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Other Side Of The Coin

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

Hi…..I just recently came across this site and have spent hours reading your posts. What a wonderful place you have here. Strangers helping strangers. Strangers becoming friends and a community of survivors entwining themselves in the lives of others, with one overwhelming theme……………………to help.
Although my case has had a pretty happy ending for the time being, I’d like to become part of this message board. It’s possible that I might even be able to help a bit.
For more than 30 years, I was the guy doing your CT and MRI scans. I was doing CT scans when the first scanners came to this country back in the mid 70’s. The Cat Scans you have today with and without contrast…..asking you to hold your breath for about 20 seconds possibly 6 times total, used to take close to 90 minutes. MRI did not exist. During the past 30 years I’m guessing I’ve measured thousands of renal cell carcinomas. I was the good guy Technologist. If you asked how things looked…..whether things were better or worse, I’d tell you to pull up a chair and I’d run through the images explaining everything I could to put you at ease. Whether it was a CT or an MR a day didn’t go by where I could not have lost my job, simply to send everyone home with enough information to either know they had a long way to go, or things were looking better. It was always those “things are looking better” late, on a Friday that made me feel good. Knowing that I gave a patient a good week-end. I worked for one group of Radiologists for 28 of those years and the only complaint they ever had about me was and I quote…..”YOU SPEND MUCH TOO MUCH TIME WITH THE PATIENTS”. I always said to myself…..I can live with that. If once a year I had to hear about that in my evaluation, so I heard it about 30 times. Big deal.
I decided to retire a couple of years early. Needed to take care of Mom who was in the final stages of Alzheimer’s. All those years I made sure I always had the best health insurance possible. I always paid those extra few hundred a month to make sure I had what is called today the “Cadillac Plan” Actually I never liked Cadi’s but it just meant the best of the best. After retiring, I paid for COBRA and when it was gone I applied to Blue Cross, Aetna, Vista, Humana, Cigna, and United and have denial letters from all. Seems being on blood pressure meds and Crestor for elevated cholesterol are both pre-existing conditions. (Only in America). Thank God in 67 when I graduated from high school, I enlisted and spent 6 years in the military. Back in the early 90’s I registered myself for VA healthcare and had blood work there once a year to make sure I remained in the system. So, at the age of 59, four years ago the VA became my entire healthcare system. Luckily the Miami VA Healthcare System is part of the University of Miami. The same doctors that rotate through UM and Jackson Memorial also rotate through the Miami VA. It’s an incredible facility and no matter what my healthcare needs, I was taken care of. Just small co-payments here and there.
So how do I find myself on the other side of the coin? (I love that expression) For more than ten years my hemoglobin has been elevated. Usually in the 18’s. Of course that would mean that my RBC’s and Hematocrit was also up. I was always told………………….”Jeff, that’s just you”. Since there were no other symptoms I just left things alone. Last year my primary called me after blood work and said, listen it’s at 19.1 now, and you need to see the hematologist in Miami. Drive the thirty miles and see what’s going on. After four trips to the Miami VA hematology department they were all scratching their heads. Every blood test known to man and nothing to explain it. There is a hormone produced in the kidneys called erythropoietin. It basically tells the bone marrow how many red blood cells to produce. Mine was repeated over and over again and stayed at 11. Low normal. No reason for worry. So the end result is “You have Erythrocytosis”. That means your hemoglobin is elevated and nobody on earth knows why. Let’s just have you come here three weeks in a row, give blood (500-600cc each time), no different than donating blood and bring it down for a while. No problem, done. The head of the hematology department says to me….”come back in six months and we’ll see if it worked its way back up”. I said thanks for everything and left. Just before I got to the elevator he came quickly down the hall, grabbed me and said I just thought of one thing we didn’t do and this might me the cause. He said when you first came here you told me you had bilateral renal cysts. I knew this because of a CT I had years ago for something unrelated. He said if you have many more of them now, this could be the cause. He said have a CT done with and without contrast and we’ll see. Three days later when the Cat Scan is over, I give the technologist the CT Tech Secret Handshake and he lets me sit down and check out my images. In less than ten seconds I spotted my 2.5cm RCC. The few renal cysts were just where they were ten years ago, but in the lower pole of the right kidney, there it was. I looked at what we call the delayed post contrast films, I put an ROI measurement on it pre and post contrast and knew I was having surgery. While at the table I checked out my liver and the base of my lungs. Nothing interesting there so I thought this is early and I’m good.
Heading to the urology oncology department to discuss the surgical options they notice a bit of hematuria. (Blood in the urine). Just a little and said “it’s probably just a little prostatitis” but since you’re going to have surgery, before we begin we’ll do a cystoscopy in the OR after you’re asleep.
Because a partial nephrectomy was possible, the laparoscopic plan was discussed. But because of previous hernia repair many years ago with lots of mesh, I was not a candidate for it. Too many adhesions to deal with. The surgeon says to me “are you in luck”. There’s a fairly new way of doing this laparoscopicly from the side. It’s called Retroperitoneal Laparoscopic partial nephrectomy. Same laparoscopic technique, but they simply enter the peritoneal cavity without disturbing the abdomen. My luck, the head of this department who works three days at University of Miami hospital, next door, also works two days a week at the VA. He just returned from Duke where he did a fellowship in this procedure, and off we go.
Waking up in the recovery room was an experience and a half. About fifteen minutes after waking up the surgeon comes in and says “what a lucky guy I was”. He said when we did the cystoscopy, we unexpectedly found a 3.5cm Low Grade Papillary Urothelial Carcinoma. It was hanging free and attached to the wall of the bladder by a little stalk. A simple tug and it was gone. He could not believe it was so large but non invasive. They also removed what proved to be a Multilocular Cystic Renal Call (Clear Cell) Carcinoma, 2.0cm. All confined to kidney and not involving resection margin.
The only follow up I needed was a cystoscopy at three months and a renal ultrasound. Those are done and all is well. So now it’s a check once a year and hopefully life goes on.
This was a great venting process for me today. I’ll continue to read the boards here. You’re an amazing group of people. I’d also like to say if there is any way I can help anyone……….explain CT or MRI impressions as a layman, I’d be happy to help. Sometimes doctors don’t give you enough information to clear your head. Of course nothing I say would be definitive, but bouncing things off someone who has been doing these scans for three decades might help. I wish you all well.
Jeff

Texas_wedge's picture
Texas_wedge
Posts: 2807
Joined: Nov 2011

Boy, will you be a valuable new asset on this forum!! That was an absorbing bit of bio and I'm sure your future postings will be greatly appreciated.

Texas_wedge's picture
Texas_wedge
Posts: 2807
Joined: Nov 2011

[Duplicate post, but here's a second welcome anyway!]

icemantoo's picture
icemantoo
Posts: 1528
Joined: Jan 2010

Jeff,

Feel free to respond to those members who have posted their scan results. The easy ones are those before surgery with small tumors (4cm or less and no other baggage) and those post surgery with clean scans. Unfortunately some of the scans are very challanging and are difficult to respond to.

Icemantoo

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

Reading CT and MRI scans in full can spin your head. At the bottom of every report is an Impression. I can almost always make sense of those few sentences. That's all you really need to understand. Some radiologists read three pages where others can say it all in a paragraph. Depends on how much they want to cover themselves. But an impression is an impression. Nothing left to the imagination. Radiologists love to use the words Sub Optimal. That usually means the technologist didn't know what he or she was doing and if I'm wrong it's their fault. You can't imagine what goes on.

Jeff

garym's picture
garym
Posts: 1651
Joined: Nov 2009

Hi MSM,

While I am sorry that you had to go through our little initiation process, I am also very happy to have someone with your technical expertise join the club. You seem to have a good sense of humor and a great bedside manner, so to speak, both are highly valued here.

Welcome aboard,

Gary

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

Thank you all for the welcome. Don't think for a minute that I don't know how lucky I am. Catching two cancers by accident and both early. Hope I can be of some help.

Jeff

NewDay's picture
NewDay
Posts: 172
Joined: May 2012

Hi Jeff,

Glad (and not) that you are here. Sounds like you were very lucky for things to be caught in time. Since you offered to answer questions, I'm going to be the first to ask. My tumor was an incidental finding when a gastroenterologist was investigating another problem. I also have an additional undiagnosed problem that involves pain in the pelvis. My question is, if my CT was of the abdomen and pelvis and the only thing abnormal mentioned was the kidney tumor, can I assume the reproductive organs are OK or would the radiologist have even looked at them since that wasn't related to the complaint? Hope that made sense. I have already had an ultrasound for that problem that didn't show anything. Thanks for any help.

Kathy

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

Hi Kathy
If you had a CT of the Abd and Pelvis, I'm hoping it was with and without contrast. No matter what the ICD 9 code was (that means...reason for the test), the Radiologist is going to check every image in front of him. If the images of the pelvis are in front of him and he doesn't report a finding, he'll be working for you the rest of his life. Images of the pelvis that usually come up in the pelvis for women are of course, bladder abnormalities of contour as well as ovarian cystic adenocarcinoma (Gilda Radner). But that sticks out like a sore thumb. Nobody would miss that. I would say not to worry. Check the report, I'm guessing that somewhere it would say no abnormalities found in the pelvis. Today the scanners are so fast, I don't know any facility that does not include the pelvis, even if the physician only orders a CT of the abdomen. That is simply to cover them, not you. Wish you well.
Jeff

alice124's picture
alice124
Posts: 860
Joined: Mar 2012

Jeff - thank you for your generous and welcome offer. So glad you've decided to join us. I can only hope we don't wear you down with our many questions.

I'm looking at a brand new CT scan right now but will try not to overwhelm you all at once. Thanks again Jeff.

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

Feel free Alice. Makes me feel like I'm back working again instead of watching Law and Order all day.

NewDay's picture
NewDay
Posts: 172
Joined: May 2012

First, to make sure you took my first comment the way I meant it. I'm glad you are here, but not glad you have a reason to be here. My next question is: If the contrast is what makes things light up, why do they even do them without it?

Thanks,
Kathy

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

Of course I took it the way you meant it. That's funny. As to your question on CT.....Only certain CT Scans are done with and without contrast. I'll type and I'm sure you'll understand this. Take a brain CT. For trauma no contrast is necessary. You're looking for swelling and blood. A subdural hematoma large enough to require surgery requires no contrast. Contrast, in all cases flows with the blood. If a possible mass is noticed in a brain CT with no contrast then contrast would be given to light up the mass. It would light up because the mass would be vascular and the blood flow will carry the contrast to the mass. Think of the iodine contrast as something that lights up to the radiation the scanner is zapping you with. Sometimes a chest CT will be done without contrast. Usually ordered by pulmonary doctors who are only looking for COPD or anything else not vascular. A normal CT exam of the chest needs contrast to light up the vessels in the center of the chest.....(Mediastinum). Very important for lymphoma as well as showing dissecting aneurysm of the thoracic aorta. In your case CT Abdomen and Pelvis. Always done without contrast in the ER looking for kidney stones. Contrast will actually get in the way here. Contrast works because it's an impurity as far as the body is concerned. This type of impurity is excreted by the kidneys. So imagine of you're looking for a little kidney stone and the ureters are filled with contrast sending that urine from the kidneys down to the bladder.....you'll never see the stone. For other reasons Abdomen and Pelvis CT scans are done to compare. There is a measurement that we do called an ROI.....(reigion of Interest). You measure the liver and spleen quickly without contrast and you can see if there is a fatty liver among other things. Kidney masses always have to be measured without contrast and then again with contrast. In the old days this would tell you even after the injection if a cyst is a cyst. Some RCC's can be seen with no contrast because of size. You just know. In my case because it was 2 cm and looked just like my other cysts the contrast ROI measurement left no doubt. I hope these examples helped. The bottom line is CT scans of the Abdomen are done first without contrast simply to have a comparison to what you see on the important scan post injection. If a person is allergic to iodine.....even the nonionic iodine.....which everybody should be using today then a non contrast scan can be done and there are some tricks we can do to check things by adjusting window levels.....(brightness and contrast). We sometimes do that when creatinine is above 1.5. Hope this was helpful.
Jeff

brea588's picture
brea588
Posts: 114
Joined: Jul 2012

I had an mri of abd due to lesions that showed on my liver in ct scan of chest without contrast. On MRI it was hemangiomas but found 2 cm lesion in mid posterior kidney. Radiologist reads is as enhancing complicated thick septations and calls it RCC as his impression. Can they tell most of the time from seeing this with and without contrast that it is cancer. I am having a partial neph on Aug 28th needless to say I am very scared. My urologist oncologist said it was a solid tumor and xphyotic he was my second opinion. FIrst urologist said it could be just a renal cyst. Im sure the radiologist would know the diff in cancer and cyst. This can be very confusing from one doc to another but 1st one acted stupid too me lol. He didnt see everything the radiologist did.

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

Hemangioma should always bring a smile to your face. The answer to your question is yes. If the radiologist is calling it an enhancing lesion then it is. MRI is usually used to confirm after CT. MRI without and then with gadolinium injection is usually the end of testing. The only way to make more sure would be a CT guided biopsy. I've done hundreds with my Radiologists. A little painful, lots of waiting time lying on your stomach waiting for the speciman to go to the lab for quick results and I'm guessing that the first urologist was just talking.(Hence the word "Could"). Partial nephrectomys are so routine today. I can't tell you not to be scared, but mine was the same size and laparoscopicly it was a breeze. Hope it goes well and fast for you. Worst part has to be the wait.
Jeff

brea588's picture
brea588
Posts: 114
Joined: Jul 2012

thanks for ur comments. T he waiting time is awful would rather go on and get it done lol. I have Copd asthma and decreased lung function so that is why im more anxious. My Pulmonologist in going in surgery with me to keep airways open during surgery. How long was your recovery time. Much pain involved. I have a high tolerance to pain most the time. I am a registered nurse and we just make the worse patients ever lol. Have seen too much and know too much. Sometime ignorance is bliss lol. thanks again

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

My recovery time was three days. Normal surgical pain. Second night, after dinner.....two vicodin and an hour later walking around the nursing station with the Ivac. Minimal post op antibiotics, nothing fancy and home at the end of the third day, not counting surgery. With all these extra doctors monitoring you, you'll do fine. You're an RN..............Who's better than you!

brea588's picture
brea588
Posts: 114
Joined: Jul 2012

Thank u so much u have relieved a lot of my fears. So glad i met u here tonight. You are a blessing to this web site. Doc said surgery would be about 5 hours and 3-5 days in hospital. Yes I will be fine. Thanks for encouragement. You know when noone you know has been through this it is hard for others to understand what ur feeling and thinking.

DMike's picture
DMike
Posts: 238
Joined: Nov 2011

Hi Jeff,
I'm sorry you have to be here because of RCC but your presence will be very educational and beneficial to us.
A couple of questions...First I think I know the answer to this after reading your earlier posts. I'm probably dense but I thought the preliminary action before the contrast injection was purely calibration (no one told me this I just thought this was the case) but now I believe those are the non-contrast scans you mention. Is that correct?

2. On my last CT scan the doctor ordered abdomen, thorax and pelvic scans. The scan stopped at the top of my hip, shouldn't a pelvic scan show more than that?

Thanks for your help, David

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

Yes. Non contrast films of the abdomen are very important to compare. The Thorax as you say would be a CT scan of the chest (Lungs). A CT of the Abdomen alone would stop at the top of your hip. Usually 2-3 cm below the iliac crest. The bone you feel on your side about inline with your belly button. If that's where the scan stopped then you did not have the pelvis done. The pelvis would have taken the pictures past the bladder filled with contrast to the end of the pelvic bone. Not going to get fancy here with anatomy. Can I ask you how you know that the technologist stopped at the top of your hip....as you call it? If it's because he or she was poking you there before the scan, it's a place we use to measure. It's a place the laser light goes so we know where you are.
Jeff

DMike's picture
DMike
Posts: 238
Joined: Nov 2011

Jeff,
The doctor told me that's where it stopped while scrolling/zooming through the image. So, it sounds like I didn't get the pelvis CT scan.

It was a confusing day because my doctor was leaving and it was his last day in the clinic. I was upset to learn that that day and I was looking at the scan with his resident at the time I learned they stopped at the top of the hip.

Thanks for the info and welcome to the group again!

--David

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

David, you might want to check with the center that did your scan. Could be that the tech didn't send all the images to the radiologist. When the scan is over, the images are sent from one computer to another. For all you know the pelvis images are right there on the computer in the scanner. If that was the case those images would simply be sent to the radiologist and your report would have an adendum added. I would check. I've seen it happen and it takes only seconds to send the images.
Jeff

DMike's picture
DMike
Posts: 238
Joined: Nov 2011

Will do, Jeff. Thanks!

foxhd's picture
foxhd
Posts: 1899
Joined: Oct 2011

Welcome Jeff. Boy, you got the full initiation pretty quickly. Thanks for offering your knowledge and expertise. Fox

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

Thanks for the welcome Fox. I've been reading your posts for a couple of weeks now. Everyone actually. I didn't just jump in. The interaction here was great and I wanted to be a part of it. Glad you're doing well!

sunlover_56's picture
sunlover_56
Posts: 110
Joined: Apr 2012

Wow, How fortunate are we to have you join our group. (Not so fortunate for you, though, I'm sorry) Dare I jump in with a question? I am due for my very first 3 month scan this August. A lower abdomon and pelvic was ordered along with an upper chest xray. My concern is the chest xray. I wondered why they dont just do a full body scan which is more likely to pick up any thing that has spread to my lungs etc? (By the way I had a full lap scope nephr in April taking out a 7.5 RCC tumor which was contained to the kidney)

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

I think the normal follow-up for RCC is a chest x-ray to look for nodules....as we all know RCC can go to lungs and either a renal ultrasound or a CT Abdomen the keep an eye on the other kidney as well as to make sure nothing shows up in the liver. Mine was only 2cm and I simply had the Ultrasound at 3 months and an in office Cystoscopy for the bladder tumor which seems to be completely gone.....for now. Your doctor is thinking why expose you to that extra radiation that you'd get with the CT Chest when nodules can be seen pretty well on a simple chest x-ray. Not to make everyone run away from the CT machine but the amount of radiation you receive during a Chest Abdomen and Pelvis with and without contrast is probably close to a few thousand chest x-rays. We think about radiation as a bad thing, but when medically necessary the best way to think about it is "If you can't see it....it can't hurt you". At 7.5cm I would much rather my follow up be the CT scan rather than the ultrasound. Good luck with the results.

adman's picture
adman
Posts: 260
Joined: Jul 2012

I just had a 5.0cm ( path - stage 1/ grade 1 ) right radical a few weeks ago.
Pre tests were cyst, CT abd/ pelvis w/ wo contrast, MRI abd, MRA abd, Nuc Med bone scan, mag 3 renal, chest X-ray, PSA.
- All negative

I had a small cyst on my remaining left kidney which obviously needs to be very closely watched.
Surgeon just told me my 3 month is blood work & a ultrasound.

I've been wondering if this is aggressive enough.

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

I'm guessing that your follow up blood work will always be Bun, Cratinine and GFR. Just to make sure that the kidney you have is functioning well. For that small cyst, I think Ultrasound is fine for three month follow up. I have a question for you though. Looking at your pre tests.....if you were in my diagnostic center you would have made the rounds of every department other than Mammo. I'm not getting the MRA. I've done many MRA's of the abdomen, but they were anatomy specific. Most of them were for renal artery stenosis. Were your numbers so high that a stent was being considered? Just wondering why you had to have the MRA. Good to meet you.

Jeff

adman's picture
adman
Posts: 260
Joined: Jul 2012

Jeff,

Not sure why the MRA was ordered to be honest. I don't recall any 'pre-surgery' mention about needing any stents.

Thanks for the valuable input & perspective.

PS
After speaking to my family doc yesterday - ( post surgery ) I have made a decision to be treated by a nephrologist moving forward.
I feel I want their perspective on future blood work, diet, meds, etc.
I will also see my surgeon as well.

Thanks.

garym's picture
garym
Posts: 1651
Joined: Nov 2009

MSM,

I had a feeling you we're going to be a popular guy, but WOW! I have a question related to Sunny's, I'll be having my 3 year CT in December and I won't have had a chest x-ray for 2 years. As i understand it a CT usually catches the bottom of the lungs so my question; is the CT sufficient or should I request an x-ray as well?

Thanks,

Gary

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

Gary

I surely can't say how often your doctor feels it necessary to have the f/u chest x-ray. That would vary by physician. I can tell you that the base of the lungs that show at the beginning of the CT Abdomen is small. Maybe 3-4cm. Just enough for the technologist to know that he gets a running start to the Abdomen. If you take a big breath on the first pass, more of your lungs will show. The lung seems to move down (as scans go) when a real deep breath it taken.

Jeff

love_of_my_life
Posts: 28
Joined: Jul 2012

Thanks for joining this board.

I have a feeling that your insight will be extremely valuable for many.

Tom

NewDay's picture
NewDay
Posts: 172
Joined: May 2012

You only thought you had retired. It is so good to have your expertise here. I hope we don't run you off with all of our questions.

Thanks,
Kathy

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

You're very welcome. If I can help I will. If I don't know......I'll say so. I did that once today. I almost felt bad that I had no answer but I'm not going to snow anybody here. I'll do my best. It's the only place I can type where I don't get political. You have to come to a place like this to get your faith in humanity restored.......but I had to get cancer to get here...........Funny

Jeff

pjune127's picture
pjune127
Posts: 127
Joined: Dec 2011

You are a good man! We are lucky to have you with us for this awful ride. My oncologist believes he can get all the information he needs with a chest/abdomen CT with no contrast. He says it is not necesssary to stress out my remaining kidney. While this makes me happy to not have to drink that disgusting stuff, I worry that he might be missing something. I had a 10 cm tumor that had invaded my VC and some mets in my lungs at diagnosis. RCC Stage 4 Grade 4... My scans are every 2-3 months, next one the beginning of September. Am on Inlyta now after Sutent for 10 months. Can't wait to have you interpret my next scan. Welcome aboard. Hope you won't get tired of us.

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

It's not always necessary to drink what you call (that disgusting stuff).....I've heard other words for it, not suitable for this board. But it is simply barium. The same barium you drink when having a G.I. series for a look at your stomach. Just a different consistency. There's one called Scan-C that is made in Canada and tastes a lot better than EZ Cat used by most. I used to order that for my patients. The people I worked for never realized the difference in cost so the hell with them. Patients used to say "this ain't half bad". There are other things to drink but usually only if you're being considered for Gastro surgery. Now that stuff is icky. If your creatinine is lower that 1.4 and your BUN under 20, I wouldn't think your doctor should be worried about the other kidney excreting the injection of nonionic iodine quickly. Since you already have your diagnosis, he's probably right. If all he needs are measurements of the remaining kidney, as well as checking for lung nodules, IV contrast wouldn't be needed. If he (or you) are worried about anything else.......liver, pancreas, anything in the pelvis.....lymph nodes.....etc., then IV contrast is definitely needed. I look forward to hearing what the radiologist dictates in his impression at the bottom of your next CT report. I hope I can help you make sense of it all.

Be well,

Jeff

DMike's picture
DMike
Posts: 238
Joined: Nov 2011

Hi Jeff,
I did check on my pelvis CT and it was done. It seems they're working in 2 computer systems at the moment and my doctor was trying to view it on the old system. Anyway, I have the radiology report and it's good!

I noticed on the reports for chest, abdomen and pelvis it states:
"Technique: Axial images of the abdomen were obtained following the administration of oral contrast material. Next, axial images of the abdomen were obtained in the arterial and portal venous phases following intravenous injection of contrast medium per protocol. Coronal reformatted images were reviewed. IV Contrast: Omnipaque 350, 120ml, per protocol. Oral Contrast: Gastrografin, diluted per protocol, 32 oz. IV contrast injection rate: 3 ml per sec. Scan delay: 35/100 sec. Scan field of view: 330mm."

I did not take oral contrast material. Isn't this saying I did? I did have IV contrast. Just trying to be well informed for the next round of CT scans. Thanks so much for your help. --David

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

First of all let me say that you really did get a great scan. You had non Ionic Contrast (Omnipaque....best stuff), probably made you warm down below for about 15 second and maybe a little warm in the throat but no nausea. Years ago everybody got nauseous. The technologist not only did a venous and an arterial phase (meaning they were able to measure delayed iv contrast images, but he had the scanner reformat the axial images into a coronal view. That’s like stacking all the images on top of each other to get a complete view of your body from front to back. As far as the oral contrast, it does say that before the non contrast films you drank Gastrografin. This contrast takes the place of Barium.....tastes very bitter and for an Abdomen and Pelvis you would have had to drink two glasses.....then sit for a while and then a final glass before lying down. If you don't remember drinking that stuff (and you would, believe me), then the radiologist made a mistake in his reading. I'm glad they found your pelvis images. I told you they were in a computer somewhere. Hope you're having a good week-end.

Jeff

Texas_wedge's picture
Texas_wedge
Posts: 2807
Joined: Nov 2011

Jeff, I'm interested in the differences in practice in CT scanning. I'm confident that I'm in the very best of hands with a large, highly expert multi-disciplinary team, so I'm intrigued that I've had 3 CAP scans so far, with and without Omnipaque, but I've only had water to drink before and after the scans - nothing like barium or Gastrografin.

(Also, for my rad neph and subsequent open op for a recurrence, I wasn't required to drink anything beforehand, other than water to keep myself adequately hydrated. Do such practices - use of what I seem to remember Fox referring to as Drano - depend on the individual patient's health profile or habits?)

Your expert knowledge will yet again be much appreciated.

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

Good morning.....Normally whenever you have IV contrast you'll be asked to drink water for a good 24 hours so as to be well hydrated and your veins will be easier to stick. As far as Water being used in place of Gastrografin or Barium.....The very hi speed (New scanners) are so fast that even without oral contrast very little is missed in the GI track. The oral contrast is only meant to show stomach, small bowel, large bowel, and recto/sigmoid. When contrast shows in the rectum then the Radiologist feels the exam was complete. Some people are called back for a delayed scan of the lower pelvis if no contrast reached the area. As for water as contrast.....there is a Dr. who knows more about CT scanning than anybody in the country. He's at Hopkins and his name is Dr. Elliott Fishman. I do all my continuing education with him He travels with a lecture team all over the country and does full week-end seminars. Radiologists and Technologists getting their education credits together. I go for my CEU's and the Doctors get their CME's all at the same time. Below is what he says about Water Contrast in place of the others. Also you might find of interest the web site CTisUs.com. It’s his teaching site from Hopkins. There is so much you can see there. Every disease…..every way to scan them……movies to watch. It’s truly amazing. Read below. It may help.

Jeff

Recent advances in computed tomographic (CT) technology and three-dimensional (3D) imaging software have sparked renewed interest in using CT to evaluate gastric disease. Multidetector row CT scanners allow thinner collimation, which improves the visualization of subtle tumors as well as the quality of the 3D data sets. When water is used as an oral contrast agent, subtle disease is easier to visualize, especially when a rapid contrast material bolus is intravenously administered. Adenocarcinoma is the most common gastric malignancy and typically appears as focal or segmental wall thickening or a discrete mass. Gastric lymphoma can have a CT appearance similar to that of adenocarcinoma. Both gastric adenocarcinoma and lymphoma may be associated with adenopathy. Gastrointestinal stromal tumors (GISTs) tend to appear as well-defined masses that arise from the gastric wall and may be exophytic when large. GISTs are usually not associated with significant adenopathy. In addition to gastric malignancies, CT can also help detect inflammatory conditions of the stomach, including gastritis and peptic ulcer disease. CT angiography is especially helpful for depicting the gastric vasculature, which may be affected by a variety of disease conditions.

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Texas_wedge
Posts: 2807
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Thanks for the informative reply Jeff and the link (which I've started to follow up and shall doubtless delve into further later on). My guys are using the very latest scanners so your explanation makes sense of my personal experience.

Since we're exploiting your generosity relentlessly, I'll put another question. I won't try to camouflage its naivete, because I think most of us here will have had it cross our minds many times, but I appreciate that it may be a somewhat foolish question with no sensible answer. Anyway, here goes:

On the thread entitled "Oncologist" Greg asked a question about follow-up and this has elicited a response from John flagging the topic of second opinions. iceman has often advocated consulting a nephrologist in certain situations and the general consensus seems to be that the first line is urological surgery and thereafter oncology.

How do you see the respective roles of urologists, radiologists, oncologists and nephrologists in determining the optimal monitoring protocols for RCC patients? The information fed back by radiology is presumably primary but is handed over to other doctors. Urologists cover a good deal more than kidneys and may or may not know much about urological oncology. On the other hand, RCC is a less common cancer and many oncologists may not know all that much about kidney cancer. By the same token, nephrologists cover a lot more diseases and conditions than just cancer and may not be well-versed in the more arcane aspects of RCC, e.g. rarer sub-types.

I suppose it's important to ascertain how much any practitioner of one of these specialties knows about RCC specifically? If it's not actually too stupid a question to address, I'd welcome your thoughts, including what the parameters of individual cases are that would commend who should call the shots on the manner and frequency of follow-ups.

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MedScanMan
Posts: 108
Joined: Jul 2012

OK....I won't refer back to the other thread you mentioned. The best I can do is tell you what the job is of each physician. (in my opinion). Radiologists are a breed of their own. If you've made up your mind to be a doctor, you have a couple of decisions to make after you graduate from Med School. Internship can be anything, but most of all it will tell you if deep down you're a "person". If the answer is yes because you enjoy speaking to, helping and getting close to patients and their families, then you have many choices. If during your internship you find yourself feeling holier than thou, flying above all the patients that want a simple moment of your time but you're too "good" to give that moment......if you find that you can't go on unless you begin anger management classes so as to bring you back to earth.....then Radiology should be your residency. These people (and I use the term loosely) should never expose themselves to patients and family. They need to come to work.....lock themselves in their room.....put the headset on and begin dictating. Actually the locks on these doors should be on the outside and they should have to knock a few times to be let out......for lunch.....etc.
As far as I know, all Urologists are trained in general surgery during their urology residency. I never knew a urologist that did not do his own Nephrectomy’s. Sometimes assisted by another general surgeon in case there were other unknown problems but they all spend at least one day a week in the OR.
Nephrologists are kidney disease specialists. Renal Hypertension, elevated BUN and Creatinine levels and dozens of other renal problems other than the many forms of kidney cancer including RCC. I know some Nephrologists that like to do their own renal biopsy work. They might not trust the Radiologist or their patients might ask them to do it as to not be exposed to another stranger.
Until my RCC I never had exposure to a Urology Oncology department. The hospital I worked in was a little over 500 beds and specialized in open heart. We had four ICU's. One for cardiac, one for surgical, one for renal (usually end stage dialysis) and one called CVICU. That was the busiest. Post open heart. Ten beds in each unit but CVICU was always filled. When introduced to the Urology Oncology Department at the Miami VA facility this healthcare worker found himself in unfamiliar territory. It had a staff of about twenty people. Doctors from the University of Miami spent two days a week there. The two hospitals practically shared the same parking lot. These very special urologists are in a category all unto itself. This is where you want to be if you're in our position. They're the most up to date on the newest procedures. They do fellowships at other teaching facilities and then return with new techniques. I've never seen anything like it. The attending had three 5th year residents with him at all times and they continuously bounced things off of one another. I felt very secure in their hands. I believe, and many on this board might disagree with me, but the Urology Oncology Department is where we as RCC patients belong. Even post op, because I knew all the doctors in the department I didn't care who came to see me during the day. And.....unlike most places where doctors turn things over to PA's I never saw one.

Hoped this helped a little. Just my opinion.
Jeff

Texas_wedge's picture
Texas_wedge
Posts: 2807
Joined: Nov 2011

Thanks for that very skilful reply Jeff! The first para is a scream and could well have gone into Gary's Friday funnies thread.

On the serious side, I draw the conclusion that RCC patients should ensure they have access to the opinion of an oncologist specialising in urology, ideally in RCC.

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

Next Friday I'll try and come up with something. But if you want something funny, it won't be about Radiologists.

Jeff

Texas_wedge's picture
Texas_wedge
Posts: 2807
Joined: Nov 2011

Looking forward to that already! It's strange though - you gave me the impression that there's something funny about radiologists :)

DMike's picture
DMike
Posts: 238
Joined: Nov 2011

Jeff,
Thanks for your help! You've already taught me so much. I'm glad you're here!
--David

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

You're welcome. Let me know if I can make sense of any other "Radiologist speak" you come across.

Jeff

dl650a
Posts: 31
Joined: Feb 2012

Hello Jeff,
Welocome to the forum, although we really do not like getting new members. I had my nephrectomy in March and will be coming up for my 6 month scan (blood tests and chest X-ray) in September.

Thanks for your expertise and I hope we don't overload you

Ed

MedScanMan's picture
MedScanMan
Posts: 108
Joined: Jul 2012

Don't even think about overloading. Glad to help, if I can. Hope your next round of exams go real well.
Jeff

DMike's picture
DMike
Posts: 238
Joined: Nov 2011

I go in for my second-6 month post surgery CT scan in one month. Hopefully all will go well.

I know I'll have a conversation with my new doctor about the type of scan we will do on my third-6 month post op scan in June, 2013. My original doctor, who has taken a new job and is no longer at the university, said he wanted to start rotating types of scans (because of radiation)after the second round. He would change over to MRIs for year 2. I don't know yet if this will be my new doctor's plan but I want to be prepared to answer and ask questions.

From reading Jeff's post and others it seems like MRIs are just as effective as CT scans with contrast. Am i correct on this? Also, it seems I remember a post that said cost for a MRI can be 2X that of a CT scan. Am I correct on that?

My goal is to get the best scan I can get to stay on top of the situation and catch anything early. Is moving to an MRI a good idea?

Jeff, I value your response and those of others who have been through this.

Thanks, David

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