as well.

3:42

Always correlating anatomically.

3:43

And yes they are abnormal, they're rounded sub centimeter

3:47

by short axis, but definitively PSMA expressing

3:50

so consistent with um, sites of nodal metastatic disease.

3:55

In terms of these auxiliary nodes, I would downplay them.

3:59

Um, they're symmetrical, the uptake is less.

4:01

Um, and this is a common spot for reactive lymphadenopathy.

4:06

Another thing that we want

4:08

to correlate in this patient here is this little spot.

4:11

So coming through

4:13

and looking here at the top,

4:15

we wanna see if there is PSMA expression

4:18

and yes there is, I'll just put that onto an invert window.

4:23

And these are the ganglia up higher,

4:25

but there's something going on here.

4:27

So let's bring in our lung window on our low dose CT

4:30

and see if we can work out what this is.

4:34

Yes, there it is there.

4:36

So this is unfortunately a pulmonary metastasis

4:40

as well in this case with um,

4:42

focal PSMA uptake in there as well.

4:46

So this on the other side

4:47

that looks like might be something too, but less definitive.

4:50

That could also be a thoracic ganglia

4:52

'cause it's kind of more posterior,

4:54

but this is more anterior with a definitive CT correlate.

4:57

Unfortunately.