Objective: Tumours of the nasal septum are a rare and heterogeneous group of lesions in the sinonasal tract. The management of the different lesions of this site is debated. The aim of this study is to share our experience on a rare clinical condition and stimulate other centres to publish theirs. Methods: We retrospectively analysed the databases of sinonasal tumours treated at the Sections of Otolaryngology (ENT) of two University Hospitals  between 2012 and 2020. Results: From the two databases, a cohort of 32 patients with tumours of nasal septum were selected. All patients underwent an endoscopic examination. Large tumours underwent preoperative computed tomography (CT) scan without contrast medium. In 22 (68.7%) cases, the preoperative radiologic evaluation also included magnetic resonance imaging (MRI) with gadolinium to obtain a better differentiation of the lesions and study the vascular pattern. All the large lesions were biopsied under endoscopic guidance using local anaesthesia; the same approach was used to remove the tumours and their attachment with safe resection margins. Conclusions: While malignant lesions require an excision of the mass with resection of all layers of the nasal septum, benign lesions must be typed according to histological considerations in order to plan the most appropriate type of surgical resection. Tumours of the nasal septum belong to a rare and heterogeneous group of lesions in the sinonasal tract. According to the published literature, the incidence of benign neoplasms is not known since many of them occur sporadically in the sinonasal area . LobularWe performed a retrospective analysis of the databases of sinonasal tumours treated at the Sections of Otolaryngology of two University Hospitals  between 2012 and 2020. Only primary tumours with origin from the nasal septum were included in the study. Clinical, demographic, histologic, radiographic characteristics, as well as operative and post-operative findings, complications, adjuvant therapy and follow-up data were analysed.All patients underwent endonasal endoscopy to evaluate the extension of the neoplasm. Small lesions  were removed by endoscopic resection in local anaesthesia without imaging. In the large tumours , a CT scan and/or a contrast-enhanced MRI were/was performed to study the lesions, if imaging was not clear about the involvement of other anatomical structures and/or endoscopy did not show a secure implant base, a biopsy under local anaesthesia was always performed, to be followed by endoscopic resection in general anaesthesia. About the malignancies, the adjuvant therapy was discussed with multidisciplinary team, and it was used for the cases with involved margins, advanced staging (III–IV) or grading (high grade) and involvement of critical regions, such as frontal sinus, sphenoid sinus, anterior skull base , lamina papyracea or periorbit and nasopharynx.Postoperative follow-up was performed with nasal endoscopy every 15 days until complete healing of the surgical cavity, every 3 months during the first year and every 6 months thereafter. Post-operative MRI with gadolinium was performed 6 months after surgery and every year thereafter for the large tumours. For the malignancy, systemic staging through total body positron emission tomography (PET) or total body CT scan and ultrasound of the neck was performed once a year. In the small lesions, an endoscopic exam was considered to be enough.A cohort of 32 patients with tumours of the nasal septum were detected, including 19 males and 13 females (M:F = 1.5:1). The mean age was about 56.24 years (SD ± 14.69 years) with a range from 14 to 86 years.In 17 patients (53.1%), the symptom was unilateral nasal obstruction, 10 (31.2%) reported unilateral epistaxis and 4 (12.5%) reported unilateral epistaxis and nasal obstruction . One  cases, the preoperative radiologic evaluation also included an MRI with gadolinium to obtain a better differentiation of the lesion and to study the vascular pattern. In cases of malignancies, the presence of local or distant metastases was assessed with a total-body contrast-enhanced CT scan and ultrasound of the neck.In cases of small tumours, an endoscopic resection was performed, while in the large lesions, a biopsy preceded the surgery.All the specimens were sent to the Department of Human Pathology for histopathological diagnosis. A total of 28 (87.5%) cases were benign neoplasm, of which 9 (28.1%) patients had a lobular capillary haemangioma (LCH), also called pyogenic granuloma; 13 (40.6%) had an inverted papilloma (IP); and 1 (3.1%) case of Schwannoma, 1 Warthin’s tumour (WT), 1 respiratory epithelial adenomatoid hamartoma (REAH), 1 Pleomorphic Adenoma (PA), 1 blue nevus (BN) and 1 solitary fibrous tumour (SFT). Four (12.5%) cases were malignant tumours, of which one was Mucosal Melanoma (MM), one was non-Intestinal-type adenocarcinoma (n-ITAC), one was poorly differentiated non-keratinizing squamous cell carcinoma (SCC) and one was low grade chondrosarcoma . Based o-In the lobular capillary haemangioma, only the mucoperichondrium was removed.-In the others lesions, the mucoperichondrium with cartilage and/or bone was removed.The biopsied cases with histological diagnosis of benign neoplasm underwent endoscopic resection, whereas, in cases of malignancies, the presence of local or distant metastases was assessed with a total-body contrast-enhanced CT scan and an ultrasound of the neck. Treatment planning based on a common management strategy was discussed by the multidisciplinary team. In the cases of benign tumours, a partial resection of the nasal septum was performed. In particular:In all malignant tumours, an endoscopic endonasal resection without external approach was possible, and a resection of all layers of nasal septum was performed . In someThe nasal septum is supported by a plate of hyaline cartilage (quadrangular cartilage) and a plate of bone (perpendicular lamina of ethmoid and vomer) covered by respiratory epithelium (pseudostratified ciliated columnar). This structure is mainly made ofciliated columnar and goblet cells attached to a basal lamina. Basal cells are observed just above the basal lamina. Septal glands with their ducts, vessels and nerves are present in lamina propria or rather mucoperiosteum/mucoperichondrium. The glands are not the same in all the septums: the anterior glands of the nasal septum are tubulo-alveolar with a serous secretion; the posterior glands are of the branched acinar type with a mucoid secretion. They lie partly within the vomeronasal capsule and most of the ducts of the posterior glands open into the cavity of the vomeronasal organ along the groove between the olfactory and columnar epithelia . To syntThe most frequent tumour was lobular capillary haemangioma (LCH) . This one, also known as pyogenic granuloma, is a benign vascular tumour with a microscopically distinctive lobular architecture that affects the skin and mucous membranes of the oral cavity and nasal region. The disease may appear in all ages. According to published literature, the incidence of this lesion is variable (7–29%), probably because its presence may be underestimated as it is confused with a bleeding angioma, and therefore small LCHs are simply electrocauterized. Usually, this lesion, if smaller than 1 cm, arises from the anterior portion of the nasal septum. In this case, imaging studies are not indicated, unless a differential diagnosis is needed . Endoscopic surgery is the treatment of choice for LCH. In particular, small size lesions, as in our cases, can be resected easily under local anaesthesia. Since the lesion is benign and the vessels of the nasal septum are contained in the mucopericondrium/periosteal, Puxeddu et al. suggest a radical resection on the subperichondrial or a subperiosteal plane with a margin of normal mucosa all around .About benign epithelial lesions, the IP was present in 40.6% of cases, followed by 2 cases of salivary-gland-type adenomas (one PA and one WT) and 1 case of REAH. This high incidence compared to the available literature analysed (40% vs. 2.5%) is explained by the fact that our centres represent the local referral hospital for neoplastic pathology of the nasosinusal district, and therefore, we receive the most complex cases  for surgical treatment. Usually, IP arises primarily from the lateral nasal wall and rarely from the nasal septum. Likely, focal hyperostosis, osteitis or bone remodelling are CT radiographic predictors of tumour origin or attachment. Histologically, IP shows an epithelium inverting into the stroma but with a distinct and intact basement membrane that separates both. However, the tumour may be associated with atypia, dysplasia and carcinoma in situ, as well as frank squamous cell carcinoma identified focally only with the definitive histological examination also in the area of hyperostosis. For this reason, endoscopic resection must foresee the excision of mucoperhicondrium/ostium with cartilage/bone with safety margin .Salivary gland-type adenomas arise from minor salivary glands of the sinonasal tract. In particular, PA must be carefully assessed because a malignant transformation into carcinoma ex-pleomorophic adenoma (CXPA) occurs in approximately 6% of cases. Considering the presence of the glands in the stroma, the literature suggests a complete surgical excision of the tumour with clear resection margins by endonasal endoscopic resection of the mucoperhicondrium/ostium. Luckily, the treated PA of the nasal septum are significantly associated with a low prevalence of recurrence compared to tumour originating from the paranasal sinus ,16. Our Another benign epithelial tumour is the respiratory epithelial adenomatoid hamartoma (REAH). Hamartoma can grow out in each part of the body and can be defined as epithelial, mesenchymal and mixed. In the sinonasal region, the majority of them are purely of epithelial type and are called REAHs. Its origin is from the surface epithelium with glandular elements arising from this epithelium and not from seromucous glands . They may appear as either isolated lesions or in association with inflammatory processes such as sinonasal polyposis. The majority of REAHs arise from the posterior nasal septum like our case, but some cases may arise from the olfactory cleft, middle meatus, inferior turbinate, maxillary sinus, nasopharynx and sphenoid sinus. Our case of REAH was in the right nostril between the septum and the olfactory cleft . DiffereThe only “Benign soft tissue tumours” present in our records was the Schwannoma .It is a neurogenic, slowly growing tumour which originates from Schwann cells of the sheath of the peripheral nerves. It can arise from any peripheral cranial nerve, with the exception of the olfactory and optic nerves. Only 4% of the head and neck Schwannomas originate from the nasal cavity and paranasal sinuses, often arising from the ophthalmic-maxillary branches of the trigeminal nerve and from the sympathetic parasympathetic nerves . The risAccording to the literature, as well as in our cases, the most frequent site of Schwannoma is the posterior nasal septum followed by the midportion and anterior nasal septum. Although it is unusual to identify a particular nerve of origin, the possible source for nasal septal schwannoma includes the sympathetic nerve to the septal blood vessels, the parasympathetic nerve to the septal mucous glands and the sensory nerve to the septum. Actually, there are no studies explaining the reason why nasal septal schwannomas arise from the posterior portion of the nasal septum, but considering that nerves are present in the stroma, an excision of the mucoperhicondrium/ostium extended to cartilage/bone is mandatory to be effective in this case.Concerning the “Borderline and low malignant potential tumours of soft tissue”, the only case was an extrapleural solitary fibrous tumour (SFT). This lesion typically involves the pleura but can rarely be present in another district. It is defined as a fibroblastic/myofibroblastic neoplasm, slowly growing, rarely metastasizing and with intermediate biological behaviour. Although most SFTs have a good prognosis, about 10–40% of cases relapse or metastasize. For instance, its clinically aggressive behaviour is related to the pathological criteria of malignancy established by the World Health Organization (WHO) as follows: presence of hypercellularity, increased mitoses (>4 mitoses per 10 high power elds), cytological atypia, tumour necrosis and/or infiltrative margins. In our case, the patient had benign histological criteria, and therefore, surgery without chemoradiotherapy was the treatment of choice. In particular, an endoscopic resection of the mass with excision of its attachment to the mucoperichondrium with cartilage was performed because, also in this lesion, malignancy is established only in the definitive histological examination, and the cartilage/bone often present hyperostosis  Figure a.Out of the 32 cases, 2 of them were “neuroectodermal tumours”: a blue nevus  and a mucosal melanoma . The BN is a very rare lesion (only 5 cases are described in the literature) and goes in the differential diagnosis of pigmented lesions. It is characteristically small and asymptomatic, and the diagnosis is only histological. Treatment is complete excision  for diagnostic and therapeutic purposes. The risk of recurrence is very low. Differently, in case of MM, patients often come late to medical observation because it grows asymptomatically until the last disease course. This lesion is rare  and more frequent in black patients. The primary approach is surgical resection . PostopeConcerning the “Malignant tumours of bone and cartilage”, the only case present was a low-grade chondrosarcoma. This lesion is a slowly growing malignancy of cartilage that arises from remnants of cartilage after ossification . Three dIf possible, en-bloc excision is the preferred surgical treatment because these lesions are partially radio-resistant. Chondrosarcomas, especially low-grade tumours, are associated with an excellent prognosis if the lesions are completely resected. Our case showed an involvement of bilateral layers of nasal septum and bilateral invasion of the medial wall of the maxillary sinus b. TherefSquamous cell carcinoma (SCC) is the most common malignancy of the sinonasal tract. The peak incidence is between 60 and 70 years of age and it is more frequent in men than women (M:F = 2:1) . An assoNasal septal tumours are a heterogeneous group of rare lesions even compared to other neoplasms of the nasosinusal tract. CT and RM are the gold standard for diagnosis overall for large lesions in which a biopsy is mandatory. While malignant lesions require an excision of the mass with resection of all layers of the nasal septum, benign lesion must be typed according to histological considerations in order to plan the most appropriate type of surgical resection. In line with the available literature in the field, we performed a mucoperichondrium with cartilage/bone excision in patients with IP, Schwannoma and SFT, while an excision of mucoperichondrium was performed for LCH, WT, PA and REAH . The end


Plexiform schwannoma is an uncommon soft tissue tumor that could even rarely presented on the foot and toes. Plexiform schwannoma is an uncommon soft tissue tumor that could even rarely presented on the foot and toes. The presentation of this tumor on the dorsum of the foot is very rare. Herein, we describe a rare case of pretty large plexiform schwannoma on the dorsal surface of the toe.Plexiform schwannoma is considered an uncommon benign peripheral nerve sheath tumor that stems from the slow proliferation of Schwann cells in a meshwork configuration.2A 33‐year‐old male patient was referred to our dermatology clinic due to the growing soft tissue mass on his foot. Initially, the mass appeared on his second toe of the right foot 20 years ago. Recently, he has noted a progressive growth in the bulk for the last 6 months. He denied any significant past medical history or drug history. He did not mention any relevant familial history, as well.In the physical examination, there was a nontender erythematous nodule on the phalanx of his second right toe. The nodule was immobile and measured 3 cm in diameter Figure . No simiPunch biopsy was taken from the nodule while considering myxoid cyst, neuromas, and giant cell tumor of tendon sheath as the differential diagnoses. Microscopic examination revealed a portion of plexiform neoplasm in the dermis composed of multiple nodules of proliferated spindle cells with wavy nuclei in a fibrillary matrix. There were areas of nuclear palisading forming verocay body appearance of intervening stroma between the nodules composed of a loose meshwork of spindle cells with microcystic change and scattered inflammatory cells Figure . In addi3Herein, we reported a case of plexiform schwannoma with an unusual size that developing in an unusual location. Generally, Schwann cell tumors are categorized as neurofibromas, schwannomas, and malignant peripheral nerve sheath tumors (MPNSTs). In addition, these tumors can be considered as a manifestation of genetic diseases, such as Neurofibromatosis type 2 (NF‐2), carney complex type 1, and schwannomatosis. Moreover, these tumors have been rarely reported in unusual locations such as gingiva.Schwannoma is considered as a benign peripheral nerve sheath tumor that stems from the slow proliferation of Schwann cells. Schwannoma mostly appears as a solitary nodule with slow growth which can be histologically classified into cellular, plexiform, and melanotic variants.The plexiform variant is a benign tumor, which develops in a plexiform pattern; nevertheless, the malignant transformation is rarely reported.From the histopathological view, various nodules which locate intradermally or subcutaneously consist of cellular Antoni A, in which areas with both nuclear palisading and verocay bodies are detected. In contrast to schwannomas, plexiform schwannomas develop in a plexiform configuration including various interconnecting nodules and fascicles in Antoni A areas.4Plexiform schwannoma is a rare benign tumor that can rarely occur on the toes. It is recommended to keep in mind this diagnosis facing bizarre large soft tissue tumors on the foot or toes. Histopathological studies are required to avoid misdiagnosis with other lesions. The treatment is limited to surgical treatments and complete excision is recommended in order to prevent the recurrence.None declared.FA: Acquired the data and prepared the manuscript. MT: Acquired the data and wrote the manuscript. KK: performed the laboratory test and wrote the manuscript. M‐MF: acquired the data and wrote the manuscript. RMR: served as the corresponding author and designed and supervised all the aspects and contributed to manuscript editing. All authors: contributed sufficiently and met the criteria for authorship.The ethical issues were completely considered to prepare this case report according to our institution's ethical board guidelines. Moreover, this article was prepared regarding the declaration of Helsinki.Published with written consent of the patient.


Dermoscopy allowed the identification of Lisch nodules in the iris, bilaterally. The combination of these findings allowed the diagnosis of neurofibromatosis type 1, according to NIH criteria. Lisch nodules are melanocytic hamartomas of the iris, which must be evaluated through a visual augmentation method, usually employed in ophthalmology. Alternatively, dermoscopy can be used and contribute to the early diagnosis of neurofibromatosis type 1.Neurofibromatosis is a common genodermatosis, whose diagnosis often involves the participation of a dermatologist. A case of a 38-year-old female patient with four  She had no axillary or inguinal freckling. She denied a history of visual or bone alterations. She reported a history of cognitive impairment, which had not been objectively assessed, and a paternal family history of similar skin lesions, without a diagnosis and no possibility of objective assessment at that time.A 38-year-old female patient was referred to the Dermatology Service for the evaluation of nodular lesions present since adolescence, with progressive growth. On physical examination, she had ten soft, normochromic nodules, distributed on the trunk and limbs, compatible with neurofibromas. She also had a lesion measuring 10 cm in diameter, on the back of the left thigh, compatible with a plexiform neurofibroma, and four At this time, the patient had several findings suggestive of neurofibromatosis type 1; however, she still did not meet the diagnostic criteria of the National Institutes of Health (NIH) .1 The auThe diagnosis of neurofibromatosis usually requires a multidisciplinary team, in which the role of the dermatologist is essential. It is based on the NIH clinical criteria and generally does not require genetic testing. These criteria are highly sensitive and specific, except in very young children.Lisch nodules are well-defined melanocytic iris hamartomas, with a dome appearance, light brown color, and do not cause any visual alterations.5café-au-lait macules and no family history of neurofibromatosis, as they appear before the neurofibromas.The observation of Lisch nodules can be especially useful in young children with multiple café-au-lait macules, but without a previous diagnosis, for which the observation of Lisch nodules through dermoscopy was important for the diagnosis of neurofibromatosis type 1. Therefore, the authors highlight that dermoscopy can be an auxiliary tool for the dermatologist to assess cutaneous and the ocular lesions of this genodermatosis.This is the report of an adult patient with neurofibromas and None declared.Luciana Pavan Antoniolli: Approval of the final version of the manuscript; design and planning of the study; drafting and editing of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature.Laura de Mattos Milman: Approval of the final version of the manuscript; design and planning of the study; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases; critical review of the manuscript.Renan Rangel Bonamigo: Approval of the final version of the manuscript; design and planning of the study; intellectual participation in propaedeutic and/or therapeutic conduct of studied cases; critical review of the manuscript.None declared.


Here, we report a unique presentation of peripheral ossifying fibroma affecting the anterior mandible in a three-month-old infant. We also highlight the role of laser in the management of such lesions.Reactive hyperplasias are a group of lesions often seen in the oral mucosa, especially on the gingiva, in association with local irritation or trauma. Peripheral ossifying fibroma (POF) is a common reactive lesion, almost always affecting the tooth-bearing areas of the oral cavity. It is most often encountered in young adults but extremely rare in patients below 10 years of age. The gingiva is susceptible to a wide range of irritants, and tissue response to these irritants may vary . AccordiA three-month-old female infant was referred to our dental unit for the management of a lump in her lower front gum pad, with associated difficulty in feeding. According to her parents, she had two teeth in the lower anterior region of the mouth at birth. As the teeth were superficially present, they were removed on the same day using gauze and tweezers. Postoperative bleeding was minimal. A few days later, they observed a small lump at the same site, which slowly increased to the present size. It was initially pale pink, which turned into a reddish-purple following a minor trauma three days earlier. The baby later became very irritable and refused direct breastfeeding. The baby was otherwise healthy and was born following a full-term pregnancy without any complications. There was no history of consanguinity, and antenatal history was unremarkable. The parents first consulted a pediatrician regarding the problem, who then referred her to our dental unit for diagnosis and management.The extraoral examination did not reveal anything of clinical significance. Intraoral examination revealed solitary pedunculated nodular swelling in the mandibular anterior gum pad. The swelling appeared reddish-purple, measuring approximately 0.5 × 1 cm in size, and had the shape of a kidney bean. The mucosa over the swelling appeared tense and shiny. The surrounding mucosa seemed to be healthy. The swelling was tender, soft to firm in consistency, and mobile. The swelling was non-fluctuant and nonpulsatile and was not readily bleeding on manipulation, and the blanch test was negative  in 1 W power was used for the complete excision of the lesion, following necessary safety protocols.The procedure was uneventful with excellent hemostasis Figure , and theHistopathological study revealed spindle to stellate cells with hyperchromatic nuclei in a loose myxoid and fibrous background with no evidence of mitosis Figure . There wA final diagnosis of peripheral ossifying fibroma of mandibular anterior gum pad was made. On follow-up, a week later, complete healing of the surgical site was observed. There was no recurrence in six months of follow-up Figure .POF is a distinct clinical entity characterized as focal, reactive, nonneoplastic, tumorlike growth arising from the gingiva . The patPOF is found to be common in females and often encountered during pregnancy . The infPOF usually presents as a solitary, pedunculated or sessile, slow-growing, painless, nodular mass, often less than 2 cm in size, mostly located in the interdental papilla . POF is The tooth that is present since birth is a natal tooth, whereas the one that erupts in the first month of life is termed a neonatal tooth. Local reactive lesions in infants are infrequent and are mostly in association with a natal or a neonatal tooth . It is pSimilar to the present case, all the cases reported previously were associated with natal or neonatal teeth and presented mostly in the anterior mandibular ridge. However, in a case reported by Yip et al. (1973), there was no association with either natal or neonatal tooth, and the site was at the posterior maxilla .In adults, POF needs to be differentiated from other reactive lesions such as PG, PGCG, traumatic fibroma, and peripheral odontogenic fibroma . However2, neodymium-doped yttrium aluminum garnet (Nd:YAG), and diode have been used in mucogingival surgeries and excision of intraoral soft tissue lesions as an advanced and effective treatment modality [Complete surgical excision and follow-up are a necessity due to the known recurrence of POF. An alternative to conventional scalpel excision, lasers such as the COmodality ,18.Minor surgical procedures for infants are often traumatic for the child as well as parents and might require intervention under general anesthesia. In 2013, the American Academy of Pediatric Dentistry recommended lasers as an alternative and complementary method for providing soft and hard tissue dental procedures in infants, children, adolescents, and persons with special healthcare needs . ExcisioIn the present case, we chose a diode laser with a 940 nm wavelength, considering its precision, safety, and deeper penetration for complete excision. Hemoglobin is one of the target chromophores for diode lasers; hence, they provide superior hemostasis ,18.A literature review shows that low-level laser therapy (LLLT) is an effective, noninvasive, and safe adjuvant aid in reducing postoperative complications, providing satisfactory analgesia, and also fastening the healing process . When irInfants presenting with an intraoral swelling require immediate attention as it can affect nutrition and quality of life directly. The present case suggests that a thorough understanding of common, as well as rare, pediatric oral lesions are mandatory for drawing possible differential diagnoses, thereby providing prudent management. Parents’ anxiety and apprehension often demand counseling and reassurance. Laser-assisted excision provides advanced, effective, and easy management of such lesions with minimal operative and postoperative discomfort. In addition, photobiomodulation in the immediate postoperative phase has got promising results in further preventing postoperative complications and aiding in tissue repair. Regular follow-up of the patient is necessary due to known recurrence of POF, although it is rare after complete excision.


We report a case of 16 -year male who presented with nonproductive cough, chest pain, and hemoptysis. His chest -x-ray and computerized tomographic scan (CT) of the thorax with contrast enhancement revealed a large mediastinal mass mostly occupying the left hemithorax. Percutaneous CT scan-guided biopsy of the mediastinal mass was reported as an endodermal sinus tumor (EDST). Serum alpha-fetoprotein levels were markedly raised . After completion of chemotherapy repeat, CT scan of the thorax revealed a large residual mass. Radical resection of the tumor was carried out. Twelve-year post-surgical resection follow-up with serial serum alpha-fetoprotein (AFP) tumor marker levels and CT scan of the thorax showed no recurrence. •A 16-years old male presented with history of cough, shortness of breath, chest pain and scanty hemoptysis.•Serum alpha-fetoprotein levels were markedly high 120,000 ng/ml.•Chemotherapy was given.•Radical surgical resection was carried out.•Alpha feto protein levels were serial determined over the past twelve year, which stayed within normal range. This tumor marker has high diagnostic and prognostic value for follow up in such tumors.•Follow CT scan of thorax showed no recurrence. Physical examination of genitalia, abdomen, chest, and neck was normal, and there was no palpable lymphadenopathy. On auscultation, there was decreased air entry in the left hemithorax. Chest x-ray showed left hemithorax opacification. CT scan revealed a large anterior mediastinal mass mostly occupying the left hemithorax 2, Etoposide 100mg/m2, Bleomycin 30mg/m2. The granulocyte-stimulating factor therapy was given after the completion of chemotherapy, and the repeat CT scan of the chest revealed a large residual mass. Fig ). Alpha-fetoprotein level after completion of chemotherapy was 300 ng/ml. Subsequently patient underwent surgical resection and median sternotomy approach was used to get surgical access. We placed a purse-string suture in the soft part of mass and inserted a clamped 32F drain in the mass, and tightened the purse-string suture around it. Approximately 500 ml of turbid fluid and necrotic material was sucked out, then the tube was removed, and the purse-string suture was tightened. This very useful technique, which facilitates the dissection to achieve complete resection without the spillage of the contents in the surgical field while manipulating the mass during surgery. The tumor was meticulously dissected free of great vessels  regime chemotherapy , residual mass, pathological status, and pulmonary or distant metastasis [For long-term survival, the most important factors are Alpha-fetoprotein levels prior and post-to chemotherapy and complete surgical resection  levels for 12 - years, which stayed within the normal range, and the patient, is disease-free. Serum Alpha-fetoprotein level has diagnostic and excellent prognostic value for long-term follow-up and early detection of recurrence or metastasis. We report the longest survival of a patient with a giant mediastinal endodermal sinus tumor treated with chemotherapy and complete surgical resection.No conflict of interest and there was no funding or financial assistance in this case.No source of fundingIRB approval.Written informed consent was obtained from the patient & Guardians were informed for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request”.Abdullah M Al Ghamdi: wrote Discussion. Othman M Al Fraih: wrote Abstract. Meenal Al Abdulhai: wrote structured abstract, pictures. Yousif Al Qahtani: Arranged table. Ahmed Alshaer: images and legends. Natasha T Khan: searched references. Ikram ul Haq Chaudhry: Operating Thoracic surgeon and drafted the article.Name of the registry: Research registryUnique Identifying number or registration (7085)http://www.researchregistry.com/browse-the-registry#home/Hyperlink to your specific registration (must be publicly accessible and will be checked): Ikram ul haq Chaudhry.


Post-traumatic diaphragmatic rupture is a lesion of variable severity. It is a rare and difficult to diagnose pathology, it has been found in 0.4% of all traumatized patients and in 1.9% of blunt traumas. It can be associated with abdominal andthoracic lesions, particularly cardiac, which can be life-threatening.Our work is a retrospective case report with a descriptive aim concerning a patient operated for a post-traumatic diaphragmatic rupture within the department of general surgery of CHU Ibn Rochd Casablanca. This work has been reported in line with the SCARE 2020 criteria (17).A 60-year-old patient was admitted to the visceral surgical emergency department following a work accident (crushing between two carts) causing a thoraco-abdominal impact point trauma without initial loss of consciousness, nor externalized digestive hemorrhage or associated signs, but with a general condition alteration. The patient was conscious, dyspneic with a blood pressure of 100/50 mmHg and afebrile. Physical examination showed diffuse abdominal sensibility. The thoraco-abdomino-pelvic CT scan revealed the presence of a left thoracic hernia with gastric, colic and epiploic contents through a lateral defect of the left diaphragmatic dome. The decision was to directly send the patient to the operating room. Exploration found a large left diaphragmatic breach of 20 cm, a denudation of the pericardia, a medium-abundant hemoperitoneum and a hematoma of the right mesocolon. The procedure consisted of right hemicolectomy with ileocolic anastomosis, treatment of a diaphragmatic breach with a 2-silk raphia, thoracic drainage with a Joly drain, pericardial drainage with a Joly drain, pre-anastomotic drainage with 2 delbet slides, drainage of the Douglas and left subthreshold with 2 Salem catheters. The post-operative follow-up was simple.Diaphragmatic rupture is a rare and difficult to diagnose condition. Traumatic diaphragmatic rupture (TDR) was found in 0.4% of all traumatized patients and in 1.9% of blunt trauma. Associated lesions of the spleen, liver and/or lungs were found in more than 30% of cases, with an overall mortality rate of 26.8% (1). Pericardial rupture following blunt chest trauma is rare and associated with a high mortality rate ranging from 30% to 64% (9).The physiopathology of this type of injury is not well understood, but the most accepted hypothesis describes an increase in intra-abdominal pressure due to a blunt creating a sufficiently high-pressure gradient between the chest and the abdomen to cause a diaphragmatic rupture. The common clinical symptoms of a diaphragmatic rupture are a marked respiratory distress and diffuse abdominal pain but it can be asymptomatic. Medical imaging exams visualize the ascended organs but it's more difficult to visualize the rupture itself. The chest X-ray is currently the first examination to be requested (4) and also helps in the diagnosis of injuries and diaphragm rupture (13). Surgical treatment includes the reduction of any visceral hernia, repair of the diaphragm and restoration of circulation, breathing and digestive functions. Laparotomy is generally used because of the complete exploration of the abdominal viscera, although it is easier to reduce herniated tissue and repair the diaphragm.Diaphragmatic rupture with denudation of the heart is rare with poor prognosis and requires emergency surgery with close postoperative monitoring in the intensive care setting.Post-traumatic diaphragmatic rupture is a lesion of variable severity. It is a rare and difficult to diagnose pathology, it has been found in 0.4% of all traumatized patients and in 1.9% of blunt traumas. The lesions are more frequent in the left diaphragmatic dome compared to the right one, and exceptionally bilateral. Pericardial rupture following blunt chest trauma is rare and associated to a high mortality rate.It is often unrecognized and goes unnoticed in the acute phase. The most common clinical symptoms of diaphragmatic ruptures are respiratory distress and diffuse abdominal pain, as it can be asymptomatic. Its diagnosis is essentially radiological using CT scan, and requires emergency surgical treatment as soon as the diagnosis is suspected, in order to avoid the dreaded complications.Traumatic diaphragmatic rupture remains a diagnostic and therapeutic challenge.We report the case of a patient who presented a post-traumatic diaphragmatic rupture with pericardial damage operated in the visceral emergency department at the Ibn Rochd Hospital c in Casablanca, Morocco. •Pericardial rupture following blunt chest trauma is associated with a high mortality rate•It requires emergency surgical treatment•Intra-abdominal pressure due to a blunt creating a sufficiently high-pressure gradient to cause a diaphragmatic rupture It occurs in less than 0.5% of all trauma cases, the majority being caused by a penetration mechanism (67%), followed by blunt mechanism injuries 33%) . Diaphra3% . Diap2A 60-year-old patient, known to be a chronic 20 pack-year smoker, is admitted to the visceral surgical emergency department following a work accident (crushing between two carts) causing a thoraco-abdominal impact point trauma without initial loss of consciousness, nor externalized digestive hemorrhage or associated signs, but with a general condition alteration.The patient was conscious, dyspneic with a blood pressure of 100/50 mmHg and afebrile. Physical examination showed diffuse abdominal sensibility.Concerning the paraclinical evaluation, the thoraco-abdomino-pelvic CT scan (A) revealed the presence of a left thoracic hernia with gastric, colic and epiploic contents through a lateral defect of the left diaphragmatic dome which measures 4 cm, an effusion on each side of the hernia with collapse of the adjacent lung and a peri-hepatic effusion at the level of the right iliac fossa, its density is measured at 50 HU, probably related to a hemoperitoneum .Image 1TThe decision was to directly send the patient to the operating room.During exploration, a large left diaphragmatic breach of 20 cm, a denudation of the pericarde, medium-abundant hemoperitoneum and a hematoma of the right mesocolon with devascularization and pre-perforative lesions of the ascending colon were found . The proThe post-operative follow-up was simple. The patient was able to quit the service at D12 after removal of all drains and blades. Monitoring was very favorable over a 3-month follow-up.3Diaphragmatic rupture, as a rare and difficult to diagnose condition, was described for the first time by Sennertus in 1541 [Traumatic diaphragmatic rupture (TDR) was found in 0.4% of all traumatized patients and in 1.9% of blunt trauma. 80% of traumatic diaphragmatic ruptures were found on the left side and 20% on the right side. It was bilateral in about 3% of the cases. The incidence of post-traumatic diaphragmatic rupture among cases of penetrating traumas is 20 to 59% with gunshots and 15 to 32% with stab wounds .60 to 70% of traumatized victims with diaphragmatic rupture in car accidents are men, 30 to 40% are women, with an age going from 30 and 45 years old. A fall from altitude can also rupture the diaphragm [The right diaphragm is congenitally stronger than the left and is partially protected by the liver, which can distribute the pressure over a larger area .Associated lesions of the spleen, liver and/or lungs were found in more than 30% of cases, with an overall mortality rate of 26.8% .Pericardial rupture following blunt chest trauma is rare and associated with a high mortality rate ranging from 30% to 64% .Patients with blunt injuries tend to be older, with a median age of 44 years. In contrast, those with penetrating injuries have a median age of 31 years. Mortality is highest in patients with acute blunt injury associated to other conditions. Mortality due to late consultation with herniation of the abdominal contents in the thorax, following prior penetrating trauma, is about 20% and is significantly higher in cases of intestinal strangulation .The physiopathology of this type of injury is not well understood, but the most accepted hypothesis describes an increase in intra-abdominal pressure due to a blunt creating a sufficiently high-pressure gradient between the chest and the abdomen to cause a diaphragmatic rupture. Normally there is a positive gradient of 7 to 20 cmH2O between intraperitoneal and intrapleural pressures, but in blunt injuries this positive pressure gradient can exceed 100 cmH2O, resulting in a rupture [This is the case of a patient who is admitted for a post-traumatic rupture of the left diaphragmatic dome with denudation of the heart.The etiology of diaphragmatic trauma can be either a slowdown in car accident, falls from altitude and crush injuries to the lower chest or upper abdomen, which are the most common causes of blunt diaphragm injuries .Traumatic rupture of the diaphragm may be asymptomatic .The common clinical symptoms of a diaphragmatic rupture are a marked respiratory distress and diffuse abdominal pain ,11.This is the case of our patient who presented with a diffuse abdominal sensibility on clinical examination with a respiratory distress.Some patients may present with chest and/or abdominal pain depending on the initial point of impact and may be asymptomatic for some .Traumatic diaphragmatic rupture can be divided into three phases: acute, latent and obstructive. During the acute phase: abdominal pain, chest pain and cardiorespiratory dysfunction are usually present. During the latent phase, clinical symptoms of the hernia will be found, such as gastrointestinal disorders, pain in the upper left quadrant or chest, dyspnea/orthopnea, decreased breath sounds. In the obstructive phase, the above mentioned symptoms progress and signs of peritonitis may develop .On further examination, medical imaging exams visualize the ascended organs but it's more difficult to visualize the rupture itself .The chest X-ray is currently the first examination to be requested  and alsoIn our case, the chest X-ray was not performed.Computed tomography (CT) is the imaging technique of second choice, although the axially oriented diaphragm is not always well demonstrated on conventional CT. In a single-layer spiral CT study, the sensitivity for left and right-sided diaphragmatic lesions was 78% and 50%, but with multi-detector CT (MDCT) specificity was 100% and 83% for left and right-sided lesions. Currently, in cases of polytrauma and trauma, including patients with thoraco-abdominal trauma, a whole body CT scan is performed .The CT scan is more sensitive and can confirm the diagnosis in 68.7% of diaphragmatic ruptures .Abdominal ultrasound and chest X-ray are the examinations performed in principle at the emergency service for an unstable patient. For a stable or stabilized patient, the full-body CT scan injected at the arterial and portal times is the reference imaging technique for the lesion assessment .MRI has also been described as a useful imaging adjunct, but because it is generally a time demanding modality, it may be less useful in acute trauma situations .Diagnostic laparoscopy remains an excellent tool for the detection of hemoperitoneum, solid organ damage and diaphragmatic lacerations; And Thoracoscopy has a diagnostic accuracy of 98–100% for diaphragmatic injuries. The diagnosis may even be unsuspected and can only be made by laparotomy in 50% of cases of hemorrhage .A recognized diaphragmatic rupture constitutes an operative indication, as soon as the diagnosis is made .Surgical treatment includes the reduction of any visceral hernia, repair of the diaphragm and restoration of circulation, breathing and digestive functions. Surgical approaches, such as thoracotomy, laparotomy, and thoracotomy with laparotomy, are often used to treat a diaphragmatic rupture. Laparotomy is generally used because of the complete exploration of the abdominal viscera, although it is easier to reduce herniated tissue and repair the diaphragm .Thoracotomy may be necessary for patients with chronic injuries, to safely separate adhesions between the abdominal organs and the pleura .The actual repair is simple: once the contents of the hernia have been reduced, the rupture of the diaphragm can be closed with non-absorbable sutures. A chest drain should be left in the chest for a few days .4Traumatic diaphragmatic rupture remains a diagnostic challenge. CT scan with diaphragm reconstruction is useful for both diagnosis and differential diagnosis. Surgical therapy after diagnosis is the best treatment. Diaphragmatic rupture with denudation of the heart is rare with poor prognosis and requires emergency surgery with close postoperative monitoring in the intensive care setting.There are no sources of funding.It is a case report and not a study.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.researchregistry2464.This work was carried out in collaboration among all authors. All authors contributed to the conduct of this work. They also declare that they have read and approved the final version of the manuscript.The authors report no declarations of interest.


Rare FGF23-producing mesenchymal tumors lead to paraneoplastic tumor-induced osteomalacia (TIO) presenting with phosphate wasting, hypophosphatemia, chronic hypomineralization of the bone, fragility fractures and muscle weakness. Diagnosis of TIO requires exclusion of other etiologies and careful search for a mesenchymal tumor that often is very small and can appear anywhere in the body. Surgical removal of the tumor is the only definitive treatment of TIO. Surgical complications due to chronic hypophosphatemia are not well recognized.The current case describes severe fragility fractures in a 58-year-old woman, who lost her ability to walk and was bedridden for two years. First, the initial diagnostic laboratory work-up did not include serum phosphorus measurements, second, the suspicion of adverse effects of pioglitazone as an underlying cause delayed correct diagnosis for at least two years. After biochemical discovery of hyperphosphaturic hypophosphatemia at a tertiary referral centre, a FGF23-producing tumor of the mandible was discovered on physical examination, and then surgically removed. Postoperatively, severe hypophosphatemia and muscle weakness prolonged the need for ventilation support, intensive care and phosphate supplementation. After two years of rehabilitation, the patient was able to walk short distances. The tumor has not recurred, and serum phosphate concentration has remained within normal limits during 3.5 years of follow-up.The case report illustrates knowledge gaps in the diagnostic work-up of rare causes of low bone mass and fragility fractures. Compared to other low phosphate conditions, surgical recovery from TIO-induced hypophosphatemia warrants special attention. Increased alkaline phosphatase concentration may indicate impaired postsurgical recovery due to prolonged hypophosphatemia, underlining the need for proactive perioperative correction of hypophosphatemia. Tumor-induced osteomalacia (TIO) is a rare paraneoplastic syndrome caused by increased Fibroblast growth factor 23 (FGF23) secretion, typically from a small mesenchymal tumor. In TIO, FGF23 excess drives phosphate wasting and leads to hypophosphatemic oncogenic osteomalacia. Patients typically present with severe symptoms of bone pain, skeletal muscle myopathy, multiple fractures or pseudofractures, skeletal deformities, and impaired quality of life , 2.The diagnosis of TIO is challenging but surgical removal of the phosphaturic mesenchymal neoplasm potentially cures the patient , 3. Alth2 and she was on metformin, long-acting insulin and pioglitazone. She was a current smoker with a smoking history of 27 pack years and her dietary calcium intake was considered normal. Skeletal growth had been normal, and she had not suffered from bone fractures or abnormal skeletal pains previously. She did not have a family history of skeletal, metabolic or hormonal disorders.A 58-year-old female had a three year-history of multiple stress fractures and muscle weakness. Her medical history included well-controlled type 2 diabetes (HbA1c 43 mmol/mol) for nearly 20 years. Her BMI was 39 kg/mThree years prior to diagnosis the patient presented with multiple fragility fractures and increasing bone pain. Fractures were found in the vertebrae  demonstrated osteopenic bone mineral density . Basic biochemistry in primary care was unremarkable (data not shown). Pioglitazone treatment, initiated four years before the first fragility fracture, was suspected to underlie the multiple, low-intensity fractures and therefore discontinued. At this point, type 2 diabetes was considered as another predisposing factor.During the year before the diagnosis, she suffered from a stress fracture of the left femur with significant dislocation  and cholecalciferol (20 µg daily) supplementations were initiated to enhance recovery of bone strength after pioglitazone treatment.DMP-1, ENPP1, FGF23, PHEX and SLC34A3 genes , and she needed constant pain medication . Biochemical tests revealed hypophosphatemia, combined with high serum FGF23-concentration , inappropriately normal 24-hour urinary phosphate secretion, and increased serum alkaline phosphatase concentration Table 1.After the diagnosis was confirmed, the tumor of the right mandible was operated. Histopathological examination of formalin-fixed and paraffin-embedded slides demonstrated a 2.6 cm phosphaturic mesenchymal tumor with multinucleated, osteoclast-like cells . The his3) concentrations (27-30 mmol/l) . From the fourth postoperative day onwards, arterial pH remained within normal range. The patient was decanylated one week postoperatively  for possible studies reporting postoperative complications during surgery for TIO. The identified MeSH-terms were searched in PubMed/MEDLINE database from 1966 to February 28, 2021. No publications describing postoperative prolonged hypophosphatemia, surgical complications, or prolonged need for intensive care or mechanical ventilation support in TIO patients were found. The electronic search was supplemented by manually searching reference lists of recent review articles that revealed two case reports of postoperative recovery in patients with TIO  and 2,3-diphosphoglycerate, both of which are critical for the regulation of cell metabolism and muscle contractility . In inteAlthough the phosphate concentration normalized within two months, the C-terminal FGF23 concentration remained slightly elevated despite biochemical and physical recovery Figure 2We performed a literature search to summarize the current knowledge of surgical complications and identified only three case reports of postoperative problems associated with TIO –22, whicFragility fractures are a diagnostic challenge. They are more common after menopause and in patients with type 2 diabetes, both of which increase bone fragility by enhancing the cortical porosity and decreasing the cortical area and bone material strength . GlitazoDMP-1, ENPP1, FGF23, PHEX and SLC34A3 genes. In addition to the clinical picture, the age of our patient, the results of biochemical testing, the finding of impaired bone mineralization on bone biopsy, as well as the significantly increased serum FGF23 concentrations were consistent with the diagnosis of TIO . In our patient, physical examination revealed a tumor in left mandible region that was confirmed by ultrasound. A biopsy was obtained but is not generally recommended because it may lead to tumor seeding . CurrentPhosphaturic mesenchymal tumors are characterized by distinct molecular genetic features with high prevalence of fibronectin 1 (FN1)-FGFR1 fusion gene and less frequently a FN1-FGF1 fusion, which are detected in in 42% and 6% of cases, respectively and may aid the pathologic diagnosis . We coulThe current case illustrates knowledge gaps in the diagnostic work-up of rare causes of low bone mass and fragility fractures. Phosphorus was measured only after referral to a tertiary center. Pioglitazone use possibly further worsened the clinical course and certainly delayed the diagnosis of TIO in our patient. We emphasize the need to recognize that severe myopathy, longstanding presurgical hypophosphatemia and elevated alkaline phosphatase concentrations may indicate major difficulties in postsurgical weaning from the ventilator, and delayed recovery. In such cases, perioperative hypophosphatemia should be corrected proactively. In the future, novel FGF23-antagonists may prove useful in the preoperative treatment of severe hypophosphatemia when other approaches fail , 39.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study.NM and CS-J designed the case report. ER and NM collected the data and NM reviewed the literature. ER, CS-J, and NM drafted and revised the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that this study received funding from independent research grants from Finska Läkaresällskapet (to CS-J) and the Helsinki University Hospital Research Funds (TYH2017138 and TYH2018223 to CS-J) and (TYH TYH2020402 and M1021YLI31 to NM). The funders were not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Postoperative abdominal pain after gastric surgery requires thorough evaluation in the ED. Portomesenteric venous thrombosis (PMVT) is a rare complication after laparoscopic sleeve gastrectomy, which requires prompt evaluation and diagnosis. Patients require admission with prompt anticoagulation and broad-spectrum antibiotics due to the risk of decompensation from intestinal ischemia and sepsis from bowel translocation. This report describes the case of a 36-year-old male who presented to the ED one week after laparoscopic sleeve gastrectomy with tachycardia and gradual onset, severe, sharp epigastric abdominal pain associated with anorexia and fatigue. He subsequently developed hypotension requiring vasopressor support, acute kidney injury, thrombocytopenia, and septic shock suspected due to secondary to bowel translocation. He was transferred to another facility for consideration for thrombolysis and went on to recover. This case report describes a rare case of PMVT after laparoscopic sleeve gastrectomy. Surgical risk factors include obesity and multiple components of Virchow’s triad. These include inherited/acquired thrombophilic states, iatrogenic endothelial injury of portal vein/mesenteric vessels via direct manipulation, and increased intraabdominal pressure decreasing portal venous flow. Providers should carefully consider evaluation for genetic hypercoagulability requiring lifelong anticoagulation. On hospital discharge, anticoagulation should continue for at least six months, with repeat CT with IV contrast or USG in three to six months to evaluate for recanalization of the venous system. Knowledge of the appropriate evaluation and treatment of this rare complication after laparoscopic sleeve gastrectomy is vital to avoid unnecessary patient morbidity and mortality. Portal venous thrombosis (PVT) refers to occlusion of the portal vein by a thrombus. Portomesenteric venous thrombosis (PMVT) occurs when thrombus extends into the mesenteric venous system and commonly includes the superior mesenteric vein and splenic vein . The mosA 36-year-old male presented to the ED one week after laparoscopic sleeve gastrectomy with chief complaint of gradual onset, severe, sharp epigastric abdominal pain associated with anorexia and fatigue. Initial physical exam revealed a mildly dehydrated and uncomfortable appearing male with sinus tachycardia in the 130s and a nonacute abdomen with epigastric tenderness without rigidity, rebound, or guarding. Surgical sites were well healing, clean, dry, intact and without drainage. CT of the abdomen and pelvis with intravenous (IV) contrast was performed Figure , initialCT report detailed nonenhancement of the splenic vein with complete thrombosis of the portal venous system including main, right, and left porta veins, splenic vein with extension into the superior mesenteric vein and associated branches, with possible internal hernia following surgery. USG imaging redemonstrated thrombosis of the portal venous system. General Surgery and Vascular Surgery departments recommended continued medical management. Our patient required ICU admission on heparin drip, empiric piperacillin-tazobactam for enteric pathogen coverage, and IV hydration. He subsequently developed hypotension requiring vasopressor support, acute kidney injury, thrombocytopenia, and septic shock suspected due to secondary to bowel translocation. Our patient was transferred to an outside facility for consideration of thrombolysis, which was not performed due to patient improvement. The patient went on to recover and was discharged home on Eliquis®  for six months with repeat CT scan in three to six months to evaluate for recanalization of PMVT.Although rare after laparoscopic procedures, PVT occurs due to components of Virchow’s triad. Procoagulopathic factors include inherited/acquired thrombophilic states, iatrogenic endothelial injury of portal vein/mesenteric vessels via direct manipulation, and increased intraabdominal pressure decreasing portal venous flow ,5. WhileWhile PVT is common during certain procedures such as splenectomy and liver transplantation, secondary to direct manipulation of the portomesenteric vasculature, PVT is a rare event after sleeve gastrectomy ,4,5. In The diagnosis of PVT is challenging due to vague clinical manifestations such as non-specific abdominal pain, nausea, vomiting, fever, ascites, or larger than expected wound drainage . If PVT Physical examinations were normal in seven out of 18 patients with PVT . As a reTreatment goals in PVT and PMVT include recanalization of thrombosed vasculature, prevention of recurrence, and treatment of complications -5. PatiePMVT is a rare complication after laparoscopic sleeve gastrectomy, which requires prompt evaluation and diagnosis. Physical exam may be normal and evaluation by CT with IV contrast or USG with doppler is crucial. Patients require admission with prompt anticoagulation and broad-spectrum antibiotics due to the risk of decompensation from intestinal ischemia and sepsis from bowel translocation. Providers should carefully consider evaluation for genetic hypercoagulability requiring lifelong anticoagulation. On hospital discharge, anticoagulation should continue for at least six months, with repeat CT with IV contrast or USG in three to six months to evaluate for recanalization of the venous system. Knowledge of the appropriate evaluation and treatment of this rare complication after laparoscopic sleeve gastrectomy is vital to avoid unnecessary patient morbidity and mortality.


Acute appendicitis is the most frequent indication for emergency abdominal surgery in childhood. Despite being a common condition, the diagnosis of acute appendicitis can be challenging. Ultrasound examination remains the imaging tool of choice for the diagnosis of acute appendicitis. We report the case of a nine-year-old girl who presented with acute abdominal pain in the right lower quadrant accompanied by nausea and vomiting. Physical examination revealed right iliac fossa rebound tenderness. Ultrasound examination showed a dilated blind-ended structure in the right iliac fossa conferring the diagnosis of acute appendicitis. The patient underwent a CT scan which made the diagnosis of imperforate hymen with hematocolpos. The patient underwent hymenotomy and her symptoms showed complete resolution. Imperforate hymen with hematocolpos is a rare congenital genital tract anomaly. The case highlights the importance of appropriate genital examination in pediatric patients. In the present case, the patient might have undergone an unnecessary abdominal surgery if the correct diagnosis was not established. Acute appendicitis is the most frequent indication for emergency abdominal surgery in childhood . AccuratWe present the case of a nine-year-old girl who was brought to the emergency department (ED) with a complaint of abdominal pain for two days duration. The pain was started in the periumbilical region then shifted to the right iliac fossa. Her pain started gradually and has increased in severity. She described it as a constant pain that was not relieved by oral simple analgesic medications. The pain was exacerbated by movement and was not related to posture or meals. She scored the pain as 7 out of 10 in severity. The pain was associated with nausea and few episodes of vomiting that had food content with no blood. One day after the onset of pain, the patient developed a low-grade fever that measured 37.9℃ and was relieved by antipyretics. The parents reported that her daughter had decreased appetite and activity since the onset of pain. However, there was no change in her urinary or bowel habits.The past medical history of the patient was significant for poorly controlled asthma. She required three admissions in the past year due to asthma exacerbation. She was on an inhaled corticosteroid therapy and short-acting inhaled salbutamol. The patient did not have any surgical history. She attained normal growth and development milestones at an appropriate normal age. The gynecologic history was not obtained from the patient. The patient was a primary school student. There was no history of diseases running in their family and the parents were not consanguineous.Upon examination, the patient appeared tired and sick. She was not in respiratory distress. She did not appear pale, jaundice, or cyanosed. Her vital signs were a pulse rate of 100 bpm, blood pressure of 98/65 mmHg, respiratory rate of 13 bpm, and temperature of 37.2℃. Abdominal examination revealed a soft and lax abdomen. There was a localized tenderness in the right iliac fossa with rebound tenderness. Cardiorespiratory and neurological examination findings were normal. Initial laboratory findings were suggestive of an active inflammatory process with elevated leukocyte count and inflammatory markers (Table The patient underwent an abdominal ultrasound examination. It revealed a dilated blind-ended structure in the right iliac fossa with a distended bladder Figure . Such fiWe presented the case of a young girl with imperforate hymen with a clinical and sonographic picture mimicking acute appendicitis. Imperforate hymen is a rare genital tract anomaly with an incidence of one in 2000 girls . It resuWhile the diagnosis of imperforate hymen sounds straightforward, the diagnosis is often delayed or missed in the clinical practice because physicians do not usually obtain a detailed gynecological history of performing gynecological examination routinely . In the Ultrasound examination usually makes the diagnosis. However, in the present case, the radiologists were preoccupied with the initially provided clinical data of acute appendicitis. Hence, the abnormally fluid-filled uterus was incorrectly interpreted as the urinary bladder. Similarly, the abnormally dilated fallopian tube in the right iliac fossa was incorrectly interpreted as the appendix. It is well known that the clinical data provided to the radiologists may cause a distraction and leads to false-positive interpretations .The management of imperforate hymen with hematocolpos is hymenotomy. While this procedure is curative for imperforate hymen, regular follow-up is essential as some patients experience recurrence of symptoms. Some authors advocate performing a virginity-sparing procedure because of cultural and religious aspects .Imperforate hymen with hematocolpos is a rare congenital genital tract anomaly. Clinicians should keep a high index of suspicion for this condition when they encounter an adolescent pre-menarche girl presenting with abdominal pain. The case highlights the importance of appropriate genital examination in pediatric patients. In the present case, the patient might have undergone an unnecessary abdominal surgery if the correct diagnosis was not established.


Schwannoma (neurilemmoma) is a benign neoplasm that arises from the nerve sheath's Schwann cells. Between 25% and 40% of all schwannomas are discovered in the soft tissues of the head and neck area, but they are infrequently detected in the oral cavity, with the lips being the most unusual site of involvement. Peripheral nerves in the intraoral cavity originate only 1% of schwannomas despite the fact that lips and oral cavity are heavily innervated anatomical areas. Schwannomas are more common in people between the third and fifth decades of life, and there is no predilection based on gender or race. Here, we report a case of lip schwannomas in a 22-year-old female. The lesion was affecting her lower lip and growing steadily for the past two years. The mass measured 1.5 x 1 cm, involving the lower lip with surface telangiectasia. The patient underwent surgical removal of the lower lip mass, and the mass was sent for histopathological correlation that showed completely excised encapsulated schwannoma with free margins. The patient did not have any postoperative complications and was discharged home on the same day. The patient was followed up in the outpatient clinics, and she made full recovery and was pleased with the outcome. Schwannomas  are slow-growing, benign nerve sheath tumors derived from the neural crest and made up entirely of Schwann cells ,2. Almos1). On ultrasound examination, the lower lip showed a well-defined, rounded, hypoechoic soft tissue lesion measuring 1.4 x 0.9 cm, along with mild internal vascularity. Surgical excision with histopathological correlation was recommended. The patient was referred to plastic surgery for further management, and they planned to remove it surgically. Therefore, the patient underwent surgical removal of the lower lip mass under general anesthesia. The tumor was fully excised using a fusiform incision, and dissection around the mass was done. The mass was sent for histopathological correlation, which showed biphasic compact hypercellular Antoni A areas and myxoid hypocellular Antoni B areas with nuclear palisading around the fibrillary process  with benign free margins. The S100 stain was positive and showed strong and diffuse staining , the cluster of differentiation 34 (CD34) stain was negative , and smooth muscle actin (SMA) was also negative , which confirmed the diagnosis of schwannoma. The patient did not have any postoperative complications and was discharged home on the same day. The patient was advised to gently rub the lower lip using Vaseline and to start massaging her lower lip two weeks after the operation. The patient was followed up in the plastic surgery and dermatology outpatient clinics, and she made full recovery and was satisfied with the end result .A 22-year-old female presented to the dermatology clinic with a history of an asymptomatic skin lesion affecting the lower lip. The lesion started almost two years prior, growing gradually in size. There was no history of discharge or previous ulceration of the lesion. Upon physical examination, the patient was vitally stable with a single, non-tender, well-defined, firm erythematous mass measuring 1.5 x 1 cm, involving the lower lip with surface telangiectasia (Figure Schwannomas are slow-growing, benign neoplasms that arise from the Schwann cells that surround the sheaths of the peripheral, cranial, or autonomic nerves . SchwannSchwannomas are nerve sheath tumors that are formed solely of Schwann cells produced from the neural crest. They are benign, well-encapsulated, and slow-growing tumors. Lip schwannomas are a rare tumor with a high success rate if detected and treated early. For that reason, lip schwannoma must be considered in the initial differential diagnosis while examining a patient with asymptomatic lip growth. In cases of benign lip schwannoma, surgical excision is the gold standard of treatment, with excellent postoperative prognosis and rare incidences of recurrence.


Colonoscopy is a well-tolerated therapeutic and diagnostic procedure. Although colonoscopy is relatively safe, a few complications have been reported. Abdominal pain after colonoscopy is one of the most reported symptoms, and acute pancreatitis is uncommon after colonoscopy. We present a case of acute pancreatitis in a 51-year-old female who presented with a complaint of melena. She underwent colonoscopy to rule out lower gastrointestinal pathology and developed sudden onset diffuse abdominal pain and vomiting two hours after the procedure. She was diagnosed with colonoscopy-induced acute pancreatitis based on physical examination and detailed investigations after ruling out all other potential causes. She was treated conservatively with bowel rest, intravenous fluids, analgesic, and prophylactic antibiotics. Abdominal symptoms improved quickly in a few days with complete resolution of abdominal pain, fever, and normalization of serum amylase and lipase. Early recognition and diagnosis can lead to successful treatment, and the patients should be informed about the possibility of this complication before undergoing colonoscopy. Colonoscopy is a relatively common diagnostic and therapeutic procedure to investigate colonic pathology. While colonoscopy is generally considered a safe, effective, and well-tolerated procedure, it has also been associated with a few complications . Common A 51-year-old female with a past medical history of diabetes mellitus and hypertension was admitted to the hospital for the evaluation of dark color stool. She was compliant with insulin and lisinopril, and she denied alcohol use, smoking, and illicit drug abuse and reported no history of trauma. On examination, the abdominal examination was non-significant, and coffee-ground appearance feces with positive occult blood test were noted in the rectal vault by digital rectal examination. Her serum chemistry and blood results were normal except for low hemoglobin (9.8 mg/dL). She was found to have ulcers in the stomach and treated appropriately. Later on, she was scheduled for a colonoscopy due to her father's family history of colon cancer and universal screening. Her bowel was prepared using polyethylene glycol in 2 L of water. As premedication, midazolam and propofol with a single bolus of 50 mg were given over 10 seconds through a rapid running intravenous catheter. Colonoscopy was guided up to the terminal ileum, and there was no difficulty crossing the ileocecal valve, and the total intubation time was 10 minutes. Findings revealed one sessile polyp in the sigmoid colon and one polyp in the ascending colon. Both polyps were removed using a cold snare, and electrocautery was not performed during the procedure.3), lipase (1619 IU/L), amylase (502 IU/L), and C-reactive protein (31 mg/L)  of the abdomen was performed, which showed edematous pancreas and poorly defined borders consistent with acute pancreatitis diagnosis Figure . There wAcute pancreatitis is an inflammation of the pancreas characterized by epigastric pain, nausea, vomiting, and elevated serum amylase and lipase levels on the complete metabolic panel . The incThe pathophysiology for the development of acute pancreatitis in such cases is uncertain, and it has been proposed that moving the endoscope through the bowel causes indirect injury to the body and tail of the pancreas due to the anatomic proximity of splenic flexure to the pancreatic tail ,13. PancIn this case, the patient developed acute pancreatitis directly after a colonoscopy. She was healthy and fit previously. The procedure went smoothly, with easy passage through the colon without electrocautery and external abdominal pressure. She had no other risk factors for acute pancreatitis, and her lipid profile, autoimmune screening, and metabolic panel were non-significant. Before the procedure, she did not report any abdominal trauma, and her imaging revealed no pancreatic anatomic anomalies. It is unlikely that the patient had propofol-induced acute pancreatitis because our patient received a single dose of 50 mg propofol through rapid infusion. The literature reported that a minimum dose of 200 mg with intermediate latency of 1-30 days could lead to acute pancreatitis . It is aAbdominal pain is common after colonoscopy and warrants evaluation to rule out causes such as perforation. Although acute pancreatitis induced by colonoscopy is rare, it should be considered among the differential diagnoses after ruling out all probable causes. Early recognition and diagnosis can lead to successful treatment, and the patients should be informed about the possibility of this complication before undergoing colonoscopy.


Mixed serous-neuroendocrine neoplasm constitutes pancreatic serous cystic neoplasms and pancreatic neuroendocrine tumor, two tumor components with different underlying pathologies. The differentiation of these tumors is important as the management and prognosis depend on the pancreatic neuroendocrine tumor component. We report a case of mixed serous-neuroendocrine neoplasm in a 47-year-old female who presented with epigastric pain abdomen for two years. Imaging studies, tumor markers, thorough systemic evaluation, surgical resection, histopathological examination, and timely follow-up constituted our management approach. A 4 cm × 4 cm mass in the distal pancreas with multiple cysts in the pancreatic parenchyma containing serous fluid on distal pancreatectomy and splenectomy was found. The histopathological examination revealed combined benign serous cystadenoma and neuroendocrine tumor. She did not have any recurrence or metastasis by four years of follow-up. Pancreatic cystic lesions are relatively rare, which are mostly serous and mucinous subtypes . PancreaA 47-year-old female presented with pain abdomen especially in the epigastrium for two years. She denied any history of vomiting, jaundice, anorexia, or weight loss. She had a history of type 2 diabetes mellitus for five years controlled under oral hypoglycemic drugs. Physical examination did not reveal any abnormal findings. Laboratory evaluation showed a normal level of complete blood count, comprehensive metabolic panel, and amylase. Furthermore, tumor markers CEA , CA 19-9 , and CA 125  were normal, while Chromogranin A was elevated . The contrast-enhanced computed tomography (CECT) of the abdomen and pelvis showed an intensely enhancing mass in the tail of the pancreas along with multiple cysts with calcific foci in the body of the pancreas suggestive of a neuroendocrine tumor with multiple cysts in the pancreas Figures . Based oDespite its rarity, PSCNs are occasionally found with other concurrent tumors like PanNET, pancreatic ductal adenocarcinoma, intraductal papillary mucinous neoplasm, and metastatic tumors . Among tIn the case report and literature review of 15 cases, Li et al. categorized MSNN into four subtypes, namely, (1) diffuse subtype where numerous PSCNs occupied the entire pancreas along with one or more PanNETs, located in any part of the pancreas; (2) mixed subtype having two different tumors combined in a mass which cannot be distinctly separated; (3) solitary subtype having different components coinciding in the pancreas without any intermingling area; and (4) collision subtype with two different lesions separated from each other in most areas, but having a partially intermixed or overlapping zone . FurtherThese MSNN cases showed a higher incidence in females, and it mostly presented with pain abdomen, nausea/vomiting, weight loss, and jaundice , 8. The α-inhibin and calponin) [Transabdominal ultrasonography is the first imaging study done for a pancreatic lesion. Multidetector computed tomography (MDCT) is the gold standard test for detecting solid pancreatic tumors. Pancreatic cystic lesions are better visualized on magnetic resonance imaging (MRI), while MR with cholangiopancreatography (MRCP) is the gold standard investigation to identify the cystic pancreatic lesion . Similaralponin) , 13. PSCalponin) . In our alponin)  in our pPSCN in itself is benign  and the MSNN with associated VHL associated syndrome requires further consideration as VHL syndrome-associated MSNN presents at a younger age, has diffuse-type PCSN, has a larger PanNET size, and has other associated tumors  . MoreoveMSNN constitutes of histopathologically two distinct lesions where thorough evaluation is needed to explore other associated conditions to timely detect and manage. Since the PanNET component of MSNN is a potentially malignant tumor, close follow-up and surveillance are imperative for detecting any recurrence or metastasis.


Tracheal atresia is an extremely rare condition whereby a partial or total obstruction of the trachea is seen. It is almost always lethal, with just a handful of cases that ended with a good outcome. In this study we report on a 15-week male fetus, diagnosed with hyperechogenic lungs, midline heart position and inverted diaphragm. Sonographic findings suggest congenital High Airway Obstruction Syndrome (CHAOS) An ultrasound scan and fetal MRI were not able to point out the exact obstruction level. In spite of extensive counselling, the parents opted to carry on with the pregnancy. Fetal demise was noted on a scan at 19 weeks gestation. After the elective termination of pregnancy, a post-mortem examination showed partial tracheal atresia with no other anomalies. Despite technological progress in CHAOS syndrome, a precise diagnosis and accurate prognosis remain elusive. Congenital high airway obstruction syndrome (CHAOS) is an extremely rare and usually lethal anomaly caused by congenital total or partial obstruction of the upper airways. First described by Hendrick et al., the acronym CHAOS is most suitable since a precise prenatal diagnosis, although desirable, is usually not possible. The true incidence of CHAOS is unknown, but the scientific literature reports about 1/50,000 . As a reAdditionally, the intrathoracic pressure is increased, leading to cardiac failure, anaemia, ascites and hydrops. In this article, we report the case of a 20-week-old fetus with congenital high airway obstruction syndrome, which was diagnosed at 15 weeks, but the parents declined the termination of pregnancy as long as the fetus was alive. The postnatal autopsy revealed tracheal atresia.A 42-year-old patient with 2 previous live births (para 2) was referred to us for increased nuchal translucency of 3.2 mm following the first-trimester scan. Due to unforeseen reasons, she missed her appointment twice. When she finally presented to the doctor, the pregnancy was assessed at 15 weeks gestation, using convex probe 2D-4D RAB 6 D Voluson E10 BT16 , showing the following results: male sex fetus, with enlarged and echogenic lungs, flattened diaphragm, small and compressed heart, which was shifted toward the midline, large heart vessels and dilated bronchi . There wPermission for autopsy was obtained from the parents, and the product of conception with umbilical cord and placenta was sent to the Department of Pathology for histopathological examination.The fetus that resulted from a therapeutic abortion was a male with the following anthropometric indices: weight: 200 g, cranio-caudal length: 12.5 cm, occipito-frontal circumference: 13 cm, thoracic circumference: 10 cm, abdominal circumference: 9 cm.External examination revealed cyanotic skin and mucous membranes, normal represented subcutaneous tissue, non-palpable lymph nodes and normally shaped external genitalia. The attached umbilical cord measured 9.5/0.8 cm.Anterior fontanelle measured 2.5/1 cm and posterior fontanelle measured 0.3/0.3 cm. Leptomeninges were semitransparent, with congestive vessels, revealing an edematous encephalon with symmetrical cerebral hemispheres and reddish spots on the cut surface which disappear when immersed underwater. Cerebellum measured 2/1/0.8 cm, with normally conformed and symmetrical cerebellar hemispheres. The bones at the base of the skull revealed no noticeable macroscopic changes.The opening of the thoracic cavity revealed a grey-purple thymus, measuring 1.5/1/0.5 cm, with preserved lobulation. The esophagus was permeable, with congestive mucosa. The lungs were moderately enlarged, weighing 28 g each, with semitransparent pleura and ribs impressions on the external surface. Upon careful dissection of the upper respiratory system, airway obstruction was observed at the subglottic level, where dome-shaped cricoid cartilage appeared to be the cause of obstruction. No tracheoesophageal fistula was observed . The heaThe opening of the abdominal cavity revealed approximately 5 mL of odorless serous liquid. The spleen, liver and kidney were enlarged and engorged with blood. Internal genitals were in accordance with external ones. No additional pathological findings were noted.Histopathological evaluation showed tracheal atresia with overgrowth of the cricoid cartilage . BilaterChaos syndrome can be diagnosed on scan as early as 15 weeks as our case report showed. Laryngeal atresia is the most frequent cause but there are other etiologies such as tracheal atresia, laryngeal or tracheal webs, laryngeal cyst, subglottic stenosis or atresia, laryngeal or tracheal agenesis. Several cases where the fetus survived through fetoscopy, followed by caesarean section and EXIT (exutero intraprtum treatment) surgery, have been published . EXIT suThe median gestational age of diagnosis was 21 weeks, and the median maternal age was 31 years (range 31–35). Our case was detected at 15 weeks of gestation, and according to our review this is the earliest gestational age at which CHAOS was diagnosed. All subjects showed typical signs of CHAOS. The median age at delivery was 29.5 weeks. Recent studies show that in selected cases, performing in utero-surgery with EXIT procedure at delivery can alter the usually grim prognosis of CHOAS. We found 5 cases of long-term surviving babies with tracheal atresia. Neurological development appears to be normal in fetuses without additional anomalies, but issues such as phonation or feeding can persist for the rest of their life. Hydrops is a sign of poor prognosis . Associated anomalies and particularly those defects that can’t be detected prenatally, complicate survival rate and prognosis. The complexity of the case can be enhanced by a twin pregnancy, where a normal twin is at risk of preterm delivery due to complications of the affected fetus . This matter is reported in articles published by Siemtka and by Ellio et all ,13. The Most cases reported in the literature report a variety of histological alterations, although normal histologic aspects have also been reported. Most commonly described is the presence of congenital cystic adenomatoid malformation of the lung, especially in cases presenting with laryngeal atresia. A notable case of laryngeal atresia was described by Witters et al., who reported a case associated with pulmonary atresia, thymus hypoplasia and Fallot tetralogy, constellation consistent with the diagnosis of DiGeorge defect. Other issues presented with an increased number of alveoli, an aspect suggestive for the diagnosis of polyalveolar lungs while some authors report a subglotic stenosis, due to the hyperplasia of the fibrous connective tissue from the submucosa ,7,18. AsOur case showed an isolated anomaly of tracheal atresia diagnosed at 15 weeks of gestation. Parents option to carry on with the pregnancy allowed us to follow the natural course of the condition. However, the situation worsened at 19 weeks of gestation when fetal demise was noted on ultrasound examination.Several years ago, CHAOS was considered universally lethal. Technological and medical progress have partially changed the fatal outcome in selected cases. The etiology of CHAOS is of utmost importance, primarily, since cases of tracheal pathology are known to have a worse prognosis than those of larynx atresia. The presence of a tracheal web or a natural fistula is an important factor in selecting patients for in utero intervention. EXIT procedure has proved helpful in improving the outcome of the pregnancy. Nevertheless, the prognosis of CHAOS syndrome is overall poor, and in many cases presence of multiple malformations or other genetic syndromes can be diagnosed only after birth. Therefore, a thorough discussion and counselling in a multidisciplinary format of the future parents are compulsory, requiring explanations regarding all options.


Cecal gastrointestinal stromal tumors (GIST) constitute a rarer subtype of all GISTs. Rarely, it can present with ileocolic intussusception in adults making it a challenging diagnosis due to non-specific clinical features.A 30-year previously healthy woman presented with lower abdominal pain and a distended abdomen who was subsequently diagnosed with ileocolic intussusception on a CT scan. Intraoperatively, a pedunculated polypoid hard mass was identified in the cecum and thus, a standard right hemicolectomy was performed with the suspicion of malignancy. Histopathology of the resected mass confirmed CD117 negative, spindle type GIST.Cecal GIST presenting in the form of ileocolic intussusception is rare. Contrast-enhanced CT scan is the preferred imaging modality for the evaluation of patients with suspected GIST to determine the extent of the tumor, the presence or absence of metastatic disease alongside evaluation of the possibility of complete resection. Adjuvant imatinib therapy following complete resection decreases the disease recurrence.Intussusception in an adult can be the first manifestation of underlying malignancy like GIST. Complete surgical resection of the tumor with a negative margin offers long-term survival. •Ileocolic intussusception is rare in adult and often associated with pathological lead points like neoplasm.•Cecal GIST is an uncommon cause of ileocolic intussusception in adults.•Diagnosis of this entity is challenging because of its non-specific presenting features. Intussusception in adults comprises 1% of all intestinal obstructions and only 0.003%–0.02% among all hospitalized patients . As thesIn the literature, very few cases of bowel intussusceptions from a stromal tumor in adults have been described. Here, we present a case of an adult female with ileocolic intussusception due to underlying CD117 negative cecal GIST. The coexistence of these pathologically distinct and rare entities has seldom been reported and represents a unique finding. This case has been reported in line with SCARE criteria .2A 30-year regularly menstruating non-alcoholic and non-smoker, previously healthy female presented to our center with a complaint of insidious onset, severe, colicky, and non-radiating right lower abdominal pain for 10 days along with multiple episodes of vomiting containing ingested food particles. However, there was no fever, hematochezia/melena, weight loss, or trauma to the abdomen before the onset of the symptom. There was no surgical history or any family history of malignancy.2 of 97% in the room air. On abdominal examination, the lower abdomen was soft, tender, distended with increased bowel sound without any sign of peritonitis. Examination of all other systems was grossly normal.On examination, she was afebrile with a BP of 100/80 mmHg, pulse rate of 80 beats per minute, respiratory rate of 15 breaths per minute, and SpOBlood counts were within normal limits with Hb of 11.1 g%, total count of 12,000 and platelets of 351,000, serum sodium of 134 mEq/L, serum potassium of 3.6 mEq/L, RBS of 4.1 mmol/L (3.1–7.8), urea of 3.7 mmol/L (1.6–7.0), and creatinine of 58 μmol/L (40–110). Plain abdominal radiograph revealed dilated small bowel loops and multiple air-fluid levels suggesting small bowel obstruction. A contrast-enhanced CT scan of the abdomen showed telescoping of ileal segments into ascending colon .Fig. 1CEWith the suspicion of intussusception causing intestinal obstruction, she was resuscitated with intravenous fluids along with nasogastric decompression and intravenous antibiotics. Emergency laparotomy was done and on exploring the abdomen, ileal loops invaginating into ascending colon with proximal dilated bowel loops were revealed. After the reduction of the intussusception, a hard mass was felt at the cecum. With suspicion of a malignant lesion, a standard right hemicolectomy was performed by the experienced team of gastrointestinal surgeons of Tribhuvan University Teaching Hospital. On opening the specimen, a pedunculated polypoid hard mass of size 9 cm × 5 cm × 3 cm was seen arising from the posteromedial wall of the cecum with separated visualization of the appendix .Fig. 2RiHistopathological examination of the excised mass showed spindle-shaped cells arising from the muscularis propria and arranged in fascicles with oval to elongated nuclei having mild nuclear polymorphism and vesicular chromatin along with dense infiltration of lymphocytes in the intervening collagenized stroma . The mitThe post-operative period was uneventful and the patient recovered well. The patient was started on imatinib considering the large size of the tumor with a moderate-risk category. The patient is doing well and remains disease-free at 6 months of follow-up, and is happy with the treatment she is receiving.3GISTs are rare gastrointestinal tumors that arise from interstitial cells of Cajal or stem precursors cell and commonly seen among male above 40 years of age ,8. The pMost of the surgeons opt for surgical procedures among adults with intussusception because of its greater incidence with structural anomalies and malignancy . The opeTumor size and mitotic index help in determining the malignancy potential of GIST. Intestinal GISTs with size >5 cm have moderate risk while tumors with 5 mitoses per 50 high power field mitotic activity have high risk . The mitPDGFRA D842 mutations [C-kit-positive GISTs are treated with surgery and/or imatinib. For patients with intermediate and high-risk GIST, adjuvant imatinib therapy after surgery is required which reduces the recurrence rate and improves survival . As therutations . Our pat4Cecal GIST presenting in the form of adult ileocolic intussusception is rare and poses adiagnostic challenge for a surgeon because of its non-specific presentation. This entity has to be considered in adults presenting with intussusception. Surgical resection is the mainstay of the treatment.None.


Fibroepithelial polyps represent a frequent cutaneous lesion of mesodermal origin, with a prevalence of 1.2% and are rarely located at palatine tonsils. We present a rare clinical report of a 70-year-old female patient with fibroepithelial polyp of palatine tonsil. This entity represents the eighth case of palatine tonsil fibroepithelial polyp in the English literature. She presented with a polypoid mass at the right tonsil and unspecified throat symptoms. Physicians should pay attention to such lesions because of the residual risk of malignant transformation, along with non-specific symptoms. Differential diagnosis was among neurofibroma, lipoma, squamous papilloma and fibroepithelial polyp. Histopathological examination following tonsillectomy showed a structure rich in vesicles inside lamina propria and surrounding inflammation, establishing the diagnosis of a fibroepithelial polyp. It requires vigilance during complete clinical examination, in order to detect masses at patients with throat symptoms that could have remained undiagnosed until they become even life threatening. Fibroepithelial polyps (FPs) are benign lesions with exceptionally low incidence of malignant change . They arPatient information: a 70-year-old female patient presented to the ear, nose, and throat (ENT) outpatient department, mentioning a four-month history of throat lump. There was no history difficulty in swallowing and breathing, throat pain, change in voice or injury. It is of importance that the patient did not report foreign body sensation in her throat, ipsilateral to the lesion. According to her medical history, she suffered from hypertension and hyperlipidemia and was under medication. The patient did not mention a significant family history. She was a housekeeper, married with children and grandchildren and was under normal psychological condition. She did not mention any surgeries at the oropharynx or nasopharynx.Clinical findings: the examination of the oropharynx revealed a polypoid, painless, well-defined and smooth-surfaced lesion arising from the superior pole of the right palatine tonsil, with dimensions of approximately 2.5 x 1.5cm ( x 1.5cm . It was Timeline of current episode: the patient had a 4-month history of throat lump when she came to our hospital. She visited the emergency department of another hospital, about one month after the onset of the symptoms. She did not receive any diagnosis or treatment, so the throat lump insisted. She visited our outpatient department and one month later she underwent tonsillectomy.Diagnostic assessment: pre-operative blood test results did not reveal any abnormal values, while no imaging examinations were necessary. Similarly, the rest of ENT examination was normal.Diagnosis: fibroepithelial polyps was not the first diagnosis that we considered. We included tumours such as angiolipomas, lipomas, neurofibromas, lymphangiomas and squamous papilomas. Prognosis of FPs is excellent when they are completely removed, as they are benign lesions, while the relevant risk of malignancy is very low, about 0.37% [ut 0.37% .Therapeutic intervention: a cold steel dissection bilateral tonsillectomy under general anesthesia was performed. Both tonsils, the right one containing the polypoid mass and the left, the normal one, were sent for histopathological examination. Results from the pathology department showed, in macroscopic description, a protruded, ash grey colored, polypoid lesion at the superior pole of the right tonsil. Microscopically, the subepithelial stroma was containing variable sized, thin walled, vascular channels, along with perivascular infiltration of lymphocytes and plasma cells. All these findings were compatible with a fibroepithelial polyp, which was completely removed ( removed . There wFollow-up and outcome of interventions: postoperative care was uncomplicated, and the patient was discharged the second postoperative day in excellent general condition. It was decided that it was not necessary to carry out further examinations because of the benign nature of the mass and the complete excision of it. At 1-year follow-up period assessment, the patient was symptom-free and there was no evidence of FP recurrence.Patient perspective:“when I first visited your department, I was quite disappointed because I had a 4-month history of throat lump and could not find a solution to my problem. That symptom made me depressed because I thought that I would die with it. The fact that you detected the polyp, made me trust you and gain a positive attitude towards treatment. Although I thought that the treatment would be medical, I finally decided to proceed to surgical treatment. I was fully informed about the procedure, its duration, its risks and the recovery time. I was in excellent condition during my stay at the hospital, as well as during recovery. At my follow-up appointments, I was optimistic and happy and relieved from my throat symptoms”.Informed consent: patient was fully informed about the risks, benefits and alternatives of the proposed treatment. She was also informed about the case report and the fact that her case was rare. She gave the permission to write and publish a case report, in order to add some more information about such cases to the existing literature, and she provided a written informed consent.Fibroepithelial polyps, also known as acrochordons or soft fibromas, are benign, mainly solitary cutaneous protrusions that only very rarely undergo malignant change . They caMost patients are asymptomatic, but polyps can sometimes cause cough, chocking, or foreign body sensation . MoreoveFibroepithelial polyps constitute a very rare benign lesion when they arise from the palatine tonsils. When they do not cause obstructive phenomena, they are not life-threatening. Surgical excision is the treatment of choice, as there is always the risk of malignant transformation or airway obstruction. Despite not common they should be considered by clinicians in the differential diagnosis when such tumours are revealed at palatine tonsils during intraoral examination.