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門朝陽醫師於嘉義市聖馬爾定醫院 (9/14 pm2-5).  若是你作特定不正常的健檢病人 PET/CT 那麼你我可能報 告敘述是對的但是 … 不是這東西 / 不是你我用語如 high possibility or low possibility for lung cancer 解釋那你要怎麼 說.

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Presentation on theme: "門朝陽醫師於嘉義市聖馬爾定醫院 (9/14 pm2-5).  若是你作特定不正常的健檢病人 PET/CT 那麼你我可能報 告敘述是對的但是 … 不是這東西 / 不是你我用語如 high possibility or low possibility for lung cancer 解釋那你要怎麼 說."— Presentation transcript:

1 門朝陽醫師於嘉義市聖馬爾定醫院 (9/14 pm2-5)

2  若是你作特定不正常的健檢病人 PET/CT 那麼你我可能報 告敘述是對的但是 … 不是這東西 / 不是你我用語如 high possibility or low possibility for lung cancer 解釋那你要怎麼 說 ? 我們應當看到 a 講 A; 而非看到 a 講 B( 差之毫釐失之千里 )  role of PET in patients in the literatures(clinical indication?)  Rades et al detected the primary site in 18 of 42 patients using PET, all these patients had localized cancer of unknown origin by using conventional staging procedures. PET was positive for disseminated diseases in 38% patients. In 69% patients PET results influenced the selection of the definitive treatment. 不明原發癌症 Cancer of Unknown Primary (CUP) roles? PET/CT training is important, most of us, self training!

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4 高醫張醫師選特定病人作前瞻性研究發 現 : 以 PET/CT 篩選即將動手術的病人

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8  Right massive pleural effusion.  s/p pleural fluid drainage with recurrency.  Pleural fluid analysis: no malignant cells.  He had umbilical itching and scratched and wound was still found during PET/CT study. No major systemic disease was told.

9 MIP for case 1: twice  C:\Users\user\Desktop\Yeh Heng Ming_2010- 3-5.avi C:\Users\user\Desktop\Yeh Heng Ming_2010- 3-5.avi  C:\Users\user\Desktop\Yeh Heng Ming_2010- 6-28.avi C:\Users\user\Desktop\Yeh Heng Ming_2010- 6-28.avi

10 PET/CT: E:\AutoRun.exe Others imaging study: E:\LaunchPad.exe And What is your diagnosis?

11 umbilical metastasis (Sister Mary Joseph's nodule) from malignant peritoneal mesothelioma.

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13 In medicine, the Sister Mary Joseph nodule or node, also called Sister Mary Joseph sign, refers to a palpable nodule bulging into the umbilicus as a result of metastasis of a malignant cancer in the pelvis or abdomen.( 維基百科 ) Gastrointestinal malignancies account for about half of underlying sources (most commonly gastric cancer, colonic cancer or pancreatic cancer, mostly of the tail and body of the pancreas[1]), and men are even more likely to have an underlying cancer of the gastrointestinal tract. Gynecological cancers account for about 1 in 4 cases (primarily ovarian cancer and also uterine cancer). Unknown primary tumors and rarely, urinary or respiratory tract malignancies cause umbilical metastases.[2] How exactly the metastases reach the umbilicus remains largely unknown. Proposed mechanisms for the spread of cancer cells to the umbilicus include direct transperitoneal spread, via the lymphatics which run alongside the obliterated umbilical vein, hematogenous spread, or via remnant structures such as the falciform ligament, median umbilical ligament, or a remnant of the vitelline duct.[3] Sister Joseph nodule is associated with multiple peritoneal metastases and a poor prognosis

14 The most common origins of Sister Mary Joseph Nodule are gastrointestinal (52%), gynaecologic(28%), stomach(23%) and ovarian (16%) carcinomas. 15-29% of all cases have an unknown origin ( as depicted by our case ) and 3% originate from the thoracic cavity. Primary tumours in many other sites like gall bladder, uterus, liver, endometrium, small intestine, fallopian tube, appendix, cervix, penis, prostrate, urinary bladder, breast, lung & kidneys have also been reported to cause Sister Mary Joseph Nodules. Histology of the metastatic umbilical tumour usually reveals adenocarcinoma but rare reports of umbilical metastasis from sarcomas, mesotheliomas and melanomas have also been seen.

15  E:\AutoRun.exe E:\AutoRun.exe  General history: only routine chest X-ray film revealed left lung mass of unknown etiology.  Found left lung mass. With elevated in CEA level.  What is your diagnosis?

16  C:\Users\user\Desktop\Hsiao Cheng Nen_2010-5-3.avi C:\Users\user\Desktop\Hsiao Cheng Nen_2010-5-3.avi

17  6/21 report:adenocarcinoma, favor of colorectal origin, 60% of tumor cells in selected region. Genomic DNA with PCR sampling was compared with cDNA sequence of K-RAS from Genbank using proteinase K digestion by DNA extraction. Exon 1 of K-RAS gene was amplified by nested PCR.

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22  Clinical indication: C(pleural fluid will decrease SUV(mostly <2.5). Has limitation for tumor in transdiaphragmatic extension and mediastinal nodal metastases, the value of PET/CT in mesothelioma is identify extrathoratic metastases, obviating thoracotomy. SLC: C and NSLC: B; SPN:A; Pulmonary meta vs benign nodule: C(because of BAL).

23  Apotosis(for CRC pedicle rupture!)  Disappearance due to chemotherapy  Self immune condition  Other known reason.

24 Article Review :

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28 PET-CT Type: Lung Clinical Information : Persistent left lower lobe collapse/consolidation. No endobronchial lesion at bronchoscopy ? malignancy. Technique: 604 MBq 18F-FDG injected. Blood glucose 5.2 mmol per litre. Skull base to upper thigh acquisition.Findings: No prior imaging available for comparison. There is a 4.9 x 3.8 cm extremely FDG avid mass which occludes the left upper lobe bronchus resulting in distal atelectasis and consolidation (SUV max 18.8). A left pleural effusion is present demonstrating low-grade tracer uptake.There is no separate FDG avid hilar or mediastinal lymph node disease. No focal hepatic or adrenal metastases. However, there are markedly FDG avid bone lesions. The largest of these involves the left iliac blade which shows a mixed lytic-sclerotic appearance (SUV max 14.4). There are further FDG avid lesions within the left lesser trochanter and proximal left femoral shaft. The appearances are highly suspicious for bone metastases.There is a small focus of moderate FDG uptake localising to the posterior myometrium in the mid-corpus of the uterus (SUV max 5.7). This is an indeterminate finding. If this would impact on the patient's clinical management, a dedicated gynaecological ultrasound would be recommended to clarify.There is prominent tracer uptake within the anal canal which either represents physiological anal sphincter activity or localised inflammation. The remainder of FDG biodistribution is physiological.The unenhanced CT provides no additional clinically significant information. Conclusion: The appearances are consistent with a primary malignancy in the left upper lobe with occult bone metastases (stage IV disease). Focal tracer uptake within the myometrium which is of uncertain aetiology, and could be clarified with a dedicated gynaecological ultrasound if this would alter patient management. There is a mildly FDG positive left pleural effusion, aspiration of fluid for cytology may yield a diagnosis.

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30 PET-CT Type: Head & NeckClinical Information y : Tongue base squamous cell cancer. CRT followed by glosso-laryngectomy for recurrence. Increasing trismus and neck pain.Technique: 368 MBq 18F-FDG injected. Blood glucose 6.5 mmol per litre. Skull vertex to upper thigh acquisition.Findings: Comparison was made with a prior CT from 24/04/2009.There is a marked and diffuse increase in tracer activity throughout the right side of the jaw involving the symphysis, body and ramus of the mandible (SUV max 13.1). The CT component demonstrates osteolysis within the right side of the mandibular body, there is also stranding within the adjacent fat. In addition, there is a contiguous 32 x 22mm focus of markedly increased FDG uptake within the right parapharyngeal soft tissues extending from the inner aspect of the right mandibular ramus to the right prevertebral area at the axial level of C3 (image 252, SUV max 11.8). There is some increased activity around the ramus of the left mandible that presumably relates to asymmetric masseter muscle activity secondary to altered biomechanical stress. A moderate focus of increased tracer uptake is also present within the odontoid peg which demonstrates corresponding osteosclerosis on the CT component (SUV max 6.4). All these changes could relate to osteonecrosis secondary to prior radiotherapy. However, the avid FDG uptake within the right parapharyngeal soft tissues raises the suspicion of local recurrence, and this could be clarified by direct inspection +/- biopsy.A 5 cm segment of proximal sigmoid colon demonstrates moderately avid FDG uptake with associated mural thickening, diverticulosis and pericolic stranding (SUV max 9.9). The appearances are consistent with active diverticulitis. Clinical correlation is advised, with sigmoidoscopy if indicated. The remainder of FDG biodistribution is physiological.The unenhanced CT confirms previous radical neck dissection and glosso-laryngectomy. A percutaneous gastrostomy is in situ and there is evidence of subsegmental right middle lobe atelectasis.

31  Clinical indication: B  Staging: B  Recurrence : A

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33 PET-CT Type: Lymphoma Clinical Information : Multiple relapsed Hodgkin's lymphoma. Re-staging prior to chemotherapy. Mantle radiotherapycompleted 01/05/2009. Technique: 401 MBq 18F-FDG injected. Blood glucose 5.9 mmol per litre. Skull vertex to upper thigh acquisition.Findings: Comparison made with prior PET/CT 10/02/2009 and bone scan 27/04/2009. There is a large focus of markedly avid FDG uptake within the posterior left iliac bone corresponding to an area of osteolysis (SUV max 15.1). There is a further area of moderate tracer uptake within the antero- lateral right 7th rib corresponding to ill-defined medullary sclerosis (SUV max 5.1). No definite rib fracture is seen. The appearances are consistent with areas of focal bony involvement. There is low-grade residual tracer activity in small right paratracheal nodes (SUV max 4.1, previously 7.7) and in the anterior mediastinum within a 20 x 17 mm node (SUV max 3.8, previously 4.5). The interpretation of these findings is made more challenging by recent radiotherapy which may give rise to an inflammatory response resulting in false-positive FDG uptake. No other site of FDG avid disease demonstrated. Specifically, normal FDG uptake within the spleen and liver. There is a mild increase in tracer activity throughout the bone marrow which is in keeping with a reactive marrow following recent therapy.There are multiple, inflammatory-looking parenchymal nodules within both lungs, some of which demonstrate low-grade tracer uptake. The appearances are likely to relate to current infection, and atypical infection in particular should be considered. There is a focus of relatively avid tracer uptake in the nasopharynx to the right of the midline, but there is no morphologic abnormality at this site and this is likely to be physiological. Similarly, there is physiological vocal cord uptake and muscle activation in the left infraspinatus and within the paravertebral muscles. The remainder of FDG biodistribution is physiological. The unenhanced CT provides no additional clinically significant information. Conclusion: FDG avid lesions within the left iliac bone and right 7th rib consistent with areas of focal bone involvement. Residual tracer uptake in the right paratracheal and anterior mediastinal areas which may represent residual disease or an inflammatory response following recent radiotherapy. Multiple inflammatory-looking pulmonary nodules- atypical infection should be considered.

34  Staging: A1  Therapeutic response: A  Relapse: C

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36 PET-CT Type: Rectal Clinical Information : Recurrent rectal carcinoma. Being considered for re-do pelvic resection. ? extra-pelvic disease.Technique: Half body acquisition from skull base to upper thigh. 385 MBq of 18F-FDG injected. Blood glucose = 6.3 mmol/l.Findings: Comparison is made with a previous pelvic MR scan from 18/02/09 and a CT of the abdomen and pelvis from 19/02/09 both performed at Trafford General Hospital.In the interim since the prior imaging there has been marked progression of disease. Within the pelvis the suspected tumour recurrence adjacent to the rectal stump has markedly increased in size and now measures 8.9 cm in diameter and demonstrates intense FDG uptake with a maximum SUV of 24.7. There is now evidence of overt invasion into the uterus. There is a 2.9 cm left pelvic side wall nodal mass which is FDG avid. Further small volume FDG positive nodal disease is present within the left common iliac chain and within two mesenteric nodes adjacent to the sigmoid colon. There is a new FDG bone metastasis within the upper body of the sacrum (SUV = 19.1) with an adjacent pre-sacral soft tissue component. Within the remnant liver the previously demonstrated metastasis adjacent to the cut surface has increased in size to 5.6cm and demonstrates avid FDG uptake.There are unfortunately now also innumerable other small FDG avid lesions which are widely disseminated throughout the remaining liver segments which are highly likely to represent multiple metastases. No retroperitoneal adenopathy demonstrated. There is diffuse low grade tracer activity within the bone marrow which may reflect recent chemotherapy. The PET component reveals no additional information.On review of the low-dose CT there is a tiny calcified granuloma within the right lower lobe, the lungs are otherwise clear. There has been a prior right hemihepatectomy, the remaining liver has hypertrophied. There is moderate splenomegaly which is unchanged from the prior CT. Previous bowel surgery and a left iliac fossa stoma is noted. Conclusion: Extensive pelvic recurrence with likely uterine involvement, pelvic sidewall, left iliac and mesenteric nodal disease. Sacral bone metastases. Widely disseminated liver metastases.

37  Clinical indication:C  Recurrence and restaging: A  Initial staging: B  Therapeutic response: C

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39 PET-CT Type: Oesophageal Clinical Information: : Gastro-oesophageal adenocarcinoma extending into the stomach. Staging.Technique: : Half body acquisition from skull base to upper thigh. 353 MBq of 18F-FDG injected. Blood glucose = 6.4 mmol/l.Findings: Comparison was made with the CT performed in February 2009. There is marked circumferential mural thickening of the distal oesophagus extending from the level of the pulmonary veins to the gastric fundus and antrum. This demonstrates markedly increased FDG activity. The minimally enlarged gastro-hepatic ligament nodes demonstrated on the prior scan are FDG positive and likely to represent nodal metastases. In addition, there are multi-focal areas of increased FDG uptake within the bones corresponding to multiple lytic metastases which have developed since the prior CT. The largest is within the left iliac blade. Further similar abnormalities are present within the C4 vertebral body, the sternum, and multiple ribs, and the proximal left femur. The left adrenal is slightly thickened and demonstrates abnormal FDG uptake consistent with an adrenal metastasis. There is cervical brown fat uptake and uptake related to dental caries. CT demonstrates a small peripheral nodule within the left lower lobe with no FDG activity, this is below the size threshold for accurate characterisation. Conclusion: Gastro-oesophageal tumour with multiple occult bone and left adrenal metastases.

40  Detection of primary esophageal cancer:D  Staging of esophageal cancer: A  Recurrence : C  Therapeutic response: B  Stomach cancer: clinical indiation: C  Nodal metastasis: 78 to 96%.

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42 Clinical Information: Right breast carcinoma 1999. Previous chest wall recurrence. Brachial plexus dysfunction.Technique: 363 MBq 18F-FDG. Blood glucose 5.5 mmol/l. Skull base to upper thigh acquisition.Findings: There are heterogeneous foci of abnormal FDG activity involving the soft tissues and ribs in the lateral right chest wall at the level of the right 7th-10th ribs, in the area of prior surgery. There is linear moderately avid uptake involving the overlying trapezius muscle (SUV Max 9.1) with further focal uptake in a soft tissue nodule overlying the lateral aspect of the right 8th rib and in the right 9th intercostal space. Focal abnormal FDG avidity is also demonstrated within the right 9th and 10th ribs with evidence of previous fractures at these sites on the CT component of the study.There is moderately avid FDG uptake within an 8mm right axillary node (SUV Max 6.2) and a further extremely avid uptake within a 6 mm pre- vascular node (SUV Max 14.6). Several other small mediastinal nodes are demonstrated on the CT component but these are not FDG avid.There is an intense focus of abnormal FDG activity at the costovertebral junction of the right second rib corresponding to an area of osteolysis on the CT component (SUV Max 13.7). There is associated paravertebral soft tissue which is FDG avid and extends anteroinferiorly into the supraclavicular fossa. This is highly likely to be involving the right sided brachial plexus and may account for some of the patient's symptoms.There is a subpleural area of atelectasis in the peripheral right upper lobe which demonstrates mild FDG uptake in keeping with prior radiotherapy change.The unenhanced CT demonstrates an 8mm nodule in the left lower lobe which does not appear to be FDG avid although there is mild FDG activity immediately medial and cranial to this site. There may be some respiratory mis- registration, but this nodule is strictly indeterminate for aetiology. Incidental gallstones but no other clinically significant finding.Conclusion: Appearances in keeping with chest wall recurrence, nodal and bone metastases. There is also right brachial plexus involvement which accounts for some of the patient's symptoms.

43  Clinical indication: B  Staging: B  Recurrence: B  Therapeutic response: B


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