A 77-year-old male presented with diarrhoea, weight loss and faeculent vomiting. CT scan identified a stricturing lesion in the transverse colon. The man, however, had no features suggestive of large bowel obstruction. This unusual presentation of faeculent vomiting raised a suspicion of a possible communication between the colon and stomach. A subsequent CT scan with oral contrast confirmed the presence of a gastrocolic fistula. During explorative laparotomy, a transverse colonic tumour communicating into the stomach via the gastrocolic fistula was detected. The patient underwent an extended right hemicolectomy and distal gastrectomy as a palliative measure. A gastrocolic fistula is a rare, yet important find and should be recognized as a possible sequel of this disease process. A 77-year-old male presented with a 7 day history of “dark coloured faeculent” vomitus and diarrhoea. He further reported unintentional weight loss of 7 kg over the last 4 months, lethargy and being “unwell”. He denied any abdominal pain or distension. His medical history included chronic hyponatraemia, myocardial infarction, Type II diabetes mellitus and sigmoid diverticular disease.His observations on admission were a temperature of 36.2°, respiratory rate of 22 with saturation of 97% on air, heart rate of 63 beats per minute and a blood pressure of 109/51 mmHg. Abdominal examination revealed a soft, non-distended, non-tender abdomen with mild fullness over the caecal pole. There were no signs of peritonism. Per rectal examination revealed an empty rectum with no evidence of a mass or bleeding. The faeculent vomiting prompted a surgical opinion leading to a series of investigations.Based on the history and presenting symptoms, our differential diagnosis included acute or subacute intestinal obstruction secondary to a mechanical, inflammatory or neoplastic pathology.−1 and mean corpuscular volume of 84 fl. His white blood cell count was 11.4 × 109 l−1, CRP 5.2 and platelet of 372 × 109 l−1. Urine and electrolytes revealed low sodium of 128 mmol l−1 in keeping with chronic hyponatraemia. A low serum albumin of 29 g l−1 was found, as expected in locally advanced colon cancer. The coagulation profile, lactate level and CEA were normal. Both urine dipstick and stool sample were also negative.Blood tests revealed a microcytic anaemia with haemoglobin of 76 g lAn oesophagogastroduodenoscopy revealed duodenitis with no evidence of acute or recent stigmata of bleeding. The initial CT scan with intravenous contrast revealed a stricturing mass in the proximal transverse colon in close proximity to the pylorus of the stomach. Further examination with oral contrast demonstrated a distended stomach and a communication between the pylorus and transverse colon, thus confirming the presence of a gastrocolic fistula . ImagingThe patient was subsequently transferred to a regional specialist centre for further optimization and investigations including a staging CT scan that reported T4 N0 MX disease with no radiological evidence of distant spread. Following multidisciplinary team meeting discussion (MDT), he underwent a distal gastrectomy, extended right hemi-colectomy with Roux-en-Y reconstruction. Intraoperatively, there was no evidence of metastatic disease.Histology confirmed a Duke’s B  moderately differentiated adenocarcinoma of the transverse colon with no evidence of extramural vascular invasion.10 days post-laparotomy, the patient developed a duodenal stump leak and therefore, underwent exploration, repair of the leak, and a feeding jejunosotomy.The patient had a prolonged stay in the hospital needing organ and nutritional support. He has now made a full recovery.1 It is a rare find with only a handful of cases being reported in existing literature. A greater incidence has been reported in females between the ages 50–60 years.2A gastrocolic fistula is an abnormal communication between a segment of large bowel  with a portion of the stomach, most commonly the greater curvature.3 The patient may present with an array of signs including anaemia, weight loss, malaena, ascites, palpable mass, faeculent vomiting or faecal oris.5 There is, however, a well-known triad of diarrhoea, weight loss and faeculent vomiting which in fact our patient displayed.6 Whether the cause of a gastrocolic fistula is benign or malignant, the process of formation of fistula is thought to be due to a prolonged inflammatory response resulting in migration of intestinal epithelial cells into deeper layers of the intestinal wall causing localized tissue damage and subsequently a communication to other organ or the body surface.7First described in 1755 by Albrecht von Haller, a gastrocolic fistula may result secondary to various pathologies including chronic pancreatitis, diverticular disease, malignancies of the stomach or colon or tumours invading the biliary tract, pancreas and duodenum.8 Examination with gastroscopy may fail to identify the abnormal fistulous tract opening. Colonoscopy may fail to assess the pathology, progress beyond the stricture itself or identify the tract. In addition, biopsies, although key to establishing the diagnosis, may be inconclusive due to technical reasons.2The potential risk factors for this clinical presentation include helicobacter pylori status, tumour genetics and microsatellite instability and should be further investigated if necessary.9 Further management is discussed at MDT. In patients deemed suitable for resection, an en bloc resection of the tumour remains the mainstay of treatment. Additional neoadjuvant treatment is tailored per the histology and the individual’s needs. The main prognostic factors include the age of the patient, the stage of disease at time of diagnosis and the tumour genetics. These patients unfortunately have a poor prognosis with the mean survival of less than 2 years.10The presence of frank faeculent vomiting in a soft and non-distended abdomen raised a strong possibility of gastrocolic fistula in our patient. This was eventually confirmed via oral contrast studies. Other imaging methods to demonstrate gastrocolic fistula include a barium enema study.Our case demonstrate a rare but important complication of a common large bowel pathology. Faeculent vomiting is usually observed in intestinal obstruction resulting in a distended abdomen. Our patient, however, had a completely soft, non-distended and non-tender abdomen. In addition, he did not have any risk factors for this pathology. The faeculent vomiting, in the absence of an obstructed colon raised a strong suspicion of gastrocolic fistula subsequently confirmed via imaging studies. These clinical findings, hence, are important for clinicians to recognize enabling early diagnosis and appropriate treatment.Patients presenting with faeculent vomiting in absence of signs of obstruction raise suspicion of a gastrocolic fistula.Radiological studies such as CT scan of the abdomen with intravenous and oral contrast is an extremely valuable tool for confirming the diagnosis.Management is tailored individually and based upon discussion via a MDT.


Self-expandable metallic stent placement is a widely performed palliative procedure or bridge to surgery for obstructive colorectal cancer. However, the feasibility of this procedure for large bowel obstruction induced by effective neoadjuvant therapy is unclear.We herein report three such cases involving a 61-year-old man who underwent neoadjuvant chemoradiotherapy for lower rectal cancer, a 56-year-old woman who underwent neoadjuvant chemotherapy for lower rectal cancer, and a 63-year-old woman who underwent neoadjuvant chemotherapy for lower rectal cancer. All were emergently hospitalized with large bowel obstruction that developed while undergoing neoadjuvant therapy. Colonoscopy revealed smooth strictures caused by effective neoadjuvant therapy. Self-expandable metallic stents were placed across the obstruction as a bridge to surgery, and laparoscopic low anterior resection was uneventfully performed in all patients.We successfully treated three patients with large bowel obstruction induced by a good response to neoadjuvant therapy using self-expandable metallic stents as a bridge to surgery. Further studies with larger sample sizes are warranted to assess the feasibility of this strategy. Neoadjuvant therapy (NAT) such as neoadjuvant chemotherapy or neoadjuvant chemoradiotherapy for advanced lower rectal cancer is widely performed to reduce the risk of distant metastasis or local recurrence and to ultimately improve long-term outcomes –4. HowevPlacement of a self-expandable metallic stent (SEMS) to relieve colonic obstruction as a bridge to surgery (BTS) has recently become an effective alternative modality in patients undergoing elective operations for malignant LBO . HoweverWe encountered three patients with rectal cancer who developed LBO induced by effective NAT and were successfully treated by the BTS approach.A 61-year-old man visited our hospital with constipation. Colonoscopy revealed a circumferential tumor in the lower rectum, 60 mm from the anal verge Fig. . Biopsy A 56-year-old woman presented because of lack of defecation. She underwent colonoscopy, and a circumferential tumor was found in the lower rectum, 45 mm from the anal verge Fig. . The tumA 63-year-old woman presented with bloody stool. Colonoscopy revealed a circumferential tumor in the lower rectum, 80 mm from the anal verge. The tumor was diagnosed as cT3N2M0 stage IIIb rectal cancer. mFOLFOX6 plus cetuximab was started as NAT. Upon completion of five courses, the patient visited our hospital on an emergency basis complaining of no defecation for several days. Emergency colonoscopy showed a stenosis in the lower rectum, where the primary tumor was located. CT showed that the tumor had obviously shrunk and that an LBO had developed. The tumor exhibited a cPR to the NAT. We estimated that the stenosis had been caused by effective NAT, as in cases 1 and 2. A SEMS (Niti-S Colonic Stent) 6 cm in length by 18 mm in diameter was placed as a BTS across the stenosis. After SEMS placement, the patient began oral intake and NAT was restarted immediately. Upon completion of six courses, laparoscopic low anterior resection with diverting ileostomy was performed. The duration of the operation was 218 min, and the blood loss volume was very small. The pathological diagnosis was well-differentiated adenocarcinoma, T3 (SS), INFc, ly0, v1, PN1a, pPM(−), pDM(−), pRM(−), pN1 (1/18), and stage IIIa. The tumor cells contained atypical cells with growth of fibrous tissue and inflammatory cell infiltration. Histopathologically, the chemotherapeutic effect was grade 2. The patient had an uneventful postoperative course and was discharged 24 days after surgery. mFOLFOX6 was started after surgery as adjuvant chemotherapy. At the time of this writing, the patient had been alive without recurrence for 11 months.LBO with growth of fibrous and edematous tissue can occur as an adverse event during NAT. Neoadjuvant chemoradiotherapy for rectal cancer causes tumor regression by eradication and replacement of carcinoma cells by fibrous or fibroinflammatory tissues . PreviouThe three cases described herein suggest that SEMS placement can be a good strategy as a BTS for LBO associated with a good response to NAT. In general, three treatment options are available for LBO: an emergency operation, transanal decompression tube placement, and SEMS placement. SEMS placement as a BTS is a widely accepted alternative intervention for malignant LBO because its short-term outcomes and preoperative quality of life are better than those of emergency surgery and transanal decompression tube placement , 13. PreThe selection of the most appropriate SEMS with respect to the type and diameter for LBO induced by effective NAT is a critical concern for successful placement. In our institution, we usually select the 18-mm-diameter Niti-S Colonic Stent, the radial force of which is mild considering the vulnerability of the rectal wall when affected by NAT-induced fibroinflammation.Generally, SEMS placement as a BTS for lower rectal cancer has not been recommended because of problems such as anal pain, anastomotic leakage, and difficulty in anal preservation. When placing a SEMS for lower rectal cancer, we believe that the distance between the proximal edge of the SEMS and the anal edge of the tumor should be kept at ≤ 10 mm. Although it is generally thought to be difficult to place the proximal edge of a distal-releasing type SEMS exactly at the most appropriate location, the stents in the current cases were successfully placed by the expert endoscopist in our institution. Placement of an uncovered stent with a proximal-releasing delivery system is reportedly a feasible, safe, and effective treatment for patients with a malignant lower rectal obstruction within 5 cm from the anal verge . HoweverAlthough the short-term safety and efficacy of SEMS placement as a BTS for malignant LBO are well known, the long-term oncologic effects of SEMS placement for LBO remain unclear. According to the 2015 European Society of Gastrointestinal Endoscopy Clinical Guideline , SEMS plWe encountered three patients with LBO caused by a good response to NAT who were successfully treated by SEMS placement as a BTS. Further studies with larger sample sizes are needed to fully evaluate the safety and efficacy of this technique.


Deformities associated with Charcot neuroarthropathy (CN), a rare and devastating post-diabetic complication, place patients at risk for infection and amputation. In the present case, a 56-year-old male with idiopathic CN presented with complaints of progressively growing plantar soft tissue deformity. Routine hematology, biochemistry, paracentesis, and fluid analysis were conducted. The patient was treated conservatively and will continue to be monitored for progression of the condition. Charcot neuroarthropathy (CN) of the foot and ankle, also known as Charcot joint, Charcot neuropathic osteoarthropathy, or Charcot foot, is a serious and limb-threatening complication that typically affects 1% of patients with longstanding neuropathy of differing etiology, and places patients at risk for adverse outcomes . The mosA 56-year-old non-diabetic male with CN presented with symptoms of new-onset pain and concerns about progressive volumetric changes of the plantar rocker bottom deformity of his left midfoot over a six-month period. He had a past medical history significant for hyperlipidemia and tobacco use and was previously diagnosed with CN, resulting in midfoot collapse, after a traumatic forefoot injury that occurred in June 2016 Figures .He had been treated conservatively with the use of an offloading CROW boot, but reported increasing discomfort when placing his foot in the offloading device, believing it does not fit him anymore. The enlargement was most prominent on the plantar lateral aspect of the midfoot. The patient did not report any recent trauma, increased weight bearing, or plantar ulcerations. On physical examination, the left foot showed a 14 cm long and 8 cm thick, fluctuant, non-tender, non-illuminating, non-mobile, gel-like mass over the plantar lateral left midfoot. No palpable bony prominences or open lesions in the skin were noted. The left foot did not show any signs of increased warmth relative to the contralateral limb, erythema, calor, crepitus, or signs of infection. The patient’s dorsalis pedis pulse was palpable, the posterior tibial pulse was non-palpable, and loss of protective sensation to a 5.07 g Semmes-Weinstein monofilament was noted. Radiographs of the left foot were obtained and revealed no new osseous changes or progression of deformity; however, mild cuboid plantar subluxation was noted. These findings are consistent with inactive and stable CN; however, a substantial increase in soft tissue density with an associated plantar lateral compartment expansion was noted, suggesting fluid collection Figures .Advanced imaging was ordered, and an MRI of the afflicted limb further confirmed a well-organized large heterogeneous thick rim-enhancing fluid collection within the plantar lateral tissue Figure .The fluid collection was plantar to the cuboid and calcaneus, communicating with the midfoot joint capsules, and measuring 8 cm in the x-direction and 4 cm in the y-direction Figures .3 , and no malignant cells or crystals present. In addition, direct stains and cultures were performed and were negative. In conclusion, the diagnosis of the lesion was a benign synovial cyst communicating with the disrupted capsules of the midfoot. While surgery was contemplated to encourage a functional outcome, it was concluded that risks outweighed the benefits and the patient was at risk for delayed wound healing due to the presence of persistent synovial fluid drainage, resulting in a progressive rocker bottom deformity [Despite the lack of a wound or source of infection, infection was considered in the differential diagnosis but was considered highly unlikely due to patient’s relatively unremarkable inflammatory markers . After consent was obtained, paracentesis of the plantar lateral midfoot was performed to rule out potential malignancy and further confirm lack of infection. Paracentesis of the plantar mass yielded 30 mL of a yellow hazy serous fluid, with a WBC count of 185 white blood cells/mmeformity . Since teformity . Continueformity . On his et al. demonstrated that 32% and 48% of synovial cysts in the lower extremity were found in the ankle and dorsum of the foot, respectively [Synovial cysts are benign, gelatinous fluid accumulations that are usually found in subcutaneous tissue and are derived from disrupted joint capsules or tendon sheaths, allowing for the accumulation of synovial fluid outside of the capsule. They are most commonly found around joints in wrist, elbows, shoulders, knees, and the foot . While mectively . In the ectively . The etiectively ,19.Regardless of the causative nature of the rocker bottom deformity, whether it be cystic or osseous in nature, conservative and surgical management of CN is an increasingly challenging task that requires advanced knowledge of the condition itself, presence of complicating comorbidities, and surgical skill.


Artificial implantable pacemakers have long been a challenge to neurosurgeons seeking to perform advanced diagnostic imaging on their patients. Unfortunately, while the use of implantable pacemakers has been a life-saving advance for those with cardiac arrhythmias, they also often prevent these patients from undergoing magnetic resonance imaging (MRI). There have been multiple reported cases of pacemaker failure in the context of MRI use. Recent technological advances, however, have allowed the development of pacemakers that are not affected by the MRI scanner. Similar technology has also been applied to the development of MRI-compatible spinal cord stimulators and other neurostimulation devices. In this paper, we discuss four specific neurosurgical cases where the use of MRI was critical for diagnostic and therapeutic decision-making. Current non-MRI-compatible pacemakers were exchanged for MRI-compatible pacemaker technology with some associated cost and risk. The diagnostic cranial and spinal MRIs subsequently obtained were critical for forging the ensuing neurosurgical care. Based on these cases, we extrapolate the importance of MRI-compatible pacemakers to society at large and advocate for the use of such devices in all patients going forward. The concept of artificial pacing of the heart is one that traces its origins as far back as the French Revolution, where researchers performed electrical experiments on the executed bodies of the condemned . The firGiven the advanced average age of patients with pacemakers, it is not surprising that these patients carry a higher disease burden than the general population. In fact, it has been estimated that 50%-75% of patients living with a pacemaker will require magnetic resonance imaging (MRI) over the course of their life . UnfortuAs a result of this problem, there has been a concerted effort by device manufacturers to develop MRI-compatible pacemakers. These MRI-compatible systems have been designed to minimize the impacts of the abovementioned magnetic fields, which can result in device malfunction . SeveralCase 1A 67-year-old male with a past medical history of congestive heart failure, non-ischemic dilated cardiomyopathy, atrial fibrillation, and pacer-dependent heart block, presented to the University of Miami emergency department with refractory complex partial seizures. Due to the fact that the patient was pacemaker-dependent, he was unable to undergo MRI. Therefore, a contrasted CT scan of the brain was performed, which demonstrated a heterogeneously enhancing left frontal mass just anterior to the left motor cortex thought to be either a primary central nervous system tumor or a metastatic lesion Figure .Mycobacterium tuberculosae brain abscess. The patient was placed on anti-tuberculosis medication and intravenous (IV) antibiotics and discharged home. Approximately one year later, he returned to the hospital after suffering a partial seizure with subsequent right upper extremity weakness. He was found to have a recurrence of his left frontal lesion and was again taken to the operating room for surgical resection. Repeat imaging at one year did not demonstrate any further recurrence of his previously seen lesion.A full metastatic workup was conducted with no primary lesion detected. Given the location of the lesion, further imaging was thought to be necessary for two reasons: 1) to further elucidate the differential diagnosis of the lesion and 2) to help safely guide resection or biopsy of a lesion in close proximity to eloquent brain tissue. As a result, cardiothoracic surgery was consulted for the possible replacement of the patient’s current pacemaker with an MRI-compatible alternative. The patient subsequently underwent the removal of their pacemaker and replacement with a Surescan Medtronic DDD Pacemaker RVDR01 . Following this procedure, an MRI was performed and demonstrated a multi-lobulated, relatively uniformly enhancing left frontal lesion  computed tomography (CT) was subsequently performed, which seemed to confirm that the lesion was neoplastic and likely intramedullary in location. Given the advanced age of the patient and multiple comorbidities, further clarity on the nature of the lesion was needed in order to drive a treatment plan and, as a result, cardiothoracic surgery was consulted for the replacement of the pacemaker with an MRI-compatible alternative. The patient subsequently underwent the removal of their pacemaker and replacement with a DDD Medtronic Advisa SureScan pacemaker . Subsequent MRI demonstrated that the lesion was in fact not intramedullary, but presented as a dorsal, extramedullary dural-based lesion at T3 causing significant canal stenosis and cord compression, likely representing a meningioma Figure . Given tCase 3A 38-year-old female [The patient was transferred to our service for further workup and treatment. At the time of her initial presentation, the lesion seen on the CT scan was favored to represent metastatic disease with lymphoma high on the differential diagnosis. Due to the presence of a non-MRI-compatible pacemaker, an MRI was unable to be performed at that time and a full metastatic workup was otherwise unrevealing. Ultimately, given the uncertainty regarding the pathology of the lesion and, as a result, the optimal treatment modality, the decision was made to replace the patient’s pacemaker with a DDD Medtronic Advisa SureScan MRI-compatible pacemaker. Postoperatively, an MRI of the brain was performed, which demonstrated an enhancing, likely extra-axial mass favored to represent a meningioma. As a result, the patient was taken to the operating room for a suboccipital craniotomy. A gross total resection was achieved and pathology returned as a high-grade peripheral nerve sheath tumor. Unfortunately, the patient developed a postoperative hematoma in her surgical cavity, which required emergent evacuation and the placement of an external ventricular drain and, ultimately, a ventriculoperitoneal shunt. The patient, however, made a full recovery and was discharged with plans for adjuvant chemotherapy and radiation.Case 4A 50-year-old male presented with a chief complaint of chronic back pain since 1997. He had a history of lumbar surgeries, including a right-sided L4-L5 and L5-S1 hemilaminectomy in 1999. The patient reported that after a car accident in the distant past, he “lost feeling” in his right leg and was told he had severe nerve pain and damage. His chief complaint during his visit to our office was a weakness in his left quadriceps along with back and leg pain and numbness. On physical exam, the patient had subtle weakness in the left hip flexor and left quadriceps, as well as the extensor hallucis longus and the gastrocnemius on the right. He had decreased pinprick in the L3 dermatome on the left but sensation otherwise appeared grossly intact. Deep tendon reflexes were 1+ to 2 throughout bilaterally. Nerve conduction studies revealed axonal loss and motor neuropathy of the peroneal nerve on the right along with chronic irritation of the right L5 nerve root but were otherwise unrevealing. Unfortunately, the patient had a non-MRI-compatible pacemaker, which prevented him from undergoing an MRI. A plain CT of the lumbar spine demonstrated multi-level spondylosis with severe loss of disk height at L3-L4, L4-L5, and L5-S1. In lieu of an MRI, a CT myelogram was performed . In addition, by using software modifications, MRIs can provide data on brain chemistry , cerebrospinal fluid flow (Cine MR), brain and spinal cord vascularity (magnetic resonance angiogram (MRA) or magnetic resonance venography (MRV)), important regional differences in brain function , and, more recently, can provide a non-invasive technique of measuring intracranial pressure .In this paper, we present four cases of patients with conventional non-MRI-compatible pacemakers who required MRI scanning for diagnostic and therapeutic purposes. In all cases, the patient outcome and surgical decision-making process were significantly impacted by the MRI results. In the first case, the MRI scan aided in preoperative planning and facilitated stereotactic guidance for an awake, open surgery. In the second case, while the lesion was initially thought to be intramedullary based on the CT myelogram, a subsequent MRI demonstrated an extramedullary, dural-based lesion, amenable to a straightforward surgical resection with low risk of morbidity. In our third case, while the CT scan suggested an intra-axial cerebellar mass, the MRI scan favored an extra-axial mass, significantly changing preoperative planning. In the final case, while the patient presented with complaints suggestive of radiculopathy, MR imaging clearly demonstrated no significant neural compression, leading us to advise the patient that a decompressive surgery alone was unlikely to provide significant symptomatic relief. These cases serve as an example of the indispensable importance of MRI in modern neurosurgery. Unfortunately, however, the surgeon is often limited in their ability to perform an MRI based on the presence of metallic components in the patient, including shrapnel, artificial valves, pacemakers, spinal cord stimulators, and implanted defibrillators. While some of these factors such as the presence of shrapnel are beyond the surgeon’s control, we propose that the presence of an artificial pacemaker should no longer serve as a barrier to obtaining appropriate imaging.As with any clinical decision, the benefits of placing a new pacemaker must, of course, be weighed against the risks. In one prospective study, which studied the risk of pacemaker replacement at 72 different academic and private practice centers, the overall major complication rate from replacement without the addition of new transvenous leads is at 4.0% and the complication with the placement of new leads at 15.3% . In the While pacemakers have historically been a relative contraindication to MR imaging, the technology now exists to safely perform magnetic resonance imaging in patients with modern pacemakers designed expressly for this purpose -12. IndeNeedless to say, our proposal must be supported by a clear understanding of the costs of MRI-compatible pacemakers compared to traditional, non-MRI-compatible pacemakers. It is important to note that the new MRI-compatible devices do come at a premium when compared to the traditional devices. The exact differential in price is difficult to determine, as it will vary based on hospital and vendor, and in cases where the pacemaker must be explanted and replaced, the cost of surgery must also be considered. While these costs undoubtedly add to a large sum on a population level, they cannot be considered in isolation but must instead be compared to the cost of not implanting such devices. Namely, the cost to the healthcare system of patients not receiving the necessary treatments or receiving un-indicated surgeries or procedures due to the inability to make an appropriate diagnosis using MRI technology.In the four cases presented in this paper, our patients would have had significantly different clinical courses had they not received an MRI. In the first case, MR imaging allowed for stereotactic guidance, which assisted in operative planning, specifically in avoiding damage to the nearby eloquent brain. In the second case, our elderly patient would likely have not received a life-altering surgery had we accepted his CT myelogram studies as the benefit of resecting an intramedullary lesion and its attendant risks of dorsal column dysfunction would have outweighed any potential benefits. This likely results from the fact that with the advent of MR and the subsequent marked reduction in the number of myelograms performed annually – the technical proficiency of imaging specialists in obtaining diagnostic quality myelogram-CTs has likewise declined. This worsened proficiency undoubtedly leads to diagnostic dilemmas, as was seen in the case described above. In the third case, we again demonstrate the diagnostic benefit along with the value in surgical planning of MR imaging. Finally, in the fourth case, our patient was spared an unnecessary operation, which would have likely provided him with no symptomatic improvement. While the cost-savings from such cases as the ones we presented are difficult to predict at a population level, we believe that they would far outweigh any additional cost incurred by implanting an MRI-compatible device. The other cost concern is that changing a pacemaker to an MR-compatible version is not a diagnostic code or trigger for insurance companies to approve the procedure. We hope that examples like these will shed light on the importance of placing the devices de novo and the flexibility of changing the pacemakers as the clinical scenarios warrant.Considering the importance of MR imaging in neurosurgical patients along with the disproportionate disease burden in the population of patients with pacemakers, MRI-compatible pacemakers offer a clear benefit. The four cases presented in this paper all provide evidence of instances where MRI findings significantly altered the patients' clinical course. In the cases where patients have an existing non-MRI-compatible system, the benefits of replacement must be carefully weighed against the risks.


The anti-Müllerian hormone triggers the regression of uterus and fallopian tubes in male embryos; if there are problems in the synthesis or action of this protein, Müllerian structures persist in an otherwise phenotypic male. The most frequent clinical presentation of Persistent Mullerian Duct syndrome is cryptorchidism and inguinal hernia. The few cases reported in adults are incidental findings or inguinal hernias. However, we present an adult male with history of bilateral cryptorchidism with unsuccessful orchidopexy, who presents with a large abdominal mass with the finding of a seminomatous tumor and persistence of Müllerian structures, in whom the variant c.916delC (p.Leu306Cysfs*29) in the AMHR2 gene not previously reported was documented. Male sex determination is a process determined by: 1) testis formation of the primitive gonad (sex determination) through various transcription factors, and 2) differentiation of internal and external genitalia by action of hormones secreted by the fetal testicle (sex differentiation). It starts by activation of SRY gene in the precursor cells and translocate to the nucleus and binds to the enhancer region of SOX9, to intervene in the differentiation and proliferation of Sertoli cells and the tubular organization of the testis that secret anti-Müllerian hormone (AMH) to promote the regression of Müllerian ducts   (1). TesAMH is a glycoprotein secreted by the Sertoli cells of the testes from the moment of sexual differentiation until puberty. The AMH gene, a member of the transforming growth factor-𝛽 (TGF-𝛽) is activated by SRY but also by genes upstream and downstream as SOX9, SF-1, WT-1 and GATA415 -5. The dAMHR2 is a membrane protein, which contains a N-terminal extracellular domain that binds AMH, a transmembrane domain, and an intracellular domain with serine/threonine kinase activity. The AMHR2 gene is located at 12q13 and contains 11 exons. The extra cellular domain of AMH binding is encoded by the first 3 exons ; the exoThe incidence of PMDS is low, with near 200 cases documented in the world. Individuals with PMDS are phenotypical male with karyotype 46, XY with presence of Wolffian and Müllerian structures and normal virilization, consequently with normal external male genitalia. However, some individuals have infertility secondary to prolonged cryptorchidism or anomalies in the communication between the testis and the male ducts (epididymis and upper deferent duct) secondary to presence of Müllerian ducts attachments to testes preventing the normal descent. According to previous case reports, delayed diagnosis at adulthood may cause infertility .The determination of serologic levels of AMH is useful when it is suspected in childhood  , 9, withRecently, we detected a mutation not previously reported in the AMHR2 gene in a male with congenital cryptorchidism with failed orchidopexy and unsuccessful surveillance who arrived with an abdominal mass corresponding to a seminomatous tumor.A Colombian 33-year-old married man, son of consanguineous parents, with history of orchidopexy at 4 years, without follow-up after surgery to evaluate the testicular position, was recently admitted to our clinic with complaints of urinary symptoms. Physical examination showed that the patient was phenotypically male with bilateral cryptorchidism and normal penile length. His secondary sex characteristics were normal but an abdominal mass was palpated in the hypogastrium; therefore, additional tests were done. The patient had a personal history of infertility not studied.The hormonal evaluation of the patient at the time of consultation revealed hypergonadotropic hypogonadism FSH (2.2mUI/mL-reference: 0.2-1.4), LH (0.08ng/mL-reference: 0.01-0.5), testosterone  and AMH: 816pg/L (reference: 360-668pg/L). Other laboratory results showed elevated tumor markers alpha-fetoprotein and human chorionic gonadotropin. The pelvic MRI showed a heterogeneous mass of tumoral aspect in the pelvis, extension to the hypogastrium and retrovesical space, with a volume of 640cc. Features of the mass suggested a mixed lesion with solid and multilocular cystic component, with some hemorrhagic foci, which contacts the dome of the bladder and base of the prostate, displacing the seminal vesicles to the left, with suspicious image of Ewing’s sarcoma.Diagnostic laparotomy and resection of the mass revealed a 20cm multi-loculated mass arising from the left undescended gonad. Right hypotrophic undescended gonad was adhered to Müllerian ducts . Total eSections from both fallopian tubes showed congestion and fibrosis. No ovarian tissue was seen. The patient received multidisciplinary management by endocrinology, urology, genetics, oncology and psychology. His family received genetic counseling for the risk of recurrence and the carrier status.Cytogenetic analyses of the patient were carried out based on phytohemaglutinin-stimulated peripheral blood lymphocyte cultures, according to standard laboratory protocols. Chromosome preparations were treated with HCl and stained with Wright for banding G. A total of 50 metaphase cells were analyzed at the 550-band resolution level.Molecular cytogenetics using fluorescence in situ hybridization (FISH) with the following probes and probe sets was subsequently performed following the manufacturer’s instructions: SRY , DYZ1 . Also, a control probe for Xp11.1-q11.1 was hybridized. As counterstain 4’,6-diamidino-2-phenylindole DAPI was used. 200 metaphases and 50 nuclei were analyzed with the ZEISS ZEN© microscope software.Genomic DNA was extracted from the peripheral blood of the proband, following standard salting-out protocol. DNA was amplified by PCR using specific primers for the AMH and AMHR2 genes, reported by Yumie et al.  Table-1Table-1. Patient’s karyotype showed 46.XY.ish Yp11.31 (SRY+). Sanger sequencing revealed the existence of a homozygous variant NM_020547 (AMHR2) c.916delC (p.Leu306Cysfs*29) in the 7 exon of the AMHR2 gene, that produces a change in the amino acid that results in a pathogenic frameshift with a shorter protein of 334 amino acids, respect to the normal protein of 574 amino acids, removing a significant part of the intracellular serine/threonine kinase domain responsible of biological activity. This variant has not been previously reported. The amino acid Leucine is conserved in some mammal species , indicatAlthough this variant has not been reported previously in the dbSNP, 1000G, and ExAC databases, it has been identified as pathogenic by bioinformatics analysis tools Protein Variation Effect Analyzer (provean.jcvi.org/index.php) and Polyphen (http://genetics.bwh.harvard.edu/pph2/).To date, 4 patients with PMDS have been reported in Colombia: two children with diagnosis during laparoscopic treatment of cryptorchidism without molecular study,  and two This case report highlights the importance of a continuous and multidisciplinary evaluation of patients with cryptorchidism, a clinical spectrum of disorder of sexual differentiation, whereas the post-operative follow-up of the patient would have contributed to the timely management of the failed orchidopexy and to avoid secondary consequences as tumor and infertility.The initial laboratory evaluation in a phenotypically male with bilateral nonpalpable testes must include karyotype, ultrasonography of the pelvic structures, serum testosterone, gonadotropins , anti-Müllerian hormone level, and exploratory surgery is usually necessary for definitive diagnosis. In males, serum levels of AMH remain high until 2 years of age and persist in measurable levels until puberty, before decreasing to undetectable levels at puberty .AMH is a possible screening assay in young patients with bilateral cryptorchidism, due to the possibility of differential diagnosis of PMDS, even more in the presence of a positive history of consanguinity, bilateral cryptorchidism and male infertility, as in this case, which was susceptible to be diagnosed in childhood. An opportune diagnosis allows an adequate surgical management, and giving advice in the surveillance of the tumoral risk and in the possible compromise of the fertility, but even the molecular diagnosis allows confirming the diagnosis and providing genetic family counseling.Mutations in the intracellular domain, like this, have been reported previously, all with lack of the kinase activity , 18 and Likewise, the importance of long-term postoperative follow-up of orchidopexy is highlighted, due to possible complications associated with non-descendant testicular tissue  as occurred in this patient, who, due to lack of knowledge and non-adherence to periodic follow-ups, had a late diagnosis of PMDS and testicular tumor.In conclusion, PMDS is a condition that is observed in men with cryptorchidism and/or inguinal hernia. It must be diagnosed and treated promptly to protect the fertility and prevent the potential risk of tumors. Our results expand the mutational spectrum of this infrequent condition and emphasize that PMDS should be included in the differential diagnosis of cryptorchidism. Genetic counselling should be considered in cases of parental consanguinity.


Leiomyosarcoma arising from the external iliac vein is uncommon. This is a report of a 51-year-old Japanese man with venous leiomyosarcoma originating from a branch vessel of the left external iliac vein. The tumor was found during a medical examination, and the patient had no symptoms. Computed tomography showed a 72 × 49 mm mass adjacent to the left external iliac vein. The tumor was resected en-block along with ligation of the external iliac vein due to strong adhesion with the tumor. Histological examination showed venous leiomyosarcoma, and its origin was thought to be a branch vessel of the left external iliac vein. The patient has remained free from recurrence at 30 months after surgery. Leiomyosarcomas account for approximately 6% of all soft tissue sarcomas, and venous leiomyosarcomas account for 2% of all leiomyosarcomas . Venous A 51-year-old Japanese man was referred to our hospital for abnormal ultrasound findings during a medical examination. He had no complaints or relevant family history. His past history included diabetes, hypertension, dyslipidemia, and fatty liver. Physical examination showed nothing of note. Laboratory findings, including serum concentrations of oncological markers such as alpha fetoprotein, cancer antigen 19–9, neuron-specific enolase, and carcinoembryonic antigen, were within the normal range. A contrast computed tomography (CT) scan revealed a 72 × 49 mm mass closely adjoining the left external iliac vein. Magnetic resonance imaging showed that the mass was isointense with muscle in the T1-weighted image . A positBefore surgery, we discussed with the vascular surgeons how to deal with the left iliac vein. In general, blood vessel reconstruction and subsequent anticoagulation therapy are performed. However, the patient was engaged in physical labor and did not want to take an anticoagulant after surgery. So, we finally decided to perform combined resection of the left iliac vein with the tumor. Extirpation of the tumor was performed. We could easily peel the tumor from surrounding tissue except at the left external iliac vein where, as predicted, the tumor was strongly adhered. Therefore, complete tumor resection was achieved by combined resection of the external iliac vein.α-SMA (Pathological examination revealed a gross, well-defined, firm tumor of 60-mm at the greatest diameter. The cut surface was gray-white with a whorled appearance. Microscopically, the tumor was mostly composed of interlacing fascicles of spindle cells with a mild to moderate degree of cellular pleomorphism and was considered to be a low-grade leiomyosarcoma. Furthermore, there were focal areas of high cellularity and bizarre nuclei . Immunosα-SMA  was posiα-SMA . Contrarα-SMA . There wα-SMA . Its vesα-SMA . Howeverα-SMA . TherefoImmediately after surgery, the patient developed left leg pain and swelling. However, the painful swelling of his left thigh improved one week later and ultimately disappeared by about 3 months after surgery. The patient has remained free from recurrence at 30 months after surgery.Vascular leiomyosarcomas usually arise from a vein, approximately 5 times more often than from an artery , 3. A prStandard treatment for vascular leiomyosarcoma is surgical resection, and 40–60% of patients undergo surgery . OptimalIn most of the reports of vascular leiomyosarcomas originating from the external iliac vein, blood vessel reconstruction was performed. However, a recent report revealed that blood vessel reconstruction had a higher incidence of thrombosis while providing no additional benefit in reducing symptomatic extremity edema compared to ligation in patients with isolated external iliac vein injuries . Further


Lipomas of the larynx, oropharynx and hypopharynx are rare, accounting for approximately 1% of benign laryngeal neoplasms. We present a rare case of a simple lipoma arising from the right vallecula. A 55-year-old male presented with worsening dysphagia for 1 week. CT scan revealed a lesion of fat attenuation in the right vallecula. The patient underwent surgical excision and recovered uneventfully. To our knowledge, there are only two cases of vallecular lipoma that have been reported and they are both of spindle cell subtype and located on the left side. This is the first reported case of a simple lipoma arising from the right vallecula and causing obstructive symptoms. CT scan or MRI is essential in confirming the diagnosis and assessing the extent, thus allowing prompt excision, especially when the patient is symptomatic. To the best of our knowledge, only two cases of vallecular lipomas have been described, both of which were spindle cell variants and located on the left side.3Lipomas are one of the most common benign neoplasms found in humans, but occurrence in the oropharynx is rare. Their overall incidence in the oral cavity and oropharynx is between 1% and 4.4% of all benign oral lesions. The more common anatomical sites for oral lipomas are the major salivary glands, buccal mucosa, lip, tongue, palate, vestibule and floor of the mouth.A 55-year-old Malay male presented to our hospital with a history of dysphagia for 1 year, worsening over the past 1 week. He was only able to tolerate soft diet and liquids. Occasionally, he experienced odynophagia and mild shortness of breath. However, there was no stridor and hoarseness of voice. He did not complain of neck swelling or any ear symptoms. On examination, there was a smooth, well-defined, non-lobulated soft tissue mass between the base of the tongue and epiglottis. It occupied about 70–80% of the oropharyngeal opening. Endoscopy showed no extension of the mass into the laryngeal inlet. Both vocal cords were mobile and symmetrical. The aryepiglottic folds and pyriform sinuses revealed no abnormality.CT scan of the neck showed a well-defined, smooth margin, hypodense lesion occupying the right vallecula and measuring 2.8 × 4.0 cm in size. It had a mean attenuation of −81 HU . There wThe patient underwent endoscopic excision of the lipoma under general anaesthesia. Intraoperatively, the mass was seen to partially occupy the lingual surface of the epiglottis and the right vallecula. It was excised into without any complications. Histopathological diagnosis was of right vallecular lipoma. The lesion was composed of mature univacuolated adipocytes separated by thin fibrovascular septae and covered with non-keratinizing squamous epithelium. Postoperatively, the patient recovered well, with resolution of symptoms. Follow-up endoscopy at 1 month showed no recurrence.4 Oral lipomas with decreasing frequency occur in the cheek, tongue, floor of the mouth, buccal sulcus, palate, lip and gingiva.5Lipomas are the most common benign mesenchymal tumours that arise from mature white fat cells. They occur everywhere in the body. However, only about 15–20% of them occur in the head and neck region and 1–4% in the oral cavity.6Lipomas are usually found in patients after 30 years of age, although they may also be congenital. They may occur at any time between early childhood and advanced age, with more than 50% being found in the fifth to sixth decades, when fat begins to accumulate in inactive, underexercised individuals. Occurance is twice as high in females as in males.7 Otherwise, the sessile lipomastend to be asymptomatic but may cause obstructive symptoms such as dysphagia and stridor when their size increases.7 Our patient had dysphagia for a year, indicating that the lesion was slow-growing. Later, it was large enough to occupy 70–80% of the oropharyngeal space.Even though they are benign lesions, they can be life-threatening owing to their location. Morphologically, oral lipomas may be sessile or pedunculated, and thus can present with different symptoms. A few cases of pedunculated lipoma at the epiglottis, posterior cricoid and aryepiglottic fold causing laryngeal obstruction leading to death have been reported.5 MRI is superior than CT in evaluation of soft tissue and tumour extension; it is, however, not readily accessible and is more time consuming.2 Our patient definitely showed the typical findings of lipoma on CT imaging.CT scan has the ability to definitively diagnose a lipoma in virtually all cases owing to its typical characteristic feature—homogeneous low attenuation that measures between −65 and −125 HU. They are non-enhancing. No clear identifiable capsule can be seen, but most lesions are easily delineated from the adjacent soft tissues. The other possible diagnosis could be a ranula or dermoid, which have characteristics similar to lipoma.8 Simple lipomas make up 80% of the oral lipomas while all the other variants constitute the remaining 20%. Our patient had the simple lipoma histology, but at a rare location.Histologically, lipomas can be classified as either simple ordinary lipomas or their variants, which include spindle cell lipomas, fibrolipomas, intramuscular lipomas, angiolipomas, myxolipomas, salivary gland lipomas, pleomorphic lipomas and atypical lipomas.9 The prognosis for this disease is excellent. However, long-term follow-up is needed owing to the possibility of initial missed diagnosis of liposarcoma as histological differentiation of lipoma and low-grade liposarcoma can be difficult.3The recommended treatment for pharyngeal and laryngeal lipomas is surgical excision; the extent of the procedure depends on the size and site of the tumour. In our case, surgery was indicated as the lipoma was obstructing the oropharynx and causing dysphagia. It had the potential to cause a life-threatening event by obstructing the airway. Endoscopic removal was recommended but large masses would need an external approach. Complete removal is essential to reduce the risk of recurrence.Even though lipomas are benign tumours and slow-growing, they can cause life-threatening conditions if they occur at certain locations, such as in the oropharynx and larynx.CT scan or MRI is important in demonstrating the fat content to confirm the diagnosis of vallecular lipoma and helpful in assessing the extent prior to surgical removal.Long-term follow-up is needed as there is a possibility of initial missed diagnosis of liposarcoma.Written informed consent was obtained from the patient for publication of this case report, including accompanying images. The record is held by the corresponding author.


Lymphoproliferative disorders presenting with clinical features similar to ovarian tumors are a rare clinical condition. Even though lymphomas of ovarian origin are rare, they should be considered during the differential diagnosis of tumors of ovarian origin. In this case report, we aimed to present a case of Burkitt lymphoma that mimics advanced ovarian carcinoma. Lymphoproliferative disorders presenting with clinical features similar to ovarian tumors are rarely met, and they may be observed as primarily of ovarian origin or secondary to systemic disorders . Non-HodA 46-year-old female patient presented to the outpatient clinic with the complaints of abdominal distention and constipation lasting for approximately six months. The clinical examination revealed abdominal distention and ascites. In the conducted lower abdominal MR imaging study, the left ovary was 5.5 cm x 3.5 cm in dimension, and solid areas having cystic parts centrally and showing peripheral contrast dyeing were observed Figure .An intraabdominal omental cake appearance was present. No pathological lesion was detected in the performed upper and lower GI endoscopies. The positron emission tomography-computed tomography (PET-CT) imaging revealed increased fluorodeoxyglucose (FDG) uptake at the field corresponding the left adnexal site (SUVmax:15.4). Additionally, lesions with increased FDG uptake in the abdominopelvic regions were determined to be consistent with peritonitis carcinomatosis. The laboratory investigation revealed serum lactate dehydrogenase (LDH) level as 404 U/L normal < 250 U/L), serum albumin level as 3.9 g/dl , serum CA-125 level as 1375.2 U/ml . The CA 19-9, CA 15-3, carcinoembryonic antigen (CEA), and alpha-fetoprotein (AFP) levels were determined to be within normal limits. A diagnostic laparoscopy was performed. The exploration revealed an ascites with a volume of approximately 3 L and peritonitis carcinomatosis. The left ovary was approximately 6 cm x 4 cm in dimension. The right ovary was normal. A wedge biopsy of the left ovary was performed together with omental and peritoneal biopsies , MUM1 , and CD43 . Ki-67 index was determined to be 95% (Figure The pathological diagnosis was reported as a high-grade non-Hodgkin’s B-cell lymphoma. The high proliferation index of the case, together with the histomorphologic and immunohistochemical findings led the patient to be considered to have Burkitt lymphoma on a preferential basis. The patient was transferred to the hematology clinic for treatment.The ovarian involvement has been reported as 7-26% in lymphomas . They coAs a conclusion, even though lymphomas of ovarian origin are rare, they should be considered during the differential diagnosis of tumors of ovarian origin, and diagnostic laparoscopy and biopsy may be performed.


Uterovaginal prolapse is a rare condition in newborns which is usually associated with spinal cord defects. It is usually diagnosed at birth. Different treatment options have been proposed for genital prolapse in newborns. Most of the treatment options recommended are conservative; radical approach is rarely suggested for the treatment of these cases. We report a 6-hour-old newborn that was diagnosed to have congenital uterovaginal prolapse and was successfully managed conservatively with digital reduction of the mass and strapping of both legs together. Congenital uterovaginal prolapse in newborns can be managed conservatively with simple digital reduction followed by strapping of the legs together; this approach is simple and cost-effective and has no associated complications. Congenital uterovaginal prolapse in a newborn is a rare condition which is usually diagnosed at birth or in the first few days of life. Often times the condition is associated with spinal cord defects –3. VarioA 6-hour-old female neonate born from a 22-year-old Para 1 mother after term pregnancy. The newborn had protrusion of mass per vagina since birth; she also has a defect at the lower back with no discharge since the time of birth. Additionally the mother has noticed deformity on both legs and feet which barely move. The baby was active since the time of delivery and is sucking well and she passed meconium. The mother had two ANC visits and was vaccinated according to the national schedule and she reported the whole course of the pregnancy as uneventful. She did not have any known medical illness and has never taken any medication during the entire course of the index pregnancy except iron folate which was prescribed during the ANC visit.She had spontaneous onset of labor and the membrane was ruptured spontaneously intrapartum. She gave birth to a 2330-gram female neonate after 5 hours of labor at a local health center. Baby had good APGAR score. Health care providers at the health center noticed defect at the back of the baby and referred her to Hawassa University Comprehensive Specialized Hospital (HUCSH) with the diagnosis of spinal bifida.During the initial evaluation at HUCSH the baby was active, vital signs were in the normal limits, and all neonatal reflexes were intact. There was 4x4 cm pink mass protruding through the introitus, cervical os is noted at the tip of the mass, the external genitalia appears normal, no discharge or bleeding from the mass, and the mass was reducible digitally and increases in size when the baby cries see . There wOn investigation, the complete blood count was normal, creatinine level was 0.4mg/dl, and transfontanelle ultrasound scan shows mild dilatation of the lateral and third ventricles with an index of “mild hydrocephalus” and abdominal ultrasound was normal.After obtaining consent from the parents, under aseptic technique, the baby was catheterized, the vaginal mass was reduced digitally, and bandage was applied from the lower abdomen, both buttocks and legs were strapped in the bandage to the level of the mid-thigh leaving an opening at the anal orifice for passage of stool see . The banUterovaginal prolapse is defined as the downward displacement of the normal pelvic structures to or through the vagina and introitus. The first case of genital prolapse in a newborn was reported in 1723. The first formal review on the condition was written by Ballantyne and Thomson in 1897. Neonatal uterovaginal prolapse is generally a rare condition [The uterus and the vagina are suspended in their normal anatomic place by the pelvic diaphragm and the endopelvic fascia . Congenital uterovaginal prolapse is a result of weakness in the pelvic muscle and ligaments; this weakness could be either secondary to congenital weakness in the pelvic musculature or defective innervation , 9, 10. Even though the exact etiology of uterovaginal prolapse in newborns is not well known, few risk factors have attributed to the development of the condition in newborns, the most common of which is spinal bifida (82-86%) , 3, 5, 9Timely management of uterovaginal prolapse in newborns is essential to prevent injury and metaplasia to the endometrium from prolonged exposure to the external environment and to prevent other associated complications like urinary retention and obstructive uropathy , 9.Based on few available cases reported so far, authors recommend conservative treatment of uterovaginal prolapse in newborns as effective management options. After reduction of the prolapse, since the maternal estrogen exposure ceases and edema subsides the uterus will be fixed to its normal anatomic location. The reported success rate with conservative management is more than 90%. The major concern with conservative management of UVP is recurrence of the condition , 9.Use of vaginal pessary after digital reduction has been reported as successful intervention which involves digital reduction of the prolapsed mass followed by insertion of pessary and fixing the pessary to the vaginal wall using fine stitches, the pessary is then removed after one month . Other aRarely radical approaches especially for cases with associated spinal cord defect and recurrent prolapse following conservative management have been suggested in literatures. These approaches are recommended when there is repeated prolapse despite multiple reduction of the prolapse or when there is evidence of vaginal hypertrophy or laceration. Methods of fixation that have been suggested include sling procedure, cervical sacropexy, ventrosuspension, and abdominal sacrocolpopexy. There were also rare cases which were reported to be managed by hysterectomy and cervical amputation , 12.Uterovaginal prolapse is a rare condition in newborn babies which is usually associated with spinal bifida. The condition can be managed successfully with digital reduction and strapping of both extremities together in a gauze bandage. We recommend this simple and effective management for cases of congenital uterovaginal prolapse in newborns as it is easy to apply and cost-effective, which can be performed at a primary facility and has no associated complications other than possible recurrence of the prolapse.


Solitary fibrous tumor (SFT) of the pleura is a rare neoplasm which is challenging for clinicians to treat and radiologists to diagnose. Herein, we report a case of recurrence of SFT of the pleura in a 77‐year‐old patient which was diagnosed and surgically treated on the first occasion in 2005. The patient had a recurrence in 2016 which was treated and then six months later, he again experienced chest pain and a further local recurrence was found. Taking into consideration the age and comorbidities of the patient, CT‐guided percutaneous microwave‐thermal ablation was preferrable to surgery and a safe and highly effective local ablative technique with few side‐effects. Microwave thermoablation is an effective and safe technique for pleural solitary fibrous tumor.Microwave thermoablation helps reduce tumor‐related pain in patients affected by pleural solitary fibrous tumor.Solitary fibrous tumor (SFT) of the pleura represents less than 5% of all pleural neoplasms. Effusions are frequently large, occupying 50% or more of the hemithorax and obscuring the pleural tumor.In September 2005, a 65‐year‐old patient attended the clinic complaining of exertional dyspnea. His medical history was unremarkable and laboratory tests were normal. Chest X‐ray revealed an enormous space‐occupying lesion in the left hemithorax which was causing left lung collapse and right‐sided mediastinal shift. Multi‐detector computed tomography (MDCT) confirmed these features, but the relationship to the parietal pleura and mediastinal structures was unclear. Intravenous contrast administration with multiphase acquisition showed high vascularity of the tumor, with no lymphoadenopathy or compression of the left pulmonary artery. Surgical thoracotomy showed an encapsulated tumor, occupying the left pleural cavity and compressing the lung without invasion of mediastinal structures. The tumor was surgically removed en bloc and the left lung immediately re‐expanded. The tumor was enormous measuring 30 × 19 cm and weighed 4050 g.After a period of 11 years, in April 2016, the patient returned to the clinic for a routine chest X‐ray which showed a small rounded area of high attenuation, confirmed by multiphase MDCT, and the mass was surgically removed a few weeks later. In October 2016 a new mass of 40 x 36 mm was found in a different pleural location  is a widely used ablation technique based on inducing necrosis through high temperatures. MWA systems generate an ellipsoidal microwave field around a needle‐like applicator that is introduced into the tissue. Since water molecules have a positively and a negatively charged pole, they tend to align with the electromagnetic waves. The oscillation of the electromagnetic wave therefore causes a rapid flip motion of the water molecules which results in heating of the adjacent tissue through the mechanism of dielectric hysteresis. If the MW frequency perfectly matches the molecule‐specific resonance frequency of the water molecules, all the energy will be turned into heat, but the penetrability into the tissue will be low. The frequencies used by the current MW manufacturers (915 MHz and 2450 MHz) only partially match the resonance frequency of the water molecules, thus assuring efficient energy conversion into heat with satisfactory tissue penetrability.In conclusion, MW thermoablation is safe and highly effective for the local ablative treatment of lung lesions and particularly in cases of SFT of the pleura recurrence after surgery. Moreover, this technique avoids long‐term hospitalization and all the risks associated with surgery.The author declares there is no conflict of interest.


An incidental liver mass was discovered in a 65-year-old male during a routine ultrasound (US) check-up of his hiatal hernia. The mass, which showed no malignant characteristics, was interpreted as a focal nodular hyperplasia (FNH). Due to normal blood tests and tumor marker levels, as well as the patient's asymptomatic presentation, only regular monitoring was performed. At a check-up 18 months later, CT examination indicated hepatocellular carcinoma (HCC). Surgery was no longer possible due to diffuse liver involvement. Transarterial chemoembolization (TACE) and chemotherapy were started. A possible metastasis to the right adrenal gland was detected. The patient started to experience headaches, vertigo, paresthesia, and pain of the right jaw. A CT scan of the head showed a mass in the right masticatory space. A CT-guided biopsy confirmed a HCC metastasis. Hepatocellular carcinoma (HCC) is the most common primary tumor of the liver. It has a very poor five-year survival rate, second only to pancreatic cancer. More than 782,000 people worldwide died from liver cancer in 2018, with the majority due to HCC . Due to A 65-year-old male had a check-up for a large hiatal hernia. He had diabetes and was suffering from benign prostatic hyperplasia (BPH). An abdominal ultrasound (US) examination revealed an incidental hypoechogenic mass with irregular borders in the sixth segment of the liver, measuring 5.5 cm x 5 cm Figure . The lesA CT scan performed the following day confirmed the presence of a nonhomogenous change in the sixth segment of the liver Figure . Tumor mThe patient's clinical and laboratory findings were unremarkable. He used to be a smoker but had stopped more than 20 years ago. He denied excessive use of alcohol. The blood tests for a hepatitis infection were negative. Owing to the typical findings of the FNH, the lesion was considered benign, and only regular check-ups were performed every six months. The lesion did not show any notable changes at the first two check-ups, but 18 months later an enlargement was detected by US and another CT scan was performed. It revealed a sizable increase of the main lesion, now measuring 8 cm x 10 cm Figure . Before Nine months later, an increase of AFP was detected for the first time, although still only slightly above the normal limit, at 13.6 U/mL. The patient clinically deteriorated. In the follow-up CT examination, a mass in the right adrenal gland was discovered Figure . No addiA CT-guided percutaneous needle biopsy of the lesion was performed via a subzygomatic approach Figure . A cuttiPalliative treatment was started, including radiotherapy for the lesion in the masticatory space. Two months later, the patient died after several cardiac complications and eventual multiorgan failure. This was four years after the discovery of the first liver change and two years after establishing the HCC diagnosis.In the presented case the diagnosis of HCC was delayed probably owing to the atypical appearance at the first US and CT examinations. The findings were misleading toward the FNH, which does not have any potential for malignant transformation . At the Some HCC variants can also present very similarly to FNH. Early distinction is made mainly by the presence of cirrhosis or vascular invasion in HCC. Neither was present in our case. The liver was not cirrhotic, although it was steatotic. Only recent research indicates a possible risk of the progress of HCC development in the setting of non-alcoholic fatty liver disease (NAFLD) -11. AFP Unfortunately, once the diagnosis of HCC was established, surgery was no longer an option. The use of TACE and chemotherapy temporarily slowed down the disease progression. Extrahepatic metastases to the masticatory space and possibly to the adrenal gland were discovered. The metastasis in the masticatory space could have been the cause of his additional symptoms . Symptomatic treatment was indicated.The use of image-guided percutaneous needle biopsy for diagnosis of the masticatory mass is minimally invasive, which is especially valuable for patients with an already progressed disease. When dealing with nonpalpable, deep-seated head and neck lesions, CT-guided percutaneous needle biopsy is considered as a safer and more accurate option than an open surgical biopsy -16.While HCC metastases to the adrenal glands are relatively common , metastaThe presented case demonstrates that in liver lesions, even a typical benign radiological presentation, including Doppler, CEUS, and even CT, could be misleading. Therefore, caution is warranted with more frequent US follow-up as well as possible MRI examination, which has a higher sensitivity and specificity. With prolonged survival, the metastases may appear more often in unusual locations, such as in the masticatory space.


Transformation of lymphoma is an infrequent phenomenon, and involvement of the eye as such is even uncommon. Histological transformation in patients with follicular lymphoma who were previously treated with immune‐chemotherapy carry a poor outcome. Here, we illustrate such a case with aggressive histological transformation from a low‐grade lymphoma. Transformation of FL (TL) to an aggressive lymphoma is a well‐recognized phenomenon. FLs most commonly transform to diffuse large cell lymphoma (DLBCL).2A 66‐year‐old man with extensive lymphadenopathy  and splenomegaly was diagnosed with FL, predominantly grades 1‐2 with focal areas of grade 3A, Stage IV, with high‐risk FL International Prognostic Index 2 (FLIPI2) score. He had a good response to bendamustine and rituximab. Three months into his treatment, he noticed left eye swelling and visual disturbance. Clinical examination revealed erythematous left orbit with restricted extra‐ocular movements and elevated Intraocular pressure (IOP). MRI was highly concerning for orbital cellulitis with a secondary anterior displacement of left globe. In the emergency room, ophthalmology performed canthotomy and cantholysis to decrease IOP and broad‐spectrum antibiotics were initiated for suspected orbital cellulitis.MYC and BCL2 translocation. In light of the patient's history of FL, this B‐lymphoblastic leukemia/lymphoma is presumably a transformed lymphoma. Further diagnostic workup showed the cerebrospinal fluid involvement by B‐lymphoblastic lymphoma. There was no evidence of lymphoma/leukemia in the bone marrow. Subsequently, he received intrathecal cytarabine and methotrexate for leptomeningeal carcinomatosis. He was also started on systemic chemotherapy with HyperCVAD . Unfortunately, the patient could not tolerate intensive chemotherapy after two cycles of therapy and decided to enroll in hospice care.On the following day, orbitotomy revealed a firm mass compressing the optic nerve. An excisional biopsy of this mass was obtained. Subsequently, the patient received steroids due to optic nerve compression and antibiotics were discontinued. He later received radiation therapy the following day. Excisional biopsy of the orbital mass revealed a B‐lymphoblastic lymphoma Table , entirel3Transformation of lymphoma (TL) is an infrequent phenomenon and has been reported in approximately 30% of FL.3.1Several large studies reported the incidence of TL in FL, mainly in the prerituximab era, showing a 5‐ and 10‐year risk of 15% and 30%, respectively, with an estimated incidence rate of 3% per year. The outcome for patients with TL was poor with median survival of 1‐2 years and reported 10‐year survival for patients with nontransformed FL of 75%, as opposed to 36% in patients with evidence of transformation.After the wide adoption of rituximab in the management of NHL, the incidence and outcomes of TL were restudied. The incidence of TL was ranging between 2% per year3.2Studies have been done to determine prognostic factors in patients with TL in prerituximab era. Some of the indicators for worse survival include high lactate dehydrogenase (LDH), advanced stage disease, and not having achieved complete remission.3.3Transformation of lymphoma is generally diagnosed by histology. Transformed FL may or may not retain markers similar to its original follicular origin. Although changes in the antigenic marker are common, the light chain restriction is usually preserved. Therefore, a change of the light chain restriction from kappa to lambda or vice versa should raise the concern for a second malignancy rather than TL.Less commonly, clinical diagnosis of TL can be made, if the histological diagnosis is not feasible, based on reliable predictors such as rising LDH, rapid nodal growth, the involvement of new extranodal sites, sudden decline in performance status, new “B” symptoms and hypercalcemia.3.4BCL2 gene. Most reported cases (upward of 90%) of lymphoblastoid transformation of FL are double‐hit . While the prognosis of lymphoblastoid transformation with double‐hit is slightly worse than that of de novo double‐hit lymphoma, its unclear whether the lymphoblastoid morphology or the double‐hit nature of this transformation confers a worse prognosis than what would be expected from a typical tranformation of FL to DLBCL.Acquiring MYC rearrangement is a detrimental step contributing to the development of transformed lymphoma.3.5Ocular Lymphoma is the most frequent tumor of all malignant ocular tumors, constituting up to 55% of all orbital tumors.3.6The management of TL is mainly derived from the evidence of treating FL transformed to DLBCL. The treatment, in general, includes rituximab‐containing high‐dose chemotherapy, with and without autologous hematopoietic stem cell transplant. It has been shown that intensification of regimens, including transplant, can improve survival.The management of ocular adnexal lymphoma on the other hand, given its anatomical involvement, generally involves radiotherapy. While radiotherapy is the most extensively employed approach, the response rates are usually low. Other management approaches include chemotherapy, immunotherapy, and surgical excision followed by observation.4MYC and BCL2 translocation (double‐hit) in the eye. A presentation of what seems like orbital cellulitis in patients with indolent lymphoma may, in fact, be a presentation of ocular lymphomatous involvement.Transformation of indolent lymphoma to more aggressive lymphoma is an infrequent event and carries a poor prognosis. TL isolated to the orbit is extremely uncommon. To the best of our knowledge, this is the first case report of such transformation of FL to B‐lymphoblastic lymphoma with a simultaneous None declared.RKV: involved in conception and design of work, drafting, and final approval of the version. AH: drafted the manuscript and collected data. VD: involved in revision of the article. MM: involved in critical revision of article.


Giant cell tumor of the tendon sheath (GCTTS) is a benign soft tissue  tumor that rarely involves the hands or wrists. And Tendon impairment caused by GCTTS is extremely rare.Here, we reported a case of a 60-year-old female with a 10-year history of gradually increasing mass in her left dorsal wrist. The EIP tendon was partially impaired by the mass.The patient was treated with surgical excision of the mass and reconstruction of the EIP tendon. The histopathological examination suggested the presence of GCTTS. After surgery, the patient had adequate functional recovery and no tumor recurrence after 2 years’ follow-up.GCTTS in hands and wrists rarely damages the tendon. Early diagnosis and proactive interventions may likely contribute to good prognostic outcomes. Giant cell tumor of the tendon sheath (GCTTS), which originally arises from the synovial cells of tendon sheaths or tendinous spaces, is a slow progressing benign tumor –3. GCTTSWe report a 60-year-old female patient presented with an asymptomatic nodular lesion in her left dorsal wrist over the 10 years. The mass had grown gradually from the size of a green pea initially, and no history of trauma was mentioned. The mass slightly weakened the degree of dorsal extension of her left wrist, but did not cause any pain or numbness. Upon local examination, we found that the mass was firm, non-tender, and located on the dorsal side of the left wrist. It measured 5 × 6 × 18 mm. The mass was free from the skin but was attached to the extensor indicis proprius tendon. The range of motion of her wrist was 45° extension to 80° flexion. The results of the laboratory studies were as follows: the blood routine, antistreptolysin O (ASO) level, erythrocyte sedimentation rate (ESR), high-sensitivity C-reactive protein (hs-CRP) level, anti-cyclic peptide containing citrulline (anti-CCP) level, and other immune indices were normal. The levels of biological markers of the tumor were also normal. MRI scans Fig. , we founThe etiology of GCTTS has not yet been fully elucidated. Some possible etiologies include disturbances in lipid metabolism, neoplasms, inflammation, trauma, and hemorrhage , 14. HowWhile GCTTS is still considered a rare benign clinical disease, it has become more common in recent times. GCTTS can be classified as either localized or diffuse based on its clinical presentation and biological behavior; the latter is known to be more aggressive. In accordance with previously published literature, we diagnosed this case of GCTTS in the wrist as a benign and noninvasive tumor. However, during surgery, we found that the lesion had surrounded, partly infiltrated, and damaged the extensor indicis proprius tendon. Such observations are extremely rare. In this case, the tendon injury seen could not have been iatrogenic because the patient had not received any prior treatments . In addition, what’s the possible reasons resulting in the repture of the EIP tendon? We thought that the likely cause of the EIP tendon rupture was combination of GCTTS infiltrating into the tendon and also the mechanical or pressure effect of the EIP tendon excursion under the wrist extensor retinaculum.So decreasing the movement of the left wrist may be helpful to protect the EIP tendon in this case.Intraoperative view, we found that the strength of extensor indicis proprius tendon was satisfactory.We transected part of the affected tendon and sutured longitudinally. Three days after surgery, the patient began functional training and rehabilitation under the guidance of a doctor. The patient recovered well, had no functional impairments, no tendon re-rupture or adhesion, and no recurrence for over 2 years. It is important to closely monitor tendon re-rupture and tumor recurrence. If the tendon re-ruptures or the tumor recurs, tendon repair or radical resection of the tumor must be performed . In addiThe clinical presentations and radiological findings of patients may initially indicate the presence and margin of a mass and this may be useful for primary diagnosis, surgical planning and postoperative follow-up.However, the final diagnoses must be made on the basis of the histological examination .SometimeIn the case, postoperative pathology showed pervasion of the synovial mononuclear cells and the multinucleated giant cells were dispersed in the interstitial tissue. Immunohistochemical examination also showed the presence of CD68 (+) and Ki-67(+). We found that, in some cases, the cytoplasm of the synovial mononuclear cells contains deposits of iron-hemoflavin particles . TogetheIn conclusion, GCTTS originating from the hands or wrists are usually benign and localized, but in extremely rare cases, there is a possibility of tendon damage. In this report, we detailed a case of GCTTS in the wrist that impaired the extensor indicis proprius tendon. Based on this case, we learned that early radical resection is recommended upon diagnosis,at the same time,the decreasing movement of the involved tendon will be helpful.All these will help to prevent the destructive proliferation of the tumor, maximumly reserve the tendon’s function, and contribute to good prognostic outcomes.


Insulinoma is a rare neuroendocrine tumor that causes inappropriate release of insulin, resulting in episodes of hypoglycemia. It classically present with neuroglycopenic and autonomic sympathetic symptoms. These symptoms resolve promptly following glucose administration. Demonstration of elevated C-peptide level in the presence of hypoglycemia and absence of plasma sulfonylurea is suggestive of the diagnosis. Pre-operative localization of the tumor is essential. Herein, we present the case of middle-aged man who had a 6-month history of recurrent episodes of irritability and fatigue that resolved after eating. Pancreatic insulinoma was localized by computed tomography scan. The patient underwent successful resection of the tumor, and his symptoms showed complete resolution. Insulinoma is an insulin-secreting tumor resulting in hypoglycemia. Although it is the most common functional pancreatic tumor, insulinoma is very rare with an annual incidence of four cases per million . Most inWe report the case of a 45-year-old man who was referred from primary health center due to complaints of frequent episodes of fatigue and irritability for the last six months. He reported having the need to take frequent breaks during work. His spouse reported that his concentration gets impaired during those episodes and he exhibits shaking-like movement without losing of his consciousness. These episodes resolved after eating. He also had a road traffic accident two months prior to presentation that was related to loss of consciousness as a result of hypoglycemic event. His medical history is remarkable for a recently diagnosed hypertension that is well controlled by amlodipine 5 mg daily. He underwent elective laparoscopic cholecystectomy five years ago. His family and social history are noncontributory.Upon presentation, he was afebrile, and his blood pressure, pulse rate, and respiratory rate were observed to be 115/68 mmHg, 72 beats/minute, and 14 breaths/minunte, respectively. Examination of the neurological and cardiorespiratory systems was normal. Routine laboratory investigations including hematological and biochemical values were all within the normal limits. He was admitted for observation and further investigation. Few hours after admission, the patient developed an episode of irritability and exhibited a tremor. On this event, blood analysis revealed a serum glucose level of 50 mg/dL, insulin level of 40.1 uIU/mL (2.5-25.0), and C-peptide level of 4.8 ng/mL (1.5-5.0). The symptoms quickly resolved following the administration of intravenous dextrose.Given the aforementioned clinical and laboratory findings, abdominal computed tomography (CT) scan was performed to confirm the diagnosis of insulinoma. It demonstrated a single enhancing lesion located at the head of the pancreas measuring 1.5 × 1.0 cm  and sympathetic symptoms  in the presence of low serum glucose level (less than 50 mg/dL) that resolve promptly following the administration of glucose . In the The diagnosis of insulinoma can be difficult. While insulinoma is typically diagnosed after less than 1.5 years after the onset of symptoms .Insulinoma is usually a benign and solitary tumor. In some cases, it might occur in conjunction of multiple endocrine neoplasia type 1 (MEN-1 syndrome), which includes parathyroid hyperplasia, anterior pituitary adenoma, and neuroendocrine tumor of pancreas or duodenum. MEN-1 syndrome is an autosomal dominant disorder caused by a mutation in the MEN1 gene in the chromosome 11. Insulinomas associated with MEN1 syndrome are often multicentric and develop earlier compared to sporadic insulinomas .After diagnosis, imaging modalities are used to localize the tumor. Accurate diagnosis is essential for planning the surgery. This is due to the fact that not all tumors are palpable intraoperatively. The noninvasive imaging modalities include CT scan, magnetic resonance imaging, transabdominal ultrasonography, pentetreotide scintigraphy, and positron emission tomography. The choice of these modalities depends on the availability and local radiologic skills . In our The treatment of choice of insulinoma is surgical excision. Complete enucleation is performed in most cases as insulinoma is a solitary and benign tumor. If enucleation is not feasible, distal pancreatectomy or Whipple procedure is performed. Laparoscopic resection is gaining popularity . After sInsulinoma is a very rare tumor. Clinicians should have a high index of suspicion for this condition in patients with history of recurrent episodes of fatigue and irritability, particularly if they are resolved after eating.


Splenosis is a medical condition that seldom occurs after splenic tissue spillage via trauma or surgery. Ectopic spleen tissues can be found almost anywhere within the body. Albeit benign, it is often misdiagnosed as a tumor. Surgery is not indicated unless symptomatic. The imaging of choice for pelvic splenosis, although conventional, is a sulfur colloid nuclear scintigraphy. Splenosis is a medical condition that seldom occurs after splenic tissue spillage via trauma or surgery. Ectopic spleen tissues can be found almost anywhere within the body. Albeit benign, it is often misdiagnosed as a tumor. Surgery is not indicated unless symptomatic. The imaging of choice for pelvic splenosis, although conventional, is a sulfur colloid nuclear scintigraphy. Semen analysis showed severe oligospermia, but otherwise normal testosterone and follicular stimulating hormone levels. Pelvic ultrasound performed for vague nonspecific flank pain revealed an incidental large pelvic mass. Further imaging with a multiparametric pelvic MRI showed a 12 × 10 cm right pelvic mass compressing the right seminal vesicle and deviating the rectum laterally (Figures Splenosis is usually an incidental finding and commonly occurs after splenic trauma or after splenectomy, None of the contributing authors has any conflict of interest, including specific financial interest or relationships and affiliations relevant to the subject matter or materials discussed in the manuscript.JD and NAH: wrote the manuscript, performed the literature review on the subject, and approved the final version of the manuscript prior to submission.Written informed consent was obtained from the patient for publication of this case and any accompanying images. A copy of the written consent is available for review by the Editor‐in‐Chief of this journal upon his request.


Dear Editor,We report a case of multiple warty dyskeratoma (WD). The patient is a 55-year-old Chinese man who presented with a four-year history of multiple pruritic papules and plaques on the scalp. The number and size of the lesions were gradually increasing. No family history of similar lesions was recorded. Physical examination revealed multiple, discrete, hyperkeratotic papules and plaques, but no vesicles or erosions on his scalp . No otheNone declared.Qiang Zhao: Elaboration and writing of the manuscript.Hongmei Zhou: Obtaining, analyzing and interpreting the data.Songmei Geng: Approval of the final version of the manuscript.None declared.


Ultrasound (US) imaging represented an isoechogenic lesion with high vascularization in both power Doppler and microflow imaging with central feeding artery. Both strain elastography and shear wave elastography demonstrated a stiff lesion compared to surrounding testicular tissue. While contrast-enhanced ultrasound (CEUS) clearly depicted high vascular load, time intensity curve (TIC) analysis was able to show shorter median transit time, higher peak enhancement, and higher wash-in area under the curve compared to regular testicular tissue. Histopathological examination revealed a lobular constructed and rich vascularized proliferation without cellular atypia and feeder vessels with positive reaction to CD34, CD31, CD99, and Vimentin. Proliferative activity was quantified to 3–5% by Ki-67 index. Two days after surgery, the patient could leave the hospital in subjective wellbeing. While histology remains the gold standard to make a precise diagnosis of capillary hemangiomas due to small case numbers and variety of this benign tumor, the combination of multiparametric US and clinical information may be a promising future tool in preoperative assessment.Capillary hemangioma is a rare entity among testicular tumors. We demonstrate the case of an 18-year-old patient with palpatoric and sonographic conspicuous left testicle and negative serum tumor markers ( Capillary hemangioma is a rare entity among testicular tumors. Nevertheless, this benign vascular tumor is an important differential diagnosis since the most common malignant neoplasm in young men is testicular carcinoma, with increasing incidence . Testicuα-fetoprotein , β-human chorionic gonadotropin , and lactate dehydrogenase .We demonstrate the case of an 18-year-old patient who was admitted to our interdisciplinary US centre by an external urologist with palpatoric and sonographic conspicuous left testicle. Clinical examination revealed a caudal induration of the left testicle, which was nevertheless indolent. Epididymis and contralateral testicular parenchyma were inconspicuous. Serum tumor markers were negative: B-mode ultrasound of the left testicle showed an isoechogenic, round-shaped lesion in the central left testicle up to 11 mm diameter with a hypoechogenic peripheral rim . Power DCEUS examination was performed and interpreted by a single high-experienced radiologist with more than fifteen years' experience in CEUS (EFSUMB level 3) using a high-end ultrasound system  with a linear broadband transducer . B-mode US was optimized using spatial compounding, frequency-based compounding, ApliPure™ level 5, differential Tissue Harmonic Imaging (dTHI)©, and Precision Imaging© with level 4 Speckle Reduction (SR). CEUS was performed at 9 MHz, 10 fps configured with a very low MI (0.07) to avoid early microbubble destruction. A bolus of 2.4 ml of ultrasound contrast agent  was injected up to three times.The hypervascularized lesion showed early and strong contrast enhancement compared to the surrounding tissue. Arrival time imaging depicted a shorter arrival time feeder vessel with short central filling of the lesion due to high vessel density . In compThe patient received enucleation and intraoperative incision by highly experienced surgeons. Histopathological examination revealed a lobular constructed and rich vascularized proliferation without cellular atypia and feeder vessels. Immunohistology revealed positive reaction to CD34, CD31, CD99, and Vimentin. Moreover, there was a significant capillary growth form in the tumor's periphery between preexisting testicular tubules. The capillaries were continuously endowed with pericytes and showed partial expression of WT-1. Proliferative activity was quantified to 3–5% by Ki-67 index. Two days after surgery, the patient could leave the hospital in subjective wellbeing.The high vascularization in our case could have been shown congruous with PDI, SMI, and CEUS. Since hyperenhancement of a testicular lesion had a positive predictive value of 97.4% for neoplasia . The wasIn general, CEUS can be a very helpful method to investigate microvascularization of testicular lesions. CEUS may be valuable in the assessment of contrast enhancement in small intratesticular masses (<5 mm) where color-coded duplex sonography comes to its limits because small testicular tumors may appear avascular. Since it is possible to distinguish solid and cystic or burn-out tumors, previous studies found no key finding in enhancement pattern to differentiate between benign and malignant tumors especially in small lesion (<10 mm). Furthermore, clinical presentation may be similar between testicular hemangioma and malignant testicular lesions with slight testicular pressure leading to pain.CEUS has advantages over contrast-enhanced magnetic resonance imaging (MRI) including unmatched temporal resolution due to continuous real-time imaging . US remaWhile orchiectomy is recommended as the method of choice, enucleation and intraoperative incision showed a benign stroma tumor in this case, so the rest of the organ could remain. Nevertheless, histology remains the gold standard to make a precise diagnosis of a testicular tumor. Due to small case numbers and variety of this benign tumor, the combination of contrast-enhanced ultrasound, elastography, and clinical information (tumor markers) may be a promising future tool for treatment planning to avoid unnecessary orchiectomy especially in young patients.