Findings and interpretation:

MR abdomen:

• There are innumerable small lesions in both kidneys; most of these lesions show uniform high T2 and low T1 signal indicative of simple fluid with thin walls. However, some of the lesions show heterogeneous signal and exhibit avid heterogeneous post contrast enhancement (such as the large pelvic and lower pole lesion in the left kidney and cortical interpolar lesions in the right kidney).

• There are multiple simple cysts in the pancreas.

• There is a small enhancing lesion in the right adrenal gland.  

MR cervical spine:

• There is an intramedullary, small nodule at the posterolateral aspect of the cervical spinal cord at the level of C1, which shows high T2 SI and intermediate T1 SI with slight surrounding T2 hyperintensity; it exhibits avid post contrast enhancement. There is another similar, yet smaller lesion at T1. None of these lesions have a cystic component.

Negative findings:

• There are no solid lesions in the pancreas suggestive of neuro-endocrine tumours.

There is a mix of benign and malignant findings in this case; the solid enhancing lesions in the kidneys represent malignant neoplasms, most characteristic of renal cell carcinomas. The cystic disease in multiple organs is indicative of a congenital cyst forming multi-system disease. The lesions in the cervical spine almost certainly represent solid haemangioblastomas when seen in conjunction with the other findings.

Principal diagnosis:

 The constellation of findings is pathognomonic for a congenital, hereditary cancer syndrome, namely Von Hippel Lindau disease.

Differential diagnosis:

• Seen on their own, the cervical spine lesions may represent drop metastases.
• The adrenal lesion might represent an adenoma vs an early phaeochromocytoma.

Management:

Review prior studies if available to assess growth of existing lesions and document presence of new lesions.

Recommend active surveillance by brain and cervical spine MRI and MRI / US of the abdomen is indicated every 1 – 2 years.

Discussion at oncology MDT.

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 left adnexa. It contains criss-crossing T2 hyperintense stroma within.
• The mass shows mild heterogeneous post-contrast enhancement.
• The endometrial stripe is grossly thickened, given the patient’s status as a post-menopausal woman.
• There is a small amount of free fluid in the pelvis.

Pertinent negative findings:

• There is no evidence of metastatic spread to the peritoneum / invasion of adjacent organs.

Incidental:

• There are multiple cervical Nabothian cysts.

The findings represent a left adnexal / ovarian neoplasm showing benign characteristics. The endometrial hyperplasia indicates that it is hormonally active.

Principal diagnosis:

Hormone secreting fibrothecoma with endometrial hyperplasia.

Differential diagnosis:

• Broad ligament fibroid (leiomyoma) and unrelated endometrial thickening.

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.