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Challenging Body Case 5

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Best case I really like, the CT scan,

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probably one of my favorite CT cases that I've come across relatively recently.

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All right, so maybe I'll give you a little bit of history on this one.

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This is a,

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I think it was a 35, 40-year-old gentleman who had an ultrasound,

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retroperitoneal ultrasound.

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They couldn't find the kidney, the left kidney.

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And when they scrolled down to the bladder, they saw a mass.

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And so they thought that this was a...

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that the mass in the bladder is the pelvic kidney.

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And so they got a CT scan to further evaluate the findings.

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And so they did it as a hematuria protocol.

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And so I'll go through the different

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phases for the hematuria protocol, just so that I present to you everything

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that we would be presented with as we go through.

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So, this is the non-contrast CT.

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Recall, they couldn't see a left kidney

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on the ultrasound.

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And they saw a mass in the bladder, or the location, the bladder.

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So we see something, perhaps, in the pelvis over there.

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So that's our non-contrast CT.

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Scroll through our contrast,

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the nephrographic phase just goes through the kidneys.

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So I'll just go start from the top again

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and just sort of scroll through that, see if there's anything there that can

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help you figure out what's going on over here.

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And then I'll finish up with delayed image,

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excretory phase, about 8 to 10 minutes out.

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And this is going to go through everything.

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So we're scrolling through,

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scrolling through, scrolling through,

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we get to this lesion in the pelvis, what they saw in the ultrasound.

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And so, those are the axial images.

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And let me just show you coronal excretory phase,

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so you get a relationship

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of what this mass looks like with respect to

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some of the other organs, perhaps, that you're seeing in the pelvis over here.

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And I'll show you sagittal,

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excretory phase image as well.

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Okay. So one more time,

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I'm just going to scroll through the axial images linked.

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Just scrolling. I don't know if this is folia.

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This is looking pretty good here.

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And just scroll down to the pelvis,

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so you can get a sense of the pre and post contrast appearance of this lesion.

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All right.

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So, let's move on to the question.

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This is going to be question number five,

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is regarding the pelvic mass that I've shown you,

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what is the most likely diagnosis?

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And so,

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the options here,

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urachal adenocarcinoma.

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We talked little bit about that, actually, in our first case.

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So try to remember what the association and where the location should be for that.

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Gastrointestinal stromal tumor.

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Certainly, a possibility can happen in these locations.

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Germ cell tumor as well.

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That's another option I'm presenting to you.

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Solitary fibrous tumor.

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Uncommon tumor.

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But these are challenging cases, at least I think they're challenging.

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So let's see if...

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And I will tell you that based on these images,

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could come with a specific diagnosis.

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All right.

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So I think we're a little bit all over the place.

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This one, we have SFT at the top diagnosis,

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solitary fibrous tumor, gastrointestinal tumor,

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urachal adenocarcinoma, and germ cell tumor is number one.

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Okay. So let's go through this case.

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This was a fun case to go through.

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So, I'll stop the linking.

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So the first thing you notice, the history as I said, you know,

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they got this on this young gentleman, they didn't see a left kidney.

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So the question, is there pelvic kidney?

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Well, if you look at it,

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and it turns out there is a very, very small left kidney.

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It's atrophic.

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I'm not really sure, we didn't have much

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more history on this gentleman that there was a prior insult or something.

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But certainly, my assumption was that this

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is going to be sort of, congenitally, a very small kidney.

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Right kidney, on the other hand, looks very robust, looks very good.

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And as you scroll down all the way here, you'll see the mass and,

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you know

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not much, I think, to be gleaned from the pre and post contrast

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edges except for the fact that it is a mass, that it has enhancement.

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There's soft tissue components to it.

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Perhaps some of it is necrotic or just hypovascular,

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pretty well-defined mass.

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If we look at our options,

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urachal adenocarcinoma was one of them.

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And this is what I want to show you in the sagittal,

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that it really doesn't look like it's arising from the bladder.

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It looks like it almost has some mass effect on the bladder.

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Urachal adenocarcinoma, you'd expect to arise from this tip of the bladder.

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So I think it's a good thing to think about when you see these large

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sort of masses,

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heterogeneous masses, which may be associated with bladder.

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But I think if you were to scroll through this and really look at it

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at your own pace,

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you would see that there's almost a fat plane over here.

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So this is sort of causing mass effect on the bladder.

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So we can sort of knock that one out.

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I think the gastrointestinal stromal tumor is always something

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I think about when I see these masses and I can't quite locate them where they are.

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Solitary fibrous tumors, as well, are rare tumors.

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Something to think about, imaging appearance is often nonspecific.

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What's been described is they are quite vascular on MRI.

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They can have flow voids.

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And classically, they've been associated

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with these perennial plastic syndromes, where they get hypoglycemia

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because the tumor secretes some insulin-like growth factor.

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So, you know, I think those are not bad thoughts,

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but the right answer in this case is actually germ cell tumor.

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So kudos to, I think, the one person who got that right.

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And so, what's the other finding that can

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allow us to make a specific diagnosis here?

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Well, we have this mass, that's not going to help us,

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the appearance itself.

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As you scroll through, what do you notice it's missing over here?

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Right.

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So the left spermatic cord is actually missing in this instance.

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The right spermatic cord is intact, left spermatic cord is missing.

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And so, that tells us that this is a patient who had no other prior surgery.

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Nothing like that.

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May have an undescended testicle somewhere.

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And so, if you were to follow then his testicular vein,

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gonadal veins, you were to see that they would actually

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scroll right into this lesion over here.

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So I want you to follow this vessel right over here,

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going all the way up, going all the way up,

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draining into the left renal vein.

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Now, I didn't expect you to see that,

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obviously, as you're scrolling through it.

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But if we go through it very carefully,

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you can see that this actually germinates right through these masses.

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And so, this turned out to be proven

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mixed germ cell tumor, and somebody who had an undescended testicle.

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And the other cute finding you can see here

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is that his left,

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some of the vesicles either atrophic or just missing.

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And so that probably goes along with some of the other congenital findings that he has,

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a very atrophic left kidney and an undescended left testicle.

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And as you know, cryptorchidism, you know,

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the testicle in those instances can be located anywhere from upstairs

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in the kidney to the inguinal canal, but almost always are included

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in the inguinal canal, about 80% of the times.

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And why do we worry about undescended testicles?

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There is an increased risk of malignancy

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and there's an increased risk of fertility.

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And so, this is one case where relatively

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older gentleman, we see a tumor developing in an undescended testicle.

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All right.

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So that was that case.

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As I said, one of the ones that was

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a relative favorite of mine in the last few years.

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I was happy to share that one with you.

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Lets move on to the next case.

Report

Description

Faculty

Mahan Mathur, MD

Associate Professor, Division of Body Imaging; Vice Chair of Education, Dept of Radiology and Biomedical Imaging

Yale School of Medicine

Tags

Testicles

Neoplastic

Genitourinary (GU)

CT

Body

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