0:01

Dr. Finazzo, this 84-year-old lady. We're back with her

0:01

3 00:00:03,690 --> 00:00:06,650 again, and she's got this lower pole hyperintense

0:06

lesion in the out-of-phase and in-phase, uh, GRE.

0:11

Um, let's match it up, and we can see

0:13

on the T2, it's low signal intensity.

0:15

The FATSAT, it's also low.

0:18

Here's the coronal, it's got a mixed

0:19

low signal intensity character.

0:21

And then we've enhanced it

0:22

all the way across the board.

0:24

It does not diffusion restrict at the bottom,

0:26

and here is the subtraction at the bottom.

0:29

So what are we going to do with this lesion?

0:33

So this is another classic example of how, uh,

0:36

complex cystic lesions can look very different on MRI.

0:40

But we can still feel comfortable that this is probably

0:43

a watch lesion, rather than, uh, being aggressive.

0:47

And when I look at the T2 image, I

0:49

see a heterogeneously complex lesion,

0:53

not like the other cysts that we saw.

0:56

Thank you.

0:57

Then I go to the T1 sequence, and I see

1:02

that the lesion is bright, making me think

1:05

that there could be hemorrhagic components.

1:06

Sure, and that's

1:07

before contrast.

1:08

And that's

1:08

before contrast.

1:10

But this is a diagnostic dilemma, which is probably

1:12

why we received this, is, is there enhancement?

1:16

And this is where MRI really has the biggest

1:19

benefit, is trying to identify enhancement.

1:22

Uh, I struggle to look at the pre and

1:25

the post if I were to magnify these to

1:27

determine, is there real enhancement?

1:30

And as we talked about on the prior vignette, can we

1:32

take the post minus the pre divided by the pre and

1:36

look and identify more than 15 percent enhancement?

1:40

And secondly, and, and if not, can we

1:43

look at the subtractions to help us out?

1:45

Thank you.

1:45

And here, we don't see anything

1:48

that we can clearly say enhances.

1:53

Yeah, there's this little spot

1:54

that you and I noticed earlier.

1:56

This may be a little bit of

1:57

disregistration, which we do have.

2:00

Perhaps it is a little bit of enhancement.

2:01

There is some diffusion restriction there, however.

2:04

So I think the jury is probably out on this

2:06

one, although more likely in an 84-year-old lady

2:09

with everything else going on, it is a cyst.

2:11

And I, I think you would probably elect for

2:13

watchful waiting on this one, wouldn't you?

2:14

That's exactly right, and if you look at

2:16

the size also, uh, there have been articles

2:19

written that anything greater than, less than

2:21

3 centimeters, we can leave, we can watch.

2:25

And one other thing I did want to point out is, you

2:27

know, if you look at this lesion as a standalone on

2:29

the T2, you might think about a papillary tumor, uh,

2:32

papillary carcinoma, which occurs more frequently

2:34

in men, but it does have some internal architecture

2:38

change, which. But then when you match it up and you go

2:40

over to the, to the T1 in-phase image, many papillary

2:44

cancers with this internal complexity and some

2:47

papillary projections have siderotic material inside.

2:51

And, and so on, on the, on the in-phase T1

2:55

type image, they're, they're gonna be dark

2:57

more likely than they are to be

2:59

white, like say an AML or a hemorrhagic cyst.

3:01

So that can be very helpful, the fact that it's

3:04

bright on the T1 GRE goes against the papillary tumor.

3:07

And there are two types.

3:08

There's the classic type 1, which is basophilic, not

3:11

very aggressive at all with cuboidal epithelium, and

3:14

then there's the type 2 that you and I were talking

3:16

about, which is kind of this ethereal, kind of mixed

3:19

bag of a lesion with eosinophilic character to it.

3:22

It's more pleomorphic, it's more aggressive, has a more

3:24

guarded prognosis, and that classification may change.

3:28

But the fact that this lesion is not dark

3:30

and dark goes against the diagnosis of a

3:33

papillary tumor, as does the fact that you

3:36

know, it doesn't have much enhancement at all.

3:39

Shall we move on to the next renal

3:40

lesion in this 84-year-old lady?

3:42

Sure.

3:42

Let's do it.