0:00

So we've seen a patient where there is a primary tumor.

0:04

We've seen a patient where there is a single definitive

0:07

lymph node and as you may have guessed,

0:09

tumor nodes metastases.

0:10

We're now going to look at two cases

0:12

where the patients have metastatic disease.

0:15

So in this case, as always, let's start

0:16

with the rotating nib and give it a spin

0:19

and compared to the MIP from the prior study

0:22

and why don't we just bring it up,

0:23

we'll bring it in, just have a look.

0:26

You can really do see that there is a difference.

0:29

We're seeing more and more spots,

0:31

whereas this patient prostate with a node,

0:33

in this case we see the bladder

0:35

and a very bulky, intensely avid abnormality in the region

0:39

of the prostate with multiple dots tracking up

0:42

through the retroperitoneum

0:43

and then also these avid lesions

0:45

through the thorax and elsewhere.

0:47

So let's get stuck into this one.

0:49

We will start with the primary tumor as we always do,

0:53

clicking our scroll tool and coming down,

0:55

and this is bulky disease

0:56

and there's a lot going on here is the hot bladder.

1:00

But coming down into the prostate there is an extensive

1:03

abnormality and these ones can be quite hard to report,

1:07

like trying to find the words.

1:08

We no longer are gonna be calling this focal.

1:10

It's not like something you could get

1:11

a texter and put a dot on.

1:12

This is something that is extensive.

1:15

So there is extensive abnormal PSMA expression

1:19

through the prostate extending from apex down here to base,

1:24

um, and through both the right and left glands

1:26

but more um, confluent on the right.

1:29

What we do see here, and this is why we always check the

1:31

seminal cle, is this seminal CLE is involved.

1:34

There's abnormal PSMA leg

1:36

and uptake throughout the right seminal vesl

1:39

and also through the left.

1:40

So coming, this is the top of the left glamp coming down,

1:42

you can see that abnormal uptake.

1:45

So there's seminal vesl involvement, B lateral prostate

1:48

and this looks aggressive.

1:51

So moving on to our nodes

1:53

and we'll do our same um, pattern

1:55

of search, but there's more.

1:57

And if you compare to those equivocal nodes

1:59

that we saw on the prior case, you know,

2:00

they were subtle, they weren't enlarged.

2:01

Whereas even here these nodes they look bulky.

2:05

But really the money is with these intensely PSMA um,

2:09

expressing lymph nodes in the pelvic sidewall.

2:12

And then following it up we follow it up along the

2:15

external iliacs and even common iliacs.

2:17

We're seeing multifocal nodal disease coming up

2:20

to common iliacs and all the way up

2:21

to the aortic bifurcation

2:22

and retroperitoneum repeating for the other side.

2:25

This is ureter here and this is where the contrast

2:27

that we give is really useful,

2:29

especially when you've got multiple sites of nodal disease,

2:32

multiple pelvic sidewall, external iliac nodes

2:35

as well coming down or obterator nodes.

2:38

Um, sorry that was ureter there.

2:40

Um, but on the other side there is, so yeah, obterator

2:42

or pelvic sidewall and then even in the presacral space

2:45

and we know that there are ganglia.

2:46

So I think in isolation, if I was to say

2:47

that I might kind of blow it off.

2:49

But here this is focal, this is intense.

2:52

Um, at the rectum at three o'clock,

2:53

that's gonna be an involved node as well.

2:56

And coming all the way up multiple

2:58

PSMA expressing nodes

3:00

through the retroperitoneum including here.

3:02

Um, it can be a little bit tricky if patients have like

3:05

low weight for example.

3:07

So it's good to get the low dose CT or toggle your fusion on

3:10

and off if that's, you've got that capability

3:12

with your viewer.

3:13

Um, because through here let's just kind

3:16

of match up that slice.

3:18

You can see that there's two bulky lymph nodes, two mild,

3:20

um, enlarged lymph nodes.

3:22

Um, but then all this rest is small bowel kind

3:24

of draping over the top.

3:26

And when we see nodes all the way up here,

3:28

you've really gotta be on your game.

3:29

There are probably gonna be nodes elsewhere and here we go.

3:32

This is um, could be the celiac ganglion here,

3:35

it could be a node, doesn't matter.

3:37

Probably not. There's so many other sites

3:38

of disease including here in the retro choral space.

3:40

So now we are above the diaphragm

3:43

and even behind the esophagus there.

3:45

So you've really gotta follow up the vessels

3:47

and follow those lymphatic drainage pathways.

3:49

'cause even this has kind of drained up

3:51

through the mediastinum into the left supra clavicular.

3:54

And we have an involved supraclavicular node to both on

4:01

CT and the PET scan.

4:03

So there it is just nestled in there between the vessels.

4:07

So we've really gotta be on our toes here for metastases

4:10

and I'll bring in a sagittal, I like these

4:13

for assessing the spine and there's a little bit going on,

4:16

but since we are here on the axial,

4:18

we've got this bone lesion centered on the scapula there.

4:22

So g glenoid process and then at the coracoid process

4:25

of the scapula coming down

4:27

and we saw the eagle eye among you would've seen

4:29

that there was a spinous process involved

4:32

or posterior elements involved in the upper thoracic spine

4:36

going down this, oh,

4:38

tough one uptake at the tip of that transverse process.

4:41

It's near the articulation.

4:43

We know that arthritis can give us uptake.

4:45

So I might describe and say maybe a metastasis,

4:47

maybe arthritis not too much elsewhere.

4:52

But then what do we make of this?

4:54

What do we make of, of this area here?

4:57

There's a superior nplate compression fracture at L three

5:00

with depression of this, um, the central nplate,

5:03

but there's patchy heterogeneous uptake.

5:05

And the question that they're gonna be asking me is,

5:07

you know, Sally, do you think this is a metastasis

5:10

with a pathological fracture

5:11

or could this be an osteoporotic fracture?

5:14

And honestly, I, I don't really know.

5:16

Um, but I do know

5:17

that the metastasis elsewhere are intensely PMA expressing

5:22

and I would consider this pattern of uptake to be more, um,

5:26

just bring our rotating MIP to help us out here.

5:29

Um, it doesn't seem as intense

5:33

as the other, um, sites of

5:37

skeletal disease, so let's just fix up our mip.

5:41

There we go. So we'll bring in to the side

5:43

and it's a bit tricky 'cause the,

5:44

the kidneys are right there.

5:46

Um, but it doesn't seem like it's as intense

5:48

as something like that scapular lesion

5:50

or even that lymph node that we see in the thorax.

5:54

Um, so I would probably put more weight on it being an

5:57

insufficiency fracture and a bit of a bystander,

5:59

but we would certainly pay attention on progress imaging.

6:02

Another thing with any bone lesions is we wanna see if

6:04

there's any extension into the spinal canal,

6:06

which there isn't in this case.

6:08

So that would also be reassuring that they may be able

6:10

to watch this lesion and progress it.

6:14

I tend to go back, especially with cases of complex disease

6:17

and metastatic disease, go back to the rotating nib

6:20

as a review area for myself.

6:22

And so things I've kind of haven't seen

6:25

and accounted for in my axials is these rib lesions.

6:28

And as we'll see in some upcoming cases,

6:30

some subtle rib lesions can be seen on PSMA pet, which are

6:35

essentially accounted for by fibrous dysplasia,

6:37

f*g fibrous dysplasia or small little chondro lesions.

6:40

But these are a bit too hot

6:41

and since we've got metastatic disease elsewhere,

6:44

we are concerned that this patient does have

6:46

rib metastases as well.

6:47

And then we go through our systematic review reviewing the

6:50

brain, the lungs, um, very closely looking

6:53

for sites of mets.

6:54

We'll just do a quick view of the lungs now.

6:56

And then with the lungs, I tend to drill by quadrants

7:01

coming up all the way to the top.

7:03

This patient does have some emphysema, so I would note

7:06

that in my other findings in my report coming down

7:10

all the way to the bottom, some mild bronchial thickening,

7:13

this patient may be a smoker picking up the other side.

7:17

And you'll notice as we're coming through here that the

7:22

cts are acquired as non breath hold.

7:24

That's for a few reasons. One, it's mean to, um, ask our

7:29

patients to hold their breath for five

7:30

or 30 minutes as we acquire their PET scans.

7:32

So we need to acquire it in free breathing

7:34

just so we can get that.

7:35

Um, kind of lung volumes for attenuation correction

7:38

and anatomical localization.

7:40

Um, and these aren't diagnostic cts.

7:42

The aim here is not to find every

7:44

single initial abnormality.

7:45

We are mostly looking for that attenuation correction

7:47

and anatomical localization as we've mentioned.

7:51

So here as well incidental note, patient has a, um,

7:55

a cardiac pacing device also in situ.

7:58

So this patient does have, um,

7:59

quite a multifocal disease in the prostate extending

8:03

to bilateral seminal vesicles, um, with extensive pelvic

8:09

and retroperitoneal

8:10

and, um, super diaphragmatic lymphadenopathy, which

8:15

remembering that nodes outside

8:16

of the true pelvis are considered M1 disease

8:19

and meta metastatic disease as per the TNM classification.

8:23

And then multiple sites of bony metastases as described.