0:00

Dr. Finazzo, this is a scary looking 2 00:00:00,870 --> 00:00:02,320

0:02

case because there are so many images.

0:03

This is a real smorgasbord of lesions in the kidney,

0:09

many or all of which are different types of lesions,

0:13

perhaps cysts, perhaps not, but we'll make that

0:15

determination, or you will, as we go through them.

0:18

Let's start with the easiest one, and

0:19

we'll break this up into two vignettes.

0:21

Start with this big, giant lesion

0:23

in the upper pole posteriorly.

0:25

Obviously, the patient has some spine issues.

0:27

We'll ignore those for right now.

0:29

Here is the in phase and the out of phase, not

0:32

much difference there on the coronal projection.

0:36

And then we've got a T2 spin echo, without fat

0:39

suppression, a smooth lesion, no papillary projections,

0:44

pretty round looking, the internal character of

0:47

it is very water-like in its behavior.

0:51

Here's a fat-suppressed

0:52

one, still more of the same.

0:54

Here's a coronal, and I think you had mentioned

0:56

before that a lot of the surgeons like to have a

0:58

long-axis view, both a coronal and at least one

1:02

sagittal because it's something that they're used to.

1:04

Then we went through a whole liturgy of dynamic

1:07

imaging going all the way across for this lesion.

1:10

And I won't articulate each individual phase,

1:13

but you can see this is a pre and then we

1:15

progressively get into the time-activity curve here.

1:19

Here's some diffusion imaging down here at the bottom.

1:22

And then we've got subtractions

1:24

all the way at the bottom.

1:25

So for this lesion, what would

1:27

be your determination and why?

1:29

Yeah, so again, we're going through that whole pattern

1:31

of is it a cystic lesion or is it a solid lesion?

1:35

Our goal in MRI is to determine cyst versus solid.

1:41

And then to try to do some subtyping

1:42

if we do find enhancing lesions.

1:45

And in this lesion, I always start off

1:47

with the T2 to try to characterize it.

1:49

So I see a multi-septated lesion, but at this point

1:53

I don't see any wall thickening, and I don't see any,

1:57

um, signal intensity different than just fluid signal.

2:01

And with that, same thing when I go to

2:04

the T1-weighted images, same thing, I see

2:07

very dark without any brightness to think

2:10

that there's any hemorrhagic components.

2:12

And then my multi-phase sequences are strictly to

2:16

see, do I or can I identify any areas of enhancement?

2:20

If I question any areas of enhancement, then I may

2:24

go to my subtraction-weighted images to look to

2:27

see if I see areas of enhancement, keeping in mind

2:30

looking for, uh, mismapping or misregistration.

2:34

You have a little bit in the

2:35

liver right here.

2:36

And I do see,

2:36

yeah, I see that rind around the liver, so there

2:39

was probably some breath hold issues or some

2:41

misregistration when they, uh, subtracted these.

2:44

But in this case, we're just dealing

2:46

with a mildly complex Bosniak 2 cyst.

2:50

Um, so I feel very comfortable that

2:52

this has no malignant features.

2:56

And as we know, Bosniak classification has withstood

2:59

the test of time, but there is a new version coming

3:03

out to help make some of the concepts of how many

3:09

septum are considered acceptable, how many areas

3:13

of wall thickness are considered acceptable.

3:16

So those are going to come to help us

3:18

differentiate a Bosniak 3 from a 2F.

3:24

So, in looking at this lesion, does it bother you?

3:26

It doesn't bother me, actually, that

3:28

there's this cobwebbing or linear

3:30

signal around the kidney on both sides.

3:32

You know, when you first look at it, it's a

3:33

little bit scary because it's a large lesion.

3:36

But I think when you take the compilation of

3:38

all the findings that you made, you come up

3:40

with a diagnosis of a large cyst, wouldn't you?

3:42

That's exactly right.

3:43

And again, we're looking at the morphologic

3:45

characteristics of a lesion, and in this

3:47

case, morphologically it looks benign.

3:49

Well, in the next vignette, let's take on

3:51

another comparison lesion that is in the

3:55

lower pole of the kidney on the right side.

3:58

It's bright on both the out of

4:01

phase and the in-phase image.

4:02

Here's the in-phase image.

4:03

Let's take it up in the next vignette, shall we?

4:05

That sounds great.

4:06

Okay.

4:06

P and P out.

4:06

P and P out.