Gaze Tracking to Learn Mammography

"An experiment showed that a novice could be subtly guided to follow an expert’s scanpath across a mammogram and that this subtle nudging improved the novice’s accuracy. The experimental results will be presented at the Eye Tracking Research & Application Symposium this March.  Grimm and her colleagues say the technique, should it prove durable, is widely applicable to visual search tasks. Not only might it improve the reading of mammograms and other types of medical images, such as MRIs and PET scans, but it might also be used to improve the accuracy of airport screening and learning in virtual environments. According to her, expert diagnostic radiologists have a particular search pattern that is not the same as that of a novice, they tend to do a fairly broad scan and then fixate on parts of the image that have a tumor-like texture. "

Cindy M. Grimm, PhD is an associate professor of computer science and engineering in the School of Engineering & Applied Science at Washington University in St. Louis.

Further reading & Reference:

Visual nudge improves accuracy of mammogram readings

Possible Pulmonary Embolism-Plain Film

This is a plain CXR film of 73 year old referred to us with clinical suspicion of pulmonary embolism. Chest xray findings are suggestive, with elevated right hemidiaphragm, pleural effusion and rounded wedge shaped opacity showing convexity towards hilum, may indicate the classical hampton's hump. Lesser opacification and pleural effusion is noted in left side as well.  Possibility was suggested and CT angiography was recommended.

Appendicitis-Plain Film

There is evidence of mild prominence of the small bowel loops and localized dilated loop in the right iliac fossa along with air fluid level, which may be an indirect sign of appendicitis. This patient was followed up and turned out to be acute appendicitis.  Still a lot can be diagnosed on Plain films if you look for them.

Other radiological signs for acute appendicitis: 1) Fluid levels localized to the caecum and terminal ileum, indicating inflammation in the right lower quadrant, 2) Localized ileus with gas in the cecum, ascending colon and terminal ileum, 3) Increased soft tissue density of the right lower quadrant, 4) Blurring of the right flank stripe and presence of a radiolucent line between the fat of the peritoneum and tansverus abdominis, 5) Fecolith in the right iliac fossa, 6) Gas filled appendix, 7) Intraperitoneal gas, 8) Deformity of the cecal gas shadow occurring due to adjacent inflammatory mass and 9) Blurring of the psoas shadow on the right side.

Wegener's Granulomatosis-Plain Film

These are plain PNS film and CXR of a patient of known case of wegeners, with extensive soft tissue opacification of the nasal cavities and thinning of nasal septum,which is deviated as well. Chest Xray is non-contributory.

Aqueductal Stenosis MRI

This is a case of child with aqueductal stenosis and third ventriculostomy was done . MRI shows prominent flow void in relation to aqueductal stenosis and turbulent flow in relation to ventriculostomy. 

Benign Versus Atypical/Malignant Meningiomas on DWI

Benign meningiomas have a variable appearance on diffusion-weighted images, they tend to have higher Dav values compared with normal brain, with the exception of densely calcified or psammomatous meningiomas, which may have a low Dav.  Furthermore, the average Dav values of malignant and atypical meningiomas are significantly lower compared with benign meningiomas.  It seems that the quantification of the diffusion constant may reliably predict the histopathologic features of meningiomas before resection, useful because atypical and malignant meningiomas are more prone to recurrence and aggressive growth. 

Learning Point:  Malignant meningiomas will be  hyperintense (‘‘lightbulbs’’) on the diffusion- weighted images and hypointense on the corresponding ADC maps.

Reporters required for IRIA 65

Requesting volunteers to act as Reporters for my blog to cover IRIA 65. Volunteers will have the job of covering the day at IRIA with photographs , some idea about the lectures of that day and what was the experience like. Reporters' profile will also be shared on my blog. Unique opportunity to share the Top Indian Radiology congress experience globally.

Also anyone who wants to share their Arab Health Imaging experience on my blog is welcome. His profile will also be featured.

Email us at sumerdoc-AT-yahoo.com

Term of the day: "Mini Brain Sign"

Many tumors involving the axial skeleton can be expansile, have low signal intensity on T1-weighted images and high signal intensity on T2-weighted images, and involve the entire vertebral body. These imaging characteristics are nonspecific. Minibrain appearance has been found characteristic of Plasmacytoma. The characteristic appearance of thickened cortical struts is probably a result of a stress phenomenon from the lytic process of the plasmacytoma forcing the remainder of the bone to increase thickness as a compensatory response to weakening bone.

Requesting readers for any characteristic images you may have for sharing.

Further reading

AJR 2000;175:261–263

Follow up on US FDA withdrawal of CardioGen-82

FDA told physicians to stop using the CardioGen-82 some time back after identifying an increased risk of radiation exposure, Following which it was withdrawn. Now US FDA says that "improper usage" of the generator at certain sites is the likely cause of radiation exposure to patients and not faulty devices.  According to them increased radiation exposure seen at specific sites was likely was due to the administration of CardioGen-82 generator eluates that contained excessive concentrations of strontium-82 (Sr-82) and strontium-85 (Sr-85).

Physeal bar-Plain film & MRI

This is 7 yr old girl with unclear past history but had progressive genu on right side. X ray was done followed by MRI. The x ray showed linear metaphyseal and epiphyseal dense striations with a bony bridge across the right distal femoral growth plate.  This is a physeal bar and is seen to involve the lateral portion of metaphyses causing growth arrest and explaining the valgus. Similar striations were also seen in both proximal tibia.  MRI was done to evaluate the extent of the bar. It confirmed the findings and showed that <30% of the growth plate is involved. Case Submitted by Dr Prashant Gupta and Dr Himani Agarwal, Consultant Radiologists, Delhi

LEARNING POINTS:

- Physeal bars are focal bony defects in growth plate that result in continuity of meta and epiphysis.

- Physeal bars occur either post infective(meningococcemia) or post traumatic(salter harris injury)

- Features that favor infective etiology - multiple sites, lesser involvement than post traumatic, associated epiphyseal irregularity, "flame shaped" striations on MRI.

- Management- if <30 % of physis- conservative, if between 30-50 % - excision with interposition of fat, >50%- require extensive surgery.

Radiological Quiz Series- CXR- Winners to be featured here.

Here is another case, a CXR, for your opinion what are the findings and possible diagnosis? What investigations do you want to see now? We will be uploading the answer and confirmatory studies soon. Please submit your answer in the comment section with full name to be featured here.

Winners - None, no one gave this even in the differentials


Answer: Pectus excavatum:  the sternum is depressed so that the ribs on each side protrude anteriorly more than the sternum itself. Posteroanterior radiograph depicts an area of increased density in the inferomedial portion of the right hemithorax. Along with blurred right cardiac border and displacement of heart towards left. CT images confirming the diagnosis are also provided. 

Changes in ABR Pattern of Examination -Other Boards should take a cue.

In response to radiology residents sharing answers on their certification exams, the American Board of Radiology (ABR) is implementing a new testing procedure that relies less on memorization of facts and more on testing concrete skills. Previous CNN investigation revealed to the public what appears to be a well-known fact in the radiology community: Residents preparing for their board certification exams often get a leg up by studying past questions, which come from a repository contributed to by past test-takers. In the new system, tests will assess the doctors' abilities to actually interpret imaging studies and perform image-guided procedures rather than just memorize facts. In addition, the test will no longer include an oral exam, which has been criticized in the past for being too subjective. The entire test will be computerized, which seems to be a trend among a number of other boards of medicine.


I have a feeling this is something Indian examination pattern should look into this and start taking a cue. Oral examinations have always been subjective and never give an overall assessment of the candidate especially in a field like Radiology, where actual reporting and common sense should be given weight-age. What are  your thoughts? Comments are requested.

Tendoachilles Complete Tear-MRI

This is a 33year old male and had running injury 3 weeks back followed by inability to plantar flex the ankle. MRI was suggested. There is evidence of discontinuity and altered signal intensity, fluid collection in relation to the myotendinous junction of the tendoachilles with gap measuring 1.4cm with retraction of muscles. Likely consistent with complete tendoachilles tear.

To report or Not to report

Another interesting question.

What should we do if the organization that we work in has inadequate software and work-stations for angiographies or some studies and yet force the radiologist on pay-roll to make the report. Simply said, you should refuse but being within an organization like this and saying no to these suboptimal images and lack of state of the art facilities, sometimes become difficult. Balance is between relationship and ethics at times. What should you do when such a situation arise? And this gets trickier when your colleague is game for all such suboptimal cases and becomes the star in the eye of the management (read owners).  In India this is a relatively common situation. Do we have a way out? What do you say to a study which is inadequately done and payment has been made and patient is unwilling to come back or equipments are insufficient and management does not like a NO?

Comments are welcome.


Follow up comments to this post on facebook by three prominent radiologists. What is your opinion?

Ahamad Mastan Mukarrab Inadequate / suboptimal studies should never be reported in the best interest of the patient,. We are responsible for the quality of report as well as quality of the study. Reporting a suboptimal study will never help the patient. Ethically we are correct if we do not report. Reporting just to win accolades of management or satisfy the management is absolutely criminal and unwarrented. This is my honest opinion.


Mallapragada Gopala Krishna Murthy Do not forget no child's or verysick pts invs are optimal including chest xray and whole of India doesnot have optimal eqpt and denying them diagnosis ,,,,,,ethical.?


Ahamad Mastan Mukarrab I have seen a chest xray posted on teleradiology with extensive possible developer artifacts completely obscuring the lung fields In a genuine patient with lung disease , Now what should i do ? what is ethical ? Should i report it as developer artifact? should I call it as lung opacity. Even in a sick patient a suboptimal radiograph or investigation would do more harm to the patient than good. If some information is available we should definitely report it and ask for a repeat investigation.


Ahamad Mastan Mukarrab sometimes the quality of CTS is affected by extensive uncontrollable movements of the patient involuntarily in such cases best way is to stabilise the patient first , and then send for ct scan or take anaesthetists help or choose an alternative investigation which is not movement dependent . There are many instances where patient movement artifacts are wrongly reported as bleed etc etc Is it justifiable ?


Vineet Marwaha Thats very correct Dr. Ahamad Mastan Mukarrab . i think radiologist should report as nobody else could see better. Ofcourse, comment pertaining to exposure and other physical characteristics must be mentioned.


Ahamad Mastan Mukarrab I have seen a DWI artifact in medulla which was wrongly reported as lateral medullary syndrome when the patient had no relevant clinical symptom


Vineet Marwaha people who have installed such systems are not going to change them for us. If it will go unreported, they would 'try' to get information by themselves anyway, but would not change the machines.


Ahamad Mastan Mukarrab I have huge list of examples of suboptimal studies which were wrongly reported in almost every case resulting in lot of diagnostic dilemma, and almost all the times the radiologist has reported under the pressure of the mangement .


Ahamad Mastan Mukarrab That is the tragedy of Indian system where there is no standardisation of radiology equipment or quality assurance . There are no stringent laws to address these issues. If we give wrong report on a suboptimal study How does it help the patient ?In the first place such centres using third grade equipment should be banned from practise.There is no other way.



Mallapragada Gopala Krishna Murthy A s a professional , i would report anything that is exposed and give whatever suggestions / riders/ clinical relvances/followups/labdata help that is needed to confirm/ expose - that is ethical according to me my freinds .


Mallapragada Gopala Krishna Murthy do not sinlge out Pvt centers and sit on judgemnts, becoz the whole ofthe govt setups are no better .


Sumer Sethi i think Dr Mallapragada Gopala Krishna Murthy sir is not following oour argument, if the case cannot be done on a certain machine, patient should be referred to next centre where it can as he is paying for it, instead giving a report with riders and just earning a few bucks for the centre owners and getting into the good books.. we all are game for reporting infants and emergency cases,..


Ahamad Mastan Mukarrab It has nothing to do with a private or government or charitable organisation. Reasonable acceptable quality with good report and immense benefit to the patient is the key. If patients treatment is getting compromised because of our report we should definitely avoid.


Vineet Marwaha Another point i would like to notify as far as CT/MR is concerned. I always wright down in the Technique: so and so images were taken on a so and so Tesla scanner of so and so company.port we should definitely avoid.

Intradiploic Epidermoid with Intracranial Extension

Intradiploic epidermoid cyst of the skull is a rare clinical entity that can exceptionally grow to a large size with intracranial extension. This is a case of a 60-year-old man with a giant epidermoid cyst of the occipital bone with possible  intracranial extension, presenting with focal neurological symptoms. The diagnosis was suggested at CT and MRI was advised for confirmation. We will post the operative findings when we have follow up.

Winking Owl Sign-Plain Film

Spinal metastases are common in malignant tumors. On X rays one of the first signs is disappearance of the pedicle on the AP X-ray. This is known as the winking owl sign. Spotter case contributed by: Indra Neil Mekala, Consultant Radiologist, Rajahmundry.

Detached Membrane-Serpent Sign- Hydatid cyst

Multivesicular cysts manifest as well-defined fluid collections in a honeycomb pattern with multiple septa representing the walls of the daughter cysts (7). Daughter cysts appear as cysts within a cyst. When daughter cysts are separated by the hydatid matrix (a material with mixed echogenicity), they demonstrate a “wheel spoke” pattern. The matrix represents hydatid fluid containing membranes of broken daughter vesicles, scolices, and hydatid sand. Membranes may appear within the matrix as serpentine linear structures, a finding that is highly specific for hydatid disease. Spotter case contributed by: Indra Neil Mekala, Consultant Radiologist, Rajahmundry.

 

 

Osteopoikilosis- "Spotted Bone Disease"

Imaging Findings
Well-defined sclerotic lesions clustered symmetrically around joints
The long axis of the lesion is typically lined-up with the long axis of the bone
Bone islands may have a thorny appearance
Low signal intensity on T1 and T2 weighted MRI images
Bone scan is normal

Case submitted by Dr MGK Murthy & Hari Om

Differential Diagnosis
Osteoblastic metastatic disease :Osteopoikilosis is symmetrical, periarticular and the lesions are uniform in size
Tuberous sclerosis
Mastocytosis

Radiologists may not be Good Businessman-CNN

According to an article on CNN-Money,  "Another of the mistakes of Doctors is putting their money in risky investments, such as radiology centers, urgent care centers or even medical devices, "These deals are structured so that doctors are taking the financial risks and these investors reap the rewards," he said. "Not all of these deals are bad, but doctors should at least have an attorney review the terms so that they're protected. Doctors can also get burned by buying expensive equipment."

Reference and further reading :  Doctors' money mistakes

Using Recalled Question to Pass ABR Exam Amounts to Cheating-CNN Report Claims

This is in the news today:
-------------------------------

For years, doctors around the country taking an exam to become board certified in radiology have cheated by memorizing test questions, creating sophisticated banks of what are known as "recalls," a CNN investigation has found. The recall exams are meticulously compiled by radiology residents, who write down the questions after taking the test, in radiology programs around the country, including some of the most prestigious programs in the U.S. "It's been going on a long time, I know, but I can't give you a date," said Dr. Gary Becker, executive director of the American Board of Radiology (ABR), which oversees the exam that certifies radiologists.

Further reading on CNN website

_-------------

Well this news item possibly should be shown to lot of other Indian and international examination boards which often use same question year after year and students just seek mugging of those questions instead of learning the desired skill, what is the solution to this- is it banning recalls or i feel the answer is encouraging examiners to create newer exam files each year..

What are your thoughts on this, and ethical and legal implications of such behavior... Share your thoughts and comments here...

Radiology Quiz- Winners to be featured here.

Please give your comments on these MRI images. Please submit your answers in the comments section only for consideration, give the findings and possible diagnosis or D/D.  List of people who give correct answers within 3days will be featured in this blog along with the correct answer which will be posted on 17th January.

Answer: Tumefactive demyelination with open rim enhancement.

Explanation: The open-ring or white-matter-crescent sign. This sign may help distinguish ring enhancing lesions caused by demyelination from more frequent causes, like neoplasms or abscesses. Note that the ring enhancement in the demyelinating lesion is open in areas abuting the cortex or other gray matter areas, such as the amigdala. The enhancement corresponds to the areas of most active demyelinating activity, with marked breakdown of the blood brain barrier. Once demyelination is complete, in the center of the lesion, enhancement abates. The cortex does not enhance.

The open ring sign is a relatively specific sign for demyelination, helpful in distinguishing between ring enhancing lesions. The enhancing component is thought to represent advancing front of demyelination and thus favours the white matter side of the lesion. The open part of the ring will therefore usually point towards the grey matter 

Often patients with such lesions undergo biopsy, where the histology can be difficult to interpret. Abundant bizarre astrocytes with frequent mitoses can suggest the diagnosis of GBM. Toxoplasmosis may also be suggested by the presence of giant cells (Creutzfeldt cells). As such, careful assessment of imaging is essential to avoid unnecessary and misleading intervention.

Further reading: Open-ring imaging sign: highly specific for atypical brain demyelination.

Masdeu JC, Quinto C, Olivera C, Tenner M, Leslie D, Visintainer P. Source. Departments of Neurology, New York Medical College (St. Vincent's Hospital and Westchester Medical Center), Valhalla, NY , USA. masdeu@nymc.edu

Winners

On the blog:

1. Wael Nemattalla
2. SN Desai
3. shahnawaz Abshir 
4. Mitesh
5. Vikas
6. Girish
7. Karunakaran
8. Robert
9. Prashant Gupta
10. Prashant Ahire
11. Imuwithash
12. Joe Jose

On Facebook

1. Ram Mohan Vadapalli
2. Imran Jindani

Via email

1. Dr Shiva Deep
2. Elvis M'mene

Teaching Points-Differentiation between pleural and ascitic fluid

Differentiation between pleural and ascitic fluid on CT scans is sometimes a problem, and may be resolved by a number of signs, which are describe below. This portion from Suttons is very often asked to residents and is a very important exam question as well.

1. Displaced crus sign:  pleural fluid may collect posterior to the diaphragmatic crux and therefore displace the crus anteriorfy, whereas ascites collects anterior to the crus and may cause posterior

displacement.

2. Diaphragm sign:  As an extension of the displaced crus sign, any fluid that is on the exterior of the dome of the diaphragm is in the pleura. whereas any that is within the dome is aseites

3. Interface sign:  The interface between the liver or spleen and pleural fluid is said to be less sharp than that between the liver or spleen and ascites 

4. Bare area sign: The peritoneal coronary ligament prevents Such defects are the result of lung pathology, trauma or deliberate ascitic fluid from extending over the entire posterior surface of the liver, whereas in a free pleural space, pleural fluid may extend overthe entire posterior costophrenic recess behind the liver

PET-CT Teaching Case

Let's go through key learning points:

Summary of PET CT report should include these all relevant findings: Increased metabolic activity is noted in the irregular spiculated lesion in the apicoposterior segment of the left upper lobe. No evidence of active lesion in other segments of the lungs or elsewhere in the given images. No significantly enlarged or metabolically active mediastinal or axillary lymphnodes seen. No pleural lesions / effusion. Most likely cause for such lesion is malignancy such as non small cell carcinoma of the lung. An aggressive infection or lymphoma can give a similar appearance. Should biopsy show this to be due to a primary lung tumour then PET staging would be T2,N0,M0. Note: At another institute this case was reported as the left upper lobe carcinoma of the bronchus. No other D/D was considered! Biopsy showed Marginal Zone Lymphoma. This case and write up is contributed by Dr Sanjay Gandhi, MBBS, MD, DNB, FRCR, FHEA, Consultant Radiologist, Frenchay Hospital, North Bristol NHS Trust. Honorary Senior Clinical Lecturer, University of Bristol and Visiting Senior Lecturer, University of West of England

Further PET learning points: Cardiac activity is physiological on PET. Low grade gastro-intestinal activity especially in stomach and large bowel is also physiological. Kidneys and bladder show normal FDG excretion. Ovaries can show increased activity near ovulation (correlate with size). Trainees should read all information given with the images. This case was known to have an extra renal pelvis, therefore at the very start residents were told to ignore the left kidney. BROWN FAT UPTAKE: A potential source of false-positive FDG PET interpretations in oncologic imaging. commonly seen in neck, medaistinum. Sometimes, also in abdomen. No abnormal soft tissue lesion would be seen in the areas of increased activity.

Horse Shoe Kidney: Spot Diagnosis

Horse shoe kidney- described classically as : Large kidney mass consisting of two lateral lobes and an isthmus of apparently normal kidney tissue between the lower lobes. Each lateral lobe possessed a hilum on its anterior surface from which the calices emerged to form the ureter. The ureters passed downward over the anterolateral surface of the lower poles, then across the terminal parts of the common iliac vessels, to enter the bladder in the usual manner. Though Aorta and IVC appear normal with no accessory renal arteries, however thin sections required to comment on the same. Both kidneys were in symmetrical ptosis and in close proximity to the vertebral column.   Case Submitted by Dr Rishu Sangal.

Virtual Precontrast Images-Dual Energy CT

An important clinical application of dual-energy CT is to generate pre-contrast images from a post-contrast dual-energy scan so that the pre-contrast scan can be avoided, potentially reducing radiation dose. The image quality and dose saving of Virtual non contrast technique depend on three factors: dose partitioning between the low- and high-energy scans, patient size, and spectra separation.
 Case submitted by Dr Rohit Khandelwal, MD Radiology. 

Periosteal reaction for the Radiology Residents

Periosteal reaction for the residents, this is what you should keep in mind while reporting a skeletal case.

With slow-growing processes, the periosteum has time to respond to the process. Therefore,  it can produce new bone just as fast as the lesion is growing-solid, uninterrupted periosteal reaction.
 


With rapidly growing processes, the periosteum cannot produce new bone as fast as the lesion is growing. Therefore, rather than a solid pattern of new bone formation, we see an interrupted pattern. This may result in a pattern of one or more concentric shells of new bone over the lesion-lamellated or "onion-skin" periosteal reaction.




If the lesion grows rapidly but steadily, the periosteum will not have enough time to lay down even a thin shell of bone, and the pattern may appear quite different. In such cases, the tiny fibers that connect the periosteum to the bone (Sharpey's fibers) become stretched out perpendicular to the bone. When these fibers ossify-"sunburst" or "hair-on-end" periosteal reaction.

Rapidly growing processes - Codman's triangle. When a process is growing too fast for the periosteum to respond with even thin shells of new bone, sometimes only the edges of the raised periosteum will ossify.

Radiology Resident Club on Facebook

Well, to call me a child of web 2.0 will not be an understatement. I have been blogging & tweeting  for last so many years. But somehow I have been using facebook as more of a personal social media. And I have been playing with idea of a resident learning module on facebook for sometime now but was resisting it on various pretexts such as lack of time, too much social  media blah blah and blah. Then something unexpected happened, my mom, who has never touched a computer in her life, few days back asked me “what is this facebook” , and I was shell shocked. She has never asked about emails while I believed they were big as well, messengers or even orkut. Why suddenly facebook? All of sudden I realized if I have to take my elearning  initiative alive which I had build over the years , it had to take facebook along.  Facebook no longer can be ignored.

Initially I started off with a page of my  Teleradiology company on facebook, but was missing something. It had to become a dialogue from a monologue. Hence this concept of Radiology Resident Club. Where we share exam cases, MCQs, tips and tricks from the masters, and anything which would mean something for the radiology resident. It clicked, day 1 we have 100 odd residents already on it.

Radiology Resident Club

Facebook

Lets see what heights we can take it to and take our zeal of web 2.0 principle which is essentially sharing to another level. If you are radiology enthusiast or resident, feel free to join.

Hemorrhagic Secondaries in the Brain

This section is for the radiology residents. Very easy to remember it is:
“MATCH” - hemorrhagic mets

Melanoma
Anaplastic lung Ca
Thyroid Ca
Choriocarcinoma
Hypernephroma (RCCa)

Concept of Enhancement in Brain Lesions-For the Beginners

Why do some tumours enhance and some don't?

Answer to this question lies in the concept of Blood brain barrier. The brain has a unique triple layered blood-brain barrier (BBB) with tight endothelial junctions in order to maintain a consistent internal homeostatis. Contrast will not leak into the brain unless this barrier is damaged. 

Enhancement is seen when a CNS tumor destroys the BBB. 

Extra-axial tumors such as meningiomas and schwannomas are not derived from brain cells and do not have a blood-brain barrier. Therefore they will enhance.  There is also no blood-brain barrier in the pituitary, pineal and choroid plexus regions as these are normally out of BBB.

New Year Card Radiologist Style

Leiomyosarcoma with Hepatic Secondaries- CT

This is a case of 70 yr old male who came to us with abdominal distension, pain and weakness and was diagnosed as CA pancreas, elsewhere. Whole cancer work up was advised and USG abdomen was performed. There was an irregular illdefined heteroechoic conglomerate mass seen in the region of lesser sac, extending into right anterior pararenal space and infrahepatic space. Multiple large nodular peritoneal and retroperitoneal deposits were also present along with complex ascites and multiple necrotic liver secondaries. Case contributed by Dr Rishu Sangal, MD Radiology.

Pancreatic tail region appear clear of the mass. CECT upper abdomen was advised again to r/o pancreas as the primary site and thin section were taken in the region of pancreas. Again a conglomerate, heterogeneous necrotic mass diffusely infiltrating the peritoneal and retroperitoneal spaces was noted.  Though aorta and IVC appear uninvolved, however branches from upper abdominal aorta were encased within the mass lesion. Pancreas had intact fat planes with the mass lesion. Our differentials were retroperitoneal sarcoma with peritoneal and omental involvement, lymphoma, peritoneal disseminated, metastases from unknown primary

USG guided FNAC was advised from the epigastric mass, but a significant volume of foul smelling aspirate was obtained which showed nothing else than inflammatory cells. Repeat USG guided FNAC was advised, but due to necrotic nature of liver secondaries, sample was taken from the solid surface deposit from the liver. This time FNAC was positive, and it came out to be mesenchymal tumour more related to leiomyosarcoma.