Age: 68
Sex: Male
Indication: Back pain
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Case #19
Findings
- Enhancing soft tissue mass centered in the right paraspinal musculature at T6-T7 with destruction of the adjacent superior articulating facet, lamina, transverse process, and posterior right T7 vertebral body. Additional erosion of the posterior right seventh rib as well as of the inferior right T6 and T7 articulating facets
- Enhancing soft tissue extends into the right epidural space at T6-T7 with severe associated mass effect on the thecal sac and cord
- Additional destructive lesion in the left eleventh rib
- No acute fracture
- Bilateral lower lobe pulmonary nodules
- Right nephrectomy and adrenalectomy changes
Diagnosis
- Spinal metastasis with epidural extension
Sample Report
Enhancing soft tissue mass centered in the right paraspinal musculature at T6-T7 with destruction of the adjacent articulating facets, lamina, transverse process, posterior right T7 vertebral body, and posterior right seventh rib. Enhancing soft tissue extends into the right epidural space at T6-T7 with severe associated mass effect on the thecal sac and cord. Findings are most compatible with a metastatic lesion with epidural extension resulting in severe central stenosis. No evidence of pathologic fracture. T spine MRI with and without contrast can further assess extent of disease.
Additional metastatic lesion in the left eleventh rib.
Bilateral lower lobe pulmonary nodules, likely metastatic.
Right nephrectomy and adrenalectomy changes.
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