Duke Duncan, MD

44-year-old woman presents for screening mammogram.

Multiple non-calcified rounded cutaneous and subcutaneous lesions are seen bilaterally on these CC and MLO mammographic images. This patient had a history of neurofibromatosis type 1 and this is a classic appearance of neurofibromas on mammogram. Neurofibromatosis type 1 is an autosomal dominant disease characterized by two or more of the following diagnostic criteria: cafe au lait spots, neurofibromas, axillary or inguinal freckling, lisch nodules, optic gliomas, characteristic bony lesions, first degree relative with the disease.

Recent studies have shown a possible increased risk of invasive breast cancer in neurofibromatosis patients although current guidelines do not place these patients in a high-risk category.

1. Ferner RE, Huson SM, Thomas N, Moss C, Willshaw H, Evans DG, Upadhyaya M, Towers R, Gleeson M, Steiger C, Kirby A. Guidelines for the diagnosis and management of individuals with neurofibromatosis 1. 

2. Cao MM, Hoyt AC, Bassett LW. Mammographic signs of systemic disease. 

3. Madanikia SA, Bergner A, Ye X, Blakeley JO. Increased risk of breast cancer in women with NF1. 

4. Wang X, Levin AM, Smolinski SE, Vigneau FD, Levin NK, Tainsky MA. Breast cancer and other neoplasms in women with neurofibromatosis type 1: a retrospective review of cases in the Detroit metropolitan area. 

Poll

Image IQ: 44-year-old Woman, Screening Mammogram

74-year-old with history of aortic valve repair at an outside hospital.

First figure represents volume-rendered image of the heart with the right coronary artery demonstrated.

Myocardial bridging of the right coronary artery

Malignant course of the right coronary artery

Answer: Malignant course of the right coronary artery.


This case demonstrates a malignant course of the right coronary artery. Best seen on the volume-rendered image, the right coronary artery courses between the aorta and the main pulmonary artery, an interarterial course often referred to as a malignant course. A congenital anomalous origin of the right coronary artery is seen, arising from the left cusp of the aortic valve adjacent to the left main artery.

Anomalous courses of the coronary arteries are thought to be present in 0.3%–1.6% of the population and are usually discovered incidentally. Anomalous courses of the coronary arteries are the second most common cause of sudden cardiac death in young healthy individuals, second only to hypertrophic cardiomyopathy. A malignant course is defined as passage of the coronary artery between the aorta and the pulmonary artery.

An anomalous left coronary artery with a malignant course has a much higher risk of sudden death than an anomalous right coronary artery with a malignant course. As patients age, their risk of sudden death with these anomalies decreases significantly and surgical management is rarely warranted. In young patients with malignant right coronary artery courses, proper management is not fully defined and the decision to perform surgery is multifactorial. Young patients with malignant left coronary artery courses usually undergo surgical correction.


Warnes CA, Williams RG, Bashore TM, Child JS, Connolly HM, Dearani JA, del Nido P, et al. ACC/AHA 2008 guidelines for the management of adults with congenital heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Develop Guidelines on the Management of Adults With Congenital Heart Disease). Developed in Collaboration With the American Society of Echocardiography, Heart Rhythm Society, International Society for Adult Congenital Heart Disease, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. 

PeÃ±alver JM, Mosca RS, Weitz D, Phoon CK. Anomalous aortic origin of coronary arteries from the opposite sinus: a critical appraisal of risk. 

Image IQ: 74-year-old, History of Aortic Valve Repair

An 85-year-old male with history of aortic stenosis receiving contrast-enhanced CT for preoperative evaluation.


This is a classic appearance of an adrenal myelolipoma. Adrenal myelolipomas are rare, benign tumors of the adrenal gland. They are encapsulated and well-circumscribed. Incidentally discovered, they are well-characterized on CT examinations as heterogeneous fatty attenuation adrenal masses. They contain fatty elements and hematopoietic tissue and, rarely, may rupture and bleed into the retroperitoneum when extremely large. A benign appearing, encapsulated adrenal mass containing pure fatty elements is highly suggestive of an adrenal myelolipoma.


Rao P, Kenney PJ, Wagner BJ, Davidson AJ. Imaging and pathologic features of myelolipoma. 

85-year-old male with history of aortic stenosis receiving contrast-enhanced CT for preoperative evaluation.

Image IQ: 85-year-old Male, History of Aortic Stenosis 

67-year-old male with history of worsening fatigue and jaundice.

Cirrhosis likely secondary to Hepatitis C 

Answer: Cirrhosis likely secondary to Hepatitis C

This is a great example of macronodular cirrhosis. The most common cause of cirrhosis, chronic ethanol consumption, is micronodular cirrhosis. Hepatitis C, an increasingly common cause of cirrhosis in the United States, is a cause of macronodular cirrhosis and was the etiology of the cirrhosis in this case.  Screening for hepatocellular carcinoma is important in this population.

The classic morphologic changes of cirrhosis are demonstrated in this case.  There is enlargement of the caudate and lateral segment of the left lobe of the liver with atrophy of the right lobe and medial segment of the left lobe.  There is a markedly nodular liver contour.

Gupta AA, Kim DC, Krinsky GA, et al. CT and MRI of cirrhosis and its mimics. 

Zhang BH, Yang BH, Tang ZY. Randomized controlled trial of screening for hepatocellular carcinoma. 

Author | Duke Duncan, MD

Articles

Image IQ: 44-year-old Woman, Screening Mammogram

Image IQ: 74-year-old, History of Aortic Valve Repair

Image IQ: 85-year-old Male, History of Aortic Stenosis

Image IQ: 67-year-old Male, Worsening Fatigue, Jaundice