Workup Of Progressive Shoulder Pain Leading To The Diagnosis Of A Lytic Bone Lesion - Page #4

Working Diagnosis:
Left lung mass with mediastinal lymphadenopathy and left supraclavicular soft tissue mass and adjacent adenopathy. CT guided needle biopsy revealed Grade III Neuroendocrine Carcinoma. Question still remained if the initial abnormal marrow signal seen on MRI o left shoulder was secondary to a lytic process from metastatic disease or a separate process included in our initial differential diagnosis.

Outpatient chemotherapy, radiation therapy to chest, and prophylactic brain irradiation.

After treatment, re-staging CT scan had shown excellent response. The only focus of disease was a small residual lesion in the left upper lobe consistent with the near complete resolution of his disease. Patient recently required readmission to hospital for worsening shortness of breath. CT scan of chest revealed large left-sided pleural effusion and a new left upper lobe mass, which appeared to be in the same place as previous small cell lung cancer, with new metastatic liver lesions. Patient was ultimately restarted on chemotherapy.

Editor's Comments:
This case exemplifies the need to have a broad differential diagnosis and consider obtaining other imaging when things don't add up. The original shoulder radiographs were read to imply rotator cuff tear, but without MR or CT, the real diagnosis would not have been found.

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