Question:

Which of the following findings may be a clue for malignant thrombus?
1. Similar HU densities of primary tumor and thrombus on contrast enhanced CT.
2. Non enhancement of the thrombus on contrast enhanced CT.
3. Lower signal intensities of thrombi compared to primary tumor on MRI.
4. Lower ADC values of thrombi compared to primary tumor on MRI.
5. High signal intensity of the thrombus and the thymoma compared with the spinal cord.





Answer:

The correct answers for the question "Which of the following findings may be a clue for malignant thrombus?" are:

1. Similar HU densities of primary tumor and thrombus on contrast enhanced CT.

4. Lower ADC values of thrombi compared to primary tumor on MRI.

5. High signal intensity of the thrombus and the thymoma compared with the spinal cord.



Explanation
1. On contrast enhanced CT primary tumor and thrombus shows similar HU densities. [ In our case, quantitative enhancement of the thrombus was found significantly high (>15 HU). The thrombus had almost the same HU density with the primary tumor on CCT images and this clue is also valuable for diagnosing malignant thrombus. The amount of change in HU values from early to late phases (<15 HU) were also similar.]

2. Enhancement of thrombus is an important finding of malignant thrombus.[The presence of enhancement on CT was found to be a strong proof of malignant portal thrombus by Tublin et al. and Shah et al. They stated that the intensity ratio of enhanced to non-enhanced CT images is valuable and an enhancing portal vein thrombus is suggestive of hepatocellular cell carcinoma. In our case, quantitative enhancement of the thrombus was found significantly high (>15 HU).]]

3. On MRI thrombi and primary tumor shows similar signal intensities. [Catalano et al.  stated that signal intensities of portal vein tumoral thrombi are similar to those of the primary masses in cases of hepatocellular carcinoma. In our case, we demonstrated that the thrombus and the coexisting thymoma had the same high SI compared with the spinal cord on the same image, suggesting that the thrombus was malignant.]

4. [Catalano et al.  stated that signal intensities and ADC values of portal vein tumoral thrombi are similar to those of the primary masses in cases of hepatocellular carcinoma. In our case the ADC of the atrial thrombus (0.98 x10-3 mm²/s) was similar to the ADC value of the coexisting thymoma (1.15 x10-3 mm²/s) and both measurements were quite low, highly suggestive of a  malignancy according to previously reported threshold ADC values.]

5. [As we stated the thrombus and the coexisting thymoma had the same high SI compared with the spinal cord on the same image, suggesting that the thrombus was malignant.]



From the manuscript:
Characterization of Malignant Thrombus in an Invasive Thymoma with Intravascular Growth
Radiology Case. 2013 Feb; 7(2):17-23


This article belongs to the Chest section.




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From the manuscript

Characterization of Malignant Thrombus in an Invasive Thymoma with Intravascular Growth

Free full text article: Characterization of Malignant Thrombus in an Invasive Thymoma with Intravascular Growth

Abstract
We report an unusual case of an invasive thymoma with a thrombus in the right atrium and describe the radiological findings consistent with the malignant nature of the thrombus. The thrombus showed significant enhancement on computerized tomography images similar to the tumoral mass. On magnetic resonance imaging, both the tumor and the thrombus have heterogeneously high signal intensities on T2-weighted images. On diffusion-weighted images they both exhibit high signal intensity and low apparent diffusion coefficient (ADC) values which support the malignant nature of the thrombus and the mass.






References



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