Pitfalls: Question and Discussion (1)

Splenic Lesion vs. Metastasis

You showed a patient with lung cancer who had a abdominal lesion.

And the question was, is this possibly spleen or tumor?

And you showed a pet CT and said that because it was FDG avid that proved that it was metastasis.

And I'm gonna challenge that a little bit because I've actually seen that mistake made.

Splenic tissue is often FDG avid.

In fact, I had a patient a with osis, a woman with breast cancer who had a PET scan interpreted by my nuclear medicine colleagues before the ct and they said she had multiple sites of metastases in the abdomen.

I was reading her CT and said, Jesus looks like osis to me.

I went across the hall and talked to her and she in fact had had trauma years before as a teenager 20 years before, and it was osis.

So I'd be cautious about recommending PET is the problem solving thing in that city.

The only problem with this patient is the normal spleen tissue was not avid, did not pick up the isotope.

So we did not see uptake in the normal spleen and that area ditch on uptake.

But this wasn't really convincing to the clinician.

Yes, you are absolutely right there are cases report of osis or accessory spleens, but normally if you see that, you expect to see some uptake also in the normal splenic tissue.

Mm-hmm. And this case wasn't any apache in that.

So there was a discrepancy between normal uptake in the spleen and abnormal uptake in that small nodule, which is in the past clinic area.

And that's why we wind up to biopsy that case, because generally the surgeon will not accept staging if there is a questionable of variation.

Normally when you see a pet, you don't biopsy that, but if there is a questionable variation, you got to biopsy that.

Diagnostic Tests for Splenic Tissue

One of the tests that I've used a lot in these cases, I agree with the principles that you made about following the enhancement pattern along with the spleen.

Heat damage, red blood cell scan can be a very effective means of diagnosing it because almost nothing will show up on the heat damaged red cell scan except splenic tissue.

So that might be useful as a principle.

Mention that the FDG was not specifically done for that lesion.

It was done for the staging of lung cancer. Mm-hmm.

And that just happened to be a part of that.

If you found this and you don't really want to do FTG for staging lung cancer, which was done in this patient.

Yes. Isotope study with red blood cell is probably your more specific text to do that, as I showed you.

In the case of stenosis of patient who has slen ulcer tissue all over the abdomen, lateral to the liver, that was done by red blood cell damage blood cells.

Adrenal Gland Biopsies

Jaws, I know you have a specific interest in the adrenal gland.

Ali showed a number of cases of biopsies, of adrenal lesions, which I would say 15 years ago I used to do a lot of biopsies of indeterminate adrenal masses.

And actually it seems like we rarely do that anymore.

And I'm curious as what your experience has been in that regard.

Quite correct and mainly because as we know, we've got the adrenal algorithms down pretty well.

Mm-hmm. The reasons we still biopsy, which as you say, are uncommon, one of the reasons we are sort of obligated to do it because for tissue diagnosis, for some of these newer clinical trials, which require tissue as opposed to what we would consider our informed opinion on from imaging.

The other area I've found we've two other areas in the adrenal which confuse us.

One is, and we've done the studies on this, looked at increasing, we're doing pet CT as you know, for follow up for lymphoma or other malignancies.

And you can get a hot area in the adrenal, but you can see there's an adrenal mass on prior imaging.

Mm-hmm. So what do you do?

And it looks really hot, but by the way, 10% of adrenal adenomas are mildly hot.

Not really hot, but very infrequently.

Adenomas can be as you know, can be really hot.

And so sometimes the referring physicians say, look, I really wanna know here, even though we've got prior imaging, which trumps everything.

Because if an adrenal gland hasn't changed in three years a mass, it's not gonna be a metastasis except we've had one of these cases be aware.

And this would, I'm not sure whether you showed one Ali a collision tumor.

Yeah. Where we've had that, where it's become hot and the gland has maybe the same size a little bit bigger.

Finally, we've had normal appearing glands by ct, which are avid at PET in lymphoma and lymphoma can give can involve adrenal glands without changing its morphology sometimes in early lymphoma.

And we biopsy those and surprise, surprise they've been involved in lymphoma.

I don't want to ignore any questions from the audience.

So please let us know what your concerns may be.

I think regarding our general biopsy, I should mention that we really haven't, or not doing biopsy as it used to, as was mentioned, that here, rarely we do that.

And except the cases like the one which was biopsy was that collision lesion, because there was the question about was really is what's going on in the posterior aspect of the right adrenal gland when the rest of the adrenal gland has a dark signal void, if you will, on the outer face.

And then that nodule enhances.

So the clinician wanted to know as a part of staging of lung cancer, what it is.

And that's why we wound up biopsy in this case.

I, whether or not that was a part of some of the protocols for treatment oncology, I don't recall that, but that was biopsy transplant approach.

Yeah. But we don't routinely biopsy adrenal glands. No.

Because I think with the CT scan particularly, you know, enhancement and the enhancement washout if you will, that is really pretty much characteristic for benign conditions.

Pancreatic Lesions and Double Duct Sign

Giles Yes. Question here, Pancreatic about the utility of the double duct cost.

Yeah. So if I heard it correctly, the question was question of a pancreatic pseudo tumor and the value of the presence or absence of a double duct sign. Is that correct? Mm-hmm.

Well, first of all, pancreas always go through different protocol than abdominal routine abdominal CT scan.

Okay. We always use multiple plain multiplanar reconstruction in these patients.

Quite often these patients go to 3D lab technologies.

Some centers have, we happen to have one which do basically linear reconstruction of the duct from the tail all the way to the head displayed multiple planes.

So this is really more sophisticated way of workup of pancreatic lesions and that, so the coronal sagittal axial combination, all, yes, we do use all of the signs, obviously, for diagnosis of tumor, not just one axial image.

IgG4-Related Sclerosing Disease

I was gonna comment on some of the cases of IgG four sclerosis disease, and I'm using the broader term because it often is not just the autoimmune pancreatitis.

You showed some cases where I'm sure everybody in the audience said, come on, there's no way in the world you would look at that focal mass in the pancreatic tail and say, I'm confident that's autoimmune pancreatitis.

And that's true. Some of these cases are really difficult.

In fact, I was giving a lecture on the pancreas at a Hopkins meeting one time.

Stan Siegelman was in the front row, and he passed me a note saying that at this time, this was now about eight years ago, autoimmune pancreatitis was the most common cause for a false negative Whipple procedure.

In other words, they operated thinking it was pancreatic cancer, even at a place like Hopkins, which probably does more pancreatic surgery than any place in the world.

That was a problem. It isn't happening so much now.

And I am with Elliot Fishman from Hopkins frequently throughout the year.

And the big difference is we know more about it.

So in addition to the appearance of the pancreas itself, if you're even thinking about the diagnosis, have them consider it.

Usually the elevated, significantly elevated IgG four level and response to steroids is considered essentially diagnostic.

And we have saved many people the diagnosis of pancreatic cancer and surgery.

Reporting Errors and Recommendations

Which kind of leads to my next comment and I, this, I think the first time I've heard this said from the podium, but I really commend this.

Giles mentioned errors of confidence and recommendation errors.

And I really think that's an important, so I'm gonna get on my soapbox following you.

I know a lot of radiologists feel that, I gotta cover all the bases to keep from getting sued.

So even in a non-cancer patient, I see these multiple hypodense lesions in the liver.

I'm just gonna say too small to characterize.

Can't rule out metastases, recommend re-imaging at six months.

Personally, I think that's a horrible thing to do to patients.

I've given a whole course here for the same organizers on Incidentalomas and how to deal with these kind of things.

And one of the anecdotes I give is my brother-in-law who lives in Cincinnati, where, by the way, everybody has cytoplasms.

He gets the CT scan of the abdomen for some unnecessary reason.

They include a bit of the lung bases.

There are a couple of noncalcified nodules in the lung bases.

The radiologist says, you know, no abdominal pathology incidentally seen are multiple nodules in the lung bases, metastases to be ruled out.

And my brother-in-law is a self-employed architect.

His insurance company reads that he probably has metastatic disease, drops him from his insurance.

He goes through two years of hell, all kinds of workups and tremendous, tens of thousands of dollars of expense, which was totally unnecessary.

A little common sense would've gone a long way.

So I would say be very careful about lightly tossing off the idea that I can't rule out cancer.

We'll just get a follow up in six months because a lot of patients nowadays are reading their own reports.

I know. Because I get feedback on this and they see, my God, I might have cancer and I'm supposed to wait for six months to get an answer on this.

So be judicious about that and I'll have some comments in my talks about how I think we can do better than the too small to characterize or can't rule out cancer things.

Peer Review and Report Language

J do you have thoughts about this topic as well?

Yes.

One of the areas we are, and I think I'm gonna talk a little bit about this tomorrow, is we are shifting in our peer review is from looking at errors of seeing the lesion or not seeing the lesion and very much into the report.

In fact, we have more discussion over the format Mm-hmm.

And the language in the report now in our peer review process than anything else.

And I'm not saying that we are perfect, but that's where we now focus most of our peer review.

So this sort of issue will come up and frequently we'll be in discussion and you know, we are fairly vocal in our group as Mike knows, we'll say, come on, what on earth do you mean by that type of issue?

What's how's it gonna help the referring physician?

How's it gonna help the patient? Or we'll look and say, recommend MRI, how's that gonna help?

But we are even drilling down to what I alluded to was in my talk about things like suspicious of, or suggestive of Mm-hmm.

I mean, what do those mean?

If you're the referring physician and now the patient looking at this, now obviously we can't be absolutely definitive in many of the times, but it's too easy for us to put out there these vague waffly nebulous terms, frankly, because often there's no really comeback to us.

I think we've been let off the hook, if you will, for far too long by these nebulous comments.

And I was speaking with Ali just before the coffee break is that have we really gone back and asked our referring physicians ourselves what this means to them, what the impact is to their ability to take care of patients, their thought of what we are and how we script our reports.

And most of the times when you go back and ask them on this pulmonary nodule one, I was seeing my PCP for a routine yearly physical thing, and I was talking about what I'm gonna talk about tomorrow about using standardized recommendations.

He says, you guys drive us absolutely nuts.

Yeah. This is published in their literature now.

It's one of the main complaints that we, and first of all, they often see it as self-referral.

Yeah. We're just generating more studies and they say it is a huge time sink for them to keep tracking down things that almost invariably turn out to be nothing.

And we just sort of glibly say it.

And I see it all the time. I'm sure I'm guilty of it.

And without any real sense of ownership of that actionable report we talked about, we really have to change the way we do this.

Suggestions for Improved Reporting

Here. Wouldd be a good suggestion.

I think this is a really good exercise to go through for two reasons.

So you see a lesion in the liver, you see a hypervascular solid lesion in the liver.

Rather than saying impression hypervascular lesion in the liver, recommend colon something else.

Try to think if I recommend another imaging study, is it likely to be definitive?

If it's not be a little leery, I think about recommending it also before you, I don't like reading there is a descriptive lesion recommend additional imaging thing without the radiologist saying, what's in your differential diagnosis?

I mean, so if you said, for instance, let's say it's a young woman or a young man and you're saying there is a pretty uniformly hypervascular lesion in liver, but it's pretty big.

This is a real life case that I've seen many times.

And you say, I'm pretty sure it's FNH, in which case it's of no significance whatsoever, but I'm not a hundred percent sure.

Well then think about what one additional study will make you 100% sure.

It's not gonna be ultrasound, it's not gonna be pet, it would be mr.

But nowadays you can do even better. Mr.

And Vist enhanced MR will be 100% diagnostic in diagnosing FNH and excluding anything more worrisome, better than a biopsy.

Absolutely better than a biopsy.

So often when I speak at meetings like this, people will come up and they'll say, you know, it's nice that you guys think you can diagnose these things specifically, but what difference does it make?

Anything we see that's abnormal, we're just gonna biopsy.

And that's the wrong take home message.

Take FNH for instance.

If you give them a biopsy of an FNH, here's what a hedgie pathologist will say.

I see fairly well differentiated hepatocytes in a disorganized fashion paragraph.

Impression could be FNH, could be adenoma, could be well differentiated HCC.

How is that better than a hedgie radiology report?

So I don't think we can get off the hook by just throwing out some things and saying recommend biopsy.

That's and you really wanna avoid this merry-go-round of, I saw something on an ultrasound, I don't know what it is.

Recommend CET, don't know what it is, recommend Mr.

Don't know what it is. Recommend nuclear medicine, don't know what it is.

And you just keep going around and around if you think about what's on your differential diagnosis and with a little reading and so forth, you can often think of the one specific additional test that will make a specific diagnosis.

And that's why I mentioned the heat damage, red blood cell scan.

If you're saying, I see this lesion in the tail of pancreas.

I looked at Ali's five cases up there and I recognize what a couple of 'em, one were for sure, but three of 'em I couldn't distinguish.

I personally would probably not have gone to mr.

There's nothing wrong with mr.

But I would've gone probably either to the reformatted images for that splenic artery aneurysm or heat damage, red blood cell scan.

But try to think of the one thing it'll do that you can do to make a specific diagnosis.

And in my opinion, it's not always a biopsy.

Some cases it is, but not always.