Findings and interpretation:

• There is a large mass in the left retroperitoneum, displacing the left kidney caudally and the stomach and pancreas anteriorly. The left adrenal gland is not visualised separately.
• The mass shows avid peripheral enhancement on the arterial phase, and persistent enhancement on the portal venous phase with a large, central non-enhancing component.
• There are two small, soft tissue nodules in the right lung base. 

Pertinent negative findings:

• The mass contains no calcifications or fat density components.
• There is no invasion of the left renal vein or the splenic vein. There are no liver metastases. There are no enlarged regional lymph nodes. There are no bony metastases.

Incidental:

• There are multiple, healing left lower rib fractures.

The mass most likely represents a malignant neoplasm of the left adrenal gland, with metastases to the left lung. 

Principal diagnosis:

Adrenocortical carcinoma

Differential diagnosis:

Phaeochromocytoma (these are usually smaller in size)

Adrenal metastases (these are typically much smaller in size and are not hyper-enhancing)

Management:

Alert the referring physician of the findings. Recommend staging CT of the thorax.

Refer for general surgery MDT to discuss image guided biopsy for histopathological diagnosis.

Findings and interpretation:

• There is a tear in and detachment of the antero-inferior glenoid labrum from the glenoid bone. The adjacent scapular periosteum is also torn and remains attached to the labrum.
• There is a defect in the postero-superior aspect of the humeral head; this area shows high STIR signal.

Pertinent negative findings:

• There is no fracture of the glenoid bone.

The findings represent traumatic tear of the anterior glenoid labrum, with an associated humeral head impaction fracture and bone oedema.

Principal diagnosis:

Bankart lesion with Hill Sachs defect

Differential diagnosis:

None

Management:

Alert referring physician of findings and recommend orthopaedic referral.  

Findings and interpretation:

• There is a large, lobulated, well defined, encapsulated T2 hypointense mass arising from the right adnexa. It contains criss-crossing T2 hyperintense stroma within.
• The mass shows minimal post-contrast enhancement.
• There is a small amount of free fluid in the pelvis.

Pertinent negative findings:

• The uterus is normal, and is identified separate from the mass.

The findings represent a non-aggressive right adnexal neoplasm.

Principal diagnosis:

Fibrothecoma

Differential diagnosis:

• Fibroid (leiomyoma)

Management:

Refer for gynaecology MDT discussion for further management, which will likely be excisional biopsy of the mass.

Findings and interpretation:

• There is a large, plexiform soft tissue mass in the left thigh and gluteal region, extending caudally to involve the quadriceps muscle.
• The mass is heterogeneously hyperintense on T2, with similar T1 intensity to muscle.
• The mass is heterogeneously enhancing on the postcontrast images.
• There is an enlarged pelvic side-wall lymph node on the left side (external iliac group).

Pertinent negative findings:

• There is no involvement of the adjacent left femur.

The findings represent a malignant mass of musculoskeletal origin, with spread to ipsilateral deep pelvic lymph nodes.

Principal diagnosis:

Soft tissue sarcoma (it is impossible to distinguish the subtype based on imaging characteristics)

Differential diagnosis:

• Leiomyosarcoma
• Fibrosarcoma
• Malignant fibrous histiocytoma
• Malignant peripheral nerve sheath tumour

Management:

Alert physician of findings. Recommend staging CT thorax abdomen and pelvis.

Refer for sarcoma MDT discussion with regards to image guided biopsy and possibility of resection. Referral to tertiary sarcoma centre may be required.

Osmotic demyelination syndrome

Findings and interpretation:

• There is a T2/FLAIR hyperintense lesion in the pons, located centrally with a triangular/trident shape.
• This lesion shows high signal on the DWI sequence with corresponding low ADC values, indicating restricted diffusion.
• There is diffuse, symmetric basal ganglia and thalamic FLAIR and T2 hyperintensity.

Pertinent negative findings:

• There is no mass effect from the pontine lesion.

The findings represent a symmetric process involving the central pontine fibres while sparing the periphery. This is most likely a de-myelinating process. This process extends to the basal ganglia and thalami.

Principal diagnosis:

Osmotic demyelination syndrome with extra-pontine myelinolysis.

Differential diagnosis:

• Pontine infarction: this is unlikely to be symmetric and to spare the periphery.
• Multiple sclerosis: atypical location; it is extremely unlikely to have a single pontine de-myelinating plaque in multiple sclerosis.

Management:

Urgently alert referring physician of findings.

Findings and interpretation:

Chest radiograph:

• There are diffuse micronodules throughout both lung with bilateral upper lobe airspace opacification and thin walled cavities.

CT thorax:

• There are diffuse centrilobular nodules, as well as multiple cavities in both upper lobes, some of which show air-fluid levels.

MRI brain:

• There are multiple, scattered T2 and FLAIR infiltrating hyperintensities in the cerebral and cerebellar hemispheres.
• There are hyper-enhancing nodules in the centre of the lesions.

Pertinent negative findings:

• No significantly enlarged mediastinal / cervical / axillary lymph nodes.
• No involvement of the spine / visualised bones.

The findings represent multi-system involvement by an infectious disease, with active endobronchial infection, post-primary pulmonary manifestations, and infectious lesions in the brain with surrounding vasogenic edema.

Principal Diagnosis:

Multi-system active tuberculosis

Differential diagnosis:

Metastases to lung and brain from unknown primary (however, metastatic nodules follow a random pattern as they are hematogeneously spread, as opposed to the centrilobular pattern seen in this case)

Management:

Urgently contact referring physician and inform of findings. Correlate with sputum cultures for acid-fast bacilli. The patient should be isolated and close contacts screened for disease.