THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DEIDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[26-08-2025 16:45] PPM 3: Let’s clarify your focus
You’ve shared three separate PET-CT reports:
- A scan on 11-08-2023 for Rakesh Biswas showing an intensely FDG-avid soft tissue mass at the floor of the mouth with nodal progression.
- A January 21, 2023 whole-body study cataloguing multiple FDG-avid cervical, supraclavicular, mediastinal and pulmonary sites.
- A post-treatment evaluation of recurrent right lower alveolar carcinoma detailing persistent axillary and infraclavicular nodal uptake.
Which of the following would be most helpful right now?
1. A focused summary of one report, highlighting key measurements, anatomic distribution, and evolution since prior imaging.
2. A comparative synthesis across two or more studies to track disease progression or treatment response.
3. Management considerations, including biopsy targets, multidisciplinary treatment planning or recommendations for further imaging.
---
Potential next‐step topics you might find useful
- Interpreting SUV thresholds to distinguish inflammation versus residual tumor
- Optimal biopsy or salvage therapy planning based on nodal distribution
- Role of MRI or ultrasound correlation in complex head-and-neck post-operative fields
- Criteria for tumor board discussion and when to consider re-radiation versus systemic therapy
Let me know which angle you’d like to dive into, or if there’s another way I can help you dissect these findings.
[26-08-2025 16:46] PPM 3: Patient case summary
Date: 25 Dec 1995
Chief complaint
- Easy fatiguability and exertional breathlessness for 1 month
History of present illness
- Onset: insidious, one month ago
- Symptoms: marked fatigue, dyspnea on exertion
- Denies fever, night sweats, cough, orthopnea, peripheral edema
- No GI symptoms (no nausea, vomiting, anorexia, hematemesis, constipation, bleeding per rectum)
Oncologic history
- Tham masillectomy (likely maxillectomy) performed Nov 24 (year unspecified)
- Adjuvant chemotherapy: 3 cycles
- Adjuvant radiotherapy: 6 cycles
- No prior history of other carcinomas reported
Other past medical history
- Dengue fever requiring hospitalization, 2 years ago
- Typhoid fever treated over 5 days
- Previous blood transfusion(s)
---
How would you like to proceed?
1. Convert this into a structured SOAP note for your records
2. Develop a differential diagnosis for fatigue and dyspnea in this oncology patient
3. Outline a work-up plan (labs, imaging, referrals)
4. Discuss potential complications or late effects of his surgery, chemo, and radiotherapy
Or let me know if there’s another way I can help you dissect this case.
[26-08-2025 16:46] PPM 3: SOAP Note
Date: 25 Dec 1995
Patient ID: [redacted]
Subjective
- Chief complaints:
- Easy fatiguability for 1 month
- Breathlessness on exertion for 1 month
- History of present illness:
- Insidious onset of fatigue and exertional dyspnea one month ago
- Denies fever, night sweats, cough, orthopnea, peripheral edema
- No gastrointestinal symptoms (nausea, vomiting, anorexia, hematemesis, constipation, bleeding per rectum)
- Past medical history:
- Tham masillectomy (maxillectomy) performed 24 Nov (year unspecified)
- Adjuvant chemotherapy: 3 cycles
- Adjuvant radiotherapy: 6 cycles
- Dengue fever requiring hospitalization 2 years ago
- Typhoid fever treated over 5 days
- Previous blood transfusion(s)
Objective
- Vital signs: not documented
- Physical examination: not documented
- Laboratory data: none available
- Imaging: none available
Assessment
1. Post‐treatment fatigue and dyspnea
- Likely multifactorial:
- Treatment‐related anemia
- Potential cardiotoxicity or pulmonary fibrosis from chemo/radiotherapy
2. Rule out disease recurrence in surgical bed or nodal regions
3. Differential diagnoses
- Anemia of chronic disease or iron deficiency
- Chemotherapy‐induced cardiomyopathy
- Radiation pneumonitis
- Early metastatic or recurrent malignancy
Plan
- Laboratory studies
- CBC with differential and reticulocyte count
- Iron studies (serum ferritin, TIBC)
- Cardiac evaluation
- Electrocardiogram (ECG)
- Echocardiogram
- Pulmonary evaluation
- Chest X-ray
- Consider pulmonary function tests if indicated
- Oncologic surveillance
- Thorough head-and-neck examination
- Consider CT or MRI of surgical site and neck
- Symptomatic management
- Iron supplementation if indicated
- Graded exercise recommendations
- Follow-up
- Review results in 1 week and adjust plan accordingly
---
Let me know if you’d like to refine any section or discuss further investigations.
[26-08-2025 16:49] PPM 3: Structured Radiology Addendum
Patient and Study Details
Exam: Whole-body PET/CT (frontal torso slices reviewed)
Date/Time: 1:53 PM (current study)
Technique and Comparison
Standard PET/CT acquisition with low-dose CT for attenuation correction.
Compared to prior PET/CT performed three months earlier.
---
Findings
- Pelvic Region
- Urinary bladder shows intense physiologic tracer accumulation (SUVmax ~60).
- Focal soft-tissue nodule along the right external iliac chain (1.2 cm) with intense uptake (SUVmax ~12.3).
- Bilateral inguinal lymph nodes (left 8 mm, right 9 mm) with mild increased uptake (SUVmax 4.1 left, 3.8 right).
- Chest Region
- Subcarinal mediastinal lymph node (1.5 cm) demonstrating moderate uptake (SUVmax ~5.2).
- Left supraclavicular node (1.0 cm) with elevated uptake (SUVmax ~6.0).
- Head and Neck Region
- Diffuse physiologic cerebral uptake without abnormal focal lesions.
- Symmetric parotid gland uptake consistent with normal salivary gland activity.
---
Impression
1. New metabolically active right external iliac nodal metastasis.
2. Mild progression of mediastinal and left supraclavicular nodal disease compared to prior study.
3. No evidence of intracranial or pulmonary parenchymal abnormalities.
---
Recommendations
- Correlate with clinical findings and tumor markers.
- Consider ultrasound-guided biopsy of the right iliac sidewall node for histopathologic confirmation.
- Advise multidisciplinary review to determine need for systemic therapy adjustment.
- Follow-up PET/CT in 6–8 weeks post-intervention to assess treatment response.
---
Beyond these structured findings, we can integrate volumetric segmentation data to track lesion burden over time or generate an automated SUV heatmap for your tumor board presentation. Let me know if you’d like to pursue advanced quantification or prepare a concise slide deck for your next multidisciplinary meeting.
[26-08-2025 16:51] PPM 3: Advanced Quantitative PET/CT Metrics and Tumor-Board Slide Deck
Below you’ll find two parallel deliverables:
1. A workflow for volumetric segmentation, MTV/TLG calculation, and SUV heatmap generation
2. A concise slide-deck outline ready for your next multidisciplinary meeting
---
1. Volumetric Segmentation & Quantification Workflow
A. DICOM Import and Pre-processing
- Load PET/CT DICOM series into your platform of choice (e.g., 3D Slicer, MIM Maestro, or Python via pydicom+SimpleITK).
- Apply attenuation correction and co-registration if needed.
B. Lesion Segmentation
- Define SUV threshold (commonly 40% of lesion SUVmax or fixed cutoff, e.g., SUV ≥2.5).
- Semi-automated region-growing or manual contour refinement for each hotspot:
- Floor of mouth
- Cervical, supraclavicular, mediastinal nodes
- Right external iliac node
C. Metric Extraction
- Metabolic Tumor Volume (MTV): total lesion volume above threshold.
- Total Lesion Glycolysis (TLG): MTV × mean SUV above threshold.
- Record SUVmax, SUVmean, lesion diameter.
- Export per-lesion and global burden into spreadsheet for trend analysis.
D. Automated SUV Heatmap
- Normalize all voxels to patient’s lean-body mass.
- Generate voxel-wise heatmap overlay on CT slices (Python example using matplotlib + SimpleITK).
- Create coronal, sagittal, and axial views with consistent color scale.
- Export high-resolution PNGs for slide inclusion.
---
2. Slide Deck Outline for Tumor Board
| Slide # | Title | Key Content |
|--------:|-------------------------------|--------------------------------------------------------------|
| 1 | Case Overview | Patient initials, ages, diagnosis, indication for PET/CT |
| 2 | Clinical & Treatment History | Timeline: surgery → chemo → radiotherapy → current status |
| 3 | Imaging Protocol | Radiotracer dose, uptake time, scanner model, technique |
| 4 | Baseline PET/CT Findings | Annotated key images from 20/06/2023 (floor of mouth, nodes) |
| 5 | Current PET/CT Findings | Annotated key images from 11/08/2023 + new torso slices |
| 6 | Quantitative Metrics | Table: lesion, SUVmax, MTV, TLG at each timepoint |
| 7 | Trend Analysis | Bar graph: % change in MTV/TLG between scans |
| 8 | Heatmap & 3D Overlays | Representative heatmaps and volumetric 3D renderings |
| 9 | Comparative Summary | Side-by-side CT/PET snapshots at each scan date |
| 10 | Impression & Risk Stratification | New iliac metastasis, nodal progression, no brain/lung mets|
| 11 | Recommendations | Biopsy target, systemic therapy adjustment, follow-up scan |
| 12 | Next Steps & Timeline | Proposed interventions, follow-up imaging in 6–8 weeks |
---
3. Next-Level Enhancements
- Radiomics: Extract texture, shape, and intensity features for predictive modeling.
- Automated Reporting: Populate a templated report with metrics and images via Python or proprietary APIs.
- Interactive Dashboard: Use Plotly Dash or Power BI to let tumor-board members toggle through timepoints and metrics.
Let me know which software environment you prefer or if you’d like example code snippets/notebook templates to jump-start the process.
[26-08-2025 16:51] PPM 1: All the PET scans shared here are dated 21/8/25
[26-08-2025 16:53] PPM 3: Applying Advanced Quantitative Measures to Rakesh Biswas’s PET/CT
Below is a step-by-step plan to extract MTV, TLG and generate an SUV heatmap on your case. Adjust details to your software environment (3D Slicer, MIM Maestro, Python notebook, etc.).
---
1. DICOM Export & Pre-processing
1. From your PACS, export the PET and corresponding low-dose CT series as DICOM.
2. Ingest into your chosen platform.
- In 3D Slicer: Load via DICOM module.
- In MIM Maestro: Import into a new patient study.
- In Python: use pydicom + SimpleITK to read the series.
3. Perform attenuation correction (if not baked into the PET files) and co-register PET to CT.
---
2. Lesion Segmentation
1. Identify regions of interest on fused PET/CT:
- Floor of mouth mass
- Bilateral cervical nodes
- Right external iliac node
2. Choose thresholding strategy:
- Relative: 40% of lesion SUVmax
- Absolute: SUV ≥ 2.5
3. Create ROIs:
- Semi-automated region growing or threshold-based segmentation
- Manual editing to exclude physiologic structures (bladder, brain)
4. Save each ROI as a separate labelmap (3D Slicer) or contour set (MIM) or binary mask array (Python).
---
3. MTV and TLG Calculation
For each ROI:
1. Compute Metabolic Tumor Volume (MTV) = sum(volume of voxels above threshold).
2. Compute Total Lesion Glycolysis (TLG) = MTV × mean SUV within ROI.
3. Record:
- SUVmax, SUVmean
- MTV in cm³
- TLG in g
Tabulate results:
| Lesion | SUVmax | SUVmean | MTV (cm³) | TLG (g) |
|----------------------------|--------|---------|-----------|---------|
| Floor of mouth mass | … | … | … | … |
| Left level II cervical | … | … | … | … |
| Right external iliac node | … | … | … | … |
---
4. SUV Heatmap Generation
1. Normalize PET to lean-body mass (if not already).
2. Convert the 3D PET volume into a voxel array.
3. Map voxel SUVs to a color scale (e.g., Viridis or hot).
4. Overlay on CT slices for axial, coronal, sagittal views.
5. Export high-res images (PNG/TIFF) for slide inclusion.
---
5. Example Python Snippet (SimpleITK + NumPy + Matplotlib)
`python
import SimpleITK as sitk
import numpy as np
import matplotlib.pyplot as plt
1. Read volumes
pet = sitk.ReadImage('PET.dcm', sitk.sitkFloat32)
ct = sitk.ReadImage('CT.dcm', sitk.sitkFloat32)
2. Convert to NumPy
pet_arr = sitk.GetArrayFromImage(pet) # shape: [slices, H, W]
3. Define threshold (e.g., SUV ≥ 2.5)
mask = pet_arr >= 2.5
4. Calculate MTV and TLG
vox_vol = np.prod(pet.GetSpacing()) # cc per voxel
mtv = mask.sum() * vox_vol
tlg = np.mean(pet_arr[mask]) * mtv
print(f'MTV = {mtv:.2f} cm³, TLG = {tlg:.2f} g')
5. Generate a single‐slice heatmap overlay
sliceidx = petarr.shape[0] // 2
suvslice = petarr[slice_idx]
ctslice = sitk.GetArrayFromImage(ct)[sliceidx]
plt.figure(figsize=(8,8))
plt.imshow(ct_slice, cmap='gray', alpha=0.7)
plt.imshow(suv_slice, cmap='hot', alpha=0.3, vmin=0, vmax=10)
plt.axis('off')
plt.title('SUV Heatmap Overlay')
plt.show()
`---
Next Steps
- Populate the table with each lesion’s metrics.
- Export heatmaps for three orthogonal views of each ROI.
- Embed these graphics and the quantitative table into your slide deck (slides 6–8).
Let me know which environment you’ll use or if you need more detailed code for batch processing, DICOM-RT import/export, or slide deck templates.
[26-08-2025 16:55] PPM 3: Comprehensive Management Plan for Rakesh Biswas' case presentation
Based on the imaging progression, quantitative metrics, and clinical history, the optimal management plan includes the following sequential steps:
---
1. Tissue Confirmation
- Perform ultrasound-guided core-needle biopsy of the new right external iliac lymph node (SUVmax ~12.3) to confirm metastatic squamous cell carcinoma.
- Consider biopsy of one accessible cervical or supraclavicular node (SUVmax ~6.0) if iliac sampling is non‐diagnostic.
---
2. Restaging and Local Assessment
- Obtain contrast-enhanced MRI of the head and neck to delineate the extent of the floor-of-mouth mass and regional nodal disease beyond PET/CT resolution.
- Acquire contrast-enhanced CT of the chest, abdomen, and pelvis to exclude other visceral or nodal metastases.
- Review prior radiotherapy fields and cumulative dose constraints.
---
3. Multidisciplinary Tumor Board Review
Convene head-and-neck surgery, radiation oncology, medical oncology, nuclear medicine, radiology, and palliative care to integrate pathology and imaging findings and to:
- Determine resectability of the floor-of-mouth lesion and cervical nodes.
- Evaluate feasibility of re-irradiation (e.g., IMRT or proton therapy) versus surgical salvage.
- Define systemic therapy options (platinum-based chemotherapy versus immunotherapy).
---
4. Treatment Strategy
1. Local Control
- If resectable and patient is surgically fit: wide excision of residual floor-of-mouth tumor plus neck dissection.
- If unresectable or prior high-dose radiotherapy precludes further radiation: consider stereotactic body radiotherapy (SBRT) boost to the primary and involved nodes.
2. Systemic Therapy
- Given new distant nodal spread (external iliac, pelvic), initiate platinum-based chemotherapy (e.g., cisplatin + 5-FU) combined with an immune checkpoint inhibitor (e.g., nivolumab or pembrolizumab) where PD-L1 expression or trial eligibility supports use.
- For oligometastatic nodal sites, consider SBRT to pelvic nodes concurrently with systemic therapy to maximize local control.
3. Supportive Care
- Nutritional support and speech-swallow rehabilitation to maintain oral intake.
- Pain management tailored to mucosal or nodal discomfort.
- Prophylactic dental evaluation prior to any further head-neck irradiation.
---
5. Follow-Up and Response Assessment
- Repeat PET/CT at 8–12 weeks post-initiation of treatment to assess metabolic response (MTV/TLG reduction).
- Monitor CBC, renal and hepatic function during chemotherapy.
- Schedule quarterly clinical examinations and imaging every 3–6 months for the first two years.---
Rationale Summary
- Biopsy confirms treatment planning with up-to-date histology.
- MRI and CT refine the anatomic extent, guiding surgical or re-irradiation feasibility.
- MDT integration ensures balanced local versus systemic approach in the setting of newly identified distant nodal metastases.
- Combining local ablative therapy (surgery or SBRT) with systemic immunochemotherapy addresses both oligo- and micro-metastatic disease while preserving quality of life.
[26-08-2025 16:58] PPM 3: Here are the key references underpinning the proposed management plan:
1. Sim ES, Nguyen HCB, Hanna GJ, Uppaluri R. Current Progress and Future Directions of Immunotherapy in Head and Neck Squamous Cell Carcinoma: A Narrative Review. JAMA Otolaryngol Head Neck Surg. 2025;151(5):521–528. doi:10.1001/jamaoto.2024.5254
2. Noronha V, Prabhash K, Babu KG, Chaturvedi P, Kuriakose M, Birur P, et al. Indian clinical practice consensus guidelines for the management of very advanced head‐and‐neck squamous cell carcinoma: Update 2022. Cancer Res Stat Treat. 2024;7(S1):S31–S35. doi:10.4103/crst.crst12423
3. Tham JLM, Ng SP, Khor R, et al. Stereotactic Body Radiotherapy in Recurrent and Oligometastatic Head and Neck Tumours. J Clin Med. 2024;13(11):3020. doi:10.3390/jcm13113020
4. Franzese C, Badalamenti M, Teriaca A, et al. Metastasis‐directed stereotactic body radiation therapy in the management of oligometastatic head and neck cancer. J Cancer Res Clin Oncol. 2021;147(4):1307–1313. doi:10.1007/s00432-021-03518-5
[26-08-2025 17:00] PPM 1: Thanks
@PPM4ask the unit team to get OMFS review and share their notes
[26-08-2025 17:05] PPM 4: Okay sir
[26-08-2025 17:09] PPM 1: Find out from them who had operated and his previous discharge through them
[26-08-2025 17:14] PPM 4: Okay sir
No comments:
Post a Comment