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Okay, and welcome to our first live case

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and we're using the arm reviewer.

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I've loaded up a few different cases, um,

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through the masterclass to help kind of work through things

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and you're able to do this in your own time

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and also follow along with me.

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So there's a few different things

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that you'll see on this menu

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and I always start with the rotating mip,

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but you'll notice that this black

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and white man doesn't look like the ones

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I've been showing in the lectures.

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So we need to adjust it and we go up to pallets

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and we click on invert.

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And now we've got black and white,

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but it does look a little bit oversaturated already.

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So we're gonna click on levels and we're just gonna adjust

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it up and down and side to side

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until we get a little bit more of that definition,

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which I think I'm kind of happy with there.

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That looks pretty good. I've just got a faint

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outline of the person.

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I can see that I've got hot saliva glands, liver,

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spleen, and kidneys.

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And you can really get a sense of the variability of

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that liver uptake, especially on this rotating MIP

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and how bright it is with our adjustments.

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So what I do, the first thing I do is I'll bring up this

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image and then I'll give it a spin

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and I wanna get a sense of what do I see,

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does the uptake look physiological?

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Is there anything kind of big going on?

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And this really gives us an idea

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of the patterns of what's going on.

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Now this is a normal study

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and I'll tell you this straight off the bat.

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Um, and it's just to get a sense of the normal appearance

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and get our eye in.

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Now let's have a think about how we wanna display our data.

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So what I might do is I'll just pop a few

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axial side by side to start.

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We'll put our fusion in here to drag

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and drop our axial low dose CT and our functional imaging.

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Um, and then again come up to pallets and invert it.

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And then we'll just pick our

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levels and we'll just adjust this.

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And this isn't necessarily kind of the same kind of viewer

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that we use, so it might not be as functional

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as the nuclear medicine software,

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but we've got a lot of good information with our fusions

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so we'll be able to work through the case as well.

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So in my practice this is how I will display it,

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but for the sake of the masterclass,

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I'm gonna be working mostly off the fusion

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that I pre-prepared and the low dose ct.

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So let's bring in our fusions.

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So here we go here, axial, coronal and sagittal.

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And remembering that patients are three dimensional,

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so we wanna make sure that we go through all three.

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And let's work with the axial first,

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though, nice and traditional.

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So going right from the very top.

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So I'm gonna pick on my stack scroll, come up

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to the very top and I always check the brain

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to make sure I don't forget it.

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Coming down we'll notice

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that there is some uptake through the nasopharynx.

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That's normal. Lacrimal glands, saliva glands,

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and a little bit of inflammatory uptake in the tonsils.

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That is also normal. Oh, I'm quite happy I picked this case

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because you can see there's a bit of a.here out in space

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and that's gonna be accessory saliva, duct tissue.

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So coming down subular glands, floor of mouth,

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that's all fine and a little bit of uptake as long as um,

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symmetrical at the larynx is also fine as well.

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Interestingly, this patient has a little bit

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of patchy uptake at the lung AEs

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and that can be seen um, as a pitfall.

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Just inflammation can be seen

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as mildly PSMA expressing. Um, and this patient

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Probably has some, I'll just bring in here,

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just bring on a long window,

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probably has some fibro apical scarring just at the top.

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And we'll confirm that with alloid ct. Yes they do.

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Little bit of apical scarring with that mild divinity.

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So we'll come back. Great, we've accounted for that.

3:15

We've got our ganglia allo, um,

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ganglia here at the base of neck.

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We know that that's normal coming down.

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Mild divinity in lymph nodes is acceptable as long

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as it's not focal and intense.

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We can see how hot our liver and spleen are.

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So I'll be going through

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and adjusting this in my viewer to make sure

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that there are no focal liver lesions.

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Same going for kidneys.

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And coming back to the side by side here,

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we'll put yes back on soft tissue windows

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and you can see that we have given intravenous contrast.

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We've got a ureters there.

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So we've got then nicely pacified on this case actually.

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And then coming down to the bladder, which is full

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with a enlarged prostate.

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So moving back, great.

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So we've gotta pacify so we know

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that we can track those ureters really well following them

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as they come down the sous muscles.

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And then do a bit of a dog leg into the pelvis

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and inserting at the back

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of the bladder at the vasco ureteric junction.

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And there's some mild kind

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of patchy uptake in that right prostate.

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I believe that this was a patient with known disease, so

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that might have been the site of the primary,

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although I would actually call this kind of equivocal

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and I'd be really looking at the MRI

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and we'll see why in a moment.

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So some focal uptake, which I would describe correlate

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with the MRI, um,

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because not everything in the prostate is cancer.

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You can get uptake post biopsy with inflammation

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with prostatitis and some prostate cancers aren't

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necessarily PSMA expressing.

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So that's really important to keep in mind as well.

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Notice that the wall of the

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rectum has a little bit of uptake.

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That's normal. We get a little bit in bowel.

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Um, some of the small bowel can demonstrate quite a lot

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of uptake and that's also normal

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when I do my systematic interpretation, we'll have a look at

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that in the next um, section.

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I will use tumor, then look at the primary tumors,

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look at the prostate, um, seminal vesicles, prostate bed,

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if they've had a prostatectomy, then nodes, metastases

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and systematically work through that,

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through the abdomen and through the lungs.

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Um, but we will kind of just skip

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as we are looking at a normal

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case just through the skeleton.

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It's always a really good way to have it.

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And if you can get a sagittal bone reconstruction without

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the fusion, that's really important as well.

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Um, to see if there is any skeletal lesions,

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really scrutinizing through that lumbar spine to make sure,

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um, there's no abnormal sites

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of uptake which aren't accounted for by,

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by degenerative arthropathy or other causes, um,

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because you don't wanna miss that

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kind of metastatic disease.

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Um, but this is a near normal study.

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In practice we'd be correlating with that kind

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of patchy uptake in the right prostate

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and considering the patient's, um, presentation to see if

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that is significant or not.