Background The aim of our study was to determine the value of single-voxel proton MR spectroscopy (1HMRS) in distinguishing benign from malignant focal bone lesions in the peripheral skeleton. MRI and 1HMRS was performed in 50 focal lesions (> 1 cm size) detected on radiographs of peripheral skeleton.1HMRS was performed at 1.5 T with TE of 144 ms with automatic shimming and water suppression. Qualitative analysis for a discrete choline peak at 3.2 ppm was done. Significance of the presence of choline peak on 1HMRS in distinguishing benign from malignant lesions was calculated using histopathology as a gold standard. Chi-square test was used and p value < 0.05 was considered significant. Results Forty-one benign and 9 malignant lesions were confirmed by histopathological results. Amongst malignant lesions, choline peak was positive in all but 1 case of low-grade lymphoma. MR spectra of 11 benign lesions showed the presence of choline peak. All 7 benign giant cell tumors (GCT) were positive for choline peak. The sensitivity, specificity, PPV, NPV of proton MR spectroscopy in differentiating benign from malignant lesions were 87.5%,71%,38.8%, and 96.4% respectively. p value was significant (< 0.05). Conclusion 1HMRS in focal bone lesions can help in the differentiation of malignant from benign musculoskeletal tumors. Although some benign lesions may show false-positive result, absence of choline peak is a reliable reassurance against malignancy. GCT is an exception amongst benign bone tumors as it consistently shows the presence of choline peak on 1HMRS.

The development of venous collaterals is a sine quo non of a number of diverse clinical entities. Of them, the systemic-to-pulmonary venous collaterals are rather uncommon.These collaterals, though essentially owe their birth to a complete superior vena cava obstruction, may be of diverse kinds. Categorized traditionally into anatomical, congenital or acquired varieties, they produce a right-to-left shunt and leave the patient susceptible to embolic stroke, brain abscess and a high cardiac output state. 1 Among these uncommon shunts, the rarest is the acquired kind. We present a case of a 90-year-old female with lung malignancy, who developed such an acquired shunt. A robust knowledge of such an event is critical from the perspective of understanding potential complications and taking timely steps to mitigate them.