Musculoskeletal case 9. Presentation

Peter L. Munk; Mark J. Lee

A 69-year-old woman presented to her general practitioner’s office with complaints of a vague fullness in her upper back, which she had noticed over several years and which she thought was gradually becoming more prominent.

On physical examination, only vague, deep fullness was found on the right side. Radiographs were unremarkable. Magnetic resonance imaging (MRI) was done. Axial images were obtained. Fig. 1 (repetition time [TR] 500 ms, echo time [TE] 16 ms) demonstrates a well-circumscribed lesion deep to the chest-wall musculature but superficial to the ribs (arrows) of mixed signal intensity, with streaks of higher signal intensity running through it. This elliptical lesion shows very minimal brightening on T₂- weighted imaging (Fig. 2, TR 4083 ms, TE effective 96 ms). A fat-suppressed gadolinium-enhanced image, using T₁-weighted imaging (Fig. 3, TR 550 ms, TE 16, ms), demonstrates modest enhancement in a patchy fashion. Little free water is seen in the lesion on the fat-suppressed image (Fig. 4, TR 5083 ms, TE effective 30 ms, inversion time [TI] 120 ms). The lesion is virtually impossible to discern on this sequence.

FIG. 1

FIG. 2

What would be your next step? What would be your diagnosis? For the answer see page 142.

Footnotes

Section Editor: Peter L. Munk, MD
Inquiries about this section should be directed to Dr. Peter L. Munk, Professor, Department of Radiology, Vancouver General Hospital and Health Sciences Centre, 855 West 11th Ave., Vancouver BC V5Z 1M9.