66-year-old man with gleason 3+3, psa 23.3, and history of ... · thyroid acropachy hypertrophic...
TRANSCRIPT
Case Review!
J. Anthony Parker, MD PhD Beth Israel Deaconess Medical Center
Boston, Massachusetts
Caveat Lector
Mid-Eastern Chapter, SNMMI
44th Annual Spring Meeting April 11, 2014
66-year-old man with Gleason 3+3,PSA 23.3, and history of spinal Tb!
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Bone Scan
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What should be done next?!
223Ra therapy 6 month follow up MRI 111In capromab pendentide SPECT/CT
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What should be done next?!
223Ra therapy 6 month follow up MRI 111In capromab pendentide SPECT/CT
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66-year-old man with Gleason 3+3,PSA 23.3, and history of spinal Tb!
SPECT/CT
Subhepatic Mass!
Subhepatic Mass! What should be done next?!Contrast CT Contrast MRI SPECT/CT Damaged RBC scan Biopsy
What should be done next?!Contrast CT Contrast MRI SPECT/CT Damaged RBC scan Biopsy
What should be done next?!Contrast CT Contrast MRI SPECT/CT Damaged RBC scan Biopsy
Heat Damaged RBC – SPECT/CT! Subhepatic Mass!
38-year-old woman with anxiety, recent toe surgery, pleuritic CP, and SOB!
38-year-old woman with anxiety, recent toe surgery, pleuritic CP, and SOB!
Q
V
RAO Ant LAO L lat
38-year-old woman anxiety, recent toe Sx, pleuritic CP, and SOB!
Q
V
RPO Post LPO R lat
The BEST diagnosis is:!
normal, rules out recent pulmonary embolism very low likelihood ratio for recent pulmonary embolism low likelihood ratio for recent pulmonary embolism intermediate likelihood ratio for pulmonary embolism high likelihood ratio for pulmonary embolism
The BEST diagnosis is:!
normal, rules out recent pulmonary embolism very low likelihood ratio for recent pulmonary embolism low likelihood ratio for recent pulmonary embolism intermediate likelihood ratio for pulmonary embolism high likelihood ratio for pulmonary embolism
Lung Scan InterpretationConsensus Favors 2 or 3 Categories!
Positive Negative Non-diagnostic
Reader Estimate of PE (%) vs.Fraction of Patients with PE in PIOPED!
Worsley, J Nucl Med 1995; 36:2380
One month later
Initial scan
The MOST likely diagnosis?!
Burkitt’s lymphoma Coccidioidomycosis Pulmonary embolus Bronchogenic cancer Aspiration
One month later
The MOST likely diagnosis?!
Burkitt’s lymphoma Coccidioidomycosis Pulmonary embolus Bronchogenic cancer Aspiration
One month later
Thyrotoxic 50 y/o woman, right 3.1 and left 1.5 cm nodules. What should be
done next?!
RAO Ant LAO
Methimazole Thyroidectomy 131I Rx Biopsy
Thyrotoxic 50 y/o woman, right 3.1 and left 1.5 cm nodules. What should be
done next?!
RAO Ant LAO
Methimazole Thyroidectomy 131I Rx Biopsy (left)
Thyrotoxic 50 y/o woman, right 3.1 and left 1.5 cm nodules. What should be
done next?!
RAO Ant LAO
FNA left nodule: suspicious for papillary carcinoma
Pathology: Bilateral Papillary Carcinoma!
RAO Ant LAO
Corrected pathology: Right 1 mm incidental papillary carcinoma in a degenerating follicular adenoma
Chest X-ray!
Impression: Increased lower lobe markings, question of infiltrates
What should be done next?!
Antibiotic trial DVT ultrasound Lung scan CT angiography Anticoagulation
What should be done next?!
Antibiotic trial DVT ultrasound Lung scan CT angiography Anticoagulation
Lung Scan: V (top) / Q (bottom)!
RAO Ant LAO L lat
RAO Ant LAO L lat
Lung Scan: V (top) / Q (bottom)!
LPO Post RPO R lat
LPO Post RPO R lat
The BEST interpretation for the lung scan (CXR, ventilation, and perfusion) is!
normal, rules out recent pulmonary embolism low likelihood ratio for recent pulmonary embolism intermediate likelihood ratio for pulmonary embolism Indeterminate for pulmonary embolism high likelihood ratio for pulmonary embolism
The BEST interpretation for the lung scan (CXR, ventilation, and perfusion) is!
normal, rules out recent pulmonary embolism low likelihood ratio for recent pulmonary embolism intermediate likelihood ratio for pulmonary embolism Indeterminate for pulmonary embolism high likelihood ratio for pulmonary embolism
Bayes’ Theorem!
O(D|T) = LR(D|T) • O(D)
O(D) : 1 number describing the patient
LR(D|T) : 1 number describing the test
O(D|T) : the product of 2 numbers which combines the
patient information with the test information
Sequential Bayes’ Theorem!
If LR(D|T1) and LR(D|T2) are conditionally independent, then O(D|T1,T2) = LR(D|T1)•LR(D|T2)•O(D) In this patient, CXR is not independent of
ventilation/perfusion scintigraphy Best interpretation relies on joint reading
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This 47 y/o woman likely has a(n):
metabolic abnormality congenital abnormality neurologic disease infection artifactual finding
HCC
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This 47 y/o woman likely has a(n):
metabolic abnormality congenital abnormality neurologic disease infection artifactual finding
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This 47 y/o woman likely has a(n):
metabolic abnormality congenital abnormality neurologic disease infection artifactual finding
Crossed-Fused Ectopia!
The findings are due to:!
Ant
LAO
Ant
LAO
intramammary lymph node
early imaging technique inflammatory
carcinoma dermal backflow
The findings are due to:!
Ant
LAO
Ant
LAO
intramammary lymph node
early imaging technique inflammatory
carcinoma dermal backflow
The uptake is due to:! inflammation muscle activity glotic cancer radiation
The uptake is due to:! inflammation muscle activity glotic cancer radiation
The findings are likely related to:!
metastatic disease chemoembolization 90Y microspheres cyst resection GI bleeding
The findings are likely related to:!
metastatic disease chemoembolization 90Y microspheres cyst resection GI bleeding
This study shows:!
normal flow vascular pathology vascular variant renal dysfunction artifact
This study shows:!
normal flow vascular pathology vascular variant renal dysfunction artifact
The most likely history is:!normal LFTs melana bright red blood per rectum biopsy hip fracture
The most likely history is:!normal LFTs melana bright red blood per rectum biopsy hip fracture
The finds are MOST likely related to:!
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electrical injury contamination renal disease thyroid acropachy hypertrophic osteoarthropathy
The finds are MOST likely related to:!
Ant Post
electrical injury contamination renal disease thyroid acropachy hypertrophic osteoarthropathy
Thyrotoxicosis, TSH 0.15,Dominant Left Lower Pole Nodule!
Ant RAO LAO
Nodule marker
24-hour Uptake 46%
TSH 0.15, left lower pole nodule.What is the BEST next step?!
Rx with methimazole Rx with 131I Thyroidectomy FNA Nodule Ultrasound
Ant RAO LAO
Nodule marker
24-hour Uptake 46%
TSH 0.15, left lower pole nodule.What is the BEST next step?!
Rx with methimazole Rx with 131I Thyroidectomy FNA Nodule Ultrasound
Ant RAO LAO
Nodule marker
24-hour Uptake 46%
Ultrasound Left Lobe!
sagittal
transverse
Tissue superior and medial
Predominantly Cystic Autonomous Nodule!
sagittal
Ant RAO LAO
Nodule marker
24-hour Uptake 46%
The left arm finding is MOSTlikely related to:!
fibrous dysplasia Paget’s disease osteosarcoma radiation necrosis technique
The left arm finding is MOSTlikely related to:!
fibrous dysplasia Paget’s disease osteosarcoma radiation necrosis technique
Which cells account for the finding?!Parietal chief mucoid gastrin-secreting signet ring
Which cells account for the finding?!Parietal chief mucoid gastrin-secreting signet ring
Meckel’s Scan Technique!
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Post Ant
The abdominal finds are likely related to:!cardiac disease Chron’s disease renal disease contamination artifact
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R lat
L lat
The abdominal finds are likely related to:!cardiac disease Chron’s disease renal disease contamination artifact
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R lat
L lat
The findings are due to:!prior study delayed image micro embolism hepatorenal syndrome injection Ant
Transmission
The findings are due to:!prior study delayed image micro embolism hepatorenal syndrome injection Ant
Transmission
65 y/o Man with SOB and Hypoxia!
RAO Ant LAO
LPO Post RPO
What imaging should be done next?!
RAO Ant LAO
LPO Post RPO
Head images SPECT/CT Ventilation CTA DVT ultrasound
What imaging should be done next?!
RAO Ant LAO
LPO Post RPO
Head images SPECT/CT Ventilation CTA DVT ultrasound
MAA Head Images!
Whole Body Scans!Diagnostic I-123 Post-Rx, 7 days later
The difference between scans is due to:!Diagnostic I-123 Post-Rx
biological variability false positive post-Rx photon energy resolution post-Rx is more sensitive
The difference between scans is due to:!Diagnostic I-123 Post-Rx
biological variability false positive post-Rx photon energy resolution post-Rx is more sensitive
20 y/o man with bilateral knee pain starting on the right.!
Ant
Post Ant Post R Lat
L Lat
20 y/o man with bilateral knee pain starting on the right. BEST diagnosis?!
Ant
Post
Stress fracture Shin splints Rheumatoid arthritis Osteoarthritis Lymphoma
20 y/o man with bilateral knee pain starting on the right. BEST diagnosis?!
Ant
Post
Stress fracture Shin splints Rheumatoid arthritis Osteoarthritis Lymphoma
Differentiated Thyroid Cancer!40-year-old woman 1.9 cm multi-focal Papillary carcinoma, follicular variant No lymphovascular invasion Extends to margin focally 2 negative lymph nodes TSH 53 (0.27-4.2) µIU/mL Anti-Thyroglobulin 242 (0-40) IU/mL
Differentiated Thyroid Cancer!
Ant Post Transmission
SN
10 cm 24-hour uptake
10%
What is the BEST next step?!
Therapy with 1.85 GBq (50 mCi) Therapy with 3.7 GBq (100 mCi) Re-image after at day 3 SPECT/CT Repeat TSH measurement
What is the BEST next step?!
Therapy with 1.85 GBq (50 mCi) Therapy with 3.7 GBq (100 mCi) Re-image after at day 3 SPECT/CT Repeat TSH measurement
Differentiated Thyroid Cancer!
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Diagnostic 123I Scan
I-123 SPECT/CT!
Post 7.4 GBq (200 mCi) I-131!
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69 y/o Woman with Acute SOB and Near Syncope !
RAO Ant LAO
LPO Post RPO R lat
L lat
Ventilation
69 y/o Woman with Acute SOB and Near Syncope !
RAO Ant LAO
LPO Post RPO R lat
L lat
Perfusion
69 y/o Woman with Acute SOB and Near Syncope !
RAO Ant LAO
LPO Post RPO R lat
L lat
Perfusion toasted
What percent of the lung is involved?!
RAO Ant LAO
LPO Post RPO R lat
L lat
20% 40% 60% 80% 100%
What percent of the lung is involved?!
RAO Ant LAO
LPO Post RPO R lat
L lat
20% 40% 60% 80% 100%
Well Perfused: RML & LLL Superior Segment. Defect (segments): 15/18 = 83%!
RAO Ant LAO
LPO Post RPO R lat
L lat
Perfusion
RML
LLL superior segment
Papillary Thyroid Carcinoma!
79-year-old man Thyroidectomy for goiter 10 y previously
Incidental 2.5 cm papillary carcinoma Presents for hip pain Destructive lytic metastasis
Biopsy: papillary carcinoma
Papillary Thyroid Carcinoma!
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7.4 GBq (200 mCi) 131I
24 h uptake
8%
The most likely diagnosis (arrow) is? !
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7.4 GBq (200 mCi) 131I
24 h uptake
8%
Liver metastasis Adrenal metastasis Gastric activity Contamination Duodenal diverticulum
The most likely diagnosis (arrow) is? !
Ant Post
7.4 GBq (200 mCi) 131I
24 h uptake
8%
Liver metastasis? Adrenal metastasis Gastric activity Contamination Duodenal diverticulum
Contrast CT!
Post-Rx 131I Scan (3.7 GBq, 100 mCi)!
Ant Post
Ant
Maker: abdominal wall nodule
The MOST likely diagnosis (arrow) is:!
contamination furuncle diverticulum abdominal wall metastasis rib metastasis Ant
marker
Ant
The MOST likely diagnosis (arrow) is:!
contamination furuncle? diverticulum abdominal wall metastasis rib metastasis Ant
Ant
FDG-PET/CT!At time of 131I post-Rx scan. Path papillary thyroid.
7-years later
Applause!