Wk 3, Case 5 - Review

Technique:
Preparation: Last oral intake (except water): ----- at -----.
Blood glucose at time of FDG administration: ----- mg/dL.
Radiopharmaceutical: ----- mCi of F-18 FDG administered IV at -- via ----.
Uptake time: ---minutes.
Oral contrast: -----.
Positioning: Arms raised.
PET/CT scanner: -----.
PET/CT acquisition: skull-base-to-mid-thighs.
PET reconstruction method: Point Spread Function-Time of Flight (PSF-TOF), 2 iterations, 21 subsets, with and without CT-based attenuation correction.
Standardized uptake value (SUV): Corrected for BW or LBM.
CT: Low-dose, non-breath-hold, without intravenous contrast.
TOTAL DLP (Dose Length Product): ----- mGy.cm.

Comparison/Correlation:
--

Findings:
Technical quality: --------.

Measurements: Unless otherwise specified, all SUVs refer to maximum value in the target.


Head and Neck:
Solitary intensely hypermetabolic 10 x 7 mm left supraclavicular lymph node, maximum SUV 6.2.
No other suspicious hypermetabolic lesions in the head or neck.
Unremarkable thyroid gland.


Breast:
Intensely hypermetabolic large lobulated infiltrative left upper outer quadrant breast mass measuring 6.6 x 3.5 x 5.2 cm with maximum SUV 18.6 consistent with biopsy proven invasive ductal carcinoma.
Multiple intensely hypermetabolic metastatic left axillary and left internal mammary lymph node. Examples are:

12 x 26 mm with maximum SUV 13.1.
10 x 13 cm sub-pectoral/level II axillary lymph node, maximum SUV 8.3.
Small 7 x 6 mm let internal mammary lymph node maximum SUV 4.3.
Chest:
No suspicious hypermetabolic lesions within the chest.
No suspicious pulmonary nodules or masses. No large areas of focal consolidation.
Dependent hypoventilatory changes.
Paraseptal emphysematous changes.
Stable heart size and caliber of the major vessels.
Mild aortic and multivessel coronary artery atherosclerotic calcification.


Abdomen and Pelvis:
No suspicious hypermetabolic activity in the abdomen or pelvis.
Solid Abdominal Organs:
Hepatic steatosis.
No focal hypermetabolic activity in the liver significantly greater than the heterogeneous physiologic uptake.
Unremarkable noncontrast appearance of the liver.
Normal gallbladder.
No hydronephrosis.
Unremarkable spleen.
No suspicious adrenal masses.
No suspicious pancreatic findings.
GI Tract/Mesentery/Peritoneum:
Physiologic bowel activity, without suspicious focal FDG uptake.
The large and small bowel appear normal in caliber.
Sigmoid diverticulosis.
No suspicious peritoneal/mesenteric findings.
Lymph Nodes: No pathologically enlarged or hypermetabolic lymph nodes in the abdomen or pelvis.
Pelvic Viscera: Unremarkable uterus and ovaries.
Vasculature: Extensive aortoiliac atherosclerotic calcification.
Free Fluid: No ascites or drainable fluid collection.


Skeleton and Soft Tissues:
No suspicious hypermetabolic activity in the visualized osseous structures.
No aggressive osseous lesions.
Degenerative changes throughout the spine.

Impression:
1. Intensely hypermetabolic large lobulated infiltrative left upper outer quadrant breast mass, consistent with biopsy proven invasive ductal carcinoma.
2. Multiple intensely hypermetabolic metastatic left axillary, left internal mammary and solitary left supraclavicular lymph nodes.
3. No convincing evidence of metabolically active distant metastatic disease.

Technique:
Preparation: Last oral intake (except water): ----- at -----.
Blood glucose at time of FDG administration: ----- mg/dL.
Radiopharmaceutical: ----- mCi of F-18 FDG administered IV at -- via ----.
Uptake time: ---minutes.
Oral contrast: -----.
Positioning: Arms raised.
PET/CT scanner: -----.
PET/CT acquisition: Vertex-to-mid-thighs.
PET reconstruction method: Point Spread Function-Time of Flight (PSF-TOF), 2 iterations, 21 subsets, with and without CT-based attenuation correction.
Standardized uptake value (SUV): Corrected for BW or LBM.
CT: Low-dose, non-breath-hold, without intravenous contrast.
TOTAL DLP (Dose Length Product): ----- mGy.cm.

Comparison/Correlation:
--

Findings:
Technical quality: --------.

Measurements: Unless otherwise specified, all SUVs refer to maximum value in the target.


Head and Neck:
No suspicious hypermetabolic lesions in the head or neck.
No suspicious cervical adenopathy.
Thyroid gland is unremarkable, without suspicious FDG uptake.


Breast:
Complete metabolic resolution with significant decrease in size of previously seen intensely hypermetabolic large lobulated infiltrative left upper outer quadrant breast mass, currently measuring 1.5 x 1.1 x 2.2 cm (AP x TRA x CC) with maximum SUV 1.7 (similar to background breast tissue), previously measuring approximately 6.6 x 3.5 x 5.2 cm with maximum SUV 18.6.
Complete metabolic resolution with significantly interval decreased number and size of previously seen numerous left axillary, left internal mammary and solitary left supraclavicular lymph node. For example:

Largest left axillary lymph node on comparison study measured 12 x 26 mm with maximum SUV 13.1, now measures 7 mm in maximal dimension without discernible FDG uptake.
Complete resolution of previously seen 1.3 x 1.0 cm sub-pectoral lymph node, previously showed maximum SUV 8.3 in prior scan.
Chest:
No suspicious hypermetabolic lesions within the chest.
Right middle lobe peri-fissural 5 mm nodule with trace FDG uptake likely infectious or inflammatory given absence on prior PET/CT.
No suspicious pulmonary nodules or masses.
No large areas of focal consolidation.
Dependent hypoventilatory changes.
Multiple new small to borderline mild to moderately hypermetabolic mediastinal and bilateral hilar lymph nodes, an example is the Subcarinal lymph node measuring 9 mm with maximum SUV 3.6.
Stable heart size and caliber of the major vessels.
Mild aortic and multivessel coronary artery atherosclerotic calcification. No abnormal esophageal activity.


Abdomen and Pelvis:
No suspicious hypermetabolic activity in the abdomen or pelvis.
Solid Abdominal Organs:
No focal hypermetabolic activity in the liver significantly greater than the heterogeneous physiologic uptake.
Unremarkable noncontrast appearance of the liver.
Normal gallbladder.
No hydronephrosis.
Unremarkable spleen.
No suspicious adrenal masses.
No suspicious pancreatic findings.
GI Tract/Mesentery/Peritoneum:
Physiologic bowel activity, without suspicious focal FDG uptake.
The large and small bowel appear normal in caliber.
No suspicious peritoneal/mesenteric findings.
Lymph Nodes: No pathologically enlarged or hypermetabolic lymph nodes in the abdomen or pelvis.
Pelvic Viscera: Unremarkable uterus and ovaries.
Vasculature: Extensive aortoiliac atherosclerotic calcification.
Free Fluid: No ascites or drainable fluid collection.


Skeleton and Soft Tissues:
No suspicious hypermetabolic activity in the visualized osseous structures.
No aggressive osseous lesions.
Degenerative changes throughout the spine.

Impression:
1. Complete metabolic resolution with significant decrease in size of previously seen intensely hypermetabolic large lobulated infiltrative left upper outer quadrant breast cancer with no residual FDG uptake above background breast tissue.
2. Complete metabolic resolution with significantly interval decreased number and size of previously seen numerous left axillary, left internal mammary and solitary left supraclavicular lymph node.
3. New mildly hypermetabolic mediastinal and bilateral hilar lymph nodes most consistent with sarcoid like reaction to immunotherapy.
4. No convincing evidence of new metabolically active metastatic disease.