A pleomorphic adenoma is a mixed salivary gland tumor. The parotid gland is the most common site. The intraoral palate is the most common site due to the abundance of accessory salivary glands in the palatal area. It has a very slow growth rate and is usually painless. Consequently, patients often have a lengthy history of presentation.Herein, we report a case of pleomorphic adenoma of the palate in a 53-year-old male patient. The mass was 5 cm by 4 cm in size. The growth rate was rapid, and it attained a large size in just nine months. On clinical examination, the overlying mucosa was ulcerated. On general examination, lymphadenopathy of the right side level 1 b lymph node was found. These clinical findings were consistent with malignancy. However, the histopathological report negated the clinical findings of malignant salivary gland tumors. The tumor was managed with a wide local excision of the tumor with a 1 cm clear margin. The postoperative course was uneventful. No recurrence was seen after two years of follow-up. A thorough cytological or histological examination is a prerequisite to defining the malignant nature of the lesion. Pleomorphic adenoma is the most common tumor of the salivary gland. It affects both major and minor salivary glands. It mostly affects the major salivary glands. The parotid is the most common site, with an incidence of 75%. Minor salivary glands account for around 7% of the affected glands. Intraorally, the palatal salivary glands are most commonly affected, with an incidence of about 45%. It has a female predilection, with an age distribution of 20 to 75 years , 2.Clinically, it presents as a firm, painless submucosal mass. It has a very slow growth rate, increasing in size slowly over the years. The overlying mucosa is mostly intact, with a few cases reporting ulcerated mucosa . The ulcMinor salivary gland carcinoma accounts for more than half of all salivary gland carcinomas reported in the head and neck. Around 60%-80% of reported minor salivary gland tumors are malignant -6. TheseThe aim of this paper is to report an unusual clinical presentation of pleomorphic adenoma of the palate with ulceration of the overlying mucosa and a rapid growth rate. The clinician should be aware of these rare clinical findings and wait for the histopathological examination before making a final diagnosis.A 53-year-old male patient reported a mass on the right side of the palate for nine months. The mass had been slowly growing for the first six months, but the growth was very rapid in the last three months. The mass became ulcerated and painful in the last month. There were no other symptoms like numbness, dysphagia, stridor, or speech difficulties.Past medical history revealed the patient was hypertensive and was on medications. Personal history revealed that the patient was a tobacco chewer. There was no previous history of biopsy or trauma to the mass. On lymph node examination, lymphadenopathy was seen in the right submandibular region.A clinical intraoral examination detected a well-circumscribed mass covering the hard and soft palates. The mass was mostly present on the right side of the palate. It was 5 cm by 4 cm in diameter. It was somewhat spherical in shape with a well-defined edge. The mass was translucent. As the overlying mucosa was ulcerated Figure , it was The temperature of the overlying mucosa was normal, and its consistency was firm. The mass was immobile, and no pulsation was felt. A computed tomography scan revealed a 4.5 cm x 4cm x 3 cm mass involving the right side of the palatal bone. The mass was well-circumscribed, and it was extending into posterior airway space. The mass caused cupping and resorption of the hard palate. However, a thin layer of palatal bone was intact Figure .The rapid growth of the tumor, along with ulceration without any history of trauma or biopsy, raised suspicion of malignancy. Fine needle aspiration cytology (FNAC) of the mass showed epithelial components in tubules and trabeculae with hyperkeratotic and hyperplastic squamous epithelium. However, no malignant cells were seen. The FNAC of the enlarged lymph node showed inflammatory changes.After a routine preoperative blood examination and pre-anesthetic checkup, an excision of the tumor was planned. Under general anesthesia, the excision of the tumor with periosteum was carried out with overlying mucosa and a 1 cm clear margin Figure .The excised sample, as seen in Figure Histopathological examination revealed that the tumor was biphasic in nature. It was composed of both epithelial and stromal components. Epithelial components were arranged in tubules, trabeculae, and cords. The cellular components were composed of epithelial and myoepithelial cells. Stroma was myxoid and showed adipocytes. The focal melting of epithelial components into the stroma was identified. This confirmed the diagnosis of pleomorphic adenoma. No malignant cells were seen Figure .Immunohistochemistry showed negative results for CD 117, CD 43, smooth muscle actin (SMA), and glial fibrillary acidic protein (GFAP), which ruled out malignant transformation. The patient's postoperative period was uneventful. After 15 days, soft tissue covered the bared bone Figure .A significant amount of healing was seen in six months Figure .The patient is under regular follow-up, and there is no evidence of recurrence after two years of follow-up.The minor salivary glands are smaller salivary glands that are distributed across the upper aerodigestive tract. They numbered between 450 and 1000, and they are mostly present around the oral cavity . Minor sThe malignant tumor is known to occur in the hard and soft palates. Pain and ulceration are usually the first clinical findings. The pain usually results from the local extension of the neoplasm into adjacent hard and soft tissue. The other findings are rapid growth and lymphadenopathy ,10. In oImaging plays a crucial role in the diagnosis of benign and malignant salivary gland tumors. Benign tumors mostly have smooth margins. Malignant salivary gland tumors usually have an ill-defined margin, and they show destructive growth and invasion into adjacent soft tissue or underlying bone. However, the imaging characteristics may vary depending on the histological grade of the salivary tumors. Low-grade salivary tumors also have smooth borders and may cause pressure erosion of adjacent bone, like benign tumors. However, high-grade tumors have irregular borders . TherefoHistologically, palatal tumors are mixed tumors composed of both ductal epithelium and myoepithelium. The tumor is surrounded by a fibrous tissue called a pseudocapsule . The pseThe treatment of palatal pleomorphic adenoma is controversial. Some authors suggest the enucleation of the tumor. The advantage of enucleation of tumors is that it helps shave the overlying mucosa. However, the majority of authors suggest a wider local excision of the tumor. This is because of the uneven thickness of the pseudocapsule. The pseudocapsule is substantially thick in some places; it is thin and delicate in other sites, while in other places it is incomplete. This means that where the pseudocapsule is absent or incomplete, the normal tissue and tumor tissue are in close contact. Therefore, although the tumor tissue is clinically shelled out after enucleation, it may be left behind adhering to the normal tissue. Wu et al. observed on histopathological examination of 74 palatal pleomorphic adenomas that the tumor can be fully encapsulated 16%), partially encapsulated (54%), or unencapsulated (30%) [6%, partiThe above characteristics of the tumor strongly suggest wide local excision of the tumor with a clear margin. A clear margin of 1 cm is recommended by most surgeons. Excision or scraping of the palatal bone is not required, as pleomorphic adenoma does not release any osteoclast-activating factors to invade bone. Moreover, the periosteum is an effective anatomical barrier.The presence of ulceration and rapid growth in palatal pleomorphic adenoma usually suggests malignancy. However, these clinical findings do not guarantee malignancy. Histological examination is the gold standard for diagnosis. We should wait for a histopathological examination before making a final diagnosis based only on clinical findings. A wide local excision with a clear margin of 1 cm is an ideal surgical technique to prevent recurrence.


An uncommon form of CNS tuberculosis called non‐osseous IDEM tuberculoma frequently results from paradoxical drug interactions. It should be considered one of the differentials when patients receiving ATT experience acute neurological impairment.Tuberculoma affecting the spinal cord is a rare condition in modern times. The occurrence of non‐osseous intradural tuberculosis, specifically in the spine, is even more exceptional. In fact, it is uncommon to encounter an intradural extramedullary tuberculous granuloma that lacks radiological indications of vertebral involvement, especially within the thoracic region. We present a case of a patient with a neurological deficit caused by a non‐osseous intradural tuberculoma in the thoracic region, without any associated bone involvement. The patient experienced a gradual deterioration of neurological function. An MRI of the thoracic spine revealed the presence of a tuberculoma located intradurally, extramedullary, and juxtamedullary of the T5 vertebra. The compression of the spinal cord resulted in paraparesis which was worsening to paraplegia. A D4–D6 laminectomy and microsurgical excision were performed under intraoperative neurophysiological monitoring (IONM), and the patient showed clinical recovery. Excellent clinical outcomes were achieved. However, it is crucial to consider the possibility of a non‐osseous intradural tuberculoma as a rare condition when encountering a SOL, particularly in patients with a history of tuberculosis and spinal cord compression. In cases where a progressing neurological deficit is present, a combination of surgical intervention and anti‐tuberculous treatment should be considered as the optimal approach. The MRI images of the thoracic spine. (A) Coronal T1‐weighted MRI image shows a ring‐like enhancing intradural lesion after gadolinium. (B) Sagittal T1‐weighted MRI image shows a 2.1 × 1.7 × 1.45 cm intradural/juxtamedullary and extramedullary mass with central necrosis and marginal enhancement after gadolinium suggestive of immature tuberculoma at T5 level. (C) Axial T2‐weighted image. The CNS involvement in developing countries constitutes nearly 10% of all tuberculosis patients.Here we will be discussing a case of intradural extramedullary tuberculosis of the thoracic spine, with progressive neurological dysfunction. Surgery aims to decompress the spinal cord and remove the tuberculoma, thereby relieving the pressure on the neural tissues and preventing further neurological deterioration.Following surgery, anti‐tubercular therapy is initiated to target the underlying tuberculosis infection. This typically involves a combination of multiple anti‐tuberculosis medications, such as isoniazid, rifampicin, ethambutol, and pyrazinamide.This report aims to discuss the diagnostic challenges, treatment strategy, and clinical outcomes, highlighting the importance of a multidisciplinary approach in managing this uncommon condition.2A 29‐year‐old man, who had been under treatment for disseminated tuberculosis for 7 months, was admitted with progressive weakness of both lower limbs leading to difficulty in walking. There was no history of fever, cough, palpitations, or breathlessness. Physical examination revealed a palpable spleen but no lymphadenopathy. He had spastic paraparesis with involvement in right side more than the left. There was severe girdle pain at T5 level. The patient underwent a computed tomography (CT) chest, which revealed multiple patchy resolving ground glass opacities and interlobular septal thickening in bilateral lower lobes, predominantly superior and posterior basal segments, suggesting resolving tuberculosis. Also, mild centrilobular emphysema in bilateral upper lobes with sub‐centimeter right paratracheal and left paraaortic lymph nodes, the largest measuring 7 mm, were present. Other findings included splenomegaly measuring 17.6 cm and calcified hepatic granulomas (segment VII).Magnetic Resonance Imaging (MRI) thoracic spine revealed a single 2.1 × 1.7 × 1.45 cm intradural/juxtamedullary and extramedullary mass appearing as well‐defined T1‐weighted low signal/T2‐weighted FLAIR bright signal with central necrosis and marginal enhancement after gadolinium (Gd) suggestive of immature tuberculoma at T5 level with surrounding edema Figure .No evidence of vertebral TB, spinal tract infiltration, or engulfment was noted. A diagnosis of D5 intradural extramedullary space‐occupying lesion (SOL) with spastic paresis, cord compression, compressive myelopathy, disseminated tuberculosis, and post‐tuberculous medication‐induced hepatic granuloma was made. D4‐D6 laminectomy and microsurgical excision under IONM were planned to remove the lesion. After pre‐anesthetic assessment and consent, the patient underwent the procedure with the head held in a horseshoe, subperiosteal muscle dissection made, and laminae exposed. Durotomy was performed under a microscope, and the lesion was visualized. A grayish‐white, firm lesion with a central necrotic area was exposed Figure .The pus was aspirated, followed by internal bulking using ultrasonic surgical aspirator Figures , 4, 5. T3Tuberculosis (TB) remains a common health issue in developing countries, even though TB has not been seen widely as before.M. tuberculosis neuropathogenesis. Although it helps in granuloma formation and control of mycobacterial infections, local production of TNF‐α in the central nervous system can alter the permeability of the blood–brain barrier and promote the progression of TBM.The pathogenesis of central nervous system tuberculosis involves the development of small foci of tuberculosis, known as rich foci, in the brain, spinal cord, or meninges.M. tuberculosis, and the CD14 receptor facilitates engulfment of unopsonized bacilli by microglia. Microglia infected with M. tuberculosis produce a variety of cytokines and chemokines, including TNF‐α, IL‐6, IL‐1β, CCL2, CCL5, and CXCL10. Microglia play a central role in the neuropathogenesis of tuberculosis, and their infection can lead to immunosuppressive effects, especially in more virulent strains.Human microglia are selectively infected by Similarly, among various forms of spinal TB involvement, such as Pott disease, non‐osseous spinal TB, tuberculous spinal meningitis, and tuberculous arachnoiditis, non‐osseous spinal tuberculoma is infrequent. In a review conducted by Dastur, 74 cases of spinal tuberculomas were analyzed, revealing that 65% were located extradurally, 8% were intramedullary, 5% were intradural extramedullary, and 20% were arachnoidal.The clinical presentation of the case aligns with the findings reported in the literature, which often show a higher prevalence among males.A combination of surgical intervention and medical treatment has shown excellent outcomes. While some authors argue that anti‐tuberculous therapy alone is sufficient when a paradoxical reaction develops into a tuberculoma,The list of similar published cases is mentioned in Table 4IDEM tuberculoma is a rare manifestation of CNS tuberculosis, often arising as a result of paradoxical reactions to anti‐tubercular medication. When patients on anti‐tubercular therapy develop new‐onset neurological deficits indicative of compressive myelopathy, IDEM tuberculoma should be considered as one of the potential causes. Early and accurate diagnosis, along with timely initiation of appropriate medical or surgical interventions, is crucial to prevent irreversible dysfunction. Excision plays a pivotal role in the treatment of this uncommon condition.Shyam Duvuru: Conceptualization; data curation; formal analysis; investigation; methodology; writing – original draft; writing – review and editing. Vivek Sanker: Formal analysis; investigation; methodology; project administration; resources; supervision; validation; visualization; writing – original draft; writing – review and editing. Syed Naureen: Resources; software; supervision; validation; visualization; writing – original draft; writing – review and editing. Gupta Prakash: Software; supervision; validation; visualization; writing – original draft; writing – review and editing. Rajurkar Sanjana: Resources; software; supervision; validation; visualization; writing – original draft; writing – review and editing. Tirth Dave: Resources; software; supervision; validation; visualization; writing – original draft; writing – review and editing.None.None declared.The ethical approval was not required for the case report as per the country's guidelines.Written informed consent was obtained from the patient to publish this report.


We report the case of a tertiary cytoreductive surgery for isolated lymph-node recurrence (ILNR) in a 54-years old Brest cancer 2 (BRCA 2) mutated patients, with a personal history of ovarian cancer previously treated elsewhere. She was admitted to our department for a suspected isolated lymph-nodal pelvic recurrence. A positron emission tomography acquisition with contrast enhanced computed tomography (PET-CT) scan revealed an increased node at the level of the right external iliac (SUV 6.9) in correspondence with the obturator nerve, which was confirmed by transvaginal ultrasound. Since the recurrence was in a single site and the patient had previously undergone three lines of chemotherapy and maintenance with Poly(ADP-ribose) polymerase (PARP) inhibitors, we decided to perform tertiary cytoreductive surgery by minimally invasive laparoscopic approach. After gradual and careful isolation of the obturator nerve, lumbo-sacral trunk and venous vessels afferent to the external and internal iliac vein, the suspected node has been removed. No intra- and postoperative complications occurred. The patient was discharged three days after procedure. We decided to quarterly follow-up; actually, after 16 months no recurrence was detected. Several studies have reported ILNR as a unique clinical disease with low growth rate and less chemosensitivity; this can lead to considered ILNR more susceptible to take advantage of surgical treatment, even in case of second or third recurrence. The BRCA mutational status seems to play a role in the decision-making process in the approach to patients with platinum sensitive relapse of ovarian cancer or in specific isolated forms of recurrence such as the hepatic one. However, data on frequency and prognostic impact of BRCA gene mutation in ILNR are very limited. In this article we investigated the role of BRCA 1 or 2 mutational status in this rare pattern of recurrence according to more recent advances in literature. BRCA genes or homologous recombination deficiency (HRD), and the pattern of relapse have played an increasing role in suggesting potential appropriate personalized treatment [BRCA gene mutation could help to predict the platinum sensitive disease [BRCA status and ILNR [The major clinical challenge in epithelial ovarian cancer (EOC) is the management of relapse, which occurs in around 60–75% of patients within two years from diagnosis ,2. Currereatment ,4,5. Thereatment . Howeverreatment , and thireatment ,11. Suchreatment ,13,14,15reatment , accountreatment . Severalreatment ,19,20. T disease . Howeverand ILNR ,22.BRCA 2 mutated patient previously treated by PARPi. We also systematically investigated the role of BRCA 1 or 2 mutational status in this rare pattern of recurrence according to more recent advances in literature.In this article, we report our experience with a laparoscopic eradication of pelvic ILNR in a 2 and Carboplatin AUC 6 every 21 days were administered.We present the case of a 54-years old woman, with a personal history of ovarian cancer previously treated in another hospital. In 2016, because of ascites and carcinomatosis, she underwent to radical hysterectomy with bilateral salpingo-oophorectomy and rectosigmoid resection with primary anastomosis, radical omentectomy, performed by a midline laparotomy, with complete cytoreduction (CC-0). Histological examination revealed a high grade serous ovarian cancer (HGSOC), FIGO stage IIIC. Six cycles of Paclitaxel 175 mg/mBRCA 2 mutation. A further recurrence occurred 15 months after the end of second-line chemotherapy. For this, she underwent to surgical management with pararectal node excision, hepatic node excision and diaphragm nodes ablation by laparotomy, with an optimal residual tumor (CC-1). Three cycles of platinum-based chemotherapy followed the surgery, and Olaparib was administrated until it was discontinued, 24 months later, following an episode of transient subocclusion, managed with nonsurgical treatment. After further 22 months, a PET-CT scan revealed FDG uptake (SUV 6.9) at a right external iliac increased node (24 mm in maximum diameter) in correspondence with the obturator nerve (After 12 months of platinum-free interval an isolated pelvic peritoneal recurrence occurred. Additional six cycles of platinum-based chemotherapy were administered achieving complete disease remission. She was successively diagnosed with a germ-line or nerve . The traor nerve . She wasAt laparoscopic exploration, severe pelvic visceral adhesions were found, with no signs of peritoneal carcinomatosis nor ascites. Following a careful adhesiolysis, the lateral and medial features of the right external iliac vessels were exposed by access to ileo-lumbar space. On the right side, the obturator nerve, the lumbo-sacral trunk and vessels were gradually and gently isolated . After cStraight-stick laparoscopy successfully managed the entire intervention, and no intra-operative complications occurred. The whole operating time was 125 min. The estimated blood loss was 90 mL. The post-operative course was uneventful, and the patient was discharged three days after the procedure. Histological examination confirmed the serous ovarian cancer intranodal recurrence . Since t+ and CD8+ cell infiltration compared to extranodal relapse [ILNR is actually considered as a rare entity in the context of EOC since it affects only 1–5% of relapsed EOC ,17. Thes relapse . For the relapse ,22,26,28 relapse . Further relapse . In lite relapse ,18,28,31 relapse . However relapse ; also a  relapse ,32,33.BRCA 1 or 2 mutational status, as evidenced by Marchetti et al. [BRCA 1 or 2 gene mutational status on specific relapse settings, such as in the case of ILNR; even because treatment with a PARPi should not be offered to patients with recurrent EOC that have received a PARPi [BRCA status.Moreover, the management of platinum-sensitive ROC, must consider i et al.  or in spi et al. . However a PARPi . Even ifHollis et al., reported a molecular characterization of ILNR that did not show marked enrichment or depletion of cases with BRCA mutational when compared to isolated extranodal relapses counterparts .BRCA 1 or 2 mutational status does not appear to be associated with better clinical significance in terms of OS and PFS in ILNR, differently from what happens in relapses in other sites [BRCA 1 or 2 mutated patients was statistically higher in the ILNR group [Gallotta et al., showed that er sites . This isNR group .BRCA mutational status does not currently have an impact on ILNR, and the number of BRCA 1 or 2 mutated patients with ILNR who previously underwent PARP is set to increase, surgery in highly selected patients appears to play a crucial role.In this context, the management of ILNR and the choice of a more personalized strategy be related to a series of factors: since the BRCA 1 or 2 mutational status in the ILNR; in addition to the molecular biology of this rare disease, still little known today. Because of the lack of studies on this topic, our case report represents an isolated case and emerges from a choice of personalization of the treatment. Despite that, it is our opinion that our research can be a useful source for a deeper investigation to other expert center groups.In our specific case, we proposed minimally invasive tertiary cytoreductive surgery because at the time of the diagnosis the patient presented a pelvic ILNR recurrence, with a highly predictable optimal cytoreduction. Moreover, the patient had already undergone treatment with platinum and maintenance with PARPi in the previous peritoneal recurrence; therefore, in particular cases, surgery could adequately represent the possibility of achieving the best clinical benefit. We believe that the number of this kind of patients with specific isolated recurrence settings, already treated with PARPi, is destined to increase. For these reasons, these knowledges are precious to personalize the treatment in the early future. However, further prospective studies are needed to investigate the prevalence and the role of the BRCA 1 or 2 mutated already treated with PARPi. The personalization of the strategy and the achievement of a complete cytoreduction must be the aim of the treatment. To date, the impact of the BRCA 1 or 2 mutational status on this specific recurrence setting is still under investigation, therefore further studies will allow us to have more adequate knowledge in the management of increasingly complex patients.Our experience confirms that tertiary cytoreductive surgery can be considered an effective therapeutic option for the ILRN’s management even in patients


Malignant lymphoma rarely mimics an infected arterial aneurysm and a ruptured arterial aneurysm because of similar imaging findings, leading to misdiagnosis. The hematomas of ruptured aneurysms are radiologically difficult to distinguish from those of malignant lymphoma in emergency settings. Hence, a definitive diagnosis is crucial to avoid unnecessary surgery.A man in his 80s with hematuria and shock vital had right internal iliac artery aneurysm (IIAA) and perianeurysmal fluid retention, which appeared to be a ruptured or an infected aneurysm. Treatment was initiated for infected IIAA instead of for ruptured IIAA. Systemic inflammatory response syndrome developed, and the infectious sources were assessed. Pacemaker lead and urinary tract infections were identified and treated; however, blood pressure was unstable. The aneurysm was treated with endovascular aortic aneurysm repair following antibiotic therapy; however, fluid retention increased, and inflammatory status and hematuria deteriorated. Open surgical conversion was performed to manage the infected lesions. Although an iliopsoas abscess was detected during surgery and nephrectomy and ureterectomy were performed to control the hematuria, analysis of the removed tissues led to the pathological diagnosis of diffuse large B-cell lymphoma (DLBCL).We encountered a case of DLBCL with imaging findings mimicking an infected internal iliac artery aneurysm, and definitive diagnosis was made more than 2 months after the initial examination. Definitively diagnosing malignant lymphoma around an iliac artery aneurysm based merely on symptoms and imaging findings is extremely difficult. Thus, histological examination should be actively performed in atypical infected aneurysms. The iliopsoas muscle, ureters, and para-aortic lymph nodes are in proximity to the abdominal aorta, a retroperitoneal organ. Thus, an iliopsoas abscess and retroperitoneal malignant lymphoma need to sometimes be distinguished from an infected abdominal aortic aneurysm (AAA) and hematoma of a ruptured aneurysm , 2. WithHerein, we reported the case of a patient with diffuse large B-cell lymphoma (DLBCL) who was referred to us with a suspected infected internal iliac artery aneurysm (IIAA) and required two laparotomies before a definitive diagnosis could be reached, following which the patient’s life could not be saved.Staphylococcus hominis was detected in one of four sets. Urine culture revealed the presence of methicillin-resistant Staphylococcus aureus and Enterococcus faecalis. Echocardiography demonstrated a 15-mm mass in the right atrium with movement at the pacemaker lead  revealed a 28-mm right IIAA and perianeurysmal fluid retention causing right pyelectasis. He was transferred to our hospital, on an emergency basis with a suspected ruptured IIAA. AAA was also detected, and although the IIAA appeared to have ruptured, the IIA was occluded Fig. A, B. HisUreterography revealed no evidence of communication between iliac arteries and right ureter and a ureteral stent was placed on the day of admission. Furthermore, the intravenous antibiotic administration of meropenem and vancomycin was initiated for treating urinary tract infection and pacemaker lead infection. On day 2 of hospitalization, the pacemaker was removed. On day 3, improvements in the WBC count (7030/μL) and CRP level (9.97 mg/dL) were observed following the above interventions. Therefore, systemic antibiotic dosing was planned for approximately 3 weeks before aneurysm treatment. However, low blood pressure was noted on day 18. CT revealed an increase in retroperitoneal fluid retention around the right IIAA, raising a suspicion of ruptured aneurysm and uretero-iliac artery fistula  positron emission tomography (PET)–CT performed on day 21 revealed the accumulation of FDG, consistent with retroperitoneal fluid retention around the aneurysm (Fig. The removed tissues were examined pathologically, which led to the definitive diagnosis of DLBCL Fig. . FollowiThe number of patients diagnosed with retroperitoneal tumors has been increasing over time, and malignant tumors are larger and more frequently found in older people . MalignaFDG PET–CT and gallium scintigraphy reveal positive accumulation in non-Hodgkin’s lymphomas ; howeverIn our practice, it is worth exploring when a definitive diagnosis is difficult to make, because a definitive diagnosis could avoid unnecessary surgery. Valentine et al. reported the clinical results of 16 patients who had nonvascular emergencies presenting as ruptured AAAs . MisdiagWe encountered a case of DLBCL with imaging findings similar to those of an infected IIAA, and a definitive diagnosis was made more than 2 months after the initial examination. Making a definitive diagnosis of malignant lymphoma that has developed around an IIAA based merely on symptoms and imaging findings is extremely challenging. Thus, histological examination should be actively performed in atypical infected aneurysms.


Extramammary masses are infrequently encountered in breast examinations. They may occur in the chest wall and axilla as neighbors of the breast. It is important to determine the nature of the lesion. However, some benign tumors, such as granular cell tumors (GCTs), also show malignant characteristics, which leads to misdiagnosis. To the best of our knowledge, multimodal ultrasound features of GCT have not been elucidated. We report two cases of women with GCTs encountered upon breast cancer screening; the tumor was not located in breast tissue. The first patient was a 37-year-old woman who presented with a slow-growing mass in the right breast and the GCT was located in the pectoralis major muscle. The second patient was a 52-year-old woman who presented with a palpable left axillary mass and the GCT was located in the axilla. Mammography failed to detect the masses in the two patients upon breast cancer screening. However, two-dimensional ultrasonography revealed a solid heterogeneous hypoechoic mass. Shear wave elastography showed that the masses had an increased hardness compared with the surrounding tissue. Further contrast-enhanced ultrasonography showed that the contrast patterns of the two masses were different. In case one, contrast-enhanced ultrasonography showed an inhomogeneous annular high enhancement, and the dynamic curve showed rapid enhancement and regression. In case two, contrast enhanced ultrasound showed slight enhancement around the lesion but no enhancement inside. Postoperative pathology confirmed that the GCT was benign in both cases. The patients showed no signs of recurrence at the 2-year follow-up. Here, we report two cases and present the multimodal ultrasonography findings of this tumor for the first time. Radiologists and surgeons should be aware of these imaging manifestations and include them in their differential diagnoses. GCT In clinical practice, for suspected breast masses, imaging examination is carried out to find out whether there is a breast lesion, and attention is paid to the condition of the axilla. Ultrasound examination of the breast and axilla is mainly used to evaluate symptomatic patients or further investigate findings determined by other imaging methods . HoweverGCT is occasionally encountered in breast tissue or extramammary areas during breast ultrasound examination –11. EvenTo the best of our knowledge, multimodal ultrasound imaging findings of GCT has not been reported to date. Herein, we report two cases of patients with GCT and focus primarily on their multimodal ultrasound imaging characteristics.22.1A 37-year-old woman presented with a right-sided chest wall mass that had been gradually increasing in size for 8 months. The patient denied her cancer history. No previous surgical history was recorded. A physical examination revealed a solid mass at the outer upper quadrant in the right breast. No enlarged lymph nodes were palpable in the axilla. Notably, this mass was not apparent on mammography. Therefore, she underwent an ultrasonographic examination, which was performed using a 9-4-MHz linear array probe . The ultrasonography revealed a solid hypoechoic mass that measured approximately 18 × 21 × 12 mm in the muscular layer of the chest wall , and negative for pan-cytokeratin and neuron-specific enolase. The Ki-67/MIB-1 positivity rate was 2%. A diagnosis of GCT was made based on the results of pathological and immunohistochemical analyses.The mass in the right pectoralis major muscle was completely resected. Postoperative pathology confirmed the presence of a GCT Figure 22.2A 52-year-old woman had a palpable left axillary mass for a year before she visited our hospital. Although the patient denied any sensation of pain in the mass; abnormally red, swollen skin with discharge and progressive changes were observed. The patient had no relevant history of familial breast cancer or previous interventional procedures. A physical examination revealed a palpable, hard-textured mass of approximately 1.5×1.5 cm at the left axilla in proximity to the skin. The skin on the surface of the mass was ulcerated. No palpable right axillary or bilateral supraclavicular lymph nodes were found. The mass was not apparent on mammography. Subsequently, the patient underwent ultrasonography revealing a solid subcutaneous soft tissue mass of approximately 13×9×15 mm in the axilla, with unclear boundaries, irregular shape, and an aspect ratio greater than one , partially positive for transcription factor E3, and negative for CD163, cytokeratin, epithelial membrane antigen, human melanoma black-45 (HMB-45), chromogranin A, and thyroid transcription factor-1, which supported the diagnosis of a GCT.The patient was subjected to preoperative magnetic resonance imaging (MRI) to further confirm the extent of the lesion. The T1- and T2-weighted scans revealed a slightly long nodular signal shadow of approximately 2.3×1.9 cm in the left axilla, with an irregular shape, rough edges, unclear boundaries in the deep surface of the muscle, and a slight thickening in proximity to the skin; the enhanced MRI showed an uneven enhancement.The patient underwent resection of the axillary mass and biopsy of the axillary lymph nodes under general anesthesia. The axillary tissues containing the mass were completely resected with a 3–5 cm resection range. In addition, four hard-textured lymph nodes of approximately 0.5–1.5 cm were found in the left axilla. While postoperative paraffin section examinations confirmed the diagnosis of GCT Figure 4See Annex 1 for the timeline for the cases.3GCT, often confused with myogenic tumors with a granulosa cell variation , is alsoIn view of the variability and clinical importance of this tumor, we briefly reviewed the conventional ultrasound features of GCT in similar studies. In reports by Patel et al., on ultrasound examination, the GCT root in the pectoral muscle presented as a hypoechoic mass with unclear boundaries . In addiClinically and radiologically, it is challenging to differentiate these two cases from other entities. The differential diagnosis for case one included breast tumors, intramuscular benign and malignant tumors, and inflammatory lesions located in the pectoralis major muscle. The intramuscular tumors that need to be excluded included neurofibroma, hemangioma, desmoid fibroma, sarcoidosis, and fibrosarcoma . InflammThe diagnostic value of ultrasound elastography for GCT is unclear. Further studies need to be conducted to determine whether the quantitative analysis of elastography images has any diagnostic value for GCT. However, in the study by Tavare et al., the higher shear-wave velocity in deep lesions was associated with benign tumors, while the higher shear-wave velocity in subcutaneous lesions was associated with malignant tumors .Contrast-enhanced ultrasonography can provide real-time data on blood perfusion to enable the qualitative and quantitative analysis of the lesions. In case one of this study, contrast-enhanced ultrasonography showed an earlier initiation of enhancement, a shorter time to peak enhancement, a more intense contrast enhancement than surrounding tissue, and an uneven high enhancement in the entire mass. This contrast-enhanced ultrasound pattern may be caused by rapid cell proliferation with resultant higher interstitial pressure, thereby causing inadequate central perfusion, and eventually, no enhancement in the necrotic area and the tumor blood vessels –25. In tCore needle biopsy is a useful diagnostic tool for diagnosing a GCT. However, a needle biopsy for a GCT at the deep surface of the mammary gland may cause damage to the pleura. In addition, a needle biopsy of the axilla may cause damage to its major vessels, especially when the operator is inexperienced. If the biopsy results suggest malignancy, a biopsy of the sentinel lymph node is necessary .While a complete or extended resection may be necessary, there have been rare reports of post-resection recurrence. For cases with high Ki67 levels (≥10%), an aggressive resection, including the dissection of axillary lymph nodes, should be considered even if a histological diagnosis of atypical GCT is made . The patIn conclusion, our cases are of clinical significance as they are rare cases of extramammary GCT encountered upon breast examination. We believe that their ultrasonographic, shear wave elasticity, and CEUS characteristics, along with detailed clinical information provided here will increase the awareness of clinicians, aid in avoiding misdiagnoses, and enable the formulation of an appropriate treatment plan.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by Bioethics Committee of West China Hospital of Sichuan University. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the participant/patient(s) for the publication of this case report.MZ collected the case information and wrote the paper. YP and YC edited and reviewed the paper. HX obtained the pathological images and was responsible for the pathology content of the text. All authors contributed to the article and approved the submitted version.


Epididymal cyst is commonly seen in adults and sometimes in children. In most cases of the epididymal cyst, there are no symptoms and the diagnosis is made incidentally during ultrasonography. However, in rare circumstances, such as infection, trauma, or torsion, an epididymal cyst could become painful and require surgical or medical intervention. We report the case of an 11-year-old boy admitted to our hospital with acute right scrotal pain and treated surgically for epidydimal cyst torsion. Torsed epididymal cysts may cause symptoms exactly like testicular torsion. Therefore, It should be considered a differential diagnosis of testicular torsion in pediatrics. There were no urological symptoms and no history of previous scrotal trauma. On physical examination tenderness of the right scrotum, swelling, and erythema was noted. Abdominal and groin examinations were unremarkable. All routine hematology, urinalysis, and serum biochemistry were normal.Ultrasonography showed normal size, echogenicity, and vascularity of both testes. The left epididymis showed normal appearance and vascularity. On the right side, a thick-walled cystic lesion measured 30 × 23 × 18 mm with internal echoes was seen in the head of the epididymis . An incrThe patient was admitted to the operating room with a diagnosis of epididymal cyst torsion. On the supine position under the transverse scrotal incision, the tunica vaginalis was opened. On surgical exploration, a large cyst was seen connected to the head of the epididymis by a twisted pedicle with torsion-developed necrosis . Therefo3,,The acute scrotum is common in the pediatric population. Several etiologies should be considered for this setting, and almost all are best diagnosed with examination and ultrasonography.In conclusion although the clinical symptoms of torsed ECs are exactly similar to testicular torsion, due to the non-emergency nature of torsed ECs surgery, correct diagnosis with ultrasound is very important.No funding was obtained for this study.NR, MV, MS, and EZ participated in writing and helped to draft the manuscript. All authors read and approved the final manuscript.All relevant data are shown in the manuscript.The patient gave written informed consent to participate.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Collagenous colitis (CC) is generally benign, and serious complications are rare. It is important to note that spontaneous perforation of CC is a possible complication. In the case of colon perforation of unknown origin, CC should be considered. A rare complication of collagenous colitis. There were no symptoms of diarrhea. Her past medical history consisted of hypertension, insomnia, constipation, and a 38‐year smoking history. Her medications at presentation were lansoprazole, irbesartan, amlodipine besilate, and etizolam. She had been on this medication for several years. As computed tomography (CT) detected colon perforation, she was transferred to our hospital for surgery and intensive care. Her vital signs on arrival were as follows: blood pressure, 114/60 mmHg; pulse rate, 60/min, oxygen saturation, 99% on room air, and body temperature 37.2°C. Physical examination revealed left lower abdominal tenderness and rebound tenderness. The laboratory test results were as follows: white blood cell counts of 11,500/μL; C‐reactive protein, 1.95 mg/dL. An abdominal CT scan showed a thickened descending colon, accompanied by free air (Figure 2CC is a type of the microscopic colitis, characterized by chronic, nonbloody, watery diarrhea,Colonic perforation is a rare complication of CC. The leading cause is iatrogenicity, such as colonoscopy, and most of these perforations occur in the right‐side colon.Watery diarrhea is the main symptom of CC, but almost 10% of patients with CC have no typical symptoms.The criteria for the histological diagnosis of CC are thickened subepithelial collagenous band ≧10 μm.3We encountered a rare complication of CC. Only a few cases were described in medical literature so far. In the case of colon perforation in an uncommon site, without diverticulum or tumor lesion, and when no obvious cause of perforation can be identified from the specimen, it is important to examine the patient's background, particularly medication history, and symptoms in detail to identify the etiology and consider CC as a potential cause. In addition, when performing an endoscopic examination on patients suspected of having CC, there is a risk of perforation, so caution is required.Kei Ito: Writing – original draft. Keita Nakatutumi: Writing – review and editing. Yuko Oofuti: Visualization; writing – original draft. Yasuhiro Otomo: Supervision; writing – review and editing.None.The authors declare no conflicts of interest.Written informed consent was obtained from the patient.


Reduplicative paramnesia (RP) is a very rare content-specific delusional misidentification syndrome (DMS). RP entails the delusion that a place, an object, or an event has been duplicated or exists in two different places at the same time. RP is thought to result from an organic rather than psychiatric cause distinguishing it from other DMS. It has been suggested that damage to the right frontal and temporal lobe plays a crucial role, although other areas involved in visuospatial processing have also been reported.The aim of this study is to review the literature and report a clinical case of RP.We describe a case of an 81 year old woman admitted in a Neurology ward, with a 2 week clinical presentation of temporo-spatial disorientation, behavioural changes, persecutory delusions and reduplicative paramnesia phenomena concerning her house. She had previous history of a stroke 3 years prior to admission and, about one year before, the patient also started to present cognitive decline in the context of Parkinson’s dementia. One month before admission, treatment with Rotigotine was started and later suspended when the aforementioned clinical manifestations started. Upon admission it was diagnosed an urinary tract infection and treatment with antibiotics was started. Two days afterwards, the patient recovered orientation and her usual behaviour, but persecutory delusions and RP persisted. She then started treatment with low dose Olanzapine. Following 2 weeks of treatment the psychotic symptoms fully remitted, including RP.We underline CT-scan and EEG relevant findings upon admission. In the CT-scan sequelar lesions in left frontoparietal junction, right posterior frontal cortex, left inferior occipital cortex, bilateral cerebellar hemispheres, left caudate nucleae and thalamus were identified. The EEG showed a preserved posterior alpha rhythm associated with slow discontinuous right temporal and mainly left parieto-temporo-occipital activity, indicating dysfunction in these locations.In line with literature our patient had lesions in the right frontal and temporal lobe. She also presented lesions in other areas involved with visuospatial processing. Particularly the involvement of the left hemisphere reported in our case seems to be an exception. Other factors potentially played a role triggering this episode, namely the cognitive compromise due to dementia interposed with infectious disease, and the rotigotine treatment as well. Another aspect worth mentioning in our case was the remission of symptoms with the use of Olanzapine, even though only a few cases in literature have fully remitted with treatment with antipsychotics.None Declared


Non-ossifying fibroma (NOF) is not prevelant in the mandible. It appears mostly in the long tubular bones in children and adolescents. We are presenting a case of a four-year-old girl reported to the maxillofacial department with painless swelling over the lower right side of the jaw. On the orthopantomogram (OPG), a well-defined multilocular radiolucency with a sclerotic margin was present. On computed tomography (CT), an expansile lytic lesion with cortical thinning without a breach in cortical continuity was noted. By correlating clinical and radiological features, a diagnosis of odontogenic and/or osteogenic lesion was made. The patient was considered for an excisional biopsy with curettage. On histopathology, NOF was confirmed. On postoperative follow-up, there was no sign of recurrence, and bone regeneration was significant. Non-ossifying fibroma (NOF) is a benign lesion of the skeletal system that occurs mostly in long tubular bones, rarely in the mandible . The disA four-year-old Caucasian girl was referred to the maxillofacial surgery unit for assessment of an asymptomatic swelling over the right angle of the jaw Figure .The non-tender swelling gradually increased to the current dimension within a time span of one year. There was no history of trauma due to a fall or any sports injury to the area of the chief complaint. There was no pain or trismus, and there was no significant previous medical history. There was a hard, non-tender mass palpable near the right mandibular angle. Upon intraoral examination, the overlying mucosa appeared normal in colour and texture. Cranial nerve functions were reported to be intact. There was an absence of local lymphadenopathy. A positive result from a test of pulp vitality was obtained. Orthopantomogram (Opg) revealed a well-defined multilocular radiolucency located at the angle region of the right mandible Figure .A well-defined expansile lytic lesion arising from the angle of the mandible on the right side, extending anteriorly till the deciduous molar tooth, superiorly till the upper border of the mandible, and inferiorly till the inferior border of the mandible and also marked buccal expansion was noted on the CT Face plain axial and coronal section bone window. Significant cortical thinning was noted at the perilesional area. No evidence of an obvious cortical breach was noted Figures , 4.A differential diagnosis was made of odontogenic and/or osteogenic lesions for dentigerous cyst, ameloblastoma based on clinical and radiological features. The alkaline phosphatase level was minimally raised. The lesion was curetted using an intraoral wards II incision under general anaesthesia, and a peripheral ostectomy was carried out.Postoperatively, the formalin-fixed, paraffin-embedded tissues underwent microscopic inspection, which revealed stellate to spindle fibroblastic cells amidst a myxoid background and reactive bone formation with osteoblastic rimming. There was a focal cluster of osteoclast giant cells seen around the bone as well as scattered singly amidst the stroma. The spindle cells had sparse eosinophilic cytoplasm and oval nuclei. There were no regions of necrosis, mitoses, or unusual nuclei found Figure .There were no signs of bone production or hemosiderin pigment. The histopathologic findings and their correlation with the radiographic presentation led to the diagnosis of NOF. The patient was evaluated one month, six months, and a year after the surgery. The most recent data available, a panoramic radiograph taken during the one-year follow-up, showed persistent bone consolidation around the right mandibular angle Figure . On postNon-ossifying fibroma is a non-neoplastic lesion of the long tubular bone . It is pDue to their modest size, FCDs typically have no symptoms and are subject to spontaneous regression. The FCD expands and extends into the medullary cavity by gradually separating from the growth plate, which distinctly differentiates it from NOF. NOF is larger morphologically than FCD . AlthougHistologically, the presence of giant cells can lead to the differential diagnosis of benign fibrous histocytoma (BFH) and malignant fibrous histocytoma (MFH), as well as central giant cell granuloma (CGCG). BFH is usually symptomatic and affects people in their 60s and older. MFH radiologically presents as a lytic lesion with a corticol breach. MFH histologically has nuclear pleomorphism and an increase in mitotic activity. CGCG has hemosiderin deposition, erythrocyte extravasation. The giant cell arrangement is diffusely arranged in CGCG .Jaw lesions of the NOF can either show enlargement or be asymptomatic. A well-demarcated multilocular radiolucency of this rare case report with sclerotic boundaries, is comparable to the normal radiographic appearance in the long bones. It is similar to previous cases reported in the literature. The isolated gnathic NOF appears to present at a later average age at diagnosis than the long bones, which may explain this difference in the age of presentation. In 2012, Bowers et al. treated a case of NOF in a 22-year-old female with curettage and peripheral ostectomy . Large lThis case report reveals an extremely rare form of NOF in a four-year-old girl who presented with painless swelling in the lower right angle region for one year. The present case highlights the significance of considering the asymptomatic nature, radiographic presentation, histopathology features, and lack of cortical breach as important factors in the diagnosis of multilocular radiolucency in the mandible. This case report adds to the growing knowledge of co-relating histopathological characteristics with clinical and radiological features. In addition, the current case describes the importance of considering curettage as a treatment modality in the management of NOF.


Herein we report the case of a 63-year-old female tourist who presented to our Emergency Department with complete rectal prolapse. She had complained of diarrhea with traces of blood and mucus and had experienced fatigue after hiking. After the initial evaluation, it became clear that prolapse bares a large rectal tumor as a leading point. The prolapse was reduced under general anesthesia, along with a tumor biopsy. Further workup confirmed locally advanced adenocarcinoma of the rectum, which was treated with neoadjuvant chemoradiation followed by curative surgery in another hospital after repatriation. Rectal prolapse affects people of all ages, but it is more common in older adults, particularly women. Treatment options vary depending on the severity of the prolapse and can range from conservative measures to surgical interventions. This case report highlights the importance of early recognition and appropriate management of rectal prolapse in the emergency setting and the possibility of an underlying malignancy. When irreducible and painful, it is classified as incarcerated . DelayedRectal prolapse is a rare condition that most commonly affects older adults, particularly women. The exact cause of rectal prolapse is unknown, but it has been associated with various factors, including chronic constipation, elongated rectosigmoid junction, weakened pelvic floor, and repetitive straining at defecation. Underlying bowel tumorous growth is a rare cause of prolapse but can occur even in children –6. A risHerein we report a 63-year-old female patient with the emergency presentation of incarcerated rectal prolapse caused by a locally advanced rectal tumor. The case is written in accordance with the CARE checklist .2.A 63-year-old slim and fit female tourist arrived at the Emergency Department (ED) with complete rectal prolapse. A few days before, the patient had diarrhea with traces of blood and mucus. She recently noticed fatigue associated with intense hiking. After having the last stool in the mountains, a “massive prolapse” through the anus occurred. Ambulance Emergency Service transferred her to our hospital's ED. Until now, she didn't have any problems related to bowel habits and, therefore, never had an endoscopic workup. She took regular medication for hypertension.A clinical examination revealed a complete rectal prolapse with a bulky exulcerated tumor occupying the posterior and right rectal wall, 8 cm × 10 cm in size . The abd3.9/L; reference range 3.4–9.7), with predominant neutrophilia , and almost normal C-reactive protein (CRP) level . The complete blood count showed severe hypochromic microcytic anemia. Red blood cell (RBC) count was 3.41 × 1012/L (reference 4.34–5.72), hematocrit (HCT) was 21% (reference 41.5–53), hemoglobin (Hb) level was 62 g/L (reference 138–175), mean corpuscular volume (MCV) was 61.5 fl (reference 83–97.2), mean corpuscular hemoglobin (MCH) was 18.1 pg (reference 27.4–33.9), mean corpuscular hemoglobin concentration (MCHC) was 294 g/L (reference 320–345), with increased red cell distribution width (RDW) , and elevated platelets (PLT) count .Initial laboratory findings showed elevated white blood cell (WBC) count  with 4.9 ng/ml , while the value of CA 19–9 marker was within normal limits (17.6 U/ml); reference value <39. The histopathology report confirmed that prolapsed rectal tumor was adenocarcinoma  and American Association for the Surgery of Trauma (AAST), issued in 2021, under the chapter on complicated rectal prolapse, authoritatively advise performing an urgent contrast abdominopelvic computed tomography scan in all patients except for those with hemodynamic instability (There is a consensus that colorectal tumors can act as a leading point in the telescoping of the bowel in adults, being the cause of intussusception . The exaExisting literature on rectal prolapse has focused chiefly on its diagnosis, treatment, and associated risk factors, with little attention paid to the possible association between rectal prolapse and colorectal cancer. In this case, the main challenge was identifying the rectal prolapse containing cancer in the emergency setting and resolving the imminent danger of rectal strangulation. The acute situation was translated to elective, allowing time to complete the work-up and repatriate our patient. This case report adds to the existing literature on rectal prolapse. It highlights the importance of early recognition and appropriate rectal prolapse management, especially with emergency presentation.Clinicians, teachers, and researchers should be aware of the potential association between rectal prolapse and rectal cancer and consider this possibility when evaluating patients with rectal prolapse. Early diagnosis and prompt management can improve patient outcomes. Further research may be necessary to understand the relationship between rectal prolapse and rectal cancer and to develop more effective diagnostic and treatment strategies. Overall, it is crucial to maintain a high level of clinical suspicion for rectal cancer in patients with rectal prolapse to provide timely and appropriate care.


A 20-year-old female, right-hand-dominant Division I softball player, presented to her pre-participation exam endorsing numbness that started in her left thumb and had progressed to involve her entire hand and left medial elbow. She had no change in her physical health over the past year prior to presentation and denied injury illness or trauma to the left upper extremity or neck. She reported no change in her softball off-season training regimen or equipment. Exam exhibited decreased sensation in C6, C7, and C8 dermatomes and weakness in the C8 myotome. Magnetic resonance angiography (MRA) displayed a right parietal lobe mass which biopsy confirmed as glioblastoma multiforme (GBM). GBM, also known as glioblastoma or grade 4 astrocytoma is an aggressive form of cancer that can affect the brain and spinal cord. Despite being the most common malignant primary brain tumor in adults, current treatment is mostly palliative. Treatment for this student-athlete included surgery, radiation, and chemotherapy. The selection of aggressive treatment including excision of the tumor was largely elected due to her age. She received chemotherapy with temozolomide in conjunction with radiation for a total of nine months. Following treatment, she worked with physical therapy to help improve her functional deficits, caused both by the tumor as well as the excision. Additionally, psychological and emotional support was provided to the patient during the course of the diagnosis and treatment of her athletics career-ending diagnosis. The same support services were also extended to the entirety of her teammates as well as her family members. This case outlines the diagnosis, treatment, and challenges of GBM in a Division I softball athlete including the challenges of providing emotional support for an athlete living away from home while being diagnosed with a life and athletics-career altering condition.  Glioblastoma multiforme (GBM), also known as glioblastoma or grade 4 astrocytoma, is a highly aggressive tumor of glial cells and is the most common malignant primary brain tumor in adults . In the GBM typically presents with functional impairments corresponding to the location of central nervous system involvement ,2. CommoDespite recent advances in the treatment of GBM, it remains very difficult to treat and carries a generally poor prognosis with a mean five-year survival of 5% . Poor prThis report outlines the diagnosis and treatment of GBM in a Division I softball athlete and highlights the unique circumstances associated with the management of the condition in this patient population. We aim to outline the clinical approach to the diagnosis of GBM and describe current treatment options and their limitations. Although a diagnosis of high-grade glioblastoma in a collegiate athlete is rare, this case provides learning opportunities for the field of sports and exercise medicine.HistoryA 20-year-old female Division I right-handed softball athlete presented for a routine returning pre-participation examination (PPE). Her past medical history was significant for attention deficit hyperactivity disorder (ADHD), which was controlled by taking methylphenidate. Her only other medication was a combined oral contraceptive. She had reported no change in her physical health over the last 12 months prior to her PPE. At the time of evaluation, the patient reported numbness that started in her left thumb and progressed to involve her entire hand and left medial elbow over the course of the summer without any other symptoms. She denied injury illness or trauma to the left upper extremity or neck. She reported no change in her softball off-season training regimen or equipment.Physical examVital signs were within normal limits and the patient appeared well-nourished and had an athletic build. The vision was grossly intact. Lungs clear to auscultation bilaterally. Cardiac exam revealed a regular rate and rhythm with no murmurs, rubs, or gallops appreciated. The abdomen was soft and non-tender with no palpable masses. There were no visible skin lesions or rashes. No lymphadenopathy was appreciated in the cervical or axillary regions. The athlete displayed a normal mood and affect.Examination of the left upper extremity revealed no obvious deformity, atrophy, induration, or erythema. Palpation slightly distal to the left medial epicondyle elicited mild tenderness. There was a full and equal active range of motion for the cervical spine, hand, wrist elbow, and shoulder. Special tests including Tinel’s at the cubital tunnel and wrist, Phalen’s, and Spurling’s maneuver were negative. Functional testing of the wrist and hand demonstrated age-appropriate fine motor skills and adequate hand strength to grasp and manipulate small objects.Sensory examination demonstrated decreased sensation to light touch in the cervical 6, 7, and 8 dermatomes. The patient’s myotome testing revealed slight weakness in the cervical 8 dermatome. There were no changes in strength or sensation in the right upper extremity or bilateral lower extremities.Differential diagnosisThe differential diagnosis for this case was broad given the patient's presentation. The initial differential diagnosis included the following: cervical nerve root disorder, median nerve entrapment, interosseous nerve entrapment, cerebral vascular accident, multiple sclerosis (MS), and brain tumor.Cervical radiculopathy can cause pain, numbness, tingling, and weakness in the upper extremity, and location on the upper extremity depends on the cervical level involved. The patient had no neck pain or reproduction of symptoms with Spurling's during the exam. Median nerve entrapment often causes numbness in the first three digits and paresthesia. Symptoms can mimic injury to the cervical 6 and 7 nerve roots. The patient's symptoms did not involve any digits other than her thumb. Phalen's and Tinel's tests at the wrist during examination were also negative. Similarly, interosseous nerve entrapment causes deficits in sensation where the nerve provides innervation. Our patient also demonstrated C8 myotome weakness making an interosseous entrapment less likely. A cerebral vascular accident was considered as she was at higher risk for a vaso-occlusive event being on an oral contraceptive pill. A frontoparietal infarction could lead to the deficits displayed by the athlete; however, without a personal history or family history of prior coagulopathy, the likelihood of a cerebrovascular accident (CVA) in a 20-year-old was unlikely.MS was also considered given MS's predilection for being diagnosed in young females in their 20s. However, typically symptoms wax and wane, unlike our patient's symptoms which not only remained present but were also progressive. The location of the brain lesions associated with MS corresponds to the symptoms it presents, which can include change in vision, numbness, tingling, or muscle contraction difficulties among others.Brain tumor at the time of evaluation was considered unlikely given the low number of brain tumors diagnosed annually, the majority of tumors being diagnosed in elderly populations, and no presence of other commonly reported symptoms such as headache, change in vision, nausea, vomiting, or seizure activity. Imaging/diagnosticsPrior cervical radiographs demonstrated no abnormal findings. Electromyography (EMG) of the left upper extremity revealed no evidence of left-arm mono or polyneuropathy, brachial plexopathy, or cervical radiculopathy Table . Given tThe athlete was immediately transferred to the university-affiliated trauma hospital. At the emergency room, the athlete was placed on aspirin, and she was evaluated by the stroke team. Her coagulopathy profile was negative. Echocardiography was negative for thrombus, valvular abnormalities and patent foramen ovale. MR angiography (MRA) of the carotids demonstrated no significant hemodynamic stenosis.She was discharged from the emergency room with recommendations to take aspirin daily, discontinue her oral contraceptive pill, and follow up with neurology and cardiology outpatient. She was held from sports participation at this time. Over the next few days, she reported progressive, more pronounced upper extremity paresthesias and weakness. A MRA brain was consequently ordered, which displayed a mass in the right parietal lobe measuring approximately 4x3x3 cm with decreased T1 and subtle patchy enhancement, suggestive of a primary tumor Figure . She wasTreatmentThe final diagnosis was a high-grade glioblastoma positive for mutation in EGFR, MGMT promoter methylation of the right parietal lobe as confirmed by histopathology during stereotactic biopsy. The treatment plan was formulated following this report by a team consisting of neuro-oncology and neurosurgery and followed the current gold-standard approach for GBM: surgical resection, radiation, and chemotherapy. The brain tumor was excised prior to radiation and chemotherapy. Excision is the principal element of GBM treatment as it often reverses symptoms that are present at the time of diagnosis, can control seizure activity, provides an opportunity for local placement of therapeutic agents, and overall can help improve the patient's quality of life . GBM canRadiation following surgical resection is commonly performed in an attempt to destroy any remaining cancer cells that may not have been excised. Radiation has been shown to improve life expectancy following resection in those with high-grade gliomas; thus, it is a staple in GBM treatment . RadiatiShe underwent further adjuvant chemotherapy treatment following these six weeks with TMZ for three additional rounds of six weeks each followed by a three-week hiatus. TMZ, an alkylating agent, is currently the standard chemotherapy agent used against GBM. Other alkylating agents that have been used previously have been shown to produce early cell resistance and have unfavorable side effect profiles, making TMZ the only effective alkylating chemotherapy agent . TMZ achAs the patient received chemotherapy, she was prescribed anti-convulsant, anti-emetic, and medications to assist with pain. She also continued on her stimulant medication for ADHD. As the patient was considered a student-athlete, her school team physician still provided support and primary care throughout treatment. Additionally, she had access to additional services through the athletics department including physical therapy and psychology services, which were able to be initiated immediately upon diagnosis for mental and physical well-being. Physical therapy and/or occupational therapy are typically included in treatment to help patients with deficits either caused by the location of the tumor itself or after excision.Psychology and emotional support resources were additionally provided to her family and teammates through the school's services. The team physicians, sports psychologist, certified athletic trainers, and coaching staff provided continuous resources to all student-athletes and university athletic personnel affected by the situation. OutcomeDue to diagnosis and treatment requirements, the athlete did not return to competitive softball and was required to take a medical leave of absence from school initially. She was able to return to school where she is still a student today and continues to receive care from her team primary care physician. At this time, two years later, her GBM treatment is ongoing with continued palliative chemotherapy and radiation. This report outlines the diagnosis and treatment of a 20-year-old softball player who was diagnosed with GBM. She presented to her PPE for the upcoming school year endorsing new numbness in her left hand without a history of recent trauma, injury, or changes to her training or equipment. Her physical exam displayed decreased sensation to light touch in the cervical 6, 7, and 8 dermatomes and slight weakness in the cervical 8 dermatome. Due to the presenting symptoms, she underwent extensive testing which included negative cervical spine x-rays, negative EMG, abnormal MRI brain scan concerning for CVA, negative MRA of the carotids, and a negative echocardiogram. She was subsequently treated for a CVA and follow-ups with neurology and cardiology were scheduled. However, prior to follow-up, her upper extremity numbness continued to worsen prompting repeat brain imaging with an MRA which demonstrated a mass in the right parietal lobe. A stereotactic biopsy of the mass confirmed the diagnosis of GBM. The athlete then was treated by her neuro-oncology team with surgical resection of the mass followed by radiation and chemotherapy. Back at the university, the athlete received continued support and treatment through the school’s physical therapists, psychologists, and team doctors as well as support from her teammates, coaching staff, and athletic training staff. Unfortunately, due to the nature of her diagnosis, she was unable to continue her softball career and had to take a medical leave of absence from the university while undergoing extensive treatment following her diagnosis. Eventually, she was able to return to her university as a student while continuing care under the guidance of both her neuro-oncology team as well as her former team doctors. Although a diagnosis of high-grade glioblastoma in a collegiate athlete is rare given the median age at diagnosis in the United States of 55-60 years, this case provides learning opportunities for the field of sports and exercise medicine . The preGiven the presentation, nerve studies were conducted first with EMG. In this case, her normal EMG findings made neuropathy and similar etiologies less likely and redirected the cause of this athlete’s symptoms toward a cerebral etiology. Though an EMG was not of significant diagnostic value in this case, clinicians need to be aware that EMGs conducted earlier than four to six weeks following the onset of symptoms may provide a false negative result . The locIn the 1980s, MRI using gadolinium-based contrast agents (GBCAs) was introduced into clinical practice, improving the detection of cerebral lesions and disease characterization for many cerebral and vascular pathologies investigated with MRI . DiseaseTo date, GBM is one of the most difficult brain tumors to treat due to its high resistance to both radiation and chemotherapy. Even with this known resistance, both chemotherapy and radiation are integral components of treatment due to GBM’s high likelihood of recurrence within a 2-3 cm margin of the excision of the primary tumor ,9. ConveWith currently utilized treatment options, survival rates remain very low with median survival following a diagnosis of GBM currently only 15 months . ApproxiAs with many other fields, advances in therapy have been made since a better understanding of the molecular and genetic basis of glioblastoma as these enable the utilization of agents that are able to target specific signaling pathways during the cell’s lifecycle as well as genetic mutations. These therapies include immunotherapy, both active and passive therapies . PassiveAdditional research into the cause of GBM is ongoing, with most recent advancements being made in the understanding of its pathogenesis. Specific genes that are responsible for the growth and triggering the formation of the tumor have been identified in addition to a better understanding of which gene expressions confer better or worse outcomes. Expression of the gene Tumor Protein, TP53, for instance, is associated with worse outcomes due to its responsibility in tumor cell malignancy, drug resistance, and metastases . IdentifThe weight of a GBM diagnosis should not be underestimated. Given the low number of treatment options, the likelihood of recurrence, and unfavorable chances of survival to five years, it is not surprising that there are high rates of anxiety and depression among those with a GBM diagnosis . While pUniversity athletes are in a unique scenario where they are frequently cared for by a multidisciplinary team at the university that includes medical, psychological, coaching, athletic training, nutrition, and conditioning team members from the start of their career as a student-athlete. Regardless of the diagnosis, this team remains available to the student-athlete so long as they are enrolled at the university. These team members also have the advantage of having known the athlete prior to the diagnosis and therefore have established bonds with them. This increases the level of support the student-athlete has, in addition to increasing the overall number of care team members once the student-athlete is established at a cancer institution. In the care of our student-athlete, it was also imperative that teammates, members of the athletic organization, and family members have access to personal psychological support and be educated on how to positively interact with the ill student-athlete. It has been demonstrated that caregivers frequently experience caregiver burden and request additional support services similar to those requested by the patient diagnosed with GBM . At the While the diagnosis of GBM is unlikely in a collegiate athlete, maintaining a broad differential, including brain tumor, when a patient presents with symptoms similar to ours is important. If in the event a student-athlete does receive this diagnosis they have the advantage of previously being cared for by a multi-disciplinary team in the university setting that they can continue to receive care from during at least the initial stages of GBM treatment while they are still enrolled at the university. GBM continues to be a daunting diagnosis but with the advent of an improved understanding of the genomics of the tumor cells, hopefully, new treatment options are on the horizon.GBM is an aggressive form of cancer that affects the brain and spinal cord. Treatment of glioblastoma involves a multi-factorial approach with surgical resection, radiotherapy, and chemotherapy. Many patients benefit from cancer rehabilitation programs in which a multidisciplinary team manages physical, psychological, and social domains. When treating competitive athletes, it is recommended that they continue to receive support from their previously established university care team in addition to their newly established neuro-oncology team. With this diagnosis, it is imperative to provide personal psychological support and education to the athletic organization and teammates on how to positively interact with the ill athlete.


Functional gonadotroph adenomas (FGAs) are rare, manifesting symptoms like menstrual irregularities or ovarian hyperstimulation syndrome (OHSS). We present a case of OHSS caused by an FGA during the follow-up of a pituitary tumor initially considered nonfunctioning. The patient presented with lower abdominal pain, abdominal swelling, and dyspnea. Magnetic resonance imaging (MRI) revealed 15 cm enlarged ovarian cysts and pleural effusion. Laboratory examination showed an elevated serum estradiol (E2) level (5741.4 pmol/L [1564.0 pg/mL]), suppressed luteinizing hormone, and nonsuppressed follicular-stimulating hormone (FSH). However, no pituitary hormone disorders were observed when a 19 mm pituitary tumor was discovered 11 months prior. Given the absence of human chorionic gonadotropin (hCG) administration, OHSS due to the FGA was suspected. Cabergoline, known for alleviating the severity of OHSS, was administered, but the ovarian cysts continued to enlarge. Subsequently, endoscopic transsphenoidal surgery was performed, and immunohistochemical analysis confirmed the diagnosis of the FSH-producing adenoma. Follow-up MRI scans showed reduced ovarian cysts and successful pituitary tumor resection with a reduced E2 level. This case highlights the importance of considering FGAs when encountering OHSS without hCG administration or following up on pituitary tumors in premenopausal female patients to take appropriate measures for accurate diagnosis and management. Most immunohistochemically gonadotroph-positive pituitary adenomas are clinically diagnosed as nonfunctioning . FunctioHerein, we describe a patient who developed OHSS due to an FGA during the follow-up of a pituitary tumor initially considered nonfunctioning. Our case highlights the possibility of FGAs in cases of OHSS without hCG administration or during the surveillance of pituitary tumors in premenopausal females.2) presented to our hospital with lower abdominal pain, abdominal swelling, and dyspnea. She was undergoing a follow-up for a previously discovered 19 mm pituitary tumor  revealed an approximately unchanged pituitary tumor and markedly enlarged multiple ovarian cysts measuring 15 cm . AdditioIn addition to saline, cabergoline, which can alleviate the severity of OHSS , was admWithin one week after the surgery, the ovarian cysts decreased to 11 cm, and the E2 level reduced to 21.3 pmol/L (5.8 pg/mL), accompanied by an increase in LH level (0.95 mIU/mL) and a decrease in FSH level (1.76 mIU/mL) . In the Follow-up MRI scans after surgery showed successful pituitary tumor resection Fig.  and notiIn the present case, we characterized OHSS caused by an FGA, presenting with markedly enlarged multiple ovarian cysts and pleural effusion. Administration of cabergoline improved the pleural effusion but did not affect the enlarged ovarian cysts. Subsequently, surgical intervention resulted in a marked reduction of the ovarian cysts. To our knowledge, this is the first reported case of FGAs identified during the follow-up of pituitary tumors initially considered nonfunctioning.OHSS is commonly known as a complication of ART with hCG administration. It is characterized by the enlargement of ovarian cysts and an acute fluid shift from the intravascular space to the third space. This shift is caused by increased systemic vascular permeability, resulting in decreased circulating blood volume, hemoconcentration, pleural effusion, and ascites . VasculaMost gonadotropin-producing pituitary adenomas are clinically nonfunctioning, as reported in a case series involving 213 clinically nonfunctioning pituitary adenomas, 64% of which were immunohistochemically gonadotroph adenomas . The chaSurgical intervention is considered the primary treatment approach for FGAs, restoring normal gonadotropin secretion and improving associated symptoms such as menstrual irregularities, OHSS, and enlarged ovarian cysts . Indeed,We describe a case of OHSS with an FSH-producing pituitary adenoma. Consistent with previous reports, medical treatment alone proved ineffective in managing the condition, highlighting the pivotal role of pituitary surgery in addressing the underlying cause of OHSS associated with FGAs. The present case demonstrates OHSS caused by an FGA during the follow-up of an initially deemed nonfunctioning pituitary tumor. It is noteworthy that the E2 level was not measured until the presentation with OHSS, and therefore its elevation at that time cannot be ruled out. Clinicians should consider FGAs when encountering OHSS without hCG administration or during the follow-up of pituitary tumors in premenopausal female patients for accurate diagnosis and management.Gonadotropin-producing pituitary adenomas can cause OHSS in premenopausal females.OHSS caused by FGAs is characterized by the enlargement of ovarian cysts and a rapid fluid shift from the intravascular space to the third space, typically accompanied by an elevated serum E2 level, suppressed LH level, and nonsuppressed FSH level.Surgical intervention is the primary treatment modality for FGAs, restoring normal gonadotropin secretion and improving associated symptoms.Medical treatments are typically used as complementary measures due to limited evidence of effectiveness. Among them, cabergoline can alleviate OHSS by reducing vascular permeability and normalizing FSH/E2 levels, but it does not lead to pituitary tumor shrinkage or reduction of ovarian cysts.Clinicians should consider the possibility of FGAs when encountering OHSS without hCG administration or when monitoring premenopausal females with pituitary tumors.All authors made individual contributions to authorship. All authors were involved in the diagnosis and management of this patient. R.T. and M.H. were involved in writing the first draft and submission. S.H and A.H critically revised the manuscript with important intellectual content. All authors read and approved the final draft.


Rathke’s cleft cysts are thought to have a benign clinical outcome apart from associated hypopituitarism and visual defects. Synchronous central nervous system lesions, including pituitary adenoma and intracerebral aneurysms, are rarely reported. Diagnosis of Rathke’s cleft cyst after presenting with a subarachnoid hemorrhage due to a ruptured arterial aneurysm is reported only once before.A 33-year-old Sri Lankan female presented with a subarachnoid hemorrhage due to a ruptured anterior communication artery aneurysm. She underwent pterional craniotomy and aneurysm clipping. She was found to have partial cranial diabetes insipidus and hypogonadotropic hypogonadism. She had a cystic lesion occupying enlarged sella turcica with characteristics of a Rathke’s cleft cyst. Subsequently, she underwent trans-sphenoidal excision of the sellar lesion. Histology confirmed the diagnosis of Rathke’s cleft cyst.Rare co-occurrence of a Rathke’s cleft cyst and an anterior communicating artery aneurysm would have been missed if subtle manifestations atypical for subarachnoid hemorrhage were not further pursued. This could have led to progressive visual deterioration and hypopituitarism. Rathke’s cleft cyst (RCC) is a benign non-neoplastic cystic lesion occurring in the sellar or suprasellar region from the remnant of Rathke’s pouch . Most arMost of the large series reporting patients with RCC do not report co-occurrence of any intracranial pathologies , 4–6. ThWe report a young female who initially presented with subarachnoid hemorrhage (SAH) due to a ruptured anterior communicating artery (ACOM) aneurysm unveiling the diagnosis of RCC.A 33-year-old Sri Lankan woman presented with sudden-onset severe headache, neck pain, vomiting, and transient loss of consciousness. On presentation, she was in pain, alert, and oriented. There was neck stiffness. There were no neurological deficits including normal vision. Pulse rate was 80 beats per minute, and blood pressure was 130/70 mmHg. The rest of the examination was normal.Urgent non-contrast computed tomography (CT) of the head showed high-density areas in the basal cisterns suggestive of acute subarachnoid hemorrhage (SAH). There was nonspecific hypodensity in the sellar area Fig. A–C. DigiPre- and postoperative periods were complicated with partial cranial diabetes insipidus. After recovery from the surgery, on further questioning, it was revealed that she has had polyuria, polydipsia, nocturia, and secondary amenorrhea for 6 months before the presentation. She has not sought any medical advice for the symptoms. She had no other symptoms or co-morbidities. She has not had any intracranial lesions in the past.She was started on desmopressin, which produced improvement of symptoms. Pituitary hormone profile and pituitary magnetic resonance imaging (MRI) were performed after recovery from the acute event. Low gonadotropins for an amenorrheic female with low estradiol were noted 6 weeks after the surgery. Partial cranial diabetes insipidus persisted. Biochemical investigation results are summarized in Table MRI-pituitary showed a 1.5 cm × 1.7 cm × 1.7 cm lesion occupying enlarged sella turcica with suprasellar extension and optic chiasmal compression. This lesion had high signal intensity on T1 and low signal intensity on the T2 phases of MRI. There was no contrast enhancement. . Hydrocortisone, levothyroxine, and desmopressin were continued. The recovery was uneventful.Histology showed cyst wall focally lined by stratified columnar epithelium. Wall showed sheets of foamy cells with multinucleated giant cells and pigment-laden foamy cells. Normal pituitary tissue was seen. There was no evidence of a pituitary tumor. Features were in favor of a Rathke’s cleft cyst.Three-month postoperative MRI did not show any residual masses. She remained amenorrheic with low gonadotropins. She was started on combined oral contraceptive pills. At 1 year follow-up, she was clinically well while on levothyroxine and oral contraceptive pills. Hydrocortisone and desmopressin were omitted due to clinical and biochemical evidence of resolution of adrenocorticotrophic hormone and vasopressin, respectively. She is stable and satisfied with her current clinical status with a Global Physical Health Raw Score of 18/20 (90%) and Global Mental Health Raw Score of 16/20 (80%) according to the patient-reported outcomes measurement information system (PROMIS) scale [Our patient presented to the healthcare due to SAH, and the diagnosis of RCC was made subsequently even after the surgery for the ACOM aneurysm. Adipsic diabetes insipidus has been reported in patients following SAH  and clipA report from Japan describes the presentation of a 44-year-old man with a sudden-onset headache due to subarachnoid hemorrhage. Evaluation has revealed a ruptured aneurysm in the A1 portion of the left anterior cerebral artery and an RCC . This isThere are few case reports in the literature reporting RCC and cerebral aneurysms occurring in the same patient, though none of the large case series in international literature describes this association. In a Japanese case series, five patients with intracranial aneurysms and RCC were mentioned according to the information in the abstract . HoweverIn most of the reported cases, aneurysm was detected subsequently when the patient presented with features of RCC. A 57-year-old female who underwent trans-sphenoidal surgery for an RCC developed SAH 3 days later from a very small aneurysm in the superior hypophyseal artery . AuthorsOne case report describes a patient with an RCC and intracranial aneurysms diagnosed after presenting with a stroke . This paWhether the association of an RCC and an ACOM aneurysm purely represents random co-occurrence or any pathophysiological association remains elusive. A similar association was noted in patients with pituitary adenoma for the past several decades. There is possible evidence suggesting a higher prevalence of aneurysms among patients with pituitary adenoma than that of the general population . This maThere were few limitations experienced during the management of this patient due to resource limitations and work demand. Ideally, aneurysm clipping could have been performed as early as possible. However, patient initially presented to a center without neurosurgical facilities, and after the transfer, arranging DSA and surgical intervention required substantial time. Hydration and nimodipine were continued to overcome vasospasm. There was some nonspecific hypodensity in the sellar region, though this did not receive much attention during the acute phase where the focus was on SAH. Routine radiology reporting of all non-contrast CT scans of the head is not available due to limited specialist capacity.While co-occurrence of RCC and aneurysms is rare, this combination initially presenting with SAH is exceptional. Thorough attention to subtle clinical clues will prevent delayed diagnosis and risk of progressive hormonal and visual deterioration.


Hepatic angiomyolipoma (HAML) is a rare mesenchymal neoplasm that predominantly affects middle-aged women. In this study, we present a case of a 49-year-old woman with a giant HAML accompanied by spontaneous subcapsular rupture. The patient initially experienced nausea and abdominal distention, followed by an enlargement of the upper abdominal circumference. Laboratory examination revealed decreased serum hemoglobin, while tumor biomarkers were within normal ranges. Imaging studies, such as abdominal ultrasound and contrast-enhanced computed tomography (CT), demonstrated a large upper abdominal mass with heterogeneous density and hypervascularity. The tumor appeared to have invaded the left liver, raising concerns about possible malignancy. Subsequent positron-emission tomography/CT confirmed increased fluorodeoxyglucose uptake in the mass. Laparoscopic exploration revealed a protruding, well-encapsulated tumor from the left liver, exhibiting subcapsular hemorrhage. Surgical resection of the tumor and the left liver was performed, leading to a successful outcome. Hepatic angiomyolipoma (HAML) is a rare hepatic mesenchymal neoplasm first reported in 1976 . A revie18F-fluorodeoxyglucose (FDG) intake, with a standardized uptake value (SUV) max of 2.4.A 49-year-old woman presented with a 6-month history of nausea and abdominal distention after meals, followed by an enlargement of the upper abdominal circumference. She had no symptoms of jaundice, abdominal pain, or constipation. Her laboratory examination showed decreased serum hemoglobin (78 g/L) and normal white blood cell counts. Tumor biomarkers, such as alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), and carbohydrate antigen 125 (CA125), were all negative. Abdominal ultrasound showed a slightly hyperechoic mass in the upper abdominal region, exhibiting echo heterogenicity, without obvious blood flow signal. Contrast-enhanced computed tomography (CT) revealed a 15 cm × 10 cm upper abdominal mass with heterogeneous density . However, in contrast to HAML, hemangiomas typically demonstrate a homogeneous enhancement pattern during the arterial phase, followed by a progressive centripetal filling and delayed washout during the venous phase. Furthermore, the absence of a central scar and the presence of fat components in HAML can aid in differentiating it from hepatic hemangioma.As the preoperative diagnosis was uncertain, there was a risk associated with puncture due to potential hemorrhage. Therefore, we decided to proceed directly with surgical intervention. During laparoscopic exploration, a protruding, well-encapsulated tumor from the left liver was identified. A laparoscopic approach was employed for the resection of the tumor and left liver. Subcapsular hemorrhage indicated a spontaneous rupture  (2%–72% 4. HoweverHAML is typically difficult to diagnose before biopsy due to its significantly varying composition. It was summarized that only 28.2% of patients had the correct diagnosis before resection . In thisAlthough HAML is typically regarded as benign, its aggressive potential is drawing more and more attention as evidence increases. Thus, radical resection should be considered for suspected patients, especially taking into consideration that the tumor has a risk of rupture. Some risk factors, e.g., tumor size greater than 5 cm, infiltrative growth pattern, high nuclear grade, necrosis, and mitotic activity >1/50 high power field, were proposed . This pa


Myofibroblastic tumor is a mesenchymal neoplasm composed of myofibroblastic spindle cells with inflammatory infiltrate and considered to be of low-malignant potential tumor. Epithelioid inflammatory myofibroblastic sarcoma (EIMS) is a variant of myofibroblastic tumor with malignant characteristics; it mainly consists of round-to-epithelioid cells with positive nuclear membrane/perinuclear immunostaining for anaplastic lymphoma kinase (ALK) receptor tyrosine kinase. A gastric EIMS case in a 7-year-old boy is discussed. Our patient presented with severe anemia and melena. Magnetic resonance imaging of the abdomen and pelvis revealed a solid tumor (2.7 × 1.9 × 2.6 cm) at the posterior stomach wall. Upper gastrointestinal endoscopy revealed an irregular, protruding, highly vascular, approximately 2 cm mass close to the gastrooesophageal junction. Endoscopic biopsies were taken for histology; tumor cells were epithelioid with eccentric nuclei, prominent nucleoli, and abundant eosinophilic cytoplasm. Immunohistochemistry showed positive staining for desmin, smooth muscle actin, epithelial membrane antigen, cluster of differentiation CD30, and strongly positive staining for ALK. Fluorescence in situ hybridization analysis confirmed the presence of ALK rearrangements. A full-thickness surgical excision of the tumor with clear margins was performed. No adjunct treatment was administered and our patient has remained in full remission at 12 months following the surgery. To the best of our knowledge, this is the first pediatric case of gastric EIMS. Raised awareness and prompt recognition of special histological and immunochemical characteristics of EIMS can lead to accurate diagnosis and targeted therapy. Epithelioid inflammatory myofibroblastic sarcoma (EIMS) is an aggressive variant of inflammatory myofibroblastic tumor (IMT)EIMS usually occurs in children and young adultsEIMS is mainly located in the abdomen and pelvisGastric EIMS can present during childhoodGastrointestinal bleeding can be the major symptom of gastric EIMSInflammatory myofibroblastic tumor (IMT) is a mesenchymal neoplasm, which is composed of myofibroblastic spindle cells in a myxoid or collagenous stroma with inflammatory infiltrate, mostly consisted of plasma cells, lymphocytes, and occasionally eosinophils and neutrophils. IMT is common in children and young adults, although a broad age range has been reported. IMT is usually located in the abdomen, pelvis, mediastinum, or retroperitoneum. IMT, which had previously been considered as reactive tumor under the spectrum of “inflammatory pseudotumour,” is now recognized as a distinctive neoplasm of intermediate malignant potential. Recurrence rate ranges from <2% to 25% with metastasis rate of <5%  . EIMS isThe recognition of EIMS as a distinct IMT variant is very important because patients with ALK rearrangements can benefit from targeted therapy.To the best of our knowledge, this is the first case report of gastric EIMS in a 7-year-old boy. Due to its rarity, the characteristics and differential diagnosis are discussed.A 7-year-old boy presented with melaena and severe anemia (Hb = 4.4 g/dL). Abdominal ultrasound and Meckel’s scan were unremarkable. Upper gastrointestinal endoscopy revealed an irregular protruding highly vascular 2 cm mass close to the gastrooesophageal junction Figure .Endoscopic biopsies were sent for histology. Urgent computed tomography of the abdomen and pelvis was performed. Computed tomography revealed a gastric mass and raised the suspicion of lymphoma. Bone marrow examination was within normal limits. Magnetic resonance imaging showed a solid tumor (2.7 × 1.9 × 2.6 cm) at the posterior stomach wall, resembling to a mesenchymal origin tumor, such as a gastrointestinal stromal tumor (GIST)  within 11 reported pediatric cases (Table EIMS share the following common characteristics : (i) epiIn our case report, all those characteristics were identified except the presence of RANBP2-ALK fusion.ALK is a tyrosine kinase receptor gene located in chromosome 2p23 . RANBP2-Diagnosing EIMS can be a challenge due to its unusual round-to epithelioid cell morphology and atypical nuclear characteristics; ALK expression is essential but not pathognomonic. EIMS should be differentially diagnosed from diseases such as follows :i. Anaplastic large cell lymphoma (ALCL): differential diagnosis can be difficult in case of a rare sarcomatoid type of ALCL can exhibit spindle cell morphology with an overlapping immunophenotype, exhibiting positive staining for CD30, ALK, and smooth muscle actin, negative for epithelial membrane antigen and weak desmin expression; RANBP2-ALK fusion protein has not been reported in ALCL to date.ii. Malignant mesothelioma: MC, CK5, and calretinin stains are positive in immunochemistry analysis, while ALK is absent.iii. Epithelioid GIST: immunohistochemical stain is positive for CD117, DOG-1, CD34, C-KIT but negative for ALK. In the case of epithelioid GIST, cells have smaller nuclei than those observed in EIMS and there is no inflammation.iv. Alveolar rhabdomyosarcoma: frequently ALK positive but lacks fibrovascular stroma. Myogenin and MyoD antibodies can lead to its diagnosis.v. Epithelioid leiomyosarcoma: it often presents with cellular atypia and pleomorphism; however, it lacks the myxoid stroma, inflammatory infiltrate, and ALK expression seen in EIMS.Surgical resection, where possible, remains the treatment of choice for IMTs/EIMS. Incomplete tumor resection is associated with higher possibility of recurrence , 23, 26.2 twice daily  . The Chice daily . The mosce daily . If tumoce daily . A seconce daily  and had ce daily .In conclusion, EIMS is an aggressive variant of IMT, which can present in the stomach and cause upper gastrointestinal bleeding in children. The detection of ALK rearrangements with fluorescence in situ hybridization or RT-PCR is important for establishing the diagnosis. Further research is required in order to explore the benefits and risks associated with ALK-targeted therapy in pediatric EIMS cases.The authors would like to acknowledge Dr Maria Kourasi who participated in the technical editing of the manuscript.