Findings and interpretation:

Non-contrast CT:

• There is high density fluid within the lower abdomen and pelvis, extending into the pouch of Douglass. There is also free fluid around the liver and spleen. The density of the fluid indicates acute haemorrhage.

Contrast enhanced CT:

• There is a poorly defined right adnexal mass within the haematoma.
• There are foci of contrast density within the adnexal mass on the portal venous phase images. This indicates extravasation of intravenous contrast media.

The findings represent haemoperitoneum, due to acute, active haemorrhage from a right adnexal mass.

Principal diagnosis:

Acute haemorrhage from a ruptured ectopic tubal pregnancy.

Differential diagnosis:

Bleeding from a ruptured corpus luteum cyst.

Management:

Urgently contact referring physician and inform of findings.

Consider serum beta-HCG testing to confirm ectopic pregnancy.

Findings and interpretation:

• There is an ill-defined, hypodense lesion in the head and uncinate process of the pancreas, with a focus of punctate calcification.
• The lesion is causing extra and intra-hepatic bile duct as well as main pancreatic duct dilatation.

Pertinent negative findings:

• There are no enlarged local / abdominal lymph nodes.
• There are no hepatic parenchymal / pulmonary / bony metastases.

The findings represent a likely malignant mass in the head of the pancreas / ampulla causing pancreatic and biliary ductal obstruction and resultant dilatation.

Principal diagnosis:

Pancreatic head / ampullary carcinoma

Differential diagnosis:

• Neuroendocrine pancreatic tumour (these are typically hyper-enhancing and well-defined)

Management:

Alert referring physician of findings.

Recommend endoscopic ultrasound with biopsy for tissue diagnosis.

Refer for discussion at hepatobiliary MDT regarding further management / amenability for resection.

Findings and interpretation:

• There is generalised effacement of the cerebral sulci and loss of grey/white matter differentiation.
• There is global hypodensity of the cerebral hemispheres, with more pronounced hypodensity of the basal ganglia. The cerebellum appears hyperdense in comparison.
• There is an air-fluid level in the right maxillary sinus. There are nasal bone fractures.

Pertinent negative findings:

• No intra/extra axial intracranial haemorrhage.
• No fractures of the skull / skull base.

The findings represent global hypoxia of the brain with evidence of traumatic injury, as indicated by maxillary haemosinus and facial bone fractures.

Principal diagnosis:

Hypoxic ischaemic encephalopathy

Differential diagnosis:

None

Management:

Urgently inform referring physician of findings.

Obtain bony reconstructions, as well as further imaging of the facial bones and cervical spine to assess for traumatic injury in those regions.  

Metastatic breast cancer and synchronous left renal cell carcinoma

Findings and interpretation:

• There is a mass in the left breast, situated posteriorly and in contact with the left pectoralis major muscle, which is thickened. The skin overlying the left breast is thickened. There are prominent left axillary lymph nodes.
• There is a moderate sized left pleural effusion and small pericardial effusion. There are small pulmonary nodules in the right lung base; these may or may not be metastatic in origin.
• There are scattered hyper-enhancing liver lesions, likely representing metastases.
• There is a large, heterogeneously hyper-enhancing, upper pole left renal mass. This may be causing thrombosis at the most peripheral end of the left renal vein. The mass likely represents a synchronous malignancy rather than metastasis from the breast mass.
• There are diffuse sclerotic bony lesions, representing breast metastases. These are causing pathological collapse of T7 and T9 vertebral bodies.

The findings represent a metastatic malignant disease. Two primary malignancies are identified: a left breast carcinoma and a left renal cell tumour. Skin thickening of the left breast may indicate inflammatory carcinoma, or post-radiotherapy changes. The liver metastases may have originated from either tumour.   

Principal diagnosis:

Metastatic disease with synchronous left breast carcinoma and renal cell carcinoma.

Differential diagnosis:

The renal cell carcinoma may represent a breast metastasis; however, this is unlikely based on imaging characteristics.

Management:

Recommend image guided tissue biopsy of breast mass for pathological diagnosis.

Refer for oncology MDM discussion to plan further management by radio/ chemotherapy.

Inflammatory breast carcinoma

Findings and interpretation:

Mammograms:

• There are clustered micro-calcifications in the outer-upper / central quadrant of the right breast.
• There is thickening of the skin of the breast anteriorly.
• There are a few irregular lymph nodes in the right axillary region.
• The left breast is normal.

US:

• There is a large, heterogeneously hypoechoic mass in an area that corresponds to the region where the micro-calcifications were found on the mammogram.
• The mass is ill-defined, and shows prominent posterior acoustic shadowing.
• Skin thickening is also demonstrated on ultrasound.
• The axillary lymph nodes are abnormal in appearance, showing loss of the fatty hilum.

CT:

• There are innumerable hypodense lesions spread throughout the liver parenchyma.
• There are sclerotic bony lesions diffusely spread throughout the bony skeleton.
• Bilateral pleural effusions.

Pertinent negative findings:

• No pulmonary metastases.

The findings represent metastatic breast carcinoma. The skin changes indicate inflammatory breast carcinoma.

Principal diagnosis:

Inflammatory breast carcinoma with disseminated metastases

Differential diagnosis:

None

Management:

Ultrasound guided core biopsy of breast mass for tissue diagnosis.

Refer for breast MDT after obtaining biopsy result to discuss further management.

Findings and interpretation:

• The thalami are bilaterally enlarged and show high T2 and FLAIR signal hyperintensity. Patchy high T2/FLAIR signal intensity is also seen in the corona radiata and subcortical white matter of the frontal and parietal lobes.

Pertinent negative findings:

• There is no significant post contrast enhancement in the thalami.
• No evidence of haemorrhage on SWI images.
• No diffusion restriction in the thalami. 

The findings represent inflammation / demyelination of both thalami with patchy involvement of the white matter.

Principal diagnosis:

Acute viral encephalitis (likely Japanese encephalitis)

Differential diagnosis:

• Acute disseminated encephalo-myelitis

Management:

Urgently contact referring physician and inform of findings and suspected diagnosis.