Fig. 1

a Liver sagittal ultrasound shows a hypoechoic lesion in the right hepatic lobe (white arrow). b Axial T1-weighted volumetric interpolated breath-hold examination pre-contrast image shows a lesion in segment 7 (white arrow) that is hypointense to hepatic parenchyma. c After 20 cc of intravenous MultiHance® contrast agent administration heterogeneous mild enhancement was detectable in the arterial phase (white arrow). d, e The lesion washes out to isointensity in the portal venous and 5-minute delayed phases. f Axial T2*-weighted gradient echo shows decreased liver and spleen signal intensity, lower than that of the paraspinal musculature, consistent with diffuse parenchymal iron deposition, with non-visualization of the segment 7 lesion due to iron deposition similar to the rest of the hepatic parenchyma (white arrow). g Diffusion-weighted axial scan shows absence of restriction and non-visualization of the lesion (white arrow). h Hematoxylin and eosin stain demonstrates a sinusoidal-based infiltrate of bone marrow elements, including three megakaryocytes at the lower right (black arrows). i C-KIT immunostain highlights frequent myeloid blasts (black arrow), reflecting this patient’s evolving myelodysplastic syndrome. j Perls’ iron stain highlights massive iron accumulation (black arrow). k Blood smear with Wright’s stain, × 500, oil emersion demonstrates a peripheral monocytosis (the larger cells with convoluted nuclei and pale, basophilic, vacuolated cytoplasm, thick arrows) and left-shifted granulopoiesis with a few bands and a single myeloid blast (thin arrow); a nucleated red blood cell is also noted in the right half of the image (dashed arrow). l, m Computed tomography angiogram of the chest shows an enhancing mass within the right main pulmonary artery suggestive of tumor thrombus (white arrow)