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Model Answers

Case 1

Case 1 Model Answer:

Findings and interpretation:

CT:

  • There is marked, uniform dilatation of the intrahepatic bile ducts, down to the level of the common hepatic duct; at this level, there is a short segment of tapering followed by occlusion.
  • At the hilum of the liver and point of bile duct obstruction, there is a small, ill defined soft tissue mass which shows nondescript soft tissue enhancement.

MRI / MRCP:

  • Dilatation of the intrahepatic bile ducts is again demonstrated, showing smooth tapering at the common hepatic duct on the MRCP images.
  • There is an oval soft tissue lesion at the point of biliary obstruction, showing intermediate T2 signal intensity.

Negative findings:

  • The common bile duct is not dilated; there are no pancreatic masses.
  • No stones are detected on the MRCP images.

 

There is a soft tissue lesion causing obstruction of the common hepatic duct and pressure changes on the intrahepatic biliary tree. This is most likely a neoplastic lesion arising from the duct itself.

 

Principal diagnosis:

Klatskin tumour (ductal cholangiocarcinoma).

 

Differential diagnosis:

Other soft tissue lesion causing compression of the duct such as an enlarged lymph node.

 

Management:

Alert referring physician of findings.

Further management by ERCP with biliary stenting and brushings for cytology vs. percutaneous biliary drainage.

Recommend hepatobiliary surgery referral / discussion at gastro-intestinal MDM.  

Case 1 Your Answer:

No Answer Submitted

Case 2

Case 2 Model Answer:

Findings and interpretation:

  • There are large, multilocular cystic lesions in both ovaries / adnexae (larger on the left side), showing slightly thick walls which contain calcifications.
  • The left ovary itself appears enlarged with engorged vessels.
  • There is thickening of the left ovarian pedicle / fallopian tube, which is also twisted and shows a swirling appearance.

Pertinent negative findings:

  • There is no solid component in either ovary.

Incidental findings:

  • There is an exophytic lesion arising from the left lateral border of the liver, which is low in density and shows peripheral enhancement. This most likely represents a haemangioma.  

There are bilateral mucinous ovarian tumours with mostly benign appearance, one of 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 of the left ovary.

 

Principal diagnosis:

Bilateral ovarian mucinous cystadenomas; the left sided lesion has led to ovarian torsion.

 

Differential diagnosis:

Bilateral ovarian mucinous cystadenocarcinomas.

Bilateral ovarian serous cystadenomas.  

 

Management:

Urgent referral to gynaecology for surgical management.

Mucinous cystadenomas are typically excised surgically.

(Note: Mucinous ovarian cystadenomas are bilateral in 5 – 10% of cases.)

Case 2 Your Answer:

No Answer Submitted

Case 3

Case 3 Model Answer:

Findings and interpretation:

CT:

  • There is a large, ill defined soft tissue density lesion centred mostly in the posterior mediastinum, and extending between the liver and the right lung. It appears to infiltrate the diaphragm, and invades the dome of the liver and right lower lobe of the lung.
  • There is atelectasis of part of the right lower lobe, caused by mass effect.
  • There are a few, focal curvilinear hyperdensities peripherally within the lesion, representing calcifications.

MRI:

  • There is one large, lobulated mass centred within the right chest / mediastinum, and surrounded by multiple smaller masses, some of which are located within the dome of the liver. One of the masses superiorly arises within the lower lobe of the right lung.
  • These masses are heterogeneously T2 hyperintense, and mostly hypointense on T1. They are solid with no cystic component.
  • There is a right pleural effusion.
  • The masses are bright on the DWI sequence with corresponding low ADC values indicating restricted diffusion.
  • On the post-contrast images there is heterogeneous enhancement of the masses, showing mostly peripheral enhancement and hypo-enhancing centres. These likely correspond with areas of necrosis.

The findings represent an aggressive neoplasm which is very likely malignant. It does not appear to arise from a particular organ, yet is centred at the posterior mediastinum and invades the liver and right lung. The presence of calcifications suggests pluripotent stem cell origin.

 

Principal diagnosis:

Primary mediastinal germ cell tumour.

 

Differential diagnosis:

  • Neuroblastoma- however, this is more likely to show distant metastases and arise from the adrenal gland.
  • Lymphoma- however, this is not likely to show central necrosis and is more likely to be homogeneous; it does not calcify primarily.

 

Management:

Alert referring physician of findings.

Recommend image guided biopsy for histopathological diagnosis.

Refer to paediatric oncology MDT for discussion regarding further management.

Case 3 Your Answer:

No Answer Submitted

Case 4

Case 4 Model Answer:

Findings and interpretation:

CT:

  • There are numerous infra and supra-tentorial, small brain parenchymal lesions of varying density and location. These lesions are seen in the midbrain, cerebellum and grey-white matter junction, as well as the cortex and deep white matter.
  • Most of the lesions are hyper-attenuating.
  • Some of the lesions show hypodensity in the surrounding white matter, indicating vasogenic oedema.

MRI:

  • The lesions are seen on MRI to be T2 and FLAIR hyperintense, while also being sharply hyperintense on the T1 images. They are also detected in the cervical cord. Some show slight surrounding vasogenic oedema as indicated by FLAIR hyperintensity, but many do not.
  • On the T1 images, the lesions are well circumscribed and rounded; while some of the smaller nodules appear nodular, many of them show clearly defined walls of varying thickness, indicating a cystic nature. Some of the lesions have an eccentric nodule in the walls.
  • The lesions are avidly enhancing on the post contrast images; some of them show ring enhancement with enhancement of the eccentric nodule.

Pertinent negative findings:

  • The lesions do not show restricted diffusion.
  •  

Incidental findings:

  • There are some CSF density small round lesions in the right basal ganglia, representing old lacunar infarcts.

 

There are mostly cystic brain parenchymal lesions with a nodule within, which may represent a scolex. The hyperdensity on CT and hyperintensity on T1 MRI indicate thick / turbid proteinaceous content within the lesions / cysts. The features are highly suggestive of an infectious aetiology.

 

Principal diagnosis:

Neurocysticercosis (colloidal vesicular stage).  

 

Differential diagnosis:

  • CNS tuberculomas
  • Toxoplasmosis
  • Melanoma metastases- however, these typically show greater surrounding oedema.

 

Management:

Recommend discussion at neurology MDT to correlate with the clinical data.

Case 4 Your Answer:

No Answer Submitted

Case 5

Case 5 Model Answer:

Findings and interpretation:

CT:

  • There is a large soft tissue lesion occupying the entire right maxillary sinus, causing expansion of the sinus and sclerosis of the walls. The lesion extends through the medial wall, widening the ostium and eroding the medial wall to infiltrate the right nasal cavity- indicating bony remodelling.
  • The lesion extends into the right ethmoid air cells, infiltrates and absorbs the right nasal turbinates and completely occludes the right nasal airway.
  • There is some extension of the mass into the nasopharynx.

MRI:

  • The lesion is hyperintense on T2, yet shows alternating straited lines of high intensity and iso-intensity, showing the so called ‘convoluted cerebriform pattern’.

 

Pertinent negative findings:

  • The mass shows no osseous destruction or invasion. There is no intracranial or intra-orbital invasion.
  • There are no parts of the mass that show loss of the striated pattern (this may indicate malignant transformation).

Incidental:

  • Mild mucosal thickening / inflammation in the left maxillary sinus.

 

The findings represent a sino-nasal mass with benign, non-aggressive features.

 

Principal diagnosis:

Inverted papilloma.

 

Differential diagnosis:

  • Inflammatory polyp- antrochoanal polyp- however, this is typically homogeneously hyperintense on T2.
  • Sino-nasal carcinoma.
  • Esthesio-neuroblastoma- this is typically larger and more invasive.

 

Management:

Obtain contrast enhanced MRI images.

Refer to ENT surgeon for further management, which may be operative.

Case 5 Your Answer:

No Answer Submitted

Case 6

Case 6 Model Answer:

Findings and interpretation:

  • There is a tear in and detachment of the antero-superior glenoid labrum from the glenoid bone; there is also stripping and elevation of the adjacent glenoid periosteum which remains attached to the labrum yet torn from the bone.
  • There is high PD signal intensity at the anterior aspect of the glenohumeral joint and surrounding the subscapularis tendon, indicating a tear of the anterior aspect of the glenohumeral joint capsule and release of fluid into the surrounding structures.
  • There is a defect / cortical depression in the postero-superior aspect of the humeral head; this area shows high PD signal indicating bone oedema. This indicates a Hill Sachs fracture.
  • There is slightly increased thickness and PC signal intensity of the rotator cuff tendons, indicating tendinosis.
  • There is synovial / capsular hypertrophy of the acromio-clavicular joint, indicating degenerative changes.
  • There is a gleno-humeral joint effusion.

 

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

 

Principal diagnosis:

SLAP (superior labral anterior posterior) tear with Hill Sachs fracture.

 

Differential diagnosis:

None.

 

Management:

Alert referring physician of findings and recommend orthopaedic referral.  

Case 6 Your Answer:

No Answer Submitted

Case 7

Case 7 Model Answer:

Findings and interpretation:

CT:

  • There is marked, uniform dilatation of the intrahepatic bile ducts, down to the level of the common hepatic duct; at this level, there is a short segment of tapering followed by occlusion.
  • At the hilum of the liver and point of bile duct obstruction, there is a small, ill defined soft tissue mass which shows nondescript soft tissue enhancement.

MRI / MRCP:

  • Dilatation of the intrahepatic bile ducts is again demonstrated, showing smooth tapering at the common hepatic duct on the MRCP images.
  • There is an oval soft tissue lesion at the point of biliary obstruction, showing intermediate T2 signal intensity.

Negative findings:

  • The common bile duct is not dilated; there are no pancreatic masses.
  • No stones are detected on the MRCP images.

 

There is a soft tissue lesion causing obstruction of the common hepatic duct and pressure changes on the intrahepatic biliary tree. This is most likely a neoplastic lesion arising from the duct itself.

 

Principal diagnosis:

Klatskin tumour (ductal cholangiocarcinoma).

 

Differential diagnosis:

Other soft tissue lesion causing compression of the duct such as an enlarged lymph node.

 

Management:

Alert referring physician of findings.

Further management by ERCP with biliary stenting and brushings for cytology vs. percutaneous biliary drainage.

Recommend hepatobiliary surgery referral / discussion at gastro-intestinal MDM.  

Case 7 Your Answer:

No Answer Submitted

Case 8

Case 8 Model Answer:

Findings and interpretation:

  • There are large, multilocular cystic lesions in both ovaries / adnexae (larger on the left side), showing slightly thick walls which contain calcifications.
  • The left ovary itself appears enlarged with engorged vessels.
  • There is thickening of the left ovarian pedicle / fallopian tube, which is also twisted and shows a swirling appearance.

Pertinent negative findings:

  • There is no solid component in either ovary.

Incidental findings:

  • There is an exophytic lesion arising from the left lateral border of the liver, which is low in density and shows peripheral enhancement. This most likely represents a haemangioma.  

There are bilateral mucinous ovarian tumours with mostly benign appearance, one of 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 of the left ovary.

 

Principal diagnosis:

Bilateral ovarian mucinous cystadenomas; the left sided lesion has led to ovarian torsion.

 

Differential diagnosis:

Bilateral ovarian mucinous cystadenocarcinomas.

Bilateral ovarian serous cystadenomas.  

 

Management:

Urgent referral to gynaecology for surgical management.

Mucinous cystadenomas are typically excised surgically.

(Note: Mucinous ovarian cystadenomas are bilateral in 5 – 10% of cases.)

 

Case 8 Your Answer:

No Answer Submitted

Case 9

Case 9 Model Answer:

Findings and interpretation:

CT:

  • There is a large, ill defined soft tissue density lesion centred mostly in the posterior mediastinum, and extending between the liver and the right lung. It appears to infiltrate the diaphragm, and invades the dome of the liver and right lower lobe of the lung.
  • There is atelectasis of part of the right lower lobe, caused by mass effect.
  • There are a few, focal curvilinear hyperdensities peripherally within the lesion, representing calcifications.

MRI:

  • There is one large, lobulated mass centred within the right chest / mediastinum, and surrounded by multiple smaller masses, some of which are located within the dome of the liver. One of the masses superiorly arises within the lower lobe of the right lung.
  • These masses are heterogeneously T2 hyperintense, and mostly hypointense on T1. They are solid with no cystic component.
  • There is a right pleural effusion.
  • The masses are bright on the DWI sequence with corresponding low ADC values indicating restricted diffusion.
  • On the post-contrast images there is heterogeneous enhancement of the masses, showing mostly peripheral enhancement and hypo-enhancing centres. These likely correspond with areas of necrosis.

The findings represent an aggressive neoplasm which is very likely malignant. It does not appear to arise from a particular organ, yet is centred at the posterior mediastinum and invades the liver and right lung. The presence of calcifications suggests pluripotent stem cell origin.

 

Principal diagnosis:

Primary mediastinal germ cell tumour.

 

Differential diagnosis:

  • Neuroblastoma- however, this is more likely to show distant metastases and arise from the adrenal gland.
  • Lymphoma- however, this is not likely to show central necrosis and is more likely to be homogeneous; it does not calcify primarily.

 

Management:

Alert referring physician of findings.

Recommend image guided biopsy for histopathological diagnosis.

Refer to paediatric oncology MDT for discussion regarding further management.

Case 9 Your Answer:

No Answer Submitted

Case 10

Case 10 Model Answer:

Findings and interpretation:

  • There is a tear in and detachment of the antero-superior glenoid labrum from the glenoid bone; there is also stripping and elevation of the adjacent glenoid periosteum which remains attached to the labrum yet torn from the bone.
  • There is high PD signal intensity at the anterior aspect of the glenohumeral joint and surrounding the subscapularis tendon, indicating a tear of the anterior aspect of the glenohumeral joint capsule and release of fluid into the surrounding structures.
  • There is a defect / cortical depression in the postero-superior aspect of the humeral head; this area shows high PD signal indicating bone oedema. This indicates a Hill Sachs fracture.
  • There is slightly increased thickness and PC signal intensity of the rotator cuff tendons, indicating tendinosis.
  • There is synovial / capsular hypertrophy of the acromio-clavicular joint, indicating degenerative changes.
  • There is a gleno-humeral joint effusion.

 

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

 

Principal diagnosis:

SLAP (superior labral anterior posterior) tear with Hill Sachs fracture.

 

Differential diagnosis:

None.

 

Management:

Alert referring physician of findings and recommend orthopaedic referral.  

Case 10 Your Answer:

No Answer Submitted

Case 11

Case 11 Model Answer:

Findings and interpretation:

CT:

  • There are numerous infra and supra-tentorial, small brain parenchymal lesions of varying density and location. These lesions are seen in the midbrain, cerebellum and grey-white matter junction, as well as the cortex and deep white matter.
  • Most of the lesions are hyper-attenuating.
  • Some of the lesions show hypodensity in the surrounding white matter, indicating vasogenic oedema.

MRI:

  • The lesions are seen on MRI to be T2 and FLAIR hyperintense, while also being sharply hyperintense on the T1 images. They are also detected in the cervical cord. Some show slight surrounding vasogenic oedema as indicated by FLAIR hyperintensity, but many do not.
  • On the T1 images, the lesions are well circumscribed and rounded; while some of the smaller nodules appear nodular, many of them show clearly defined walls of varying thickness, indicating a cystic nature. Some of the lesions have an eccentric nodule in the walls.
  • The lesions are avidly enhancing on the post contrast images; some of them show ring enhancement with enhancement of the eccentric nodule.

Pertinent negative findings:

  • The lesions do not show restricted diffusion.

Incidental findings:

  • There are some CSF density / hyperintensity small round lesions in the right basal ganglia, representing old lacunar infarcts.

 

There are mostly cystic brain parenchymal lesions with a nodule within, which may represent a scolex. The hyperdensity on CT and hyperintensity on T1 MRI indicate thick / turbid proteinaceous content within the lesions / cysts. The features are highly suggestive of an infectious aetiology.

 

Principal diagnosis:

Neurocysticercosis (colloidal vesicular stage). 

 

Differential diagnosis:

  • CNS tuberculomas
  • Toxoplasmosis
  • Melanoma metastases- however, these typically show greater surrounding oedema.

 

Management:

Recommend discussion at neurology MDT to correlate with the clinical data.

Case 11 Your Answer:

No Answer Submitted

Case 12

Case 12 Model Answer:

Findings and interpretation:

CT:

  • There is a large soft tissue lesion occupying the entire right maxillary sinus, causing expansion of the sinus and sclerosis of the walls. The lesion extends through the medial wall, widening the ostium and eroding the medial wall to infiltrate the right nasal cavity- indicating bony remodelling.
  • The lesion extends into the right ethmoid air cells, infiltrates and absorbs the right nasal turbinates and completely occludes the right nasal airway.
  • There is some extension of the mass into the nasopharynx.

MRI:

  • The lesion is hyperintense on T2, yet shows alternating straited lines of high intensity and iso-intensity, showing the so called ‘convoluted cerebriform pattern’.

 

Pertinent negative findings:

  • The mass shows no osseous destruction or invasion. There is no intracranial or intra-orbital invasion.
  • There are no parts of the mass that show loss of the striated pattern (this may indicate malignant transformation).

Incidental:

  • Mild mucosal thickening / inflammation in the left maxillary sinus.

 

The findings represent a sino-nasal mass with benign, non-aggressive features.

 

Principal diagnosis:

Inverted papilloma.

 

Differential diagnosis:

  • Inflammatory polyp- antrochoanal polyp- however, this is typically homogeneously hyperintense on T2.
  • Sino-nasal carcinoma.
  • Esthesio-neuroblastoma- this is typically larger and more invasive.

 

Management:

Obtain contrast enhanced MRI images.

Refer to ENT surgeon for further management, which may be operative.

 

Case 12 Your Answer:

No Answer Submitted
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