Fibrolamellar Hepatocellular Carcinoma

Findings and interpretation:

• There is a large, irregular, lobulated mass in the left upper quadrant of the abdomen, which appears inseparable from the lateral border of the left lateral segments of the liver. The mass is heterogeneously T2 hyperintense with a T2 hypo-intense central scar.
• The mass is iso-intense on the T1 sequence, with a hyperintense focus which likely represents a focus of haemorrhage. The central scar remains hypointense on T1.
• The mass is displacing both the stomach and spleen posteriorly, with no frank invasion of these organs.
• The mass shows avid heterogeneous post-contrast enhancement on the arterial phase with enhancement equal to normal liver on the portal venous phase, except for the central scar which does not enhance. There is no contrast retention on the hepato-biliary phase.
• There are scattered lesions in the right lobe of the liver, which are hyper-intense on T2 imaging, and show avid post-contrast enhancement on the arterial phase, with no retention of contrast on the hepato-biliary phase.

Pertinent negative findings:

• There are no local enlarged lymph nodes.
• The background liver parenchyma is normal. There is no liver cirrhosis.

The findings represent a large malignant mass arising from the liver, with hematogeneous metastatic spread to multiple other sites within the liver.

Principal diagnosis:

Fibrolamellar hepatocellular carcinoma.

Differential diagnosis:

• Hepatocellular carcinoma (This is typically associated with a different demographic and underlying parenchymal liver disease. Also, the radiological features would not be typical of this entity.)
• Large haemangioma (The enhancement pattern is completely different in this entity.)
• Focal nodular hyperplasia (This is effectively ruled out by the lack of contrast retention on the hepatobiliary phase images. This entity tends to be much smaller and more well defined, the scar is T2 hyperintense, and is less heterogeneous.)

Management:

Alert referring physician of findings and recommend discussion at hepato-biliary MDM to discuss further investigation by image guided biopsy.

Complete staging with a CT thorax abdomen and pelvis.

Findings and interpretation:

• There is a well defined, large lesion with smooth borders in the left ovary, composed mainly of macroscopic fat with a few focal calcifications in the periphery; there is an internal component which shows slightly higher density. The lesion shows no post-contrast enhancement.
• The left ovary is significantly enlarged, with follicles pushed to the periphery. The left ovary also shows hypo-enhancement on the post contrast images.
• There is thickening of the left ovarian pedicle / fallopian tube, which is also twisted and shows a swirling appearance.
• There is a mild amount of free fluid in abdomen and pelvis.

Pertinent negative findings:

• The right ovary is of normal size.
• No evidence of ovarian haemorrhage.

Incidental:

• There are small lesions in the uterus which show variable enhancement, representing fibroids.
• There is diverticulosis of the descending and sigmoid colon.

There is an benign left ovarian mass, which has acted as a lead point for twisting of the left ovary around its vascular pedicle; this has led to compromise of the vascular / venous outflow and subsequent oedema and impaired vascularization of the left ovary.

Principal diagnosis:

Left ovarian torsion caused by mature ovarian teratoma / dermoid.

Differential diagnosis:

Complex ovarian mass without torsion: however, the finding of the twisted pedicle makes this unlikely.  

Management:

Urgent referral to gynaecology for surgical management.

Findings and interpretation:

• There is an irregular, heterogeneous, infiltrating mass centred at the supraglottic larynx, and extending into the laryngo- and oropharynx. It contains a few punctate calcifications.
• The mass is invading the hyoid bone, superior aspect of the thyroid cartilages, epiglottis and aryepiglottic folds, and obliterating the valleculae and right pyriform sinus. It is causing a degree of obstruction of the oesophageal inlet.
• The mass is extending anteriorly into the platysma muscle, with necrotic masses in the anterior midline of the neck.
• There is a single level II (right carotid sheath) enlarged and heterogeneously enhancing lymph node.

The findings represent a large, aggressive, malignant neoplasm originating from the supraglottic larynx and causing stenosis of the airway as well as obstructing the oesophageal inlet. There is one metastatic cervical lymph node with central necrosis.

Principal diagnosis:

Supraglottic squamous cell carcinoma

Differential diagnosis:

• Laryngeal adenoid cystic carcinoma

Management:

Alert referring physician of findings.

Recommend staging CT thorax abdomen and pelvis.

Refer for ENT MDT to discuss further management; tissue biopsy by laryngoscopy would be the next step in management.

Findings and interpretation:

• There are multiple thin walled cysts of varying shapes and sizes, with a predominantly upper lobe distribution.
• There are widespread peribronchiolar nodules with a centrilobular distribution. These show an irregular margin.

Pertinent negative findings:

• There are no areas of ground glass opacification / consolidation in the lungs.
• There are no focal lesions in the visualised bones of the thorax.

The findings represent an interstitial, cyst forming disease of the lung.

Principal diagnosis:

Langerhans cell histiocytosis

Differential diagnosis:

• Pulmonary lymphangioleiomyomatosis

Management:

Alert physician of findings and recommend respiratory physician referral.

Recommend discussion at pulmonary MDT with regards to further management / confirming diagnosis by tissue biopsy.

Findings and interpretation:

• There is a large, trans-spatial, lobulated, insinuating mass with serpiginous contours, located in the right side of the neck, face and thorax. The mass extends from the right para and prevertebral space in the superior mediastinum to the neck, and insinuates through the spaces of the right side of the neck to form a large, superficial component.
• The mass is heterogeneously T2 hyperintense with multiple internal flow voids.
• The mass is intimately related to the cervical spine and shows extension through the intervertebral foramina at multiple levels.
• The mass encases blood vessels with no occlusion or invasion of the vessels.
• The mass is heterogeneously enhancing post contrast.

Pertinent negative findings:

• The mass is not causing any destruction or invasion of the adjacent structures.

The findings represent a neurogenic neoplasm with no overtly aggressive features.

Principal diagnosis:

Plexiform neurofibroma in a patient with type 1 neurofibromatosis

Differential diagnosis:

• Malignant peripheral nerve sheath tumour
• Soft tissue sarcoma

Management:

Alert referring physician.

Recommend performing image guided biopsy for tissue diagnosis.

Recommend imaging surveillance as there is a risk of malignant transformation.

Recommend discussion at plastic surgery MDT.

Findings and interpretation:

• The right adnexa is enlarged with a thick walled, septated cyst showing internal high T2 and low T1 signal intensity.
• One of the cystic structures shows high T1 signal intensity which persists on the fat saturated sequences.
• The fallopian tube is fluid filled and distended.
• The walls of the cyst and fallopian tube show post contrast enhancement.

Pertinent negative findings:

• There is no soft tissue neoplastic mass.

The findings represent an inflammatory process involving the right adnexa, with one of the cystic structures containing blood products.

Principal diagnosis:

Right tubo-ovarian abscess, with an adjacent haemorrhagic cyst

Differential diagnosis:

• The cyst containing blood products may represent an unrelated endometrioma
• Ovarian neoplasm

Management:

Alert referring physician of findings.