Interactive Transcript
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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.
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