0:00

Okay, so let's look at another case

0:02

and hopefully this is one that I've selected

0:03

that has read the textbook.

0:05

So I'm gonna start with my rotating mit,

0:07

we'll invert it in Arma

0:08

and then adjust the levels so

0:10

that I'm just seeing outline of the patient's skin.

0:12

That looks pretty good. Now we're gonna give our rotating

0:15

MIP a spin and we're seeing physiological uptake,

0:18

lacrimal glands, Sali glands a bit in the head and neck.

0:21

That looks fine. Some mild uptake in the

0:23

thorax is probably reactive.

0:24

Lymphadenopathy, liver, spleen, kidneys,

0:27

bowel coming all the way down

0:28

through our ureters to the bladder.

0:30

But what we are seeing here is something inferior

0:33

to the bladder, which is exactly where the prostate is.

0:35

And this is a patient who saw us prior

0:38

to radiotherapy treatment.

0:40

So this is where the pro,

0:41

we're gonna be looking very carefully for

0:43

that primary prostate cancer.

0:45

But while we're here on this rotating mip, I'm also looking

0:47

for some dots in the pelvis.

0:48

Are there lymph nodes I need to scrutinize?

0:50

Is anything jumping out?

0:51

Is there potentially skeletal lesions somewhere else in the

0:54

field of view that I need to be worried about?

0:56

So let's now jump into our axial fuse

0:59

and I'm just gonna make that a little bit bigger.

1:01

There we go. So here, um, we're going to jump

1:05

to the, the pelvis.

1:07

So coming down 'cause

1:08

with our tumor nose metastasis are the findings we really

1:11

want to kind of hone in, um, on the primary tumor first

1:16

and bringing in, we're just gonna put in a second layout.

1:18

I'll put in my CT

1:21

and then come down we can see

1:22

that the patient's had intravenous contrast for delineation

1:24

of the urinary tract, which is very helpful.

1:27

And then coming down, we'll zoom this up a little bit

1:31

and scroll it to the middle.

1:33

Um, this patient actually has some

1:36

high density material here.

1:37

This is hydrogel to separate the rectum from the prostate

1:40

for radiotherapy planning.

1:41

And then these bright things.

1:44

So there should be 3 1 2, 3 are radiotherapy seeds.

1:47

So this patient is being planned for radiotherapy.

1:50

So I'm treating a little bit.

1:51

I know that this patient is um, already coming

1:54

to us already a therapy with a diagnosis of prostate cancer.

1:58

So scrolling back down again, now that we know

2:00

that they've got their fiducials

2:01

and their hydrogel and situ.

2:02

So this is a patient who probably has comparison imaging.

2:05

So I'll have that up side by side.

2:06

And what I'm looking for is this intense uptake

2:09

as opposed to background.

2:10

And you can get some heterogeneous uptake

2:12

elsewhere in the prostate.

2:13

And we'll have a look at some benign patterns

2:15

in the upcoming section.

2:17

And this is probably within normal limits

2:18

but this kind of bright white that is not.

2:21

And this is corresponding pretty much exactly to

2:24

what we saw in our rotating mi.

2:25

We'll just adjust that again

2:28

and bring down our levels so we can see

2:30

that this heterogeneous uptake more to the left

2:33

of the midline is corresponding to this intense uptake, um,

2:36

through the prostate.

2:38

So here is the prostate base near the bladder coming down,

2:42

so to the mid gland to the apex.

2:43

So the left hemi gland involving the peripheral zone

2:46

and a lot of through the central gland as well.

2:48

So this is quite a large tumor.

2:50

After that I'm going to be considering um,

2:52

our pelvic lymph nodes

2:54

and looking very closely here at the pelvic sidewalls

2:57

to look for focal

2:58

Uptake. And

2:59

I'll pick one side, I often go left first,

3:01

then I follow up the ureters coming up

3:06

and there's a ureter here just crossing over

3:09

and then it, taking it out to the inguinal region

3:12

and then up again then reviewing the internal ILI X,

3:17

knowing that that's the ureter.

3:18

Then going in, then repeating it backwards on the other

3:21

side, internal iliacs up to the pelvic sidewall

3:24

and then going up and down, checking that out

3:26

and then picking up the external iliac vessels

3:28

and coming all the way back to the retroperitoneum.

3:31

And then really concentrating my eye here in the

3:33

retroperitoneum as I move upwards

3:35

and then using that as my landmark

3:38

because lymph nodes like to follow vessels.

3:40

Um, and so here we go.

3:41

We've got our ganglia here and then up into the mediastinum

3:43

and then I'm going to re-review those mildly avid lymph

3:45

nodes and agree, yeah, there's a little bit of uptake.

3:48

I'll mention them in my report

3:49

but downplay them as reactive and go up.

3:52

And again, we've got our little, we've got a little bit

3:55

of um, mildly avid fibro scarring in the lungs.

3:59

And then just looking for our ELLA ganglia,

4:01

which are probably somewhere in here.

4:02

And then going through systematically looking

4:04

for our M staging.

4:06

And I do the abdomen first,

4:07

turning the avidity on the liver and spleen up.

4:09

I'll jaw by quadrants really look at this liver through here

4:13

as well and I can't, I'll see if I can adjust that liver up.

4:16

There we go. So that's what we really wanna be looking

4:18

for enough to see through the liver here on there, on there

4:21

to see if there's any, um, lesions through it.

4:23

And then also as we saw

4:25

with the video is turning on our lung windows, moving up

4:30

and down and just systematically drilling by quadrant

4:34

and then using our um,

4:38

MI tool if you have it on your viewer

4:39

to increase your sensitivity for nodules.

4:42

It's a couple little peric things here but no avidity

4:45

and then going through the bones

4:47

and the sagittals are great for that.

4:49

Now interestingly, this patient does have an abnormality in

4:52

the bones here and it is mildly avid.

4:53

There's a wedge compression fracture at,

4:56

um, I'd count from the top.

4:57

So it looks like near the thoraco lumbar junction.

4:59

Um, that doesn't have too much uptake.

5:01

But in saying that, the referrals will ask me,

5:03

do you think this is a pathological fracture?

5:05

And usually the answer will be no if it has this typical

5:08

anterior compression fracture morphology

5:09

without significant uptake.

5:11

But keep in mind that recent fractures can be mildly avid.

5:14

And so I'm looking for patterns.

5:16

And if there was no other sites

5:17

of skeletal metastatic disease,

5:18

this would be unlikely with my fusion.

5:20

I'd be looking at bone windows, reconstructing the data

5:23

and going through closely checking every bone, um,

5:26

and then reading the total body pet

5:28

with a systematic reproach, checking head

5:29

and neck, thorax, abdomen, pelvis,

5:32

and skeleton to ensure there are no clinically significant

5:35

incidental findings.