0:00

So as promised, we are coming up

0:03

to the systematic approach to image review.

0:05

We've had a look at our normal study, had a bit of a tour

0:07

through, and now we are going to be thinking about

0:10

how we do our oncology reporting

0:13

and applying that to prostate cancer.

0:15

So I do have a confession to make.

0:17

I am a chest radiologist, so what on earth am I doing here?

0:19

Talking about the prostate. Um,

0:21

but no, I'm a nuclear medicine specialist as well.

0:23

And between lung cancer

0:24

and prostate cancer, they're my two main areas

0:27

and the two MDTs that I cover.

0:29

Um, and so, but I do like to take a lot

0:31

of my learning about oncology reporting

0:33

and plug it into my approach to prostate cancer.

0:37

So systematic oncology reporting tumor nodes,

0:40

metastases, other findings.

0:42

And then with our prostate cancer staging,

0:44

I break it into prostate

0:45

and seminal vesicles in the case of prostatectomy,

0:48

look at the prostatectomy bed.

0:49

Um, and then nodes, metastases, and other findings.

0:52

Um, and a good way that I like to think about my stage.

0:56

Um, my staging is even though I don't kind of, you know,

0:58

plug in and start to talk about N one or M1 A

1:01

or T two B disease, I don't assign those numbers on, um,

1:06

or those classifications on.

1:08

But I like to be mindful about the components

1:10

of the staging investigation

1:12

and how they are going to impact practice.

1:15

So t um, with our T staging, our tumor staging,

1:18

I wanna think about whether or not the uptake I'm seeing is

1:21

confined to the prostate or is it looking like

1:23

it's extending outwards?

1:24

Keeping in mind

1:25

that very intense uptake can look like it extends under

1:28

border when really it's just because of the counts.

1:31

So you wanna look at the morphology of it as well

1:32

and really turn it up and down.

1:34

Um, in terms of your SUV assessment.

1:37

Um, then with n our nodes,

1:39

I wanna think about whether the lymph nodes

1:41

that I'm concerned about are loco regional or distant.

1:44

And so with our, our local nodes, they're actually

1:46

below the pelvic brim, confined within the pelvis.

1:49

Um, and it does not include common iliac or inguinal nodes.

1:52

They're considered M1 disease.

1:55

Um, and then with our M metastases, distant nodes,

1:58

but also skeletal metastases

2:00

'cause as we saw in the very first lecture,

2:01

they could be present in up to 90% of patients

2:04

with metastatic disease, but then also visceral

2:06

or other soft tissue sites as well.

2:08

And our search patterns really have to encompass a full view

2:12

because we've, we've imaged the whole body

2:14

so we can't just look at the pelvis,

2:15

we've gotta look at every part

2:16

of the patient which has been included.

2:19

So this is my approach We saw from the earlier that I like

2:22

to look at the rotating MI first

2:23

and I think this gives us a great overview.

2:25

Um, then look at the prostate and seminal vesicles

2:27

or prostate bed for our T staging

2:29

lymph nodes in the pelvis first.

2:31

And I tend to follow the vessels

2:33

and also have a really good look at the pelvic

2:34

sidewalls, then the abdomen.

2:36

And as a radiologist who reports nuclear medicine,

2:38

I have my search patterns from

2:40

how I approach abdomen imaging, going through organ by organ

2:43

and drilling, um, up and down as I scroll.

2:45

Um, and then looking at the thorax

2:48

and the lungs with the use of MIP projections

2:50

to increase my chance of detecting pulmonary nodules.

2:54

What I mean by MIPS is thicker slabs,

2:56

which accentuates the high density structures on the

2:58

Lung window.

2:59

And then I finish with skeleton

3:01

and really looking closely knowing how common

3:04

skeletal metastatic disease is in prostate cancer.

3:07

So let's have a quick look at this video

3:09

that I've recorded on my workstation.

3:11

So this is how I go about it.

3:13

So I have a look at the rotating nip, really think about it.

3:18

And already on this case I can see

3:19

that there's something going on up here in the thorax.

3:21

This is a patient who's already had a prostatectomy

3:24

and I'm thinking about this uptake down here

3:26

in the penile bulb.

3:27

And that may be urine, it may be within the urethra.

3:30

So I know I need to check that.

3:31

And I'm also kind of looking for dots elsewhere.

3:34

So I've slowed down my MIP

3:36

'cause it was going a little bit too fast for me.

3:38

But here I'm really worried.

3:40

This is too intense for physiological nodal disease.

3:43

It's asymmetric, it's very bright.

3:45

So we need to go and have a look at the

3:48

cross-sectional imaging on this.

3:50

So moving forward

3:52

and then I have adjusted the SUV window.

3:56

And this is what I mean by adjusting it to make sure

3:58

that I have a good sense of the different tissues.

4:00

And you'll notice if I adjust, I'm just gonna pause that

4:03

and just go backwards a little.

4:06

So here, here black, the liver looks

4:08

and now I've adjusted it.

4:10

So now I have much more soft

4:11

tissue definition within the liver.

4:13

So I'm getting a good assessment

4:14

because you do get visceral

4:16

metastases to the liver occasionally.

4:17

And I wanna make sure that I'm not missing something.

4:20

Um, just from the technical factors.

4:22

So after that, all right, we'll press play again.

4:25

And now we're about to move into our systematic review

4:27

and I'm correlating those things

4:28

that I saw on the rotating nip, but I try to be systematic.

4:33

So tumor nodes, metastases.

4:35

So I'm looking at the prostate bed at first,

4:37

so I'm double clicking it, making it big.

4:39

You can see that we've got the bright bladder there

4:41

and it's dipping down and the patient

4:42

has had a prostatectomy.

4:44

You can see that the organ is absent and going up and down.

4:46

I'm adjusting my window.

4:48

I've just gone onto zero to to 15 and up

4:50

and down again to really try and negate that radio urine

4:53

because it is so bright.

4:55

Taking off the fusion confirming that I can see radio urine

4:58

and that the black spot there, which is that accumulation

5:01

of trace or bright on the fusion,

5:03

is corresponding to where I see uptake.

5:05

And this is what I'm doing here. I'm looking

5:06

through the bulb of the penis to ensure that

5:09

what I saw down lower was corresponding to excreted tracer.

5:14

So moving on, I then try

5:16

and go through the pelvis on the gray scale or the black

5:19

and white looking for lymph nodes

5:20

'cause I just find that it's so useful in terms

5:22

of detecting small volume disease.

5:24

The eye is able to see so many more shades of gray.

5:27

And with the fusion sometimes, especially with small sites

5:30

of disease, I find that my eye can't find it.

5:32

So I'm constantly moving between the different fusions

5:36

and really trying to follow

5:37

where I know anatomically the blood vessels are

5:40

to see if there are other dots.

5:41

And those two dots that we're seeing just here

5:43

and there, these two dots here.

5:45

I know that they are the ureters, um, just from a lot

5:48

of practice and by doing that practice you'll find them too,

5:51

but also looking for additional dots that don't follow

5:53

that anatomical line.

5:55

Um, to indicate that there may be avid

5:56

Nodes within the pelvis, um,

5:58

or the retroperitoneum as we're moving up now.

6:00

So we're all pretty much just at the bi bifurcation,

6:03

we're now in the abdominal aorta coming up

6:05

to see if there are sites of focal uptake

6:09

that don't quite match the patient's actually got a

6:11

prosthetic pin pump in situ, which is

6:12

what this abnormality is

6:14

or this structure is here anteriorly in the pelvis.

6:16

And then I found a little lymph node next to it,

6:18

which I've put a little SUV measure on.

6:20

Now I'm trying to determine whether

6:21

or not I think it's clinically significant.

6:24

Um, and it can be really tough.

6:25

Um, sometimes you'll see an O that has have some avidity.

6:28

Um, so you kind of measure it.

6:29

You think about, think about the drainage,

6:31

think about the pattern of disease.

6:32

I'll try and describe what I see.

6:34

Um, and then pull it together in a conclusion.

6:37

And if I think it's inflammatory I'll say, you know,

6:39

node most likely reactive

6:40

or stable over serial imaging, you know, likely benign

6:44

or um, try to vocalize my index of suspicion.

6:48

We saw, um, just as I was talking about those nodes,

6:51

we jumped through the stellate ganglia in this case

6:54

has a really nice one.

6:55

So we'll try and see if I can come back to that.

6:57

There we go. Press play right here.

6:58

Coming up here you can see those stellate ganglia.

7:00

They're gorgeous.

7:02

So they're bright elongated, typical um, location,

7:04

so they're not going to be lymph nodes

7:06

and then coming all the way up through here.

7:09

And then at this point I'll tend

7:11

to put on lung windows as well.

7:13

Um, and now we're um, sorry soft tissue windows

7:15

and then lung windows coming through.

7:18

But we know that there's lymphadenopathy in the the chest.

7:22

So we're still actually in lymph nodes at this point.

7:24

I've jumped ahead. Um,

7:25

so I'm following the mediastinal chain

7:27

and this patient has had already had radiotherapy

7:30

to the retroperitoneum,

7:31

which is why we're getting nodal disease up in the thorax.

7:33

It's followed that chain all the way up

7:35

and you can see that there was that hot nodes.

7:39

Um, then next we're going to, I'm systematically going

7:41

to looking for metastases now, work through the abdomen,

7:44

scroll up and down, look for areas

7:45

of abnormal trace for accumulation.

7:48

Um, and then skipping ahead to the thorax

7:52

where this is just me kind of systematically going

7:54

through up and down, turning it on and off

7:57

and now having a look through the lungs.

7:59

And so zoom it up. Excellent. So, um, I'm a lung person.

8:03

Um, I always try and look through, I drill by quadrants

8:06

so I'll keep my eye through here.

8:08

Um, go all the way down and pick it up again at the back.

8:11

And then kind of jumping up, we'll often do a MIP as well.

8:13

MIP projection like here just to see that thickening

8:16

to increase our conspicuity of nodules.

8:19

So the eagle eye among you would've seen

8:21

that there is a little nodule here.

8:22

And I have to admit, this is one that kind

8:24

of was a bit tricky to see.

8:26

It was actually smaller than the prior study

8:27

and this was a, um, a previous examination.

8:30

So looking through and getting mint, that allowed us to see

8:32

that little nodule.

8:33

But a good tip that I have and what I try and do

8:36

after we look through, so we're coming back down,

8:38

coming back to our nodule there.

8:41

Just stop short. There it is right there.

8:44

And so if we go to our functional data is

8:47

that lung nodules actually pop out more on the gray scale

8:50

'cause lungs shouldn't have any uptake at all.

8:51

And you can see it, right? Oh, there we go.

8:53

We've just gone straight through it. So we're gonna

8:54

Come, come back down again.

8:56

You will see it just in that anterior middle lobe

8:58

as we come down just there winking in.

9:00

And so it does pop out more on the gray scale.

9:02

So a great review area

9:03

and good tip for the lungs is

9:05

to have a look through on the gray scale.

9:07

And the last thing that I do after I look through the lungs

9:10

and review the head

9:11

and neck soft tissues, the rest of the body, um, is that,

9:14

I'll check the skeleton.

9:16

And this patient did have an abnormal spot

9:18

of uptake there in the thorax, um,

9:21

just in the transverse process there.

9:23

I believe that was, um, T two on the left,

9:26

you can see focal increased uptake there,

9:28

which we can correlate on three views.

9:30

And as we can see here, it's demonstrated

9:33

to be a sclerotic lesion.