Findings and interpretation:

HRCT / CT chest:

• There is decreased density and increased volume of both upper lobes; the parenchyma here is replaced with air spaces with no walls, indicating destruction of the entire secondary pulmonary lobule. This indicates pan-acinar emphysema. The apical segments of the lower lobes show centrilobular emphysema. The lower lung zones are spared.

• There is a small spiculated mass in the left upper lobe.

• There are fibrotic bands in both lower lobes / bases.   

CT abdomen and pelvis:

• There is uniform intrahepatic bile duct dilatation down to the CHD level; at the liver hilum there is an ill defined soft tissue mass which is causing biliary obstruction.
• There is marked, diffuse thickening of the right hemicolon involving the terminal ileum, caecum, ascending and half of the transverse colon.
• There is splenomegaly.
• There are enlarged mesenteric lymph nodes in the RIF.
• There is diffuse thickening of the gallbladder wall and mesenteric fat stranding, likely due to oedema.

Incidental findings:

• Surgical clips at the RIF indicating status post appendectomy.

End stage upper lobe emphysema is likely caused by heavy cigarette smoking due to the distribution. The lung mass shows the characteristic features of a malignant neoplasm.  

The findings in the abdomen are in keeping with a multisystem process which favors lymphatic malignancy.

Principal diagnosis:

Smoking related pan-acinar emphysema and lung carcinoma.

Multisystem abdominal lymphoma.

Differential diagnosis:

• Alpha 1 antitrypsin deficiency: however this typically involves the lower lobes and spares the upper lobes.
• Klatskin tumour / cholangiocarcinoma: however, this would not explain the splenomegaly and diffuse colonic thickening.
• Typhlitis / neutropaenic enterocolitis might explain the bowel findings, especially if the patient is immunocompromised.

Management:

Contact referring physician and convey findings.

Placement of a biliary stent by endoscopy to relieve biliary obstruction; EUS can be performed at the same time and samples taken from the hilar mass.  

Recommend CT guided biopsy of lung lesion.

Discussion at the relevant MDT.

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.