Date : 00.00.0000
Name of the Patient : Abc Xyzranath Slmn / M / 37 yrs.
Referred by : Dr. Abc Xyz/ Dr. Abc Xyzi.
Examination : M.R.I. of the Left Shoulder.
CLINICAL PROFILE :
H/O recurrent dermato-fibrosarcoma of the left shoulder for which the patient was operated 4 times.
C/O pain with swelling in the left shoulder joint since 4 months.
M.R.I of the left shoulder was performed using the following parameters :
8 mm thick T1 Weighted and T2 Weighted (with fat saturation) axial images.
7 mm thick T1 Weighted and STIR coronal images.
9 mm thick T1 Weighted and T2 Weighted (with fat saturation) sagittal images.
There is a large, well-marginated, lobulated mass lesion in the region of the left shoulder girdle, which is slightly hyperintense to normal muscle on the T1 Weighted images and turns heterogenously hyperintense on the T2 Weighted and STIR images. Superiorly, there is a large, soft tissue component of the lesion in the supraclavicular region. Posteriorly, the lesion is deep to the trapezius muscle and is superficial to the supraspinatus and infraspinatus muscles. Laterally, the lesion extends along the antero-lateral margin of the proximal left humerus. The deltoid muscle is not well-identified, separately. The lesion extends into the supraspinous fossa with slight inferior and anterior displacement of the supraspinatus muscle.
The gleno-humeral joint, per se, seems unremarkable. There is no obvious bone erosion or destruction seen. ..2/.
- 2 - Scan-00005
The visualized axilla is unremarkable. The left pectoral muscles are decreased in bulk.
Incidentally noted are very small, pleural based nodules in the lung fields on either side, in the mid zones, posteriorly (scans 104.21-22)
In a known C/O dermato-fibrosarcoma of the left shoulder, the MRI features are suggestive of recurrent/residual mass lesion in the region of the left shoulder girdle with extensions as described. No previous scans were available for comparison.
Pleural based lesions in the lungs are ? metastasis. A CT Scan of the chest is indicated.