0:33

Okay.

0:33

Good afternoon, everybody.

0:34

Um, it's really nice to, uh, see people online and hope

0:38

you're all keeping healthy and safe during this time.

0:41

Um, things have certainly been change in

0:43

terms of how we're doing our education.

0:45

Um, and I've taken advantage of some of these

0:47

online courses and happy to be a part of one today.

0:50

So today I'm going to be, um, sharing

0:52

some interesting body cases that I've

0:54

encountered actually fairly recently.

0:56

I've been keeping track of some of

0:58

the interesting ones for this course.

1:00

So, um, I have six cases to share.

1:04

And I'll just share my screen there.

1:06

So hopefully you can all see that.

1:09

Um, and so we'll get right into it.

1:10

I have questions for each case.

1:13

Um, so I'll scroll through the images first and then,

1:15

um, we will do some online polling for the questions.

1:19

So this first case is a 46 year old woman.

1:22

Who presented with severe abdominal pain and nausea,

1:25

and this was, um, right at the beginning of the

1:27

pandemic, actually, um, whether or not that's useful

1:30

information for you, I'll leave that to you to

1:32

decide, but I'll scroll through the images here.

1:36

So again, 46 year old woman, severe abdominal

1:39

pain and nausea is the presentation.

1:44

So there's a few findings here in the upper abdomen

1:52

and we'll keep it focused on soft tissue windows here.

1:56

And then we're going into the pelvis.

2:01

And I'm going to show you the coronal

2:02

images as well, just to give you another

2:06

look at the pertinent findings here.

2:11

So there's maybe two or three, um, features

2:15

that I want you to try and pick up on here.

2:19

And so this is done with IV contrast only,

2:22

uh, no inter contrast has been administered.

2:29

Okay, and I'll just take you through

2:31

the axials just one more time.

2:36

So going from the pelvis now into the mid abdomen

2:43

and upper abdomen.

2:46

So, um, just try and keep, um, track of the two or

2:51

three findings you think are most important here.

2:54

Um, so this case came across my desk and I spoke

2:58

with the referring physician about the patient.

3:00

Um, we made, um, a management plan together

3:03

and then the patient came back for some

3:05

follow up imaging exactly three weeks later.

3:09

And I will show you what that looks like.

3:11

So this is the follow up imaging here.

3:16

So you'll probably notice some

3:17

changes from the first scan.

3:23

Okay, and here are the coronal images

3:29

and one more time just scrolling

3:31

through the ambulance on the coronals

3:35

and just so that you get a good look at the changes.

3:39

I'll put the most recent scan on the right and

3:43

then I'll put the original scan on the left.

3:47

Let me see if I can link these up here.

3:49

There we go.

3:50

Okay, so, um, the pre intervention scan is

3:53

on the left and the post is on the right.

3:58

So again, just compare and contrast.

4:01

The findings that you're seeing between the two scans.

4:06

Okay, so maybe we can put up the poll question now.

4:09

So the question I'm asking is, which

4:12

mechanism of the choices do you see here?

4:15

Which of these is the most likely

4:17

underlying cause of the CT finding?

4:20

Is it A, increased venous

4:21

congestion from portal hypertension?

4:23

Um, B, high vascular permeability and leakage of

4:26

serum by a small enteric vessel, C, an embolic

4:30

phenomenon originating from a central site, or D,

4:33

transmural non caseating granulomatous inflammation.

4:38

So I'll give you a few seconds here to submit your

4:41

responses and then we'll talk about the answer.

4:45

And let's see what we thought.

4:46

Okay.

4:47

So the majority of the participants thought that

4:50

the findings were due to high vascular permeability

4:53

and leakage of serum by a small enteric vessel.

4:57

And that is the correct answer.

4:59

So, uh, well, very well done.

5:00

Um, so this, uh, patient actually permeability

5:04

ACE inhibitor induced small bowel angioedema.

5:07

So, um, this is something that we may start

5:11

to see more often as patients are being

5:13

increasingly treated for hypertension.

5:16

Um, so just to review what this is, um, ACE

5:19

inhibitors are commonly prescribed medication

5:21

as we know for treatment of hypertension and the

5:24

mechanism for doing that is via vasodilation.

5:27

Um, now the vasodilation can lead to accumulation

5:30

of serum in interstitial tissue, uh, spaces.

5:34

And, um, that's thought to be due

5:36

to accumulation of bradykinin.

5:38

And as the bradykinin levels spike, um, you

5:42

may actually get, Um, increasing levels of

5:46

serum accumulation at various time points, so

5:49

it's not necessarily a slow or even process.

5:51

It may occur with with a spike at random

5:55

time intervals, and that causes angioedema.

5:59

Now, this can happen in about 0.

6:01

5 to 1 percent of patients who are on ACE inhibitors.

6:04

And what's interesting is the time

6:06

lag for this to develop can be years.

6:08

So it's not necessarily something that happens

6:11

right away when someone's on a new medication.

6:13

And in fact, this patient had been

6:15

on ACE inhibitors for 10 years.

6:17

So it was, um, unexpected.

6:20

to see this happen 10 years later,

6:22

but it certainly can happen.

6:23

And again, it has to do with that

6:25

spiking of the bradykinin levels.

6:27

Um, it can also occur in angiotensin

6:29

receptor blocker therapy.

6:31

So it's not just ACE inhibitors, but also the

6:33

blockers, um, less common, but can happen.

6:36

And typically patients present

6:38

with, um, very generalized abdominal

6:41

symptoms that are not very specific.

6:43

So those may include abdominal pain, nausea, vomiting,

6:46

diarrhea, um, and all of those can mimic other.

6:50

Um, entities such as ischemia.

6:52

And now in the time of COVID, obviously some

6:54

COVID, um, presentations can present that way.

6:57

Um, but what we want to try to avoid is, um,

7:00

unnecessary surgery and exploratory laparotomy.

7:03

Um, so the hallmark CT findings, I want you to

7:05

take note of, and I'll just put up the coronal

7:08

images again, so we can look through those.

7:11

These are the hallmark CT findings.

7:12

So ascites, which we see here, So we have

7:16

upper abdominal and pelvic hepatitis, um,

7:18

patients often present with small bowel

7:20

thickening, dilatation, and straightening, um,

7:24

that usually involves a fairly long segment.

7:26

And what's, what's key here is that, um,

7:29

the bowel that's involved is not obstructed.

7:31

So you can see here the bowel in the upper

7:34

abdomen, so the duodenum and the jejunum

7:37

appear thick walled over a fairly long length.

7:40

Um, but there's really no, um, small bowel obstruction.

7:43

There's no dilatation of the lumen, and it's a

7:46

fairly long segment of bowel that's involved.

7:49

Um, one could suggest that there's

7:51

some straightening of the bowel here.

7:52

Normally at the DJ flexure, we get, um, some looping

7:56

and, um, some curvatures, which we're not seeing here.

8:01

So that's another sign of increased

8:03

tissue turgor in the small bowel wall.

8:05

So an interesting way to think about

8:07

this is that the small bowel is actually.

8:10

experiencing urticaria.

8:11

So if you think about the hives that we get on

8:13

our skin, sometimes with allergic reactions,

8:16

that's a similar process to what's happening

8:18

with the small bowel wall, which is why we get

8:20

that straightening appearance of the small bowel.

8:23

Um, and the jejunum is the most

8:25

common location of involvement.

8:27

Um, you might see a target sign, which, um, we often

8:30

hear about When there's any sort of infiltrative

8:33

bowel wall process, and, um, that means that you

8:36

see all layers of the bowels because of edema.

8:39

Um, now the therapy for this is, um, um,

8:43

depends on what the patient is taking.

8:46

So often this Uh, disease is self limiting,

8:50

so it may just go away on its own.

8:52

But most experts suggest that

8:54

the patient changes medication.

8:56

So the scan that I showed you three weeks later, the

8:58

patient had been off the ACE inhibitors and was on

9:01

calcium channel blockers, and it had just gone away.

9:04

So really interesting, um, finding that

9:07

you might see come across your desk.

9:10

So again, the hallmark findings are

9:12

ascites, small bowel thickening, Without

9:15

obstruction, um, straightening of the small

9:17

bowel, um, and long segment involvement.

9:22

All right, so that is the first case,

9:27

and I'll just get the second case loaded up here.

9:33

All right, so, uh, case two.

9:37

We're going to start with an ultrasound here.

9:38

So this is an 18 year old female, um, who

9:42

presented with left sided pelvic pain, and

9:45

that started about four days prior to her

9:47

coming to the ultrasound department, and the

9:50

question was, is there a left ovarian cyst?

9:53

What's going on?

9:53

What's the cause for the pelvic pain?

9:56

So here we go.

9:56

I'll just show you some ultrasound

9:58

images here, and we'll just scroll them,

10:00

scroll through them fairly quickly.

10:05

So here's the uterus here.

10:08

And I'm sorry, I can't put more images on a page.

10:11

So we're just going to look at these kind of zoomed in.

10:16

So there's a question of

10:17

whether this is the right ovary

10:22

and then we've got this structure here.

10:25

And the technologist has annotated

10:27

this as possibly the left ovary.

10:32

You can see it looks very large,

10:34

um, and it's measuring 10 by 7.

10:37

5 centimeters by 8.

10:39

4 centimeters.

10:40

So quite large.

10:42

So those are the main findings on the ultrasound.

10:44

Um, so based on this, you know, I would tell my

10:47

residents, okay, so what do we know about this patient?

10:49

She's 18, she's got pain.

10:50

First thing is you want to, um, make sure

10:53

she's not pregnant, and this patient was not.

10:55

Thank you.

10:55

So, um, the patient did not have, um,

10:59

peritoneal findings or severe pain, but, um,

11:03

there was kind of intermittent low level pain.

11:05

So, um, at the time, it was thought that

11:08

the patient, um, could probably come

11:11

back some other time to follow this up.

11:14

So, she did come back for an MRI, and just bear

11:17

with me here while I just load up the sequences.

11:22

I'll put all of these up, and I

11:24

will Go through them with you.

11:28

All right, so we've got multi

11:29

planar multi sequence MRI images.

11:31

Um, most of them are T2 weighted and I've

11:34

also got an inversion recovery over here.

11:36

And then on the bottom, we've got axial

11:39

pre and post gadolinium T1 fat fat.

11:41

So, um, so let's scroll through.

11:44

the coronal and sagittal images here.

11:48

So the abnormality looks like it's

11:50

centrally located within the pelvis.

11:52

So here's the bladder.

11:54

So I'll just enlarge this here.

11:55

We've got the bladder and the uterus and the rectum.

11:59

And so I will just scroll through these just

12:02

so you can get a sense of where things are.

12:10

And then I'll go through the axials here.

12:14

So Just to point out, here's the right ovary.

12:17

So, you'll recall that on the ultrasound,

12:19

we were able to see the right ovary.

12:21

So, that's here, we can see some nice follicles there.

12:33

And I should mention too, this MRI, um, was actually

12:37

done, uh, six months following the ultrasound.

12:42

Okay, so just keep that in mind, six months post.

12:45

So the patient did get better and

12:47

then presented again with pain.

12:49

There was actually another ultrasound in between

12:51

which I haven't shown you, but it showed very

12:53

similar findings to the first ultrasound.

12:55

So she had a three month follow up ultrasound,

12:57

similar findings, and then her pain kind

13:00

of waxed and waned and got bad again.

13:02

And then she came for the MRI.

13:05

Okay, so let me show you the inversion recovery here.

13:09

See if I can window this a little bit.

13:16

So here's the inversion recovery, and there's a

13:19

specific reason I wanted to show you these, and

13:22

we'll talk about that as we go through the case.

13:27

Okay, and then pre and post gadolinium.

13:31

Um, maybe I'll just load those up

13:34

here so it's a little easier to see.

13:37

All right, so here's pre and post gadolinium.

13:42

And again, this is something that just came

13:44

across my desk as I was trying to collect

13:46

cases, um, and the Ultrasound was done in a

13:49

different institution, so, um, I only started

13:52

to get involved when the MR came through.

13:57

Okay.

13:59

Alright, so hopefully that gives you a good overview.

14:02

So we'll put up the polling question here.

14:05

So, based on the history, the ultrasound, and the MRI,

14:09

what would you think is the most likely diagnosis?

14:12

Alright, so, um, the responses are kind of

14:17

spread over all of the different choices,

14:19

which I'm not surprised by, but a majority

14:22

of people thought this is ovarian torsion.

14:25

So, um, well done.

14:28

That's actually the correct answer.

14:29

It's a chronic ovarian torsion,

14:31

um, which is not common to see.

14:34

And, um, it, it, um, it was a bit, um, difficult

14:39

to make that diagnosis based on the ultrasound

14:43

because, um, the patient had two ultrasounds.

14:45

So one was, um, six months prior to this MR, and

14:48

then as I mentioned, there was this, uh, follow up

14:50

ultrasound at three months, um, and the patient's

14:53

pain was a little bit atypical, so it wasn't,

14:56

you know, the severe kind of pain you'd expect

14:58

that you'd learn about with ovarian torsion.

15:00

Um, so, uh, I will go through the,

15:04

uh, MRI findings with you now.

15:06

The ultrasound findings are not

15:08

really typical for anything.

15:09

It just shows a big cyst.

15:11

So your differential diagnosis

15:12

would be pretty wide with that.

15:14

But let's look at the MRI findings.

15:17

Okay.

15:18

So on the T2 rated images, we've

15:19

got a very large cystic structure.

15:22

We've got a fluid fluid level, so

15:24

low T2 signal and high T2 signal.

15:26

So this could represent hemorrhage

15:28

or protein or some sort of debris.

15:30

The wall of the cyst looks fairly

15:33

Thick, but regular, so it's not nodular.

15:36

Um, and then on the post gadolinium images,

15:37

you can see there's smooth enhancement.

15:39

There are no septations, um, there's

15:41

no, uh, large hemorrhagic components,

15:44

um, on the T one weighted images.

15:46

Um, and then we've got this structure here.

15:49

Which is, um, not normal, obviously.

15:53

So, um, initially when I looked at this, I

15:57

thought, is this kind of a nodule with an assist?

15:59

Is this some sort of fibrous tumor?

16:01

But what really makes you think about, um, potentially

16:06

an inflammatory process, or something that's not

16:10

neoplastic, two things, um, one, the inversion

16:13

recovery images, You can see that there's actually

16:17

some edema in the soft tissues surrounding the ovary.

16:20

So there's abnormal T2 signal in the fat,

16:24

um, anterior and poster to the ovary and,

16:26

uh, sorry, to the cyst and surrounding it.

16:29

So this is not typical for a neoplastic process.

16:32

So all of this, um, edema here would not be

16:35

expected unless there was, um, potentially

16:38

peritoneal carcinomatosis, but we don't

16:40

really see that on the post gatilineum images.

16:43

The shape of the abnormality is also quite unusual.

16:47

So I'm a big believer that in

16:48

radiology, shape is really important.

16:50

You can see how the shape of

16:52

the abnormality is not round.

16:55

It's got kind of angulated and triangular

16:58

margins, suggesting that this is maybe something

17:01

more inflammatory, potentially infectious.

17:06

And then if you look at the coronal images,

17:09

I just want you to keep an eye on This here.

17:14

So if you scroll through centrally, just

17:18

posterior to this enlarged ovary here,

17:22

you can kind of see a whirling pattern.

17:25

Hopefully you guys can see that like you

17:27

would see with, um, um, a, a torsion somewhere

17:31

else in the body or, um, maybe in the bowel.

17:35

So you can see kind of that twisting appearance.

17:37

And so that's what really caught my

17:40

eye back in the inflammatory change.

17:42

And then I realized, okay, this

17:44

is actually a swollen ovary.

17:46

So this is a chronic ovarian torsion.

17:48

And this is the.

17:50

Left ovary that's just, um, necrotic and hemorrhagic.

17:52

So the patient did go to the or, and um,

17:56

in indeed there was a necrotic, hemorrhagic

17:58

ovary, which had accounted for this.

18:00

So, um, what's neat about this case is that it,

18:03

the presentation is quite atypical, so normally

18:06

we think about torsion happening very acutely.

18:08

In this case, it was chronic.

18:09

So don't forget about that with the ovaries.

18:11

And again, here's that nice whirling pattern

18:14

and I'll just put up the sagittals again.

18:16

So you can see that in both planes.

18:19

So if you keep your eye here, this

18:20

is the pedicle, ovarian pedicle.

18:22

And it is kind of got a beak, beak appearance to it.

18:27

Um, and it's twisting around and it

18:28

hears that beak here on the sagittal.

18:30

So nice case of chronic ovarian torsion.

18:34

All right, good job, everybody.

18:36

So let's move on to.

18:39

Case number three.

18:41

All right, so this patient, um,

18:45

is a reproductive age woman.

18:48

Um, I believe 32 and, um, she presented for evaluation

18:54

of, um, findings in the pelvis that had kind of been

18:57

reported on over multiple, um, ultrasound studies.

19:02

Sorry, I'll start that at the beginning here.

19:07

There we go.

19:08

Okay, so, um, I got her

19:10

ultrasound as a follow up study.

19:12

So let's just go through the ultrasound.

19:14

Um, she's got an IUD.

19:17

And then, again, just along that, um, tiny team,

19:21

we've got something going on in the left adnexa.

19:25

And this is a transverse image, uh, poster to

19:27

the bladder, kind of this bilobed structure here.

19:33

And lots of different angles, again,

19:35

that we're seeing here in the pelvis.

19:39

Then we went ahead and did the transvaginal scan.

19:42

Um, Nice looking uterus with an IUD.

19:47

And then this is the area I

19:48

want you to just focus on here.

19:52

So nice transverse images.

19:55

And then we've got something that the technologist

19:57

has annotated potentially as a left ovary.

20:02

So just take stock of what's going on back here.

20:08

And just get, um, a sense in your mind of

20:11

what you think might be happening here.

20:14

So we've measured, um, some sort of

20:16

abnormality in the right adnexal region we're

20:19

thinking, uh, about six by four centimeters.

20:25

And then we're just, um, zooming in on it here.

20:28

Some nice Doppler images for you.

20:34

And I want you to not only, um, take stock of what

20:38

the, uh, abnormality looks like, but, um, what

20:41

do you think of the position of the abnormality?

20:45

And let's see if I can play a

20:47

couple of clips for you here.

20:52

Not sure that one's helpful.

20:53

Let's try this one.

21:00

Okay, this is probably the best clip here.

21:03

Let's

21:03

just take a look at this clip.

21:09

So again, think about shape.

21:11

What do you think about the shape of the abnormality?

21:18

Okay, so for this question, we're going

21:20

to put up the poll, um, first, and

21:22

then I'll show you the patient's MRI.

21:25

So let's, uh, let's put up the question now.

21:27

So based on the ultrasound findings,

21:29

what is the most likely diagnosis?

21:32

Okay, so let's see what people thought.

21:34

All right, so the overwhelming majority

21:36

of people thought that this was pelvic

21:39

inflammatory disease with tubal ovarian abscess.

21:42

And I can see why, um, Unfortunately,

21:45

that's not the correct answer.

21:47

I'll show you why in just a minute.

21:49

We'll look at the MRI.

21:50

Um, but certainly this is not an easy case.

21:53

Um, it just looks like there's

21:55

stuff going on in the pelvis.

21:57

It looks kind of ugly and messy.

21:59

Um, and if you look at this clip here,

22:04

Let's take a look at this image here.

22:07

So we've got one structure that's kind of

22:10

lobulated, another one, and then it looks

22:13

like there's something pulling them together.

22:15

Like there's some sort of

22:17

process that's causing tethering.

22:19

So this kind of linear, um, abnormality here,

22:22

the linear shape almost looks like something

22:25

that's just pulling structures together.

22:27

So that's a hint or a clue of what's going on.

22:30

Okay.

22:31

So I will put up the MRI.

22:34

And then, um, we'll see what we see.

22:37

Hopefully I got the right sequences here.

22:41

Okay.

22:42

So here we have axial images.

22:45

So we've got, um, T2, inversion recovery, and

22:48

this is pre Galilean T1 on the bottom left.

22:51

And I think I had more and I'm not sure if they

22:53

just didn't come over or I just didn't choose them.

22:55

But anyway, I think we've got enough information here.

22:58

So here's the uterus and you can see

23:01

there's a couple of little fibroids here.

23:04

So as we go.

23:08

Oh boy.

23:09

Hopefully as we go up, we have the right

23:14

images here.

23:15

Okay.

23:16

I think my images are just loading here.

23:18

So I'm going to just give it a minute.

23:21

So what I'll do actually, I'll just load up

23:23

the, um, inversion recovery and the T1 because

23:27

I think my T2s maybe didn't all come over.

23:30

So, all right.

23:31

So here we've got, um, two sequences

23:34

depicting what's going on in the ultrasound.

23:36

So again, um, remember what, uh, we were

23:41

looking at in terms of the shape here.

23:44

And I'll see you back in.

23:45

Load these up

23:48

together so that we can take a look.

23:55

Okay, so I think this is probably a really

23:58

good representation of what's going on between

24:02

the two, um, the ultrasound and the MRI.

24:05

Okay, so really nice correlation

24:08

between the sonogram and the MRI.

24:10

So we've got these two structures that

24:12

have been kind of pulled in together like a

24:14

heart shape and the MRI really makes it easy

24:18

because the signal characteristics, right?

24:20

So on the T1 weighted images, this is pre GAD.

24:23

We've got very, very high signal in these T2

24:25

structures or in these two structures rather.

24:28

And then the corresponding T2 signal is very low.

24:31

So that tells us that there's

24:33

hemorrhagic components here.

24:35

And then this shape, um, is pretty

24:38

characteristic of what we're seeing

24:40

here, which is actually endometriosis.

24:41

So when both ovaries are involved by endometriosis,

24:46

there can be quite a few adhesions that develop between

24:49

the ovaries, and that's what's causing the ovaries to

24:52

come together centrally in the midline with this shape.

24:55

And this has the name of kissing

24:57

ovaries, is what it's called.

24:59

Um, so when you see this on ultrasound, Um, and

25:03

again, one of the giveaways on the ultrasound is

25:05

the low level internal echoes, which I think we

25:07

saw pretty nicely on the, um, transvaginal images.

25:12

So here we go.

25:12

These low level, um, ground glassy, um, internal

25:17

echoes are pretty characteristic of endometriosis.

25:20

So this is kissing ovaries or

25:21

middle compartment endometriosis.

25:23

And the reason why, um, the shape is what it

25:27

is, is because there's, um, been endometriosis.

25:31

endometrial deposits, which have settled in

25:33

the middle compartment of the pelvis and have

25:35

pulled together those ovaries, creating this

25:37

mass like structure in the middle compartment.

25:40

And you can also see here that the anterior wall

25:43

of the rectum is being tethered a little bit.

25:45

So, um, this, is probably not limited just to the

25:49

ovaries, but probably involves the middle compartment.

25:51

You can almost see another little tiny deposit here.

25:54

So remember when you are reviewing cases of

25:57

endometriosis on MRI, um, I like to break

26:00

it up into three compartments, the anterior,

26:02

middle, and posterior compartment, where the,

26:05

um, anterior compartment is, uh, the anterior

26:08

wall of the uterus, and anterior to that.

26:11

The middle compartment basically involves

26:13

the, um, uterus, and then The posterior

26:17

compartment is everything posterior to

26:18

the uterine cirrhosis, the posterior wall.

26:21

Um, so look in all three compartments because

26:24

especially in the posterior compartment back here,

26:26

that area is blind to, um, the laparoscopist.

26:31

So they would not be able to necessarily

26:33

see endometrial deposits back here.

26:35

And sometimes those can cause very unusual symptoms

26:38

like leg pain or, um, you know, sciatic nerve.

26:42

Types of symptoms.

26:43

Um, and really the MRI is the

26:47

best way to identify those.

26:48

So this is a really interesting case of,

26:50

um, kissing ovaries or endometriosis.

26:54

All right.

26:55

Uh, let's move on to case four.

27:01

Okay.

27:01

And I've just given selected images here.

27:04

So, um, this was a 29 year old female

27:08

who presented to our department, um,

27:11

with abdominal pain, epigastric pain.

27:13

Um, so this is her first set of images.

27:16

So we've just done a few images through the liver here.

27:19

So I'll just scroll through those

27:26

so you can see what the findings are here.

27:32

So lots of little findings throughout the liver.

27:41

Let me think it back to the beginning now.

27:43

So I'll just scroll through them once more.

27:51

Okay.

27:53

So those are the ultrasound findings.

27:55

And, um, I will put up the MRI findings now.

28:00

So, um, because of what we saw in the ultrasound,

28:02

we suggested the patient should, um, have an MRI.

28:07

And I'm just hoping that, like,

28:08

the correct images came over.

28:11

I'm going to just set this up a little bit differently

28:13

so that we can, um, see more of the case here.

28:18

Okay.

28:19

Um, so my in and out of phase seems

28:21

to have come over as two separate.

28:24

Okay, there we go, scrolling a little bit better.

28:27

So, all right, so we've got the

28:28

in and out of phase on the top.

28:29

So in phase here, out of phase here.

28:32

And then we've got inversion recovery.

28:34

And a the middle on the right, and then I've got

28:37

a dynamic, um, free and post gadolinium vibe.

28:42

So this is the unenhanced here, the middle

28:45

on the left, and then I've just chosen

28:46

to series from, um, the post Gatling.

28:50

So we've got a 60 60 2nd and a five minute.

28:55

So I will just scroll through that.

28:56

So just focus on the liver for this case,

28:59

not worried about any of the other viscera.

29:02

So just trying to see what Corresponds

29:06

to the ultrasound findings.

29:10

I know it's a lot of images to look at.

29:12

So, um, you might have seen this before,

29:19

and if you haven't, you'll definitely see it again.

29:25

So why don't we put the poll question

29:28

up, because this is a diagnosis case.

29:30

So I'll just keep scrolling through

29:33

while the poll question is up.

29:34

What do you think is the most

29:35

likely diagnosis in this case?

29:38

And, um, I might have, in case you have.

29:42

The diffusion.

29:43

I'll just put a diffusion

29:44

here in case you're wondering.

29:48

You'd have to scroll through it.

29:49

There we go.

29:51

So that's the high B value diffusion

29:53

there

29:53

as well.

30:02

And just for comparison, I'm going to put up the, um,

30:07

put up the T2 as well.

30:09

All

30:19

right, so I'll just keep scrolling while people are,

30:22

um, thinking about this,

30:28

and we'll give you another 30 seconds or so.

30:35

I know it's hard when someone else is

30:36

scrolling, so I apologize in advance.

30:39

I know you probably would want to proceed

30:41

in a different direction maybe than I am.

30:55

Okay.

30:56

Ashley, do we have, um, enough responses?

31:02

Okay.

31:03

So, yeah, so we had, um, most people, um,

31:09

thought this might be hepatic adenomatosis.

31:12

And then we had some people vote for nodular fatty

31:14

sparing and others for multiple dysplastic nodules.

31:17

So, yeah, so this is a, quite a challenging case.

31:20

Um, and I've seen this, I've seen this more and more.

31:23

Now in my practice, so this is a young patient.

31:26

Um, and then if we just go back to the ultrasound

31:30

here, you can see from the ultrasound that, um,

31:34

the background liver parenchyma is abnormal.

31:36

It's echogenic.

31:37

Um, there's poor posterior acoustic

31:40

transmission, but the surface looks quite smooth.

31:43

So it's not overtly cirrhotic, but there's

31:45

certainly, um, some fatty change there.

31:49

So the question is, what are these

31:51

hypoechoic Multiple a vascular lesions

31:54

that we're seeing throughout the liver.

31:56

So that's what prompted the MRI.

31:59

And then on the MRI again, you can see that

32:02

there's clearly hepatic steatosis here.

32:05

And the key to this diagnosis is that the

32:09

nodules that we saw on the ultrasound are much

32:13

more conspicuous on the out of phase images.

32:16

And then they kind of blend in with

32:18

the background parenchyma on me.

32:20

In phase images.

32:21

So, um, if you take a look at the focal

32:24

fatty sparing, which I think we had, yeah,

32:27

so we've got this area of, um, focal fatty

32:30

sparing that's periportal on the ultrasound.

32:33

And then it pretty much corresponds

32:35

to this area here on the MRI.

32:38

So take a look at that signal and then

32:40

compare it on the in phase images.

32:42

And it just melts away.

32:43

Um, because that's, um, pretty much normal, uh,

32:47

hepatic parenchyma, or, uh, what's been spared.

32:52

By, um, fatty change.

32:54

So the key is again, the outer phase images

32:57

show the nodules, the in phase images, they

33:00

blend in with the background parenchyma.

33:02

So this is actually nodular fatty sparing.

33:04

So all of the liver is fatty except

33:07

for these areas of nodularity.

33:10

And then the other key is that you can see these

33:12

areas on the pre gadolinium, uh, T1 rated images.

33:18

They're pretty conspicuous there.

33:19

And on the post gadolinium images, Um,

33:22

I could have, I probably should have

33:24

showed you some subtraction images.

33:25

Those are very helpful.

33:27

But over time, the lesions do not

33:29

really change in their signal intensity.

33:31

Um, they tend to, the background liver tends

33:34

to take up the contrast a little bit more

33:36

slowly because it's fatty and then it kind of

33:38

matches the, um, areas of nodular fatty sparing.

33:42

So those areas of sparing are just

33:45

areas of normal liver that have not been

33:47

infiltrated by, um, intracellular lipid.

33:50

So they're, they're normal.

33:52

Um, hepatocytes.

33:54

So those areas will take up contrast

33:55

faster than the rest of the liver.

33:58

So it takes a while for the background

33:59

fatty liver to match up to those areas.

34:02

Now the diffusion can be a little bit

34:04

confusing because it looks, um, those, um,

34:07

nodular areas can look a little bit bright.

34:10

Um, but then if you look at

34:16

the ABC map, which I put up

34:18

here, There is no restriction.

34:20

And again, on the, um,

34:24

the inversion recovery, we don't

34:26

see any high signal T two lesions.

34:29

So, um, the main sequences to be

34:32

aware of are this out of thing.

34:34

Um, and the pre contrast vibe where you

34:37

can see, um, the lesions that has signal

34:40

intensity prior to administration of contrast.

34:42

So adenomas are a good thought.

34:45

And, um, certainly, you know, Um, are

34:48

one of the differential considerations.

34:50

They tend to be ISO intense or hyper

34:52

intense to liver on pre contrast images.

34:56

Um, because they contain primarily hepatocytes,

34:59

but they don't typically tend to stand out

35:01

like this on the out of phase images, and they

35:03

should have some sort of T2 signal or some

35:06

sort of enhancement that develops over time.

35:08

And in this case, there's really

35:10

no enhancement of these areas.

35:11

So, the management, um, for a case

35:14

like this would be to follow up.

35:16

Probably with MRI in about six months and

35:18

make sure that there's no change over time.

35:21

And if you have stability for 12 months

35:23

or so, you can safely say, okay, it

35:26

looks like this is nodular fatty sparing.

35:27

But, um, the main reason for being able to recognize

35:31

this is to, um, prevent unnecessary biopsy or,

35:34

you know, sometimes liver resection as well.

35:37

So this is another term for this is hepatic

35:40

pseudotumor due to nodular fatty sparing.

35:44

Um, I should also mention that when examining these

35:47

patients, you must have, um, a T2 weighted sequence and

35:52

dynamic post gatilineum sequences in addition to the

35:55

in and out of phase, which most of us would normally

35:57

have anyway as part of our regular liver protocol.

36:02

All right, so we'll move on to case number five.

36:06

And I'm just going to scroll through here.

36:09

Okay.

36:10

All right.

36:10

So we will start with the CT here.

36:13

So I just have axial images.

36:15

And this is a, um, 47 year old male.

36:20

And this is the initial imaging

36:21

test that the patient had.

36:32

So I'm going to show you,

36:33

uh, three sets of images here.

36:36

So the first is the CT.

36:39

And there's only one name finding

36:41

here that I want you to focus on.

36:49

Okay.

36:50

And then I'm going to show you an MRI.

36:55

Okay, we'll leave that up there.

36:59

Um,

37:05

sorry, bear with me here while I load these up.

37:10

All right,

37:12

so here's the MRI, and I might actually

37:17

just find you a different post catalyneum.

37:21

Here we go.

37:22

Alright,

37:23

so, um, you've seen the CT now.

37:27

This is the MRI, and so we've got, um, diffusion rated

37:33

imaging, so this is a high B value DWI on the bottom

37:36

left, and then above that we've got ADC, and then

37:39

we've got a T2 axial, T2 coronal, MRCP, and then a post

37:44

gatilinium, um, T1 with FAT FAT on the bottom right.

37:49

So, I'll just scroll through those for you.

37:53

And again, we're focusing on the

37:55

abnormality that was visible at

37:57

CT.

38:04

So pretty striking findings here.

38:11

All right, and actually, I think we'll

38:12

put up the poll question now, Ashley.

38:15

So, which of the following treatment

38:16

regimens do you think would be most

38:19

likely recommended for this patient?

38:21

So, we're all doing quite a bit more multidisciplinary,

38:24

um, tumor boards these days, so we probably have heard

38:27

of these treatments, so let's see how good we are at

38:31

matching up the diagnosis of the therapy in this case.

38:35

So, we're kind of spread across the board again, so,

38:37

um, nobody thought radiation was would be offered.

38:41

Um, some people thought we would do a six

38:43

week trial of steroid therapy, thinking

38:46

that this might be autoimmune pancreatitis.

38:49

Uh, Whipple resection was a

38:51

possibility, and then chemotherapy.

38:53

So CHOP chemotherapy is cyclophosphamide

38:56

deoxyrubicin, um, Oncovin, which is

38:59

increased in sulfates and prednisone.

39:02

Um, and that's usually administered for lymphoma.

39:06

And, um, actually, answer D was

39:08

the correct answer in this case.

39:10

So, this turned out to be pancreatic lymphoma.

39:13

So, let's talk about, um, why that is.

39:16

So, Whipple resection could be offered.

39:19

For pancreatic lymphoma, and it sometimes

39:20

is, um, but usually it's reserved for

39:24

cases where the diagnosis is uncertain.

39:27

So we're not getting good, um, histopathology,

39:30

perhaps on the biopsy, um, or, um, you know,

39:35

we're just, we're seeing some features on

39:37

the imaging, which could, um, actually, um,

39:41

which are shared features with adenocarcinoma.

39:44

So let's talk about the adenocarcinoma features.

39:46

So typically with pancreatic

39:48

adenocarcinoma, it's a ductal malignancy.

39:52

So it starts in the duct, which means that the

39:55

tumor cells grow out in the duct, out into the

39:57

parenchyma, and they typically obstruct the duct.

40:00

So one of the hallmark features is seeing a dilated

40:04

duct, which we don't see at all in this case.

40:07

And once the duct is dilated, it means that

40:09

the secretions can't really go anywhere.

40:12

So that pancreatic parenchyma that's upstream

40:15

from the ductal obstruction tends to atrophy.

40:18

So we look for atrophy, we look for ductal

40:21

obstruction in pancreatic adenocarcinoma.

40:24

And you can see in this case, the pancreatic

40:26

duct really looks pristine on the MRCP.

40:29

There's no dilatation.

40:30

There's no, um, atrophy of the parenchyma.

40:35

And usually pancreatic adenocarcinomas are quite small.

40:38

They rarely go to grow to a size like this

40:42

because the patient will present long before,

40:45

um, it ever gets to this size because of

40:47

pain or perineural invasion, for example.

40:50

Again, shapes, is really important in radiology.

40:53

So typically, adenocarcinomas

40:55

tend to be a bit fibrotic.

40:56

So they tend to have irregular margins.

40:59

They're not usually spherical.

41:00

They tend to, um, cause some

41:02

retraction of the adjacent structures.

41:05

For example, um, adjacent to the IVC here, you

41:08

can see that the lesion is very, very small.

41:10

bumping the anterior wall, it's abutting it,

41:12

but it's not really invading it or narrowing

41:14

it, which adenocarcinoma tends to do.

41:17

Um, you can see that, um, the portal vein is

41:20

coursing very close to this lesion, but it's

41:22

not encased, which adenocarcinoma tends to do.

41:26

And then one of the other strong features that's

41:28

pointing against from, against adenocarcinoma

41:32

is the degree of diffusion restriction.

41:36

So adenocarcinoma certainly can restrict, but this

41:39

degree of Restrictions suggest tightly packed cells

41:43

with a round blue cell tumor, which is lymphoma.

41:47

So this turned out to be pancreatic lymphoma,

41:49

and this was suggested from the imaging study.

41:54

And then the patient underwent

41:55

biopsy and lymphoma was proven.

41:58

So the patient did undergo

41:59

chemotherapy rather than liposuction.

42:02

And I'll just show you out of interest

42:04

the PET CT so you can see how avid

42:09

This tumor is, um, with FDG uptake.

42:12

Again, very typical for lymphoma.

42:14

So, wow, really, really hot tumor here.

42:17

Um, so that's again quite typical of lymphoma.

42:20

So there are a few features here that point away

42:23

from your typical pancreatic adenocarcinoma.

42:26

So keep that in mind.

42:27

So ductal absence of ductal dilatation,

42:30

absence of pancreatic atrophy, absence of

42:32

encasement or abutment of adjacent vessels,

42:34

despite the tumor touching those vessels.

42:37

Um, those are the strongest features.

42:38

And then, you know, the other features that

42:41

are indeterminate, but suggestive are the

42:43

degree of diffusion restriction, really,

42:45

really strong diffusion restriction, the large

42:48

size of the lesion and the margins, which are

42:50

rounded and not really, um, irregular, which

42:53

is typical for pancreatic adenocarcinoma.

42:56

All right, so that was great.

42:58

And then we have one more case, which is actually

43:00

a pretty quick case, so I think we'll have time.

43:03

So it's just a CT scan here.

43:06

Okay, so I'm going to scroll through it.

43:08

This patient has recently had surgery, so you

43:12

can scroll through, and I'll scroll through,

43:13

and you can see what surgery the patient had.

43:17

And there is a complication of this surgery,

43:20

which I would like you to try to find.

43:23

And that's really it for this case,

43:24

so we'll just talk about that.

43:26

And I'm sorry, I think the images are still

43:29

loading here, so this is going to take a minute.

43:31

Let's see if

43:34

I can scroll through here.

43:42

Oh, sorry.

43:43

I think I put up the wrong axis.

43:44

There we go.

43:45

All right.

43:46

So, what surgery has the patient had

43:50

and what is the complication?

44:02

And coronal may not be that helpful,

44:05

but I'll just scroll through them quickly.

44:09

Alright, so hopefully you've

44:10

seen the two findings here.

44:14

So let's put up the poll.

44:16

So based on these findings, how are

44:18

patients most likely to present?

44:20

Isuria, flank or pelvic pain, or asymptomatic?

44:25

Alright, so most people thought the patient

44:28

might present with flank or pelvic pain.

44:31

So I'll just go through the findings.

44:32

So the surgery the patient has had is

44:34

is a partial nephrectomy on the left.

44:37

So you can see the surgical clips

44:38

and there's some fat necrosis here.

44:40

Um, so this has been as a follow up for RCC to

44:44

see if there was any recurrence and there was

44:46

no recurrence, but the incidental finding was

44:49

actually in the bladder and it's this here.

44:53

So there's, um, a fat fluid level

44:57

or a fat urine level in the bladder.

44:59

So you can see this little strip of fat that has

45:02

floated to the top of the urine in the bladder.

45:06

Um, and you may or may not have seen this

45:10

before, but that's a sign of chyluria.

45:13

So, um, in the setting of partial nephrectomy, The

45:18

lymphatics can be disrupted during the, um, resection

45:22

and then you can get some leakage of lymph into the

45:25

collecting system and that layers in the bladder.

45:28

So the patients usually are asymptomatic.

45:30

They normally do not get flank pain or pelvic pain.

45:33

Um, but they may actually report, uh,

45:35

white or milky discharge in the urine.

45:38

Um, and then some patients can develop quite

45:41

significant proteinuria or hypo hypo albuminuria.

45:46

And then, um, eventually, if it's not

45:48

treated, uh, weight loss, malnutrition in

45:51

very severe cases, but that's not very common.

45:54

Um, and in those cases, uh, the urologist may

45:57

actually look for the chile leak to try to repair it.

46:00

But otherwise, um, most cases have no treatment.

46:03

spontaneous remission within 6 to 12 months.

46:05

But the reason for showing this is just so

46:08

that as radiologists, we're familiar with this

46:10

complication, it does need to be reported.

46:13

And we also don't want to mistake this fat

46:15

for air in the bladder because then we can

46:18

erroneously raise the possibility of a bladder

46:21

fistula and then that can trigger additional

46:24

investigations which are not necessary.

46:26

So just be aware that with partial

46:29

nephrectomy, um, Transcribed by https: otter.

46:29

ai There is potentially disruption of the

46:32

lymphatics, which can lead to a chile leak.

46:36

Um, and you might see this fat fluid level.

46:39

So you might want to add that into your search

46:40

pattern for post partial nephrectomy patients.

46:43

It doesn't happen with complete nephrectomy because

46:46

obviously there's no parenchyma left for that,

46:49

um, tissue for the contents to drain through.

46:52

So only with partial nephrectomy.

46:54

So I suggest just adding that to your search pattern

46:56

for these types of cases, which we see quite commonly.

47:00

Okay, so that's all I have to present.

47:02

So maybe we'll just go through

47:03

if there's any questions.

47:04

We'll go through what um, What you guys have submitted.

47:07

Okay.

47:08

All right.

47:08

Thanks everybody.

47:09

Take care.

47:09

Thank you.

47:10

Bye