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Case of the Week 240: Courtesy of Marcel Marchand, DC, Uster, Switzerland

Case of the Week 240: Courtesy of Marcel Marchand, DC, Uster, Switzerland.

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Case of the Week 240: Courtesy of Marcel Marchand, DC, Uster, Switzerland

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  1. Case of the Week 240:Courtesy of Marcel Marchand, DC, Uster, Switzerland This 45 year old male presented to Dr. Marchand in February 2012 with primarily right sided neck pain which radiates to his right shoulder, upper arm and anterior chest. The patient feels that the right side of his neck is swollen. He also has some tingling in his hands. On examination tightness in the right SCM muscle was noted and there appeared to be swelling over the region of the right scalenes. A pea sized hard nodule was noted under the skin in the paracervical region.

  2. Cervical spine radiographs were taken by Dr. Marchand. What are the most worrisome abnormal findings? What category of Diagnosis is most likely? What should be done next? R

  3. ANSWERS R Most worrisome abnormal findings: There are lytic and sclerotic densities within the body of C7. The articular pillars of C7 are partially destroyed and the right transverse process of C7 is very lytic. (Less serious are the spina bifida occulta of C1 and the degenerative changes at C5-6). Category of Diagnosis: This is in the category of malignant bone tumour. The adjacent discs and endplates are intact. What should be done next? Immediate referral for advanced imaging and biopsy.

  4. One axial and one sagittal CT bone window slices are shown below. The mixed sclerotic and lytic destruction of all parts of C7 is clearly shown.

  5. Below are relevant slices from the first MRI scan taken in March 2012. What are the abnormal findings? T1-weighted sagittal T2-weighted sagittal T1-weighted axial slice with gadolinium contrast

  6. ANSWERS Abnormal Findings: The C7 vertebral body and spinous process are riddled with low signal intensity lesions on the T1-weighted slice and both high and low signal intensity lesions on the T2-weighted slice. Large soft tissue masses are noted posterior and lateral to C7, larger on the right. They encroach into the intervertebral foramina. Additionally, soft tissue masses are noted within the spinal canal.

  7. Follow-up • The patient was referred immediately for biopsy. • The results were diffuse, large-cell non Hodgkin lymphoma of C7, the right first rib and surrounding soft tissues. • Further examination of his neck, chest, abdomen and bone marrow revealed no additional evidence of the lymphoma. • He was treated with radiation therapy and chemotherapy and is currently in remission. • Importantly, he is feeling much better as well.

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