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Thread: seemingly contradictory scan reports

  1. #1

    seemingly contradictory scan reports

    Hi folks. I thought I would start a new thread for better visibility here on my dad's situation with his diagnosis. His two scans seem a little contradictory to me, though I realize CT scans measure sizes and dimensions of visible lesions and masses, and PET scans measure cancerous activity (or otherwise).

    He had his PET/CT scan on Tuesday, and the radiologist's impression was:

    1. Moderately FDG avid masslike uptake in the uncinate process is worrisome for
    a primary neoplasm.

    2. Suspicious focal uptake involving the inferior and anterior right mid liver
    may represent metastatic disease. MRI recommended.

    He then had a regular CT on Friday, and that radiologist had this impression:

    1. Tumor: 3.9 cm mass in the pancreatic head involving the ampullary region with
    upstream dilation of the pancreatic and common bile ducts.
    2. Vascular contact: The lesion abuts the rightward margin of the inferior vena
    cava. Although the lesion does not directly contact the superior mesenteric
    artery, there is hazy attenuation extending along the proximal vessel as well as
    an adjacent branch just inferior to the anterior inferior pancreaticoduodenal
    artery.
    3. Metastasis: Absent

    On the PET scan, the report states regarding the liver, " Ill-defined masslike area of moderate FDG uptake in the uncinate process of the pancreas immediately anterior and to the right of the intervally placed common bile duct stent, SUV max 5.2. This measures approximately 3.6 cm x 2.3 cm x 3.9 cm in greatest orthogonal dimensions. Suspicious focal FDG uptake involving the anterior right mid liver and possibly in the inferior margin of the right liver."

    On the CT scan, the report states regarding the liver, "Liver: No suspicious lesions concerning for hepatic metastasis. Right lobe cyst measuring 1 cm. 6 mm segment VII lesion was not well seen on prior imaging; this lesion is not appreciated on arterial phase imaging, but is identified on pancreatic and portal venous phases without FDG avidity on the recent PET/CT. Other subcentimeter lesions measuring low density likely represent cysts or hemangiomas and were seen on more remote imaging.

    Peritoneum/Omentum: A 1.2 x 0.9 cm low-attenuation lesion with peripheral calcification is noted along the medial surface of the right lobe of the liver. This is been present on multiple prior studies and does not demonstrate FDG avidity. Fat stranding is appreciated in the greater omentum adjacent several loops of small bowel, without discrete omental nodularity."

    Any thoughts on this? How do the doctors interpret the findings, between the two scans? Does this suggest no lesions that could be mets, but possible cellular activity that could be?

    Thanks for any feedback!

    David
    David
    Age 51
    March 1, 2011 - Grade 1 Follicular Lymphoma from node removed from neck.
    2/22 PET/CT scan revealed one additional node in groin - also removed.
    Officially Grade 1 / Stage 3 due to second node.
    No Other Evidence of Disease.
    7/8 PET/CT shows two new small nodes - opposite sides, neck and groin.
    1/06/12 Completed Rituxan x 4 Monotherapy. 2/29/12 NED! Completed 4 additional maintenance doses of Rituxan. 12/12 NED! 6/14 NED! 2/15 NED! 2/16 NED!
    6/17 CT shows 2 small nodes, neck and groin. 7/17 doing Rituximab monotherapy, x 8 this time. All is good again!

  2. #2
    Super Moderator Top User ddessert's Avatar
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    This radiology information site explains these types of scans in pretty good detail:
    https://www.radiologyinfo.org/en/info.cfm?pg=bodyct

    The PET scan is sensitive to any type of increased metabolic activity, not just tumors. Infections or damage that is undergoing healing would light up on a PET scan but perhaps not show on a CT scan.

    The CT scan sometimes shows larger tumors than actually exist. After treatment, scar tissue may remain behind that shows on a CT scan but not a PET scan.

    I am confused that they did a PET/CT scan and then another CT scan just a few days later. The combination PET/CT scans are done so that these types of findings can be aligned to each other from the same imaging session. I’m not sure why another CT scan was necessary unless it was with a different protocol. It also seems unlikely an insurance company would approve a 2nd scan so close to the first.
    BRCA2 3398del5
    Dec 2010 - back/abd pain
    May 2011 - Unresectable stage III, 2.5cm tumor
    Jun-Aug 2011 - Gem/Cis, 9 rounds
    Oct-Nov 2011 - Radiation+Xeloda, 25 days in 5 weeks
    Oct 2011-Sep 2012 - shrinking tumor
    Feb 2012 - National Familial Pancreatic Study
    Aug 2012 - Downgraded to stage IIA, PGP
    Sep 2012 - Whipple, T3N0M0, 0.5cm tumor, 0/16 lymph nodes
    Dec 2012 - Quebec PanCan Study
    Sep 2012-May 2018 - NED
    Mar 2013-present - NCT01088789
    @pancanology

  3. #3
    This confused me too. The regular CT was done 3 days after the PET/CT. I asked my mom about it and she had no clue.

    I'm familiar with the differences in scans (I've had 3 PET scans myself), but I think I've worked out the different findings - at least how it makes sense to me. The radiologist can only see the lesions and cysts that are visible on the liver in the CT, but the PET picked up activity on the liver not visible as the cysts and such that the CT radiologist mentioned. Therefore the PET radiologist is concerned about suspicious potentially metastasis on the liver, and the CT person sees no metastasis there. Does this seem reasonable?

    It is so odd to me though that these scans were both done.

    Thanks for the feedback!
    David
    Age 51
    March 1, 2011 - Grade 1 Follicular Lymphoma from node removed from neck.
    2/22 PET/CT scan revealed one additional node in groin - also removed.
    Officially Grade 1 / Stage 3 due to second node.
    No Other Evidence of Disease.
    7/8 PET/CT shows two new small nodes - opposite sides, neck and groin.
    1/06/12 Completed Rituxan x 4 Monotherapy. 2/29/12 NED! Completed 4 additional maintenance doses of Rituxan. 12/12 NED! 6/14 NED! 2/15 NED! 2/16 NED!
    6/17 CT shows 2 small nodes, neck and groin. 7/17 doing Rituximab monotherapy, x 8 this time. All is good again!

  4. #4
    Super Moderator Top User ddessert's Avatar
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    That does make sense, except that the radiologist reading the PET/CT should have had both the PET and CT images in front of them and been able to come to the same conclusion without a new scan.

    There are some people who get PET scans only and need to go back and get a CT scan, but from what people in this forum report, the two are usually done together.

    My initial assumption was that she really only had the PET to begin with. The way to find out for sure are: the insurance/invoice and downloading the radiologist report(s).

  5. #5
    Which do you think we should take most seriously? I'm assuming the PET/CT from Tuesday.
    David
    Age 51
    March 1, 2011 - Grade 1 Follicular Lymphoma from node removed from neck.
    2/22 PET/CT scan revealed one additional node in groin - also removed.
    Officially Grade 1 / Stage 3 due to second node.
    No Other Evidence of Disease.
    7/8 PET/CT shows two new small nodes - opposite sides, neck and groin.
    1/06/12 Completed Rituxan x 4 Monotherapy. 2/29/12 NED! Completed 4 additional maintenance doses of Rituxan. 12/12 NED! 6/14 NED! 2/15 NED! 2/16 NED!
    6/17 CT shows 2 small nodes, neck and groin. 7/17 doing Rituximab monotherapy, x 8 this time. All is good again!

  6. #6
    Super Moderator Top User ddessert's Avatar
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    The liver. Metastatic pancreatic cancer puts a person in an entirely different position.

  7. #7
    I mean the CT scan, or the PET/CT? PET said suspicious uptake for metestasis, and regular CT said no metestasis seen.
    David
    Age 51
    March 1, 2011 - Grade 1 Follicular Lymphoma from node removed from neck.
    2/22 PET/CT scan revealed one additional node in groin - also removed.
    Officially Grade 1 / Stage 3 due to second node.
    No Other Evidence of Disease.
    7/8 PET/CT shows two new small nodes - opposite sides, neck and groin.
    1/06/12 Completed Rituxan x 4 Monotherapy. 2/29/12 NED! Completed 4 additional maintenance doses of Rituxan. 12/12 NED! 6/14 NED! 2/15 NED! 2/16 NED!
    6/17 CT shows 2 small nodes, neck and groin. 7/17 doing Rituximab monotherapy, x 8 this time. All is good again!

  8. #8
    Perhaps the PET, then. I was in a similar situation. My CT with contrast showed nothing. But a PET two weeks later lit up at the liver. Then, another CT with contrast showed what is probably the spot that lit up on the PET. It was so small and unclear on the CT, but once the PET lit up and gave an indication of where to look more carefully, the doctor saw something on the CT that is in the same location.
    February 2016- diagnosed with PC
    March 2016- inoperable due to arteries, also liver mets suspected
    March 2016-January 2017 -Gemzar/Abraxane
    February 2017 surgery-PC tumour and liver mets removed at same time
    July 2018 Back on Gemzar/Abraxane due to rising CA 19-9. Scans were clear.

  9. #9
    Moderator Senior User BrigitteM's Avatar
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    My doctors always told me that the best for pancreas is the CT/scan with pancreas protocol and never used PET/SCAN so far.

    On the other end, they preferred MRI for the liver. In my case, the MRI made it possible to identify the nature of suspicious new spot in the liver. It was in fact a sclerosed area due to non-alcoholic fatty liver disease. So if they recommend MRI, I would go for it to get a diagnosis of the liver suspicious areas.

    We should not forget that diagnosis imaging procedures still have a lot to improve, and it especially true regarding pancreatic cancer. It is often very hard for doctors to differentiate pancreatic tumors from inflamed tissues.

    Finally, usually a multidisciplinary tumor board gathers around all the images and analyzed the findings along with the clinical information to make appropriate treatment plan decisions. Do you know whether this is the case for your mother?
    __________________________________________________ ___________________
    1/12/2016 No symptoms except ongoing fatigue; blood test revealed elevated liver enzymes
    1/18/2016 Liver ultrasound, then MRI confirmed enlarged bile duct
    1/21/2016 ERCP and placement of a temporary stent
    1/28/2016 CT-Scan showed a lesion on the head of pancreas
    2/09/2016 2nd ERCP + EUS + FNA
    2/12/2016 DX Borderline resectable pancreas ductal adenocarcinoma - Stage 3 @ 61
    2/24/2016 FOLFIRINOX 3 cycles (6 infusions)
    5/12/2016 CYBER-KNIFE Stereotactic Radiation 3 sessions
    6/16/2016 WHIPPLE + portal vein and right hepatic artery reconstructions - 0/19 nodes pos - no mets. Restaged to 1A
    8/31/2016 FOLFOX for 3 cycles (6 infusions)
    Sept 2016 Know Your Tumor - PANCAN.org
    11/4/2016 CT Scan clear - NED
    May 2017 Liver lesion - DX mild fatty liver disease - NED
    Aug 2017 Several small lung nodules - slow growth - NED until August 2018
    Aug 2018 Pancreatic metastasis confirmed by biopsy.
    Sept 2018 Starting clinical trial with RX-3117 and Abraxane (NCT03189914)
    March 2019 Lung nodules are stable

  10. #10
    I double-checked it, and the PET was definitely a PET/CT. It was a PET CT SKULL TO THIGH FDG. That was on the Tuesday. Then he had a CT ABDOMEN PELVIS ANGIOGRAM WITH IV CONTRAST that Friday. Make zero sense to me, and this Mayo Clinic in Rochester.

    There still is no biopsy actually scheduled. On Monday he has an endoscopic ultrasound, and then an abdominal ultrasound on Wednesday. Again, I'm totally confused. Why two?

    thanks again for the feedback on this. I really appreciate it! I know my dad is really scared, but I keep telling him just to take one day at a time. I feel bad for my mom too having to try to navigate the whole system there and shuttle my dad to and from all his appointments.

    David
    David
    Age 51
    March 1, 2011 - Grade 1 Follicular Lymphoma from node removed from neck.
    2/22 PET/CT scan revealed one additional node in groin - also removed.
    Officially Grade 1 / Stage 3 due to second node.
    No Other Evidence of Disease.
    7/8 PET/CT shows two new small nodes - opposite sides, neck and groin.
    1/06/12 Completed Rituxan x 4 Monotherapy. 2/29/12 NED! Completed 4 additional maintenance doses of Rituxan. 12/12 NED! 6/14 NED! 2/15 NED! 2/16 NED!
    6/17 CT shows 2 small nodes, neck and groin. 7/17 doing Rituximab monotherapy, x 8 this time. All is good again!

 

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