Male, 47 years old, with multiple myeloma, pre-proton therapy evaluation. Brain:Findings are seen compatible with right frontal approach endoscopic third ventriculocisternostomy. A small defect is evident in the corpus callosum at the point where the endoscope penetrated the ventricular system. There is susceptibility artifact and diffusion restriction at this site which may represent a combination of blood product and cytotoxic edema. The ventricular caliber has returned to normal when compared to the planning MRI dated 4/26/2016.The solid enhancing left posterior frontal tumor has clearly increased in size compared to the examination of 3/29/2016, but is stable to only minimally increased in size when compared to the most recent planning MRI. As before, enhancement extends from this lesion into the adjacent precentral sulcus. Surrounding parenchymal edema is similar in geographic extent. Patchy leptomeningeal enhancement more anteriorly in the left frontal lobe and minimally along the right frontal lobe appears to have slightly increased as well. The solidly enhancing pineal mass shows no convincing interval change in size. A 4 mm enhancing nodule along the undersurface of the vermis at the level of the foramen of Magendie is stable when compared to the immediate prior examination, but increased when compared to the older exam. No entirely new intracranial lesions are seen.Cervical spine:A subcentimeter focus of nonenhancing T2 hyperintensity is seen within the C4 vertebral body which is nonspecific. No definite myelomatous lesions are seen in the marrow space. Vertebral body height and morphology are within normal limits. Alignment is anatomic.The spinal cord demonstrates normal signal intensity and morphology. No focal cord lesions are seen. No pathologic intramedullary or leptomeningeal enhancement is detected.The intervertebral discs are preserved. No significant spinal canal or foraminal stenosis is seen.Thoracic spine:A subcentimeter T2 hyperintense and mildly enhancing lesion is evident within the T9 vertebral body, nonspecific. No additional marrow space lesions are seen. Mild anterior wedging of the T11 and T12 vertebral bodies is seen without evidence of marrow edema. Vertebral body heights are otherwise preserved. Spinal alignment is anatomic.The visualized spinal cord demonstrates normal signal intensity and morphology throughout. No focal lesions are seen. No pathologic intramedullary enhancement is seen. There may be minimal dorsal leptomeningeal enhancement at the T9-10 level versus vascular structures.Scattered small disc protrusions are seen but there are no areas of significant spinal canal or foraminal stenosis.Incidental findings include basilar atelectasis and multiple renal cysts.Lumbar spine:Alignment is anatomic. Vertebral body heights are preserved. A small hypointense focus is seen along the inferior T12 endplate which may represent a Schmorl's node. No concerning marrow replacement, edema or pathologic marrow enhancement is observed.Somewhat diffuse enhancement of the nerve roots of the cauda equina is seen. In addition, there are five or six frank enhancing nodules within the thecal sac and extending into several neural foramina.L1-2: Mild disc bulge. No significant spinal canal stenosis. Mild left foraminal narrowing. L2-3: Small left foraminal disc protrusion. No significant spinal canal stenosis. No significant foraminal narrowing. L3-4: Mild facet arthropathy. No significant spinal canal stenosis. Mild foraminal narrowing. L4-5: Facet arthropathy. Loss of disc height and disc bulging with a right paracentral annular fissure. No significant spinal canal stenosis. Moderate bilateral foraminal narrowing. L5-S1: Facet arthropathy. Loss of disc height and disc bulging asymmetric to the left. No significant spinal canal stenosis. Severe bilateral foraminal narrowing.
1.The left frontal lobe enhancing parenchymal lesion is stable to slightly increased in size.2.Scattered leptomeningeal enhancement in the left frontal lobe, and to a much lesser degree in the right frontal lobe, also appears more prominent.3.No significant change in the size of a pineal region enhancing lesion.4.A small enhancing nodule along the undersurface of the cerebellar vermis has increased in size also likely representing tumor.5.Sequelae of endoscopic third ventriculocisternostomy are seen with return of ventricular caliber to normal size.6.No definite myelomatous disease is seen in the marrow space of the spine.7.However, diffuse leptomeningeal disease is seen along the nerve roots of the cauda equina with numerous superimposed intradural and foraminal nodules.