Case 1

Intravenous urography was performed on this young child with suspected congenital anomalies. This investigation is no longer performed routinely. So these vintage pictures demonstrate a solitary, ectopic dysplastic kidney in the region of right iliac fossa. Either this can be ectopic solitary kidney or crossed fused renal dysplasia. To establish this, you need to see if the two ureters have crossed renal fusion. In this case it was a solitary kidney, as single ureter is seen with no other renal tissue on renogram. Did you notice wide-open sacral hiatus? There is an association with anorectal, bladder anomalies with sacral defects.

Case 2

Again you may not see this kind of radiograph, taken at intervals – at birth and at the age of 3 years. Did you notice anything abnormal in these two radiographs? If you are familiar with normal anatomy, you will notice that there is wide separation of symphysis pubis, more evident in a slightly older radiograph. This is part of the ectopia vesicae. You should also scrutinize the radiograph for any spinal anomalies.

Case 3

Intravenous urography film and sonography of the urinary system is provided. It is easy to appreciate a somewhat low lying malrotated right kidney on the intravenous urography. This finding may be difficult to appreciate on routine sonography. You might see an empty right renal fossa. So it is necessary that you scrutinize the rest of the abdomen or the location of the right kidney. Findings are much more difficult to recognize when it occurs on the left side. Note that in the sonography, the right kidney is somewhat lower. Liver is not visualized in the images.

Case 4

9-year-old female with pelvic pain. CT is not an examination of choice for a young female. MR examination is the present examination of choice when you see ambiguous findings on sonography. This is an old examination which reveals a large unilocular cystic lesion in the adnexa. Obviously this appears to be an ovarian cyst. Follicular cysts beyond 5 cm are uncommon. Serous cystadenomas are not very common in this age group. Sonographic followup is necessary. If findings are progressive, appropriate management is mandatory.

Case 5

You are seeing more of old, conventional images in the session. An imaging specialist should be versatile to appreciate anatomy in different forms. The first radiograph is a plain film which shows bilateral radiopaque renal calculi. Intravenous urography films demonstrate dilated pelvicalyceal system, predominantly of the calyces. What is more interesting is the kind of mass-like area of between the calyces of the right renal system. Obviously sonography would be necessary in this case to show what it is.

In this case an additional CT examination was performed. Bilateral renal calculi are noted, as seen in the intravenous urogram. There is dilatation of the calyces bilaterally, more extensive on the left side with the areas of the un-opacified calyces due to infundibular obstruction. This non-contrast containing calyces are contributing to the apparent mass-like filling defects, which will opacify depending on the amount of the secretory renal parenchyma. So it is a calyceal pseudotumour due to obstructed calyx.

Case 6

This is one of the Aunt Minnie radiographs. Once again, familiarity is the key. Calyces on IVU generally look outwards. If any one of them look inwards, especially in the lower part, it may be part of a horseshoe kidney. Also, the renal pelvis and ureters tend to come from the outside in a horse-shoe kidney, rather than from the medial aspect. Overall, the kidney may be somewhat lower in position.

Case 7

This is a 2 day old neonate who presented with a palpable abdominal mass. A hypoechoic, heterogenous mass was demonstrated on sonography. This contrast CT examination examination of kidneys demonstrate a somewhat normal appearing superior pole of the right kidney. However, there is a non-enhancing lobulated hypodense mass is noted in the lower part, almost preserving the renal shape. Left kidney is normal. The delayed image (the last one) shows opacification of the contrast in the calyces. However, the renal mass does not show any enhancement. In this age group such a presentation can be due to developmental renal masses like nephroblastoma (Wilms tumour), nephroblastomatosis or mesoblastic nephroma. Wider differential diagnosis can be considered in older children which includes renal cell carcinoma, rhabdoid tumours, angiomyolipoma, or lymphoma.

Case 8

This is a 6 month old male with voiding difficulty. Sonography of the kidneys demonstrate gross dilatation of the pelvicalyceal system with reduction in renal parenchyma. The bladder was also distended.

Views of a voiding cystourethrogram are shown above. You may notice dilatation of posterior urethra showing some intra-luminal irregularity/filling defects. Anterior urethra is non-distended. There is some suspicion of a valve-like defect in the view on the left side. This is a case of posterior urethral valve. Irregularity of the lumen is sometimes due to earlier catheter manipulations which should be avoided when there is a suspicion of a valve.

Case 9

This is frontal projection of a cystogram. This radiograph is shown for illustrating normal variations of the urinary bladder. In this case anterolateral aspects of urinary bladder is showing an outpouching, like a diverticulum. Findings are more obvious on the left side. This outpouching is a dynamic process, as part of the bladder bulges into the internal inguinal ring in some children. Findings can be bilateral sometimes striking while straining.

Case 10

Plain radiograph of the pelvis and the contrast examination is presented. Do you have any suggestions or diagnosis? If you have made one, either your senior radiologist or you might have spent some time in the Middle East. Hope you got the clue. Plain films demonstrate urinary bladder calcification of bilharzias origin. These bladders, despite calcification, showed great range of distension. In the intravenous urogram you will also noticed that ureters show irregular outline, variation in calibre changes and wall thickening. In this case the bladder is partially distended. You should also look for calculi in association.

Case 11

The initial radiograph is sonography showing renal areas and urinary bladder. You may notice that the kidneys appear normal and urinary bladder wall is somewhat thickened and irregular. If you carefully notice in the transverse view, there is a cystic structure on the left side.

This is a post-void frontal radiograph after cystourethrography. In cystourethrography, visualization of abnormal ureter (VUR) can be graded according to the extent. In this case there is grade 4 vesicoureteric reflux. Notice that the bladder is also distended and dilated ureters show gross dilatation and tortuosity. Vesicoureteric reflux is a dynamic process that can show great variation. The cystic area noted in the transverse view of bladder by ultrasound is an example wherein reflux was demonstrated when the sonography examination was being performed. Patient was diagnosed to have congenital cystis- megaureter syndrome.

Case 12

Palpable, mobile mass in a 32-year-old female.

Mammography is a specialized technique. Objectives of mammography are to accentuate contrast between lesion and surrounding soft tissues, which is achieved by soft tissue radiography. Interpretation of mammography needs understanding normal range of breast densities. They are graded according to the BI-RADS into 4 categories ranging from fatty to dense breast. Lesion detectability depends upon the density of the breast. Once the lesion is detected, characterization depends on the morphological features. Above example is demonstrated in a patient with the type A breast with the large fatty component. Lesion is well detected. It should be described in relation to its position using the clock face concept. Distance from the nipple can also be included into 3 grades. Characterization of the lesion is done using simple parameters like outline, shape, infiltration, intrinsic calcification etc. Significance of the lesion is described ultimately in BI-RADS terminology (1-6). Sonography should be integrated with the interpretation of breast lesion, so that a single window opinion is provided with combined modalities.

Above example was graded as BI-RADS 3, on surgery turned out to be a fibroadenoma.

Case 13

49-year-old female with a suspected large mass at the upper outer quadrant of breast.

Above example demonstrate lesions in a dense breast. Notice that multiple lesions are present with obscured outlines. Detection of morphological features are technically difficult. Sometimes magnification views help in detecting micro-calcification. Sonography is superior when the breast density is high; type D breast. MRI evaluation has value in detecting masses in the dense breast. Examination was characterized as BI-RADS 4. This patient was diagnosed to have breast carcinoma.

Case 14

6 month child investigated with intravenous urography for suspected left hydronephrosis.

3 images of the intravenous urography are provided. Currently there is no role for this imaging modality. There is an interesting observation in the evolution of contrast opacification of left kidney. If you note in the first image, some contrast in the form of a linear crescent is shown in the left renal area - called a Crescent sign. This sign was seen in the past in the hugely dilated calyces. In the early contrast opacification stage, contrast was only visible at the margins, creating a crescent sign. If there is adequate renal secreting capacity, delayed films will opacify the rest of the dilated system completely.

Case 15

37-year-old female with abdominal distension, pain and discomfort. Sonography revealed a pelvic mass.

Contrast enhanced axial and coronal CT images are provided. Mass is obvious in the examination showing areas of solid and cystic components. The question is about the origin of the mass, which may be a challenge in large masses. Differentiation should be made between uterine versus ovarian masses. Next, in the ovarian group, you should look for signs for any specific characterizing features. This patient had a mucinous cystadenocarcinoma of the left ovary. Uterus not clearly identified from the mass due to invasion.

(Prepared in colloboration with Dr Hemanth)

Case 16

A 30-year-old female had a history of a hemicolectomy for a suspected malignancy. Presenting with progressive abdominal distension and generalized weakness.

Limited Axial and sagittal plan contrast-enhanced CT images are provided. The lesion is clearly identifiable, predominantly cystic, and extends from the pelvis upwards. If you carefully observe, you will note thin septations within the mass lesion. The question is whether we are dealing with a serous or mucinous cystadenoma, or in view of clinical history, a Krukenberg’s tumour. Often the final diagnosis is made by the pathologist. This patient had a Krukenberg’s tumour.

(Prepared in colloboration with Dr Hemanth)

Case 17

30-year-old female with incontinence. Patient had a history of previous hysterectomy.

Sonographic examination of the urinary bladder is shown in multiple views. This is a very rare case wherein anatomy is clearly delineated. If you see carefully you will notice a defect in the superior aspect of the urinary bladder with adjacent outpouching filled with fluid. Defects appear to vary in size during the phases of examination. Also note that the outpouching appears to have a lining. In the post-void examination, there is no visualisation of the cystic space. However, wall structure and a slightly hyperechoic lumen is seen. This is a case of a vesico-vaginal fistula. Such a clear-cut demonstration is rarely possible on sonography. Small lesions may need a battery clinical tests, cystography and contrast MR for diagnosis.

(Prepared in colloboration with Dr Hemanth)

Case 18

9-year-old male with right loin pain

9-year-old male with right loin pain. Plain film and sonography of the right kidney are provided. Observations on sonography are quite striking in the form of grossly dilated renal pelvis. What is the cause of dilatation? You should be able to detect the small calculus in line of the right lower ureter. This clinical context does not demand any further radiological study. However, such a study was performed in the past due to some clinical need, which confirms the observation of a distal ureteric calculus with secondary back pressure changes.

Case 19

56 year old female with a long history of swelling in the labial region with occasional bleeding and discharge.

This is another rare diagnosis in clinical practice. There is a large, diffuse soft tissue swelling involving the labial region with predominant abnormality on the right side. Lesion has attenuation values ranging from 2-10 HU, showing areas of focal enhancement on contrast. This can be any soft tissue mass in the labial region like liposarcoma, vascular malformation or haemangioma. This patient had an angiomyxoma.

(Case prepared in collaboration with Dr. Vinay Belval.)

Case 20

3-year-old child, unable to pass urine spontaneously. Underwent a surgical procedure.

Two views of a contrast study are provided. What do you think is this radiological study? How is this examination performed? What do you think is the abnormality in the urinary bladder? Finally, do you have a diagnosis?

Many questions were asked. Hope you had good answers. This patient had undergone cystoplasty for a small capacity bladder. The outline of the urinary bladder is explained by the procedure. Note that there is a tube into the bladder directly from the abdominal wall. Therefore the study of urinary bladder (cystourethrography) was done through this suprapubic catheter. Patient was not able to spontaneously void due to a posterior urethral valve. A combined contrast study retrograde and antegrade was performed outlining the posterior atrial valve and defining the anatomy of the anterior urethra.

Case 21

Follow-up mammography done in a patient with the nodularity of outer quadrant of right breast.

What are your observations and how would you characterize this lesion? What will be an algorithm for investigation?

There are a few observations on mammography. If you notice, the right breast shows some reduction in the size at outer quadrant with retraction of the nipple. There are linear nodular densities at the 9 to 10 o’clock position of the breast, although a discrete mass is not seen. Left breast is essentially normal and shows type A parenchyma. Since she has undergone follow-up study, it is extremely important that we compare with the old examinations. Present examination can be supported with sonography. In this case, it did not add much to the information. Previous surgery was performed on this patient for a fibroadenoma. Occasionally, breast scarring can occur following surgery. Lesions tend to be stable over time.

Case 22

6-month-old infant investigated for urinary tract infection.

Images of the urinary bladder during retrograde cystography are provided. What is your impression on the set of images? What do you think about the mass around the bladder base? Is it a Foley catheter bulb? This patient was not investigated with a Foley’s catheter. So we have a filling defect in the urinary bladder. What happened to the filling defect in the last film? Answering most of these questions used to be simple in the past with good experience of this procedure. Now you may be scratching your head. This is a case of a ureterocele. Though it is in the midline, it is originating from the right side. Early phases of bladder filling are important in observing the small ureteroceles. Too much contrast can obscure the abnormality. Occasionally, ureteroceles invert like a diverticulum. In this patient, such a phenomenon occurred, additionally leading to grade 5 reflux. Unfortunately a good demonstration of inversion was not documented.

Case 23

34-year-old female with lumpy breast.

MLO views of the breasts and sonographic examination are provided.

Just to remind you that interpretation of Type D breast (very dense) needs additional supportive investigation. Even in this dense breast, you can appreciate obscured masses, manifested as opacity with convex margins in the upper quadrant of left breast. These examinations must be supplemented with sonography or MRI. In this case, sonography shows a large unilocular cyst in the left breast, in association with gross ductal ectasia.

Case 24

This is a 6-month-old child, investigated for recurrent urinary tract infection. Images of the intravenous urography provided

These examinations were frequent when sonography was just beginning to test its role. Sonography did reveal dilated collecting system on the right side, but there were some doubt about multiple tubular shadows in relation to the dilated pelvis.

These two images demonstrate non-dilated collecting system on the left side. Upper element of right renal collecting system is also non-dilated. There is severe dilatation of the middle and lower calyces of the right kidney. If you follow the contrast, you will notice that proximal ureter of the lower moiety is duplicated, probably joining at the level of the pelvic brim. Also there is transient non-obstructive dilatation of the distal ureter. This is a duplex collecting system of the right kidney, lower moiety showing hydroureteronephrosis, secondary to gross vesico-ureteric reflux. Lower ureter of the duplex system, often enter the bladder at a more direct angle, leading to an incompetent vesico-ureteric junction.

What is the difference in the bowel gas pattern in the two provided images? Why is the stomach so much distended in the second radiograph? There is some historical information. Distending the stomach with an effervescent gas, used to be a practice to see the kidneys better by displacing the adjacent large bowel loops. But it used to be very ineffective technique, as the gas is often belched out. But some infants cry a lot after intravenous contrast. (Present radiologists cannot imagine how fortunate they are while performing contrast studies of the urinary system [or any other system for that matter]. Thanks to the development of low osmolar contrast media, that has revolutionized imaging practice; made the examination smooth and safer.)

Case 26

A 7 year old, with a suspected urinary tract infection. Sonography failed to reveal kidneys in the anatomical position.

MR examination of the lower abdomen and pelvis are provided. Coronal and axial images of the renal fossa revealed bowel loops occupying the renal bed. Visualised liver and spleen appear normal. Even the psoas muscles appear to show normal appearances. There are 2 right parasagittal images. I hope you are able to see a soft tissue density in the right leg fossa with the cystic centre. In the axial image it is obvious that we are seeing a single right pelvic kidney with a dilated renal pelvis. Patient had a single pelvic kidney with the pelviureteric junction obstruction,

Case 27

Cystography and sonography of a 1-year-old female is provided. Patient investigated for urinary tract infection.

What is your impression of the cystography? Do you think there is a urethral diverticulum? Is the posterior urethra pathological? Well, if you have done a few cystourethrography in a female, you will realize that this is a normal configuration of the posterior urethra while voiding, and appearance called a spinning top urethra. It is not associated with any pathology. Occasionally you will see this when doing a sonography, this will be seen as a diverticular dynamic outpouching at the bladder base

Case 28

Neonate with abdominal distension and anaemia. Plain radiography and CT examination are provided. Diagnosis in this case is somewhat straight. Plain radiograph is not very helpful. CT examination pre-and postcontrast demonstrate hypodense lesions in the adrenals, the right one showing more obvious findings. Postcontrast images show non-enhancing cystic areas in the enlarged adrenals. The rest of the abdomen is normal. Findings are due to bilateral adrenal haemorrhages. Some larger haematomas persist longer, appearing as adrenal cysts. The HU value of this lesion on the plain scan sometimes provides clues. (10-20 HU). Sonography and CT are the additional modalities which can help to make precise diagnosis. On sonography some internal echoes/layering may be seen. MRI clearly demonstrates blood products. Sonography is a good way to follow these patients without financial or radiation burden.

Case 29

28-year-old lady with lower abdominal discomfort. Plain film is provided. There is a diffuse density on the right side of the pelvis, causing indentation on the adjacent rectum. The question is whether the finding is due to the distended bladder or is it due to a mass lesion? Usually the distended urinary bladder flattens the rectal air column. Rarely a displacement is noted. Mass lesions tend to displace established positions of the bowel. I guess you have seen a certain area of calcification!!!. This patient had a dermoid cyst of the right ovary. Sonography revealed mostly cystic contents. Occasionally this may be the only observation. CT and MR examination may reveal additional components of the lesion.

Case 30

Intravenous urography in a patient with the genetic metabolic disorder is provided. There is bilateral nephrocalcinosis. One of the image provided is a plain tomography( blurred image), an imaging option in the previous era, to show lesions in particular plane, avoiding overlapping structures. Etiology of nephrocalcinosis is many. This patient had hypomagnesaemia. This family had one more sibling with a similar imaging appearance.

Case 31

Setup radiographs of the abdomen are provided along with an image of an intravenous urogram. Nothing special in this exam, except that minor migration of the radiopaque calculus is demonstrated. This is an expected phenomena in a patient with renal colic and such migrations are occasionally seen during the radiographic examination. Just a transient excitement for an imaging person.

Case 32

Sonography and CT examination of the abdomen are provided in a child with anaemia and failure to weight gain.

These examinations demonstrate a hypoechoic lesion in the left upper abdomen on sonography. Solid lesions in the adrenal and a child often tend to be a neuroblastoma. What are your observations on plain radiography? I think hepatosplenomegaly is obvious. CT examination in this patient demonstrates a hypodense lesion with hyperdense component anterior to the left adrenal. Lesions appear separate from the kidneys. There is no regional lymphadenopathy. There is enlargement of the liver which appears homogeneous. Incidentally there is a calculus in the gallbladder and right pleural effusion.

In suspected adrenal lesions, local and regional extension of the lesion need to be shown on the CT examination. Lesion may be well defined or insinuating. Often tend to encase the vessels–the mesenteric artery vein, coeliac axis et cetera. Regional lymphadenopathy is fairly common. Hepatic and osseous metastasis are also expected. So these findings need to be scrutinised.

Our Patient had an additional radionuclide bone scan. The lesion did not show any uptake. There is no evidence of osseous lesions. Patient was operated on and had an extra-adrenal neuroblastoma.

Case 33

These images are courtesy of my colleague, Dr. WS. This examination is venography of the left testicular vein. Patient is catheterised by a venous route, through the left renal vein, the left testicular vein is catheterised. Contrast opacification reveals enlarged tortuous left testicular vein with a large varicocele in the testes. These advanced tests are not required at the moment as sonography took a major role. This examination was performed just around the time of introduction of sonography . Also coil occlusion can be attempted to treat the varicocele.

Case 35

This patient was investigated as there was a family history of polycystic renal disease. father had autosomal dominant polycystic renal disease. Our patient also showed multiple small peripheral cortical cysts on sonography and MRI. There is loss of corticomedullary distinction. There is no evidence of the dilatation of the collecting system. Visualised liver spleen appears normal.

In the ADPKD kidneys are generally normal at birth, slowly developing cysts, invariably visible in the later adult life. Patients have an increased risk of renal failure and malignancy. Distribution of the cysts are there in the cortex as well as in the medulla. Unlike APKD, recessive form of the disease, presents in children with large kidneys with myriad of tiny cysts. Kidneys may appear echogenic or may demonstrate small cysts. There are many known associations with the APKD, some of them are important as patient’s may manifest with these symptoms.( source Radiopaedia)

• Cerebral berry aneurysms

  • found in 6% of patients with ADPKD without a family history of aneurysms

  • found in up to 16% of patients with ADPKD with a family history

• intracranial dolichoectasia: 2-3%

• hypertension: up to 80% adults

• colonic diverticulosis

• bicuspid aortic valve

• mitral valve prolapse: up to 25%

• aortic dissection

• multiple biliary hamartomas

• cysts in other organs

  • liver: most common, 75% by age 60 years

  • ovaries

  • spleen: ~5 %

  • seminal vesicles: 60% by age 40 years

  • prostate: 11%

  • pancreas: ~10%: N.B. pancreatic cysts are more common in von Hippel Lindau disease (vHL)

Case 36

This child had a history of abdominal injury following which he developed abdominal pain and haematuria. You may be a little anxious to look at intravenous urography images for making a diagnosis. But interpretation is generally straightforward. What do you see in this patient? Do you think kidneys are normal in position? Or they are displaced by a haematoma–mass? This patient has a horseshoe kidney. Pelvicaliceal pattern compatible with the diagnosis, lower part being medially located and abnormally oriented. Does this explain the clinical picture? We know that horseshoe kidneys are more prone for injury, being lower and superficial in location. Did you look at the lateral view in greater detail? Certainly you should question some ill-defined contrast accumulation above the urinary bladder. This patient had a ureteral injury beyond the pelviureteric junction with extravasation of contrast.

Case 37

MCU examination of a 2-year-old female child is provided. What is your impression based on the radiograph? Is it a normal study? The vesico-ureteric reflux? Or is it a recto- vesical fistula. I have posed more questions than answers to explore possibilities.

I have provided a very difficult case for analysis. Morphologically, you get an impression that this is voiding cystourethrogram of a male child!!!!. This is a female child who had an ambiguous genitalia. On cystourethroscopy, urethra is elongated and there is opacification of urogenital sinus through a narrow tract. These morphological changes have resulted due to congenital adrenal hyperplasia, a condition of the abnormal steroid synthesis due to defect in 21-alpha-hydroxylase deficiency (90% of cases) or similar related hormone deficiency. Patients will have an abnormal ACTH challenge test on lab analysis. Spectrum of urethral changes depends on the extent of virilisation. Sometimes examinations get complicated by unintentional catheterisation of the urogenital sinus, rather than bladder. ( Kumar and Bhat et al). Enlarged adrenal glands are generally visualised on ultrasound and CT imaging.

Case 38

This child had difficulty passing urine and a poor urinary stream. Any diagnosis you can offer?

Imaginative radiology residents should at least bring up some differential diagnosis of what looks like a distended/dilated anterior urethra. What is happening to the posterior urethra? There is a linear tract extending posteriorly, even the catheter appears to be located around the opening of the tract. Urinary bladder is enlarged in capacity. This type of case you may not see often. Diagnosis was obvious to me when I was examining this patient !!!. You do not have to applaud my skills! I simply observed when the patient was voiding -- just to notice his prepuce was bulging like a balloon while passing urine !! This child had tight phimosis. Though urethra was anatomically normal, there was a gross accumulation of urine in the distended prepuseal chamber, subsequently leading to retrograde distension. You can also note that the navicular fossa of anterior urethra is dilated. The posterior tract seen from the posterior urethra is a distended prostatic utricle, due to retrograde pressure. This patient likely to have a good prognosis and management is straightforward.

Case 39

2 images of the male child during the cystourethrography is provided.

Similar illustrations are available in the series. This case is just to give additional familiarity with a condition. Frontal view is a postvoid radiograph after VCU. Simple observations are present like the presence of grade 4/ 5 right vesicoureteric reflux and abnormal shape of the urinary bladder, resembling a pine tree. Bladder capacity is not significantly large in this view (post void). This appearance is common in the chronic bladder outlet obstruction and neurogenic bladder. In the other image in oblique projection, the primary condition leading to these findings is obviously diagnosed– A posterior urethral valve. Classically 3 varieties of valve are described, single or double leaflet valve and a diaphragm (Young’s classification). Other classifications are also available.Additionally a variety of other forms of obstruction of posterior urethra are described. One such common variety is a posterior urethral dysplasia wherein calibre of the posterior urethra is irregularly reduced without any obvious demonstration of a value. Such conditions may be associated with other anomalies of the upper urinary tract. Mangement is more complicated.

Case 40

4-year-old female child with the episode of UTI. Sonography, intravenous urography and radionuclide studies (DMSA) are provided. I just wanted you to go through all the images and guess what would be the abnormality. Nothing special on sonography, almost normal appearing renal parenchyma without any obvious dilatation of the pelvicalyceal system. On intravenous urography you are seeing a subtle difference in the contrast opacification of the kidneys, the right kidney appears less opacified than the left. Left kidney appears somewhat enlarged in outline. The next image provided is a voiding cystourethrography with grade 3 reflux in the left collecting system. What are the observations on a radionuclide study? You will notice that the left kidney outline is enlarged (posterior scans) and there is persistent contrast in the LK as seen with dense nephrographic phase, whereas the right kidney shows partial clearance into the calyceal system. This is an indication of slow transit in the left kidney–an event that happens in an acute nephritis/pyelonephritis. These events represent subtle transient patho-physiological changes, rarely demonstrated and appreciated during the imaging studies. Dynamic changes in vascular flow of kidneys is sometime seen(trueta shunt) in renal agniography.

Case 41

2 images of the abnormal appearing urinary bladder in a child is provided. Abnormal urinary bladder shape could be due to deformities, surgery or due to bladder reconstruction. This patient had a cystoplasty. Ureteric continuity is made by reimplantation of ureters. In this particular case both ureters are joined in the form of a 'Y' anastomosis, subsequently anastomosed with the reconstructed bladder. Note that there is a free reflux, a finding associated with the poor prognosis.

Case 42

This child presented with the history of trauma and haematuria. We have sonographic studies and CT examinations. Congenital anomalies, obstructed pelvicalyceal system, unusual position of kidneys( like transplanted kidneys) often predispose them to trauma. This patient had a left flank trauma. Sonographic images demonstrate a grossly dilated pelvicalyceal system and proximal ureter. There was no obvious collection around the kidney or ureter No obvious intraluminal abnormality was noted. However evaluation of the bladder demonstrated a filling defect due to a clot. Combination of these findings could be due to ureteral injury. For better demonstration CT evaluation was performed. CT images demonstrate dilatation of the left renal collecting system system and proximal ureter. Ureteric outline at the point of transition shows lack of mucosal enhancement and a subtle stranding along the posterior aspect. In delayed films there was no obvious extravasation of contrast. These observations suggest partial ureteral disruption injury.(contained injury) Patient was stented and subsequently had a complete recovery.

Case 43

The 4-year-old child had a history of trauma, haematuria and abdominal distension. CT examination was performed. You will notice that the study was done 25 years ago- explaining the type of studies and protocols. The observations in this case are not difficult to appreciate. We have a retroperitoneal collection on the right side, starting at the lower pole of the right kidney and extending down to the pelvis. Collection has an insinuating plane and multiple septations. Minimal fluid is noted around the urinary bladder. Following intravenous contrast, the right kidney demonstrates a non-enhancing anterior cortical lesion and there is an obstructed collecting system. No contrast was noted in the collecting system during the study. We did a follow-up plain radiography after 1 hour. Do you have the diagnosis after this film? There is obvious dilatation of the right renal pelvicalyceal system and right ureter is not seen. There is an extravasation of contrast with opacification of retroperitoneum. Left kidney appeared normal. This patient has an urinoma following the proximal ureteric injury.

Case 45

Patient is a 4-year-old, incidentally detected to have an abdominal mass. Images provided here are those of a large right renal mass with the typical appearance of a nephroblastoma (Wilms tumour). Mass has typical features with a beak sign with the superior medial kidney, solid and necrotic areas and distortion of the collecting system. This is the most common pediatric renal mass. (85%). Nephroblastomatosis is a well known risk factor. Lesion can present in earlier age group in patients with syndromes. It is associated with a few conditions which makes the topic interesting. It is important to note that syndromic patients are a minor group (2%) [Radiopedia].

Overgrowth syndromes (WT2 gene)

• Beckwith-Wiedemann syndrome

• Perlman syndrome

• Sotos syndrome

Non-overgrowth syndromes (WT1 gene)

• WAGR syndrome

• Denys-Drash syndrome

• Frasier syndrome

Isolated abnormalities:

• cryptorchidism: hemihypertrophy:

• hypospadias:

• sporadic aniridia

• renal fusion

Loco-regional and Pulmonary metastases are very common. There is tendency for the lesion to invade the renal vein and the IVC. One variety of the renal mass, rhomboid renal tumour has histological-morphological similarity with Wilms tumour, presents in association of intracranial masses.

Wilms tumor classically follows a "rule of 10s (Radiopedia)

• up to 10% may have unfavorable histology

• 10% are bilateral

• 10% have vascular invasion

• 10% have calcifications on CT

• 10% have pulmonary metastases at presentation

Staging of renal tumour is necessary for adequate management.

Stage I: Disease limited to kidney

Stage II: Disease extends up to and limited to immediate surroundings including renal vein

Stage III: Regional lymph nodes and peritoneal disease. No distant spread.

Stage IV: Distant metastasis

Stage V: Bilateral renal Wilma tumors.

Case 46

A 3-year-old child with abdominal distension and loss of appetite was investigated with the sonography and subsequently an abdominal CT.

You have a good set of images for analysis in this case. Let us start with abdominal sonography. In the given images, a homogeneous mass lesion is seen below the liver, through which part of the IVC is seen traversing. In one image there is a lobulated intraluminal defect in the subhepatic IVC. With this information we can be certain that there is a central abdominal mass in the retroperitoneal plane.

Now you are ready for analysis of the abdominal CT. There are two sets of the abdominal CT images, done approximately 3 months apart. Now that you have seen and confirmed a large retroperitoneal mass, what is your impression regarding etiology?. I suppose you have certainly made note of an enhancing retroperitoneal mass with the left pulmonary metastases. Generally large retroperitoneal mass calls for a range of differential diagnosis, like mesenchymal tumours, lymphoma, retroperitoneal lymphadenopathy etc. What is on the top of the list for you? You can exclude masses of renal origin. Though kidneys are displaced laterally, they do not show parenchymal abnormality. There is right hydronephrosis. Did you observe the missing right spermatic cord? This patient has absent right testis. This raises the possibility of the mass being of testicular origin or related to an abnormal testes. This patient had an embryonal carcinoma in the retroperitoneum. There was a thrombus in the inferior vena cava. Patient responded very well to chemotherapy, as documented in the followup CT examination. In retroperitoneal masses careful inspection of the testes should be made as a possible source of lesion. Absence of the testes, history of orchiectomy or testicular masses should be carefully evaluated.

Case 47

A 56-year-old female presented with a lump in the left axilla of 3 month duration. Mammographic images are provided. I enclose these images just to enhance the process of detection of microcalcification without obvious mass in a breast lesion. You can see that it is a type C breast pattern. Clusters of microcalcifications are detected at the very periphery of the left breast. There are a few additional asymmetric densities noted around. In the MLO view you can appreciate microcalcification at the 2 o’clock position, partially obscured by the breast density. There appears to be an associated focal increase in the breast density, which was not clearly appreciated in the CC view. The reasons for the exam, axillary swelling is obvious. There are clusters of enlarged lymph nodes, some of them showing microcalcifications. This is a classical appearance of a locally advanced breast carcinoma.

Case 48

An infant,3 months old presented with a painful swelling in the left inguinal region. Clinically this presentation may be a possible acute inguinal abscess or necrotising lymphadenitis. Children generally present with fever, leukocytosis and painful limitation of limb movement. It is important to establish the correct diagnosis. CT is a preferred imaging method, sonography although useful, is painful and has limitations in the assessment of beyond the area of interest. CT/MRI diagnosis is very simple. Necrotic area with surrounding oedema is shown with some element of regional lymphadenopathy.

Inguinal abscesses could extend from gastrointestinal, genitourinary, or retroperitoneal sites as well as being of haematogenous origin. Computed tomography provides a means for establishing the correct diagnosis and planning treatment.. Gram-positive pathogens are associated with infections involving hip or thigh muscles and gram-negative pathogens are associated with infections involving the gastrointestinal and genitourinary tracts and abscesses of the psoas muscle. Anatomically The inguinal region communicates with the peritoneal and retroperitoneal spaces as well as with the tissue planes in region of the thigh. The lymphatics drain from the external genitalia, inferior anal canal or perianal region, adjoining abdominal wall, and the lower extremities.

Case 51

Mammography of an adult patient with suspected mass is presented. After going through the images, what is your impression? Normal study, inconclusive examination? What is your next step?

It is extremely important to supervise mammography examinations done at the institutions. Screening mammography has a simple protocol. Mammography at the institution must be supervised and well-tailored. In this case I want you to notice subtle differences in the breast coverage in the MLO views. CC views appear nearly symmetric, no obvious pathology demonstrated in a relatively dense breast. When there is inadequate coverage, you should question either the technique or some factors related to the patient. In this case, careful observation should see some densities in the upper region of the left breast. An attempt should be made to include the deeper areas by altering the angulation or repositioning the patient to include more of the axillary region. In this patient one more review is obtained which partially exposes the deeply located mass and the lymph-node. Even this examination has failed to show the posterior extent. This calls for an MR evaluation, although ultrasound to some extent can give an idea.

Case 52

Views of the retrograde cystourethrogram are provided in a patient with difficulty in voiding. In this patient anterior urethra is mildly dilated and there is a stricture in the region of the membranous urethra. There is passage of contrast into the small capacity urinary bladder, however in the region of the prostatic urethra there are subtle extravasation of contrast - some linear and some pouchlike. This appearance indicates vascular as well as periurethral interstitial extravasation. Such phenomena are most common in urethral strictures with multiple catheterization attempts. Excessive pressure should be avoided while performing the retrograde urethrography in such instances. You can observe that this patient had VP shunt for drainage of congenital hydrocephalus. These patients having neurogenic bladder and recurrent UTI, hence more vulnerable to injury due to repeated catheterization

Case 55

MRI examination of the upper abdomen in a 10-month child is provided. What is your impression of MR? Can you guess the anomaly? When the lower poles of the kidneys are closer to the midline,there is always a possibility of a horseshoe kidney. Kidneys can be completely fused with a parenchymal bridge or may be separate, joined by a fibrous component. In our patient union is partial. Another observation is to note the position of the renal pelvis. You can see that the left renal pelvis is pointing outwards. There is also a radionuclide DMSA study on this patient. If you are familiar with the normal anatomy, you will appreciate that there are functioning renal elements in the lower medial part of the right kidney. Also, the orientation of the right kidney is abnormal, somewhat vertical medially oriented lower pole. Detection of Horseshoe kidney is important as kidneys are more superficial, prone for trauma.

Case 56

A 1-year old male child with recurrent urinary tract infection is investigated with cystourethrography, renal sonography ,radionuclide studies and an MRI examination. With this case I am illustrating the case of a neurogenic bladder and its imaging manifestations.

Sonographic images are straightforward, demonstrate gross dilatation of the renal pelvis and near uniform reduction in renal parenchymal thickness. Renal parenchymal thickness should be measured at both poles and interpolar region. Measurement of the renal pelvis should be done in the transverse plane, anteroposterior dimension should be measured. In this case additional ureters were also dilated. Urinary bladder is extremely thick-walled with an elongated appearance. This appearance can result from chronic inflammation, neurogenic bladder or bladder outlet obstruction. Voiding cystourethrography in this patient did not show urethral abnormality. There was no evidence of a vesicoureteric reflux. So it appears that hypertrophic bladder musculature is likely to be causing a distal ureteric obstruction. MR urography confirms our observations on sonography. There is also a fancy 3D display showing the gross anatomy of the urinary system. Do we need a radionuclide study for additional evaluation? Of course. This is a tool to evaluate renal function and provide more sensitive detail about renal scarring. Split renal function is recorded in the radionuclide studies. You can see the provided illustration.

Case 1

Patient with vague lower abdominal symptoms, sonographic evaluation was performed. You see a well outlined cystic lesion in relation to the posterior aspect of the abdominal wall in the midline, just below the umbilicus. Location and description of the lesion itself is indicative of a possibility of a urachal cyst. Embryologically this is an interesting condition. There are many variations possible. This patient is evaluated with a CT scan. CT evaluation confirms a cystic lesion just posterior to the abdominal wall in the midline. I should have provided you with a sagittal view. Somehow, I could not find it in my reservoir.

Congenital urachal anomalies can be divided into five groups: patent urachus, umbilical-urachal sinus, vesicourachal diverticulum, urachal cyst, and alternating sinus. Patient urachus is often detected at birth whereas the rest may be asymptomatic. The patient comes under the urachal cyst. There is a general recommendation to surgically treat symptomatic lesions, although there is no conclusive proof of malignant transformation.

(Roychowdhury M. Urachal lesions-benign. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/bladderurachalbenign.html. Accessed October 27th, 2021).

Case 58

Plain radiography and MR urography of a child is presented. Value of plain radiography in the evaluation of a urinary system is to exclude radiopaque calculi or calcification. Another important contribution is to exclude any bony anomalies or additional incidental lesions in the bones, especially in adults. In this patient there is no useful information on radiography. There is an MR urography. What is your impression, apart from the obvious hydroureteronephrosis? Did you consider the possibility of a duplex pelvicalyceal anatomy? Actually, to answer this question careful evaluation of the renal anatomy is required. Notice that there is clustering of upper and lower calyces, separated by a parenchymal bridge.(Most noticeable on the left side). When both moieties are dilated, interpretation may be difficult. Often there is some asymmetry in dilatation. In our patient upper moiety is less dilated. Another important observation to make on MRU is to look for a ureterocoele and ectopic drainage of the ureters.

Case 1

Patient is a 3-year-old male who had vague soft tissue mass in the mid abdominal region. Initially a sonographic examination was performed, followed by a contrast-enhanced MR.

There is a sonographic image of the left kidney in the coronal plane!! Left kidney itself appears normal. But we suspected a hypoechoic soft tissue mass medial to the kidney. This location is a retroperitoneal. Sonographic observation led to an MR and a radionucleotide study. In the MR examination one can see a retroperitoneal mass at mid lumbar region showing lobulated outline. Lesion is mildly T2 hyperintense, lies ventral-medial to the left kidney and merges medially with the retroperitoneal vascular structures. Contrast enhancement was noted with a somewhat lobulated multiple hypo-enhancing components. Aorta appear non-encased whereas the anatomy of the other vessels were not clear. There is a subtle blush.

Do you think the renal artery is involved in this case? Renal outline is well shown in the provided MR images, showing vertically oriented left kidney. But where is the left kidney in the early arterial phase? It is not visualised!! So, this patient has encasement of the left renal hilum with the delayed enhancement of the left kidney. Also note that there are multiple left renal arteries

Findings are highly indicative of a retroperitoneal mass like a neuroblastoma. This tumor is likely to be arising from the sympathetic chain as the location is lower and closer to the midline. A radionuclide study with MIBG is given. You can notice an area of increased uptake left lumbar area corresponding to neuroblastoma. Radionuclide studies are very sensitive in detection of metastatic disease and any osseous disease if present. General description of the neuroblastoma is as follows.

• Occurs anywhere in distribution of sympathoadrenal neuroendocrine system

• Most in adrenal gland (~40%), followed by connective / subcutaneous / soft tissue (~20%), retroperitoneum (~15%), mediastinum (~10%) (SEER Program: NIH Pub No 99-4649; Bethesda, MD, 1999)

• Urine biochemistry for catecholamines or their metabolites (dopamine, vanillylmandelic acid, homovanillic acid)

Classification

Histologic classification systems

• Shimada Classification (J Natl Cancer Inst 1984;73:405)

  • Histologic classification system first proposed in 1984 with prognostic implications

• International Neuroblastoma Pathology Classification System (INPC) (Cancer 1999;86:349)

  • Original Shimada classification system was modified and renamed in 1999

  • New system also shown to have prognostic implications (Cancer 1999;86:364)

  • 3 subtypes of neuroblastoma: undifferentiated, poorly differentiated, differentiating

• International Neuroblastoma Risk Group (INRG) Staging System (J Clin Oncol 2009;27:289, J Clin Oncol 2009;27:298)

  • More recent

  • Pre-surgical risk assessment tool

  • Based on clinical features and imaging studies

Stage

Description

L1: Localized tumor not involving vital structures as defined by list of image-defined risk factors (IDRF). Confined to one body compartment

L2: Locoregional tumor

• One / more IDRF

M: Distant metastases (except stage MS)

MS: Children <18 months of age

• Metastases confined to skin, liver and/or bone marrow

( Perrino C., D Zynger, M Tretiakova. Neuroblastoma. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/adrenalneuroblastoma.html. Accessed October 27th, 2021.

Case 60

Voiding cystourethrography of a male child with the poor stream is presented. You see several different illustrations for this anomaly in the sections. In this case the anatomy of the bicuspid valve and hypertrophic verumontanum is very well shown. Dilatation of posterior urethra is present. Did you notice that the tube could be only negotiated up to the level of the valve? Sometimes the examination is carried out through the narrow opening of the valve, like in this case. Bladder appears extremely small in capacity, thick-walled shows multiple diverticula. Apparent small capacity may be due to the technique, not allowing enough contrast to be injected at ease.

Case 61

This child presented with a distended abdomen and had an abnormal sonogram, suspecting intestinal obstruction.

In the provided images of MR urography, you will see a normal right kidney and ureter. Appearance on the left side is somewhat bizarre. There are multiple, parallel oriented, fluid distended structures in the left renal fossa and left lumbar region. In fact, this is a hugely dilated ureter, due to an obstructed upper moiety of a duplex pelvicalyceal system. This is described as ‘intestinalization’ of the ureter. This hugely dilated ureter can be mistaken for fluid distended bowel loops. Lower moiety also shows mild-to-moderate dilatation. Urinary bladder is compressed otherwise it appears normal. Any other observations do you have? Did you observe a persistent filling defect in the lower ureter? This defect may be due to a sludge/calculus/ or a filling defect due to a malignant transformation. In long-standing cases this must be assessed with the contrast MR or attempted ureteroscopy.

Case 62

The 7-year-old female underwent ureteral catheterisation with an attempt to dilate a narrowing at the pelviureteric junction. Few hours following the procedure the patient had severe back pain and abdominal discomfort. CT evaluation is performed for assessment of the retroperitoneum. Did you observe any findings to suggest a possible diagnosis? You might notice right perirenal collection, small collection at the level of the kidneys becoming slightly larger in the lower retroperitoneum. Right psoas muscle is somewhat bulky. Right renal pelvis is somewhat ill-defined, mildly dilated. All these findings indicate a possible renal pelvic contained injury. No contrast extravasation was noted in the delayed images. Such injuries are common after interventional procedures. Temporary Urinary diversion is done if obstruction is significant.

Case 63

A-4-years-old girl was investigated for recurrent UTI. Initial sonography and subsequent cystography were performed. This is not a case with a diagnostic challenge. It is evident that the right kidney is small, a reduction in the parenchymal thickness. Nonuniform. Near normal size of the left kidney is visualised. There is no dilatation of the pelvicalyceal system. Considering a general approach, unilateral small kidneys can be due to hypoplasia, atrophy, sequelae of chronic infection and due to renal artery stenosis. Patient has a setting of recurrent UTI; hence we expect chronic pyelonephritis with renal scarring/atrophy. Provided use of cystography, show the sequence of the reflexes phenomena. In the early phase you see a distended bladder with minimal opacification of distal ureters. Then there is a sudden reflux into the right renal collecting system, followed by the left. With no distension there is complete visualisation of the pelvicalyceal anatomy with blunting of renal papillae (grade 4 reflux)

This disease affects about 1% of otherwise normal children, 30–50% of those who present with urinary tract infections, and approximately 10% with prenatally diagnosed hydronephrosis. VUR is considered as dysfunctional elimination syndrome, with the anatomic as well as dynamic dysfunction. Management of VUR in children is complex. Endoscopic treatment of VUR has a lower success rate than open surgery, surgery is important in severe hydronephrosis with the dilated, redundant system.

(Web source): Gargollo, P., Diamond, D. Therapy Insight: what nephrologists need to know about primary vesicoureteral reflux. Nat Rev Nephrol 3, 551–563 (2007). https://doi.org/10.1038/ncpneph061

Case 64

This patient,7-yr.-old male had an abnormal appearance of the abdomen and absence of the testis in the scrotum. You have been provided with sonographic images, IVU, retrograde cystourethrography and radionuclide study. Please go through all the images and see whether you can suggest a diagnosis.

To start with there is a very bizarre appearance of the left kidney with a hugely dilated baggy renal pelvis. Right kidney appeared normal. Urinary bladder was elongated slightly thick-walled. Small outpouchings are also noted in the urinary bladder.(Not shown in the illustration). On intravenous urogram. the dilated left renal pelvis is confirmed. Right renal collecting system shows mild dilatation. Anatomy of the calyces, however, not very well shown. Ureters are tortuous, laterally oriented. Urinary bladder showed near normal capacity, with a slightly irregular outline. Diagnosis?

Retrograde cystourethrography confirmed elongated configuration bladder with multiple diverticula, small ones and wide mouthed.. Urethra was normal. Findings were confirmed also on radionuclide study. Obstructive components were present in the left renal pelvis and the right distal ureter. Diagnosis? I have not included the scrotal sonography. Patient had an inguinal location of the somewhat small testes. The whole spectrum of findings is indicated of prune belly syndrome

Prune belly syndrome, (Eagle Barrett syndrome ³ or triad syndrome) is a rare anomaly. It consists of three major findings:

• gross pelvicalyceal and ureteric dilatation with renal dysplasia ⁷

• anterior abdominal wall underdevelopment (resulting in the "prune belly" appearance)

• bilateral undescended testes (cryptorchidism) in males

Associations

• aneuploidic syndromic associations

  • trisomy 18 , trisomy 13

• other associations

  • congenital cardiac anomalies

    • ventricular septal defect ,atrial septal defect (ASD).tetralogy of Fallot

  • intestinal malrotation. imperforate anus

  • polydactyly/syndactyly, talipes equinovarus

The differential diagnosis, urographic appearances can be mimicked by posterior urethral valves, however other components will be missing. Another differential diagnosis is major cystic microcolon intestinal hypoperistalsis syndrome, a rare disease affecting the urinary and GI system. In both conditions, specific features of prune belly syndrome are absent.

(Singh, G., El-Feky, M. Prune belly syndrome. Reference article, Radiopaedia.org. (accessed on 27 Oct 2021) https://doi.org/10.53347/rID-1927)

Case 76

40-year-old female with a palpable breast lump is evaluated with a mammogram. How do you report this examination? General descriptions for mammographic examinations are mentioned elsewhere, describing lesions by morphology, by mentioning clockwise location, and lesion extent including the assessment of chest wall and axilla. BI-RADS grading is a standard for mammography reporting.

Which BI-RADS grading this lesion belong to? Obviously, we will place it under BI-RADS 4 category, as you see irregular strands from the lobulated breast lesion located at the 3 o'clock position. You also notice the linear strands extending from the lesion to the subareolar location leading to retraction of the nipple and adjacent areola. Although the retromammary area is clear, there is an axillary lymph node. Node is not very large but morphologically abnormal due to a rounded configuration and loss of fatty hilum

Case 77

This mammogram was performed in a middle aged lady with a mobile breast mass. In this example a well-defined lesion is demonstrated at 12 o’clock position showing coarse calcification. Calcification is scattered throughout the lesion. Overall appearance of the lesion is highly suggestive of fibroadenoma. This will be classified as BI-RADS 2.

Case 78

A 12-year-old male patient with stunted growth is investigated with abdominal sonography, CT examination. Patient did not have urinary tract infection or known systemic disease

Sonography images demonstrate relatively small kidneys, approximately measuring between 7-8 cm on both sides. There is loss of corticomedullary distinction. The renal parenchyma is heterogeneously hyperechoic. Tiny peripheral cysts are noted mostly located subcortically. Collecting system is not significantly dilated. Along with the clinical context, these findings may represent renal dysplasia or a form of cystic renal disease. This patient is investigated with a CT (old case). In the present set up this examination to be replaced with an MR examination. CT evaluation demonstrated persistent fetal lobulation of both kidneys. There are multiple subcortical cystic areas. Vague hypodensities are noted in the corticomedullary junction. Findings are consistent with renal dysplasia. Occasional differential diagnosis is chronic glomerulonephritis or chronic pyelonephritis. Presence of multiple cysts are not associated with both diseases. Unilateral renal dysplasia is known by an entity called 'Ask Upmark kidney’. Biopsy examination in our patient revealed a disorganized renal architecture, fibrous replacement renal tissue.

Case 79

A 13-year-old patient with acute scrotal swelling was operated. Post-operative CT of the pelvic region is provided. Examination demonstrates the post-operative bed of the left testis containing a pocket of air. Additional image of the removed testis is presented. Examination demonstrates areas of calcification in an enlarged testis. Small pockets of fat density are also noted in the vicinity. This is the specimen radiograph of a testicular teratoma. Acute presentation is relatively uncommon in the testicular masses. Occasionally masses with bleeding or torsion may present in an acute setup. Post-operative evaluation in this case involves CT examination of chest and abdomen. PET CT is preferable

Case 80

Screening mammography for middle-aged lady is presented. This breast demonstrates BI RADS type C parenchymal pattern. There are no focal lesions or any signs of abnormal breast parenchyma. Also, did you notice unusual folds in the axillary region bilaterally? There are subcutaneous densities resembling breast parenchyma on the left side. This is an example of an accessory breast, a frequent observation in the screening mammography. When an accessory breast is present, evaluation should include the complete extent of the accessory tissues and any existing pathology.

Case 81 : 37-yr-old involved in a RTA, now has erectile dydfunction

Case 82 : 40-yr-old male with left flank pain, eleveted serum creatinine

Case 83 : 34-yr-male with abdominal distension, CLD on sonography

Case 84 : 29-yr-old female,had previous ruptered left ectopic, now 7 month amenorrhoea

Case 85

Elderly male presented with backache, was investigated with a CT examination of the spine. This is also part of an old collection of 80s; photographs being digitised subsequently. I am sharing this case just to point out a certain combination of findings which are relevant to the radiologist.

There is a lytic disease involving the lumbar vertebrae on the right side with associated large soft tissue swelling. Lesion is partly extending into the right pedicle. Additionally there is narrowing of the spinal canal with hypertrophic apophyseal joints. When we see osteolytic vertebral lesions with involvement of the pedicle, possibility of metastatic disease is always considered. Typically metastatic lesions do not show gross associated soft tissue swelling as against primary bone neoplasia or inflammatory processes like tuberculosis. Thus in this case spinal tuberculosis is a strong differential diagnosis. While covering the lumbar spine and incidental solid lesion with a speck of calcification was detected in the left kidney. Lesion is well-circumscribed and shows beak sign indicating lesion arising from the kidney. Lesion on histology was an adenocarcinoma. Spinal lesion was metastatic disease. The renal neoplasms are well known to present with osseous and pulmonary metastases. At times the metastatic disease is an initial manifestation. Occasionally metastasis is single, and can be resected along the primary lesion if the primary lesion is resectable. Typical causes of osteolytic metastatic disease are, renal neoplasm, thyroid, breast, bronchial, plasmacytoma, sarcoma and adrenal neoplasm including pheochromocytoma. Some osteolytic lesions expand the bone significantly, leading to a terminology called blowout lesions. Common causes of blow out metastases are

• Renal cell carcinoma

• Thyroid cancer

• hepatocellular carcinoma

• Pheochromocytoma

• melanoma

• gastric carcinoma

One important mimic for the expansile osteolytic lesion is a brown tumour of the hyperparathyroidism.

Pathology Illustrations: Pathology outlines Contributed by Debra L. Zynger, M.D.

Case 86

A 26-year-old male presented with the painless scrotal swelling. Sonographic evaluation was performed. These sets of images are obtained from an old study performed more than 30 years ago (1986-89). These are the digital replications of the photographs. Observations on sonography are straightforward. There is enlargement of the right testis showing heterogeneous parenchymal echoes. No obvious areas of necrosis were noted. There is no significant hydrocoeole. Left testis was normal. Incidentally this patient had an absence of the right kidney. Sonogram of the right upper retroperitoneum showed absence of the renal echoes. This patient also underwent a CT scan for further assessment. With the CT information, perhaps your diagnosis is complete. Testicular enlargement is associated with the focus of calcification and heterogeneously enhancing enlarged right testes. This patient had a teratoma testis in association with the unilateral renal agenesis. The phenotype of testicular germ cell tumor, developmental renal anomalies, and urethral hypospadias constitutes a discrete syndrome caused by a gene distinct from WT1.

Histologically there are 3 predominant types, postpubertal type, prepubertal type and a teratoma with somatic malignancy (often sarcoma) histological components may be varied like Mixed germ cell tumor, teratoma ,seminoma,embryonal carcinoma ,yolk sac tumor and choriocarcinoma . (Pathology outlines)

Case 87.

38-year-old lady underwent ultrasound examination of the urinary system and an intravenous program for a recurrent UTI. This is also part of the old collection, digitally converted from photographs of examinations performed 30-years-ago.

Sonographic examination of the urinary system revealed an intravesical pedunculated filling defect along the posterior wall of the bladder on the left side. Base of the polypoid lesion was in relation to the left vesicoureteric region. The rest of the urinary bladder was normal. Kidneys were normal. Intravenous urogram, follow-up examination of the bladder revealed a linear filling defect, lying obliquely across the urinary bladder. Cystoscopic excision of the lesion demonstrated malakoplakia.

Malakoplakia is a chronic granulomatous disease, common in patients with diabetes, immune suppression and acquired immune deficiency. It is more frequent in female, most common location is urinary bladder. Single or multiple plaque-like or polypoidal solid mass like lesions are seen in the urinary bladder. Size may vary considerably from a few millimetres to over centimetres. Biopsy confirmation is essential.