HISTORY AND CLINICAL COURSE:A 16-year-old male presented with worsening abdominal pain, non-bloody diarrhea, and unintentional weight loss. On exam, he had diffuse abdominal tenderness and unnoticed left testicular swelling. US demonstrated a heterogeneous left testicular mass; CT demonstrated a large heterogeneous left testicular mass with extensive tumor thrombus propagating along the left gonadal vein, into the renal vein, the IVC, right atrium, right ventricle with several metastatic pulmonary emboli. The patient underwent left orchiectomy, and pathology showed testicular mixed germ cell tumor with immature teratoma and yolk sac components. The patient was referred to our institution for further management of his intravascular and intracardiac tumor components, given the patient’s pathology fell under an intermediate category based on the “Intermediate Germ Cell Consensus classification” which supports treatment with curative intent given an 80% long-term survival rate. PROCEDURE:An open surgical approach was used to remove tumor tissue from the right heart and supra-hepatic IVC. Percutaneous endovascular thrombectomy was then used to remove the tumor from the infra-hepatic IVC and the left renal vein 24 hours after the cardiac surgery. Step 1: Distal Embolic Control: A single disc from an Inari Flow Triever device was deployed, via the right internal jugular vein, below the level of the hepatic veins to provide distal embolic control throughout the procedure. This is an alternative application for this device. Step2: IVC tumor removal: An Inari Clot Triever device was deployed via the right common femoral vein. Multiple 360-degree sweeps throughout the IVC to ensure intravascular tumor removal as validated on follow-up IVC venography. Step 3: Left renal vein tumor removal: The left renal vein thrombus was removed using a combination of the Flow Triever and aspiration catheter systems. IVUS and left renal venogram confirmed the tumor removal. FOLLOW-UP:The hospital course was uneventful. The patient was anticoagulated with a tight INR goal of 1.5-2 to balance the need for anticoagulation and avoiding the risk of bleeding from recent cardiac surgery. Chemotherapy with Bleomycin, Cisplatin, and Etoposide was initiated upon discharge and will be reviewed by surgical oncology for retroperitoneal nodal clearance later. This case demonstrates the multi-disciplinary team approach to caring for a complex case of an extensive testicular tumor in a pediatric patient. Read More

Meeting name: SPR 2022 Annual Meeting & Postgraduate Course , 2022

Authors: Jayapal Praveen, Alharthi Omar, Thakor Avnesh

Keywords: Endovascular, thrombectomy, testicular tumor

Children with cancer typically require a local MRI scan for primary tumor staging, which is often supplemented by a whole-body PET scan for whole-body staging. Over the past decade, PET-CT was the most widely used modality for whole-body staging across the world. Seven years ago, our team pioneered whole-body 18F-FDG PET-MRI of children with cancer as a "one-stop" alternative with 80% reduced radiation exposure and optimized child-tailored fast and efficient Whole-Body PET/MRI protocols. We then replaced all whole-Body PET/CT studies at our Institution with whole-body PET-MRI as the standard of care for our patients and have performed over 800 Pediatric Whole Body PET MRIs in the last three years. The purpose of this educational exhibit is to provide a comprehensive review of whole-body PET/MRI technique, imaging patterns in common pediatric malignancies. The first aim is to briefly explain our Institution's protocol for simultaneous PET/MRI acquisitions. Such simultaneous acquisition results in a convenient, faster, and safer approach for local and whole-body staging in one session. Furthermore, it avoids the need for repetitive anesthesia and imaging and also avoids potential ionizing radiation from PET CTs. The excellent contrast resolution in the MRI provides superior diagnostic detail compared to the CT. The second aim will present PET/MRI case examples, where either the PET component added value to the MRI or the MRI component added value to the PET, thereby confirming the importance of this integrated hybrid imaging technology. We will present PET/MRI case examples of the following pediatric tumors: 1. Lymphomas: 2. Osseous Sarcomas including Osteosarcoma and Ewing Sarcoma 3. Soft-tissue Sarcomas such as Rhabdomyosarcoma, Desmoplastic small round blue cell tumor. Synovial Sarcoma, Fibrosarcoma, Epithelioid Sarcoma, Alveolar Soft part sarcoma, and Liposarcoma 4. Neuroblastoma 5. Neuroendocrine tumors 6. Malignant Peripheral Nerve Sheath Tumor 7. Germ cell tumors 8. Renal tumors 9. Malignant Liver tumors 10. Langerhan Cell Histiocytosis As a result of this educational presentation, participants will be able to prescribe a PET/MRI exam for children with cancer, implement tumor-specific protocol modifications, and improve their tumor diagnoses' sensitivity, specificity, and accuracy. Read More

Meeting name: SPR 2022 Annual Meeting & Postgraduate Course , 2022

Authors: Jayapal Praveen, Baratto Lucia, Rashidi Ali, Daldrup-link Heike

Keywords: PET-MRI, PET, 18F-FDG PET-MRI