Findings and interpretation:

Chest radiograph:

• The right lung is over-inflated, causing mild contralateral mediastinal shift.
• There is an area of hyper-lucency in the right lung at the mid-zone peripherally, which shows a paucity of vessels.

CT abdomen:

• The imaged lower lungs confirm the findings noted on the radiograph, showing hyper-lucency and hyper-inflation in the right lower lobe with paucity of vessels.
• The upper poles of both kidneys show somewhat wedge-shaped yet ill-defined regions of hypo-enhancement.
• There is regular, circumferential thickening of the bladder wall.
• There is a small amount of free fluid in the pelvis.

The findings represent a congenital developmental abnormality in the lung, and unrelated inflammatory pathology in the urinary tract.

Principal diagnosis:

Congenital lobar over-inflation in the right lung with concurrent bilateral lobar nephronia and cystitis.

Differential diagnosis:

• Lung lesion: Swyer James syndrome, bronchial atresia.
• Kidneys: Renal infarction, renal lymphoma.

Management:

Alert referring physician of findings.

Findings and interpretation:

US neck:

• There is a solid nodule in the left lobe of the thyroid gland, measuring approximately 11mm in greatest dimension; it is hypoechoic, is taller than it is wide, contains punctate echogenic foci (representing calcifications) and shows internal vascularity on the colour Doppler images. It extends past the border of the thyroid gland.
• There are left carotid chain round lymph nodes which are enlarged, are rounded and show loss of the normal lentiform shape, and demonstrate loss of the fatty hilum.

MRI abdomen:

• There is a well defined, round retroperitoneal soft tissue mass adjacent to the IVC; it shows T2 hyper-intensity and T1 hypo-intensity with a central area of high T1 signal intensity and low T2 signal intensity.
• The mass shows avid heterogeneous arterial phase post contrast enhancement; the central area shows no enhancement. The mass shows more uniform yet persistently heterogeneous enhancement on the portal venous phase, with persistent non-enhancement of the centre.

Incidental:

• There are two sub-centimetric T2 hyper-intense lesions in the liver in segment VIII, likely representing haemangiomas.

The findings in the neck represent a TR5 thyroid nodule, highly suspicious for thyroid carcinoma.

The findings in the abdomen represent a highly vascular retroperitoneal neoplasm with a haemorrhagic centre, which shows non-aggressive features.

Principal diagnosis:

Sympathetic extra-adrenal paraganglioma and medullary thyroid carcinoma. The patient likely has multiple endocrine neoplasia type II (MEN2).

Differential diagnosis:

Paraganglioma:

• Nerve sheath tumour
• Lymphoma

Thyroid:

• Different type of thyroid cancer
• Colloid nodule

Management:

Alert referring physician of findings.

FNAC for the thyroid nodule and lymph nodes.

Refer to neuro-endocrine tumour MDT to discuss further investigation by MIBG scan, and correlation with serum and urinary catecholamines.

Findings and interpretation:

• There is a posterior fossa lesion extending from the medulla to the upper cervical cord at C2 level; it is intra-axial, arising from the posterior aspect of the medulla.
• The lesion is mostly cystic, showing CSF T2 hyperintensity and T1 hypointensity; however, there is a small eccentric nodule at the caudal aspect of the lesion which is solid, showing heterogeneous T2 hyper-intensity with flow voids on the FLAIR sequence at the periphery.
• The solid nodule shows avid post-contrast enhancement.
• The lesion exerts mass effect on the caudal aspect of the 4^th ventricle, effacing it.
• There is T2 hyperintensity centrally in the cervical cord.

Pertinent negative findings:

• There is no significant hydrocephalus.

The findings represent a vascular posterior fossa neoplasm.

Principal diagnosis:

Haemangioblastoma.

Differential diagnosis:

• Pilocytic astrocytoma
• Medulloblastoma

Management:

Refer for discussion at neurosurgery MDT.

Consider genetic testing for Von Hippel Lindau disease.

Findings and interpretation:

• There is a large lateral ventral hernia sac containing a loop of small bowel with its mesentery and omental fat. The sac herniates through the linea semilunaris between the rectus abdominus and the internal & external oblique muscles.
• There are two transition points of the small bowel where the loops enter and exit and the hernia sac.
• There is a moderate degree of focal fat stranding within the hernia sac, suggesting incarceration of the hernia.
• There is dilatation of the small bowel loops proximal to the herniated loop of bowel, which also show multiple air-fluid levels and fecal matter.

Pertinent negative findings:

• There are no signs of bowel ischemia to suggest strangulation.

The findings represent an incarcerated lateral ventral herniation of a small bowel loop, causing mechanical bowel obstruction proximal to it.

Principal diagnosis:

Spigelian hernia with an incarcerated small bowel loop causing mechanical obstruction.

Differential diagnosis:

• Strangulated hernia.

Management:

Urgently contact referring physician and inform of findings.

Urgent surgical management will likely be required.

Findings and interpretation:

• There are large bilateral apical emphysematous bullae; that on the left side shows a thickened wall which likely indicates inflammation / infection.
• There is bilateral upper and middle lung zone centrilobular and paraseptal emphysema.
• There is a cluster of centrilobular nodules with surrounding ground glass opacification in the left upper lobe; this likely represents an infectious process.
• There are cystic arcades and larger interposed cysts on a background of ground glass opacification and interstitial / reticular thickening, more prominent in the lower lung zones / bases. There are also punctate calcifications and traction bronchiectasis in those regions (indicating fibrosis).
• There is a soft tissue mass with central foci of gas in the apical segment of the right lower lobe, abutting the pleura. This may represent a malignant neoplasm.
• There are a few prominent anterior mediastinal, pre-tracheal and hilar lymph nodes which are likely reactive in nature.

There is emphysema combined with fibrotic interstitial lung disease, with super-added localized pneumonia and a soft tissue mass suspicious for malignancy.

Principal diagnosis:

Combined emphysema and interstitial lung disease (probable UIP pattern), with super-added localized pneumonia and bronchial malignancy.

Differential diagnosis:

For interstitial lung disease:

• Desquamative interstitial pneumonia
• NSIP

For lung mass:

• Rounded atelectasis

Management:

Alert physician of acute findings.

Recommend discussion at pulmonary MDT regarding further management.

Recommend biopsy of soft tissue mass.

Findings and interpretation:

Radiograph:

• There is an opacity located anterior to the ankle joint, deep to the subcutaneous fat.

MRI:

• There is a well defined soft tissue mass located anterior to the tibio-talar joint and deep to the extensor tendons of the foot.
• The mass displays intermediate signal on T1, low signal on T2 and high signal on the PD weighted images.
• The mass enhances avidly on the post contrast images.

Pertinent negative findings:

• The mass shows no involvement of the adjacent bones of the ankle joint or adjacent tendons and soft tissue structures.

The findings represent a musculoskeletal soft tissue mass related to the ankle joint, yet showing no aggressive features.

Principal diagnosis:

Teno-synovial giant cell tumour.

Differential diagnosis:

• Tendon sheath fibroma
• Desmoid tumour

Management:

Biopsy may be considered.

Surgical excision is the conventional management.