Abdominal Case Conference 2026 - Session 5

Okay. So, what do you guys see?

>> You seem to be focused on the penile shaft with like a >> there's a marker.

>> Yeah.

>> Can you tell >> there's some kind of like there's like a rim enhancing thing or something?

There's like something rounded overlying the cavern. Some

the cavern. Some >> this thing.

>> It's too dense to be rim enhancing. It's

like metal.

>> Oh, no. No. I mean, that's a marker.

Wait, is that not Is that not intentional? I thought that was a marker

intentional? I thought that was a marker that the tech placed.

>> Uh, no. Not the

>> under the skin, >> but it's very rectangular. It looks

irogenic.

>> Yeah, >> it is irogenic, >> but it's like tenting the skin.

>> Yeah, you're right.

>> So, uh, any thoughts what this is? We'll

pretend we did not see the sticky note.

>> Even seeing the sticky note, I don't know what this is. hurt.

>> What?

>> Aon.

>> Yeah. Yeah.

>> As my Spanish speaking children would say.

>> Is it some kind of new like >> Well, is it like a stimulation thing like you know to heighten intercourse >> sort of? Yes. Uh this is genital beading

or penile pearling. Uh you can have one to many. They can be rounded, they can

to many. They can be rounded, they can be rectangular or squareish. And it acts like a uh spiked condom.

And I will Oops.

I will bring this article.

>> Okay.

>> Um so this is spenile pearls and there have been various reasons attributed to it and this is one of the extreme examples that we see in this case.

Wow.

>> That's that's about it.

>> Wow.

Well, there's worse things one can do than putting things in the subcutaneous tissues.

>> Mhm. Are there a lot of complications or >> There are a bunch of complications and it sums up here.

Um I'm sure like the regular complications of wound infection and absess are there and transmission of sexually transmitted

diseases injury to the partners and even they've reported squamous cell carcinoma arising because of these chronic irritation.

>> Well have not seen it yet but I will be on the lookout now. Mhm.

Uh this is a patient who has this in the adrenal glands bilaterally.

I see like bright nodules.

>> Mhm. Yeah. And then post contrast metric T2 bright. I always think about foss and

T2 bright. I always think about foss and they're very avidly enhancing it would >> so I think about foss >> so there's your and then I don't know that

>> some syndrome then if it is by natural >> and then there's no fat uh >> there's hereditary per gangloma syndrome there's carnese triad

>> so this patient I'll give you one more clue also had pancreatic narnoc tumor >> men Meen.

>> Okay. Another clue. They also had hemangobblasto.

>> Oh.

>> Yes. BHL. [laughter]

Um, so patients with bil this patient had bilateral adrenal fuel. Uh, it's

it's not diagnostic or BHL, but it's highly suggestive and it warrants genetic testing if you see bilaterality.

Uh, so like the bilateral field is a a strong indicator of hereditary disease.

I think um or they just mentioned men.

So VHL, MEN2 and then there's other ones called rest and MAX and TMEM mutations.

Um VHL counts for only a small subset of bilateral FO uh as you know like we see it with MEN2 for example. Um and then diagnostic criteria for VHL requires

more than just bilateral FIO. So uh with family history so a relative with VH VHL mutation um and a first um sorry and

then FO um can be a sole manifestation of VHL but it still requires genetic testing and it's recommended for all patients uh with bilateral FOS

uh and so VHL patients uh have a they have a different de demographics they're usually younger uh so main diagnosis in their 20s uh they're usually asytomatic

or neurotensive. The tumors are smaller

or neurotensive. The tumors are smaller um and you can't see multifocality.

>> Nice. They did not have any of the other stuff for VHL like pancreatic cyst.

>> They they had they developed a pancreatic neuron tumor later >> and then they also has they also have known cerebellar hemangoblasma that are

being actively surveyed. Uh, and this patient uh underwent a cortical sparing adrenalctomy.

And I didn't know you can do that either.

>> Wait, wait, wait, wait. Say that again.

Corticalsparing adrenalctomy. That's so

cool. So they just like just took out the foar.

>> It nucleated the Yeah.

>> Keep the cortex so you don't become like addenoid or whatever. Like

>> Oh wow.

>> Yeah. And this patient, they also had this patient on this medication called Belutapan. B E L Z- U T I F and I didn't

Belutapan. B E L Z- U T I F and I didn't realize that you can treat VHL. Uh so uh it's a HIF 2 alpha inhibitor. Uh and

it's FDA proof uh to treat VHL uh disease associated tumors. Uh so uh for RCC heangoblas uh and the CNS like the

spine and cerebellum or pancreatic neurendocrine tumor that don't require immediate surgery.

Uh so the it binds to Hif to alpha and blocks the interaction with um the kind of downstream um formation of problems

that eventually lead to uh you know tumor tumorogenesis in VHL. So now they can medically treat it.

>> Wow, that's so cool. But um is it treatment after you develop these tumors or this is like a preventative thing? It

it's they it's for tumor tumors like the tumors that have developed but that doesn't require surgery.

>> Nice.

And it was I just learned it was also recently approved for um advanced FO or paragloma nonVHL related

and for advanced RCC following treatment with like PD1 and P inhibitor VF TKIS.

Nice.

Okay.

Okay. So patient came in with abdominal pain.

>> Some rectal thickening. Yeah.

>> Yeah. What do you think about it?

>> Maybe it could be rectal cancer. It has

a shouldering. It's not really There's no inflammation. Um

no inflammation. Um >> not a lot at least.

>> Mhm. Yeah. So, this was actually an incidental 10 cm long rectal cancer.

>> I'm going to show you the MRI now, too.

But anyway, just to kind of drive home the point, like it's just a classic case we see all the time these days, but like rectal colon cancer on the rise. Follow

the colon in every patient and this is what it looks like. I remember showing this to my residents when it came up and they were like, "Wait, what? It looks

like the other stuff." And I'm like, "No, no, no, it doesn't." Like, see the thin wall and the air over here? you

know, the other the other parts of the colon. And then this kind of thick, like

colon. And then this kind of thick, like you said, shouldering, thick, densely enhancing thing circumferentially is is rectile

cancer. Much better seen on MRI. And so

cancer. Much better seen on MRI. And so

now I'm going to show you the MRI.

So starting at the bottom, this is the nice dark muscularis. This is our rectal gel. And then here we're getting into

gel. And then here we're getting into that evil gray of tumor. definitely

extending beyond the dark muscular muscularis. So at least a T3. There's a

muscularis. So at least a T3. There's a

big lymph node here. For lymph nodes, we look for if they're round, heterogeneous, and have infil um irregular margins to kind of bump them up. Um but like especially if they're

up. Um but like especially if they're less or less than or equal to 5 millime, once they get 5 to 9 millimeters, they only need two of those um features. And

then above 9 millimeters, they don't really need any. But anyway, this one looks kind of it's pretty big. Let's see

how how big was this. Yeah, 7 mm. So

suspicious. It's rounded. Um I don't know what I just did. Hold on.

Okay. Anyway, there's the tumor. And

then here we can see that it's extending to the misorrectal fascia and actually to the basically to the peritineal reflection. Um show it to you

peritineal reflection. Um show it to you here.

Take off the markings. Um, but here basically the peritineal lining goes over the bladder and sometimes we can see it but it kind of goes like along

here up to S2.

>> So um right basically right there this we thoughting the um the peritineal in flection. So that makes it a T4A. Um

in flection. So that makes it a T4A. Um

T4B means it's invading adjacent organs.

This T4A thing is a little bit like more of a prognostic thing. it doesn't really change their management. They're still

going to do chemo rads. Anything T3 or N2 above or N plus above, they will um they do pre-operative chemos. Um but

yeah, so hopefully it'll shrink away.

But um anyway, this is how nicely we see it on MR versus the CT where I'll show the coronal CT

maybe side by side. Let's see if we can I can't zoom in.

Anyway, yeah, we don't see it as well, but much better in memory. So, yeah, T4A and then N plus. You can actually see the

nodes pretty well here.

Over there, multiple nodes here.

Yeah. Okay.

Um so a couple things. So the staging for tumors that are above the paritinal reflection is different than uh those below the peritineal reflection. Uh so

uh like below the peritineal reflection we use the misoctal fascia for T-staging but above the paritinal reflection is extra peritinealized. So if there's

extra peritinealized. So if there's cerosal invasion it becomes T4. uh

versus if it's below the peritineal reflection, it's actually T3.

>> And this is like it's still considered a rectal cancer because it's crossing the peritineal reflection, right? Like cuz

if it's if it's completely above the peritineal reflection, then it's like a sigmoid cancer.

>> I think so.

>> Which doesn't go down the chem's path.

It just goes down like chemo and surgery.

That's that's actually come up for us quite a bit where like it'll get presented as a rectal cancer and we're like wait a second this is like more than 15 centimeters above the anal verge. it's completely above the

verge. it's completely above the peritineal reflection like is this even considered a rectal cancer and that's like an important conversation to bring up with the because sometimes um on

scope they like the the um colon can kind of telescope on itself and so they don't get the true measurement from the anal verge like we actually get a much better view and measurement of it and so

sometimes we can be the ones to bring up like this is not a rectal cancer this is actually a sigmoid cancer does that make sense >> yes >> in which case we shouldn't even use the

rectal cancer template. They would not be going down to like the normal chemo rads like neoagivant then you know surgery then adgiant therapy that rectal cancer does. What's really interesting

cancer does. What's really interesting actually I'm looking up open evidence and so rectal cancer is defined by the sigmoid takeoff as the upper boundary and NCCN there's different definitions

uh so NCCN guidelines define the rectum as low lane below the virtual line from the sacral promontory to the upper edge of the pubic symphysis as determined by MRI. In contrast, the American Society

MRI. In contrast, the American Society for Colon and Erectile Surgeons uh note that tumors within 15 centimeters from the anal verge are typically classified

as rectal cancer.

Hm.

>> Difference there like one >> go ahead >> of distance and one is using anatomic landmarks but like maybe converge >> pretty similarly >> and I mean like I I remember during our

tour boards like uh one of the surgeons said like different people have different anal lengths right so you know using a a centimeter to cut off is a

little bit uh it depends on how long their anal length is right so if you have a short versus a long it can change the definition.

>> Yeah.

>> Interesting.

>> Yeah. I just bring it up when it seems really high and I'm like, hm, guys, is this actually rectile cancer? Like, do

you want me to use this template or like can we come to an agreement here how you're going to actually treat it?

>> Yeah. So, in this case, it crosses both the rectum and the sigmoid. Uh, so

straddling the sigmoid take off. So, it

it's classified and treated as >> rectal. Like my tumor is mostly below

>> rectal. Like my tumor is mostly below the peritineal reflection and a little bit is above, right? Yeah.

>> Whereas if it was the opposite where like it was almost all above, I would I would that's when I bring up like is this really a rectal?

>> Yeah, agree.

>> Uh this patient came in with analopathy and septic shock.

>> Is that septic embuli causing splenic in fact >> and >> renal and coming from. Yeah.

coming from. Yeah.

And then there is also a little I'm going to absess that um Yantan this reminds me of your case that you presented with like the

left ventricular thro >> and that's and the splenic like abscess in your case looked just like this one.

>> Yeah. Yeah.

>> Crazy.

And then this for nearer gang green is reminding me of the case where I had that tram flap that they they they debreed all the foreigners gang green and then they

>> did the no VRAM flap sorry vertical.

>> Yes. Which you showed last week. Yeah.

>> Yeah. Cool.

So this is uh a case from my friend Andrew Chang and we are just sharing it online as a companion to the prior case.

So this is another case of penary beading or genital pearling and this is the B images from literature showing various types of beads which could be

implanted under the penile skin.

That's about it. Thank you.

>> Yes.

>> What is this for?

Uh this is penile bead beading or genital pearling. Um this is for

genital pearling. Um this is for enhancing the uh sexual uh pleasure and it could act

as a spiked condom.

>> What is the last thing you said? Spiked

condom.

>> Yeah, spiked condom. Like we have like regular condoms and we have spiked. So

this acts like a permanent kind of a spiked condom.

Wait, I don't know. What do you mean?

How does it act as a condom?

>> No, like for the pleasure thing.

>> Oh, got it. Got it. Got it.

>> Yeah.

Yes. Ker, you missed our earlier case of this. So, we've already been educated on

this. So, we've already been educated on it.

>> Yeah, I missed on a good case. I guess

[laughter] >> none none of us had seen it before, but um Yashant has had one and also a companion.

Yes.

So this case is again from my friend Andrew Chang and this is him plant him plant and u this is used to implant in

the subcutinous tissue of penile shaft and this increases the girth of the penile shaft. So this is more like

penile shaft. So this is more like augmentation.

>> What? Oh

>> kind of parallel. Can you augment the length too?

>> I don't know that. That's a good question. But in my head, I don't think

question. But in my head, I don't think we could be able to do that. Like

marginally, yes, definitely we can increase the girth.

>> Got it.

>> I'll have to look into that. That's

>> what material is this again?

>> Silicon.

>> H.

Thanks.

>> Sure.

All right. All right. So, this is a liver case, but the backstory is this guy had bladder cancer. Um, so they did a cystoroctctomy and his pre-operative imaging. So, his

liver looked normal. We don't see anything there. And then 3 months later,

anything there. And then 3 months later, he has these new collections um at the inferior margin of the liver. And he

also has this peritineal nodule. M

>> and then so on the PET scan.

>> Yeah. So there were there were multiple nodules along the um capsule up here.

Let's see.

So there was that one. [sighs]

This one on the back right of the liver and this largest one inferely.

>> And his gallbladder is still in. So

these are not dropped galls obviously.

>> Yes.

Okay. Yeah. Dr. J's tell me to ask uh what you all think about this so far.

>> Well, I was like one thing that came to my mind was carcinomitosis.

>> Yeah, that was a good thought. That's I

think what we were thinking initially, you know, the PET scan >> infection. I mean, is it a weird

>> infection. I mean, is it a weird infection?

>> Um, so what it was was we went and got an MRI and then so we see susceptibility artifact along here. So we looked at the op node and this guy had anal

mesh like an abdominal wall mesh and they had extensive lis of adhesions and so these are most likely little metallic fragments from the mesh and then in

hindsight looking at that there's the small little metallic density that was not there before.

>> Wait but was the like susceptibility artifact also in the like the central nodule? Uh yeah. So we just have a

nodule? Uh yeah. So we just have a coronal and it's hard to see exactly, but we're thinking that it's it's these right here.

>> It didn't look dense though. It was like centrally hypotenuating. So it's like a

centrally hypotenuating. So it's like a granulomatus reaction around it. Is that

>> Yeah. Yeah. So they biopsied it and it showed like giant cell reaction. They

biopsied the liver one.

>> Can you show the preop? Um I just want to see the mesh just like Yeah.

>> Yeah. So you don't see the mesh super well. Let me see if it's is it going to

well. Let me see if it's is it going to let me switch on the set >> the mesh like they didn't look dense on at least on some of the central didn't have the density

>> little metal or yeah I guess little metal artifact there but um yeah supposedly this guy had an umbilical hernia repair and had a mesh and then

they said when they open the abdomen the um was like extensively like adhesed to the abdominal wall and so they took out the mesh and lice those adhesions and then finish the

surgery below.

>> Did they get smaller over time?

>> Um, so that's we just have this MRI since then. So we have the CT that shows

since then. So we have the CT that shows it in the MRI that we don't even really see them because of uh the susceptibility artifact.

I mean these are postcontrast. Let me go to the haste.

>> Nelly sounds dubious, but I completely buy your theory. No, I I I am partially dubious, but I believe you. I'm just

surprised that I don't see the hyperdensity in all of them.

>> And in the original mesh, there wasn't hyper like a lot of hyperdensity, right?

>> But there's some that have it. Like the

the right subpatic one had a hyperdensity on CT.

>> Yeah.

This one. Other than that, we don't really see anything.

>> So maybe it's it's maybe the mesh is made out of hyperdense and is dense stuff.

>> Yeah. cuz we don't. Yeah, cuz on the pre-operative one like it's hard to say that we like clearly see the mesh and all that I really see is this that little metallic dot right there.

But supposedly he had a mesh according to their op note.

>> Yeah. I mean that susceptibility on MR is impressive and basically says like this is a foreign body. It does look like on the CT it looked like dropped

gallstones, like an inflammatory reaction to some foreign body, but then all of that susceptibility on the MR like really suggests like it's >> Yeah. It's metal, not not calcium.

>> Yeah. It's metal, not not calcium.

>> Yeah. Or something between. Um and so yeah, really I do buy this mesh.

>> Anyway, >> it's been biopsied and it was a granoloma. So,

granoloma. So, >> yep.

But it's a great case to show that, you know, paratonial deposits and how MR can help.

>> Yeah. And actually, it's a really good case here on CT to see show how the mesh can really blend in, but you can see it like that very thin line there. You can

see it, right? Like Yeah,

>> it'd be a hard call perspectively.

>> Yeah, maybe. But you know that thing along the liver, it does look way more inflammatory than um than like a met.

>> Yeah.

>> Yeah. [clears throat] Like we have edema around it. Yeah.

around it. Yeah.

>> Great case.

>> Yeah.

>> Yeah. Thanks.

>> So this is another companion case and um this patient has some infection and we see air and some fluid in the subcutinous tissue. So that's how

the implant which is silicon made looks on the or appears on the sagittal plane and that's the axial and I just checked him plant can cause increase in both

girth as well as length of the penile shaft.

I I have a question. Why why why would you do this and not just like a rigid implant >> rigid implant for >> Well, usually those rigid implants are for like impetence, right? Like you

can't get an erection. He's saying this is to augment the like size of the penis.

>> I see. So normal function, but this is augmenting.

>> Yeah. Make it bigger. So, and then like if it's silicone like isn't it going to stay? Yeah. Like because after an

stay? Yeah. Like because after an erection it it you know it tumines or you know it just becomes flaccid right and so this you won't really get ever

because it'll just that thing will be there right >> I think it might have some amount of stretchability so that you know it um

conforms to the changes in the size and shape >> but again I don't know a whole lot of details but that's a great question. I

might have to look into that. To answer

your question, this is in the subcutinous tissue and the metallic or inflatable penal implant that you are talking about, they will be more in the cavosum. So yes, as Arti and both of you

cavosum. So yes, as Arti and both of you rightly pointed out, this is not for altering the function. This is more for cosmetic appeal.

>> And then there's air in the center of that.

>> This is infected. This is this.

>> Okay. So like normally though it's it's not like it's like a by valve. It it's

just one continuous structure.

>> It's a subcutaneous implant that like should not have air in it after period.

>> No, it has a groove here. So I believe that groove is allowing some amount of stretchability. So it has some groove

stretchability. So it has some groove here which is what we saw in the last case but this air is abnormal.

>> Gotcha. Thank you.

>> Sure.

Uh this is a patient uh that had worsening abdominal pain, had renal transplant uh and had pancilitis and whatnot. But

I'm showing you this case for something else. Uh which is So then I I saw this

else. Uh which is So then I I saw this kind of um what I thought could be like a neural stimulator, but it was going into a place that I'm not familiar with.

>> Gastric gastric pacemaker.

>> Yes. Yes. I so here it is and then it goes right next to the right adjacent to the body of the stomach right there and

where it ends and um patient has had other surgeries uh including Nissen and whatnot so there's a lot of metallic

artifact and that's what it was a gastric pacemaker I I it's my first time seeing one >> sorry and where does it terminate like where is it supposed to

>> the body Subzero.

>> Okay. Along the gastric body. Got it.

>> Mhm.

>> Uh so it's a it's used to treat uh drug refractory gastroparesis uh by delivering electric currents to the stomach uh to modulate the symptoms. Uh

so it delivers high frequency low energy electrical stimulation and it's surgically implanted uh like they implant the electrode surgically. Uh and

then it's um it significantly reduces refractory vomiting in patients with gastroparesis uh by having you improving gastric

emptying uh and improves symptoms of nausea and vomiting uh and uh it's FDA it's available under FDA humanitarian device exemption for drug refractory

gastroparesis uh and it's typically reserved for patients who have failed standard medical and endoscopic therapies.

So that's what it looks like.

>> Do you know the success rate?

>> Uh it uh I'll find out and get back to you.

>> Okay.

>> I have because I haven't seen it a lot and we you know there's a lot of people with gastroparesis. So seems like maybe

with gastroparesis. So seems like maybe a more desperate measure.

Wait two seconds and then I'll I'll tell you. Okay.

you. Okay.

Uh so open evidence says gastric electrical stimulation GES improves symptoms in approximately 75% of patients with refractory gastropreces uh with about 43% achieving at least moderate improvement. So pretty

moderate improvement. So pretty effective.

>> Yeah, that's pretty good.

>> Uh so uh then the other thing they noted is diabetic gastroparesis patients tended to respond better than those with idiopathic gastroparesis.

>> Cool.

Okay. Um,

there's a what?

>> There's >> colon transposition.

>> Colonic in transposition, right?

>> Yes. Colonic interposition. So, just

wanted to show this case because it's not that common. Um, so this was a young patient who actually had like an emergency kind of like they

coded and they ended up with gastric necrosis and esophageal necrosis and therefore needed this colonic interposition. Um, most of the time if

interposition. Um, most of the time if you have esophageal cancer they do a gastric pull through but if you have like aia or some like catastrophic thing where you lose both your esophagus and

your stomach they might do this colonic interposition. They pull it in front of

interposition. They pull it in front of your heart. That's one of the clues. And

your heart. That's one of the clues. And

then obviously it looks like colon. And

um this person was having a lot of nausea. And there was some question like

nausea. And there was some question like is there narrowing here um that is causing this nausea and kind of vomiting. And so we did a fluuro study.

vomiting. And so we did a fluuro study.

So this is what a colonic interposition will look like on fluro. again looks

like colon um and it it I've done several flora studies on these patients and like the

colon doesn't really paristals that well not like a real normal esophagus or even like a gastric pullthrough which also has decreased paristalsis but um yeah it kind of gets caught up here but um it

was kind of it was wide open we could see the the contrast going through the pill went through um it cleared over time. Um, so yeah, and and she was

time. Um, so yeah, and and she was nauseated like before and after the s uh the the procedure. So we kind of chucked it up to like basically maybe she's

having dismotility from this colonic interposition, but also um just like chronic nausea now from like all of the surgery. So,

surgery. So, >> so Arti um just FYI, I when I did my first residency in Bombay, I was in a

cancer hospital and I'm talking of 92 to 95 and they used to do a ton of these colonic interposition surgeries at that time for esophasial cancer.

>> Oh wow.

>> Before gastric pull-ups. So I have seen and done a bunch of fluo studies on those patients at that time.

>> Oh wow. And but it seems to have fallen out of favor.

>> Yes. Yes. I think the complications were a lot.

>> Yeah. Yeah. I'm just going to show just for people who haven't seen it before.

This is if you can see my internet screen. So basically they

internet screen. So basically they mobilize the right colon but they keep the vascular pedacle and pull it up. So

there's a lot of possible complications like if the pedacle is not well supplied you know like it it could necro it could it could not be paristelsing properly.

I have case uh this is a patient with history of stroke had a throbectomy uh for over an MCA stroke and then had P um lots of

complications and they were looking for eskeemic bowel uh because patient had luccoytosis and kind of symptoms of that and I mean there's a malpositioned um G2

but I want to focus your attention to an incidental finding in the lung base here Uh, no prior chess CT, just this finding

in the lung base. Any thoughts on this lower lobe? Sorry, I know some people

lower lobe? Sorry, I know some people have an issue with me calling it lung base. So, left lower lobe.

base. So, left lower lobe.

>> Wait, what's the problem with lung base?

>> There's not a lung base.

>> It's like midpole. There's no midpole.

It's interpolar. [laughter] I was like, okay sure.

>> Whatever, man.

>> There's a base to the prostate. It's the

bottom of the prostate. like lung bottom the lung base. No.

>> No. Well, there's a base is the like cranial part.

>> But I mean like that's like the direction of flow of the prostate. We

call it the base of the prostate.

>> Yes.

I know. But it's lower lobe. Um

>> is this like um developing you know chronic adalcttois kind of thing?

>> Uh that's a great thought. Uh I thought it had a bubbly appearance. Uh so

there's these central lucencies here.

>> Is it like some foreign body or something that they left behind?

>> No surgery. No foreign body.

>> Some aspiration or some round pneumonia.

>> That's a good thought too. Okay. And did

somebody else say something? Jordan,

>> I said aspiration.

>> Aspiration. Okay. Good. So I I thought this was bubbly bubbly appearance of of the the consolidation bubbly concept and that we see with PE. So I recommended a

PE protocol to look for PE. Uh so then they got a CT chess. Here it is. And

then here's your huge PE.

>> Wow. Why do you get the bubbly appearance? Uh so uh according to open

appearance? Uh so uh according to open evidence so the bubbly consolidation represents pulmonary infuction with central lucencies caused by coexistence

of airrated non-infected lung tissue within um areas of viable tissue and this is highly specific for PE related infuction appearing in 50% of patients

with pulmonary infuction on CTA.

>> Wow.

>> And the underlying mechanism >> Yeah. So it has the bubbly central like

>> Yeah. So it has the bubbly central like the bubbly or the central lucent appearance of the here in in the lung base here. I think it should be on the

base here. I think it should be on the lung windows. Here it is this little

lung windows. Here it is this little one. So that that um that central loosen

one. So that that um that central loosen appearance on CT reflects islands of viable airrated lung tissue that survive within a predominantly infed consolidation. Hence the term survived

consolidation. Hence the term survived lung.

>> That's a great call.

>> Yeah, >> it's an awesome case. something.

>> Yeah, it's great.

>> Oh, sorry.

>> So, okay, we're anonymized. So, the

history was that he's had this chronic uh scrotal swelling. He had a history of an orchipexi 3 years ago for torsion.

So, all we have is an MRI. We don't have any other prior imaging. We have this diffuse low signal just around the base of the penis just extending all the way along the shaft and at the base of the scrotum.

>> The testes, you know, there's some small hydro seals, but they look okay. And

then um on the postcontrast, we have diffused postcontrast enhancement and apparently this guy's had this for some time. They biopsied in an outside place.

time. They biopsied in an outside place.

We don't have the path, but they just said it was benign. So we weren't entirely sure what to call this, but we said it this could represent like a diffuse fibrodic changes like a peronis

disease but >> hypo intensity is really like suggest and it's pretty dramatic.

>> Yeah. So he's yeah is a I don't know if I can say age but yeah younger male so it's not not older >> but it's beyond just I mean it's like the entire soft tissue right the entire

scrotum and the like subcutaneous tissue is like diffusely enhancing and >> I haven't seen many but I didn't realize that it could extend into the scrotum

like that >> I agree with the fibrous thing but I don't know if it is peronis it's not affecting the cavos.

>> Yeah, I don't think Peronis is the right term. It could be almost in the spectrum

term. It could be almost in the spectrum of like desmoid fibromyitosis or >> what started this process? Like what was the initial

>> uh he's had chronic uh scrotal swelling?

>> You said orchipexi was done.

>> Yes. Or yes, he had orchipexi three years ago. Yeah. For torsion. So he has

years ago. Yeah. For torsion. So he has been intervened on before. So, I don't know if it's >> and and did this process only start after that.

>> Uh I believe so. The history is kind of vague and he just got referred. So, the

urology >> Yeah, that's another thought.

>> What did you say? Kloid.

>> Yeah, kloid.

>> I mean, but when it's inside your body, isn't like that the term fibro like desmoid fibromytosis like for the same thing?

>> Uh I don't know like you know we we speak about two terms. One is hypertrophic scar and the other one is kloid.

>> Yeah, we weren't 100% sure on exactly >> why does he have vinyl nodes?

>> I'm not sure. I don't know if those are just reactive maybe to >> I'm not sure. Um, regarding peronis, so

uh open evidence it says so you get a low T2 signal uh intensity around the tuna albaginia

uh surrounding the corpora cavernosa and so like in this case that T2 dark around the cavernosa looks okay right it's more like

>> subcutious >> yeah exactly it's more sub yeah exactly Anyway, yeah, we weren't 100% on it, but just going to show it.

>> Yeah, very dramatic case.

>> Okay, I'm going to withhold history. You

guys are going to get it quickly.

>> Himango endothelium.

>> No.

>> No.

>> Why did you say that? Like the Oh, >> the target type. There's like a peripheral rim and rim >> giant heangiomas.

>> Okay, I'm going to I'm going to scroll through the rest of this case.

>> Okay, collection.

>> So, there's a device with a collection around it.

>> Where is that going?

>> There's a suture over here.

>> Is it HIPP device?

Yes. So what are these liver lesions?

>> Metastasis.

>> Yeah. Yes.

>> From wait colurectal is it because there's like this rim calcification >> also. Okay. Okay. So putting it all

>> also. Okay. Okay. So putting it all together. Right. Hemicolectomy

together. Right. Hemicolectomy

ilioonic anastmosis.

>> I have no carcinoma. Yeah.

>> Yes. And then these are colon cancer mets. Um I don't know why they're

mets. Um I don't know why they're partially calcified. I don't know if it

partially calcified. I don't know if it was mucinous or >> post treatment changes. No

>> post treatment. Yeah. Um, and then this is the hippatic arterial infusion pump, which terminates kind of like a I wanted to bring up this case after you brought up your gastric stimulator case, but

yes, it looks similar, but it's terminating in your GDA hippatic artery um confluence. They basically have to

um confluence. They basically have to surgically put these in. um they implant it into the the GDA top of the GDA here and then they they block off all the

rest of the GDA so that the chemotherapy only goes in into the hippatic artery and then directly onto the liver. Um and

actually these lesions did get smaller over time. Um so we're putting

over time. Um so we're putting chemotherapy directly onto unresectable colon cancer mets in the liver. Um a few other teaching points from this case that I learned about. we were concerned

about this fluid collection in here and we were like okay maybe it's a seroma but like how can we exclude that it's not like chemotherapy leaking out into the like the subcut tissues you know so

anyway we talked to the team and they knew about the seroma and um what basically what happened was that I don't know if you guys know how these work but

let me just bring this over so here is the device there's a cartridge that the um every like six weeks they put chemotherapy into the cartridge And then

it continuously infuses chemotherapy into your hypatic artery and they have to access it like through your skin here

um like that. And so what happened here was that they wanted to create like a shorter distance to access because there was a lot of fat here. So they they like

removed a bunch of fat but in the process basically probably like damaged some of the vessels or lymphatics. So

they've created this like chronic seroma that every time they now have to reaccess this, they have to aspirate all the fluid off of this. And then the other interesting thing that I learned

was that like this is the access port.

So this guy has flipped.

>> So every time they do it now, they have to they have to drain the seroma then palpate this device and flip it over before they can reinfuse the chemotherapy into her. So

>> Oh my god.

>> Yeah. Just something to be aware of. Um

because they've been accessing this fluid, they like they were like, "No, it looks just like seroma lymphosal fluid.

It's not a chemotherapy leak." Um and actually the the liver lesions are getting smaller. So it's working.

getting smaller. So it's working.

>> Awesome case. two things here like you know um the HIPP the port ends at the GDA and other than the regular complications which is like uh the

thrombosis of the vessels that we will anyways pick up these are best assessed on a longitudinal plane either it would be coronal and or sagittal and the

reason is this pump the the tip has to be flush with the origin of GDA it should not be pulled back which is retracted in the GTA or inside the

hippatic artery and I have an illustration to show why that is important. I will show that in a minute

important. I will show that in a minute and that's one thing we should always look for and the other thing which Arti uh pointed out that we have to look at the uh uh the port device which is in

the subcutinous tissue that it is not flipped. So one way to know it is not

flipped. So one way to know it is not flipped because the most common model which you we use is this one which is more triangular. So the triangular apex

more triangular. So the triangular apex should be more towards the skin surface or the other thing is the base if you see there is this hypodensity which is

chloropl that thin rim thin line. Yeah.

>> So that is chlorofluorocarbon which actually get heated up and that liberates continuous u continuously the chemotherapy. So that yeah that should

chemotherapy. So that yeah that should be towards the skin surface meaning more towards core temperature. So, it's

getting heated up and um >> wait, the fact that it's flipped over does that cause malfunction?

>> Uh, not really. But then how will you access it to put the chemotherapy again?

That's the thing.

>> Exactly. And my surgeon said that he manually flips it every time and there was like a big enough space here to to flip it because of this ceroma cavity kind of thing.

>> Um, did you want to share you said?

>> Yes. Just give me one sec.

>> Okay.

>> So this central picture is the ideal position where the uh the tip of the catheter should be flush and this yellow dots are the chemotherapy. What happens

when it is like slightly inside and again this will be best assided on assessed on any longitudinal plane is when it gets inside it is going to affect the flow of hippatic artery and

then it is going to cause temporary stasis and there will be thrombus formation. So again it will lead to

formation. So again it will lead to ineffective chemotherapy dose going to the liver when >> that's like a very tiny amount of movement. Yeah,

movement. Yeah, >> that I don't know if like, you know, do you think we can see that definitively on >> sometimes we do?

>> Yeah. Um, and by the way, I love this picture because I never understood how it stays in place. I didn't realize they put all these sutures on the way.

>> Yeah, they put at least two sutures so that it is like it stays like you know more secured in that location. The other

situation is when it is retracted. So

all this chemotherapy will be uh leaked here in the GDA and GDA because now there's no blood flow. So it's a uh zone where there is not much uh blood flow.

So which is the zone of stasis. So that

will give rise to sorry. So that will give rise to

sorry. So that will give rise to aneurysm of GDA.

So yeah, two things. One, we have to see is it flush and second is the device the port side is not flipped.

>> That's incredible cuz these vessels are like five six millimeters, right? It's

super tiny like Arthy was saying to get it in the right position and then to be able to double check that it's in the right position. It's

right position. It's >> Yeah. In fact, there's a great article

>> Yeah. In fact, there's a great article in AJR, I think 2019 or 2020, and it has shown almost all the

complications and it's a great feat.

>> Awesome. We also had some good cases here a few weeks ago, so um you guys can check out those prior ones. one remember

Nelly you showed one where >> yes >> they did well and they ended up getting a but then they got bilaryis >> and then had to get a liver transplant >> transplant yep

>> y >> so that's another complication but that's more from the chemo than from the actual device or the catheter placement