Findings and interpretation:

Radiographs:

• There is a mixed lytic and sclerotic lesion in the lower metaphysis of the right femur. It has a wide zone of transition with cortical invasion and aggressive periosteal reaction.

MRI:

• There is a high STIR/T2 and low T1 marrow signal intensity lesion in the distal femoral metaphysis on the right, extending to and invading the cortex with cortical destruction.

Pertinent negative findings:

• There is no soft tissue mass.
• There are no other lesions in the visualised bones.

The findings represent an aggressive bony lesion, which is most likely a primary bone malignancy.

Principal diagnosis:

Osteosarcoma

Differential diagnosis:

• Ewing’s sarcoma
• Eosinophilic granuloma (this is less likely due to the imaging characteristics)

Management:

Alert referring physician of findings.

Recommend staging CT thorax abdomen pelvis.

Recommend bone scan to search for multiple bone involvement.

Recommend discussion at sarcoma MDT regarding image guided biopsy for histopathological diagnosis (this should be planned with the orthopaedic surgeons in order to avoid biopsy tract seeding in tissue that will not be resected). It may be more appropriate to refer to tertiary sarcoma centre for further management.

Findings and interpretation:

• There is a well defined soft tissue mass in the aortocaval space at the L2 level, causing displacement with no invasion of the surrounding vascular structures.
• It is avidly enhancing on the arterial phase images, with a central hypodense area with little or no enhancement. The mass shows more uniform filling on the portal venous phase, with persistent non-enhancement of the centre.

Pertinent negative:

• No other lesions are detected in the abdomen. There is no abdomino-pelvic lymphadenopathy.

The findings represent a highly vascular retroperitoneal neoplasm with a necrotic centre, which shows non-aggressive features.

Principal diagnosis:

Paraganglioma

Differential diagnosis:

• Nerve sheath tumour
• Neoplastic lymph node (unlikely as the lesion is single, avid enhancement goes against this diagnosis)

Management:

Alert referring physician of findings.

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 an ill defined, large hypodense lesion in segment VI of the liver. This lesion shows peripheral arterial enhancement, and is hypodense to the liver in the portal venous phase. It is irregular and demonstrates capsular retraction at its interface with the anterior border of the liver.
• The lesion becomes hyperdense in relation to the liver parenchyma in the delayed phase.
• The intra-hepatic bile ducts are markedly dilated.
• There are multiple lesions in the liver, mostly within segment VIA. These show peripheral arterial enhancement and are hypo-enhancing on the portal venous phase.

Pertinent negative findings:

• There is no evidence of background liver disease.
• No enlarged local lymph nodes.
• No portal vein thrombosis.

The findings represent a hepatic malignancy involving the common hepatic duct and central biliary obstruction. This has spread locally within the liver as multiple metastatic adjacent deposits are found.

Principal diagnosis:

Intrahepatic (peripheral) cholangiocarcinoma

Differential diagnosis:

• Atypical hepatocellular carcinoma
• Lymphoma
• The metastatic lesions may represent cholangitis abscesses

Management:

Alert referring physician of findings.

Recommend referral to interventional radiology for biliary drainage.

Refer for discussion at hepatobiliary MDT with regards to image guided biopsy of the mass for tissue diagnosis, and to plan further management.

Findings and interpretation:

Chest radiograph:

• There is bilateral upper lung zone volume loss.
• There are bilateral reticulonodular interstitial opacities in the lungs with a mid and upper zone distribution.

HRCT:

• There is bilateral, reticulo-nodular interlobular septal and fissural thickening in the lungs, following the previously mentioned distribution.
• The apices contain bullae and cystic air spaces, with thick, fibrous walls. There are scattered, coarse calcifications within the fibrous tissues in this region.
• Volume loss and fibrotic changes are evident with traction on both hila, causing cranial shift of the hilar structures.
• There is nodular thickening of the pleura bilaterally, with coarse pleural calcifications.

The findings represent a chronic, interstitial lung disease with significant pulmonary fibrosis

Principal diagnosis:

End stage pulmonary sarcoidosis

Differential diagnosis:

• Coal worker’s pneumoconiosis / silicosis
• Post primary tuberculosis

Management:

Recommend tissue biopsy for histological diagnosis if not known case of sarcoidosis. Correlation with lab tests such as serum ACE may be done.

Recommend discussion at pulmonary MDT regarding further management / lung transplant.

Findings and interpretation:

CT:

• There is a large, heterogeneously enhancing, lobulated and irregular mass in the anterior/superior mediastinum, with areas of hypoattenuation / hypoenhancement. Bilateral hilar, pre and paratracheal mediastinal lymph nodes detected.
• The mass is locally invading the adjacent SVC, which is almost occluded.
• Local invasion of the manubrium sterni is noted.
• There are bilateral pleural and pulmonary metastases, as well as widespread, innumerable liver metastases.

CXR:

• Widened mediastinum with obscuration of the heart border, caused by the known anterior mediastinal mass.
• An SVC stent has been placed as management of the SVC obstruction.

Pertinent negative findings:

• No fat / calcification within the mass.

The findings indicate a malignancy that has spread to multiple distant sites.

Principal diagnosis:

Thymic carcinoma (this is the most likely diagnosis based on the pattern of metastatic spread)

Differential diagnosis:

• Lymphoma

Management:

Alert referring physician.

Refer for oncology MDT to discuss image guided biopsy and further management.  

Findings and interpretation:

CT brain:

• There is a well demarcated, wedge shaped area of parenchymal hypoattenuation within the left cerebellar hemisphere, corresponding to the vascular territory of the left posterior inferior cerebellar artery (PICA).
• There is associated mass effect within the posterior fossa with effacement of the fourth ventricle.
• There is dilatation of the third and lateral ventricles, with effacement of the extra-axial CSF spaces and sulci.

MRI:

• On the time of flight (TOF) images, there is no flow in the intracranial segment of the left vertebral artery. 

Pertinent negative findings:

• No hyperdensity within the cerebellar infarct to suggest haemorrhagic transformation.

There is a PICA territory cerebellar infarct with cytotoxic oedema causing mass effect, leading to obstruction of the fourth ventricle with resultant obstructive hydrocephalus.

This is caused by acute occlusion of the left vertebral artery.

Principal Diagnosis:

PICA territory cerebellar infarction caused by left vertebral artery occlusion. 

Differential diagnosis:

Occlusion of flow in the left vertebral artery may be caused by dissection or thrombo-embolism. 

Management:

Urgent neurological consult.

CT angiography of the head and neck arteries / T1 fat saturated images of the neck to establish the cause.

Neurosurgical assessment and referral to a tertiary neurology/neurosurgical centre.