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  1. 1. BORDERS OF HEART <ul><ul><li>Right border of heart : </li></ul></ul><ul><ul><ul><li>Aorta, superior vena cava </li></ul></ul></ul><ul><ul><ul><li>right atrium, IVC </li></ul></ul></ul><ul><ul><li>Left border of heart : </li></ul></ul><ul><ul><ul><li>aortic bulb(aortic arch) </li></ul></ul></ul><ul><ul><ul><li>pulmonary artery segment ( cardiac waist),main pulmonary artery </li></ul></ul></ul><ul><ul><ul><li>left ventricle </li></ul></ul></ul><ul><ul><li>Anterior border of heart </li></ul></ul><ul><ul><ul><li>Ascending aorta </li></ul></ul></ul><ul><ul><ul><li>The infundibular of the right ventricle, pulmonary trunk </li></ul></ul></ul><ul><ul><ul><li>Anterior border of right ventricle </li></ul></ul></ul><ul><ul><li>Posterior border of heart </li></ul></ul><ul><ul><ul><li>Left atrium </li></ul></ul></ul><ul><ul><ul><li>Left ventricle </li></ul></ul></ul>
  2. 2. Heart enlargement <ul><li>Enlargement of the heart chambers </li></ul><ul><ul><li>Left ventricular enlargement </li></ul></ul><ul><ul><li>Right ventricular enlargement </li></ul></ul><ul><ul><li>Left atrium enlargement </li></ul></ul><ul><ul><li>Right atrium enlargement </li></ul></ul><ul><ul><li>General cardiac enlargement </li></ul></ul>
  3. 3. Left ventricular enlargement <ul><li>X-ray appearance; </li></ul><ul><ul><li>cardiac apex extending to left and down </li></ul></ul><ul><ul><li>the point of opposite pulsation move down </li></ul></ul><ul><ul><li>left ventricle segment extended, rounded, expand to left </li></ul></ul><ul><ul><li>Lat : retrocardiac space become narrowed or disappeared, esophageal space disappeared, Hoffman-Rigler sign (+) </li></ul></ul><ul><ul><li>LAO ( 60° ): left ventricle and spine to overlap, interventricular sulcus move forward and down </li></ul></ul><ul><li>Common disease : </li></ul><ul><ul><li>high blood pressure </li></ul></ul><ul><ul><li>aortic incompetence 、 stenosis </li></ul></ul><ul><ul><li>mitral incompetence </li></ul></ul><ul><ul><li>congenital heart disease : PDA </li></ul></ul>
  4. 4. Right ventricular enlargement <ul><li>X-ray appearance : </li></ul><ul><ul><li>Enlargement of the RV , extending forward, left and backward </li></ul></ul><ul><ul><li>cardiac waist expanded </li></ul></ul><ul><ul><li>Lat : contact between the front surface of heart and the sternum (anterior chest wall) >1/3 </li></ul></ul><ul><ul><li>heart of mitral configuration </li></ul></ul><ul><li>Common disease : </li></ul><ul><ul><li>Mitral valve stenosis </li></ul></ul><ul><ul><li>Chronic pulmonary heart disease </li></ul></ul><ul><ul><li>Pulmonary stenosis </li></ul></ul><ul><ul><li>Pulmonary hypertension </li></ul></ul><ul><ul><li>Fallot’s tetralogy </li></ul></ul><ul><ul><li>ASD , VSD </li></ul></ul>
  5. 5. Left atrium enlargement <ul><li>X-ray : enlarged LA bulges to back & right </li></ul><ul><ul><li>PA – right border : double shadow of cardiac base , double curve of cardiac atrium segement of right border of heart </li></ul></ul><ul><ul><li>PA – left border : left atrial appendage enlargement </li></ul></ul><ul><ul><li>Lat & RAO : middle of esophagus pressed and displaced posteriorly, to divided into three grade </li></ul></ul><ul><ul><li>LAO : left main bronchus compression and to raise </li></ul></ul><ul><li>Common disease : </li></ul><ul><ul><li>mitral lesion </li></ul></ul><ul><ul><li>left ventricular failure </li></ul></ul><ul><ul><li>congenital heart anomalies : </li></ul></ul><ul><ul><ul><li>PDA </li></ul></ul></ul><ul><ul><ul><li>VSD </li></ul></ul></ul>
  6. 6. Right atrium enlargement <ul><li>X-ray appearance : </li></ul><ul><ul><li>PA : inferior segment of right border of heart extending to right , bulge, high bulge point </li></ul></ul><ul><ul><li>LAO : the right atrial curvature at least half as long as the anterior border of heart , bulge </li></ul></ul><ul><li>Common disease : </li></ul><ul><ul><li>right heart failure </li></ul></ul><ul><ul><li>ASD </li></ul></ul><ul><ul><li>tricuspid disease </li></ul></ul><ul><ul><li>atrial myxoma </li></ul></ul>
  7. 7. General cardiac enlargement <ul><li>X-ray appearance : </li></ul><ul><ul><li>PA : The cardiac shadow is increased to both sides, the transverse diameter increased </li></ul></ul><ul><ul><li>Lat and RAO : narrowing of both retrosternal space and retrocardiac space, the oesophagus is displaced backward </li></ul></ul><ul><ul><li>LAO : the trachea bifurcation is sprayed, the trachea is displaced backward </li></ul></ul><ul><li>Common disease : </li></ul><ul><ul><li>Pericardial effusion </li></ul></ul><ul><ul><li>Myocarditis </li></ul></ul><ul><ul><li>Total cardiac failure </li></ul></ul><ul><ul><li>Total cardiac failure, hyperthyroidism </li></ul></ul>
  8. 8. Pulmonary edema <ul><li>Pathology : the fluid in the blood capillary penetrate into the pulmonary interstitium and alveoli </li></ul><ul><li>Classification : </li></ul><ul><ul><li>Pulmonary Interstitial Edema </li></ul></ul><ul><ul><li>Pulmonary Alveolar Edema </li></ul></ul>
  9. 9. Interstitial pulmonary edema-KerleyA,B,C lines
  10. 10. Alveolar pulmonary edema <ul><li>Common disease : </li></ul><ul><ul><li>Uremia 、 heart disease with heart failure </li></ul></ul><ul><li>Clinical manifestation : dyspnea 、 frothy sputum </li></ul><ul><li>X-ray : </li></ul><ul><ul><li>undefined opacity shadow </li></ul></ul><ul><ul><li>Location : Inner 2/3 of the lung, near the hilum </li></ul></ul><ul><ul><li>Typical appearance :“ butterfly” or “bat wing” shape </li></ul></ul>
  11. 11. Pericardial abnormalities <ul><ul><li>Pericardial effusion </li></ul></ul><ul><ul><ul><li>Acute pericarditis </li></ul></ul></ul><ul><ul><li>Pericardial thickening 、 calcification </li></ul></ul><ul><ul><ul><li>Chronic pericarditis </li></ul></ul></ul><ul><ul><ul><li>Constrictive pericarditis </li></ul></ul></ul>
  12. 12. Pericardial effusion <ul><li>X-ray appearance : </li></ul><ul><ul><li>Direct sign : </li></ul></ul><ul><ul><ul><li>Heart shadow generally enlarge bilaterally </li></ul></ul></ul><ul><ul><ul><li>“ water-bottle ” or “ flask ” shape, globular </li></ul></ul></ul><ul><ul><ul><li>Normal arcus of cardiac border disappear </li></ul></ul></ul><ul><ul><ul><li>Pulsation of the cardiac border weaken or disappear, but the aortal pulsation is normal </li></ul></ul></ul><ul><ul><li>Indirect sign : </li></ul></ul><ul><ul><ul><li>Systemic venous return obstructed, right ventricle output decreased </li></ul></ul></ul><ul><ul><ul><ul><li>Superior vena cava widen </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Decreased lung markings </li></ul></ul></ul></ul><ul><ul><ul><li>Aortal shadow smaller </li></ul></ul></ul><ul><ul><li>Cardiac tamponade – impedes diastolic filling </li></ul></ul>
  13. 13. Pericardial thickening 、 calcification <ul><li>thickening : </li></ul><ul><ul><li>Pericardium near the diaphragm (ventricular face) thicken obviously </li></ul></ul><ul><ul><li>but the atrium area and the root of the great vessels less thicken </li></ul></ul><ul><ul><li>Epicardial fat pad ‘ sign ’ (+) </li></ul></ul><ul><ul><ul><li>Lat. / PA view: anterior pericardial stripe > 2mm </li></ul></ul></ul><ul><li>Hemodynamic change: </li></ul><ul><ul><li>Right ventricle compression : venous return obstructed, and vena cava dilatation </li></ul></ul><ul><ul><li>Left ventricle compression : left atrium and pulmonary venous pressure increased, so the left heart output decreased </li></ul></ul>
  14. 14. Constrictive pericarditis <ul><li>X-ray : </li></ul><ul><ul><li>Direct sign : </li></ul></ul><ul><ul><ul><li>The heart shadow size is normal or little, midium enlarged </li></ul></ul></ul><ul><ul><ul><li>A side or both sides of heart borders straighten, the demarcation among each arcus is undefined; contour: triangle , globular </li></ul></ul></ul><ul><ul><ul><li>Heart pulsation weaken or disappear; the portion without thickened can bulge, and it ’ s pulsation enhanced </li></ul></ul></ul><ul><ul><ul><li>Pericardial calcification : eggshell, barred, patching, </li></ul></ul></ul><ul><ul><ul><li>Pleural thickening, adhesion </li></ul></ul></ul><ul><ul><li>Indirect sign : VP ↑ </li></ul></ul><ul><ul><ul><li>Superior vena cava dilatation </li></ul></ul></ul><ul><ul><ul><li>Pulmonary venous hypertension </li></ul></ul></ul>
  15. 15. Rheumatic Heart Disease <ul><li>Involved valve : </li></ul><ul><ul><li>Mitral valve 、 Aortic valve 、 Tricuspid valve </li></ul></ul><ul><li>Pathology : </li></ul><ul><ul><li>Mitral valve stenosis: Valve ring cicatricle contraction </li></ul></ul><ul><ul><li>Mitral valve insufficiency </li></ul></ul>
  16. 16. Mitral stenosis <ul><li>X-ray appearance : </li></ul><ul><ul><li>Cardiac type : “ mitral configuration ” </li></ul></ul><ul><ul><ul><li>LA & RV enlarge , </li></ul></ul></ul><ul><ul><ul><li>pulmonary artery segment bulge </li></ul></ul></ul><ul><ul><ul><li>Aortic knob shrink </li></ul></ul></ul><ul><ul><ul><li>LV shrink : cardiac apex move upward, the lower portion of left border flatten </li></ul></ul></ul><ul><ul><li>valvular calcification </li></ul></ul><ul><ul><li>Pulmonary venous hypertension, interstitial pulmonary edema </li></ul></ul><ul><ul><li>Hemosiderin pigmentation : 1-2mm nodular shadow </li></ul></ul>
  17. 17. Retinoblastoma <ul><li>Malignant primary retinal neoplasm </li></ul><ul><li>Trilateral retinoblastoma: bilateral ocular tumor +midline intracranial neuroblastic tumor ,typically pineal. </li></ul><ul><li>Quadrilateral : bilateral disease + pineal +suprasellar tumor. </li></ul><ul><li>Most common intraocular tumor of children. </li></ul><ul><li>c/f: leukocoria, severe vision loss, retinal detachment </li></ul>
  18. 18. Retinoblastoma <ul><li>CT </li></ul><ul><li>NECT: characteristic punctate or finely speckled calcification (>90-95%) </li></ul><ul><li>CECT: Moderate to marked heterogenous enhancement. </li></ul><ul><li>MRI: </li></ul><ul><li>T1W: variable, mildly hyperintense </li></ul><ul><li>T2W: moderate to markedly hypointense </li></ul><ul><li>T1W+C : moderate to marked heterogenous enhancement. </li></ul>
  19. 19. EAR- Cholesteatoma <ul><li>It is a formation of stratified squamous epithelium in wrong site with keratin debris. </li></ul><ul><li>A cholesteatoma may be classified as either acquired or congenital in origin </li></ul><ul><li>98% is acquired </li></ul><ul><li>Is a complication of chronic otitis . </li></ul><ul><li>c/f : pain in middle ear ,hearing loss </li></ul><ul><li>CT features : bone erosion associated with a nonenhancing soft-tissue mass </li></ul><ul><li>MRI : If cholesterol present then T1W will be bright </li></ul>
  20. 20. Glomus tympanicum tumor <ul><li>Is type of glomus tumor (paragangliomas) </li></ul><ul><li>Slow growing, purple red vascular tumor that arise from chemoreceptor cells. </li></ul><ul><li>Most common middle ear tumor </li></ul><ul><li>c/f: pulsating tinnitus, conductive hearing loss. </li></ul>
  21. 21. Glomus tympanicum tumor <ul><li>CT features: </li></ul><ul><li>Presence of small soft tissue density protruding from the choclear promontory without bony destruction. </li></ul><ul><li>Enhances homogenously. </li></ul><ul><li>MRI: </li></ul><ul><li>Helpful to distinguise from glomus jugulare tumor where glomus tympanicum shows bright enhancement on T1W after Gd. </li></ul><ul><li>to see relation with carotid artery. </li></ul>
  22. 22. Mondini malformation <ul><li>Congenital malformation of inner ear. </li></ul><ul><li>Associated with hypoplasia, absence, or the presence of only a rudimentary coil of the cochlea. </li></ul><ul><li>is associated in 20% of cases with anomalies of the vestibule, semicircular canals and endolymphatic duct/sac. </li></ul><ul><li>Defect is usually bilateral associated with dilatation of vestibular aqueduct. </li></ul>
  23. 23. Acute sinusitis <ul><li>Most often due to secondary bacterial infection following an upper respiratory tract infection or from local infection from an infected tooth in upper jaw. </li></ul><ul><li>Process of sinonasal mucosa lasting < 4wks duration. </li></ul><ul><li>c/f: nasal congestion, thick postnasal discharge, headache, olfactory dysfunction, fever cough, sinus tenderness. </li></ul><ul><li>Plain radiograph: </li></ul><ul><li>Infective : mucosal thickening and secretions leading to haziness of sinus. </li></ul><ul><li>- air fluid level is common. </li></ul><ul><li>Allergic : polypoidal type mucosal thickening </li></ul><ul><li>- usually thickened. </li></ul>
  24. 24. Acute sinusitis <ul><li>CT findings: </li></ul><ul><li>Soft tissue density thickening of the mucosal layer of sinuses. </li></ul><ul><li>Enhancement after contrast administration of the inflammed mucosa. </li></ul><ul><li>Air-fluid level </li></ul><ul><li>MRI findings: </li></ul><ul><li>Mucosal layer thickening with high signal on T2W film. </li></ul><ul><li>Complications of acute sinusitis : </li></ul><ul><li>Osteomyelitis </li></ul><ul><li>Intracranial abscess </li></ul><ul><li>Orbital cellulitis </li></ul><ul><li>Chronic rhinosinusitis </li></ul>
  25. 25. Chronic sinusitis <ul><li>Due to recurrent acute sinusitis or a prolonged episode that has failed to respond to conservative management. </li></ul><ul><li>Inflammation of nose and sinuses > 12 consecutive wks duration </li></ul><ul><li>Cause: allergy, immunodeficiency, anatomic varients, mucociliary dysfunction, neoplasm. </li></ul><ul><li>c/f: facial pain/pressure, nasal obstruction /discharge anosmia </li></ul><ul><li>CT is a investigation of choice for knowing the degree and extent of involvement of disease process. </li></ul>
  26. 26. Chronic sinusitis <ul><li>Imaging features: </li></ul><ul><li>In plain radiograph soft tissue density is seen but bony changes is not clearly visualised. </li></ul><ul><li>In CT mucoperiosteal thickening and bony sclerosis is clearly visualised on wide window setting of 2000-2500 WW. </li></ul><ul><li>In MRI, high signal on T2W of the sinus mucosal layer and some time no signal is seen in dessicated state where sinus is mimicked aerated </li></ul>
  27. 27. Sinonasal polyp/polyposis/cyst <ul><li>polyps result from an expansion of fluids in the deeper lamina propria of the Schneiderian mucosa in the nasal fossa and paranasal sinuses. </li></ul><ul><li>The polyps in sinonasal polyposis are soft-tissue pedunculated masses of oedematous hyperplastic upper respiratory mucosa. </li></ul><ul><li>The cause remains unclear but there is an association with atopic rhinitis (allergic and non-allergic), asthma, infection, cystic fibrosis, aspirin intolerance and Kartagener's syndrome. </li></ul><ul><li>The commonest site of sinonasal polyposis is the ethmoids, followed by the maxillary antra and then the sphenoid sinus. </li></ul>
  28. 28. <ul><li>Sinonasal polyp/polyposis/cyst </li></ul><ul><li>Retension cysts: </li></ul><ul><li>occur as a result of obstruction of the ducts of the mucosal glands. </li></ul><ul><li>usually small, have a well-defined outline and are seen in approximately 10% of the population. </li></ul><ul><li>may occasionally enlarge to fill the sinus. </li></ul><ul><li>Imaging features: </li></ul><ul><li>The intrasinus polyp and the retention cyst cannot be differentiated on either plain films or sectional imaging. </li></ul><ul><li>Plain radiograph and CT appearance is of a smooth, broad-based soft-tissue mass with outwardly convex and borders a well-defined outline. </li></ul><ul><li>On MRI these are usually of low intensity on T1, and bright on T2, but may appear bright on T1, depending on the concentration of entrapped secretions. </li></ul>
  29. 29. CEREBRAL INFARCTION <ul><li>is a permanent injury that occurs when tissue perfusion is decreased long enough to cause necrosis, typically as the result of occlusion of the feeding artery. </li></ul><ul><li>two thirds of infarcts are caused by thrombi and one third are caused by emboli </li></ul><ul><li>Vasculitis, vasospasm, coagulopathies, global hypoperfusion, and venous thrombosis each account for 5% or fewer of acute strokes, but are important to recognize because of differing treatment and prognosis </li></ul>
  30. 30. Imaging Findings in Acute Ischemia <ul><li>Ischemia causes a cascade of cellular level events leading to the gross pathologic changes detected in clinical imaging . </li></ul><ul><li>Failure of membrane pumps permits efflux of potassium ions (K+) and simultaneous influx of calcium ions (Ca2+), sodium ions (Na+), and water </li></ul><ul><li>This leads to cellular (“cytotoxic”) edema, observed clinically as increased water content in the affected region. </li></ul><ul><li>Even a small increase in water content causes characteristic decreased attenuation on CT, low signal on T1WIs, and high signal on T2- and diffusion-weighted MR. </li></ul>
  31. 31. BRAIN HEMMORHAGE <ul><li>Hemorrhage occurs when an artery or vein ruptures, allowing blood to burst forth into the brain parenchyma or subarachnoid spaces </li></ul><ul><li>Although mixed patterns occur, hemorrhages are most conveniently divided into subaracnoid and parenchymal categories . </li></ul><ul><li>Imaging studies are critical in determining the source of bleeding and in showing any associated complications. </li></ul>
  32. 32. BRAIN NEOPLASM-ASTROCYTOMA <ul><li>LOW GRADE </li></ul><ul><li>astrocytomas tend to occur in younger patients, usually children and adults 20 to 40 years old </li></ul><ul><li>are usually well-demarcated tumors without necrosis or neovascularity, rarely hemorrhage, and are often cystic </li></ul><ul><li>show calcification in 20% of cases and rarely have surrounding edema </li></ul><ul><li>On CT, they are hypodense with little or no enhancement. On MR, compared to gray matter, they are hypointense on T1WIs, hyperintense on T2WIs, and show minimal enhancement </li></ul>
  33. 33. ASTROCYTOMA <ul><li>HIGH GRADE </li></ul><ul><li>the higher-grade astrocytomas tend to occur in patients older than 40 years of age </li></ul><ul><li>tumors are poorly delineated microscopically, although they may appear well-circumscribed grossly. Necrosis, hemorrhage, and neovascularity are common, particularly in the GBM. </li></ul><ul><li>On CT, they are typically heterogeneous. On MR they are isointense to hypointense compared to gray matter on T1WIs and hyperintense on T2WIs. A ringlike pattern on postcontrast imaging may be seen </li></ul>
  34. 34. MENINGIOMA <ul><li>most common extra-axial neoplasm of adults and accounts for 15% of all intracranial neoplasms, second only to gliomas in overall prevalence </li></ul><ul><li>The peak age of presentation is 50 to 60 years of age. </li></ul><ul><li>On CT, a well-defined hyperdense (85%) mass with variable surrounding edema and intense and homogeneous enhancement on postcontrast studies is highly characteristic . Hyperostosis of the adjacent inner table is noted about 40% of the time. Calcification is seen in 10% to 20% of cases. </li></ul><ul><li>On MR, the tumor is typically isointense to hypointense to gray matter on T1WIs and isointense to hyperintense to gray matter on T2WIs </li></ul>
  35. 35. Pituitary Adenoma <ul><li>account for about 10% to 15% of all intracranial tumors and constitute the most common sellar masses </li></ul><ul><li>Based on their size, they are considered either microadenomas (10 mm or smaller) or macroadenomas (>10 mm). </li></ul><ul><li>MR is the imaging modality of choice to detect pituitary tumors. </li></ul><ul><li>Microadenomas are usually best detected on coronal T1WIs as focal areas of hypointensity (on noncontrast studies) compared tothe rest of the pituitary gland </li></ul>
  36. 36. Medulloblastoma <ul><li>most common pediatric CNS malignancy and, along with the pilocytic astrocytoma, the most common pediatric posterior fossa tumor </li></ul><ul><li>majority (85%) arise from the cerebellar vermis </li></ul><ul><li>Extension into the adjacent fourth ventricle and subsequent development of hydrocephalus is common </li></ul><ul><li>is a highly malignant neoplasm (WHO grade IV) with rapid growth </li></ul><ul><li>Most medulloblastomas manifest as solid, hyperdense masses on CT. Cystic change or necrosis occurs in up to 60% of cases and calcification is noted in 20% </li></ul><ul><li>On MR, the tumor is usually isointense to hypointense compared to white matter on T1WIs and has a more variable appearance on T2WIs </li></ul><ul><li>Following administration of contrast, the tumor demonstrates intense although usually heterogeneous enhancement </li></ul>
  37. 37. Simple Renal Cyst <ul><li>are the most common type renal mass </li></ul><ul><li>They are found in half the population older than age 55 </li></ul><ul><li>Small cysts are asymptomatic </li></ul><ul><li>Large cysts (>4 cm) occasionally cause obstruction, pain, hematuria, or hypertension </li></ul><ul><li>Cysts are commonly multiple and bilateral </li></ul><ul><li>US, CT, and MR can each make a definitive diagnosis </li></ul><ul><li>Plain film -Often no abnormal finding. </li></ul><ul><ul><li>-A bulge in renal outline for very large cyst. </li></ul></ul><ul><li>Intravenous pyelography- Displacement and stretching of calyces </li></ul><ul><ul><li>-Clubbing of calyces </li></ul></ul>
  38. 38. Simple Renal Cyst <ul><li>CT signs include : </li></ul><ul><li>sharp margination with the renal parenchyma, </li></ul><ul><li>no perceptible wall, </li></ul><ul><li>homogeneous attenuation near water density (-10 to +10 H) </li></ul><ul><li>absence of contrast enhancement </li></ul>
  39. 39. Renal cyst <ul><li>MR criteria include: </li></ul><ul><li>homogeneous, sharply defined, round or oval mass; </li></ul><ul><li>homogeneous low signal intensity on T1WIs; and </li></ul><ul><li>homogeneous high signal intensity similar to that of urine on T2WIs. No enhancement should be seen after gadolinium administration </li></ul>
  40. 40. Polycystic kidneys <ul><li>Plain film </li></ul><ul><ul><li>-Enlargement and lobulation of the renal shadows </li></ul></ul><ul><li>Intravenous pyelography </li></ul><ul><ul><li>-Stretching of the calyces and calyceal stem which are large crescentic and sharply defined </li></ul></ul><ul><li>CT </li></ul><ul><ul><li>-Enlargement of both kidneys </li></ul></ul><ul><ul><li>-The number, size, shape and the nature of the cysts are well demonstrated. </li></ul></ul>
  41. 41. Renal Angiomyolipoma(AML) <ul><li>is an uncommon (1% to 3% of renal neoplasms) benign mesenchymal tumor composed of varying amounts of fat, smooth muscle, and abnormal blood vessels lacking elastic tissue. </li></ul><ul><li>Most (80%) are solitary unilateral tumors; they are discovered most commonly in middle-aged women. </li></ul>
  42. 42. AML <ul><li>Plain film : </li></ul><ul><ul><li>-Changes of renal outline </li></ul></ul><ul><li>Intravenous pyelography : </li></ul><ul><ul><li>-Depress and displacement of calyces and pelvis with smooth margin. </li></ul></ul><ul><li>CT : </li></ul><ul><ul><li>-Low or mix-dense mass with clear margin. The most important sign is the fat tissue within the mass with very low density. </li></ul></ul><ul><ul><li>-Unevenly enhancement of the mass on the contrast enhanced scan </li></ul></ul>
  43. 43. Renal cell carcinoma (RCC) <ul><li>accounts for 85% of all renal neoplasms </li></ul><ul><li>more common in men (male-to-female ratio = 3:1) aged 50 to 70 years and is bilateral in 2% of cases </li></ul><ul><li>Hemorrhage and necrosis are common, and cystic and multicystic forms </li></ul><ul><li>Stippled central or peripheral calcifications are present in 10% of cases </li></ul><ul><li>The tumors are commonly hypervascular, with numerous abnormal feeding vessels visualized. </li></ul><ul><li>Tumor growth into the renal vein occurs in 30% of cases and extends into the IVC in 5% to 10% of cases </li></ul><ul><li>The tumor metastasizes most commonly to lung, local lymph nodes, liver, bone, adrenal glands, and the opposite kidney </li></ul><ul><li>C/F: painless hematuria </li></ul>
  44. 44. Renal cell carcinoma <ul><li>Plain film : </li></ul><ul><ul><li>Generalized enlargement of renal outline , local bulge </li></ul></ul><ul><ul><li>Irregular or linear calcification </li></ul></ul><ul><li>Intravenous pyelography </li></ul><ul><ul><li>Little changes in small tumor </li></ul></ul><ul><ul><li>Displace, stretch and destroy calyceal stems and calyces </li></ul></ul><ul><ul><li>Dilatation of some calyces </li></ul></ul>
  45. 45. <ul><li>Renal cell carcinoma </li></ul><ul><li>CT : Local bulge or irregular mass </li></ul><ul><ul><li>Slightly low, iso- or high dense mass, which will be enhanced in contrast enhanced scans. </li></ul></ul><ul><ul><li>Destruction and displacement of calyces and pelvis </li></ul></ul><ul><li>MRI: RCC is isointense or hyperintense compared with renal parenchyma on T1WIs and shows distinct enhancement with gadolinium administration. </li></ul><ul><li>Hyperintensity on T1WIs usually reflects tumoral hemorrhage, but fat-suppression sequences should be used to ensure the high signal is not because of fat </li></ul><ul><li>S lightly hyperintense on T2-weighted sequences. </li></ul><ul><li>Contrast: Heterogeneous enhancement occurs immediately, decreasing on delayed images </li></ul>
  46. 46. Basic imaging signs of GIT diseases <ul><li>1 ) evection (protrude) </li></ul><ul><li>filling defect </li></ul><ul><li>- Filling defect is a term used to describe something occupying space within the bowel thereby preventing the normal filling of the lumen with barium. This creates an area of total or relative radiolucency within the barium column. </li></ul><ul><li>-The common cause includes tumor 、 granuloma etc. </li></ul><ul><li>2 ) indentation </li></ul><ul><li>niche (crater) </li></ul><ul><li>- an outward projection from the barium-filled lumen </li></ul><ul><li>ulcer is common </li></ul>
  47. 47. Basic imaging signs of GIT diseases <ul><li>( 3 ) thickening the wall of the bowel </li></ul><ul><li>diagnostic criteria </li></ul><ul><li>the wall of esophagus>5mm </li></ul><ul><li>the wall of stomach>10mm </li></ul><ul><li>the wall of small intestine>5mm </li></ul><ul><li>the wall of large intestine>5mm, suspected ; >10mm , confirmed </li></ul>
  48. 48. Esophageal carcinoma <ul><li>squamous cell carcinoma in 85% to 90% of cases </li></ul><ul><li>Tumor assumes four basic radiographic patterns: </li></ul><ul><li>annular constricting lesion, appearing as an irregular ulcerated stricture, is most common </li></ul><ul><li>polypoid pattern causes an intraluminal filling defect </li></ul><ul><li>infiltrative variety grows predominantly in the submucosa and may simulate a benign stricture </li></ul><ul><li>least common pattern is that of an ulcerated mass </li></ul><ul><li>COMPLICATIONS : Perforation leading to abscess,fistula. </li></ul><ul><li>Metastasis to lymph node </li></ul>
  49. 49. Gastric carcinoma <ul><li>the third most common GI malignancy, following colon and pancreatic carcinoma </li></ul><ul><li>Most (95%) are adenocarcinomas; the remainder are diffuse anaplastic (signet-ring) carcinoma, squamous cell carcinoma, or rare cell types </li></ul><ul><li>Borrman classification: </li></ul><ul><li>Types- </li></ul><ul><li>1.protruded </li></ul><ul><li>2.localized and ulcerated </li></ul><ul><li>3.ulcerated and infiltrative </li></ul><ul><li>4.diffuse infiltrative </li></ul>
  50. 50. Gastric carcinoma <ul><li>Imaging appearances </li></ul><ul><li>filling defect </li></ul><ul><li>stricture of gastral cavity, rigidity wall ( leather bottle ) </li></ul><ul><li>niche : irregular morphous, meniscus sign </li></ul><ul><li>destroyed 、 interrupted or abnormally thickened mucosal folds </li></ul><ul><li>Aperistalsis </li></ul><ul><li>CT : CT examination has limited value in detecting gastric ulcer , duodenal ulcer or early gastric cancer, whereas it is good at observing lesion range and metastasis of lymph node. </li></ul>
  51. 51. IBD- Crohn disease <ul><li>involves the colon in two thirds of cases and is isolated to the colon in approximately one third of all cases </li></ul><ul><li>Is a inflammatory disease </li></ul><ul><li>Hallmarks of Crohn colitis include early aphthous ulcers, later confluent deep ulcerations, predominant right colon disease, discontinuous involvement with intervening regions of normal bowel, asymmetric involvement of the bowel wall, strictures, fistulas, and sinus formation </li></ul>
  52. 52. <ul><li>Imaging manifestations : </li></ul><ul><li>1 、 aphthoid ulcer 、 longitudinal ulcer </li></ul><ul><li>2 、 cobblestone filling defect </li></ul><ul><li>3 、 segmented and dissymmetry distribution </li></ul><ul><li>4 、 pseudodiverticula at opposing mesentry </li></ul><ul><li>5 、 thickening 、 hardened intestinal wall </li></ul><ul><li>6 、 CT can demonstrate mural abscess 、 sinus tract </li></ul>
  53. 53. Colorectal cancer <ul><li>adenocarcinoma is the most common malignancy of the GI tract and the second most common malignant tumor </li></ul><ul><li>Approximately 50% arise in the rectum and rectosigmoid area. Another 25% occur in the sigmoid colon, and the remaining 25% are evenly distributed throughout the remainder of the colon </li></ul><ul><li>1. annular constricting lesions most common type, 2 to 6 cm in diameter, with raised everted edges and ulcerated mucosa 2. Polypoid tumors are less common,3. Infiltrating scirrhous tumors </li></ul>
  54. 54. <ul><li>Imaging manifestations </li></ul><ul><li>irregular filling defect </li></ul><ul><li>destroyed mucosa </li></ul><ul><li>annular stricture of lumens </li></ul><ul><li>rigidity of the bowel wall, aperistalsis </li></ul><ul><li>large niche </li></ul>
  55. 55. N aso p haryngeal c arcinoma <ul><li>Squamous cell carcinoma (SCC) accounts for about 70% of the malignancies arising in the nasopharynx in adults. </li></ul><ul><li>Type l, keratinized squamous cell carcinoma (25%) </li></ul><ul><li>Type 2, nonkeratinized carcinoma (12%) (sometimes called transitional cell carcinoma) Type 3, undifferentiated carcinomas (63%) </li></ul><ul><li>Most tumors arise in the fossa of Rosenmuller and tend toward submucosal spread to infiltrate the palatal muscles and eustachian tube orifice. </li></ul>
  56. 56. NPC <ul><li>Etiology: </li></ul><ul><li>Genetic susceptibility . </li></ul><ul><li>Environmental factors (including chemical carcinogens) </li></ul><ul><li>Exposure to Epstejn-Barn virus </li></ul><ul><li>(with types 2 and 3 of nasopharyngeal SCC) </li></ul><ul><li>Highest incidence found in southern china (Guangdong) </li></ul><ul><li>Risk factors include chronic sinonasal infection, nitrosamines ( in dry-salted fish), polycyclic hydrocarbons, and poor living conditions. </li></ul>
  57. 57. <ul><li>NPC </li></ul><ul><li>C/F : more common in men. </li></ul><ul><li>Early stage is asymptomatic and usually overlooked for simple postnasal drip and nasopharyngeal irritation. </li></ul><ul><li>Middle ear effusion </li></ul><ul><li>Cervical lymphadenopathy </li></ul><ul><li>Advance disease present with nasal obstruction, epistaxis, trismus, proptosis, various cranial nerve palsies (mostly trigeminal) </li></ul><ul><li>Imaging features: </li></ul><ul><li>MRI is a choice to see the soft tissue and neuro vascular extension where as CT is valuable to visualise bone invasion. </li></ul><ul><li>MRI: in early stage obliteration of fat strip between the tensor and levator veli palatini muscles, on T1W obliteration of bright signal on this area. </li></ul><ul><li>Middle ear and mastoid air cell signal changes. </li></ul>
  58. 58. <ul><li>1997 AMERICAN JOINT COMMITTEE ON CANCER STAGING FOR EPITHELIAL TUMORS OF THE NASOPHARYNX: </li></ul><ul><li>T1 Tumor confined to the nasopharynx </li></ul><ul><li>T2 Tumor extends to soft tissues of oropharynx and/or nasal fossa. </li></ul><ul><li>T2a Without parapharyngeal extension </li></ul><ul><li>T2b With parapharyngeal extension </li></ul><ul><li>T3 Tumor invades bony structures and/or paranasal sinuses </li></ul><ul><li>T4 Tumor with intracranial extension and/or involvement of cranial nerves, infratemporal fossa, hypopharynx, or orbit. </li></ul>
  59. 59. NPC <ul><li>Associated cervical lymphadenopathy, intermediate T1W and high T2W. </li></ul><ul><li>On CT in early stage, soft tissue isodense mass on the Fossa of Rosenmuller , doesnot show marked enhancement. </li></ul><ul><li>MRI on advance stage shows isotense to adjacent muscle on T1W. On T2W intermediate to high signal. Solid part of tumor shows significant enhancement on T1W. </li></ul><ul><li>On advance stage CT can demonstrate erosion of bones of skull base, paranasal sinus, orbits. </li></ul>
  60. 60. Bronchiectasis <ul><li>is the irreversible dilatation of one or more bronchi,and is usually the result of severe,recurrent,or chronic infection. </li></ul><ul><li>Morphologically, bronchiectasis is divided into three groups: cylindric, varicose, and saccular (cystic). </li></ul>
  61. 61. Bronchiectasis causes Diffuse Cystic fibrosis Dysmotile cilia syndrome Congenital immunodeficiency Postinfectious    Adenovirus (Swyer-James syndrome)    Measles    Pertussis Chronic aspiration Allergic bronchopulmonary aspergillosis Interstitial pulmonary fibrosis (traction bronchiectasis)        Localized Tuberculous scarring, upper lobes (postprimary disease) Bronchial disease    Extrinsic compression       Enlarged hilar nodes    Bronchial stenosis/occlusion       Bronchial atresia       Tuberculosis       Sarcoidosis       Prior bronchial injury    Endobronchial mass       Carcinoid tumor       Bronchogenic carcinoma Foreign body
  62. 62. Bronchiectasis <ul><li>Bronchography is gold standard but it is invasive so CT is the choice of investigation. </li></ul><ul><li>Plain x-ray is not reliable due to unclear feature unless it is prominent,eg may be incresed lung markings or atelectasis or consolidation on basal regions. </li></ul><ul><li>The CT appearance of bronchiectasis depends on the site of involvement and the type of bronchiectasis </li></ul><ul><li>Cylindric bronchiectasis in upper & lower lobe regions appears as multiple dilated thick-walled circular lucencies, with the adjoining smaller artery giving each dilated bronchus the appearance of a “signet ring.” </li></ul><ul><li>In the mid-lung, where the bronchi course horizontally, the appearance is that of parallel linear opacities (tram tracks). </li></ul><ul><li>Cystic bronchiectasis in any region is easily recognized as clusters of rounded lucencies, often containing air–fluid levels; this appearance has been likened to a “cluster of grapes ” </li></ul>
  63. 63. Pneumonia <ul><li>Classification: </li></ul><ul><li>Lobar pneumonia/segmental pneumonia </li></ul><ul><li>Bronchopneumonia/ Lobular pneumonia </li></ul><ul><li>Interstitial pneumonia </li></ul>
  64. 64. Lobar pneumonia/segmental pneumonia <ul><li>Pathology : </li></ul><ul><ul><li>Exudation & consolidation </li></ul></ul><ul><ul><li>Acute inflammation of the entire lobe/lung </li></ul></ul><ul><ul><li>Caused by Streptococcus pneumoniae </li></ul></ul><ul><li>Phase : </li></ul><ul><ul><li>Congestion 24hrs . </li></ul></ul><ul><ul><li>Red hepatisation a few days </li></ul></ul><ul><ul><li>Grey hepatisation a few days </li></ul></ul><ul><ul><li>Resolution 8~10 days later </li></ul></ul><ul><li>c/f: Fever, cough, rusty sputum, pleurisy </li></ul>
  65. 65. Lobar pneumonia <ul><ul><li>Typical X-ray : exudation & consolidation </li></ul></ul><ul><ul><li>Uniform opacity – alveolar consolidation </li></ul></ul><ul><ul><ul><li>lobar : confined within the boundaries of the lobe </li></ul></ul></ul><ul><ul><ul><li>segmental : ill-defined </li></ul></ul></ul><ul><ul><li>The lobe volume normal / slight loss </li></ul></ul><ul><ul><li>Air-bronchonogram, no lung markings can be seen </li></ul></ul><ul><ul><li>Absorption – patchy shadows with blur lung markings </li></ul></ul><ul><ul><li>complication: </li></ul></ul><ul><ul><li>Pleural reaction: pleural effusion,empyema </li></ul></ul><ul><ul><li>Incomplete resolution : fibrosis </li></ul></ul><ul><ul><li>Necrosis : lung abscess </li></ul></ul>
  66. 66. Bronchopneumonia <ul><li>Is a multifocal process which commences in the terminal and respiratory bronchioles. </li></ul><ul><li>Cause S.aureus and Gram-negative bacteria </li></ul><ul><li>clinical : elderly people, infant, Complication with other disease, Fever, cough. </li></ul><ul><li>X-ray : site : inner and middle parts of both lower lobes </li></ul><ul><ul><li>Interstitial inflammation : lung markings increased 、 fuzzy </li></ul></ul><ul><ul><li>Alveolar inflammation: small patchy (1 ~ 2 cm) opacities blur and exaggerated lung markings, lobular consolidation </li></ul></ul><ul><ul><li>d/d: </li></ul></ul><ul><ul><ul><li>Focal emphysema </li></ul></ul></ul><ul><ul><ul><li>Lobular atelectasis </li></ul></ul></ul><ul><ul><ul><li>Abscess, pleural effusion </li></ul></ul></ul>
  67. 67. Interstitial Pneumonia <ul><li>pathology : Interstitial inflammation </li></ul><ul><li>Mostly due to viral infection eg,influenza,HVC </li></ul><ul><li>Involved: Small bronchioles, Adjacent alveoli, Lymphangitis, Bronchiole obstruction. </li></ul><ul><li>X-ray: Bilateral,lower field and near the hilum </li></ul><ul><ul><li>Blur and exaggerated lung markings , form diffuse reticulation, with spot opacities </li></ul></ul><ul><ul><li>Stone-glass shadow </li></ul></ul><ul><ul><li>Hilum enlargement : </li></ul></ul><ul><ul><ul><li>Pul. artery congestion </li></ul></ul></ul><ul><ul><ul><li>Lymph nodes enlarged </li></ul></ul></ul>
  68. 68. Pulmonary tuberculosis <ul><li>Chronic infectious disease caused by mycobacterium tuberculosis </li></ul><ul><li>classification(1998 China ) </li></ul><ul><ul><li>Ⅰ : primary tuberculosis </li></ul></ul><ul><ul><li>Ⅱ : disseminated TB </li></ul></ul><ul><ul><li>Ⅲ : postprimary TB </li></ul></ul><ul><ul><li>Ⅳ : TB pleurisy </li></ul></ul><ul><ul><li>Ⅴ : extra-pulmonary TB </li></ul></ul>
  69. 69. primary tuberculosis (type I) primary syndrome Pathology X-ray Parenchyma exudation Ill-defined parenchyma opacity, Cloudy shadow lymphangitis Strip and liner shadows between the lesion and the hilar lymph-nodes lymphadenopathy Hilar & right paratracheal region lymphadenopathy
  70. 70. primary tuberculosis paratracheal region lymphadenopathy <ul><li>Lymph nodes enlargement : </li></ul><ul><ul><li>Primary foci </li></ul></ul><ul><ul><li>Lymph nodes caseous necrosis </li></ul></ul><ul><ul><li>Can cause middle lobe collapse </li></ul></ul><ul><li>healing : </li></ul><ul><ul><li>normal </li></ul></ul><ul><ul><li>Calcification </li></ul></ul><ul><ul><li>fibrosis </li></ul></ul>
  71. 71. disseminated TB ( typeⅡ ) <ul><li>Acute disseminated TB (homogenous pattern) </li></ul><ul><ul><li>large amount of mycobacterium TB spread into the blood and seed in lung in short period </li></ul></ul><ul><li>Chronic disseminated TB (heterogenous pattern) </li></ul><ul><li>minority mycobacterium TB spread into the lung in a long period recurrently </li></ul>
  72. 72. <ul><li>* Acute disseminated TB * </li></ul><ul><li>X-ray : Homogenous millet-like nodules (1.5~2mm) </li></ul><ul><ul><li>disseminated in both lung fields, with similar density and size ,can be accumulated and fused to patchy shadow </li></ul></ul><ul><ul><li>Lung markings disappear </li></ul></ul><ul><li>prognosis </li></ul><ul><ul><li>recover : disappear 、 fibrosis 、 calcification </li></ul></ul><ul><ul><li>worse : exudation 、 cavity formation </li></ul></ul><ul><ul><li>* Chronic disseminated TB * </li></ul></ul><ul><li>X-ray : heterogeneous </li></ul><ul><ul><li>distribution : upper middle lung field </li></ul></ul><ul><ul><li>Size : varies </li></ul></ul><ul><ul><li>Density : acinus nodules 、 calcification </li></ul></ul>
  73. 73. Post-primary TB <ul><li>Clinical : adult ( reactivation ) or reinfection , c/f cough and constitutional symptoms, including chills, night sweats, and weight loss </li></ul><ul><li>Common site : 2 nd ~3 rd anterior costal space 、 lung apex </li></ul><ul><ul><li>Apical & posterior segment of the upper lobe </li></ul></ul><ul><ul><li>Superior segment of the lower lobes </li></ul></ul><ul><li>X-ray: exudation 、 proliferation 、 fibrosis 、 cal. 、 cavity & mass </li></ul><ul><li>Special type : </li></ul><ul><ul><li>Tuberculoma </li></ul></ul><ul><ul><li>Caseous pneumonia </li></ul></ul><ul><ul><li>Chronic fibro- tuberculosis </li></ul></ul>
  74. 74. Postprimary TB <ul><ul><li>Pathology: Caseous material / calcified granuloma encapsuled by fibrosis to form a rounded smooth nodule </li></ul></ul><ul><ul><li>X-ray : </li></ul></ul><ul><ul><ul><li>Round nodule ; 1~3cm </li></ul></ul></ul><ul><ul><ul><li>smooth </li></ul></ul></ul><ul><ul><ul><li>density </li></ul></ul></ul><ul><ul><ul><ul><li>calcification </li></ul></ul></ul></ul><ul><ul><ul><ul><li>cavity </li></ul></ul></ul></ul><ul><ul><ul><li>Satellite lesion: small discrete nodules in the vicinity of the tuberculoma </li></ul></ul></ul>
  75. 75. <ul><ul><li>*Chronic fibrotic TB* </li></ul></ul><ul><ul><li>Late stage </li></ul></ul><ul><ul><li>Healing / recurrence </li></ul></ul><ul><ul><li>Chronic changes, multi-formities </li></ul></ul><ul><ul><ul><li>Fibrotic thick-wall cavity </li></ul></ul></ul><ul><ul><ul><li>Diffused fibrosis :hilum displacement, lung markings shrink </li></ul></ul></ul><ul><ul><ul><li>Bronchus disseminated </li></ul></ul></ul><ul><ul><li>Secondary changes : emphysema 、 bronchiectasis </li></ul></ul><ul><li>*TB pleurisy* </li></ul><ul><li>Maybe alone / coexist with intrapulmonary lesion </li></ul><ul><li>Pleural effusion </li></ul><ul><li>One side invloved </li></ul>
  76. 76. Fracture of radius <ul><li>Extension fracture(Colles fracture) </li></ul><ul><li>-most common type </li></ul><ul><li>-Fall onto dorsiflexed hand </li></ul><ul><li>-Dorsal displacement of the distal fragment. </li></ul>
  77. 77. <ul><li>Flexion fracture ( Smith fracture ) </li></ul><ul><li>-less common </li></ul><ul><li>-Fall onto palmar-flexed hand </li></ul><ul><li>-Palmar displacement of the distal fragment. </li></ul><ul><li>Fracture-dislocation ( Galeazzi ) </li></ul><ul><li>-fracture of distal radius shaft </li></ul><ul><li>-Dislocation of distal ulnar head </li></ul><ul><li>-Distal forearm completely unstable </li></ul>
  78. 78. Femoral Neck Fracture <ul><li>Usually medial fracture of the femoral neck ( in 95 % fracture is intracapsular) </li></ul><ul><li>Less often lateral fracture of the femoral neck ( 5 %) </li></ul><ul><li>Typically caused by fall onto the hip with fracture of bones weakened by osteoporosis </li></ul><ul><li>-Pain </li></ul><ul><li>-Externally rotated, shortened, and high-riding leg </li></ul><ul><li>-Hematoma </li></ul><ul><li>-Swelling </li></ul>
  79. 79. <ul><li>Monteggia’s fracture </li></ul><ul><li>hangman frac.(cervical fracture) </li></ul>
  80. 80. Bone tumors <ul><li>*OSTEOCHONDROMA* </li></ul><ul><li>- Most common benign bone tumor </li></ul><ul><li>- Benign bone and cartilage-producing tumor </li></ul><ul><li>-Bony protuberance covered by hyaline cartilage </li></ul><ul><li>Radiographic findings </li></ul><ul><li>Stalked or sessile osteochondroma </li></ul><ul><li>Lesion grows outwardly, is continuous with underlying spongy and cortical bone, and has a broad-based, conical, or cauliflower-like appearance </li></ul><ul><li>Has a trabecular matrix </li></ul><ul><li>Smooth, clearly defined borders </li></ul>
  81. 81. osteomyelitis <ul><li>* Pyogenic Osteomyelitis * </li></ul><ul><li>Definition : pyogenic infection of bone, marrow, periosteum </li></ul><ul><li>Pathogen : st soft-tissue swelling : </li></ul><ul><ul><li>blurring of fat planes </li></ul></ul><ul><li>bony destruction : </li></ul><ul><ul><li>early phase : osteoporosis in affected extremity </li></ul></ul><ul><ul><li>10~14 day : irregular bony destruction with unclear margin, with or without hyperosteogeny </li></ul></ul><ul><li>sequestrum : </li></ul><ul><ul><li>Strip-like high intensity </li></ul></ul><ul><li>periosteal reaction : </li></ul><ul><ul><li>line-like, onion-skin-like, lace-like periosteal proliferation </li></ul></ul><ul><li>pathological fracture </li></ul><ul><li>aphylococcus (95%), streptococci </li></ul>
  82. 82. <ul><li>* Chronic Pyogenic Osteomyelitis * </li></ul><ul><li>acute osteomyelitis without complete or timely treatment -> chronic osteomyelitis </li></ul><ul><li>massive sequestrum </li></ul><ul><li>sinus </li></ul><ul><li>extensive hyperostosis and osteosclerosis, with narrowed or occlusive bone marrow cavity </li></ul><ul><li>abscess in bone marrow </li></ul>
  83. 83. <ul><li>Osteosarcoma </li></ul><ul><li>-Most common primary malignant bone tumor </li></ul><ul><li>- Codman triangle </li></ul><ul><li>Ewing Sarcoma </li></ul><ul><li>- Second most common malignant bone tumor in children </li></ul><ul><li>Osteoclastoma </li></ul><ul><li>-Soap-bubble type of destruction </li></ul><ul><li>Multiple myeloma </li></ul><ul><li>- rain-drop appearance of skull </li></ul>