0:33

Good afternoon, everybody,

0:34

and thank you for joining me.

0:37

I'm going to be showing a series of cases today

0:39

that are actual peer review cases that came

0:41

up at the Mayo Clinic Enterprise where I work.

0:45

They have been obviously anonymized

0:48

and will be available afterwards.

0:50

So I'm just going to start scrolling through

0:53

our first case is a 68-year-old female

0:56

and she came into the emergency department

0:58

with lower abdominal pain, and we'll

1:01

just scroll through here.

1:07

And I'm just gonna, you know, slowly

1:09

go through here and then I'll come back and highlight

1:12

some of the features of the case and then we'll

1:14

talk about whether this was a case that was a good

1:16

call or a case that had a miss on it.

1:25

And if I'm going too fast or too

1:26

slow, you all should let me know,

1:34

and I'm just going to go back again here.

1:42

All right, so I'll

1:46

give you the fact that the patient has

1:47

a few low-density lesions in the liver,

1:49

which are irrelevant to her coming in.

1:52

And hopefully you all recognize that, starting with

1:56

the descending colon here, flexure, we get into an

2:01

area that has some wall thickening in the colon, and

2:05

it's pretty thick here, and there's a little bit of

2:07

inflammation around it, and you see a little bit of

2:09

fluid here coming down the left paracolic gutter.

2:13

And that abnormality of the colon extends all the way

2:16

down the descending colon, and all the way down and

2:22

even crosses over a bit into the sigmoid colon here.

2:26

And then we've got some diverticula here,

2:28

but the sigmoid colon doesn't actually look

2:29

quite as bad as the descending colon does.

2:33

There's a little free fluid here in the pelvis.

2:35

The patient has some prominent

2:37

uterine and periuterine veins.

2:39

I assume she's probably had children.

2:42

And then we get into a lot of streak

2:43

artifact from our hip replacement here.

2:47

So this finding was commented

2:49

on, um, it was called colitis.

2:53

And, um, that wasn't the, uh, that wasn't the miss.

2:57

There, there was, however, a miss here.

3:00

And I'm just going to pause here for

3:02

a second and let you guys look at

3:04

this image.

3:08

And pause here and let you look at this image.

3:14

And then before we give you an answer, I'm going to

3:16

pull up the coronal images here too, because I think

3:19

that gives you a better sense of the distribution

3:22

of this abnormality and the descending colon here.

3:27

And the kind of, um, abrupt cut, uh, difference

3:31

between this transverse colon, which is normal,

3:35

and the descending colon here.

3:42

All right, I'm going to go back to that axial set here.

3:49

I'm used

3:49

to people being able to just tell me what

3:52

they're thinking about cases instead of

3:53

telling you guys, but let's pull up the polling

3:55

question first and then I'll finish this off.

3:59

So we're going to pull up the

4:00

the multiple choice question.

4:01

So I'm asking you what the most common cause of

4:04

acute bowel ischemia is, and whether it's decreased

4:08

cardiac output, an SMA embolism, a hypercoagulable

4:11

state, or associated with bowel obstruction.

4:14

And let's just see what you all think.

4:19

And about 50 percent of you said it was decreased

4:22

cardiac output, 20 percent said SMA embolism, one

4:26

said hypercoagulable, and two said bowel obstruction.

4:29

The actual answer to this is an SMA embolism is

4:32

the most common cause of acute bowel ischemia.

4:35

Now that's not what we're

4:36

seeing in this particular case.

4:38

I SMA here, and that's open, but I wondered if

4:44

this caught your eye here, there's a bit of a

4:47

filling defect here in the, uh, near the portal

4:51

confluence, we've got splenic vein and SMV coming up.

4:55

And then this is the IMV here.

4:58

So the inferior mesenteric vein and some

5:01

of its branches here have thrombosis.

5:04

And that was the cause of this abnormality.

5:07

So although the report mentioned colitis, it's

5:10

actually bowel ischemia, secondary to venous.

5:14

occlusion.

5:15

And whenever you think about looking at the

5:18

distribution of bowel wall thickening in the colon,

5:22

one of the watershed areas or really the distribution

5:24

between the SMA and the SMV or the IMA and the

5:29

IMV, the, the difference between the, the superior

5:33

mesenteric and the inferior mesenteric inflow and

5:36

outflow occurs in the, near the splenic flexure.

5:39

So if you see a bowel abnormality like this,

5:41

that's confined to the descending colon,

5:43

you have to think about a vascular etiology.

5:46

So, you would automatically,

5:47

in this case, look at the IMA.

5:49

In this case, here's the IMA here, which

5:51

is open, and we can see that nicely.

5:55

But it was the IMV and its branches

5:57

that were not supplying this colon well.

6:00

So, we have to carefully look at that.

6:03

All right.

6:04

So, that was our first case, and that was a miss, but

6:07

not, it really didn't change the patient management

6:10

too much at that particular time because it was found,

6:12

the, the abnormality was found relatively quickly.

6:16

All right.

6:16

I'm going to pull up our second case here.

6:19

Okay, got our second case here.

6:24

All right.

6:25

And this is a case of a 75-year-old man, and he

6:29

had a known pancreatic mass that was discovered on

6:33

another set of images outside and he came to

6:37

our institution for staging of that pancreatic mass.

6:41

And so I'll start scrolling here.

6:51

So this is the arterial phase.

6:54

You can see we've got brisk arterial enhancement and

6:58

no, no, not good venous enhancement at this point.

7:04

So hopefully you all recognize

7:06

that there is actually a mass in

7:07

the pancreatic tail in this case.

7:11

I think you all probably also recognize

7:13

that there are a lot of abnormal, very hyper

7:17

enhancing lesions here in the lung bases as well.

7:21

Multiple of them.

7:25

There's a lesion here in the liver.

7:28

And then we get into this lesion here in the

7:30

kidney, highly vascular kind of a tangle of vessels.

7:35

And you can see that the veins are enhancing fairly

7:38

briskly as well, more so on the right than the left

7:42

so we've got early venous drainage from this lesion.

7:46

I'm going to pull up the venous phase

7:48

as well and let you guys look at that.

7:54

And here's the venous phase.

8:00

So we can see that abnormality in the liver.

8:02

We saw the lesions in the lung bases.

8:07

Here's that venous phase lesion there.

8:10

And then the lesion in the pancreas we're still seeing.

8:14

And then I've got some delayed images here too.

8:21

So the pancreatic lesion, and you can

8:24

see this is really following blood pool.

8:30

So this wasn't so much of a miss in,

8:34

in terms of a lesion wasn't seen or described.

8:36

It was really more of a misinterpretation.

8:40

So we thought, well, is this a primary pancreatic

8:43

mass with lung metastases and a vascular malformation

8:49

in the right kidney?

8:52

So that was,

8:56

so that was what was described.

8:59

This was called probably a neuroendocrine tumor

9:01

because it was highly vascular on the arterial phase.

9:04

It had vascular metastasis

9:06

to the lung and to the liver.

9:08

And then this was called a vascular malformation

9:11

in the kidney and thought to be unrelated.

9:14

So, the patient underwent a lung biopsy.

9:19

So that would help stage the patient.

9:21

We proved that these are metastases, determined

9:23

that they were from the pancreatic lesion or not.

9:26

And what would you think that we got?

9:29

We ended up getting metastatic renal

9:31

cell carcinoma out of the lung.

9:35

So the patient underwent a biopsy of the pancreas,

9:37

which was also metastatic renal cell carcinoma.

9:41

So this is an avascular malformation type

9:45

looking thing, but it really is a renal

9:47

cell carcinoma because of how vascular

9:50

it is mimicking a vascular malformation.

9:53

So this was resected as well, and a

9:56

renal cell, but just highly vascular.

9:59

So let me, let's do the polling question

10:01

if we can first and then we'll talk

10:02

a little bit more about this case.

10:05

So I wanted to know if there's any feature of

10:07

a renal AVM that assures you that it's benign.

10:11

If it has a large draining vein, a tangle of arterial

10:14

vessels, an associated bleed with it, is that a,

10:18

are all these things assumed that it's benign?

10:20

Or are none of these things good enough

10:22

to reassure you that the lesion is benign?

10:27

Yep, 89 percent of you said none of

10:29

the above, which is absolutely correct.

10:31

There's really not any feature of a

10:34

renal AVM that absolutely

10:36

assures you that it's benign.

10:38

You have to look very carefully for any associated

10:40

soft tissue, and even after therapy, often these

10:44

are followed up to make sure that there's not

10:47

an associated lesion that we're just not seeing.

10:50

Um, renal cell carcinomas produce a very high

10:52

level of angiogenic growth factor, which can

10:56

lead it to have an extremely vascular appearance.

10:59

Now, it's rare that it presents in such a fashion

11:02

that we actually think it's a vascular malformation.

11:05

Often they're just very vascular,

11:07

but they can present this way.

11:08

There are multiple reports in the literature of it.

11:11

So you do need to follow an AVM after

11:14

treatment if it's not resected to make

11:16

sure that there's no tumor progression.

11:19

Um, I realized that a couple of questions

11:22

came in that I should have, should have

11:25

answered before I moved on to this case.

11:28

Um, one question was, and I think this is related

11:31

to the first case, which I can put back up.

11:35

It was, is this a portal venous

11:36

phase to be sure about emboli?

11:40

Um, this is a decent portal venous phase.

11:44

I think we can still feel comfortable

11:46

about arterial emboli because we have very

11:48

good arterial enhancement in this case.

11:51

And then if you wanted to be sure that these were

11:53

actually embolic structures, a delayed phase is helpful.

11:57

I didn't show the, The delayed phase didn't actually

12:01

go through that we have our technologists sometimes

12:03

do delayed phases, just because they see something

12:06

in the liver or spleen or something like that.

12:08

I think we can feel, we feel really confident

12:10

though that this is actually a filling defect, but if

12:13

you weren't sure, a delayed phase would be helpful.

12:16

Someone asked if there was a lesion in the right

12:17

lung, I don't know if it was referencing this

12:19

particular case, there's definitely were lesions

12:21

in the other case, and then regarding case one.

12:24

With the descending colon wall thickening,

12:26

I've encountered very similar imaging findings

12:28

with a history of bright red blood per rectum.

12:30

The veins and arteries are normal.

12:32

Would it be incorrect to call it colitis,

12:34

likely on the basis of non-occlusive ischemia?

12:37

I think that would be perfectly reasonable to assume

12:40

that there was some event, potentially, that for

12:44

some reason, maybe the patient became hypotensive,

12:47

there wasn't actually an embolus or a thrombus,

12:51

but there may be some atherosclerotic disease or

12:54

something else, small vessel disease that maybe

12:57

puts that particular part of the colon at risk.

12:59

So I think that would be.

13:01

Reasonable to say that if it has a vascular

13:03

distribution but you can't find the embolus or

13:06

the thrombus that might be causing it, I think it

13:08

would be reasonable to suggest that as an answer.

13:11

I guess the other thing to think about is this would

13:13

be a very odd configuration in some respects.

13:17

Because we wouldn't normally like radiate the

13:20

whole side of the body like this and expect to

13:22

see absolutely none of the small bowel involved.

13:26

But I suppose, you know, if this were a shorter

13:28

segment, you'd have to make sure that it wasn't

13:30

in a radiation field, because that can also cause

13:34

small vessel disease, vasculitis, and look like this.

13:38

All right.

13:39

Um, so I think we were finished with case one, and I

13:43

didn't really have much else to say about case two.

13:46

So I think I will move on now to case three.

13:50

And that's loading.

13:52

Okay, case three is a 64-year-old female,

13:57

and she had been followed in the ICU.

14:03

She was very ill.

14:04

She had had an abscess and had a drain placed,

14:07

and we were just following up her abscess, and

14:14

she was just kind of getting scans.

14:16

Almost weekly because of various

14:18

things that were going on with her.

14:20

So you can see she's had surgery here.

14:25

She's got multiple things going on, um, some of

14:28

which are irrelevant to the reason I'm showing

14:31

you this, but she has some fluid here between

14:34

the stomach and the pancreas and the lesser sac.

14:37

There's a little bit more

14:38

fluid here below her pancreas.

14:41

She has a drain placed here into this

14:44

collection that was adjacent to the stomach.

14:48

There's some high-density fluid here,

14:51

anterior to the stomach, felt to be blood.

14:54

She's got fluid around her liver,

14:57

all kinds of things going on with her.

14:59

Uh, at some point in her stay in the

15:01

ICU, she became hypotensive as well.

15:04

You can see she has a rectal tube.

15:06

She has some fluid in the pelvis, some of

15:08

which has some higher-density layering in

15:10

it, suggesting again, some blood products.

15:13

So she clearly had a bleed.

15:16

We have blood here and blood in the pelvis.

15:18

And most of these things were, were

15:21

actually appropriately discussed, but

15:24

there were a couple of things that were

15:26

not seen, so I'll come back up to the top

15:30

here and go through again.

15:38

I'm just going to pause here at this particular moment.

15:45

And if anybody wants to type into

15:47

the question and answer session what they

15:49

think is going on here, that would be great.

15:51

If not, that's okay, we'll talk about it.

15:56

Go ahead and pull the, actually go ahead and

15:58

pull the polling question up because I think

15:59

it's a best diagnosis polling question anyway.

16:03

So in this ICU patient, I'll leave this up here.

16:08

What's your best diagnosis?

16:10

I'm drawing your attention to the kidneys.

16:11

Is it pyelonephritis, acute cortical necrosis,

16:16

medullary nephrocalcinosis, or lymphoma?

16:19

All right, let's see.

16:20

And nine of you did correctly identify acute cortical

16:25

necrosis, and I'll point out the findings here.

16:27

The acute cortical necrosis actually had been

16:29

on multiple scans of this patient and not.

16:33

And not noted, but you can see that

16:34

there's a rind of low attenuation

16:39

surrounding both of the kidneys.

16:44

Involving just the cortex.

16:48

This patient actually, we knew had a

16:50

hypotensive episode, had a bleed, and it's

16:52

usually due, acute cortical necrosis is

16:54

usually caused by a major catastrophe that

16:57

causes a sudden decrease in blood pressure.

17:01

It can lead to acute renal failure and

17:03

it's usually, unfortunately, irreversible.

17:06

So at this point, it hadn't

17:07

been mentioned in the reports.

17:09

Um, the patient's renal function was not doing well

17:12

and was worsening, and she actually ended up

17:14

having a biopsy to make a diagnosis, or I think we

17:19

could have potentially obviated the need for a biopsy

17:23

if this had been appropriately recognized.

17:26

It was, like I said, on multiple

17:27

previous studies, but not noted.

17:31

So that was unfortunate, but it was diagnosed,

17:35

the necrosis was diagnosed on the biopsy, and

17:38

she just underwent supportive care after that.

17:42

Okay, um, let me just pull this up on

17:45

the coronal too, so you can get another

17:47

sense of this cortical distribution here.

17:51

Of this abnormality.

17:54

All right, so this one, because there are multiple

17:59

phases on this, this is RGI bleed protocol.

18:02

This was an 89-year-old man who had had bright red

18:08

blood per rectum since five o'clock the previous night.

18:12

And he came in the next morning to the emergency

18:14

department; it's now around noon, and he has a history

18:18

of having had five episodes of bleeds in the past too.

18:24

So I'm just going to go quickly through a

18:27

few of these here so you can see he's got

18:29

pacemaker leads, got kind of a biggish heart here,

18:33

lots of valvular calcifications, um, large IVC and

18:40

hepatic veins probably related to his cardiac function.

18:44

So on our GI bleed protocols, it's very

18:47

important to have a non-contrast study

18:50

first so that you can identify any density

18:53

that's present in the colon or small bowel.

18:57

Kind of as a baseline before

18:58

you give any contrast at all.

19:00

Now unfortunately, this patient had gotten

19:02

contrast a couple of days previously and still had

19:05

contrast in the bladder from excretion, but we

19:09

can see he also has quite a few diverticula.

19:12

Many of which have some residual high-density

19:15

material, either ingested content, um, some

19:19

medications cause density, or he may have gotten

19:23

a little bit of, uh, oral contrast at some point,

19:26

or even the excretion of iodinated contrast

19:30

does go partly through the bile and partly into

19:33

the bowel, so some of that may be due to that.

19:36

So, that was our non-contrast, so we

19:38

know that there is some baseline density.

19:41

This is our arterial phase,

19:45

so we have to very carefully kind of

19:47

look at all the areas of the bowel here.

19:50

It's got a large duodenal diverticulum here,

19:53

but I don't see anything particularly dense

19:55

there.

19:55

That makes me worried.

20:01

You know, you start seeing

20:03

things here, and you go, all right, was

20:04

that there on the pre-contrast? Oh, there.

20:06

That's the same diverticulum,

20:08

so that's probably okay.

20:09

Okay.

20:13

A little bit denser there,

20:19

but that was their pre-contrast.

20:22

So these are not easy studies to look at, especially

20:25

when there's a lot of density there to start

20:27

with.

20:28

So I'm going to come back up

20:34

and stop there.

20:36

And I'm going to bring this up as well

20:39

to the similar location.

20:41

And then I'm going to show you the venous phase

20:43

so we always do a delayed phase because you

20:45

want to see if whatever is dense continues to

20:49

increase in intensity and pool, and that'll

20:52

give you an idea of what might be bleeding.

20:55

So as we come down here.

20:59

We see this area here in the descending colon

21:03

that was a little more faint on the arterial

21:06

phase and was not there on the pre-contrast phase.

21:13

So here we have an area of active bleeding and this

21:17

was a good call by the resident who was on at the time

21:20

to notice this in the background of all of this noise.

21:24

It would be very easy, I think, to overlook

21:26

something like this when there are

21:28

so many other areas that are dense.

21:31

And here's just a MIP projection as well.

21:37

And you can see this area of bleeding here.

21:42

Which again is not, is a little bit subtle.

21:46

So we can bring up my polling question.

21:50

And I just wanted to ask everybody, what do you

21:52

think is the most common cause of lower GI bleeding?

21:55

Is it diverticular disease, colon carcinoma,

21:58

internal hemorrhoids, or inflammatory bowel disease?

22:03

And let's see, um, five of you said diverticular

22:07

disease and that is the correct answer.

22:09

Uh, two of you said colon cancer,

22:11

five said internal hemorrhoids.

22:12

Internal hemorrhoids are a close second

22:14

to diverticular disease and inflammatory

22:17

bowel disease is not as common as others.

22:20

Um, the question, one question for this

22:22

was, was any source of bleeding detected?

22:24

And yes, we did see the diverticular disease

22:26

is likely the source here, given the

22:29

diffuse diverticulosis that this patient has.

22:32

And in fact, he had had five

22:34

previous diverticular bleeds.

22:36

That were documented in his chart.

22:38

In this particular case, if all of the bleeding had

22:41

been sigmoid, one might think that they might do a

22:44

resection, but his diverticulosis was quite extensive.

22:48

So it would probably require a colectomy to make

22:50

sure he didn't actually have that happen again.

22:52

And do we do five millimeter cuts?

22:54

We actually do.

22:55

We have five millimeter cuts and we have the thin cuts.

22:58

So it's, it's actually an interesting question.

23:00

These are the thicker cuts.

23:01

Would we see this bleed better

23:04

on something that was thicker?

23:06

You can see it here.

23:09

And this is also the five millimeter cuts.

23:12

And you can see it here.

23:13

So maybe in this case, you might

23:15

see it a little bit better.

23:15

I tend to look at both sets of

23:18

images whenever I have a question.

23:20

Um, we, we do both.

23:22

And then our, our reformats, I showed you a MIP.

23:26

Um, in this particular case, since it was

23:27

ordered as an arteriogram, we don't have

23:29

our regular sagittal and coronal reformats,

23:31

but those are three millimeters generally.

23:33

And they're not in a MIP projection usually.

23:36

Okay.

23:38

So that was a case of a good call.

23:41

So we try to show a mixture of good calls and

23:44

misses when we do our peer review conference.

23:48

All right, let me pull the next case up.

23:52

All right.

23:53

So, um, this patient is a 55-year-old female,

23:58

she has known cirrhosis, and she's getting carcinomas.

24:05

So I have several MR images.

24:08

Um, I don't normally do MR, although this was, so

24:10

this case was lent to me and I thought it was just

24:12

a very good case and had a good couple of good

24:14

teaching points, which is why I wanted to show it.

24:16

So I'll focus first on this T2 FATSAT.

24:21

So, um, as we're coming down here, the patient

24:25

doesn't, her liver doesn't actually look that bad.

24:28

I mean, she has maybe slight

24:30

enlargement of the lateral left.

24:32

Her caudate may be slightly prominent, but

24:35

she does have risk factors for hepatocellular

24:38

carcinoma, so she was undergoing surveillance.

24:42

Um, spleen not too big.

24:44

I don't see any ascites.

24:46

There really wasn't anything in her liver.

24:48

She has a renal cyst,

24:52

I'm going to just stop here on this picture for a

24:54

moment, and then I'm going to show you another set.

24:59

Okay, so this was her fat-saturated

25:03

pre-contrast T1 weighted set.

25:07

So again, her liver doesn't look too bad.

25:13

You see that cyst again in her kidney.

25:17

Let's come back up here.

25:24

Um, somebody asked me, did we do a virtual non-

25:26

contrast from, from, if we do, um, DECT?

25:31

Um, if we do dual energy for any of our, um,

25:37

our GI bleeds, yes, we can do virtual

25:39

non-contrast, which is very helpful.

25:41

And that particular case was not done on our

25:43

dual-energy scanner, so we could not do that.

25:47

Anyway, back to this case, I'm

25:48

going to pause here for a moment.

25:51

And then this is the post-contrast, or one of

25:54

the sets of post-contrast T1 weighted images

25:58

in a delayed phase.

26:00

You can see we have very dark

26:03

excreted gadolinium.

26:06

So this was a delayed phase.

26:13

I'm just going to pause there for a second.

26:18

All right.

26:18

So I've paused here on three different

26:20

images that are about the same level.

26:24

And then what I would like to do is

26:27

pull over the next set of images.

26:35

All right.

26:35

So here is an early arterial phase.

26:42

And then a little later

26:48

and a little later.

26:54

All right, so

26:57

hopefully you all can see that there is an abnormality

26:59

here in the pancreatic sort of body-tail junction here,

27:08

which enhances on a delayed phase here.

27:12

And I think it's probably the most subtle on this T2

27:16

FATSAT image, where you can see the pancreatic duct,

27:20

but there's an area where the duct is interrupted.

27:25

Let's pull up the polling case.

27:28

At what stage are most pancreatic cancers detected?

27:33

So somebody thought it might be a

27:34

pancreatic cyst, but that's a good thought.

27:37

All right, and most people thought stage three.

27:40

Actually, it's stage four.

27:42

Most of the time, they're unresectable and have spread.

27:46

So, um, it's not unfortunately stage one

27:50

or stage two when they might be resectable.

27:52

So yes, the answer for this is pancreatic carcinoma.

27:55

This one did turn out to be an adenocarcinoma.

27:58

It was resected.

28:00

So there's a couple of things to think about here.

28:02

Any interruption in the pancreatic

28:04

duct, you really need to look very

28:05

carefully to make sure that there's not

28:09

a mass.

28:10

Now, most of the time when we think about it,

28:12

the, the, one of the earliest signs of pancreatic

28:15

carcinoma, since it's an adenocarcinoma, it's ductal.

28:18

It starts in the duct.

28:19

You expect to block the duct and

28:21

get upstream ductal dilatation.

28:23

And eventually, you get atrophy of the pancreatic

28:26

tail or body, whatever the upstream pancreas.

28:30

Every once in a while, if you can pick it up really

28:32

early, you haven't seen that upstream dilatation yet.

28:36

You just have an interrupted duct.

28:39

And you can have that abrupt cutoff again

28:41

with or without the upstream dilatation.

28:44

It's a lot easier to see when you

28:45

do have that upstream dilatation.

28:47

In this case, because the patient was

28:49

undergoing surveillance for her risk

28:51

factors for hepatocellular carcinoma,

28:54

she was scanned again within six months, and

28:56

fortunately for her, her cancer remained

28:59

localized to her pancreas, and she got to

29:02

have it resected to find stage one cancer.

29:06

We don't screen for it.

29:08

There's not a good way to do that.

29:09

The patient will have to present with

29:11

symptoms referable to the tumor, you know,

29:13

abdominal or back pain, weight loss, jaundice,

29:17

something that would make you do a study.

29:19

If they have recent onset diabetes or have an episode

29:23

of pancreatitis, those could also indicate that

29:26

there's a pancreatic carcinoma underlying there.

29:28

But unfortunately, we really don't

29:29

find it very often at that early stage.

29:32

In this case, another way to find it at

29:35

an early stage is to find it incidentally.

29:37

So this was completely irrelevant

29:39

to why she ended up getting scanned.

29:42

So when would I suggest a pancreatic biopsy?

29:46

Um, that's a good question.

29:49

I guess, I mean, if you think something is

29:56

When do I, I don't do very many pancreatic biopsies,

30:01

um, but when would I suggest a pancreatic biopsy?

30:03

Often, I mean, I think you see the pretty typical

30:07

findings, if you see things that are pretty typical

30:08

for pancreatic adenocarcinoma, if you see the ductal

30:13

dilatation, the pancreatic atrophy, if you see

30:15

that it's extended beyond the confines of the

30:18

pancreas and starts expanding surrounding the SMA,

30:21

the hepatic artery, it starts portal involvement.

30:26

If it's pretty typical for pancreatic

30:27

adenocarcinoma, they'll often get, especially

30:30

in EUS and a biopsy, just so they can start

30:34

the appropriate chemotherapy and radiation.

30:36

Usually, they want a diagnosis

30:37

prior to doing any kind of therapy.

30:41

In this particular case, I don't

30:42

think we would do a biopsy.

30:44

I don't think this would be easy to biopsy

30:46

because of the stomach and surrounding structures.

30:48

If they could possibly get to it with EUS, maybe

30:51

transgastric, they might do a biopsy in that

30:54

case to decide whether or not you want to do

30:58

some sort of chemotherapy or something first.

30:59

I think if the findings are pretty typical for

31:01

adenocarcinoma, you would biopsy if it's going to change the

31:04

management of the patient, if you're going to start

31:05

radiation and/or chemotherapy first, if it looks

31:09

like something that's obstructing the duct and.

31:13

It looks like it's confined to the pancreas, often

31:15

they'll, you know, you might just go in and take it

31:17

out knowing that you probably need to do that anyway.

31:20

So you may not have a biopsy first

31:21

if it looks like it's resectable.

31:24

All right, let's move on to our next case.

31:29

All right, our next case is an 87-year-old.

31:32

And she is coming in for a six

31:35

month colon cancer follow-up.

31:37

So she had her resection six months previously, and

31:41

this is her first follow-up following that resection.

31:46

So I'm going to start here.

31:58

All right, so we've run all the way through there.

32:01

Come back up here.

32:06

All right, I'm going to give

32:07

you the coronal image as well.

32:13

Actually, sorry, this is the sagittal, not the coronal.

32:24

And this is the coronal.

32:32

All right, I'm going to go back to that axial here.

32:37

So she's had her right colon resected.

32:39

We can see that there's some suture material here.

32:42

So she's had an ileotransverse colon anastomosis.

32:52

So let's pull up the polling question here.

32:55

So the polling question is: What's our

32:56

best diagnosis in this patient's six

32:58

month status post right hemicolectomy?

33:01

So this is just normal post-operative,

33:03

expected post-operative change.

33:05

She has an abscess, colitis, or does anybody

33:09

think this could be recurrent carcinoma?

33:12

And let's see.

33:14

All right, we have three votes for abscess, three

33:16

votes for colitis, and four votes for recurrent cancer.

33:19

I'm glad nobody thought this was a

33:20

normal expected post-operative change.

33:23

All right, so let's look at this a little more closely.

33:26

We certainly have an area of the colon near the

33:30

anastomosis that looks a little dilated potentially.

33:35

There's some low-density material, there's air in it.

33:41

Sometimes when we have bowel anastomosis,

33:43

especially small bowel anastomosis,

33:45

you get kind of a localized ileus.

33:47

So you get a little bit of dilatation

33:49

at the site of an anastomosis.

33:51

So I think that's what the

33:53

person who read this thought.

33:55

Was going on, that this was just a little

33:57

dilatation at the site of where the patient

33:00

had their anastomosis, especially since the

33:03

patient was only six months out of surgery.

34:05

And, you know, just didn't think that

34:07

this could possibly be anything else.

34:11

The patient ended up coming back about six weeks later,

34:15

and I'm going to pull up an image from that study.

34:18

Whoops, not all images.

34:20

This one.

34:21

Here we go.

34:23

Six weeks later, the patient looks remarkably

34:26

similar, maybe even a little bit larger area here.

34:31

And at this point, this was called colitis

34:33

was called abnormal but thought to be colitis.

34:37

Unfortunately, um, at this time, well, or

34:41

fortunately, the physician who was taking

34:44

care of this patient called the person who

34:46

read this exam and said, you know, I just saw

34:49

this patient in my office and I palpated the

34:52

patient's abdomen, and it's really hard there.

34:55

It feels like there's a mass.

34:57

So they went back and looked at this again.

35:00

And this is actually a recurrence at the

35:03

anastomosis within six months of her original

35:07

presentation, which is unfortunate for her.

35:10

She did have, she went back in and they re-resected it.

35:13

At this point, you'll also notice

35:16

that her small bowel is dilated.

35:19

So at this point, it's actually caused a

35:20

small bowel obstruction as well, which is

35:23

what prompted her to come back after that.

35:25

Six weeks and get re-examined.

35:27

So this unfortunately was a recurrent cancer.

35:30

So something I'd like to say about this is that

35:32

sometimes looking at the original scan, going

35:35

back as far as you can to see if you have any

35:37

preoperative evaluation, is really helpful.

35:40

So I'm going to pull up, this is

35:42

the patient when she presented.

35:45

The six months previous.

35:46

This is preoperative.

35:47

So you can see she also at this

35:49

point has a bowel obstruction,

35:54

and the bowel obstruction is secondary to a

35:56

mass that was in her right colon, right near her

36:00

ileocolic anastomosis, or ileocecal valve, sorry.

36:05

So if you look really carefully at her original

36:07

tumor, you can see how much necrosis there

36:10

is in it, sort of peripheral enhancement

36:12

and a lot of maybe even mucin or necrosis.

36:15

It looks a lot like her recurrence, so I think

36:18

knowing what the primary tumor looks like will help

36:21

you decide whether something is a recurrence or not.

36:24

I think it's very helpful to know what that looks like.

36:27

It might help you differentiate something that's

36:29

a metastatic lesion versus something that's not.

36:36

It, it, it will help you decide if something else

36:38

that pops up, say, you know, in the liver, if we

36:40

suddenly had a hypervascular lesion in the liver

36:43

in this particular patient's case, I think we

36:45

would be less likely to call that a metastatic

36:47

lesion, knowing what her primary looks like.

36:51

Um, so the question is, do I follow the

36:53

AJCC surveillance schedule for colon cancer?

36:57

Um, that's a good question.

36:59

I'm, I, I'm not sure, to be honest with you,

37:03

I don't know what they do at the institution.

37:06

I've just, I've relatively recently moved to this

37:08

institution and I'm not, I'm not sure if they're

37:10

following the AJCC surveillance schedule or not.

37:14

If oral contrast was used instead of negative

37:16

contrast, they would not have missed it.

37:19

That's a very good point.

37:21

So, um, a lot of our scans are

37:23

done with positive oral contrast.

37:26

And if the positive oral contrast had been allowed

37:28

to reach this area, especially on that first scan

37:31

when the patient did not have a bowel obstruction,

37:35

I think it would have been very obvious that

37:37

this had nothing to do with the bowel itself.

37:40

It was, it has something to do

37:41

with the bowel but wasn't a lumen.

37:43

It was actually recurrent, so I agree with you.

37:46

The issue is in our emergency department,

37:48

our patients generally don't get

37:52

oral contrast, at least positive oral contrast.

37:54

And if this patient came through the emergency

37:57

department, she would not, they would not have

37:59

waited to give her positive oral contrast.

38:01

If, um, in this case, though, for some reason,

38:05

she did not get positive oral contrast.

38:07

And I don't know why, because it was

38:08

a six-month scan for her follow-up.

38:10

And I don't know why it would

38:11

have been prescribed that way.

38:13

It's also possible that the

38:14

patient declined oral contrast.

38:17

But in this case, you're absolutely right.

38:19

Positive oral contrast would have been very helpful.

38:24

All right.

38:26

So our next case is a 48-year-old female,

38:30

and she has an elevated testosterone.

38:33

So she's being scanned for an

38:35

abnormal laboratory value, basically.

38:41

You can see she's had gastric bypass surgery here.

38:45

She did get positive oral contrast for some reason.

38:51

I'll just go back and forth there a little bit.

38:59

You can see she's, um, a little bit on the larger

39:01

side and there's a lot of noise in her scan.

39:12

All right, let's pull up the polling question because

39:13

then that'll inform where we need to look anymore.

39:16

So what organs do you need to look at?

39:18

Which ones produce testosterone, abnormal

39:21

testosterone in a female, or even just low

39:23

levels of normal testosterone for that matter?

39:25

The adrenals, the ovaries, the

39:27

thyroid, or adrenals and ovaries?

39:31

And the answer is correct.

39:32

A and B is the correct answer.

39:34

Eight of you said that.

39:35

Nobody picked thyroid, which is good.

39:37

So adrenals is correct and ovaries is

39:39

correct, but it's really both of those.

39:41

So when we got this abdomen-pelvis CT, we were really

39:44

looking to see if there was an adrenal nodule that we

39:46

could detect, or was there something in the ovaries.

39:49

So her adrenals look a little full.

39:52

You know, it's hard to know if this

39:53

is actually something discreet.

39:57

Um, I thought perhaps they would need to do

39:59

adrenal vein sampling if we thought that it

40:02

could be coming from the adrenals, but let me

40:04

go ahead and skip down to the ovaries here.

40:08

So this is a case that was considered a good call.

40:12

So here's her uterus.

40:14

Here's the right ovary.

40:15

And here's the left ovary.

40:17

And if you look very carefully at that

40:19

left ovary, there's something here that's

40:23

a little bit brighter and rounded here.

40:27

And let's see if we can, if I change the

40:30

windowing a little bit, I think I can bring

40:32

that out even a little bit more, that there

40:34

looks like there's something in the ovary.

40:38

So she actually ended up having an ultrasound

40:41

that same day, which unfortunately,

40:45

she's a little on the larger side.

40:47

Here we go.

40:51

As we come down to that,

40:56

you can see this brightly enhancing lesion

41:02

in her ovary there.

41:04

So she had this

41:05

ovary resected.

41:07

And what they found was a, what's called

41:12

a steroid cell tumor, which is the

41:17

source of her elevated testosterone.

41:20

So basically the call on the CT was this could

41:23

be an acutely hemorrhagic cyst because she is

41:26

still of, um, a menstruating-age female, or it

41:31

could have been a solid mass that was enhancing.

41:33

So it could have been a little bit dense

41:35

because it was acute hemorrhage, or it

41:37

could have been an enhancing solid lesion.

41:39

So the MRI was done to show that this

41:41

was actually an enhancing solid lesion.

41:44

And that was resected in the

41:45

source of her testosterone.

41:49

All right, so that was a good call.

41:56

This is a 77-year-old gentleman that

42:00

presented with right lower quadrant pain.

42:13

So, I can see that he has a normal appendix here.

42:20

He's got some diverticulosis, a little

42:23

bit, but nothing much going on there.

42:29

Kidneys are enhancing symmetrically.

42:32

Pancreas looks okay.

42:34

Liver may be a little fatty, hard to

42:35

tell sometimes on a post-contrast exam,

42:39

except that perhaps we have a little bit

42:41

of areas of sparing here.

42:42

So

42:47

Yes, he's got an aneurysm of his iliac, but really

42:50

nothing that's causing his right lower quadrant pain.

42:55

But I'm going to pause

42:55

on this.

42:57

Here.

42:58

All right.

43:01

So he came back four years later

43:05

with left lower quadrant pain.

43:10

Yeah,

43:11

somebody, somebody's text it put in the chat box there.

43:14

So he comes back with left lower quadrant

43:16

pain, and this is four years later.

43:20

And we can see this

43:22

area a little more clearly here.

43:25

So let me go back to that first one.

43:31

And you can see that there is a little lobulated

43:33

lesion here, but that was not detected.

43:37

Uh, we have a coronal as well.

43:48

It's, it's not really well seen on the coronal.

43:50

It's really better seen on here.

43:54

A little lesion here.

43:56

This was not causing the patient any symptoms.

43:58

He had no known hematuria.

44:00

So this was just read as, as no

44:01

source of right lower quadrant pain.

44:03

The bladder itself was not

44:05

specifically mentioned in the report.

44:08

On this one, this was noted.

44:12

And fortunately for this patient, it turned out even

44:15

though it was a high-grade tumor, it was non-invasive.

44:18

So let's pull up the polling question.

44:22

So I wanted to know if people know what

44:24

differentiates a T1 from a T2 bladder carcinoma.

44:28

T1 confined to the urothelium and T2 invades the lamina

44:32

propria, or T1 is confined to the lamina propria and

44:35

T2 invades the muscle, or T1 is confined to the muscle

44:39

and T2 invades the perivesical fat, or T1 is confined

44:43

to the perivesical fat and T2 invades adjacent organs.

44:47

Does anybody know what, what differentiates

44:50

the T1 from the T2 bladder carcinomas?

44:54

And most of you got that correct.

44:56

T1 is confined to the lamina propria

44:58

and T2 invades the muscle layer.

45:01

TA is confined to the urothelium.

45:04

So that's, that's very good.

45:05

So fortunately for this patient, it, despite

45:07

the fact that it was high-grade, it was slow

45:09

growing, and the patient was able to be resected

45:12

with a TURBT four years later, and is now

45:15

just undergoing routine surveillance for that.

45:18

All right.

45:20

This case is a 73-year-old man

45:22

who had known bladder calculi.

45:25

So this was done on our dual-energy

45:27

scanner, looking to characterize

45:29

his calculi.

45:36

So you can see there, he's got a nice collection of

45:39

calculi there in the bladder.

45:41

He's got a little air in the bladder,

45:42

probably from instrumentation.

45:45

Prostate gland is not big overall, but maybe a little

45:48

big centrally, maybe some central hypertrophy there,

45:53

causing a little stasis and outlet obstruction.

45:56

Definitely has

45:56

diverticulosis.

46:00

It's going to come back up here.

46:06

All right.

46:08

So I'm going to pause right there.

46:11

And then I'm going to give you the,

46:17

this is the patient's coronal imaging.

46:20

So we can again see that collection of bladder stones.

46:27

I'm going to pause right there.

46:29

Yeah, so one of the attendees

46:31

suggested that this might be a renal cell carcinoma.

46:34

So a couple of things we might want to talk about that.

46:37

So,

46:40

first of all, I should say one should never trust

46:42

their eyes necessarily for density of something.

46:45

I think it's really important.

46:47

To always take a density measurement

46:49

on something if you're unsure.

46:50

I mean, I can make a really small circle here and I

46:53

can get 15, so that would be under 20, but there are

46:58

parts of this that are over 20, so 25, 27, 28, 26.

47:05

So this is not a homogeneously hypodense object.

47:10

This is heterogeneous.

47:12

There's definitely some heterogeneity

47:13

to the internal content of this.

47:15

Unfortunately, this was called a hemorrhagic,

47:18

I mean it was called just a simple cyst.

47:20

It was just dismissed as a simple cyst, you know, not

47:23

even didn't even make the impression of this case.

47:27

Um, fortunately for the patient because it's

47:31

predominantly cystic, when they came back

47:34

for a completely unrelated study, which was

47:38

an angiogram.

47:43

I think we can all see that this

47:45

is a lesion that is actually

47:47

enhancing here.

47:49

It's complex, has some solid components, although

47:53

it is still predominantly cystic or necrotic.

47:56

So, in this particular case,

48:03

the lesion was still confined to the kidney.

48:09

So it had not been upstaged in the interval

48:12

between when it was called a simple cyst and here.

48:16

So let's pull up the last question here.

48:19

So I want to know what percentage of Bosniak

48:22

three cysts are expected to be malignant

48:24

according to the latest 2019 guidelines.

48:28

I'm not saying this is a Bosniak three cyst,

48:30

I'm just asking about Bosniak three cysts.

48:35

And the correct answer is 50 percent of Bosniak

48:38

three cysts are expected to be malignant.

48:40

It's about 90%, hopefully a Bosniak four.

48:43

So the other things I mean, the other teaching

48:45

points here is, I think, there's kind of a sense

48:49

that this actually has a perceptible wall as well.

48:52

The cyst walls, if this were a simple

48:54

cyst, are barely perceptible, if at all.

48:58

And then again, the heterogeneity.

49:00

And if you're unsure at all, just put

49:02

a Hounsfield number on it, because you

49:04

should be able to move a small box around.

49:06

And if it's heterogeneous, it's not

49:07

going to be 20 everywhere, 10 everywhere.

49:10

It'll change like this one did.

49:11

Areas of 15, areas of 25, areas of 28.

49:16

Um, so again, any heterogeneity,

49:19

you cannot call as a simple cyst.

49:21

If the patient couldn't have contrast material,

49:24

you could do a contrast-enhanced ultrasound,

49:26

or even just start with a regular ultrasound.

49:28

You might be able to detect Doppler flow

49:30

within the lesion, even on a general

49:32

ultrasound without having to get contrast.

49:34

But we give a lot of contrast in

49:37

lesions like this at our practice too.

49:40

That was my last case.

49:41

It's exactly five o'clock.

49:43

If there are any other questions,

49:44

I'd be happy to entertain them.

49:46

Otherwise, I thank you so much for coming on

49:49

this journey with me and showing, uh, letting

49:52

me show some of our peer learning cases.

49:55

There are misses, there are good calls, but we

49:58

need to, uh, change our culture so that we're

50:00

willing to share with each other and learn from

50:02

each other by showing these kinds of cases.

50:05

Uh, thank you.

50:06

I'm glad you learned something and thank you very much.