ke/hs/nl/rg.
Date : 00.00.00

Name of the Patient : Abc Xyzlmn / M / 66 yrs.
Referred by : Dr. Abc Xyzansali.
Examination : M.R.I. of the Pelvis.

CLINICAL PROFILE :

H/O APR done on 00.00.00 for Ca rectum. Received 6 cycles of chemotherapy and radiotherapy for 5 weeks.
Histopathology s/o adenocarcinoma (Dukes Class C1)
At present mild pain in the abdomen.
For follow-up.

EXAMINATION :

M.R.I of the pelvis was performed using the following parameters:

7 mm thick T1 Weighted and T2 Weighted (with fat saturation) axial images.

6 mm thick T1 Weighted and STIR coronal images.

6 mm thick T2 Weighted (with fat saturation) sagittal images.

FEW IMAGES SHOW PATIENT MOTION.

OBSERVATION :

An intermediate signal intensity lesion is seen in the region of the rectum and anal canal on the T1 Weighted images. This lesion is also noted in the presacral region with anterior extension in the region of seminal vesicles. There is slight indentation on the posterior aspect of the bladder and the posterior aspect of the prostate. The fat planes in the region of the prostate/urinary bladder are ill-defined. Slight streaking is noted in the ischio-rectal fossa bilaterally.

There is slight dilatation of the visualized left ureter.



The sacral vertebrae show fatty changes the result of previous radiotherapy.

A colostomy is noted in the lower abdomen on the left side and a right paramedia scar with post-operative changes.

A small posterior disc herniation is seen at the L5-S1 level.

Note is made of bilateral hydrocele.

There are no abnormally enlarged pelvic lymph nodes identified. No obvious vascular anomaly is noted. There is no free fluid in the pelvis.

IMPRESSION :

1. Post-operative status.

2. A lesion in the region of the rectum, anal canal and presacral region with extensions as described most probably represents residual/recurrent lesion.

3. Marrow changes in the sacrum is most likely the result of previous radiotherapy.