....that isn't specified in this report other "sarcoma OR lymphosarcoma". (Pick one, doc!) Obviously there's the lung cancer, but I'm not sure how to code the mass (Dx code). Thanks is advance!
CT ABDOMEN AND PELVIS WITH AND WITHOUT INTRAVENOUS CONTRAST
HISTORY: Right sided mass on back for 6 months; marker placed for identification.
FINDINGS:
The media stinum and hilar structures demonstrate no abnormality. There are numerous varying sized masses that heterogeneously enhance that range in size from one centimeter to greater than 5cm and are pleural based in the visible portions of the imaged lung, bilaterally that is included in the field.
There is a large bulky mass that is heterogeneously enhancing involving the entire right hemi-abdomen. This invaginates into the base of the right hepatic lobe and portal region and displaces the right kidney anteriorly. The bowel loops are displaced from the right abdomen. There is no evidence of focal obstruction. This extends posteriorly, creating numerous areas of boney listhesis of the posterior right rib cage and obliterates the fat planes along the right psoas muscle and expands the right paraspinal musculature. This extends along the right margin of the lumbar spine and abuts several of the neural foramina. There is no obvious focal bone erosion at this level, although extension into the neural foramina and/or the spinal canal cannot be completely excluded but is not obvious on the current images. No significant adenopathy is identified.
This structure is heterogeneously enhancing and there is also enhancing nodules in the subdermal area of the subcutaneous tissue of the lateral margin of the right abdomen.
The left kidney is normal. The pelvic structures are free of distinct acute abnormality. At this time, there is no obvious obstruction of the
urinary system. The pelvic fat planes are unremarkable. The scan includes the upper half of the testes bilaterally which appear normal.
CONCLUSION:
1. Heterogeneously enhancing multiple varying sized masses in the lower lungs that are pleural based.
2. Large bulky heterogeneously enhancing mass involving the entire right hemi-abdomen with focal bone listhesis posteriorly involving the lower right rib cage and extending to the right paraspinal musculature which appears generally enlarged.
3. The gross appearance of the liver and bile ducts are normal as well as both kidneys, although the right kidney is displaced markedly anteriorly.
4. Extensive adenopathy is not identified, however. This tends to obliterate the fat planes and margins of the right psoas muscle and abutes the right margin of the lumbar spine.
5. No focal boney erosion identified at this level. Foraminal involvement not able to be excluded.
6. Findings suggest some form of sarcoma or lympho sarcoma or possible germ cell neoplasm with extensive metastatic disease to the lungs and subcutaneous space on the right.
CT ABDOMEN AND PELVIS WITH AND WITHOUT INTRAVENOUS CONTRAST
HISTORY: Right sided mass on back for 6 months; marker placed for identification.
FINDINGS:
The media stinum and hilar structures demonstrate no abnormality. There are numerous varying sized masses that heterogeneously enhance that range in size from one centimeter to greater than 5cm and are pleural based in the visible portions of the imaged lung, bilaterally that is included in the field.
There is a large bulky mass that is heterogeneously enhancing involving the entire right hemi-abdomen. This invaginates into the base of the right hepatic lobe and portal region and displaces the right kidney anteriorly. The bowel loops are displaced from the right abdomen. There is no evidence of focal obstruction. This extends posteriorly, creating numerous areas of boney listhesis of the posterior right rib cage and obliterates the fat planes along the right psoas muscle and expands the right paraspinal musculature. This extends along the right margin of the lumbar spine and abuts several of the neural foramina. There is no obvious focal bone erosion at this level, although extension into the neural foramina and/or the spinal canal cannot be completely excluded but is not obvious on the current images. No significant adenopathy is identified.
This structure is heterogeneously enhancing and there is also enhancing nodules in the subdermal area of the subcutaneous tissue of the lateral margin of the right abdomen.
The left kidney is normal. The pelvic structures are free of distinct acute abnormality. At this time, there is no obvious obstruction of the
urinary system. The pelvic fat planes are unremarkable. The scan includes the upper half of the testes bilaterally which appear normal.
CONCLUSION:
1. Heterogeneously enhancing multiple varying sized masses in the lower lungs that are pleural based.
2. Large bulky heterogeneously enhancing mass involving the entire right hemi-abdomen with focal bone listhesis posteriorly involving the lower right rib cage and extending to the right paraspinal musculature which appears generally enlarged.
3. The gross appearance of the liver and bile ducts are normal as well as both kidneys, although the right kidney is displaced markedly anteriorly.
4. Extensive adenopathy is not identified, however. This tends to obliterate the fat planes and margins of the right psoas muscle and abutes the right margin of the lumbar spine.
5. No focal boney erosion identified at this level. Foraminal involvement not able to be excluded.
6. Findings suggest some form of sarcoma or lympho sarcoma or possible germ cell neoplasm with extensive metastatic disease to the lungs and subcutaneous space on the right.
