Taeniidae family, predominantly occurring in the liver and lungs. Muscular involvement, however, remains a rarity. This report delineates the case of a 32-year-old female from Saudi Arabia presenting with a six-month history of an enlarging mass in her left thigh accompanied by significant localized pain. The clinical features were suggestive of an abscess, yet diagnostic imaging, specifically ultrasound, uncovered the presence of multiple daughter cysts within a primary lesion. MRI confirmed a well-defined encapsulated cystic mass. With an additional backdrop of a previously treated hepatic HC and living in proximity to a domestic cat, the clinical suspicion gravitated toward echinococcosis. Following surgical excision of the cystic lesion, histopathological examination confirmed the diagnosis of an infected HC. Postoperatively, the patient displayed an uneventful recovery with no recurrence or complications. This case underscores the diagnostic challenge posed by HC, especially in non-typical locations, and the pivotal role of imaging modalities in facilitating accurate diagnosis and subsequent management.Hydatid cyst (HC) is a parasitic infection originating from the cestode of the  Taeniidae family [Hydatid cyst (HC), scientifically referred to as echinococcosis cyst, is considered to be one of the important zoonotic diseases and has significant public health importance due to the difficulties of the diagnosis . It is ae family ,3. Thesee family ,5.In general, Mediterranean countries, the Middle East, India, and Australia are the endemic areas of hydatid disease due to the prominence of animal husbandry in these regions .The location of the cyst affects the clinical presentation, which differs from case to case. Years may pass without any symptoms for the patient. However, patients whose cyst mass continues to increase in size will be more likely to experience symptoms. Furthermore, cyst rupture is more susceptible to causing unexpected symptoms and signs .The manifestation of HCs within the muscular tissue is an infrequent phenomenon, exhibiting an incidence ranging from 1% to 5.4% within the comprehensive spectrum of hydatid locations . RemarkaThe clinical suspicion of echinococcosis is warranted when encountering patients originating from rural areas who exhibit progressive soft tissue mass development. Additionally, the differential diagnosis of limb masses, encompassing entities such as abscesses, both benign and malignant neoplasms, calcified hematomas, and lipomas, underscores the significance of considering echinococcosis as a prominent diagnostic contender . As a prHere, we report a case of thigh HC with a comprehensive discussion of its clinical presentation, diagnosis, management, and a review of relevant literature.A 32-year-old female who is residing in Saudi Arabia, specifically Al Ahsa city, presented at a general surgery clinic with a six-month history of progressively enlarging left thigh swelling. The condition recently evolved into intense localized pain, particularly exacerbated during physical activity. Remarkably absent are chronic diseases or comorbidities, with her medical history notable for a previous hepatic HC surgically managed a year prior. It is worth noting that according to the patient, she experienced swelling even before her liver HC diagnosis, suggesting a possible missed diagnosis in the past.On examination, the patient displayed an otherwise well state with normal vital signs. A localized assessment revealed a palpable mass measuring about 6 x 7 cm on the posterior aspect of her left lower thigh, accompanied by erythema. Palpation of the mass revealed heightened temperature, tenderness, a non-fluctuant, and firm consistency, consistent with localized inflammation. Interestingly, she shared her living space with a domestic cat. This comprehensive clinical portrait aligns with characteristics suggestive of an abscess formation, warranting further diagnostic evaluation and intervention. The results of the patient’s laboratory tests were all within normal ranges.MRI revealed a well-defined encapsulated cystic lesion in the intramuscular region of the back of the thigh, which is considered an unusual place of spread Figures , 2, whilIntraoperatively, using spinal anesthesia, a longitudinal cut was made over the skin covering the mass on the left lower thigh. While dissecting through the muscle layers, a cystic structure, resembling an HC, was identified. Pads soaked in hypertonic saline were placed around the cyst to mitigate the risks associated with potential spillage. With utmost precision, the cyst was aspirated and then excised without causing a rupture.An excision biopsy from the left thigh revealed multiple pieces of light brown fatty tissue Figures , 4, inclPostoperatively, the patient was commenced on albendazole therapy for three months. After a stable recovery, she was discharged on the fourth postoperative day and was scheduled for a follow-up consultation after 10 days. Fortunately, she did not exhibit any local or systemic complications post surgery.Hydatid disease (HD) of the musculoskeletal system represents an infrequent yet severe manifestation, predominantly secondary to the hematogenous dissemination of Echinococcus cysts from primary sites, most commonly the hepatic and pulmonary regions . It is eHumans serve as incidental hosts, whereas animals such as dogs, wolves, and foxes act as the primary hosts. Infection in humans can occur through ingestion of tainted food or water or by direct interaction with these animals, as evidenced by our patient who encountered a domestic cat .Predominantly, the lungs and liver are the primary organs impacted by the disease. However, there have been sporadic reports highlighting the disease's manifestation in diverse anatomical structures such as the heart, bones, spleen, kidneys, brain, and eyes. Remarkably, the musculoskeletal system's involvement is an uncommon phenomenon, constituting less than 1% of all diagnosed HC cases ,13.It is essential to diagnose an HC preoperatively. The sensitivity of serological tests varies by type of HD; it is more sensitive to hepatic hydatidosis. Of the patients, 90% show a positive result, whereas the result may differ if the HD is in other organs. Imaging modalities can be more beneficial in diagnosing HD. Ultrasound plays a role in detecting atypical cases of HD, and sensitivity and specificity reach 100%. The location, number, and size of the cyst, as well as its relationship to surrounding structures, can all be more obvious and clearly seen on a CT scan. Though MRI is considered a diagnostic tool for identifying muscular HD, it provides extensive information about the cyst . In the There are many factors involved in determining the treatment of HD, including the severity of the symptoms, the location of the cyst, and the presence of the complication . CompletHC is an infrequent zoonotic disease often mimicking other clinical conditions, making its diagnosis intricate and multidimensional. The presentation of an HC in the thigh is a noteworthy contribution to medical studies because of its unusual manifestation in muscle tissue, a site not frequently linked with echinococcosis. The previous oversight in diagnosis highlights the intricacies in detecting the disease, particularly in non-standard locations, advocating for increased clinical awareness. Additionally, the patient's interaction with a domestic cat, combined with the effective surgical and medicinal treatment, provides a vital understanding of the potential transmission methods, associated risks, and therapeutic approaches for muscular hydatidosis, especially in areas where the disease is prevalent.


The authors present the case of a middle-aged lady with two weeks of abdominal pain. Computed tomography imaging revealed sclerosing mesenteritis. Sclerosing mesenteritis is also known as mesenteric panniculitis and is a chronic fibrosing inflammatory disease that primarily affects the adipose tissue of the mesentery in the small intestine and colon. The clinical presentation, imaging findings, differential diagnosis, and therapeutic management are presented in this report. In our patient’s case, she was able to be managed conservatively, without the need for surgery. This reflects the most benign and self-limiting natural history of the disease. Sclerosing mesenteritis (SM), also known as retractile mesenteritis, mesenteric lipodystrophy, or mesenteric panniculitis,  is a rarA 57-year-old female presented to the ED with two weeks of left-sided flank pain. She described the pain as sharp and radiating to her left groin. She stated the pain was constant with no modifying factors. The patient denied any nausea, vomiting, dysuria, frequency, hematuria, diarrhea, fever, chest pain, difficulty breathing, or bloody stools. Her past medical history was significant for asthma for which she used an albuterol inhaler, hypertension for which she took lisinopril, and diabetes for which she took insulin. Her past surgical history was significant for cholecystectomy. She is a nonsmoker. She had no known drug allergies. Her vital signs revealed a temperature of 97.4° F, blood pressure 178/92 mmHg, pulse of 95 beats per minute, respiratory rate of 18 breaths per minute, and saturating at 99% on room air. On physical examination, the patient was a middle-aged female with mild to moderate discomfort secondary to abdominal pain. Examination of the abdomen itself was soft, and mildly tender in the left lower quadrant, without rebound or guarding. Laboratory analysis was notable for mild leukocytosis (Table 1). Computed tomography (CT) scans demonstrated a mesenteric root panniculitis (sclerosing mesenteritis) of approximately 10 x 7 x 6 cm. Also noted is diverticulosis  scans are considered the most sensitive and specific imaging modality for the diagnosis of sclerosing mesenteritis. On CT, sclerosing mesenteritis typically appears as thickening and enhancement of the mesentery, with a characteristic “coffee bean” or “target” sign, which is a combination of a central area of low attenuation and a peripheral ring of enhancement. The mesenteric fat may appear hyperdense. There is also often a well-defined mass in the mesentery that typically does not produce a mass effect. The mass is also usually delineated by what is termed a pseudocapsule. Also, the characteristic is small, scattered lymph nodes. Similar CT features are seen in other diseases such as carcinomatosis, carcinoid tumor, lymphoma, desmoid tumor, and mesenteric edema .Magnetic resonance imaging (MRI) can also be used to visualize the thickening of the mesentery, with high-signal intensity on T2-weighted images and enhancement with contrast when the disease is in the inflammatory stage. When fibrosis is predominant, the disease appears as a localized mass of fibrous tissue, hypointense in both T1 and T2 sequences . UltrasoIt is important to note that sclerosing mesenteritis can be asymptomatic, and the imaging findings may be subtle, thus the diagnosis may be missed or delayed in some cases. Additionally, the imaging findings can be similar to other abdominal conditions, such as inflammatory bowel disease or lymphoma. A biopsy is considered the gold standard for confirming a diagnosis of sclerosing mesenteritis. The biopsy typically shows fibrosis, lymphocytic infiltration, and/or granuloma formation . HoweverTreatment for sclerosing mesenteritis typically involves medications to manage symptoms and reduce inflammation. These can include non-steroidal anti-inflammatory drugs (NSAIDs) and immunosuppressive agents. Surgery is reserved for bowel obstruction or perforation or complicated panniculitis refractory to medical treatment . In manySclerosing mesenteritis is a relatively rare condition that can be seen in association with neoplasms, postoperatively, and de novo. It occurs on a spectrum, from an acute inflammatory process to a more chronic fibrosis-related presentation. Diagnosis is usually suspected on the exam and confirmed with CT or MRI imaging followed by a biopsy. Our patient had a relatively benign course which did not require surgical intervention but rather was able to be managed with only steroid therapy.


Congenital diaphragmatic hernia (CDH) is a known cause of secondary gastric volvulus (GV). Both entities are life-threatening, either alone or in exceedingly rare instances when they occur in combination. Here, we describe one such rare combination of CDH and secondary GV in a nine-year-old boy, who presented to us with recurrent episodes of abdominal pain. Urgent laparotomy was done after radiological evaluation (X-ray of chest and abdomen and contrast-enhanced CT chest and abdomen), which revealed mesenterico-axial volvulus of the stomach, secondary to an underlying diaphragmatic defect in the left hemidiaphragm, thus establishing the cause (diaphragmatic defect) and effect (GV), and resulting in a favourable outcome. Gastric volvulus (GV) is a rare clinical event that can occur in both adult and pediatric patients . It occuA nine-year-old boy was admitted with acute onset abdominal pain of three hours duration, without any complaints of vomiting. He had a history of several episodes of similar pain in the preceding three months, with resolution on conservative management. There was no history of trauma, tuberculosis, gallstones, vomiting, fever, or weight loss. Weight and height were appropriate for age. The abdomen was soft on palpation, without any point tenderness, guarding or rigidity. Air entry on left lung field was restricted with hyper resonance on percussion. The boy had tachycardia (heart rate 124/minute), and tachypnea (Respiratory rate 30/minute). Blood examination showed haemoglobin (Hb) 10 g/dl with neutrophilic leukocytosis . Blood gas analysis showed normal lactate levels and no base deficits. X-ray of the chest and abdomen was suggestive of an air pocket in the left hemithorax with a thin rim separating it from lung parenchyma. Repeat X-ray after inserting a nasogastric tube did not show any significant change  of the chest and abdomen was done, which was suggestive of secondary GV with an underlying defect in the left hemidiaphragm Figures , 3.Urgent abdominal exploration was planned after taking informed written consent from the parents. The abdominal cavity was explored through a supraumbilical midline incision. The whole of the stomach, the left half of transverse colon, and the spleen were reduced from the left thoracic cavity into the abdomen. Volvulus was reduced, and gastrostomy with anterior abdominal wall over an 8 Fr Foley catheter was performed as gastropexy. No gangrene/perforation was seen in the reduced stomach. The defect in the left hemidiaphragm was repaired with interrupted prolene sutures Figures , 5. An intercostal tube was placed in the left hemithorax. The postoperative period was uneventful, with a resumption of bowel activity on postoperative day 2. Full expansion of the left lung was seen in postoperative chest X-ray Figure .The intercostal tube was removed on the fifth postoperative day. The boy was discharged on the seventh postoperative day, and gastrostomy was removed after two weeks, on follow-up. At the time of writing this report, there have been two follow-up visits, one month apart, and the boy has been doing well.GV is a surgical emergency, with a potential threat to life if not detected early enough and intervened. Diagnosis demands awareness of the entity on the part of the attending surgeon, meticulous clinical examination, and radiological assessment. In this case, the chest X-ray was initially interpreted as pneumothorax. But the history of multiple episodes of pain abdomen in the prior three months, along with normal oxygen saturation at room air ruled out pneumothorax as the final diagnosis. A provisional diagnosis of GV with an underlying defect of diaphragm was entertained, and subsequent CT scans and surgical exploration confirmed the findings.This was a case of secondary GV due to the presence of an underlying defect in the diaphragm. The surgical principle of reduction of volvulus, decompression of stomach and fixation to the anterior parietal wall, and closure of underlying diaphragmatic defect were adhered to . InitialBarium meal or fluoroscopy have been described as investigative modalities in cases of GV, giving characteristic radiological signs . In our GV, if not detected and intervened early, carries a mortality rate approaching 80% . The maiMultiple intermittent episodes of pain in the abdomen, in this case, could be explained by incarceration of herniated stomach through the diaphragmatic defect with spontaneous episodes of reduction of the herniated stomach, leading to the resolution of symptoms.GV is a surgical emergency, and correction of underlying anatomical defect is a vital step to prevent recurrence, and persistence of symptoms. Time is gold in such cases, and delay in intervention may lead to gastric resections, and major gastrointestinal reconstructions. Astute clinical examination and disease awareness helps in early diagnosis and prompt treatment.


Gastroblastoma is an extremely rare stomach tumor with a biphasic cell morphology of epithelioid and spindle cells. Due to the low incidence rate and the lack of specific clinical characteristics, it is easy to misdiagnose. Detailed imaging analysis is also unavailable. At present, we reported a case of gastroblastoma to analyze its clinical and imaging characteristics. In addition, we reviewed the imaging findings, current diagnosis, treatment, and outcome of gastroblastoma.A 5-year-old girl was admitted to our hospital with upper abdominal pain and melena. Endoscopic examination showed a protuberant submucosal mass on the greater curvature of the gastric body. Abdominal ultrasonography and an abdominal enhanced computed tomography further confirmed the mass. The patient was pathologically diagnosed with gastroblastoma after radical surgery in February 2021.We described a rare case of gastroblastoma and may provide a new perspective on imaging diagnosis, treatment, and outcome of this tumor. Gastroblastoma tends to occur in male patients, typically affects young people, and has low malignant potential and a low rate of recurrence and metastasis. Gastroblastoma usually arises in the gastric muscularis propria with hypoecogenic and submucosal characteristics in ultrasound examination and significant enhancement in computed tomography (CT) scan. Surgical resection and regular follow-up after surgery are the main management of the disease. Clinicians should strengthen the understanding of this rare tumor for early detection and treatment. Gastroblastoma is an extremely rare biphasic gastric tumor characterized by epithelial and spindle cell components, which was first reported by Miettinen et al.  in 2009.A 5-year-old girl visited Shandong Provincial Hospital with upper abdominal pain and melena for 5 days. Two days later, she developed a fever with a maximum temperature of 38.5°C, accompanied by headache and dizziness. The patient had no surgical history, drug allergies, or family history of malignancy. Her laboratory examination showed hemoglobin of 41 g/L.An endoscopic examination was performed, and a protuberant submucosal mass measuring 3.3 cm × 3.2 cm was detected on the greater curvature of the gastric body with ulceration in the center of the mucosal surface Figure 2A laparoscopic partial gastrectomy was performed for tumor resection. The patient was placed in a supine position. After anesthesia, the urine tube and stomach tube were inserted for drainage. Approximately 10 ml of coffee-colored old bleeding was extracted from the stomach tube. Then, a laparoscope and 10-mm Trocars were inserted through small incisions in the abdominal wall under general anesthesia. Carbon dioxide pneumoperitoneum was established. Intraoperative observation demonstrated that a solid mass protruded into the stomach cavity with a rich blood supply, central surface necrosis, and bleeding. The tumor was located in the greater curvature and anterior wall of the stomach, approximately 3 cm × 3 cm × 2 cm in size. The operation duration was 2 hours 20 minutes. Intraoperative bleeding was approximately 5 ml. A rapid intraoperative pathological examination was performed, and its result suggested a small round cell tumor, possibly a neuroendocrine tumor. After the operation, the patient’s condition was stable. A total of 100 ml of dark green gastric fluid was drained by gastrointestinal decompression. There were no postoperative complications. The incision had no redness and exudation. The patient was discharged 5 days after surgery. The patient did not receive adjuvant therapy after surgery and continued to receive follow-up every 6 months; there has been no evidence of tumor recurrence 24 months after resection.Grossly, a well-demarcated tumor was located within the muscularis propria with focal protrusion into the stomach cavity. There was an ulcer on the central surface. The cut surface showed a clear boundary and yellowish-pink with pink-gray. Histologically, the tumor is located in the submucosa and muscularis propria with a well-demarcated boundary , and minor(s)’ legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article.JF is a major contributor to writing the manuscript and compiling the figures. CL and YX contributed to the design and format of figures and tables. JL confirmed the pathological findings. JF and JL designed, organized, and helped revise the manuscript. All authors contributed to the article and approved the submitted version.


Extranodal natural killer/T-cell lymphoma, nasal type (ENKL) of the small intestine, is a disease with extremely poor prognosis. We describe treatment in a case which is novel in that it demonstrated long-term survival.A 68-year-old man was admitted to the emergency department of our hospital with the complaint of severe umbilical pain with tenderness and muscular defense. An abdominal computed tomography scan revealed a thick-wall mass on the small intestine and intra-abdominal free air. He was suspected of perforation of a small intestinal tumor and underwent emergency surgery. The surgery revealed a perforated tumor ulcer, and ENKL was diagnosed from the postoperative pathological findings. The patient’s postoperative course was uneventful. He was further treated with adjuvant chemotherapy by hematologist comprising six courses of dexamethasone, etoposide, ifosfamide, and carboplatin. The patient demonstrated long-term survival and was in remission at the time of writing, four years and five months after surgery.We report a rare case of long-term survival of perforated ENKL of the small intestine achieved by surgery and adjuvant chemotherapy with dexamethasone, etoposide, ifosfamide, and carboplatin. It is essential to consult with a hematologist to determine the most appropriate chemotherapy such as DeVIC if one encounters rare postoperative pathological findings of ENKL. To elucidate the pathophysiology of this disease and to prolong survival of affected patients, accumulation of cases of long-term survival and examination of associated characteristics is necessary. Althoug2 on day 1; etoposide, 100 mg/m2 on days 1–3; ifosfamide, 1500 mg/m2 on days 1–3; and dexamethasone, 33 mg/body on days 1–3) were performed. The patient was followed-up by regular visits to the hospital and remains in remission at 4 years 5 months.A 68-year-old man was admitted to the emergency department of our hospital with the complaint of severe umbilical pain. He had noticed umbilical pain three times within a month. His blood pressure was 153/96 mmHg, heart rate elevated but regular at 101 bpm, and body temperature mildly elevated at 37.1 °C. The peripheral capillary oxygen saturation was 92% at room air. During examination, tenderness and rebound tenderness of the umbilical lesion, and muscular defense were observed. Laboratory tests showed anemia with hemoglobin level 10.9 g/dL and high inflammatory response with C-reactive protein level 6.46 mg/dL. Serum lactate hydrogenase was 162 U/L. A coagulation examination was normal. Abdominal computed tomography (CT) scan revealed an 82 × 79 mm thick-wall mass on the small intestine and intra-abdominal free air , ENKL is classified as NK-cell tumor concomitant with aggressive NK-cell leukemia and chronic lymphoproliferative disorder of NK-cells . AlthougRetrospective clinicopathological analysis of patients with ENKL involving the GI tract was reported by Asia Lymphoma study group . Of 81 pPathologically Epstein–Barr virus (EBV) infection has been suggested as a pathogenic factor  and ENKLTherapeutic strategies for malignant tumors are often decided according clinical or pathological staging. Because the main lesion of malignant lymphoma of the GI tract is extranodal, it often diverges from the progression of stage in the Ann Arbor classification . Therefol-asparaginase, etoposide), systemic chemotherapy, is recommended for first onset advanced stage and first relapse/refractory ENKL [ENKL is an aggressive lymphoma and has been traditionally treated using the same strategy as other aggressive lymphomas, mainly with anthracycline combination chemotherapy: CHOP  . Tumor cory ENKL . DeVIC aory ENKL . AlthougThe present case showed intestinal perforation on admission and underwent systemic chemotherapy after surgery. The role of surgery in GI lymphoma has been a topic of debate. For gastric lymphoma, non-surgical treatment such as chemotherapy has shown equal or better outcomes according to Ferreri et al. , based oWe report an extremely rare case of long-term survival of perforated ENKL of the small intestine, achieved by surgery and adjuvant chemotherapy with DeVIC regimen. It is essential for the surgeon to consult with a hematologist to determine the most appropriate adjuvant chemotherapy such as DeVIC if one encounters rare postoperative pathological findings of ENKL, since there are currently no guidelines or evidence of best practice for postoperative adjuvant chemotherapy for this condition.


Teaching Point: Knowledge of the accessory ossicles in the foot and the possible disorders of these ossicles are important to prevent misdiagnosis and mistreatment. A 32-year-old male presented with persistent right ankle pain four weeks after ankle distortion without clear signs of swelling. The referring clinician suspected ligament injury. To evaluate the ankle injury, a non-contrast magnetic resonance imaging (MRI) examination was performed. The MRI demonstrated a mass adjacent to the calcaneocuboid articulation and inferior to the talonavicular articulation. The mass had very high signal intensity on STIR imaging  and low To clarify the findings on MRI, an additional computed tomography (CT) examination was performed. This demonstrated a 23 × 15 × 12 mm ossific density medial to the inferior margin of the cuboid and anterior to the inferior margin of the calcaneus  consisteDespite the extensive bone marrow edema seen in the os cuboideum secundarium on MRI there was no fracture evident on CT. As there were no other abnormalities seen on MRI and CT imaging, bone marrow edema in the accessory ossicle and the plantar aspect of the talonavicular articulation are the most likely cause of the ankle pain. A stress reaction of the ossicle with the talonavicular articulation after trauma was the favored diagnosis.Accessory ossicles are normal variants in bone development which originate from unfused secondary ossification centers adjacent to the main bony mass . The foo23


Schwannoma is a type of peripheral nerve sheath tumor derived from Schwann cells. There have been only a few cases of giant lumbar schwannoma with retroperitoneal extension eroding the vertebral body documented. Thus, managing these tumors presents various challenges. This paper reports a case of a 59-year-old woman who experienced lower back radicular pain for a year. A lumbar magnetic resonance imaging revealed the presence of a giant extradural soft tissue tumor measuring 8.6x7.4x9.7 cm, compressing the right L5-S1 neural foramen and extending into the retroperitoneal space while eroding the L5 vertebral body. The patient underwent surgery via a retroperitoneal approach, and the tumor was successfully resected. Histopathological examination confirmed the diagnosis of schwannoma. In conclusion, giant retroperitoneal lumbar schwannomas with bone invasion are rare, and gross total resection is the preferred treatment option, but the size and location of the tumor can make the surgery challenging. Schwannoma is a peripheral nerve sheath tumor derived from Schwann cells. It is a slow-growing benign tumor, often well-encapsulated and seldom invasive . FurtherThe giant types with bony invasion are also rare due to their slow growth and benign nature . Only a Patient information: a 59-year-old woman presented with chronic radicular pain in her lower back that radiated to her right leg, including pain, numbness, and tingling sensations in the lateral part of her right thigh, calf, and foot. Despite treatment with nonsteroidal anti-inflammatory drugs and pregabalin, her symptoms persisted for approximately one year. The patient had no history of urinary or bowel disturbance or prior trauma, and her medical and family history were unremarkable.Clinical findings: the patient reported a pain intensity of 7 out of 10 on the Visual Analogue Scale (VAS). A physical examination revealed paraesthesia in the right L5 dermatome and positive results on the straight leg raise test at a 45-degree angle in her right foot. Furthermore, no pathological reflexes, abnormalities in muscle tone, muscle weakness, or foot drop were observed during the examination.Diagnostic assessment: a lumbar Magnetic Resonance Imaging (MRI) revealed a giant mass at the paravertebral L5-S1 vertebral bodies in a non-contrast image. The MRI with contrast showed the presence of an extradural soft tissue tumor, measuring 8.6x7.4x9.7 cm, compressing the L5-S1 intervertebral foramen and extending into the retroperitoneal space, as well as compressing the right iliac artery, as shown in Therapeutic intervention: a multidisciplinary team, comprising a neurosurgeon, general surgeon, urologist, and vascular surgeon, was assembled to plan and execute the surgical removal of the giant tumor from the patient. The vascular surgeon was stationed in the operating room to address any potential vascular complications that may arise during the procedure. Before the surgery, the ureteric stent was placed to avoid ureteral injury during resection. The retroperitoneal approach of the lumbar spine was used in the left lateral decubitus position. The L5 vertebral body and disc space were identified with C-arm fluoroscopy and then marked on the patient's skin, as shown in Furthermore, intraoperative neurophysiological monitoring using electromyography was applied to confirm neurologic changes perioperatively. A longitudinal incision was made 2 inches anterior from the L2 disc space level. This was carried down to the subcutaneous level, and muscle dissection was performed to identify the peritoneum. The external oblique, internal oblique, and transverse abdominal muscles were identified and split along the muscle lining. After identifying the peritoneum, blunt dissection was performed down to the retroperitoneal space using a sponge stick, as shown in Additionally, the tumor also infiltrated part of the L5 vertebral body, and it was excised. It was confirmed that no residual was left at the surgery site. Electrocauterization was performed to control bleeding, and suturing was performed by anatomical layer. Finally, the total blood loss during the surgery was 500 cc.Follow-up and outcomes: following the surgical procedure, the patient was admitted to the Intensive Care Unit (ICU). A blood transfusion, consisting of one bag of packed red cells, was administered due to blood loss during surgery and a hemoglobin level of 7 g/dL. The patient was monitored for 24 hours before being transferred to the surgical ward upon removal of the ureteric stent on the second postoperative day. There was no evidence of venous thrombosis, neurological deficit, or other complications.A consultation was conducted with a medical rehabilitation specialist for physiotherapy and exercise to aid in the patient's mobilization. Finally, the patient was discharged a week after the surgery.Macroscopically, the tumor appeared as a greyish-white mass with a solid-soft consistency. The microscopic examination showed rounded, oval, and spindle cells arranged in a hyperplastic and compact manner, with hypercellular (Antoni A) and hypocellular (Antoni B) areas. Antoni A area was characterized by the presence of Verocay bodies. The tumor cells exhibited eosinophilic cytoplasm, with no evidence of nuclear atypia or mitotic activity. The results followed the characteristics of a benign schwannoma tumor, as depicted in 3 in size.Based on the pathology examination, the patient was diagnosed with a giant lumbar schwannoma (WHO Grade 1). Furthermore, the Sun and Pamir Classification were utilized to stage the surgical procedure, determining that it was a Group C Type IV tumor, as it was extradural and exceeded 4 cmThe patient was monitored through outpatient visits. One-week post-surgery, the pain scale measured by the VAS was reported as 1. A Lumbar MRI was scheduled three months after the surgery, which revealed the absence of any enhancing tumor lesions. Therefore, it was suggested to conduct annual follow-up evaluations to monitor for the recurrence of the tumor.Patient perspective: the patient experienced a favorable clinical progression and reported improvement in their symptoms. No complications were reported following the surgery. Furthermore, the patient expressed a high level of satisfaction with the treatment received.Informed consent: the patient provided written informed consent to participate in the study.Schwannomas are benign tumors that develop from the nerve sheath . Due to MRI is a crucial tool in diagnosing spinal tumors, as it provides a comprehensive evaluation of the tumor's size, origin, and surrounding anatomy. In this case, it was particularly important due to the size and location of the schwannoma. Preoperative radiological evaluation is beneficial for determining the appropriate surgical approach and ensuring a successful outcome. MRI scans of schwannomas showed central and peripheral areas of high and low intensities on T1-weighted images, while T2-weighted images present the opposite pattern. Additional contributions to the investigation can be gained through MRI of the sciatic nerve and Computed Tomography (CT scans) of the spine .Consultation with other surgical departments was deemed necessary due to the location and size of the tumor. A general surgeon and a urologist were consulted, with expertise in retroperitoneal exploration and surrounding anatomical structures. Additionally, a vascular surgeon was consulted in light of the tumor's proximity to the iliac vessels to address potential vascular injuries.Schwannomas were completely removed while maintaining neurological function. They are typically not firmly attached to adjacent structures, making them relatively simple to take out. However, in this instance, the process was complicated due to the tumor's size, its extension into the retroperitoneal area, and the proximity of significant blood vessels. Obtaining an unobstructed view of the entire tumor can sometimes be difficult, leading to the possibility of residual tissue or damage to nearby structures that could result in significant blood loss .The retroperitoneal approach is utilized for tumors affecting the lower portion of the lumbar spine, down to the L4 vertebral level . The preThe resection technique used was the piecemeal method which violates the tumor capsule and resects the mass piece by piece . The en Vascular injury is an issue that could happen during the resection of retroperitoneal schwannoma . The L5 Spinal instability is an issue that can arise in schwannoma with vertebral body erosion. In other cases, it could be caused by schwannoma with massive vertebral body erosion or involvement of facet joints . In thisSchwannoma recurrence is around 4-6%, but several risk factors such as subtotal or partial removal and the tumor size could increase this chance . PatientThe retroperitoneal giant lumbar schwannoma is a unique case because of its rarity and complexity of management. The treatment goals are complete surgical resection with preserved neurological function and minimal postoperative complications, and these can be achieved through determining suitable surgical approaches and techniques. Meticulous preoperative laboratory and radiology examination should be conducted. A multidisciplinary team could be needed when the tumor extended to an unusual location. Therefore, available resources should be used to maximize the surgery outcome and minimize complications.


Subdural spinous abscess is a rare pathology that carries significant morbidity if not diagnosed and treated early; of the cases reported in the literature, very few are genuinely spontaneous in nature.Here we demonstrate the case of an otherwise entirely fit and well 56-year-old White, British female presenting with low back pain, bilateral sciatica and sensate urinary retention; lumbar subdural spinous abscess was diagnosed on urgent magnetic resonance imaging and the patient was successfully managed with surgical evacuation and prolonged antibiotic therapy. The patient made a full neurological recovery and was followed-up in the outpatient setting 12 weeks following her initial surgery; she was pain free with normal inflammatory markers and a normal neurological examination. There have been no further consultations and a telephone call at 20 weeks confirmed that she remains well.This is the second case reported in the literature of a genuinely spontaneous subdural spinous abscess, which was successfully managed with surgical evacuation following prompt diagnosis. This highlights the need to ensure infective pathologies are kept at the back of one’s mind even in the most unlikely circumstances, and that excellent outcomes can be achieved with early surgical intervention. Spinal epidural abscess (SEA) is a well-recognized clinical pathology, often associated with hematogenous spread of infection from sources outside of the spine ; howeverThere are approximately 80 reported cases of SSA in the literature –5, whichAlthough rare, the consequences associated with untreated SSAs are significant, including neurological deficit  and deatHere we present our own case of a successfully managed spontaneous SSA in an otherwise fit and well female in her sixth decade of life.A 56-year-old White, British female was referred from her local hospital to our regional neurosurgical center with a 4-week history of progressive lower back pain and sciatica, associated with (in the latter 2 weeks) lower limb weakness and sensate urinary retention and incontinence, as well as fatigue and general malaise. An unenhanced magnetic resonance imaging (MRI) of the lumbar–sacral spine was performed, demonstrating an intradural T2-hyperintense lesion displacing the cauda equina at the L4–S1 vertebral levels.9/L, with a neutrophilia of 19.66 × 109/L. MRI also demonstrated an enlarged bladder and so the patient was catheterized, draining 675 ml; she was able to feel the catheter pass. She had no medical history of note and was, until this point, very active, fit, and well.The patient was afebrile on presentation; however, blood tests revealed a white cell count (WCC) of 24.42 × 10The patient was subsequently transferred to our regional neurosurgical center for assessment and overnight contrast-enhanced imaging. On arrival she was assessed by the neurosurgical team and found to have the following:Reflexes were brisk in knee extension and ankle jerk bilaterally, plantars remained downgoing, and sensation was reduced to light touch in the L5 and S1 dermatomes bilaterally. Perianal sensation was intact to both light touch and pin prick, and anal tone was found to be normal on digital rectal examination. The remainder of the neurological examination was normal.Contrast enhanced MRI imaging of the whole spine was performed out of hours, showing that the previously demonstrated collection was peripherally enhancing Fig. , thus inGiven the patient’s good premorbid health status and evidence of neurological compromise, a decision was made to surgically evacuate the presumed subdural abscess. The patient was taken to the operating theater and right-sided hemilaminectomies of L4, L5, and the top half of S1 were performed to gain access. The underlying dura was noted to be thickened and inflamed Fig. A and, foin situ due to the risk of neural injury from too aggressive a removal. The dura was closed with 5-0 polydioxanone suture (PDS) and overlain with a hemostatic patch (Hemopatch).The subdural space was washed thoroughly with saline and a severely hyperemic nerve root was visualized Fig. C and proStreptococcus species S. pneumoniae, S. mitis, S. pseudopneumoniae, and S. oralis.The patient was continued on intravenous ceftriaxone and vancomycin and has made an excellent neurological recovery, with no pain, deficits, or postoperative complications. Initial cultures were negative for a causative organism, however 16S ribosomal DNA reverse transcriptase polymerase chain reaction (rDNA RT–PCR) revealed a 99% sequence homology to Repeat MRI imaging performed 2 weeks postoperatively demonstrated excellent evacuation of the abscess Fig.  with a vThe rarity of this case highlights a challenging diagnosis, with potentially very severe consequences, as demonstrated in the literature , 16. It This case demonstrates an excellent outcome in a patient with an extremely rare yet dangerous spontaneous lumbar spinal subdural abscess, highlighting the paramount importance of early diagnosis and prompt intervention to prevent progression, neurological deterioration, and even death. It is essential for all clinicians to keep an infective process in mind when considering the holistic clinical picture, especially when the initial spinal imaging is not clear and certainly not as expected; gadolinium contrast-enhanced MRI imaging remains the gold standard in aiding diagnosis for these cases and may not routinely be performed unless infection is specifically stated as a potential diagnosis.This case also demonstrates the clear role for surgical evacuation in patients with a good premorbid health status. In cases where the SSA is demonstrated to be secondary to another cause, which may preclude patient suitability for surgical intervention , this ca


A nodular lesion of the tongue incorporates a spectrum of entities from reactive to malignancy. A diagnostic dilemma arises when a nodular, solitary, and firm submucosal mass appears in the oral cavity of a patient. To reach a definitive diagnosis, a crucial investigation protocol needs to be followed. Leiomyomas are benign tumors that rarely occur in the oral cavity. They usually affect patients within the fourth to fifth decades of life. We report a rare case of leiomyoma of the tongue in a 12-year-old child patient. Immunohistochemical analysis revealed the positivity of tumor cells for alpha-smooth muscle actin (SMA). Surgical excision of such lesions is the treatment of choice, with a low recurrence rate. Our patient was asymptomatic and tumor-free at the follow-up visit after two years. Leiomyomas are benign, well-circumscribed, soft-tissue tumors that arise from smooth muscles. The preliminary description of leiomyoma was given by Virchow in 1884. It mainly affects the uterus 95%), gastrointestinal tract (1.5%), and skin . In the %, gastroA 12-year-old male child presented to the Department of Oral and Maxillofacial Surgery with a swelling of the tongue for one year. The patient reported no remarkable medical, dental, or habit history. No record of trauma or tongue bite was observed. Extraoral examination results were normal. Intraorally, a solitary, asymptomatic (no pain and tenderness), well-circumscribed, firm, nodular swelling of size approximately 2×1.5 cm was present on the mid-dorsal surface of the tongue on the right side Figure . It had There was no increase in the size of the nodule since it was first noticed. The ultrasonographic examination revealed the absence of any calcification or noticeable findings of hemangiomas and lipomas. Fine needle aspiration cytology (FNAC) investigation was also negative as no fluid or blood content was retrieved, which ruled out the hemorrhagic origin of the lesion. No signs of paresthesia were found. Clinical and preoperative findings clarified the benign nature of the lesion. Based on the clinical and radiographic investigations, a provisional diagnosis of solitary fibrous tumor, neurofibroma, and schwannoma was made. Taking into account the age and size of the lesion, the mass was excised under local anesthesia. Because the mass was well-circumscribed, an elliptical incision was made, and the lesion was completely enucleated with the surrounding mucosa to prevent recurrence Figure . On grosHistological examination at 10× magnification (hematoxylin and eosin stain) revealed spindle-shaped cells arranged in irregular fascicles Figure  and a whAt 40× magnification, spindle cells showed ill-defined cytoplasm and mildly pleomorphic vesicular nuclei Figure . AbnormaBased on these findings, a definitive diagnosis of oral leiomyoma was made. Due to the financial constraint of the patient, further investigations were not conducted. On follow-up visits for two years, the patient was asymptomatic and free of tumor after surgical excision of the lesion.A solitary nodule of the tongue with a smooth surface can clinically come under the differential diagnosis of fibrous hyperplasia, schwannoma, neurofibroma, lipoma, hemangioma, leiomyoma, and salivary gland tumors. . A preciA debatable pathogenesis of leiomyoma is available in the literature, although traumatic injury, venous stasis, hormonal alterations, and genetic changes can be considered. They usually occur in the fourth and fifth decades of life and on the lips, buccal mucosa, or tongue . In our Most of these lesions are asymptomatic and slow growing, as in our case, but some authors have reported symptomatic findings, such as difficulty in chewing and swallowing due to the presence of a tumor mass . Our patHistologically, it was a solid type leiomyoma that was rare in the oral cavity, comprising spindle-shaped cells interwoven in a whorled pattern with collagen strands in-between. All histological characteristic findings of solid leiomyoma were present in our case . Other sThe present case was reported to improve our understanding of leiomyoma, although it is a rare entity in the oral cavity but should not be neglected in pediatric patients. Due to its rare occurrence in the oral cavity and indistinct clinical findings, a thorough routine histological examination with immunochemical staining is demanded. The treatment selection is always considering the site and size of the lesion, although complete surgical excision is warranted.


Gallbladder agenesis is a biliary tract related congenital malformation with an incidence of 10–65 per 100,000 and associated with other congenital abnormalities. GA is usually asymptomatic, but sometimes patients become symptomatic. The most usual symptoms are jaundice, abdominal pain in the right upper quadrant, nausea and vomiting. We reported a case of GA and choledochogastric fistula in a patient with history of cholangitis. A 70-year-old man presented to Emergency Department of Modarres Hospital with jaundice, fever, right upper quadrant abdominal pain, nausea and vomiting. Clinical examination and lab test demonstrated cholangitis. He underwent ultrasonography, abdominopelvic CT scan and ERCP. ERCP revealed a CBD fistula. Due to recurrent symptoms, he underwent operation and hepaticojejunostomy was done.In our knowledge, the case of GA and choledochogastric fistula is rare. Furthermore, this type of abnormalities rarely presented with cholangitis, so probable anatomical malformation of the biliary tract should always be considered as a differential diagnosis in patients with biliary disease signs and symptoms. Gallbladder agenesis (GA) is a scarce inborn malformation of biliary tract with the incidence of 0.04–0.13% . From thA 70- year- old man presented to Emergency Department of Modarres Hospital with 2 days history of abdominal pain, nausea, and vomiting. The patient described the pain in right upper quadrant, colic in nature, dull and exacerbated with meal. He was icteric. The patient had no significant past medical history except diabetes mellitus, he had no previous operation, and had no known drug allergies. Vital sign revealed blood pressure 90/60 mmHg, body temperature 38.5 ºCelsius degree and heart rate 110/min. Physical examination demonstrated tenderness in RUQ and Murphy’s sign was positive.Vital sign revealed blood pressure 90/60 mmHg, body temperature 38.5 ºCelsius degree and heart rate 110/min. Physical examination demonstrated tenderness in RUQ and Murphy’s sign was positive. The laboratory findings have shown in According to report of ERCP and possibility of CBD to duodenum fistula, upper GI series was done and reported no evidence of fistula  After coWe reported a case with GA and CBD fistula to gastric antrum who presented to hospital with cholangitis and recurrent fever and weight loss. Finally, he underwent Roux-en-Y hepaticojejunostomy.The gallbladder is derived from the foregut at fourth weeks of gestation. During the seventh week of gestation, the gallbladder and cystic duct develop a lumen followed by vacuolation of the hyperplastic epithelium. Any abnormality in this process may lead to agenesis of the gallbladder . There iGallbladder agenesis is classified into three different groups according to the clinical manifestation; first group is that which is asymptomatic who is incidentally identified (35%), second one are symptomatic (50%), and the last one are those patients with multiple fetal anomalies who expires in the perinatal period (15–16%) . Due to


Pachydermoperiostosis is a rare genetic disease known as primary or idiopathic hypertrophic osteoarthropathy (HOA)/Touraine-Solente-Gole syndrome. It is an autosomal dominant or recessive disorder comprising digital clubbing, periostosis, hyperhidrosis, and pachydermia . Ocular manifestations are uncommon; however, blepharoptosis may occur. This case presented with severe bilateral ptosis due to the disease progression. A large 20 mm upper lid resection with levator advancement was performed to improve his ability to see. This is the first reported case of pachydermoperiostosis (PDP) in Jamaica. We present a rare case of pachydermoperiostosis with severe blepharoptosis, who attained a good result with surgical intervention. Pachydermoperiostosis is a rare disease that has not previously been described in Jamaica or the Caribbean. This patient had all of the characteristics of the disease in its complete form, also known as primary hypertrophic osteoarthropathy . The disPatient information and clinical history: a 51-year-old male was referred to the Eye Clinic of Kingston Public Hospital, Jamaica, with a 15-year history of progressive bilateral ptosis obstructing his vision. He noted physical changes of wrinkled and thickened skin of his forehead from age 16, with progressive thickening of his eyelids from 25 years of age. He complained of swollen joints and hyperhidrosis of his hands and feet. Family history revealed all eight siblings were normal; however, his two paternal uncles have deep forehead furrows.Clinical findings: the patient had deep grooves in his forehead and severe bilateral ptosis  was +1 and 0 in the right and left eye, respectively. His upper lid excursion was 7 mm bilaterally. His visual acuity was 20/25 and 20/30 in the right and left eye, respectively.Diagnostic assessment: his blood investigations, including serum calcium and phosphate, were normal. X-rays of his hands and wrist showed increased bone density at the distal ulna and radius with loss of corticomedullary differentiation, medullary bone expansion, and irregular periosteal reaction. Spiculation was noted primarily at the distal ulna and radius. Joint space narrowing was also seen at the radiocarpal and midcarpal joints  and levator muscle repair  is a rare genetic disorder with systemic findings of pachydermia (skin thickening) and periostosis  commencing from adolescence. The prevalence is 0.16%, with male to female ratio of 7: 1 . AlthougThere are limited published ocular manifestations; blepharoptosis and floppy eyelid syndrome have been described . The mecGastrointestinal features, including hypertrophic gastric folds with multiple ulcers in the gastric antrum, may be present; a gastric mucosa biopsy reveals mild and chronic inflammation and metaplasia . MyelofiThe inheritance pattern may be autosomal dominant and recessive; due to the SLCO2A1gene deficiency and 15-hydroxy-prostaglandin dehydrogenase (HPGD) gene mutations, respectively . There aMedical management includes palliative care for painful polyarthritis/osteoarthropathy with Non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, pamidronate, tamoxifen citrate, and risedronate sodium . BotulinHypertrophy of palpebral tissues causes thickening and lengthening of the upper eyelids, which override the lower eyelids . DiffusePachydermoperiostosis (PDP) is a rare genetic disorder with a wide clinical spectrum of presentation that requires a multidisciplinary approach  with a multisystem workup and pedigree evaluation.This is the first reported presentation of PDP in the Jamaican population and Caribbean region. His digital clubbing, joint deformities , pachydermia, cutis verticis gyrate, hyperhidrosis and radiological and pathological findings confirm the diagnosis. Despite the thickened tarsal plate, surgical intervention  resulted in a good functional and cosmetic result. Management of this rare condition should be multidisciplinary.


This comprehensive case report meticulously outlines the clinical manifestation, diagnostic trajectory, surgical intervention, pathology, chemotherapy, and patient follow-up in a challenging instance of a giant exophytic gastrointestinal stromal tumor (GIST) emerging from the antral part of the stomach in a 56-year-old male patient. Over the course of a year, the patient presented with symptoms including abdominal distension, a progressively enlarging lump, constipation, and abdominal fullness. Our diagnostic strategy, anchored by ultrasonography and contrast-enhanced computed tomography (CECT), yielded crucial insights into the tumor's precise dimensions and anatomical location. The subsequent surgical planning and execution were pivotal, entailing a meticulous dissection of the cystic mass from adjacent structures to ensure negative margins. Histopathological scrutiny of frozen sections from the lymph nodes and excised antral margins conclusively confirmed the absence of malignancy, facilitating primary closure. This case report underscores the decisive role of accurate diagnostic imaging in shaping surgical strategies and emphasizes the need for a multidisciplinary approach to managing GISTs. Beyond the surgical realm, the case highlights the significance of tyrosine kinase inhibitors (TKIs), particularly imatinib, in the treatment paradigm. Additionally, the report sheds light on ongoing research endeavors to refine treatment modalities in GISTs. Gastrointestinal stromal tumors (GISTs) are rare neoplasms originating from the gastrointestinal tract, with the stomach being one of the primary sites of occurrence . GastroiCharacterized by their expression of the c-kit proto-oncogene protein (CD117), GISTs represent a subset of mesenchymal tumors originating from the gastrointestinal wall, often involving the stomach and small intestine . These tThe management of GISTs has been revolutionized by the advent of tyrosine kinase inhibitors (TKIs) like imatinib mesylate (Gleevec), which target the molecular abnormalities driving GIST proliferation . AlthougThis case report focuses on a patient with a notably large and exophytic GIST originating from the antral part of the stomach, emphasizing the importance of precise diagnosis and timely surgical intervention. A multidisciplinary approach, integrating diagnostic imaging, histopathological analysis, and surgical expertise, was pivotal in successfully managing this patient. The case underscores the critical role of accurate diagnosis, individualized treatment strategies, and the evolving landscape of GIST therapy.A 56-year-old male patient, devoid of known comorbidities, presented with a one-year history of complaints regarding an abdominal lump accompanied by abdominal distension. This lump exhibited progressive growth and was associated with symptoms of constipation and abdominal fullness. The patient demonstrated good tolerance for liquid and solid diets, with no discernible history of significant appetite loss or weight reduction.The patient's abdomen was distended upon clinical examination, featuring a conspicuous protrusion in the right hypochondrium and epigastric region. The umbilicus appeared inverted, with no apparent signs of dilated veins or significant cutaneous alterations. Moreover, no inguinoscrotal swellings were detected. Upon palpation, the abdominal lump was identified as a single, sizable, non-tender mass, displaying a solid-cystic consistency and mobility synchronized with respiration.Ultrasonography (USG) of the abdomen and pelvis revealed a large, solid cystic lesion measuring approximately 30 x 15 x 14 cm, affecting all four quadrants, including the hypochondrium and left iliac fossa. Doppler imaging unveiled areas of vascularity within the lesion, which was exerting a mass effect on the liver, compressing it superiorly and posteriorly.Following the initial imaging evaluation, a comprehensive contrast-enhanced computed tomography (CECT) scan of the abdomen and pelvis was undertaken. The CECT findings revealed a noteworthy and intricate depiction of the tumor's characteristics. Notably, the mass appeared large, lobulated, and relatively well-defined, displaying heterogeneous features suggestive of both cystic alterations and internal septations Figure .This presented a unique aspect, raising questions about the coexistence of cystic components in conjunction with a neoplastic process, especially considering the tumor's origin in the gastric mucosa. Further complexity was introduced by identifying hyperdense areas within the mass, indicative of potential hemorrhages. Post-contrast imaging delineated peripheral enhancement, extending not only to the cystic elements but also to the solid internal components of the mass. Additionally, the radiological examination revealed the presence of several sub-centimetric mesenteric lymph nodes, which were cautiously interpreted as likely representing a reactive state rather than manifesting malignant involvement.Considering the diagnostic findings, the patient was scheduled for a laparotomy to excise the abdominal lump originating from the stomach. During the surgical procedure Figure , a formiThis bilobed mass was found to originate from the antral part of the stomach and was meticulously separated from the mesentery and the antral portion of the stomach. Subsequently, margins from the antral wall were excised and submitted for a frozen section for histopathological evaluation.The histopathological examination of the frozen sections, an integral part of the intraoperative interventions in this case, provided critical insights into the nature of the specimens. Evaluation of the lymph node frozen section revealed characteristics consistent with reactive lymphadenitis, reassuringly devoid of any signs indicative of malignancy. Similarly, the frozen section analysis of the excised antral margins of the stomach yielded no evidence of malignant cell infiltration. Armed with these real-time diagnostic assessments, we proceeded confidently to execute the primary closure of the antral wall.Postoperatively, the patient underwent a structured chemotherapy regimen, primarily involving the administration of TKIs, with a focus on imatinib. This therapeutic approach aligns with the evolving standards for managing GISTs and aims to optimize long-term outcomes.The patient's follow-up included regular clinical assessments, imaging studies, and laboratory evaluations to monitor treatment response and detect potential recurrence. This comprehensive follow-up strategy underscores the commitment to ensuring the patient's well-being and the importance of a vigilant and proactive approach in the postoperative phase. The amalgamation of surgical expertise, adjuvant chemotherapy, and diligent follow-up collectively contributes to the holistic care and ongoing management of the patient.Gastrointestinal stromal tumors are uncommon neoplasms characterized by their origin in the gastrointestinal tract and expression of CD117. The case presented here is emblematic of the diverse clinical and pathological characteristics that make GISTs a subject of intense study and clinical interest. Gastrointestinal stromal tumors exhibit variable clinical presentations, with some patients remaining asymptomatic. In contrast, others experience various symptoms, including abdominal pain, bleeding, obstruction, or a palpable abdominal mass ,9. The cThe diagnostic evaluation of GISTs is multifaceted and relies on a combination of clinical, radiological, and histopathological findings. In this case, the USG of the abdomen and pelvis revealed a large, solid cystic lesion, while the CECT further delineated the mass's characteristics. These diagnostic modalities are pivotal in determining the size, location, and extent of GISTs. However, it is essential to note that the final diagnosis of GISTs typically hinges on histopathological analysis and immunohistochemistry, which can confirm the presence of CD117 and CD34 markers, aiding in the differentiation from other mesenchymal neoplasms .As demonstrated in this case, surgical resection remains the primary curative modality for localized GISTs. The successful surgical management of this large exophytic GIST originating from the antral part of the stomach underscores the significance of accurate localization and complete resection. The case showcases the meticulous intraoperative approach to separating the cystic mass from the surrounding structures. Moreover, the importance of assessing the surgical margins through frozen sections cannot be overstated, as it aids in achieving negative margins, reducing the risk of recurrence .The case also highlights the pivotal role of TKIs in managing GISTs. Imatinib mesylate (Gleevec), a TKI, has revolutionized the treatment of GISTs. In cases where complete resection is not feasible, neoadjuvant or adjuvant imatinib therapy can significantly improve disease-free survival and, in some instances, render tumors amenable to surgery ,13. IncoThe case emphasizes the significance of a multidisciplinary approach in GIST management. Gastrointestinal stromal tumors are complex tumors requiring collaboration between surgeons, oncologists, pathologists, and radiologists. This approach ensures that each patient receives individualized treatment tailored to the specific characteristics of their GIST, whether through surgery, TKIs, or a combination of both .The tumor size represents a critical parameter in GIST management, influencing both diagnostic considerations and treatment strategies. In this case, the tumor's substantial dimensions, as outlined in the diagnostic imaging section, played a pivotal role in determining the surgical approach and subsequent interventions. Patient survival, a paramount aspect of GISTs, is intricately linked to various factors, including tumor size, histopathological characteristics, and the efficacy of therapeutic interventions. While the specific details of patient survival, in this case, are not explicitly discussed in the current report, it underscores the broader point that effective GIST management requires a nuanced understanding of tumor characteristics, patient-specific factors, and the dynamic landscape of treatment options. Despite the strides made in GIST management, challenges persist, particularly in cases where the unpredictable behavior of GISTs and the emergence of resistance to TKIs pose clinical hurdles . ConsequThe case report of a giant exophytic GIST originating from the antral part of the stomach exemplifies the intricate clinical and pathological features of GISTs and the importance of a multidisciplinary approach to their management. Surgical resection, aided by TKIs when indicated, continues to be the cornerstone of GIST treatment. This case underscores the need for precise diagnosis, individualized treatment, and ongoing research to improve outcomes for patients with GISTs. In an era of evolving therapeutic options, GIST management remains a compelling study area, promising improved patient care and outcomes.


Studies on ligamentum flavum hematoma (LFH) have been gradually increasing; however, no study has reported an LFH spreading to the intraspinal and extraspinal spaces. The purpose of this report is to discuss this rare condition and report that extraspinal hematoma can be formed by LFH. The authors present the case of a 78-year-old man presented with right L5 radiculopathy caused by a space-occupying lesion with intraspinal and extraspinal expansions at the L4-L5 vertebral levels demonstrated on MRI. We tentatively diagnosed these lesions as intraspinal and extraspinal hematomas originating from the ligamentum flavum based on the chronological changes seen on MRI and computed tomography-based needle biopsy. After the extirpation of these lesions, the symptoms were relieved. Three months later, the patient could walk without a cane. From the intraoperative findings and pathological examination, we concluded that the extraspinal hematoma in paravertebral muscle was caused by an LFH of unknown etiology. This case report describes the difficulty in diagnosing LFH accompanied by an extraspinal hematoma with wide-spreading expansion and highlights the usefulness of repetitive MRI over time in capturing chronological changes of the hematoma. As far as we know, this is the first study on an LFH accompanied by an extraspinal hematoma in the multifidus. Lumbar cystic lesions in the epidural space, such as synovial or ganglion cysts related to the facet joints, can cause radiculopathies . A less Magnetic resonance imaging (MRI) is the most useful imaging modality in diagnosing LFH. However, making an accurate preoperative diagnosis is difficult using single-time MRI because hemoglobin molecules in the hematoma chemically change over time, resulting in nonspecific MRI characteristics of LFH ,7,8.Here, we describe the case of a 78-year-old man with intraspinal and extraspinal space-occupying lesions (SOLs) at the lower lumbar spine revealed by MRI. The patient complained of lower leg pain and motor weakness. Initially, diagnosing these lesions preoperatively was difficult because of the wide-spreading expansion of the SOLs. A tentative diagnosis was made after several examinations including multiple MRIs. The final definitive diagnosis was made as hematomas originating from the degenerative LF according to the intraoperative findings and postoperative histopathological examination.History and presentationA 78-year-old man presented with acute lower back pain and radicular pain in the right foot and was taken to our hospital in an ambulance. The patient reported that he had low back pain one month prior. The patient was known to have hypertension, paroxysmal atrial fibrillation, and Alzheimer’s disease and was on treatment with antihypertensive agents , an anticoagulant agent (edoxaban tosilate hydrate), and an acetylcholinesterase inhibitor. While the activated partial thromboplastin time (PTT) and prothrombin time(PT)-international normalized ratio (INR) was within the normal range, the averaged PT-INR was slightly elevated at 1.3. The patient had no history of lumbar puncture, trauma, or surgery. On physical examination, he had a slight weakness of the right tibialis anterior muscle and pain and numbness in the buttocks and lateral lower leg. The straight leg raising test on the right side was positive at 30°. These findings indicated L5 radiculopathy. Plain radiography of the lumbar spine showed degenerative spondylosis and narrowing of the right L4-L5 disc height. Plain computed tomography (CT) demonstrated no calcification or ossification of the lumbar LF, except for a remarkable degenerative change of the right L4-L5 facet joint. MRI demonstrated an intraspinal and extradural SOL in the right dorsal aspect of the spinal canal and an extraspinal SOL in the right multifidus at the L4-L5 level. Furthermore, both SOLs demonstrated isointensity to hyperintensity on a T1-weighted image Figure  and partFurthermore, CT-guided biopsy of a tissue sample from the extraspinal SOL showed no evidence of malignancy or infection. The possibility of LFH accompanied by an extraspinal hematoma was the final diagnosis; however, to our knowledge, no study has reported an LF hematoma spreading so widely as in this patient. We performed MRI multiple times to confirm the chronological changes in the images. Although no signal changes were observed on T2-weighted images, T1-weighted images showed evident signal changes in a part of the extraspinal SOL Figure -2d.Therefore, we diagnosed these intraspinal and extraspinal SOLs as hematomas and performed surgery for the extirpation of both SOLs and decompression of the compressed lumbar dural sac.OperationWe performed diagnostic and therapeutic surgery on the 23rd day of hospitalization. A midline incision was made from the L4 to L5 spinous processes. An elastic, hard, golf-ball-size SOL was exposed after the right multifidus was split bluntly Figure . The SOLHistopathological findingsIn the external membrane of the extraspinal SOL, a proliferation of granulation tissue and hemosiderin-laden macrophage deposits were observed Figure . EpithelPostoperative coursePostoperatively, right leg pain and numbness were relieved, and motor weakness gradually decreased. The anticoagulant agent was resumed a week after the operation. Three months later, the patient could walk without a cane. No hematoma recurrence was observed on MRI, and the dural sac at the L4-L5 level was well decompressed  of LFH in the lower thoracic spine of the mobile segment and lumbar spine, studies have speculated that the rupture of proliferated capillaries in the degenerated LF is induced by minor back trauma , exercisRegarding preoperative diagnosis, lumbar MRI showed that the LFH expanded to the intraspinal and extraspinal spaces in our patient. Since such an expansive hematoma originating from LFH has not been reported, we could not strongly suspect that both SOLs originated from the LFH; we inevitably cited malignancy and infection as differential diagnoses on the first visit.MRI is the most useful imaging modality in diagnosing LFH. However, both T1- and T2-weighted MR images of hematomas change as hemoglobin molecules chemically change chronologically . FurtherIn this study, several histopathological findings for the resected LF are commonly demonstrated in studies on LFH in the lower thoracic spine of the mobile segment and lumbar spine, such as elastic fiber degeneration ,17, incrIn addition, the aforementioned histopathological findings of LFH resemble those reported in a study describing the histopathological findings of LF with calcium pyrophosphate crystal deposition . In this In our case, the neurological deficit was relatively mild, which allowed us to conduct non-invasive investigations, including obtaining repetitive MRI images at some intervals, and speculate that the SOLs were hematomas. However, when the neurological deficit is severe and/or progressive over time, it is better and more reasonable to opt for diagnostic surgery rather than non-invasive investigations. Therefore, our diagnostic approach may not be applicable in all the cases suspected of LFH. This case report describes the difficulty in diagnosing LFH accompanied by an extraspinal hematoma with wide-spreading expansion and highlights the usefulness of repetitive MRI over time in capturing chronological changes of the hematoma. As far as we know, this is the first study on an LFH accompanied by an extraspinal hematoma in the multifidus. However, when considering the pathophysiological mechanism of LFH occurrence, it is possible that the occurrence rate of asymptomatic occult extraspinal hematomas originating from LFH is higher than we believe. Thus, this possibility would be noteworthy when diagnosing SOLs near the LF expanding into the intraspinal and extraspinal spaces.


Multiple cholecystoenteric fistulae, Bouveret syndrome , and acute pancreatitis occurring together is very rare. Diagnosis is seldom clinical and is mostly based on computerised tomography (CT) or magnetic resonance imaging (MRI). Endoscopy and minimally invasive surgery have revolutionised the treatment of Bouveret syndrome and cholecystoenteric fistula, respectively, over the last two decades. Laparoscopic repair of cholecystoenteric fistula followed by cholecystectomy is successful on a consistent basis with skilled laparoscopic suturing and advanced laparoscopy. In patients with Bouveret syndrome, when the stone is <4cm and is in the proximal duodenum, it is usually amenable for endoscopic extraction with snares, nets, forceps and lithotripsy. When endoscopy is unavailable or fails, laparoscopic surgery is suitable for these patients. However, stones >4 cm, located in the distal duodenum, multiple fistulae, and associated acute pancreatitis may necessitate open surgery. We present here a case of a 65-year-old Indian female with multiple cholecystoenteric fistulae and Bouveret syndrome with acute pancreatitis with a 6.5 cm gallstone diagnosed on CT scan and MRI and treated successfully by open surgery. We also review the current literature on the management of this complex problem. Cholecystoenteric fistula (CEF) is a rare and late complication of calculous cholecystitis ,2. CholeA 65-year-old Indian female presented with abdominal pain, bloating, nausea, and vomiting for the past seven days. Abdominal pain was localised to upper abdomen, continuous and dull in nature with occasional intermittent colic. There were multiple episodes of vomiting, which was projectile and non-bilious in nature. The patient was constipated but was passing flatus. She did not have pale stools, dark urine, fever, or weight loss. She had never consumed alcohol. The patient was diabetic and hypertensive for 15 years; both were under control with medications. She was afebrile. Her heart rate was 120 beats/minute and blood pressure was 90/60 mmHg. Her abdomen was distended and had generalised tenderness. Bowel sounds were absent. Hernia orifices were normal. Her blood investigations at the time of admission are shown in Table Ultrasonography (USG) of the abdomen showed a solitary gallstone. CT scan of the abdomen with oral and intravenous contrast and MRI/magnetic resonance cholangiopancreatography (MRCP) showed a 6 cm calculus in the second part of the duodenum, air in the gall bladder and biliary tree, CDF, dilated stomach, oedematous acute pancreatitis, and CCF Figures -3.Since we had reached the diagnosis on imaging, a diagnostic gastroscopy was not done. In view of the size of the stone, the gastroenterologist/endoscopist decided not to attempt endoscopic retrieval and instead suggested surgery. Laparoscopy revealed dense adhesions between the gall bladder, colon, and duodenum. Hence, a laparotomy through a right subcostal incision was done. After adhesiolysis, CCF was closed with stapler with a small margin of colonic wall. Stone was densely impacted in the fistulous tract and the second part of the duodenum. Due to the impaction, orientation, and size, the stone couldn’t be manoeuvred towards the pylorus. The second part of the duodenum with the stone and inflamed pancreas/peripancreatic tissues had become a phlegmon that prevented safe duodenal Kocherization for duodenotomy on the second part of the duodenum. Hence, a pylorotomy was done to dislodge the stone from within. However, that too was unsuccessful and the pylorotomy had to be extended onto the first part of the duodenum and finally onto the fistulous tract. The stone was extracted through this pyloroduodenotomy. It could not be closed transversely or longitudinally as the tissue was friable, unhealthy, and was not holding the sutures well. Also, there was the need to remove the entire fistula tract though the frozen section examination had not shown any malignancy. Therefore an antroduodenectomy (including fistula) was done followed by Billroth II reconstruction. Figure Surgery was completed after the cholecystectomy. The stone size on gross examination was 6.5 cm  by the 18th postoperative day. She was discharged on the 20th postoperative day. Histopathology showed chronic cholecystitis. She was asymptomatic at the time of postoperative follow-ups at one and three months.The incidence of CEF in cholelithiasis has significantly dropped 0.5-0.9%) due to the high number of laparoscopic cholecystectomies at a young age ,5. But t-0.9% dueSymptoms of CEF are nonspecific like right hypochondriac pain, nausea, and vomiting . ChronicDiagnosis of CEF or BS is rarely preoperative. Abdominal x-ray showing Rigler triad  or tetrad (shifting position of the stone), barium study, USG, and endoscopy are inconsistent in diagnosis 10-60%) ,11,18,190% ,11,18Treatment for BS was a one- or two-stage open surgery till the first endoscopic stone extraction in 1985 . Since tSurgery for BS should now be reserved where endoscopy infrastructure/expertise is unavailable, endoscopy has failed, the stone is >4 cm, or when the stone is in a difficult location because surgery is associated with high 10-30%) morbidity and mortality . It invo0% morbidMinimally invasive surgery (MIS) is favoured for CEF in specialist centres -6. MeticAcute pancreatitis increases the difficulty in MIS due to added inflammation, makes duodenal closure difficult, and probably decreases the possibility of cholecystectomy ,16. In pMultiple CEF with BS and acute pancreatitis is a very rare presentation and is reported for the first time here. There is no established treatment approach for this complex situation. Evidence suggests that when the stone is <4 cm and located in the proximal duodenum, endoscopic retrieval followed by minimally invasive cholecystectomy and fistula repair is ideal. If endoscopy is unavailable, MIS can be the preferred mode of treatment. Skills in laparoscopic dissection, intracorporal suturing, and subtotal cholecystectomy are key to success with MIS. However, endoscopy and MIS is probably still not suitable for multiple fistulas, giant stone, and acute pancreatitis. In this situation, open surgery may be better. More evidence is needed to clarify the role of different treatment approaches. Till then the choice of treatment modality  should be customised for better patient outcomes.


Intussusception in adults is a rare finding with a majority of cases occurring in the pediatric population. It occurs infrequently and its presentation, etiology, and treatment differ from childhood intussusception. When discovered in adults, it raises suspicion for a neoplastic process serving as the pathological lead point. Cross-sectional imaging is the primary study of choice for diagnosis, but at times, a more invasive approach involving an exploratory laparotomy is required posing an increased risk for morbidity and mortality. Here we present a 64-year-old male who was found to have jejunal-jejunal intussusception that was surgically removed with pathology revealing metastatic melanoma as the lead point. This case highlights a unique presentation of a melanoma that was previously eradicated with immunotherapy and now had metastasized to the intestine many years later. Intussusception is a condition in which a proximal portion of the intestine invaginates into its distal aspect, a phenomenon known as telescoping . It is cThis article was previously presented as a meeting abstract at the American College of Gastroenterology Annual Scientific Meeting from October 21-26, 2022.A 64-year-old male with a history of alcoholism, 94 pack-years of smoking, coronary artery disease on aspirin 81 mg daily, abdominal aortic aneurysm repair, and stage IV melanoma presented with four days of melena and abdominal discomfort. His melanoma was initially diagnosed in 2010 via punch biopsy of a left thigh lesion and was treated with wide local excision. His follow-up lymph node scan was negative for metastasis. Approximately five years later he was diagnosed with widely metastatic malignant melanoma. He was hospitalized during that time for diffuse pain and ascites with skeletal and visceral mets, including the peritoneum. He received radiation therapy to the skull and was started on vemurafenib with near complete response. Serial PET imaging suggested progressive disease and he was transitioned to Keytruda. He was started on Xgeva in light of the bone mets. An MRI brain was negative in 2019. He had been off therapy for five years, with negative PET scans two years prior. On arrival, his vital signs showed that he was afebrile, tachycardic 112, tachypneic 23, BP 130/88, and saturating well on room air. Physical exam revealed conjunctival pallor and mild abdominal tenderness to palpation without rebound or guarding. Labs revealed hemoglobin (Hgb) 10.7 g/dL (seven months prior noted to be 15.1 g/dL), platelet count 253,000/µL, aspartate aminotransferase (AST) 40 U/L, alanine transaminase (ALT) 63 U/L, blood urea nitrogen/creatinine (BUN/Cr) 26 mg/dL, and international normalized ratio (INR) 1.0. His last colonoscopy 14 years prior demonstrated multiple tubular adenomas. He received a dose of IV Protonix 40 mg and was started on a Protonix drip given concerns for upper GI bleeding. An upper endoscopy showed mild duodenitis, as shown in Figure Intussusception can be referred to as the invagination or “telescoping” of a proximal segment of the gastrointestinal tract into the lumen of an adjacent segment. It is predominantly due to the peristaltic contractions constricting and relaxing the lumen at the transition point . Bowel iThe diagnosis of intussusception can be delayed and oftentimes missed without imaging, and the clinical picture can be challenging due to its variable presentation, often associated with its longstanding non-specific symptoms including abdominal pain, nausea, and vomiting . The claA systematic review and meta-analysis by Hong et al. showed that a metastatic carcinoma acted as a culprit in the majority of intussusception cases . Known fThe current literature review suggests that there are no clear guidelines on reducing and manipulating an intussuscepted bowel prior to surgical resection. In fact, Aydin et al. performed a case series and were able to demonstrate success with utilizing a conservative approach when exam and imaging findings suggested a self-limited intussusception given a low probability of malignancy acting as a lead point and ischemia . InteresMelanoma is one of the most rapidly progressive cancers. Metastasis of cutaneous malignant melanoma causing intussusception is a unique finding with few causes reported. Intussusception in adults can present with non-specific symptoms, and metastatic disease should be on the differential in any patient with a history of melanoma. Early detection increases the likelihood that the cancer is amenable to treatment  and exploratory laparotomy should be performed promptly in the proper clinical context. In our case, a metastatic melanoma that was treated with immunotherapy approximately greater than 10 years prior was the ultimate cause.


A 72-year-old male patient presented with a decreased level of consciousness. He had no known history of systemic disease. He also had a painful vesicular rash on the scalp three weeks prior that had resolved. His neurological examination, during which he could not respond to verbal stimuli, revealed that his four extremities responded to painful stimuli and that the plantar reflex was downgoing bilaterally. His body temperature was 37.3°C. Diffusion-weighted magnetic resonance imaging (MRI) revealed infarcted areas, indicating diffusion restriction in both suprathalamic regions  and 2. A


A variety of cutaneous disorders can present to the general surgeon either directly or by referral for surgical intervention. Some conditions are commonly seen and operated on by general surgeons which include lipoma, epidermoid cyst, etc. On the other hand, some are uncommon conditions like dermatofibrosarcoma protuberans and chondroid syringoma which require a high index of suspicion to diagnose. Most general surgeons are not familiar with the latest guidelines to treat such uncommon conditions. In this article, we provide a review of uncommon cutaneous disorders requiring surgical intervention that were encountered at our high-volume tertiary care center and a discussion about their etiology, presentation, diagnosis, management and follow-up with one case report of each condition. The objective of this article is to familiarize the general surgeon with these cutaneous disorders which though uncommon, will present in their practice at some point. It is common in surgical practice for a patient to present with a swelling that may be clearly visible externally or a mass palpable just under the skin. Most of these swellings or masses are benign in nature and familiar to the surgeon. Such swellings or masses are easily excised after appropriate investigations. However, occasionally a patient presents to the surgeon with a swelling or mass, where the clinical picture does not fit that of the common conditions that are encountered in regular practice. Sometimes, a seemingly benign swelling or mass may actually be a malignant lesion. In this article, we describe such uncommon conditions that are presented to our high-volume tertiary care center in India. We discuss the incidence, presentation, examination, investigation and management of such patients along with clinical and histopathological images. We intend to familiarize the general surgeon with these conditions that they may encounter during their practice. In this article, we discuss the following conditions: dermatofibrosarcoma protuberans, plexiform neurofibroma, chondroid syringoma, trichilemmal cyst, mycetoma foot and button osteoma along with a case report for each condition.The retrospective case series was compiled from the existing data from the Department of General Surgery, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi. Data was collected retrospectively for the time period of November 2021 to November 2022. Patients with uncommon visible swellings or palpable masses, whose data was available from their first visit till three to five months in the postoperative period (depending on case to case), were included in this study. The detailed clinical examination findings and investigations were noted. Each patient's surgical procedure was noted, and the histopathological examination report of the excised specimens was traced. All the collected clinical data and histopathology findings were compared with the existing literature.Dermatofibrosarcoma protuberans was initially excised without margins; however, following histopathological reporting, revision surgery was done and margins were revised to 4 cm in all directions including the deep fascia. Plexiform neurofibroma was excised with a margin of 1 cm sparing the deep fascia. Skin flaps on either side were mobilized to facilitate primary closure. Chondroid syringoma of the scalp was excised preserving as much normal tissue as possible. The defect was closed using a transposition flap from the adjacent scalp, and the resultant defect was covered with a split skin graft. Trichilemmal cysts were excised completely with their wall without any rupture and primary closure was done. Mycetoma of the foot was debrided radically sparing the tendons and bones, and the wound was allowed to heal by secondary intention. Button osteoma was excised using a chisel and mallet, and the wound closed primarily.Case 1A 29-year-old male presented to the outpatient department with complaints of multiple masses  over the upper anterior abdominal wall and anterior wall of the lower thorax for two years. The patient had initially noticed the mass in the upper left quadrant of the abdomen two years ago when it was approximately 0.5x0.5cm. It was insidious in onset and slowly progressed in size to 1x1 cm over two years. It was painless and not associated with any discharge. One year ago, the patient had noticed multiple smaller masses of 0.5x0.5 cm in the region surrounding the primary mass and one mass of 0.5x0.5 cm over the lower anterior chest. There was no history suggestive of constitutional symptoms or distant metastasis. On examination, there was a mass of 1x1 cm in the left hypochondrium 3 cm lateral to midline with purple discoloration of the overlying skin. The overlying skin temperature was normal; the mass was non-tender, the surface was smooth, the margins were well-defined and the consistency was firm. It was non-compressible and non-reducible, and the cough impulse was absent. It was non-pulsatile. Mass was adherent to the skin and free from the underlying muscle. There were three masses of 0.5x0.5 cm each just superior and medial to the primary mass and another mass of 0.5x0.5 cm in the midline over the sternum 3 cm superior to the xiphoid  showed fibrofatty fragments suggestive of lipoma. An excision biopsy was performed on the primary mass and surrounding three smaller masses which could be accessed from the incision. The mass on the sternum was not excised at this stage. Histopathology examination (HPE) report revealed a spindle cell neoplasm arranged in a storiform and whorling pattern. The cells were spindle-shaped with moderate eosinophilic cytoplasm, monomorphic nuclei and inconspicuous nucleoli. Mitotic activity was rare. A tumor was seen infiltrating the subcutaneous fat with a honeycomb pattern, and a deep-resected margin was involved by the tumor. On immunohistochemistry, the cells were positive for vimentin and CD34. Ki67 was 2%  of the abdomen and thorax revealed no abnormality. MRI of the right thigh revealed the swelling to be confined to subcutaneous tissue, and thus, the patient was posted for resection of the tumor with a 1 cm margin. Primary closure of the defect was achieved. Histopathology report confirmed the diagnosis of plexiform neurofibroma on account of irregularly expanded nerve bundles having Schwann cells with wire-like collagen in neurofibroma with S-100 positive Figure .The patient was followed up to look for recurrence or de novo plexiform neurofibroma Figure .Case 3A 53-year-old male presented to the outpatient department with a complaint of swelling on the left side of the head for four years. The patient was apparently asymptomatic four years ago when he noticed a swelling on the left side of the head above the ear. It was insidious at the onset of approximately 1x1 cm and gradually increased to the size of 7x7 cm. It was not associated with pain. There was no history of trauma or masses elsewhere in the body. There was no history suggestive of constitutional symptoms or distant metastasis. On examination, there was a 7x7 cm swelling on the scalp at the junction of the left frontal and parietal region. It was irregular in shape, skin-colored with an irregular surface and well-defined edge. It was non-pulsatile, and cough impulse was not present. The skin over the swelling was stretched with visible veins. The overlying temperature was normal, and the swelling was non-tender. The surface had a nodular feel, and the consistency was firm. It was non-compressible and non-reducible. It was fixed to the overlying skin but free from underlying bone Figure . There wFine-needle aspiration cytology revealed epithelial and myoepithelial cells in a fibrillary and chondromyxoid stromal background suggestive of chondroid syringoma. Non-contrast CT scan of the head confirmed the swelling to be free from the calvarium. Excision of the tumor was done with grossly negative margins Figure .The resultant defect was closed with a transposition flap, and split skin grafting of the resultant scalp defect was done Figure .Histopathology confirmed the diagnosis of chondroid syringoma as a biphasic tumor showing epithelial cells arranged in tubules and cartilage in a myxoid background Figure .There was excellent healing and no sign of recurrence Figure .Case 4A 75-year-old lady presented to the outpatient department with complaints of multiple swellings over the scalp for three years. The patient was apparently asymptomatic three years back when she noticed one swelling on the right side of the scalp approximately 2x2 cm in size. It was painless. The swelling increased in size progressively to the size of 5x5 cm. During this period, she also developed multiple small, similar swellings on the scalp. On examination, there was one large 5x5 cm swelling in the right temporal area and multiple small swellings ranging from 1x1 cm to 4x4 cm on the right half of the scalp. The swellings were spherical in shape, with normal overlying skin and hair. They were non-pulsatile and did not show cough impulse. The overlying temperature was normal, tenderness was absent, the surface was irregular, the edge was well-defined and the consistency was variable and moldable. They were fixed to the skin but free from underlying bone Figure .Non-contrast CT scan of the head was done which ruled out bony involvement. Excision of all the cysts was done under general anesthesia, and primary closure was achieved Figure .Histopathological examination revealed the diagnosis of a trichilemmal cyst Figure . The posCase 5A 28-year-old male presented to the outpatient department with complaints of a non-healing wound over the left foot for two years. The patient was apparently asymptomatic two years back when he noticed a wound on the left sole. It was about 1x1 cm in size and painless with pus discharge. The wound continued to increase in size and developed multiple openings which discharged pus and "grains" over the last two years. The patient was a farmer by occupation. On examination, there was an ulcer of 7x7 cm on the left foot on the sole just anterior to the heel and extending on the lateral aspect of the foot. Multiple sinus openings were present with yellow-colored granules Figure . Ankle aMicroscopy of the grains revealed fungal hyphae. MRI of the left leg and foot showed multiple areas with dot in circle sign limited to myofascial planes and not involving the underlying bone which was suggestive of mycetoma of the foot without bone involvement. The patient was taken for debridement under anesthesia where all visibly involved tissue was debrided sparing the tendons and bones Figure .The wound was kept open to heal by secondary intent. Microscopy of the excised specimen revealed actinomycosis. The patient was started on anti-bacterial and anti-fungal Figure .The patient was followed up with regular dressing and showed good recovery with healthy granulation tissue at the wound site and no evidence of recurrence Figure .Case 6A 46-year-old female presented to the outpatient department with chief complaints of swelling over the forehead for 15 years. The lump was insidious in onset, approximately 2x2 cm in size, and had not progressed in size. There was no history suggesting trauma or infections. The swelling was painless and hard. The patient wished to get the swelling excised for cosmetic reasons. On examination, there was a 2x2 cm non-tender hard lump on the forehead which was fixed to the underlying bone and free from the overlying skin and subcutaneous tissue Figure . A diagnDermatofibrosarcoma protuberansDermatofibrosarcoma protuberans (DFSP) is a locally aggressive rare soft tissue tumor which has a high rate of local recurrence after surgical excision. DFSP has been described in the dermatology literature for more than a century. In 1925, Hoffman gave it its current name . In apprTheoretically, MMS has a higher likelihood of providing complete surgical clearance because it is an asymmetric tumor with multiple eccentric microscopic projections which may span the dermis, subcutaneous tissue and fascia. . A reviePlexiform neurofibromaNF1 gene, which encodes neurofibromin. The incidence is approximately 1:3,500 [Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder caused by inherited or spontaneous mutations in the  1:3,500 . Plexifo 1:3,500 . They ca 1:3,500 . They tr 1:3,500 .Chondroid syringoma2 lasers.Chondroid syringoma (CS) is a rare skin appendageal tumor, with a reported incidence of 0.098% . The celTrichilemmal cystTrichilemmal cysts (TCs), also known as pilar cysts, are benign appendage lesions derived from the hair follicle's outer root sheath. Their incidence is 5%-10% and is more common in females . Of all MycetomaNocardia, Streptomyces and Actinomadura cause actinomycotic mycetoma, with Nocardia brasiliensis, Actinomadura madurae, Actinomadura pelletieri and Streptomyces somaliensis being the most common. Eumycotic mycetoma is associated with a variety of fungi, the most common being Madurella mycetomatis [Mycetoma is a chronic suppurative infection affecting the skin, subcutaneous tissue and bones. It is endemic in India, Africa, South America and Mexico. It predominates in men with a 2-4:1 ratio. The average age of presentation ranges from 16 to 40 years . Mycetometomatis . It is cetomatis . The micetomatis . Clinicaetomatis . Becauseetomatis .Button osteoma2 laser cauterization, usually performed for cosmetic reasons [Osteomas are benign bone tumors which can occur due to the proliferation of either cancellous or compact bone . Facial  reasons .We can thus conclude that a general surgeon with the knowledge of the latest literature and guidelines can effectively manage patients presenting with uncommon cutaneous disorders.