0:00

So in this case, this is our second one which has

0:03

certainly widespread disease.

0:05

Um, and we are trying to see if there's anything that we can

0:08

detect on the scan that could be potentially targeted

0:11

for therapy to improve the patient's wellbeing.

0:14

And this is a familiar, hopefully pattern that you're seeing

0:17

where there's multifocal disease

0:19

through the axial proximal appendicular skeleton.

0:22

And if we pause in the lateral,

0:25

it's really following that spinal line.

0:27

So the first thing I'm gonna do, we're gonna bring in the,

0:30

we might get a two layout

0:32

and we'll bring in the sagittal reconstruction.

0:35

So as always, we would um, start

0:40

with our tumor nodes metastasis assessment.

0:45

And although it is temp,

0:46

it's always tempting and I almost did it.

0:47

I jumped to the major abnormality in the spine.

0:50

But we are gonna take ourselves back and we know it's there.

0:52

So we'll go back and look at our tumor bed

0:56

and see that this patient has had a prostatectomy.

0:58

So there's multiple clips through here,

1:00

large mass in the prostate bed, consistent

1:02

with local recurrence unfortunately for this patient.

1:04

So they've recurred in quite spectacular fashion,

1:07

multiple lymph nodes and we'd go up and follow the vessels.

1:11

But interestingly, the multifocal lymph nodes are

1:13

through the presacral space, even within the mear rectum

1:16

as well, no doubt

1:18

because of the um, invasive nature

1:20

of this large local recurrence which has transcended

1:23

through fascial planes.

1:25

So coming up, we scroll through our lymph nodes,

1:29

we document them as appropriate, we check through our lungs,

1:33

you looking at the gray scale imaging

1:36

and the lung windows with a MIP to thicken it up,

1:39

checking our liver, which looks good, looking

1:41

through the soft tissue spaces.

1:42

Alright, so we've done all of that.

1:44

Let's go to, to assessing the skeleton,

1:46

which is the reason why I chose this case.

1:49

And this patient has come in with pain, um,

1:52

particularly in the region of the thorax.

1:55

And on our sagittal we can see

1:57

that there are multiple PSMA expressing skeletal lesions

2:00

seen throughout the thorax.

2:02

Big words to kind of encompass

2:04

and paint a picture for our referrers of what we're seeing.

2:07

But noticing that there are some dominant lesions

2:09

and there is some tracer which is extending beyond

2:12

where I would expect the skeleton to do.

2:14

So in these cases, this is where it's so important

2:17

to run the spine, check the base of skull note

2:20

of any lesions there that may be encroaching

2:22

or causing trouble and then coming down.

2:25

And so on this large lesion here, we can see

2:29

that there's avidity extending beyond the margin

2:31

of the vertebrae and into the spinal canal.

2:35

Now this can be a little bit tricky

2:37

and here's a bit of a practice pill here is

2:39

that intensely avid lesions

2:41

and that's goes for nuclear medicine

2:43

of any way, shape or form.

2:44

If there's intense uptake, it may bleed out

2:48

or appear bigger on the functional imaging than it

2:50

is in reality.

2:52

So we're going to come up

2:54

and correlate this large lesion here with our low

2:58

Dose ct. And if you

2:59

do have diagnostic imaging

3:00

or an MRI for comparison, that is so useful

3:03

for cases like this

3:04

because you can add some more certainty to it.

3:07

So let's have a look. We'll blow it up.

3:09

Let's make it nice and big.

3:10

Give ourselves the best chance

3:11

of giving us the best assessment.

3:14

So is this truly going into the spinal canal

3:17

or is this just kinda spread out from a really intensely PA

3:21

expressing skeletal lesion?

3:22

How I like to look at this as I look at the fat plains,

3:24

you can see here it's nice and black.

3:26

This is just below it,

3:27

but here you can see that there is soft tissue,

3:31

this hyperdense soft tissue.

3:33

There it go. So just through there.

3:35

So yes it is getting into the spinal canal,

3:37

this fat plane's coming across and stopping dead.

3:39

It's okay on the other side

3:41

but it's starting to get through.

3:43

But really it's getting all the way into

3:45

that neural exit foramen as well.

3:46

And here the neural exit foramen above

3:48

for comparison shows you, you've what?

3:50

We've got some black fla plains,

3:51

but here it's just filled with this abnormal soft tissue.

3:54

I'll pop on a bone window just to show what

3:56

that bone lesion is doing.

3:57

And it's kind of, you know, irregular sclerotic.

3:59

There's kind of aggressive perote reaction.

4:01

It looks heterogeneous with some lucency to it,

4:04

but this is all that abnormal

4:06

soft tissue which is encroaching into the neuro exit foren.

4:09

And this patient did come in with chest wall pain.

4:12

So it's likely that it's involving that nerve, um,

4:14

exiting from compression in that space.

4:18

So this could be, um,

4:19

provided the patient has um,

4:20

not had radiotherapy to the region before.

4:22

This could be targeted with specific radiotherapy

4:25

to manage the symptoms and then coming back,

4:27

'cause there was also a few other things to point out

4:29

with the bone metastases.

4:31

Keeping an eye here to make sure that there's no others.

4:33

This is kind of probably a good example of that spray out,

4:36

um, of expansion from a really intense lesion.

4:39

But the patient's already had Lamin Ectomies down here

4:42

and there's multifocal disease including

4:44

there at the sacrum too.

4:45

So we've interrogating this lesion here to make sure

4:47

that there's no encroachment on the neural

4:50

exit foramen as well.

4:52

Another thing to think about with these patients as well

4:54

with extensive disease is whether

4:56

or not there are pathological fractures as

4:58

that can be causing pain as well.

5:00

But overall in this patient,

5:02

vertebral body height is generally preserved.

5:04

I.