0:00

For these next couple of cases, we are going

0:02

to look at instances where the men have presented

0:05

for PSMA PET with known diagnosis of prostate cancer.

0:09

But they've come in with symptoms, they've come in

0:12

with things that are making them uncomfortable

0:13

or causing pain.

0:15

And so how the PSMA PET can help to pull this apart.

0:19

And I think on this scan you can already see

0:21

that it's really abnormal.

0:23

We've got bulky disease, it's almost black through

0:27

the abdomen, through the inguinal regions, up

0:29

through the thorax with the bulkiness

0:31

of the lymphadenopathy.

0:32

And we'll just kind of turn it down a little

0:33

bit and have a look at the liver.

0:35

And we really kind of getting a sense

0:37

that there's probably even some liver disease there as well.

0:39

Usually like when we turn down the liver we get

0:41

that homogenous gray scale look to it.

0:44

But here there's disease in there.

0:46

So in, in a case like this, it's again, as we saw with um,

0:50

those complex metastatic cases,

0:53

you wanna start systematically,

0:54

I still will always report these as tumor nodes, metastases

0:57

as subheadings, particularly with known diagnosis.

1:00

And so there's, you know, a comment on the prostatic magaly,

1:02

this is probably going to be diseased within a seminal sical

1:05

or at that recto prostatic angle.

1:07

So I may include that within my primary tumor description

1:09

based on anatomical rotation and intensity of uptake.

1:12

But we don't need to over describe in cases like this.

1:15

We don't need to measure every lymph node.

1:17

We don't need to quote, you know, shopping lists

1:19

of SUV maxes because really it's all about the pattern

1:22

and what it's doing to the patient.

1:24

And scrolling up and down through the abdomen, we can see

1:27

that pretty much every single nodal station is involved

1:30

by laterally in the pelvis

1:31

where encasing the IVC encasing the aorta, you know,

1:35

expanding that retroperitoneal space.

1:38

We've got retro choal nodes

1:39

and then coming up to that bulky disease

1:41

that we saw on the rotating MIP through the mediastinum.

1:44

And even kind of, you know,

1:45

we've got pre vascular lymph nodes,

1:47

we've got every cardio nodes

1:48

and then I believe there's also,

1:49

yeah supraclavicular nodes bilaterally.

1:53

We're seeing, we've caught here

1:55

that there's some bone lesions.

1:56

So after we finish with our lymph nodes, we know we need

1:58

to come back up here as well.

2:00

But there's something I wanna bring attention to

2:02

before we keep going through.

2:05

So this patient came in very unwell and look through here

2:08

and we'll just bring in our CT scan

2:14

and there's some cts that I pick up

2:16

and it's just like this patient is sick,

2:18

they look really sick

2:20

and look at the, the swelling through the flanks like this

2:24

fat should be black like here, the retroperitoneum,

2:25

but it's all swollen, the skin is indurated

2:28

and the more you go down, this is our bulky lymphadenopathy

2:31

that we saw was intensely PSMA avid.

2:33

But look at this leg swelling.

2:35

This patient has also got um, bilateral hydro seals

2:38

and then skin thickening

2:40

and quite pronounced lower limb edema.

2:42

And with this degree of pelvic lymphadenopathy

2:45

that we are seeing on this scan

2:46

and retroperitoneal lymphadenopathy, there's a good chance

2:49

that there's going to be some lymphatic obstruction

2:52

but this may also be compressing

2:54

and um, impeding venous drainage to the lower limbs.

2:57

So this is when I'd be saying no, I'd be, be looking

2:59

to see if there's any contrast imaging, you know,

3:01

looking at the clinical review of the patient

3:04

that we took prior

3:06

and then seeing if there's any concern

3:08

for deep venous thrombosis.

3:09

'cause there could also be, um, stasis of those veins

3:12

or venous obstruction in the setting

3:14

of this horrible bulky lymphadenopathy retinopathy.

3:18

So moving on to mets, we know that there are a couple

3:20

of skeletal mets and we will come back to them,

3:22

but since we're in the abdomen,

3:24

interestingly this is another case of really accounting

3:26

for our physiological uptake and looking outside it.

3:29

So here are our kidneys.

3:31

They are as usual have intense radio tracer uptake,

3:34

but what is this?

3:35

And in bilateral retro, um, perinephric spaces, um, anterior

3:40

to the archis muscles, there are foci of uptake.

3:43

So let's have a look. And this is a non-contrast

3:46

ct, we do know that.

3:47

So our limitation

3:48

for resolving these small soft tissue nodules is tough.

3:51

But if you look just in here,

3:53

there's some small soft tissue nodules.

3:55

There's another one in there which reflect those

3:57

sites of disease.

3:59

So this is um, going to be soft tissue deposits

4:02

and then the liver looking through here, we've got

4:06

multifocal heterogeneous uptake through the liver consistent

4:09

with sites of metastatic disease through the liver.

4:11

We'll see if we can see it on our low ct.

4:15

And this is kind of what I'm do.

4:17

I tend to always go backward

4:18

and forward continuously adjusting the windows.

4:21

This is a terrible adjustment.

4:22

Um, just trying to get it so I can get my ugly liver window

4:26

and we'll pick a head window there,

4:28

which gives us the best look

4:29

and can see that there's low density, um,

4:32

disease corresponding to that areas

4:34

of PSMA uptake consistent

4:36

with metastatic disease through the liver.

4:40

Then coming up to the Fluor X, this patient also presented

4:43

with chest pain and shortness of breath.

4:45

And there is no wonder

4:47

because there is a large right

4:52

pleural effusion or moderate to large,

4:54

moderate sized right pleural effusion.

4:57

And whenever I see oncology cases

5:00

and a pleural effusion, I've really got my guard

5:02

up for pleural disease.

5:03

And so here we've got this, it could be nodal disease

5:07

that's escaped or this could be a pleural deposit just

5:10

here just through.

5:15

And I like to also kind of, there's that pleural lesion.

5:17

I like to go and look at the gray scale

5:20

to see if there's a aligning to the pleura

5:23

and if there's a rind of uptakes surrounding that.

5:27

And I don't necessarily see it here,

5:30

but given that we know

5:31

that we've got soft tissue metastasis, we know

5:34

that we've got um, potentially pleural disease,

5:37

extensive widespread lymphadenopathy

5:39

and some skeletal lesions that we need

5:40

to go back and have a closer look at.

5:42

We'd be interrogating the lungs really

5:44

closely in this patient.

5:46

So let's have a look.

5:48

We're going to look at our lungs,

5:50

which should be bright white or clear with no ality

5:54

and they actually look pretty good.

5:56

Um, but of course then we put on our lung windows

5:58

and scroll up and down as well.

6:01

So now coming with chest pain,

6:03

we think it's due to the pleural effusion.

6:05

We're concerned that there's encroachment

6:06

or pleural disease that's accounting for that.

6:08

The lower limb swelling looks like it's being caused by

6:12

compressive effects from bulky retroperitoneal, pelvic

6:15

and inguinal lymphadenopathy.

6:17

And now we need to complete our review of the case

6:21

and we're going to start at the top

6:23

and go through looking for bone lesions.

6:25

And so skull looks okay, base of skull is a good review area

6:28

that looks okay, but as we come down, we're starting

6:31

to see metastases keeping our eye on the spinal canal.

6:35

We're seeing bony metastasis

6:37

and here all through the supraclavicular region.

6:41

So thorax going slowly,

6:46

there's more potentially pleural disease sitting in there

6:54

And coming through and documenting those bone metastases

6:57

as we see them.

6:59

So in a case like this, as we kind of started

7:03

by saying there's a propensity to kind of over describe,

7:06

but I like to keep it simple and hone in on the things

7:08

that I know are gonna be clinically relevant.

7:11

Bulky lymphadenopathy above

7:12

and below the diaphragm involving almost all nodal stations

7:15

with greatest burden in the inguinal regions and pelvis

7:17

and retroperitoneum in the mediastinum.

7:19

Extensive disease seen in X, Y, Z.

7:21

And then in metastasis, you know,

7:23

we've got soft tissue describe it in its entirety.

7:25

The thorax describe it in its entirety,

7:26

liver describe it in its entirety.

7:28

And then metastases, you know,

7:29

there are scattered PSMA expressing skeletal metastases seen

7:32

throughout or seen actually there's only a couple here,

7:36

so maybe we'll take out throughout.

7:37

There are, um, several sites of skeletal metastatic disease,

7:41

particularly involving the cervical

7:43

and upper thoracic spine,

7:44

including a larger lesion at

7:47

whatever this cervical level is.

7:49

And then conclude it that way.

7:50

You really want to alert your clinicians to things

7:52

that they can do to help out these patients.

7:54

Um, whether that's targeted radiotherapy

7:56

or a change in management line.