DESCRIPTIONA 56-year-old man presented to his general practitioner with a painless, rapidly growing left testicular mass over a period of 3 months. The patient was a known case of type II diabetes mellitus and hypertension with no relevant surgical history. He did not report any dysuria, fever or weight loss. On examination, there was bilateral diffuse, non-tender testicular enlargement without regional lymphadenopathy.Sonographic assessment revealed an enlarged left hypoechoic testicle measuring approximately 5 cm in width and 8 cm in length. It demonstrated a diffusely heterogenous infiltrative pattern ( figure 1A) and increased internal Doppler flow ( figure 1B). The right testicle measured 5 cm × 6 cm with otherwise similar sonographic findings ( figure 2A,B). These features are non-specific and the differential diagnosis includes orchitis, primary testicular tumours, leukaemia, testicular torsion and sarcoidosis. Histology is thus warranted to confirm the diagnosis.The patient underwent a left inguinal orchidectomy and was diagnosed with diffuse primary large B-cell non-Hodgkin's lymphoma. A right orchidectomy was performed 1 month later. Bone marrow aspirate and trephine biopsy were normal and he was started on a dedicated chemotherapeutic regimen.Primary testicular non-Hodgkin's lymphoma accounts for 1-2% of all non-Hodgkin's lymphomas and 5% of testicular cancers.1 It affects older men (mean age 67 years) and the most common histological subtype is diffuse large B-cell lymphoma. Presentation is usually with a unilateral testicular mass and up to 90% have stage I/II disease at diagnosis with bilateral testicular involvement occurring in 35% of cases.2 Relapse and extranodal infiltration is common. Learning points▸ Primary testicular lymphoma is rare accounting for 1% of non-Hodgkin's lymphomas and usually occurs in older men. ▸ Treatment for early stage disease comprises of orchidectomy followed by chemotherapy and prophylactic scrotal radiotherapy with/without iliac, para-aortic lymph node radiotherapy. ▸ Ultrasound usually reveals a diffuse infiltrative heterogenous process with increased vascularity on Doppler interrogation. ▸ Clinical data and inputs from a multidisciplinary team are important for effective patient management.Acknowledgements The authors would like to thank the urologists and haematologists who provided very important feedback with regard to the clinical aspect of this patient's condition. They contributed significantly to the patient being promptly diagnosed and receiving a high standard of care.
DESCRIPTIONA 35-year-old man presented with a chronic productive cough and a history of recurrent lower respiratory tract infections. Physical examination was unremarkable as were routine blood investigations.A chest radiograph demonstrated dilation of the trachea and main bronchi. Multiple perihilar cysts with air-fluid levels were seen (figure 1). Contrast-enhanced chest CT confirmed tracheal dilation with multiple tracheal diverticulae present in the posterior aspect of the proximal trachea (figure 2). Both main bronchi were also dilated. Bilateral, cystic spaces with air-fluid levels, in keeping with cystic bronchiectasis were seen to involve both lower lung zones, sparing the lung apices. This can be appreciated on coronal reformats (figure 3). Tracheal dilation and diverticulae were observed on bronchoscopy, confirming the diagnosis of tracheobronchomegaly.Mounier-Kuhn syndrome, also described as tracheobronchomegaly, is a rare condition marked by tracheal and bronchial dilatation. Presentation is usually that of recurrent lower respiratory tract infections. 1 The diagnosis is performed radiologically and is confirmed by bronchoscopy and lung function tests. These demonstrate an obstructive picture with a reduced forced expiratory volume in 1 s (FEV 1 ) and forced vital capacity (FVC) resulting in a FEV 1 /FVC of less than 70%. A tracheal diameter more than 3 cm, usually measured 2 cm above the aortic arch is diagnostic.2 A hereditary link is suggested by the occurrence of this condition in Ehlers-Danlos and cutis laxa.3 The consequence of this disease is impaired clearance of mucous resulting in recurrent Figure 1 Posterior-anterior (left) and lateral (right) chest X-ray demonstrating a dilated trachea (arrows) and perihilar cystic bronchiectasis with air-fluid levels. Figure 2 Selected images of a contrast-enhanced CT chest in lung window settings. On the left an axial image demonstrating two tracheal diverticulae posteriorly (arrows). On the right the diverticulae may be clearly visualised on the sagittal reformat (arrow).
DESCRIPTIONA 67-year-old woman presented to the emergency department reporting of epigastric fullness, fatigue and weight loss.Physical examination revealed three fingerbreadths of hepatomegaly. Blood tests were unremarkable, save for a moderately raised erythrocyte sedimentation rate.An urgent CT of her abdomen demonstrated two large liver lesions of low attenuation on the non-enhanced scan ( figure 1A), showing heterogeneous enhancement in the arterial phase (figure 1B) with contrast washout after a 5 min delay ( figure 1C), an appearance typical of hypervascular metastasis. Ultrasound-guided biopsy of one of these lesions was performed as a primary tumour was not identified. This revealed metastatic melanoma, however the primary lesion was not apparent on clinical examination.At a follow-up appointment the patient admitted to progressively worsening headaches. Non-contrast CT scan of the brain excluded any space-occupying lesions. A solid hyperdense mass was however identified at the posteroinferior aspect of the left lobe.MRI revealed a well-defined, homogenous, intraorbital mass with intrinsic hyperintensity on T1 and fluid-attenuated inversion recovery ( figure 2A), showing avid enhancement postcontrast ( figure 2B, C). There was no evidence of extraocular extension or associated retinal detachment. Given the advanced stage of the tumour, she was treated conservatively with systemic chemotherapy and symptomatic pain relief and is currently being followed up regularly by the oncology team. The imaging findings described are characteristic of malignant uveal melanoma which is the most common primary intraocular malignancy in adults and the second commonest
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