Findings and interpretation:

Non-contrast CT:

• There is high density fluid within a large left retroperitoneal, suprarenal mass which contains fat. The high density fluid extends to the perinephric space on that side, as well as into the perisplenic space with some fluid collecting within the pelvis.
• The fluid accumulates in the suprarenal space to form a collection, which displaces the left kidney caudally.

Contrast enhanced CT:

• The haemorrhage is within a fatty mass that is clearly separate from the kidney, and is replacing the left adrenal gland.
• The contralateral adrenal gland also contains a well defined, small, mostly fatty mass. There is no haemorrhage into this mass.

Pertinent negative findings:

• There is no active extravasation of contrast on the arterial phase.

The findings represent acute haemorrhage from a left adrenal fatty neoplasm. The patient has another fatty neoplasm in the contralateral adrenal gland, with benign characteristics.

Principal diagnosis:

Acute haemorrhage from an adrenal myelolipoma in a patient with bilateral myelolipomas

Differential diagnosis:

None

Management:

Urgently contact referring physician and inform of findings.

Recommend urgent endovascular embolisation of the bleeding myelolipoma.

Findings and interpretation:

• There is a large solid mass arising from the cervix, and showing relatively high T2 signal intensity compared to the normally hypointense cervical stroma.
• It shows local extension beyond the cervical walls into the parametrial fat.
• It also extends to the upper third of the vagina. There is no extension to the rectum or bladder wall.
• There is an enlarged right internal iliac group lymph node.

Pertinent negative findings:

• There are no suspicious lesions in the visualised bones.

The findings represent a malignant mass arising from the cervix with local invasion, with a metastatic deep pelvic lymph node.

Principal diagnosis:

Cervical carcinoma, FIGO stage IIB

Differential diagnosis:

• Cervical lymphoma
• Metastases to the cervix (there is no primary in this case)

Management:

Recommend staging CT thorax abdomen pelvis if not already performed.

Refer for discussion at gynaecology MDT to discuss amenability for resection after obtaining tissue diagnosis.

Findings and interpretation:

CT:

• There is a well circumscribed soft tissue mass in the posterior triangle of the neck, adjacent to the upper cervical vertebrae. It is causing displacement of the adjacent muscles.

MRI:

• The soft tissue mass is heterogeneously hyperintense on the T2 images. The mass is less well defined on the MRI study, with spread of T2 signal into the adjacent trapezius muscle.
• The mass shows ill-defined, heterogeneous contrast enhancement which appears to extend into the surrounding tissues.

Pertinent negative findings:

• There are no suspicious / enlarged cervical lymph nodes.
• The adjacent bone shows no periosteal reaction or involvement by the mass.

The findings represent an aggressive soft tissue neoplasm.

Principal diagnosis:

Soft tissue sarcoma

Differential diagnosis:

• Extra-osseous Ewing’s sarcoma
• Malignant peripheral nerve sheath tumour
• Benign nerve sheath tumour (this is less likely because of aggressive features)

Management:

Alert referring physician of findings.

Recommend staging CT thorax abdomen pelvis if not already performed.

Refer for sarcoma MDT to discuss biopsy in conjunction with orthopaedic surgeons / referral to tertiary sarcoma centre.

Findings and interpretation:

CT brain:

• There is hypo-attenuation and sulcal effacement of the right temporal lobe (particularly in the medial aspect), as well as the insular cortex.

MRI brain:

• There is T2 and FLAIR hyperintensity of the medial aspects of the temporal lobes bilaterally (greater on the right side), as well as the right insular cortex and cingulate gyrus.

Pertinent negative findings:

• There is no diffusion restriction or contrast enhancement of the involved regions of the brain parenchyma.
• No evidence of haemorrhage within the lesion.

The findings represent bilateral yet asymmetrical oedema / inflammation of the limbic system.

Principal diagnosis:

Herpes simplex encephalitis

Differential diagnosis:

• Limbic encephalitis (paraneoplastic. No known primary and typically longer history)
• Post status epilepticus transient brain changes (no history of seizure)
• Gliomatosis cerebri (typically involves basal ganglia, which are spared by HSV encephalitis)

Management:

Urgently contact treating physician to inform of findings and recommend prompt antiviral treatment.

Findings and interpretation:

• There is a large, heterogeneously T2 hyperintense abdominal mass arising from the liver.
• The mass shows avid peripheral enhancement on the arterial phase post-contrast images.
• There is gradual filling in of contrast enhancement on the delayed images, with a persistent large non-enhancing centre.

Pertinent negative findings:

• There are no calcifications in the lesion.

The findings likely represent a benign vascular neoplasm.

Principal diagnosis:

Infantile hepatic haemangioma

Differential diagnosis:

• Hepatoblastoma

Management:

Alert referring physician of findings.

Recommend testing for serum alpha-fetoprotein (which is raised in hepatoblastoma).

Refer to paediatric surgery MDT for discussion regarding further management. Image guided biopsy is indicated to rule out hepatoblastoma. If the child remains asymptomatic, then follow up imaging is advised, as these tumours undergo natural involution. In case of high output cardiac failure, endovascular embolisation may be indicated.

Findings and interpretation:

• There is a large, irregular area of consolidation in the right upper lobe.
• There is generalised nodular thickening of the fissures and interlobular septae of both lungs.
• There are widespread semi-solid nodular opacities throughout both lungs.
• There is bilateral perihilar lymphadenopathy and minimal pleural effusions.
• There is a small peripheral aneurysm in the pulmonary arterial tree in the right lower lobe.

Pertinent negative findings:

• No adrenal lesions.
• No suspicious bony lesions.

Both lungs are involved in a likely malignant process arising from the right upper lobe.

Principal diagnosis:

Invasive mucinous adenocarcinoma in the right upper lobe, giving rise to lymphangitis carcinomatosis involving both lungs.

Differential diagnosis:

• Sarcoidosis
• Kaposi’s sarcoma (no history of HIV positive status; finding of large consolidation is unusual for this diagnosis)

Management:

Alert referring physician of findings.

Refer for pulmonary MDT to recommend image guided biopsy of right upper lobe consolidation, and obtain staging CT of the abdomen and pelvis.