0:00

So this next case we're continuing with our theme.

0:03

So we're gonna start with tumor, the nodes, then metastasis,

0:07

um, in terms of our assessment

0:09

and starting as always with our rotating mip.

0:12

And we'll just zoom out a little on here

0:14

and have a look at the spins and what are we seeing?

0:18

We're seeing that they're under the hot bladder.

0:21

There are multiple focal areas

0:23

of intense PSMA uptake involving probably both

0:26

right and left gland.

0:27

But then there's also something else.

0:29

So here we've got, you know, that's ureter,

0:31

so it's coming out near the bladder.

0:32

But if we pause on the true lateral, which I like to do,

0:35

you can see that more posteriorly, then you would expect

0:38

that ureter, which you can see there with the cursor,

0:40

there is a rounded area of intense uptake.

0:43

So I'm suspicious I need to know what this is

0:46

and if there's one lesion and you have

0:48

to look really carefully for more,

0:49

but I'm not seeing too much else on this rotating map.

0:52

So let's go back and have a look at our axial

0:54

coming all the way down.

0:56

We'll click our zoom tool, our scroll tool, sorry,

0:58

and we will come all the way down

0:59

to the pelvis, hot bladder.

1:01

And then seeing that there is bilateral intense uptake.

1:05

And this is asymmetric as we saw with the primary score.

1:09

You can have bilateral physiological uptake,

1:10

but this is more intense and it's asymmetrical,

1:12

which would be consistent with multifocal disease.

1:15

So on the right I'd be describing this as there is intense

1:19

increased tracer uptake in the right basal peripheral zone,

1:23

extending to the mid gland and apex.

1:26

And then on the left there is further intense tracer

1:29

accumulation, um, in the peripheral zone

1:32

and mid gland extending from mid to apex.

1:35

And then kind of, you know, wordsmith gap going through.

1:37

So bilateral disease, let's check the seminal vels, um,

1:40

seminal SSLs coming in to here.

1:43

There may be that spot kind of at the base

1:44

of the seminal cle.

1:46

Um, so I might say that, um, abnormal uptake extends

1:49

of the base of the seminal CLE on the right,

1:50

but not necessarily into it.

1:52

And then we'll check the other side as well. Okay. Alright.

1:56

So we're concerned that we've got, you know,

1:58

quite an extensive primary tumor or multifocal disease.

2:02

So now we've gotta interrogate our lymph nodes

2:04

and we'll do our systematic approach of going up and down.

2:06

And there's a small avid lymph node here.

2:09

It's small, it's moderately avid, I would describe it,

2:11

but on its own I think that would be non-specific.

2:14

However, as we come up and checking in this internal IAC

2:18

and presacral station, on the right hand side,

2:21

there is an intensely PSMA expressing lymph node.

2:24

And this is unequivocal, this isn't one that you'd describe

2:26

and have a bit of a think about.

2:28

This is disease.

2:29

And so if we then come down to correlate that with our CT,

2:34

and we'll scroll all the way down, you can see

2:37

that it corresponds to this lymph node here.

2:40

And it's interesting

2:41

because on CT you may not actually call this, it's subter

2:45

by short axis diameter.

2:47

Um, it is kind of ovoid shaped.

2:49

It is a bit bulky and prominent.

2:50

So I think on a good day I would,

2:52

but you can see how much more

2:55

focal the uptake is when we're trying to find even these

2:58

Borderline nodes.

2:59

Looking at that intensity of uptake.

3:02

And that abnormal tracer expression in these lymph nodes is

3:05

really useful for that staging.

3:07

And so that's that lymph node that we have called.

3:10

We'll then follow up through that retroperitoneum, um,

3:12

checking for additional sites of disease

3:15

and all the way up into the thorax,

3:18

there's our ganglia again.

3:21

Um, and then systematically review for metastases, looking

3:24

through the lungs, the liver, the abdomen, and the skeleton.

3:28

Um, but in this case, this was a patient

3:30

with multifocal prostate cancer with nodal disease in

3:35

the right internal iliac station.

3:39

As we come down, just have another look at that lymph node.

3:41

Just to finish off.