0:02

Hello and welcome to Noon Conference hosted by MRI

0:05

Online. We created Noon Conference when

0:08

the pandemic hit as a way to connect the

0:10

global radiology community through free, live

0:12

educational conferences accessible for all.

0:15

It's become an amazing weekly opportunity to

0:17

learn alongside radiologists from all around the

0:20

world, and we encourage you to ask questions and

0:22

share ideas to help the community learn and grow.

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You can access the recording in today's

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conference and previous Noon Conferences

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by creating a free MRI Online account.

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You can also sign up for a free trial of

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our premium membership to get access to

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hundreds of case-based micro-learning courses

0:39

across all key radiology subspecialties.

0:42

We've partnered with Osmosis and the

0:44

National Organization for Rare Disorders

0:46

to drive awareness of uncommon diseases

0:48

that affect millions of people worldwide.

0:50

As part of this initiative, we've created a free

0:52

course highlighting diagnoses from the NORD database.

0:56

And today, we're honored to welcome

0:58

Dr. Mahan Mathur, who will be reviewing rare

1:00

disorders in an interactive case review.

1:02

Since 2013, Dr. Mathur has served as faculty

1:05

at the Yale School of Medicine, where he's

1:07

an Associate Professor of Radiology and

1:09

Biomedical Imaging and Vice Chair of Education.

1:12

He's previously served as Director of Medical

1:14

Student Education and Radiology, Associate

1:16

Program Director for the Diagnostic

1:19

Radiology Residency and Chief of Body Imaging.

1:23

Dr. Mathur is passionate about radiology

1:25

education and mentorship, and has been the

1:27

recipient of the RSNA Honor Educator Award in

1:31

2017 and 2021, as well as numerous departmental

1:35

Teacher and Mentor of the Year awards.

1:38

Over the next hour, Dr. Mathur may ask you

1:40

to submit your thoughts in the chat box.

1:42

If you have questions, please remember

1:43

to use the Q and A feature to submit them,

1:45

so we can get to as many as possible.

1:48

With that, we're ready to begin today's

1:49

lecture. Dr. Mathur, please take it from here.

1:52

Thank you very much for the kind, uh, introduction.

1:56

Let me start sharing my desktop.

2:00

We'll start with this.

2:02

So, um, really warm

2:03

welcome to everybody here.

2:05

You know, I'm always, um, so humbled by how

2:08

many people take the time, um, out of their busy days to

2:11

come and spend an hour, um, you know, with, uh,

2:15

with any sort of lecture, but certainly with me.

2:18

And as I was sort of scrolling through

2:20

some of the participants, there's one

2:21

or two names that I recognize.

2:23

So, uh, special greetings to those who

2:26

I've crossed paths with in the past.

2:28

It's so nice to see you here.

2:29

And so, um, as was said, today I'll be,

2:31

uh, doing something a little bit different,

2:33

um,

2:34

from some of the other conferences we've done for the

2:36

noon, uh, noon hour, um, where we're gonna go through

2:39

some uncommon, uh, disorders and body imaging problems.

2:42

So some gastrointestinal-related, some GU-

2:44

related, and we're gonna go through cases.

2:46

I'll be scrolling through them, and, uh,

2:49

you know, I, I'm not gonna use poll everywhere.

2:51

Um, I know probably the majority of the world likes it.

2:54

Um, I, I find it, uh, I'm not very good at

2:57

multiple choice, and so I don't like doing that

2:59

stuff, but I love, sort of, interacting, and so

3:01

type in your thoughts as we go through it.

3:03

Um, and the idea here would just be to

3:05

engage with each other and with all of us, so we

3:07

can learn together and get something out of this.

3:09

And so, this is a group

3:11

that we work with at Yale.

3:12

This is handsome Dan, our Yale mascot.

3:15

And, um, the outline is really— what we're gonna

3:18

do is really take cases out of this, uh, National

3:22

Organization for Rare Disorders database called NORD.

3:25

This is something I didn't really know about.

3:27

And so this was, um,

3:29

brought to my attention that this exists.

3:31

This is a link over here.

3:32

Um, I have no affiliation with this.

3:34

I'm just sort of providing you the link, and

3:37

there's over a thousand entries in this database.

3:40

Um, and you may be wondering what a rare

3:42

disorder is, because, you know, what may

3:44

be rare for me may not be rare for

3:47

somebody else in the audience and vice versa.

3:49

And there's a definition, and these are,

3:50

these are cases — this database is sort of,

3:53

um, takes into account the

3:56

diseases that we see in the United States.

3:58

So, a rare disease is something

4:00

that affects fewer than 200,000 Americans.

4:03

Um, but, you know, and, and, and so some

4:05

may be very rare, maybe case reports, right?

4:07

But, but a lot of the stuff that we'll see will

4:09

be things that, you know, we don't see every day.

4:11

But, uh, depending on the practice you are, maybe

4:13

you'll see a little bit more than, than others.

4:15

Okay.

4:16

And the way they, um, sort of have the

4:17

database, if you go to that website,

4:19

they have it, uh, alphabetically, and they

4:21

have some that start with the numbers.

4:23

And so you can click on any of them.

4:24

They have a whole list of diseases there.

4:25

And so.

4:27

Maybe, uh, somebody in the audience is wondering,

4:29

how did I go about picking, uh, some cases?

4:32

Um, I, I thought about that myself.

4:34

And the, the way I went about doing it was I

4:37

looked at my family members, uh, got their initials,

4:40

first name, and I just picked those letters.

4:43

And so I'll be presenting you

4:44

cases, uh, uh, based on that.

4:46

So, uh, if, I don't know if that helps anybody in

4:48

the audience, but, um, certainly that was my process.

4:51

And there's a lot of cases here, and obviously they

4:53

wanted, I wanted them to be pertinent to body imaging.

4:55

There's a lot of stuff here with neuro and MSK.

4:58

It's a really interesting

4:58

resource that, uh, that they have.

5:00

Okay.

5:01

Uh, that's enough of me sort of giving a rambling.

5:03

I know you're here D cases.

5:05

And so, uh, I have about seven today.

5:07

We'll see if we can get through them.

5:08

Maybe we get through them all in 30

5:09

minutes and, and we'll have a, you

5:10

know, uh, some engagement after that.

5:12

But if we don't, um, we'll see what we can get

5:14

through, uh, in the next, uh, 50 minutes or so.

5:18

So these are all anonymized.

5:19

Um, and so the ages, gender, all that stuff is all,

5:23

uh, sort of, uh, you know, uh, modified a little bit.

5:27

Uh, but here we go.

5:27

And not giving you much history,

5:29

but we'll work through it together.

5:30

37-year-old male, right?

5:33

Comes in with renal failure, got

5:35

an ultrasound, saw something.

5:36

They wanted to get, um, CT

5:38

scan to further evaluate this.

5:48

And so, I don't know about your

5:49

institutions, but our institutions, anything

5:53

to do with the kidneys, our urologists, if they

5:57

get involved, love doing hematuria protocols.

5:59

And so I'm gonna give you a hematuria protocol today.

6:02

And so also, let's start off with a non-contrast,

6:03

like how you would evaluate any hematuria protocol.

6:07

I'll sort of scroll through it

6:09

and at any time if people, um.

6:12

I wanna chime in on things.

6:14

Feel free to, uh, use the chat box.

6:16

I'll try to be respectful of scrolling

6:19

through, going through things and

6:21

addressing, uh, some of the comments.

6:24

Perhaps focus on the pelvis.

6:37

We'll scroll back upwards.

6:41

And I'll tell you that the ultrasound saw, uh, they

6:44

couldn't find the left kidney and they saw a mass

6:46

in the pelvis and they thought that was the kidney.

6:48

And so they were sort of looking at,

6:50

uh, this hematuria protocol to help

6:52

them figure out what's going on.

6:55

And so this is the, uh, nephrographic phase.

6:58

We do this at about 90 seconds after giving contrast

7:00

at our institution, 90 to 100 seconds.

7:02

We just go through the abdomen.

7:08

And finally.

7:12

We will have the excretory phase over here.

7:21

So we do this at about eight to 10

7:22

minutes after, uh, giving contrast.

7:25

We hope that our ureters are filled with contrast.

7:27

In this case, they are filled.

7:33

Let's go all the way down here, down to the bladder.

7:46

And just for the sake of completion, I'm going to put

7:49

this sort of on modified, uh, bone windows here a

7:54

little so you can kind of see through the contrast.

7:57

'Cause I know that we're doing this

7:58

as a hematuria, even though that's

8:00

not what the patient presented with.

8:02

You wanna make sure you look at the collecting

8:03

systems and the bladder for any filling defects.

8:05

And so.

8:10

There you have it.

8:13

So what do we think this mass in the pelvis is?

8:22

And if anybody wants to see any

8:23

other of the sequences, feel free

8:24

to, um, say that in the chat box.

8:27

I'm happy to, uh, to sort of put up any

8:31

other sequences we have with some reformats.

8:33

Uh, some may find that useful.

8:36

So, young patient, renal issues.

8:39

Couldn't

8:40

find the kidney on the ultrasound.

8:44

Found something in the pelvis, thought it was a mass.

8:49

We

8:49

have it on the hematuria protocol here.

8:53

Certainly is a mass, and they thought that

8:54

was a kidney actually on the ultrasound.

8:55

But is it, uh, is it the kidney?

8:57

Is it a weird kidney?

8:58

Is it something else?

9:00

How can we.

9:01

What's the approach here?

9:03

So, let's see.

9:03

Sacrococcygeal neoplasm.

9:06

Okay, so here are we getting, I

9:07

appreciate, you know, by the way, I always

9:09

appreciate the first two or three people.

9:10

Uh, well, I appreciate everybody, but the first two

9:12

or three people chiming in, 'cause, um, it often

9:15

takes, uh, the first couple to get the ball rolling.

9:17

And so I'm often not one of those

9:19

people who chime in initially.

9:20

So I, I'm very appreciative of, of

9:22

the few that have chimed in already.

9:24

So, let's see.

9:24

This is the coronal reformats.

9:27

I think it's a very reasonable, uh, ask.

9:31

Perhaps you can see the relationship of what this

9:33

thing is to the bladder on that and to the ureter.

9:37

See if it's arising from it,

9:41

the other chat box.

9:44

Okay.

9:45

Germ cell neoplasm.

9:46

Okay.

9:46

Seminal neoplasm.

9:48

We have seminoma up there.

9:50

Um, a, uh, multicystic dysplastic kidney, etc.

9:54

Topical.

9:54

That's an interesting thought.

9:55

So maybe the kidney's down there and that it

9:56

looks, uh, and it's really abnormal pelvic GIST.

9:59

I think that's, uh, it's a very good thought.

10:01

Um, cystic RCC, ectopic or renal cancer.

10:03

Yeah.

10:04

So these are all really, really good thoughts.

10:05

Zinner.

10:06

Oh my goodness.

10:06

I think I saw a case of Zinner the other day.

10:09

Um, I've been looking for a good one.

10:11

Um, so let's, uh, these are some

10:13

really good, good thoughts over here.

10:16

And we have somebody as well,

10:17

uh, on the other Q and A feature.

10:18

Midline mass.

10:19

Germ cell, left kidney atrophic, ureterocele.

10:21

Okay.

10:22

So I'm just reading stuff out, uh,

10:23

now and, and we will go through this,

10:25

but I really appreciate the engagement.

10:28

And, uh, what else do we have

10:30

for left atrophic kidney?

10:31

Yeah, I'll say that.

10:33

Um, yeah, vesical.

10:36

Someone's asking as well.

10:37

It's a good thought.

10:38

So I'll say, you know.

10:40

There is one person in the chat box who actually

10:43

is, I would say, on the right track, one person.

10:47

Um, I'm not gonna reveal who that is yet.

10:50

And there's others who are getting close.

10:52

And, uh, and, uh, why don't we start going

10:55

through the case together and as I go through

10:58

it, feel free to chime in so you can, um.

11:01

You can always see the, the, the answer, the

11:04

final answer before the final answer is revealed.

11:06

Right?

11:06

And so one of the correct things I think a few people

11:08

have noticed, I know it's tough when I'm scrolling,

11:11

is that, uh, the left kidney is atrophic here.

11:13

You can actually see it right over there, right?

11:15

So very, very atrophic left kidney.

11:18

Um, and so, uh.

11:20

I think some people had talked about maybe

11:21

a kidney that was a pelvic kidney or, or,

11:23

or something that was an ectopic kidney.

11:25

Um, I think that's a good thought.

11:27

But, um, in this case, you know, if you, if you had

11:29

missed the, uh, initial few slices, you can see that

11:32

kidney's actually present, but very, very atrophic.

11:34

And it is enhancing a little bit,

11:36

but really not excreting anything.

11:37

So really not functioning any, uh, very well.

11:40

The other thing that, uh, a common, uh, theme

11:43

that has been brought up I think is a GIST tumor.

11:45

I think it's a very reasonable thing.

11:47

So I'm gonna put that aside for the

11:48

moment as perhaps a differential, like

11:50

a mes— you know, like a, a pelvic GIST.

11:52

Um, doesn't really seem to be arising

11:55

from any bowel loops, but, uh, GIST can

11:56

arise within the mesentery wall rarely.

11:58

So that's a possibility.

12:00

Another common theme that's come up

12:01

with some of the comments has been

12:03

things arising from the seminal vesicle.

12:05

I think it's a really good thought.

12:07

Um, so let's look at the seminal vesicles here,

12:10

and certainly we can see the right seminal vesicle.

12:14

Maybe I'll put up the non-contrast as

12:15

well, 'cause that goes down to the pelvis.

12:17

We can see the right seminal vesicle.

12:19

Reasonably well.

12:21

One thing that I don't see very well, and maybe

12:23

this is why someone, uh, went down that pathway, I'm

12:26

not quite seeing the left seminal vesicle very well.

12:28

Maybe it's absent and, uh, maybe it's atrophic.

12:32

But certainly in the cases of seminal vesicle

12:35

masses, the couple that I've seen, or Zinner

12:38

syndrome, the one that I've seen in the

12:39

books and stuff, usually the mass is sort of,

12:43

broadly in the shape of the seminal vesicle.

12:45

Usually it's more sort of

12:46

towards the left hemipelvis.

12:47

This is a little bit towards the midline,

12:50

and so I think it's a good thought to see

12:52

if it's something arising from the seminal

12:53

vesicle, but not quite in this case.

12:56

Another couple of thoughts that

12:57

came up: is this arising from ureterocele?

12:58

I like that thought.

12:59

I think it's always a good thing to think about when

13:01

you see a mass sort of lying atop the bladder.

13:03

You know, it doesn't really look like,

13:05

uh, it's arising from the bladder.

13:07

It looks like it almost has mass effect, and

13:09

you may even see a thin fat plane over there.

13:10

So what else do we have here?

13:12

Urachal complex paraganglioma.

13:13

Adding to differential.

13:14

Yeah, good thought.

13:15

You know, um, can't forget a paraganglioma, right?

13:17

Arising from the, um, organ of Zuckerkandl in particular.

13:19

Usually that's right around the IMA takeoff, so

13:22

I would expect that to be a little bit over here.

13:24

But, um, ovarian pseudomyxoma peritonei.

13:30

Oh, pseudomyxoma. I feel so bad.

13:33

I don't know what the H stands for.

13:35

Um, right off the top of my head,

13:37

desmoid tumor is also a possibility.

13:38

We tend to see desmoid in patients who are, um, you

13:42

know, with Gardner syndrome or have had prior surgery.

13:44

This person had a prior surgery.

13:46

And so, all good thoughts.

13:47

And I don't mean to sort of push away comments,

13:49

I just wanna try to work through why, um, you

13:52

know, they're reasonable, but not— but there is

13:54

a way to get the right diagnosis in this case.

13:56

So one clue that I mentioned is that the seminal on

13:59

the left side is, um, I would say atrophic to absent.

14:04

Okay.

14:04

The other clue I haven't seen in the chat box yet,

14:08

but I'm gonna start to scroll down a little bit.

14:11

Uh, now we're starting.

14:12

Okay.

14:12

Somebody wants to see something that I'm about to say.

14:14

So you got it just in the nick of time.

14:17

Let's look at this spermatic cord.

14:19

What's missing over here? At the right

14:22

side, you can see very nicely over here.

14:24

You don't see the spermatic cord on the left.

14:26

Okay.

14:26

Now can we start putting things together?

14:28

I think.

14:29

People have started putting

14:30

things together a little bit.

14:32

Whenever you don't see the spermatic cord,

14:33

a young patient hasn't had an orchiectomy,

14:35

gotta think of the possibility

14:37

of an undescended testicle.

14:38

Correct?

14:39

Fair enough.

14:40

And we've seen our share of undescended testicles.

14:41

Not very common, but what's the next step to figure

14:46

out if this is the undescended testicle or not?

14:48

Gotta look at the, uh, testicular veins.

14:50

And the testicular veins on the left side

14:52

typically will drain into the left renal

14:54

vein, and so we can go upwards again.

14:56

Now that left kidney is quite atrophic, but it does

14:59

have a renal vein and it's gonna come out right around

15:03

here, going down, going down, going down along the

15:08

top of the left psoas muscle, coming down here, coming

15:11

down here, going a little bit more medially now.

15:14

I'm going right to this mass, right?

15:17

So this is certainly a mass that's

15:19

arising in an undescended, or

15:22

in fact, maybe even ectopic testicle.

15:23

Given the location, and it looks really heterogeneous,

15:26

it looks like it has enhancing components.

15:28

This is a neoplasm that's arising

15:30

in an undescended testicle and, um.

15:34

So I think somebody in the beginning had talked

15:37

about, uh, and, and people are starting to chime in.

15:39

This could be a seminoma.

15:40

I find that very difficult to call prospectively,

15:42

whether it's a seminoma, but all we, all I

15:44

can say is, you know, is a testicular neoplasm

15:46

and, uh, in this case arising in a, uh,

15:49

in an ectopic, an undescended testicle.

15:52

And so, um.

15:54

Good on the group for kind of going through

15:55

that systematically, and let's have a few,

15:58

uh, a few, uh, uh, bullet points on this.

16:02

Um, and so, you know, we see these undescended

16:05

testicles from, from time to time, um, and we know

16:08

that there's some risk factors associated with them.

16:11

Uh, most worrisome of course, that risk of

16:13

malignant, uh, transformation and malignancy.

16:16

And it turns out that that risk is present

16:18

both in that, uh, undescended testicle

16:20

as well as the contralateral testis.

16:21

And it may be due to some underlying abnormal

16:24

embryogenesis that in some way affects both

16:26

testicles, even though one is actually quite ectopic.

16:29

And of course, the other risk is

16:31

the increased risk of infertility.

16:33

And so.

16:35

I remember, uh, looking at this case a couple

16:37

years ago and, you know, went through so

16:40

much of the same process, uh, that, that I

16:42

think everyone in the group has gone through.

16:44

Um, and right as I was about to close, you know, it's

16:47

one of those things and we've all been through there.

16:49

You close, right?

16:50

As you're about to close, you start to

16:51

notice, hey, something's missing here.

16:53

Oh, this is also atrophic and that's something

16:55

that's associated with cryptorchidism and raphes.

16:57

Then you look at the gonadal

16:58

veins leading right to it.

16:59

And I remember having this eureka moment

17:01

where I'm like, wow, this is, this may be the

17:03

first really, um, uh, uh, you know, exciting,

17:08

kind of wacky call, rare call, whatever, however you

17:11

wanna call it, that I make as a junior attending.

17:13

And so I never forgot that.

17:14

And so I wanted to share that with the group.

17:16

Um, and certainly appreciate the group's, uh,

17:18

engagement and dialogue and in working through that.

17:21

So I'm just gonna answer these questions live in my

17:24

Q and A feature so I can clear the box, and if it's

17:27

okay with the group, we'll move on to our next case.

17:29

I don't promise they're all gonna be as

17:30

exciting as this, but, um, but, uh, hopefully

17:33

it'll be exciting for some people.

17:38

Alright, so now, um, another young gentleman,

17:41

26-year-old male, right upper quadrant pain.

17:44

And this was interesting in that the patient

17:46

got a, I'll just tell you the history, got

17:47

a CAT scan showing, uh, no real abnormality.

17:50

They got an ultrasound where they

17:52

couldn't find the gallbladder.

17:53

They got a HIDA scan that showed

17:55

no uptake in the gallbladder.

17:57

Um, and so they were like, well, you know,

17:59

worried about cholecystitis potentially,

18:01

but, um, uh, because there's no uptake in

18:05

the gallbladder, but the, or potentially, you

18:08

know, the gallbladder was just absent, but

18:10

there's no history of prior cholecystectomy.

18:12

So they got another imaging

18:13

modality to sort of sort this out.

18:15

And that's what I'll share with the group.

18:24

Somebody's asking why renal failure when

18:25

the right kidney is working perfectly.

18:27

I think that, uh, I'm, I'm

18:30

not really sure to be honest.

18:31

I think that was just a history that was provided.

18:33

I think oftentimes we get these generic

18:35

histories, but, uh, they certainly, um,

18:38

we're not, uh, this is the second case.

18:40

Yes, somebody's asking, but certainly, uh,

18:43

perhaps the left kidney was, uh, dysfunctional

18:45

enough that, uh, it was affecting the

18:46

overall renal function in the patient.

18:49

So let me show the second case.

18:50

It's an MR, so there'll be a few more sequences

18:51

to look at and I'm happy to, you know, I'll

18:53

scroll through some select sequences and I'm happy

18:55

to, uh, scroll through more if the group wants.

18:58

Okay, so I'll start off with

18:58

a T2 fat-sat sequence.

18:59

Remember, this is a young patient,

19:01

uh, right upper quadrant pain.

19:02

Hi.

19:03

A scan showed no uptake in the gallbladder,

19:05

but, uh, you know, they weren't really worried

19:07

about clinically, about cholecystitis, but

19:10

the person also never had a cholecystectomy.

19:12

So they're just wondering what's going on with

19:14

the gallbladder, what's going on in this patient.

19:16

So here's the, um,

19:19

T2 fat, fat sequence,

19:29

right?

19:29

You can see a bunch of organs here,

19:30

spleen, kidneys, adrenal glands.

19:35

Probably just sort of hone your eyes to the

19:37

sorts of things that you may be worried about.

19:39

Given this history is the

19:41

coronal T2 image.

19:51

And, um, I'll show you a,

19:53

a MIP of the MRCP that helps at all.

19:58

These images didn't come out too great, I imagine.

20:00

So I'm not sure if this will help you,

20:01

but let's look at the, um, excuse me, the

20:04

T1 pre,

20:13

let's give you a post-contrast

20:14

sequence in the arterial phase.

20:15

There's gonna be a little bit of motion here, so

20:22

I'll say that I'm not sure

20:24

if the motion will affect. I don't think it should

20:27

affect your interpretation of what's going on.

20:31

There's no mass or anything that

20:33

I'm asking you to characterize.

20:34

It's just, uh, this is probably the best

20:36

sequence, portal phase at some of the other organs.

20:39

Again.

20:51

So the question they're really

20:51

asking is, you know what?

20:53

What's going on with the gallbladder?

20:55

Is it inflamed?

20:55

Is it missing?

20:56

He said no prior history of

20:57

cholecystectomy.

21:05

I see a few

21:08

people in the chat box.

21:09

I'm just gonna address that in

21:10

a second while I go through.

21:11

The final set of sequences I wanted to

21:13

share with the group is the in and out of

21:14

phase, out of phase on this side, in phase

21:16

on this side.

21:26

All right.

21:26

And there you have it.

21:27

So I'm just gonna put up, let's see.

21:32

See,

21:35

go back to this box here.

21:37

Okay.

21:37

Let's see what we have here.

21:38

Uh, yeah, so somebody, uh, described

21:41

that there are multiple pancreatic

21:42

cysts, so that is a good observation.

21:45

Um, it's a correct observation as well.

21:46

It's a, it's a maybe useful observation.

21:49

Sclerosing cholangitis.

21:51

Okay.

21:51

Congenitally

21:52

absent gallbladder.

21:52

I, you know, I suppose that can happen.

21:54

Um, I, yeah, anything can be congenitally absent.

21:58

I haven't really seen a case of that, but, uh,

22:01

I'm sure if I go to Radiopaedia, it's there.

22:03

Fatty liver, that's another correct observation.

22:05

I don't see a gallbladder yet.

22:06

That's, uh, that's, that's absolutely correct.

22:09

David.

22:09

That's, that's, that's the tough part here.

22:11

Is it there?

22:12

Is it really, really small? Absence?

22:13

Missing gallbladder.

22:14

Yeah.

22:14

Cystic duct, obstructed stone.

22:16

Okay, so a lot of good thoughts.

22:18

Portal veins.

22:19

A little dilated.

22:19

Let's look at that observation. They

22:21

do remember being a little bit big.

22:24

Yeah, it looks a little bit big.

22:25

I don't know if it's—

22:29

a little bit bigger than normal.

22:30

I agree with you.

22:31

I'm not sure if it's, uh, pathologically big,

22:34

but the question I have for the group is, is that

22:36

the one thing I'm, I'm sort of, um, uh, omitting

22:39

obviously here is that, uh, MRCP, again, I'll show

22:42

that. The one thing I'm omitting from the group is

22:45

that, um, the patient has some underlying history.

22:49

There's an underlying history that this

22:52

patient has that I haven't given the group,

22:55

but that disease entity, that rare disease

22:59

entity as it were, will sort of put together

23:02

a couple of observations that the group has made.

23:04

Somebody asked about sclerosing cholangitis.

23:06

I think that's a good thought.

23:07

My own experience, perhaps it's just

23:09

with some of the MRCPs that we get.

23:10

It's a little bit tough on the MRCP to look for that.

23:12

I like to look at those on

23:13

the post-contrast sequences.

23:14

And what I'm looking for is, um, areas of ductal

23:18

dilatation and narrowing, which is strictures.

23:21

And on the post-contrast sequences,

23:23

bile will be dark as it contains fluid.

23:25

And so you'll see areas of biliary duct

23:26

dilatation, and then you won't see that bile duct.

23:28

And then you'll see it again as it

23:29

dilates and you won't see that bile duct.

23:30

And so you sort of have these

23:32

straining areas, they're multifocal.

23:34

Um, and so if you just look at, you know, the, the,

23:37

you know, the, um, the post-contrast sequences,

23:39

which are thinner slices, you know, you really

23:41

don't see any ducts that are dilated, nor do

23:42

you see a CBD that's, uh, dramatically affected.

23:45

And so it was one of the thoughts that

23:47

the, that somebody in the group had.

23:48

But, you know, I, I don't know if I see convincing

23:50

evidence of that, uh, based on these images.

23:54

Um, and so let me see the chat feature.

23:57

Where is the group going?

23:59

Uh, okay, here we go.

24:01

Here we go.

24:02

Congenital absence, missing

24:03

gallbladder, bronze diabetes.

24:07

Oh, I haven't heard that term in a long time.

24:09

Thank you for, uh, uh, igniting

24:11

some, uh, some memories there.

24:13

Uh, someone is asking about cystic fibrosis, which

24:16

seems to be out there, but I, uh, I appreciate, uh,

24:19

uh, them putting themselves, uh, with that diagnosis.

24:23

A true atretic ectopic gallbladder.

24:26

Okay.

24:27

PSC, cystic fibrosis, choledochal cyst,

24:30

abnormalization of gallbladder, underlying

24:31

CBD, PSC, uh, also pancreatic CFTR. Okay.

24:36

Okay.

24:37

So yeah, this is nice.

24:38

I, I, I like that people are starting to, um,

24:43

not only get warmer in sort of figuring out what

24:46

the disease is, but they've absolutely nailed

24:49

it and so I won't torture the group anymore.

24:51

Thank you for your engagement.

24:53

Um.

24:54

Ladies and gentlemen, this is a case of

24:55

cystic fibrosis, is what the patient had.

24:57

And the reason I wanted to present it with the group

24:59

is, um, you know, listen, you know, you know, in

25:02

our, in our patient population, you know, we, we, we

25:04

do see cystic fibrosis in time, time in the classic

25:06

case that we all see, that we all show in, in sort

25:09

of case conferences of that fatty atrophic, you know,

25:11

that fatty pancreas, that the absence of the pancreas.

25:13

And I'm sure if I showed you that case,

25:15

you guys would be, you know, why, why

25:17

did I even tune into this seminar?

25:18

Um, I, I, I know that, you know,

25:21

I know that day in and out.

25:22

One thing that, um, that I learned a little bit

25:26

later on in my training was the, you know, the—

25:29

Other manifestations of cystic

25:30

fibrosis in the abdomen and pelvis.

25:33

And that sort of is always interesting and it's almost

25:35

now I look for those manifestations because the ones

25:38

that we see all the time are so burned in my memory.

25:40

And one of the things you can see is

25:42

multiple, multiple pancreatic cysts.

25:45

They're diffuse, just like here, and it's thought to

25:48

be due to innated secretions, which dilate the ducts.

25:50

These are not neoplastic.

25:51

This person will not develop

25:53

cancer as a result of these cysts.

25:55

But you can see it best on the T2

25:57

weighted sequence, multiple, multiple cysts.

25:59

The first comment that I think somebody made,

26:00

which is good for you to, to recognize that,

26:03

um, and you know, you can certainly see cysts

26:06

like this, uh, you know, in other conditions,

26:08

but, uh, you know, maybe in chronic pancreatitis

26:11

you get multiple dilated ducts, but the pancreas

26:12

there is very, very atrophic in those instances.

26:15

And so, um, that's one of the

26:16

manifestations of cystic fibrosis.

26:18

Something about pancreatic cysts.

26:20

Um.

26:21

And you can also sometimes get some calcifications

26:23

so it can look like chronic pancreatitis.

26:25

So that sometimes gets confusing.

26:27

That's even rare.

26:28

But, uh, when you see these cysts,

26:29

that's what you have to think about.

26:31

One of the other things that patients with

26:32

cystic fibrosis can get in the abdomen, uh, is,

26:35

uh, hepatic steatosis, but that itself is not,

26:37

um, you know, is that an important finding?

26:41

'Cause we see that in our patient

26:42

population all the time, but certainly

26:44

this patient has hepatic steatosis.

26:45

So that's, uh, that's not subtle.

26:48

And then the final question, which I

26:49

think is the most unfair question, um,

26:52

but, uh, but, but there it is, is

26:55

where is the gallbladder, right?

26:57

And so I think a few people say

26:58

congenitally absent gallbladder.

27:00

Um, I'm sure that exists and, uh, and certainly

27:04

that's something that I would've thought

27:05

about if I'm scrolling in this setting.

27:07

But if you know a little bit about cystic fibrosis,

27:10

you'll know that there are some gallbladder

27:12

manifestations of cystic fibrosis, one of which

27:14

is for some reason this really, uh, one of my

27:16

favorite entities is micro, microgallbladder.

27:20

Um, so I think some people in the chat box said

27:22

atretic gallbladder, and I think the term is micro

27:24

gallbladder, but atretic is very reasonable.

27:26

So my goal here is to find the gallbladder.

27:28

And believe it or not, this is the

27:29

only sequence in which I could find it.

27:31

Right over here is your gallbladder.

27:34

It's small.

27:34

There's nothing else this is gonna be, it's

27:36

not a loop of bowel, it's not a bile duct.

27:39

It's right where the gallbladder should be.

27:41

And it's really small.

27:41

It's micro, in fact, uh, you know, and, um, I looked

27:45

up the definition of microgallbladder 'cause I'm

27:46

sure there are people in the, in the group that, uh.

27:50

They'll wanna know about, um, uh,

27:53

micro, you know, how do you define it?

27:55

And, you know, I think a ballpark number that I,

27:57

that I looked at that I think is easier to remember

27:59

is like two centimeters in width by one centimeter

28:02

in, uh, in transverse—uh, two centimeters in

28:05

length by one centimeter in transverse diameter.

28:08

To be honest, I'm not going about measuring

28:09

these gallbladders, but we all have a

28:10

sense of what a normal gallbladder perhaps

28:12

should look like, even if it's collapsed.

28:16

This is tiny.

28:17

And so, um, this patient has cystic—so

28:19

in fact it's, you know, knowing that

28:22

we're not surprised that we couldn't

28:24

even see any uptake in the gallbladder.

28:25

Some of the inspissated secretions, I

28:26

think somebody's talked about that in

28:27

the chat box, will contribute to, um—

28:31

to the microgallbladder.

28:32

Maybe that's the theory of why it's very small,

28:35

but even if, you know, even if there was uptake

28:37

in this, you know, good luck, um, perhaps

28:40

finding that in the context of a HIDA scan or

28:41

even an ultrasound, I think it'd be very tough.

28:43

And it was very tough on the CT.

28:45

I happened to read the CT on this patient.

28:46

I do remember seeing it and, and mentioning

28:48

in my report, microgallbladder because, um,

28:51

it's just one of those manifestations,

28:53

uh, that you can see with cystic fibrosis.

28:54

And there are others in the abdomen and pelvis.

28:55

You get distal intestinal obstructive syndrome.

28:58

They can have also issues with

28:59

the seminal vesicles in males.

29:00

Um, and so, uh, this was a case of, uh,

29:03

cystic fibrosis with a microgallbladder.

29:05

And so let me, uh, share this, uh, this,

29:09

uh, slide with you for a few words about

29:11

cystic fibrosis. Autosomal recessive.

29:13

And one of the things that I think it's important

29:15

for us to know about these other manifestations

29:17

beyond, say, the chest and the, and the—nor in

29:20

the—and the most common manifestations in other

29:21

organs is that, you know, we have better, um—

29:25

uh, treatment algorithms for

29:26

patients with cystic fibrosis.

29:27

And so these patients are surviving longer.

29:29

And so you end up seeing, you know, you will in time

29:32

end up seeing more different manifestations of, uh—

29:35

that we don't—that we haven't traditionally seen.

29:37

And in the pancreas, of course,

29:39

fatty replacement is the most common.

29:41

But, uh, you can see these cysts for the

29:42

reason that, uh, was, uh, that I mentioned.

29:46

They're very small.

29:46

They replace the pancreas.

29:48

This anti-pancreatic cytosis.

29:50

You can sometimes also see calcifications, and

29:52

that's thought to be due to abnormal, um,

29:55

physiologic milieu that promotes calcium binding.

29:58

And so these patients don't have chronic pancreatitis.

30:00

It's just calcifications with tiny

30:01

calcifications associated with—

30:04

Cystic fibrosis. Steatosis, you

30:06

can see in up to 50% of patients.

30:07

So that's, uh, pretty obvious.

30:09

You look at the anatomy phase,

30:10

images in the microgallbladder.

30:11

I look at that—almost a third.

30:13

That's, uh, not an uncommon amount, I suppose.

30:15

Um, you know, and so, um, and thought to be

30:18

either atretic with the cystic duct or chronic

30:20

stenosis and something to do with the way the

30:22

secretions are, um, manifested in these patients.

30:25

A lot of people mention PSC. They can

30:28

get PSC-type picture in their ducts.

30:30

This person did not have that,

30:31

but that's a possibility.

30:32

So, uh, I think it's a good thing to look for.

30:35

And of course, uh, other organs in the bowel,

30:38

they can get distal intestinal obstruction syndrome,

30:40

right? I look at that from time to time with Vistop.

30:43

I'm not sure Vistop's even in patients.

30:45

And that's one of the, uh,

30:46

questions that are being asked.

30:47

I find that even with patients in, um, normal

30:50

gallbladders, it's very seldom that I see

30:51

the gallbladder filling up really nicely.

30:54

It might help in the sense that

30:56

Eovist will increase the background, um, uh,

31:00

the signal intensity of the liver parenchyma.

31:02

And so maybe you see a small sort of micro

31:04

gallbladder in the gallbladder fossa as

31:08

a dark signal amidst the bright Eovist.

31:10

HIDA, in fact, was done in this case.

31:12

One of the other panelists, uh—

31:14

uh, people are asking about HIDA.

31:16

It was actually done in this case.

31:17

They didn't see the gallbladder and so my N of 1,

31:20

based on this case, would suggest that the HIDA would

31:21

not help, or at least it did not help in this case.

31:26

Alright, this is great.

31:28

I don't know if I'm gonna get through my seven,

31:29

but let's, let's see what we can get through.

31:32

Um, next case. 41-year-old female.

31:34

Hypertension.

31:50

Oops.

31:56

Hypertension.

31:59

Just window this a little

32:00

bit, just an abdomen CT.

32:02

Looks like it's in an arterial phase.

32:05

Think about what are the things you're thinking about?

32:06

Well, uh, and what would you be

32:08

thinking about in a patient with, uh—

32:13

with these demographics, with this history?

32:15

Few—

32:30

people in the chat box chiming in.

32:32

I'm gonna get to that in a second.

32:34

Lemme scroll all the way down.

32:38

It'd be unfair for me to just give you some of the

32:42

images and wanna scroll slowly as possible because—

32:47

It's very tough when, uh, other people are scrolling.

32:49

I, I'm well aware of that.

32:52

I won't show you the lung windows here.

32:53

I don't think they'll be relevant to the case.

32:55

Let's see what the chat box is showing.

32:58

Okay, so some people are chiming in.

33:00

Let me show you, uh, some other images in this case.

33:06

I'll window a little bit.

33:07

We did this at a lower kVp, I think,

33:09

which is why everything looks so bright.

33:12

We do that for some of our

33:13

arterial phase, uh, studies—

33:14

CTAs.

33:29

Alright, so we got a bunch of people chiming in.

33:31

So people are talking about fibromuscular dysplasia.

33:34

Which side is the right—

33:36

fibromuscular dysplasia in this case?

33:38

Is it the right side?

33:39

Is it the left—

33:40

side?

33:57

Yeah.

33:57

People talking about the right side.

33:58

Okay, that sounds great.

34:00

And so, um, maybe I'll ask the group then for another

34:04

question is, what is the most common, uh—there's

34:07

many different types of fibromuscular, um, dysplasia.

34:10

What's the most common, uh, type? Does anyone

34:12

in the group know?

34:18

Well, type two.

34:19

I wish I knew which one was type two.

34:21

You're probably right,

34:22

the person who said two.

34:24

Um—

34:25

The medial type.

34:26

Okay, so we can wrap it up there.

34:28

Yeah, this patient—

34:28

Um, the other thing—some other people talk about

34:31

AAA. This aorta looks pretty normal in size.

34:33

At the very least, this person has—

34:35

it looks like a duplicated right

34:36

collecting system.

34:37

Two ureters are coming down.

34:38

Some people talked about that,

34:39

uh, or had mentioned that as well.

34:40

So I wanna just, um, be respectful of that,

34:43

and I don't know if it's completely duplicated

34:45

or we sort of don't see it beyond that area.

34:46

So I actually don't know much more

34:48

than what I'm showing you over here.

34:50

Um.

34:51

Uh, and so, yeah.

34:53

Okay, so let's go through this.

34:54

So, yeah, you know, I think the history sort of,

34:56

you know, I could have provided a, a different

34:58

history, but I think that would be unfair.

35:00

Um, you know, and I think this is a, a

35:02

40-year-old female with, with hypertension,

35:04

there's a couple things you're looking for.

35:06

Certainly you wanna look at the renal arteries.

35:08

Um, other things you may want to think about

35:10

just, you know, before we go there is, you know,

35:12

could this patient have a pheochromocytoma?

35:15

You know, so look at the adrenal glands.

35:16

Make sure there's no hypervascular mass here.

35:18

Could have another paraganglioma. One brought that

35:20

up in our, in our, one of our, our first case.

35:22

So I want to scroll all the way down

35:24

to look at that organ candle area.

35:25

No mass over there or anywhere in

35:27

the retroperitoneum for that matter.

35:28

And so those are some of the things you could

35:30

think about, uh, before you approach the case.

35:31

But you really do wanna look at the renal arteries.

35:33

And I find that, um, I find that, uh, uh.

35:40

Looking for fibromuscular dysplasia is

35:42

quite challenging on the, um, axial images.

35:45

Now, if we look at this, maybe it helps

35:47

look at the left one, which is relatively

35:48

normal. You can see the smooth borders.

35:50

Maybe I'll zoom up on this a little bit.

35:52

And, um, can see the smooth borders over

35:55

there and sort of branches out and, and

35:57

looks pretty reasonable. On the right side,

35:59

you can see it come out. It looks pretty much okay

36:02

to here and all of a sudden you start to see

36:04

a little bit of lumpy bumpiness associated with it.

36:07

You can see a little bit of bumpiness

36:08

here as well associated with it.

36:11

And then look at this thing, you know,

36:12

just sort of subtle areas of irregularity

36:14

where it's just not completely smooth.

36:16

And for that I find the, uh, coronals—we did look at

36:20

these—to be incredibly useful, um, as I'm sure most

36:23

in the group would find them useful as well, though

36:26

I suppose most did diagnose it on the axials in this

36:28

case, where you can see areas of focal dilatation,

36:32

focal narrowing associated with this right ureter.

36:36

We can see it all the way, even

36:37

here, a little aneurysm that's coming

36:39

up here and even more proximally.

36:41

So it's really, um, in this case, sort of the

36:43

mid to distal ureter that's affected, which

36:45

is a common site for fibromuscular dysplasia.

36:47

And so that's what this turned out to be

36:49

in, uh, in this, uh, in this, uh, case.

36:53

Yeah, as soon as artery is still,

36:54

uh, is still in extra phase.

36:55

Yeah, it probably was a split dose technique.

36:57

That's a great question.

36:58

I mean, this study was done a while

36:59

back, so I'm not really entirely sure.

37:01

Um, but that's the only, uh, logical explanation.

37:03

So I appreciate the, um, the,

37:05

uh, the audience answering that.

37:07

There is a double ureter on the right side.

37:09

It is duplicated. It's not followed all the way down.

37:11

Um, I think autoimmune pancreatitis—

37:14

not a great look for autoimmune pancreatitis.

37:15

In this case, we're looking for, you know, a

37:17

rind of soft tissue surrounding the pancreas.

37:19

You may be looking for other, um, things associated

37:22

with the pancreas, inclu—uh, uh, other things

37:24

in the abdomen, including retroperitoneal

37:25

fibrosis, you know, inflammatory pseudotumors

37:27

of the kidneys, some bile duct abnormalities.

37:30

Um, I think polyarteritis nodosa would

37:32

be a thing to consider if I saw—

37:34

issues with more vessels.

37:35

You know, if this is not just isolated to the renal

37:37

arteries, then I think I would think of potentially

37:40

something like polyarteritis NOD as a possibility.

37:44

And so let's go through, uh, some

37:45

brief teaching points in this case.

37:46

Um, FMD, it's a non-inflammatory, non-atherosclerotic,

37:50

uh, vasculopathy involving the arteries.

37:53

The, the prime arteries are the renal arteries

37:55

and carotid arteries, though it happens

37:56

more often in the renal arteries and can

37:58

cause stenosis and aneurysms and you have

38:00

little dissections, so watch out for those.

38:02

And of course, it can cause hypertension.

38:04

And it's really classified based on

38:05

the involved layer of the arterial wall.

38:07

There's many, many different types

38:08

of FMDs. Most common: medial dysplasia.

38:11

I think that was mentioned in the chat box.

38:13

And the classic appearance: a string of beads

38:14

appearance, classically mid to distal renal arteries.

38:17

I find it easiest to see on the

38:19

reformats. And, uh, gold standard still is—

38:22

uh—

38:23

IR, uh, percutaneous, transluminal,

38:25

angio—um, you know, angiogram.

38:27

And they could do an angioplasty as well to help

38:29

out these patients and alleviate the hypertension.

38:31

So this was a, a nice case of FMD.

38:36

This was a case of the main right renal artery.

38:39

I think somebody's asking the chat box.

38:40

There was an accessory right artery that looked fine.

38:43

Maybe there'd be some abnormalities with

38:44

that, but I think it was too small for us

38:45

to really detect those. The main right

38:47

renal artery—

38:48

that was, uh, that was abnormal in this case.

38:52

Alright, next patient.

38:56

60. I'm just looking at the time.

38:58

Okay.

38:58

We have some good, good amount of time left.

39:00

68-year-old female. Elevated liver function tests.

39:03

We love that history.

39:04

Right?

39:04

Get that all the time.

39:06

So—

39:10

Just, uh—

39:16

Stop sharing for one second because I

39:19

was about to go to the answer slide.

39:29

Okay, elevated LFTs, go to the next case.

39:36

So an MRI.

39:40

Some of these renal Doppler

39:42

features to identify FMD.

39:43

So, you know, with the areas of renal, with the

39:44

areas of, uh, narrowing, you're gonna see evidence

39:47

of renal artery stenosis, elevated velocities.

39:49

There may be a little bit of tardus-

39:50

parvus waveforms more distally.

39:52

Um, and if you're lucky on both the color and the gray

39:54

scale, maybe you see that lumpy, bumpy appearance.

39:56

Typically with renal artery stenosis though,

39:58

you'll see it in the proximal portion.

39:59

So if you see evidence of that, but in the mid portion

40:02

in a young patient and, uh, and, uh, particularly

40:05

a young female patient, you may bring up the

40:07

possibility of FMD. And usually in that setting, they'll

40:09

get a CTA or an MRA as the next, uh, imaging step.

40:13

Okay, so let's look at, uh, some case—

40:15

uh, this case here, elevated LFT. 68 female.

40:19

T2-weighted image.

40:31

It's always a lot to look at these

40:33

abdomen cases, but, uh, if we have the elevated LFTs

40:36

history, perhaps that can narrow what you wanna

40:39

look at.

40:40

Look at the coronal T2s as well.

40:52

People are starting to chime in in the chat

40:53

box.

40:54

I'll have a look at that in a second while

40:55

I go through this case for the group.

40:58

What a group!

40:59

252 participants right now.

41:01

My goodness.

41:04

253. We just got a new one.

41:05

That's awesome.

41:06

So let's look at the, um, let's look

41:08

at T2 fat sat. I suppose that's—

41:09

it's always a useful thing to look at.

41:12

Uh, maybe that helps you, maybe

41:14

you already know the answer.

41:17

Maybe a T1.

41:18

And let's just look at—

41:19

one of the post-contrast sequences.

41:20

A lot of people in the chat box.

41:22

So I got a sense people know the answer here.

41:24

That's good.

41:26

You know, my goal here is—

41:27

is never to stump the group.

41:28

It's just to share some interesting cases.

41:31

And so I like it when

41:31

everyone gets the right answer.

41:38

Okay, let's scroll through enough sequences for now

41:41

and let me just look at the chat box.

41:45

Okay, here we go.

41:46

Let's go.

41:46

Oh my goodness.

41:47

Everyone's saying the same thing, huh?

41:49

So, um, CBD stricture.

41:51

So I think that's a good thought,

41:52

'cause you all had ductal dilatation, and some people

41:54

have, uh, said the same thing over and over and over.

42:01

Yeah, that spelling is tough though.

42:03

I gotta look up the spelling

42:04

every single time I do it.

42:06

So hopefully the spell I have in my PowerPoint is correct,

42:09

um, that you guys are—that, but someone, someone

42:11

took back their answer now as referred to me and

42:13

said, okay, I'll buy that in the interest of time.

42:16

Yeah.

42:16

So this is, uh, if anyone, um, you know, has trained,

42:20

uh, alongside me, with me, will know that, uh, for some

42:25

reason I really like this. Maybe I like the name Zi.

42:27

It's a nice little name with a couple of Z's in there.

42:29

And so here we have a big, um, stone

42:32

really impacted in that gallbladder neck.

42:34

Uh, but what's amazing is that look what it's doing

42:36

to its insert, you know, right at that insertion

42:38

of the cystic duct in the common hepatic duct—

42:40

that's really has the mass effect here in all this.

42:43

Quite a bit of upstream biliary ductal dilatation.

42:47

Um, and what's interesting as well in this

42:48

case I think is that, you know, if you looked

42:50

at it, patient happens to have choledocholithiasis more

42:53

distally, so it happens to actually have a CBD

42:55

stone, but that seems to be reasonably okay.

42:59

Um.

43:00

Causing maybe a little bit of prominence, but

43:02

really the bulk of this is happening by this

43:04

really massive stone at the gallbladder neck

43:06

causing, uh, common hepatic duct obstruction.

43:09

And there's a bunch of gallstones in there as well.

43:10

There's a bunch of other findings in the liver.

43:12

Um, and, uh, and, uh, so we did that.

43:17

Did that I—let's see in the chat box.

43:20

Yep.

43:20

Perfect.

43:21

And so let's look at, um, let's

43:23

learn a little bit about this.

43:24

This is, uh, I anticipated a, a quicker

43:26

case and, uh, you guys, uh, nailed it.

43:31

So you know, it's an impacted stone, um, either

43:34

in the cystic duct or, you know, and maybe I

43:36

should rewrite that really in the gallbladder

43:37

neck area as well, and causes this extrinsic

43:39

mass effect on the common hepatic duct, result

43:43

in dilatation of the intrahepatic duct.

43:44

So right there is that key image in this here as

43:46

well, showing the intrahepatic duct dilatation.

43:47

I wish our MRCP showed this in one image.

43:50

It doesn't quite do that, which is

43:52

why I didn't show you that image.

43:53

But turns out that your group didn't need it.

43:58

Segment six.

43:58

Actually, that was a hemangioma.

43:59

And so, uh, this right over here incidentally.

44:03

Um, and the reason, you know, if you look

44:04

at the T2 signal, it's not quite as bright as

44:06

CSF, but it's relatively benign T2 signal.

44:09

And as I go, um, back here, I can just show you.

44:13

And, and to be fair, I didn't really show

44:15

you a lot of the post-contrast sequences.

44:17

You can see it sort of has that peripheral

44:18

discontinuous, uh, nodular enhancement—fills in.

44:21

So that's gonna be a hemangioma there.

44:26

And—

44:27

Done.

44:27

Done line.

44:29

Done.

44:29

Okay, so, so let's move on to our next case, uh—

44:33

which is—

44:55

41-year-old female with a right upper quadrant pain.

44:58

Okay?

44:59

41-year-old female with right upper quadrant pain.

45:07

Let's show you some of these images here.

45:10

So T2. We'll start off with the T2 image.

45:12

So let's just scroll all the way from the top.

45:33

T2s.

45:38

There's a lot going on here, so—

45:43

Hopefully just focus on

45:45

some things in the right upper quadrant,

45:46

and as you—once you figure that out,

45:50

try to put other things together.

45:51

See if you can come up with a specific diagnosis here.

45:53

I think it's gonna be tough, but this is a good group.

45:56

We have—

45:57

We have about 254 now, and so see if we can

46:01

potentially suggest a specific diagnosis here.

46:05

So again, 41-year-old female, right upper quadrant pain.

46:10

Showing you some post-contrast sequences.

46:19

I'm curious to see what people

46:20

are seeing in the chat box.

46:21

Let me finish scrolling a little,

46:22

bit, then I'll have a look.

46:24

Let's put up a more delayed

46:25

three-minute sequence here.

46:37

I think that's sufficient.

46:38

I think that's, uh—

46:41

It's reasonably sufficient for the moment.

46:43

So let's see what the chat box says.

46:45

Okay.

46:46

Okay, we got a lot.

46:47

We're all over the place, which is, is great.

46:48

We're gonna sort this out.

46:50

So history, uh, was, uh, 41-year-old female, right?

46:52

Upper, upper quadrant pain, right?

46:53

Renal mass, so that's absolutely correct.

46:55

XGP.

46:55

Okay.

46:57

And abscess.

46:58

That's a good thought.

46:58

XGP, mass, liver and lung mets.

47:00

So, um, I think it pre-, uh, uh, sort of

47:04

went a step further and saw that there were

47:05

some, uh, lesions in the liver and lungs.

47:07

So good on you for recognizing that,

47:09

uh, renal vein thrombosis

47:10

RCC with mets.

47:11

RCC, never, uh, renal vein.

47:13

Okay, somebody thought a renal

47:14

vein thrombosis has been out.

47:15

Take that back.

47:15

That's fine.

47:16

Um, gallstone.

47:18

TCC.

47:18

Yeah, all over the place.

47:20

This is tough.

47:21

Okay, somebody asked.

47:22

An interesting patient is Sickler.

47:23

I don't know.

47:24

I don't know what, uh,

47:25

Her reach Patel is getting at.

47:27

But if they were to elaborate on that,

47:30

I'm happy to entertain that comment.

47:33

Can't see the right adrenal gland.

47:36

And so we really just see a very aggressive

47:39

looking mass, right in the right kidney here.

47:42

Everyone, heterogeneous enhancement.

47:44

Okay, you see a chat box one more time?

47:46

Let's see you with mets.

47:48

Okay, so again, I think we're on the right track and

47:51

I think one person at least is on the right track.

47:54

Perhaps a tiny, tiny, tiny bit more than others.

47:57

Um, and so let's go through the case.

47:59

1232 00:47:59,460 --> 00:48:04,785 So, you know, listen, I—if all of you have this

48:04

case and we interpret it as a, you know,

48:07

a very, you know, heterogeneous, right?

48:09

Renal mass and there's all this adenopathy here.

48:12

Look at, there's even retro al nodes.

48:13

When's the last time you see

48:14

a retro node from a big RCC?

48:16

I don't know.

48:16

I've seen big RCCs.

48:17

I don't quite see adenopathy all the way up there.

48:20

Quite extensive adenopathy here as well.

48:22

Um, somebody pointed out there was lung mets.

48:24

You can see one right over there and, uh, you

48:27

don't see it on all sequences really nicely.

48:29

And there are liver mets.

48:30

Um, there's one over here for

48:31

example, and there's one over there.

48:34

And, uh, you know, one over there.

48:36

I mean, there's a whole bunch of them and

48:37

they're not all that easy to see on the

48:38

post contrast sequences, but at least on the

48:40

T2, stay there. Renal vein looks okay.

48:42

Actually, surprisingly it looks pretty okay.

48:45

In this instance though, admittedly

48:46

tough to see in a few areas.

48:48

The collecting system looks a little

48:49

bit abnormal in the sense that, um,

48:51

there's a little bit of hemorrhage in it.

48:53

Okay?

48:54

But, um, you know, if I were to look

48:56

at this, I don't feel that the mass is centered.

48:59

Um.

49:00

In the collecting system per se.

49:02

It looks like it's a renal mass, but it

49:05

also doesn't look like it's a big,

49:06

you know, like, you know, big ball-like mass

49:09

that's sort of sticking out of the kidney.

49:11

It almost is reniform shape.

49:12

It's almost this infiltrative, heterogeneous,

49:14

aggressive-looking thing that's almost

49:16

in the shape of the kidney itself,

49:18

which is, I think, a little bit unusual.

49:20

Like it's not quite what you're used

49:22

to seeing with these aggressive clear

49:23

cell RCCs or other tumors like that.

49:26

So maybe that's a clue as to what's going on now.

49:28

Certainly it has some effect on the

49:29

collecting system and it's hemorrhage.

49:31

There's all this enhancement.

49:32

I think all that's probably secondary.

49:35

And it's very aggressive, right?

49:36

There's all this adenopathy, there's all these

49:38

lung mets and liver mets, and so can we

49:41

come up with a type of renal neoplasm that could

49:44

look like this, that is really aggressive?

49:50

Renal lymphoma.

49:51

That's a possibility.

49:52

I find with lymphoma though,

49:54

one of the things I failed to mention

49:56

You don't quite see—

49:57

I mean, there's areas that look frankly necrotic.

50:00

You know, they look like they're bright

50:01

and they're not enhancing too well.

50:03

You're not quite used to seeing that with lymphoma

50:04

unless there's been some sort of treatment.

50:07

But, so if I had a more homogeneous,

50:08

you know, relatively homogeneous-looking

50:10

mass, I would think of maybe lymphoma.

50:11

But these nodes and everything just don't

50:12

look like it's a run-of-the-mill lymphoma.

50:15

I think, uh, von Hippel–Lindau was something that,

50:19

uh, um, uh, someone mentioned, you know, you, you

50:23

know, for that I'm gonna look at also, I'm gonna

50:25

look at, you know, bilateral renal neoplasms,

50:27

adrenocortical carcinomas, things in the pancreas.

50:29

And so I'm looking at those primary organs.

50:31

Um, I will say that, uh, somebody's

50:33

asked this twice now, and I, uh, yeah.

50:36

Okay, fine.

50:37

So now we finally have few people who are getting it.

50:40

Uh, what I, uh.

50:43

Uh, uh, connecting the question that was asked

50:46

in the group with what I think the diagnosis.

50:48

This person is not a sickle, but has

50:51

sickle cell trait, has sickle cell trait.

50:54

And so this is a medullary renal cell carcinoma.

50:57

And I'll say that I've seen, I don't know, I've

51:00

only seen two or three cases of this, but every

51:03

time I've seen it, it happens to, you know, I

51:06

think about it when I see a, a young patient,

51:07

this is a 41-year-old female who has a very

51:11

aggressive looking mass, but it's still sort of

51:14

almost confined in a weird way to the kidney mi

51:16

with a kidney, mid kidneys or any form of shape.

51:18

And it's super aggressive.

51:19

I'm seeing, talking about quite a lot

51:21

of adenopathy, liver mets and lung

51:24

mets, uh, at the time that you see it.

51:27

And I'm not saying that's all specific for,

51:29

for, uh, medullary, but the idea is that,

51:31

think about in that instance and, uh, that

51:35

was the thought process that went into this.

51:37

They didn't tell us the patient had sickle cell trait.

51:40

But once we, uh, sort of mentioned that

51:41

possibility, they worked them up and this

51:43

indeed had the patient had sickle cell trait

51:45

and this turned out to be a medullary RCC.

51:49

And so let's talk a little bit about this entity.

51:52

'Cause, uh, you know, we don't

51:53

see it from time to time.

51:54

It's really rare, but a lot of the patients

51:56

will have sickle cell trait in particular.

51:58

So that's the key differentiation of sickle

52:00

cell trait, not sickle cell, uh, disease itself.

52:03

Uh, and it happens in young adults.

52:05

They can present with hematuria, they

52:07

present with pain and unfortunately

52:08

it's a very, very poor prognosis.

52:10

You do chemotherapy, you know you're doing

52:11

nephrectomy, chemotherapy, but you know.

52:15

It's always hard to see these cases 'cause they

52:17

happen to be young patients and, and what we

52:20

know about it is that patients don't do well.

52:21

And so, um, on imaging, uh, you'll see a mass

52:25

that in theory arises from the medulla, extent

52:27

to the cortex, the kidney maintains its er form.

52:29

She, which is what I'm trying to show you here, can

52:31

cause hydro, they tend to be large, mets are common.

52:34

In this case, it's sort of read the book

52:36

and quite heterogeneous enhancement.

52:38

It can mimic an abscess.

52:39

And that's one thing I didn't address with the

52:40

group that a lot of people thought it was XGP.

52:43

I think XGP, you know, you're getting

52:45

that sort of bear paw appearance.

52:47

You're getting that staghorn calcification.

52:48

You're not seeing heterogeneous soft tissue.

52:50

And then XGP couldn't necessarily account for

52:53

all the adenopathy, lung mets and liver mets.

52:56

Um, one potential complication is the group I know XGP.

52:59

That's really rare squamous cell cancer.

53:01

So maybe if you spun it as saying XGP with squamous

53:04

cell cancer and mets, that's a possibility.

53:07

But in and of itself, this doesn't

53:08

have that classic XGP look.

53:10

Um, and if I told you the patient, you

53:12

know, urinary tract infection symptoms of

53:14

that, maybe you could go along that pathway.

53:16

But this was, uh, not quite the case in this instance.

53:21

Oh, no, no, no one needs to

53:23

apologize for any of the diagnoses.

53:24

You, Meg, I appreciate it because I think

53:25

it's part of the, um, the dialogue that we

53:28

have, uh, about these cases and the thought

53:30

process, that's the most important thing.

53:31

Can we consistently have the right thought

53:33

process to get us hopefully to a diagnosis

53:36

that's reasonable and a lot of the diagnosis

53:38

that were mentioned are very, very reasonable.

53:40

Uh, what time?

53:41

We have 1254.

53:42

Okay.

53:42

Let's do one more case.

53:43

Let's do one more case and then we can call it a day.

53:46

Um,

53:50

Right.

53:50

Lower quadrant pain.

53:51

55-year-old male.

54:04

Yeah.

54:05

We'll, we'll do this case.

54:06

It's fine.

54:07

I thought maybe we can do the last

54:08

one instead, but we'll do this one.

54:13

Keep it going.

54:14

I, I could keep it going.

54:15

I just wanna be respectful to the group and

54:16

to, um, my hosts who are hosting us right now.

54:20

MRI Online.

54:21

Okay.

54:22

So right lower quadrant pain, go

54:24

post-contrast image.

54:42

I know the group likes reformats.

54:44

I like reformats as well in this case.

54:57

Alright.

54:57

A lot of people, people really like

54:59

this one.

54:59

Okay.

55:01

Good.

55:02

Good, good, good, good, good, good, good.

55:03

Good.

55:04

So good.

55:04

So good.

55:05

Okay.

55:05

All right.

55:06

All right.

55:06

All right.

55:06

You guys, you guys are too much.

55:08

Okay.

55:09

Everyone's all over them.

55:10

Oh, all right.

55:10

All right.

55:10

Uh, uh, this is a carcinoid.

55:13

Okay.

55:13

The group knows their carcinoids.

55:15

That's awesome.

55:16

So, um, I wanna show this case, uh, for a few reasons.

55:19

I like, I like carcinoid tumors.

55:20

It's nice 'cause you can think

55:21

of a differential as well.

55:22

And so you see a mesenteric mass here.

55:24

We see some calcifications.

55:25

I really like, um, the, uh, well, maybe I don't,

55:29

oh, yeah, there's a little bit of spiculation.

55:31

It almost feels like some vessels

55:32

are tethered to this location.

55:34

See another small node over there.

55:35

And the reason I wanted to show this case,

55:37

um, um, well, I actually got the green

55:41

light that I can go a little bit longer,

55:42

so maybe I'll show the last case.

55:43

It won't be that much longer after this case.

55:44

So we'll do that and whoever

55:45

needs to jump off can jump off.

55:47

Um, but the reason I like this case is, you know,

55:49

listen, the group has seen it. It seems that the

55:51

group knows their carcinoids, and that's fine.

55:52

We'll talk a little bit about that.

55:54

But one thing that I urge the group to do is

55:56

when you see your carcinoids and you've sort of

55:59

quote unquote mastered diagnosing a carcinoid...

56:03

The way I kind of, you know, the next

56:05

step was, can we find the primary?

56:08

Right?

56:08

That's what I always look for.

56:09

Um, let's look for the primary because

56:11

I don't know, and I have the luxury of

56:13

time in an academic practice to do that.

56:15

I understand that.

56:15

But, um, I think that's what sometimes

56:18

makes these cases interesting.

56:19

And so can we find the primary here?

56:21

I think somebody said it, they saw the primary

56:24

and, uh, and it's gonna be tough for me to, to

56:28

sort of show it to you, um, to have people chime

56:31

in on where it is, but they called it in the ileum.

56:32

That'd be a great, uh, guess if you guessed

56:35

it, but if you actually saw it, good on you.

56:38

It's right over there.

56:41

It's right over there.

56:41

Let me window it for you.

56:44

Right.

56:44

There's a mass over there, there's

56:45

some calcifications of that mass.

56:46

That's gonna be the primary.

56:48

And one of the things that our surgeons

56:49

have told us is that oftentimes, and you

56:51

can see it right over there, is that...

56:54

There'll be almost, there may be more

56:56

than one primary, so you'll see one lesion.

56:57

You may, there may be others right adjacent to it.

56:59

And so have a look in the bowel loops and

57:02

just see if you can window it to a point

57:03

where you can actually see the primary.

57:05

In this case, we can see it in, uh, right over there.

57:09

And so let's just go through, uh, this PowerPoint

57:11

to just, uh, uh, review some teaching points.

57:13

It's a neuroendocrine tumor.

57:15

It often arises in the GI tract.

57:17

Other sites are, are less common.

57:20

Almost, you know, we think about it

57:21

traditionally in the ileum, but it can't

57:22

occur in other places in the bowel.

57:24

We all know about carcinoid syndrome.

57:26

It's when you have the mets to the liver

57:28

with a spectrum of findings, right?

57:30

Due to the serotonin release.

57:31

And you're looking primarily for the mesenteric mass.

57:34

Remembering that the mesenteric

57:35

mass is the nodal metastasis.

57:37

It's not the primary tumor, it's, it's the

57:39

nodal metastasis from a lesion in the bowel.

57:43

So look at the loops of bowel.

57:44

See if you can see a similar

57:45

appearing mass somewhere there.

57:47

About 70% have some punctate calcifications,

57:50

often spiculated margins, and they will

57:52

tether adjacent loops of bowel, right?

57:54

Um, and vessels.

57:56

And they are quite often hypervascular.

57:58

And so, particularly when you're looking for liver

58:00

mets, it's important to do these studies correctly.

58:02

And we do an arterial phase of the liver,

58:04

otherwise you may miss these liver metastases.

58:06

Um,

58:11

Okay, one more case.

58:14

Alright,

58:15

let's do one more case.

58:17

I am really happy that we're doing this

58:19

case 'cause I'll just be honest with you,

58:22

I mucked up this case and I needed my

58:23

smarter colleagues to help me with this one.

58:25

So hopefully we can, we won't muck it up again.

58:28

27-year-old female got a, it was a non-contrast

58:31

CT, had an indeterminate mass on

58:33

the left upper upper quadrant.

58:35

They got an ultrasound.

58:36

We still didn't know what was going on.

58:37

Got the MR. I happened to look at it.

58:40

I still didn't know what was going on,

58:41

but I needed some people to bail me out.

58:47

And now that I've seen this case, my hope is that

58:51

I will always get this correct.

58:53

But we're all human, so I never say always, right?

58:57

So let's go through this.

58:58

So here we go.

58:59

Young female, I think, uh, I forget the

59:01

age of young female, otherwise no past

59:02

medical history, indeterminate mass seen.

59:06

And the group needs

59:08

to tell me what they think this mass is.

59:16

T2-weighted image.

59:17

Lemme show you T2 fat-sat.

59:26

It's got a pre-contrast

59:33

and post.

59:46

Gimme a coronal help.

59:56

Alright, pseudocyst.

59:57

Where?

59:57

Okay, where's

59:58

the left adrenal duplication cyst?

59:59

Okay.

60:00

Mesenteric cystic lymphatic cyst.

60:01

Which anal light bulb sign?

60:04

Lymphangio duplication cyst.

60:05

Okay.

60:05

Yeah, people are, um, gastro duplication cyst.

60:10

Are people are on the right track.

60:11

Angling neuro.

60:12

Good, good, good.

60:12

Okay.

60:13

And so let me show you the left adrenal gland.

60:15

I think somebody was, uh, asking about that.

60:17

I think it's a very, very good thought.

60:18

So let's find it.

60:20

Uh, let's see.

60:20

Where is

60:20

it?

60:28

Here it is.

60:32

One limb.

60:34

One limb.

60:37

I suppose.

60:37

It's tough, you know, I mean,

60:38

I'm looking for a claw sign.

60:42

I don't know if I quite see it.

60:43

Maybe the coronals will help.

60:50

Yeah, that's the adrenal gland right there.

60:54

So I suppose if it's arising from the

60:55

adrenal gland, it's quite pathetic.

60:57

But to be honest, I'm not quite seeing

60:58

a, uh, I have a nice claw sign here,

61:03

which you don't really see if I added.

61:04

Yeah.

61:05

That's a really good thought.

61:06

I gotta tell you, I, I love these answers 'cause

61:08

I went through every single one of these and,

61:10

uh, and, uh, you know, so I, that was my process.

61:13

So I would say that, excuse me, my approach to this

61:17

case was sort of describing the location, right?

61:19

It's, it's, um, it's, it's located

61:22

between a bunch of organs, right?

61:23

But I don't really thought, I didn't really

61:24

think it was arising from any of the organs.

61:26

Uh, somebody talked about pseudos.

61:27

I thought it's a good thought.

61:29

Patient had no history of prior pancreatitis,

61:31

and you know, let's assume that,

61:32

uh, they know their history well.

61:33

And so it'd be kind of unusual

61:34

just to have a cyst that's arising like that.

61:37

Some people have talked about neurogenic tumors.

61:38

Listen, I thought that was a very reasonable,

61:40

um, uh, uh, possibility, a neurogenic tumor.

61:44

In fact, that's what I favored.

61:45

Uh, that's what this was gonna be.

61:48

Uh, I thought of things like ganglioneuroma, you

61:51

know, some people have talked about that stuff.

61:53

And, um, well, lymphangio is a possibility.

61:57

I find those tend to not—like, this almost looks

61:59

like it has some sort of mass effect and pushing

62:01

things away, or those sort of insinuate a little bit.

62:04

So I don't know if I liked it for lymph-

62:06

angio, you know, in terms of just the way

62:09

it had more of like a, a mass effect to it.

62:11

But, um, but I think it's a good thought

62:13

of, of, of, you know, you have this, what

62:15

amounts to a cystic mass in the retro—you

62:17

know, in this location, what it could be.

62:19

Um.

62:20

And I thought there may be some low-level enhancement.

62:23

You know, when I showed it to my group,

62:24

they weren't entirely convinced—maybe

62:26

some of this low-level enhancement.

62:27

But the problem was that you look at the

62:29

gallbladder, we should have no enhancement.

62:31

There’s also a little bit of supposed low

62:32

level enhancement here, so maybe it's just

62:35

some motion and, and, and, um, and, and

62:37

misregistration that is accounting for that.

62:39

But really this is a, a cystic,

62:42

cystic lesion and diaphragmatic cyst.

62:44

And I think a lot of people are getting—many

62:46

people have gotten to the right diagnosis.

62:48

Um, and, uh, and so I won't, I

62:50

won't, uh, torture the group anymore.

62:52

And by the way, if anyone—I think WAGR has

62:54

been a favorite diagnosis that we've talked

62:56

about today, but I'm sure—and not, not in

62:58

this case, but this didn't have any fat in it.

63:00

So, um, this turns out it's a, it is

63:03

a very, uh, specific—oh, it's quite a

63:07

specific look for a, um, bronchogenic, uh,

63:11

retroperitoneal bronchogenic, uh, uh, cyst.

63:14

And, um, I remember seeing one

63:16

case of this at some point.

63:19

And then this is the second case.

63:20

And so this case I'd seen a

63:22

while ago, I forgot about it.

63:23

And so when I saw this, I mean

63:24

this is what they look like.

63:25

There are foregut duplications

63:27

as many people mentioned in the talk.

63:28

So I'm sure, uh, you guys are all over it.

63:31

Oftentimes you'll see them more in the chest.

63:33

Rarely they can be in the retroperitoneum.

63:35

And if you look at the reports out there in the

63:37

literature, they all kind of look like this.

63:39

They're somewhat ovoid, they're solitary.

63:41

They may have a little bit of debris, which this one

63:43

didn't, but it's this like weird location that it's

63:45

adjacent to the left adrenal gland and then the next

63:48

common, it's like just posterior to the pancreas.

63:50

And this sort of followed both.

63:51

And it's often asymptomatic, incidental.

63:54

If it's large, it can compress

63:55

things and cause symptoms.

63:56

But for the most part, um, the importance of just

63:58

knowing if you see a simple appearing cystic mass

64:02

in this location—that don't go wild and start

64:06

suggesting potentially these crazy diagnoses where

64:09

they have to go in and do something aggressive

64:12

about—it may end up being that depending on the...

64:15

Depending what it looks like.

64:16

But if it looks simple like this, there

64:18

is an entity that that can live here.

64:21

Um, and that's what this—this

64:23

is what this turns out to be.

64:24

Um, okay.

64:27

And so with that, uh, an ultrasound image

64:31

showing, yeah, bronchogenic, um, uh, I—

64:33

I thought those—maybe the enteric

64:36

cyst may be a little bit more classic.

64:38

I'm not sure.

64:38

I forget if the bronchogenic cyst will

64:39

have the same bowel gut signature.

64:41

I don't—my gut feeling is that they won't.

64:43

But, uh, if you know better, then, then

64:45

I'll, I'll refer—I'll, uh, defer to you.

64:47

So what are the take-home points of

64:48

some of the cases that we saw today?

64:49

Uh, let me just, uh, close up here.

64:53

Oops, here.

64:55

So we saw a case of, uh, tumor, non-descended testicles.

64:57

So look at the Sato course.

64:58

Look at the vesicles.

65:00

Remember, CF has uncommon GI manifestations.

65:02

Try to remember one or two of them from the talk.

65:04

We all—we're all over the FMD, we're all

65:06

over the Marzi, so I don't need to go there.

65:08

Remember, medullary carcinoma, young patient,

65:10

infiltrative mass, maintaining the shape

65:12

of the kidney with lots of mets everywhere.

65:15

Remember to scrutinize bowel for

65:16

sites of the primary carcinoid tumor.

65:18

The group knows how to see the mesenteric

65:19

mass, but take it a step further to see

65:22

if we can identify the mass in the bowel.

65:23

That makes cases a lot, uh, more interesting,

65:26

challenging, and of course, it's most importantly

65:28

good for our patient and our, and our providers.

65:30

And, uh, the group seemed to know this, but, uh,

65:33

this is certainly a learned lesson from me.

65:35

Cystic mass adjacent left adrenal—look simple.

65:37

Consider the retroperitoneal bronchogenic cyst.

65:42

So I truly thank the group for their engagement.

65:45

This would not be possible without

65:46

the engagement of this group.

65:47

Um, and I hope, uh, you learned something. I certainly

65:49

learned a lot from, from chatting with you, and

65:51

I really appreciate, um, uh, you attending today.

65:55

I'll stick around for a little

65:55

bit if anyone, uh, wants to chat.

65:59

Dr. Math, thank you so much for this live case

66:01

review and for everyone for participating.

66:04

That was fantastic.

66:05

Um, I know MRI Online team over

66:07

here learned a lot as well.

66:09

You can access the recording of today's

66:11

conference and all our previous Noom conferences

66:13

by creating a free MRI Online account.

66:16

And be sure to join us next week on March 16th,

66:19

where we will be featuring Dr. Giovanni

66:22

Lorenz and Dr. Emilio Faz, who will give a lecture

66:25

entitled One Heart, One Mission: Success of a

66:28

Multidisciplinary Cardiac Imaging Team Approach.

66:31

You can register for this free

66:33

lecture at MRIONLINE.com and follow us on social

66:35

media for updates on future conferences.

66:38

Thanks, and have a great day.