Ameloblastic fibro-odontoma (AFO) is a relatively rare, benign noninvasive mixed odontogenic neoplasm derived from epithelial and ectomesenchymal elements of the dental tissues. It usually presents with a mean age of 11.5 years and in the posterior segment of the mandible. It is extremely rare in the posterior maxilla. Although the latest WHO edition classified AFO as developing odontoma, here we present a locally aggressive AFO in a 21-year-old male involving the posterior maxilla and sinus with bone destruction. The patient presents with a two-year history of slowly progressive left facial swelling with malodorous drainage. The CT scan revealed a 5.5 x 4.3 cm well-circumscribed expansile mass with mixed attenuation and peripheral calcification occupying the left maxilla and sinus with bone destruction of the hard palate and orbital rim. According to the literature, most of the AFO cases were treated adequately through a conservative approach with just enucleation or surgical curettage. To our knowledge, our case is the first case treated aggressively with left maxillectomy, palatectomy, and reconstruction surgery because of its radiologic findings, which suggested a locally invasive neoplasm. Histologically, the specimen showed a mixture of proliferative epithelial, mesenchymal tissue elements, and variable amounts of mineralized deposits consisting of enamel matrix and dentinoid deposits, and the final diagnosis was AFO. In conclusion, we present a rare case of AFO with an unusual aggressive presentation, age group, and site involved. The radiographic, histopathologic features, and therapeutic approaches of this unusual locally aggressive tumor are presented with the review of relevant literature. The abstract of this article was previously presented at the College of American Pathologist meeting, Chicago, September 25-28, 2021.Ameloblastic fibro-odontoma (AFO) is a benign mixed odontogenic neoplasm that is to hamartoma . In the A 21-year-old male with a two-year history of slowly progressive left maxillary and facial swelling presented to the emergency department for further evaluation. Associated symptoms included oral pain, facial pressure, and malodorous drainage. He had been treated with antibiotics and noticed the resolution of the drainage. Medical, social, and family histories were unremarkable, as were the results of a review of systems. There was no history of local trauma or infection.The physical examination reveals a left facial swelling over the left maxillary sinus with intact dentition and mass effect on the left side of the palate. Also, there was a bulging of the hard and soft palate with extension into the vestibule.The CT scan revealed a 5.5 x 4.3 cm well-circumscribed expansile mass with mixed attenuation and peripheral calcification occupying the left side of maxilla and left sinus, with thinning and expansion of the bony walls, and destruction of the hard palate. The lesion extended into the left nasal cavity and abutted the left orbital floor. The tumor was associated with an unerupted tooth Figures , 1B.Considering the clinical and radiographic examinations, a biopsy was indicated. Based on the small, submitted specimen, there were only mixed epithelial and ectomesenchymal elements without mineralized products. Consequently, a diagnosis of ameloblastic fibroma was made.The case was discussed at the institution’s multidisciplinary head and neck tumor board and the treatment plan included maxillectomy, palatectomy with osteocutaneous free flap reconstruction under general anesthesia.Grossly, the lesion revealed a well-defined tan-white mass involving the posterior maxilla with impacted molar tooth and bone destruction. Microscopically, a well-circumscribed, non-encapsulated mixed odontogenic neoplasm consisted of epithelial and mesenchymal fibroblastic tissue elements. The neoplastic epithelial structures are present in the form of anastomosing cords and follicles with central polygonal and stellate-shaped cells surrounded by peripheral ameloblast-like columnar cells exhibiting nuclear palisading and reverse polarization. The epithelial cords and follicles are embedded in a moderately cellular fibroblastic tissue stroma with prominent ground substance imparting a myxoid appearance. No cellular atypia or mitosis was noted in neither the epithelial nor the fibroblastic tissues elements. Scattered foci of enamel matrix, characterized by its basophilic “fishscale” appearance were noted, some of which were juxtaposed to epithelial follicles surfaced by ameloblast-like cells. In other areas, hypocellular or acellular eosinophilic dentinoid matrix deposits were noted Figures , 2B. A fThe new fourth edition of the WHO classification of head and neck tumors divides the odontogenic tumors into benign  and malignant odontogenic tumors . The etiTo display the demographic presentation of AFO, a literature review of 108 AFO cases from 1967 to 2015 was used . This reAFO is a benign, usually circumscribed noninvasive lesion . Most ofWe report a rare case of a locally aggressive AFO, presented in the posterior maxilla and associated with an impacted molar tooth. The lesion is microscopically benign but demonstrated locally aggressive behavior and was treated with wide hemi-maxillectomy. Despite its benign nature, our case presented as an invasive neoplasm. Histopathological findings were consistent with AFOma without any malignant features. Clinicians should include AFO in the differential diagnosis when dealing with a mixed radiolucent-radiopaque mass in the maxilla associated with an unerupted tooth, even if presented as an invasive lesion in young people.


Primary retroperitoneal teratomas are rare non-seminomatous germ cell tumors that arise from embryonal tissues. They form only 5%-10% of all retroperitoneal tumors. These are usually asymptomatic or present as lump or mass with compressive symptoms. Most of the patients are diagnosed by characteristic computed tomography findings. The chances of malignant transformation are rare. Complete surgical resection is the definitive treatment for most patients.We had a 19 years old young man, presented with pain abdomen and awareness of a lump in the right upper abdomen. Contrast-enhanced computed tomography (CECT) of the abdomen revealed a heterogeneous soft tissue mass in the retroperitoneum with calcification. He was successfully treated with en-bloc complete surgical resection. Histopathology confirmed benign mature teratoma including all three germ layers. The patient is doing fine at nine months of follow-up and planned for CECT abdomen.Primary mature teratomas arise in the retroperitoneum due to failure of germ cells migration to their normal location. Germ cells undergo differentiation into various germ layers. Teratomas can be classified as mature, immature, or non-dermal based on their histopathological characteristics. Although complete surgical excision is the mainstay of treatment, malignant teratomas frequently recur. So, annual follow-up is recommended with imaging.A classic mature teratoma requires careful examination and interpretation of the imaging. The amount of immature components determines outcome and recurrence in these patients so en-bloc surgical resection is the treatment of choice. Teratomas are non-seminomatous germ cell neoplasms derived from embryonal tissue and have elements from two or more germ layers . Althoug2. A 9 cm x 8 cm, ill-defined lump with firm consistency was palpated in the epigastrium and right hypochondrium on abdominal examination. Genitalia were normal on physical examination.A 19-year-old young man presented with a complaint of pain in the upper abdomen for two months. He also noticed a lump in the right upper quadrant during this period, which gradually increased in size. There was no significant past medical or surgical history. Family and personal history were unremarkable. He was moderately built and well-nourished with a BMI of 22.5 kg/mContrast-enhanced computed tomography (CECT) of the abdomen revealed an 8.6 cm x 7.7 cm heterogeneous soft tissue density mass arising from the retroperitoneum with calcification within, suggestive of teratoma Figure . There wOn surgical exploration, there was a well-encapsulated tumor in the retroperitoneum behind the duodenum and head of the pancreas, which was excised in en bloc. On grossing of the tumor, there was a mass consisting of rudimentary eyes, ear, nose, jaw, gum with fully developed teeth, a long tuft of hair, and putty materials Figures , 2b. HisPRT are rare tumors with an incidence of 1%-11% . They arAbout 55% of patients with PRT present in the first decade of life ,2. The rThere is a risk of malignant transformation in 1% of PRT . This riPRT are rare tumors and usually diagnosed incidentally on imaging or symptoms due to mass effect, diagnosed by characteristic imaging appearance, and treated by en-bloc complete surgical resection. The amount of immature components determines the outcome and recurrence in these patients. Regular follow-up is recommended to detect early recurrence.


Follow-up MRI revealed small cystic changes, and the latest imaging showed progression into a large multicystic lesion with mass effect. The patient underwent surgery, and histopathological examination revealed basal ganglia germinoma. We highlight the serial MRI changes that were suggestive of basal ganglia germinoma in this case.Germinoma arising from intracranial off-midline structures is considered ectopic. Although basal ganglia germinoma is a rare occurrence, it is more commonly seen in the Asian population, particularly among boys. Here, we report a case of an adolescent boy who presented with hemiplegia and delayed diagnosis of basal ganglia germinoma with progression on serial magnetic resonance imaging (MRI). Several signal changes have been described during the early stage of the disease such as T2-weighted patchy hyperintense signal, cerebral hemiatrophy, and signal change on susceptibility-weighted imaging.  Intracranial germ cell tumors (GCT) are rare tumors that typically occur in midline structures, namely, the pineal gland and the neurohypophyseal region of the brain. The tumor is considered ectopic when it arises from off-midline structures such as the basal ganglia, thalamus, septum pellucidum, and cerebellum. Germinoma is a common subset of GCT with an incidence rate of 0.2 per 1,000,000 individuals . DiagnosA 14-year old boy with no known medical illness presented with right hemiplegia and an ipsilateral upper motor neuron lesion of the seventh cranial nerve. His symptoms had started three years ago, and, initially, he reported experiencing right-sided body weakness associated with numbness. He also complained of left-sided headache, which he described as a sharp pain. Non-enhanced computed tomography (CT) was normal Figure . There wDue to his right-sided hemiplegia and abnormal signal in the left basal ganglia, the patient was diagnosed as having an arterial ischemic stroke. However, his magnetic resonance angiography (MRA) showed no stenosis or abnormal signals in his intracranial vessels Figure . MoreoveGerminomas mainly occur in intracranial midline structures such as the pineal and suprasellar regions. Rarely, they may arise from the basal ganglia. Intracranial GCTs are thought to arise during initial rostral neural tube development from the midline stream of totipotential cells. The development of the third ventricle may cause displacement of these cells from the midline, which can explain the manifestation of GCTs in ectopic locations . The mosMRI shows early germinomas as ill-defined, homogenous, solid lesions without mass effect. In comparison to cortical gray matter, germinomas typically present as isointense to hyperintense on T2-weighted, T1-weighted, and fluid-attenuated inversion recovery images. Some also show a mild hypointense lesion concerning basal ganglia on T2-weighted imaging, likely due to iron deposition in the globus pallidus during adolescence. Contrast enhancement is not conspicuous in early imaging . These M11C-methionine positron emission tomography (MET-PET) showed high tracer uptake in ectopic germinomas which had no significant mass on conventional CT or MRI. MET-PET provides excellent contrast between the lesion and background normal brain tissue as the uptake is very low in the latter [Okamoto et al. observed atrophy of the basal ganglia particularly in adolescents who presented with convulsions as an initial diagnostic sign of ectopic germinoma . The pose latter ,13.SWI is one of the latest methods to detect early basal ganglia glioma. SWI sequences can be used to detect blood products and biologic metal accumulation, as seen in intratumoral hemorrhage. The magnetic inhomogeneity causes the lesion to appear unusually larger on SWI than other conventional MRI sequences. In addition to hemorrhage, Lou et al. discussed the possibility of abnormal iron accumulation in basal ganglia germinoma as a factor causing the signal intensity seen on SWI . This waSubsequent MRI revealed a slightly larger-sized, ill-defined, patchy hyperintense lesion in the left basal ganglia consistent with the study by Lee et al. who reported the development of intratumoral tiny cysts . In contCerebral hemiatrophy is considered to be a result of Wallerian degeneration by direct tumor infiltration of the fiber tracts or into the ipsilateral perforating arteries ,11. RetrBasal ganglia germinoma is a rare tumor found in adolescents. It should be considered as a differential diagnosis when dealing with hemiplegia, especially in adolescent boys. Albeit challenging, early diagnosis is possible with awareness of the subtle changes seen on MRI such as a hyperintense signal on T2-weighted imaging, presence of hemiatrophy, and signal changes on SWI. Additionally, MET-CT may also be used for early diagnosis. The development of cysts on follow-up imaging can raise the suspicion of germinoma. When detected early, surgery may be avoided because this tumor is radio- and chemosensitive.


Hepatic candidiasis is a manifestation of disseminated candidiasis, which typically presents in immunocompromised patients. Focal hepatic candidiasis in immunocompetent patients, however, is infrequent/extremely rare. We present the case of an immunocompetent female patient who presented with respiratory distress and right-sided pleural effusion. The pleural fluid tap did not grow anything, and a contrast-enhanced computed tomography (CT) scan revealed a right liver lobe subcapsular collection. CT-guided aspiration and culture resulted in Candida albicans growth. The patient responded to oral fluconazole, and a follow-up CT scan demonstrated resolution of the collection. Although hepatic candidiasis rarely occurs in immunocompetent patients, it should be included in the differential diagnosis of hepatic abscesses, as timely diagnosis and management are crucial in conferring a good prognosis. Candida is a commensal yeast found predominantly in the orogastrointestinal tract . ChronicA 68-year-old female patient with a past medical history of hypertension and chronic kidney disease  presented to the emergency department with a one-week history of dry cough and dyspnea. She had non-radiating, mild right upper quadrant abdominal pain and nausea without vomiting. Her presenting vitals were temperature 37.2 ºC, heart rate 85 beats/min, respiratory rate 18/min, and blood pressure 115/80 mmHg. On examination, there was mild right upper quadrant tenderness and bronchial breath sounds in the right lower lung fields. Laboratory tests showed leukocytosis of 34 x 109 cells/L with a neutrophilic predominance and an elevated C-reactive protein (CRP) of 311. Liver function tests were mildly elevated, and her blood culture revealed no growth.The chest x-ray demonstrated an obscured right costophrenic angle suggestive of minimal pleural effusion. The diagnostic pleural tap demonstrated no growth; however, it had a white cell count of 1.7 x 109 cells/L with a neutrophilic predominance. Contrast-enhanced computed tomography (CT) abdomen denoted a hypodense subcapsular thick fluid density lesion in the liver's upper pole, mainly involving the right lobe of the liver and perihepatic region Figure .Prophylactic antibiotic therapy for the pyogenic liver abscess was started, and it was decided to proceed with CT-guided drainage and abscess culture. The culture was positive for Candida albicans. The patient was prescribed oral fluconazole, and a follow-up contrast-enhanced CT scan showed resolution of the liver lesion or perihepatic fluid Figure . The patThe etiology of liver abscesses is polymicrobial. A series of 233 patients had reported a fungal component in 22% of liver abscesses . HoweverTo date, we could only identify three reports of HSC in immunocompetent patients. Gottlieb et al. reported an immunocompetent woman who developed Candidal hepatic abscesses as a result of pylephlebitis. However, the causative species was Candida dubliniensis in this case . MenacheMultiple identifiable factors might contribute to hepatic candidiasis' pathogenesis, including cytotoxic chemotherapeutic regimens, prolonged use of broad-spectrum antibiotics, neutropenic conditions, and gastrointestinal mucosal damage. Specifically, severe neutropenia, coupled with mucosal damage, can allow Candida species to deposit in the liver and spleen. Commonly observed symptoms include persistent fever, abdominal pain, loss of appetite, nausea, vomiting, dysphagia, and gastrointestinal bleeding . The exaAbdominal ultrasound and a contrast-enhanced CT scan of the abdomen are the initial investigations of choice. A contrast-enhanced CT scan is the most sensitive investigation, typically depicting multiple, round, hypoattenuating lesions with a central enhancement. A percutaneous liver biopsy can help the definitive diagnosis of Candida in almost three-quarters of the patients if performed . A diagnDespite the good prognosis of HSC in immunocompetent patients, a high index of clinical suspicion, repeat imaging, or liver biopsy is needed before initiating antifungal therapy, as in our case. Amphotericin B has been widely used as individual therapy or in combination with flucytosine . CompletFrom our case and the literature review, we conclude that hepatic candidiasis can rarely occur in immunocompetent patients without identifiable risk factors. Physicians should not exclude hepatic candidiasis in immunocompetent patients as a cause of the liver abscess. The diagnosis is challenging and might need repeated imaging and liver biopsy for confirmation. Prompt diagnosis and treatment confer a good prognosis.


Left ventricle (LV) lipoma is a very rare, benign cardiac tumor. Due to its rarity, LV lipoma is often misdiagnosed. Aspecific symptoms such as murmurs, arrhythmias, memory loss and palpitation may occur due to the mass effect.We report a case report of a 42 year old woman who was found to have left ventricle mass after check-up for arrhytmia. By a fully endoscopic approach, the mass was successfully resected from the left ventricle without the need for sternotomy.Total endoscopic removal of left ventricle lipoma’s can be done safely and has several advantages to conventional sternotomy. Larger studies are needed to confirm this hypothesis. Cardiac lipoma is a rare primary cardiac tumor. Origin in the left ventricle is seen in 33% of cases, with 57% of these cases the primary site being intracavity . Almost 2, normal pulse of 80 bpm, blood pressure 130/90 mmHg. She had no pathological murmurs nor any other abnormal findings. 12-lead electrocardiography (ECG) and exercise test were normal. Further evaluation by transesophageal ultrasound (US) and CT showed a globular mass attached to the apex of the left ventricle measuring 4.6 × 3.6 cm  of 24 kg/cmAfter general anesthesia and standard draping, connection to the extracorporeal circulation (ECC) was made by femoral cannulation combined with jugular venous return. 3 trocars were placed in second to fourth intercostal space in the right axillary line. 1.5 cm utility port was placed in the third intercostal space. 5 mm thoracoscope was used for vision. Pericardium was opened followed by aortic cross clamping and anterograde cardioplegia was given. Left atrium was accessed via Waterston’s groove. Clearly visible behind the mitral valve is a lobulated, fatty mass with a broad base pedunculated to the apex of the left ventricle Fig. . The masPostoperative stay was uneventful and after 7 days patient was discharged. Histological examination was consistent with lipoma. Final measurements were 5.5 × 3.5 × 3.5 cm. Further staining for liposarcoma was negative. Mouse double minute 2 homolog (MDM2) fluorescence in situ hybridization (FISH) was negative for malignant lipomatous tumor. Echocardiogram showed no signs of recurrence during a 2-month follow up period.Up to date, no non-sternotomy minimally invasive approach has been reported. The technique described in this report allows adequate access to the left ventricle via the left atrium through the mitral valve by use of a utility port (1.5 cm) and 3 trocars entry points. Thorough inspection of the left ventricle is possible allowing for meticulous dissection of the LV lipoma from the left ventricular wall while keeping the lipoma itself intact, minimising the risk of embolization. Lipoma growth is from interior to exterior, hence an approach from inside the ventricle allows good differentiation between LV wall and lipoma. Sternotomy comorbidity is avoided allowing for lesser postoperative pain, faster mobilisation and recovery.Literature about these rare cardiac tumors is mostly limited to isolated case reports, recently collected in a large systematic review . Of all Despite no official guideline for treatment of lipoma, current practice is surgical resection by either partial or full sternotomy. Some have reported thoracoscopic techniques, though sternotomy was still needed , 4. OtheLV lipoma is a very rare, benign cardiac tumor. Once patients become symptomatic, resection should be considered. Standard surgical approach is by sternotomy. We think a fully endoscopic approach is feasible and beneficial for most patients.


Its use was discontinued because late complications that require surgical removal were reported. Methods: Case report. Results: We report a case of left eye MIRAgel® buckle surgery 28 years ago presenting with a tender palpable erythematous swelling at the lower lid, with marked conjunctival chemosis and progressive ophthalmoplegia. Imaging revealed a large, well-defined, horseshoe-shaped lesion in the extraconal space of the left orbit with globe distortion, with histological confirmation of an expanded hydrogel buckle. He recovered well following removal of the explant but developed chronic macular oedema a year later, which persisted despite sub-Tenon’s triamcinolone injections. Repeat imaging demonstrated remaining hydrogel explant. Macular oedema settled well upon successful surgical removal with no recurrence to date. Conclusion: Our case is the first to describe macular oedema as a late MIRAgel-related complication, with complete removal of the explant being the definitive treatment. Macular oedema indicates postoperative inflammation secondary to the remaining explant fragments. Given the friability of hydrolysed MIRAgel®, we recommend ophthalmologists to warn patients regarding the possibility of further inflammation in the globe or the orbit in case of incomplete removal.Background: MIRAgel Howeverachments ,11,12. Tachments . Althougachments . Due to Herein, we present a unique case of chronic macular oedema as a late MIRAgel-related complication. To our knowledge, this is the first case to be reported in the literature. A 62-year-old male presented with a 6-week history of gradual enlarging lesion in the left lower lid. This was accompanied by worsening pain and progressive ophthalmoplegia. He had no medical history to date, but he had a left eye (LE) retinal detachment 28 years ago, which was repaired using an encircling hydrogel scleral buckle. Visual acuity (VA) was 0.04 LogMAR in both eyes (BE) with normal pupillary examination and colour vision. A large, firm, ill-defined mass was palpable on the left lower lid with overlying erythema and marked conjunctival chemosis. There was a complete restriction in all positions of gaze in the LE. Exophthalmometry measurements revealed 2 mm of LE proptosis, and the left orbit was firm on retropulsion. Intraocular pressure (IOP) was 14 mmHg in BE. Posterior segment examination revealed healthy optic nerves and retina with no choroidal folds. There was no evidence of cervical lymphadenopathy. Urgent magnetic resonance imaging (MRI) of the orbits revealed a large, well-defined, tubular horseshoe-shaped lesion in the extraconal space of the left orbit, sparing the medial portion of the orbit with globe distortion which did not enhance on post-contrast sequences . Urgent Following the histology report, complete surgical excision of the hydrogel implant was attempted. A subconjunctival incision on the left lower lid and further blunt dissection were carried out to expose the thick white capsule that covered the gelatinous material of the expanded hydrogel. The gelatinous friable hydrogel buckle was removed with gentle use of suction, taking care not to cause scleral rupture or perforation. Multiple areas of scleral thinning were noted after the removal of the hydrogel buckle. The same technique was used for the lateral and superior quadrants to ensure complete removal of the explant. The conjunctiva was closed with a 7-0 Vicryl suture. Additional material sent for histopathological analysis confirmed the previous result. There was no intraoperative complication, but transient hypotony occurred postoperatively. At one week postoperative follow-up, there was a complete resolution of symptoms with full extraocular motility. VA was 0.04 LogMAR for BE. IOP was 15 mmHg in the right eye (RE) and 10 mmHg in the LE, with no signs of inflammation or infection. The patient recovered well and was subsequently discharged as he remained asymptomatic after being followed up for 4 months.A year later, the patient was referred back with reduced vision in the LE. VA was 0.02 LogMAR on the RE and 0.96 on the LE. There was posterior subcapsular cataract and macular oedema in the LE, as shown in ®) were popularised in the 1980s as they were perceived as an improvement upon the prior available silicone buckles [Hydrogel scleral buckles  explant causing macular oedema, which is shown to resolve upon removal of the hydrogel buckle. It is not uncommon for MIRAgel to cause an inflammatory reaction. Previous reports demonstrated scleral erosions, external inflammation that could mimic cellulitis, and granulomatous inflammation presenting as an orbital tumour or orbital cyst [To our knowledge, we believe this to be the first report of a hydrogel (MIRAgeltal cyst . These ftal cyst . We believe the macular oedema in the current case we reported was inflammatory in aetiology, and was related to the residual exposed hydrogel buckle, as proven by imaging and histological analysis. Our patient initially presented with good VA in the affected eye and had no other relevant past ophthalmic or medical history that might have explained the macular oedema. Besides, the macular oedema, in this case, was also resistant to sub-Tenon corticosteroid treatment. It appears that the initial attempt to surgically remove the hydrogel caused some fragments to migrate to a more posterior part of the orbit, hence causing macular oedema. Given the well-reported inflammatory property of MIRAgel and the difficulty in its removal, we recommend ophthalmologists warn the patients regarding the possibility of further inflammation in the globe and the orbit in case of incomplete removal. Various surgical techniques have been proposed to allow complete removal of the hydrolysed explant to prevent further complications. We used a suction device to assist in pushing manoeuvres, similar to the technique proposed by Richards and Meyer . AlthougIn conclusion, our case is the first to describe macular oedema as one of the complications related to the hydrogel scleral buckle. This may be due to postoperative inflammation secondary to the remaining explant fragments. We have shown that it can resolve upon complete removal of the explant. Further studies are needed to investigate any surgical technique that can remove the explant safely and successfully so that it does not cause any further long-term complications.


The ectopic parathyroid adenoma is an important cause of refractory and recurrent hyperparathyroidism. The mediastinal location of ectopic parathyroid tissue is reported in up to 20% of cases of ectopic parathyroid adenomas. In around 2% of cases where cervical approach is unfeasible, the mediastinal route imposes a surgical challenge.We describe a case of a twenty-five-year-old male patient with manifestations of hyperparathyroidism. Computed tomography of the chest showed an anterior mediastinal mass. Nuclear scintigraphy detected a functioning parathyroid tissue in the mediastinum. The mass was excised en block with the surrounding adipose tissue using a three-port video-assisted thoracoscopic surgery. The patient showed a full symptomatic and laboratory recovery.Mediastinal parathyroid glands comprise a unique surgical entity with diagnostic and management difficulties.Mediastinal parathyroid gland is a rare yet important cause of refractory hypercalcemia. The current localization tools improve the thoracoscopic management of MPAs. VATS can provide access and exposure to ectopic parathyroid adenoma with low morbidity. •Ectopic mediastinal parathyroid glands are rare yet challenging cause of refractory or recurrent hypercalcemia.•Most mediastinal parathyroids are approachable through a neck incision.•Larger, deeper or totally mediastinal glands require thoracic access.•Historically, in challenging cases, sternotomy or thoracotomy is performed with associated high morbidity in some cohorts.•The video-assisted thoracoscopic surgery (VATS) allows surgeons to retrieve these glands guided with localization tools. Asymptomatic presentation is not uncommon Ectopic parathyroid adenomas result from migratory misbehavior during embryogenesis. The inferior parathyroid glands originate from the 3rd brachial arch which also gives rise to the thymus gland and accompany it during its descent. Therefore, deviation from the normal pathway of descent results in their ectopia anywhere in the mediastinum up to the pericardium. The superior parathyroid glands arise from the 4th branchial arch and follow the thyroid gland during its caudal migration. Mediastinal parathyroid adenomas (MPAs) are found in up to 20% of patients with ectopic parathyroid glands. In around 2%, the cervical retrieval is unfeasible as the adenoma ≥6 cm or deeply seated in the mediastinum 219mTc-methoxyisobutylisonitrile scintigraphy (99mTc-MIBI) showed increased uptake of the tracer in the mediastinum . Working ports were placed in the 3rd and 6th intercostal spaces at the anterior axillary line and the camera port in the 4th intercostal space at the mid-axillary line . Careful3Pathological examination confirmed the presence of parathyroid adenoma. Serological and symptomatic recovery was achieved, and the patient was discharged in the third postoperative day. Follow up in 1st, 3rd and 6th months postoperatively was performed, patient was seen in outpatient clinics for physical examination and serological tests which revealed normal calcium and parathyroid hormone. When asked about his symptoms, he was satisfied with the resolution of symptoms.4MPAs comprise a unique surgical entity with diagnostic and management difficulties. MPAs are either originally has developed in the neck and descended to mediastinum or most commonly originally developed in the mediastinum. In the 1–2% of cases were mediastinal exploration is needed, median sternotomy or anterior thoracotomy were the main approaches used and were associated with a high failure rate approaching 40% and sternal-related complications in 20% of cases. Less aggressive interventions such as; transcervical approach with sternal retraction, subxiphoid laparoscopy and angiographic ablation were attempted. The available localization techniques in that era were computed tomography which yielded high false negative results and parathyroid arteriography which carries neurological risks. Additionally, the angiographic ablation was associated with recurrence, early failure and hypoparathyroidism 5When MPAs are detected preoperatively with localization tools, VATS is a safe and effective approach obviating the need of sternotomy.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Not commissioned, externally peer-reviewedInstitutional Board Review (IBR) was obtained.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.1st and 2nd authors: conceptualizing, data collection, validation, investigation, data curation, writing final draft, 3rd author: data validation, investigation, curation, writing and revising the final version, supervision.N/A.Hanan M. Hemead, Ahmed Abdelaziz.None.


Intraocular osseous metaplasia is a rare histological finding associated with benign cellular transformation. Its development requires inflammatory cytokines and the process takes many years. Previous case reports of intraocular ossification manifested as linear calcification or white plaques. In contrast, our case presented with a tumor-like solid mass, in which a long-standing chronic inflammatory stimulation may contribute to the stunning appearance.This is a 48-year-old woman with past history of advanced Coat’s-like retinopathy and chronic retinal detachment in the left eye for 12 years. She underwent vitreoretinal surgery to prevent phthisis bulbi. During the operation, a 9 mm solid mass was found embedded within the proliferative tissue above the retina and was removed. Pathological findings revealed bone formation in the center of the mass surrounded by fibrous metaplasia and focal gliotic changes. Layers of cohesive cells were found lining on the external side of the mass, and further immuno-histochemical study suggested them retinal pigment epithelial cells. Postoperatively, the retina was attached with stable visual acuity and normal intraocular pressure.To our knowledge, the appearance of a tumor-like mass representing intraocular osseous metaplasia in eyes with chronic inflammation or retinal detachment has not been reported in previous case reports. This case emphasizes the importance of considering osseous metaplasia as one of the differential diagnoses of an unknown intraocular mass, especially in eyes with great severity of chronic inflammation. Also, our immuno-histochemical study provided more evidence on the pathological role of retinal pigment epithelial cells in developing ossification. Osseous metaplasia from retinal tissues is rare, previously described in case reports or case series –3. It waA 48-year-old female came to Dr. Chou’s clinic with a long-standing visual loss in her right eye for 12 years, earlier diagnosed with panuveitis in another medical unit. She denied any ocular surgery or trauma before. According to the electronic medical records from her earliest visits in our hospital 12 years ago, her vision was counting fingers in the right eye and 20/20 in the left eye. Anterior segment examination of the right eye showed iris posterior synechiae; dilated fundoscopic examination revealed diffuse lipid deposition, exudative retinal detachment, and multiple telangiectasias (Fig. This time, in September 2020, she sought medical help from Dr. Chou due to the complaint about the intolerable worsening of vision loss spanning 2 years. On examination, the best-corrected visual acuity dropped to light perception in the right eye. Anterior segment examination revealed dense fibrotic membrane covering on the intraocular lens. The fundoscopic view was totally blocked by the extensive proliferative membrane. Ultrasonography showed total retinal detachment (Fig. During the surgery, an incidental finding of a huge ellipsoid mass incorporated with preretinal fibrotic tissue at the anterior portion posterior to the ora serrata was noted Fig. A, after The surgical specimen was a grey-white hard ellipsoid mass measuring 6 mm in length, 4 mm in width, and 9 mm in height. The histopathological examination was performed by routine light microscopy with hematoxylin-eosin-stained sections showing histological features of osseous metaplasia, in which an area of marrow-like tissue with woven bone formation was shown in the center Fig. A, B. NexIntraocular osseous metaplasia, though rare, has been commonly reported in retinal detachment, uveitis, and ocular trauma . Based oAlthough previous studies mostly reported that RPE hyperplasia and ossification take place at subretinal or intraretinal level , 6, no rThe occurrence of intraocular osseous metaplasia is believed to take more than 10 years, and it requires 20–41 years to develop extensive bony tissue –11. HoweAlthough the ossified mass was indeed large, we had not been able to identified it preoperatively on ultrasonography, making us face with a structure of such dimension during the intraoperative period. Preoperatively, we had detected intraretinal calcification at the posterior pole, but extremely high amplitude signals had not been shown at the anterior portion on ultrasonography Fig. . We specIn conclusion, we report a case of intraocular osseous metaplasia presented as a tumor-like mass in a middle-aged woman on the basis of advanced Coat’s-like retinopathy and chronic retinal detachment. The tumor-like mass was embedded within the proliferative fibrous tissue. In pathological investigation, immuno-histochemical results provided more evidence on the pathological process of osseous metaplasia, which includes RPE migration, hyperplasia, and transformation. It is rare for intraocular ossification appears as a large mass. Hence, we postulate that the vigorous, long-standing inflammatory environment in this patient led to a shorter process and greater extent of ossification. Additionally, it reminds us that benign cellular metaplasia could be one of the differential diagnoses of an intraocular unknown mass, especially in a situation of chronic inflammation and retinal detachment.


Metastatic pheochromocytoma in the spine is a very rare complication during pregnancy. We report anesthesia in a pregnant woman for resection of an undiagnosed spinal tumor, accompanied by remarkable hemodynamic changes and massive bleeding.A 33-year-old woman at 17 weeks of gestation presented with the rapid progress of bilateral lower leg paralysis. A diagnosis of spinal tumor was made, and surgical resection was planned. Although the surgery was suspended because of remarkable hemodynamic changes and massive bleeding, fetal heart rate was stable. Postoperative examination revealed pheochromocytoma in the urinary bladder as a primary lesion with spinal metastasis.Although spinal pheochromocytoma is extremely rare in pregnant women, it should be suspected when abnormal hypertension is observed with accompanying neurological deficits. Preservation of maternal circulation and uteroplacental blood flow should be the first priority during anesthesia. Pheochromocytoma is an extraordinarily rare complication, with a frequency of 0.002% in all pregnancies . The diaA 33-year-old, 17-week pregnant woman  visited the department of orthopedic surgery of a neighborhood hospital with a chief complaint of back pain. Medical history was unremarkable except ventricular extrasystoles on electrocardiogram since childhood. She was transferred to our hospital for further examination, with a suspicious diagnosis of a spinal tumor.On admission, she was not able to walk unaided due to decreased muscle strength of bilateral lower limbs. Hypoesthesia below the seventh thoracic dermatome with increased bilateral patellar tendon and Achilles tendon reflex was observed. Magnetic resonance imaging (MRI) revealed a mass in the third thoracic vertebra, with T1-weighted signal intensity similar to and T2-weighted intensity slightly lower than the spinal cord  were noted during tumor resection, immediately followed by hypotension (63/43 mmHg) during the suspension period of surgical resection despite massive blood transfusion . Administration of doxazosin mesilate and carvedilol was started after the diagnosis. Fetal ultrasound on postoperative day 23 showed favorable fetal growth but indicated a tumorous lesion in the vesicouterine excavation. Based on the results of urgent pelvic MRI and needle biopsy, a definitive diagnosis of extra-adrenal pheochromocytoma in the urinary bladder with spinal metastasis was made. Since the continuation of pregnancy was life-threatening and posed a high risk to the patient, elective abortion was performed at 21 weeks and 4 days of pregnancy after discussion with the patient to prioritize the treatment of the underlying disease. Subsequently, the patient received chemotherapy and underwent surgeries for the residual tumor in the spine and the primary lesion, which led to remission.We have presented a pregnant woman who experienced unexpected hypertension/hypotension and massive bleeding during resection of an undiagnosed spinal tumor. Surgery was discontinued after agreement with the surgeons for prioritizing the lives of the patient, fetus, and stabilizing their hemodynamics. Although the patient was diagnosed with metastatic pheochromocytoma on histopathological examination, it was not suspected preoperatively due to the absence of symptoms suggestive of it such as headache, nausea, palpitation, abnormal sweating, and hypertension. Preoperative spinal MRI was not specific as pheochromocytoma, because it has various MRI appearances . Serum oOnly one case of metastatic pheochromocytoma to the spine has been reported during pregnancy . AlthougThe present case has many implications for the issue of fetal assessment in pregnant patients undergoing surgery. Clinical guidance from a committee of the American College of Obstetricians and Gynecologists recommends continuous intraoperative fetal heart rate monitoring only when the fetus is viable and an emergency cesarean delivery is possible . In addiImmediately after the operation, the maternal hemodynamics were considered to be unstable. Therefore, the patient was transferred to the ICU under sedation with propofol and extubated 6 h later. Considering the effect of propofol on the fetus, the amount and administration time of propofol should be kept to the minimum necessary in such cases. Preoperative discussion about the extent of resection of the tumor with the surgeons, implicating the malignancy of the tumor, would also be important.We have reported a case of a pregnant patient with spinal metastatic pheochromocytoma. The incidence of pregnancy complicated by a metastatic pheochromocytoma is extremely low. However, when acute drastic changes in circulatory dynamics are observed during resection of an undiagnosed spinal tumor in a pregnant patient, it is necessary to stabilize the maternal circulatory dynamics and to maintain the fetal blood flow, considering the possibility of metastatic pheochromocytoma.


The literature is rich with many studies reporting different treatment modalities and approaches for cystic craniopharyngioma (CC), including microsurgery, neuroendoscopic transventricular approach, endoscopic transnasal surgery, stereotactic drainage, and Ommaya reservoir insertion. The goals of this manuscript are to report the successful treatment of an atypical case of CC using the neuroendoscopic transventricular approach (NTVA) as well as discuss the different surgical modalities for these tumors following a comprehensive review of the literature. Our patient is a nine-year-old female with a large CC who was managed using the NTVA. No complications or recurrence occurred over two years of follow-up. Results of our literature review showed lower recurrence and complication rates of the NTVA compared to other surgical modalities.The NTVA is potentially efficient, reliable, and safe for managing CC and cystic-dominant craniopharyngiomas, with low recurrence and complication rates compared to microsurgery and Ommaya reservoir insertion. Future randomized clinical studies comparing the various treatment modalities of CC are needed to solidify these conclusions. Craniopharyngiomas arise from squamous cells of Rathke’s pouch. These benign tumors account for 10% of pediatric and 2-4% of intracranial brain tumors, are located in the intra- and suprasellar zones, and are classified as cystic, solid, or mixed -4. The oThe patient is a nine-year-old female who presented with headache, agitation, urinary frequency, and progressive visual deficits over the past two years. A large sellar and suprasellar lesion was detected on a CT scan, and a ventriculoperitoneal (VP) shunt was placed to relieve the progressive symptoms of hydrocephalus Figure . MRI solA few days prior to surgery and despite no signs of VP shunt failure, the patient’s exam was notable for acute confusion, severe ataxia, and bilateral blindness. The NTVA was performed using a rigid neuroendoscope . The cyst was accessed through a right frontal burr hole, and the contents were drained. The neuroendoscope was advanced to the right lateral ventricle, where cyst wall calcifications were visible through the thinned and elevated neural elements. The choroid plexus was then identified and tracked back to the foramen of Monro. The cyst wall was sampled and the cyst was punctured, draining a copious gray-to-green liquid content with debris. Simultaneous irrigation with a Ringer’s solution and suctioning cleared the contents of the cyst; adjacent neurovascular structures were clearly visible at the end of the procedure.The postoperative course was uneventful, and all symptoms improved in the immediate postoperative period, except for visual loss. Histopathology confirmed the diagnosis of CC. The patient did not develop any symptoms of chemical meningitis on close follow-up. Her pituitary function remained normal postoperatively as well as on long-term follow-up. We opted not to pursue any additional surgical or adjuvant therapy due to the lack of any obvious solid tumor component on postoperative MRI, very thin residual cyst wall, and extensive basal extension with involvement of the critical structures Figure . Follow-In this paper, we report a child with a large CC, which was treated via NTVA only with no complications or recurrence after two years of follow-up. As there is a lack of consensus regarding the optimal surgical approach to manage CC, we conducted a literature review about the different treatment modalities and summarized our results in tables.We found 17 reports that utilized the NTVA (with and without Ommaya reservoir insertion) for the treatment of CC in 67 patients, with a follow-up period ranging from six to 73 months; the recurrence rate ranged between nil to 54%  is the recommended strategy . GTR mayThe NTVA is recognized as a safe, efficacious, and minimally invasive procedure for intra- and paraventricular craniopharyngiomas, especially for cystic, large, and extensive lesions -3. Our lThe low complication and recurrence rates Table  followinThe NTVA is efficient, reliable, and safe for managing CC and cystic-dominant craniopharyngiomas, with potentially lower recurrence and complication rates compared to microsurgery and Ommaya reservoir insertion. Future randomized clinical studies comparing the various treatment modalities of CC are needed to solidify these conclusions.


Retained endovascular devices are becoming increasingly reported as the indications for endovascular intervention continue to expand. As such, an interventionalist needs to be prepared to extract devices that are improperly deployed. This case illustrates the successful retrieval of an incompletely opened flow diverting stent using a microsnare. This is the second reported case of this complication and the first known case specific to the flow re-direction endoluminal device . Flow diversion has emerged as a workhorse of intracranial aneurysm treatment, especially for large, wide-necked, unruptured intracranial aneurysms. Multiple randomized, prospective trials have demonstrated safety, efficacy, and ease of use of flow-diverting stents -3. FRED,The pivotal EuFRED (defined in appendix) and SAFE (defined in appendix) trials showed a complete aneurysm occlusion rate of 91.3% and 73.3%, respectively, at one-year follow-up and permanent morbidity and mortality rates of <2% and <3% for unruptured and recanalized aneurysms located in the anterior circulation [We present a case of a 72-year-old female with a known 4mm x 3mm left clinoidal internal carotid artery (ICA) aneurysm diagnosed six years prior to presentation presenting with worsening headaches for the last four days. CT and CTA (computed tomography angiography) of the head did not demonstrate any evidence of subarachnoid hemorrhage but did demonstrate an interval size increase, compared to a surveillance CTA three months prior, of the unruptured left clinoidal ICA aneurysm, now measuring 5.3mm x 3.7mm with bilobed irregular morphology. The patient’s neurologic examination was unremarkable for focal deficits. Her prior headache history was significant for migraines without aura; however, the patient indicated that her current headache was different in location and intensity, now located over the left hemicranium. Endovascular intervention was recommended based on the patient's new symptoms, as well as the increasing size of this left clinoidal ICA aneurysm with irregular morphology. Informal verbal and written consent were obtained from the patient to proceed with a flow re-direction endoluminal device  in an attempt to obliterate the aneurysm through flow diversion. The patient was started on ticagrelor 90mg twice daily one day before the procedure due to an aspirin allergy.The patient was brought to the neurointerventional suite, and the procedure was performed under general anesthesia. An 8F Cerebase guide sheath  was placed within the right femoral artery, and a 5F Berenstein diagnostic catheter  was advanced within the sheath to perform a left ICA angiogram showing the 5.3mm x 3.7mm left clinoidal ICA aneurysm with irregular morphology Figure -1B.The 8F Cerebase was then advanced into the proximal cavernous segment of the left ICA to provide proximal support. A Headway-27 microcatheter  was inserted in the 8F Cerebase, and a Synchro-2 microwire  was inserted in the microcatheter, and together were advanced into the distal left M1 segment. The microwire was removed, and a 5.5mm x 22mm FRED was advanced inside the microcatheter. The device was deployed with the distal anchors in the distal left ICA with adequate coverage of the left clinoidal aneurysm. After deployment, it was noticed that the device foreshortened and was not providing adequate coverage across the neck of the aneurysm. The decision was made to place another FRED to completely cover the aneurysm. Again, the Headway-27 microcatheter along with a Synchro-2 microwire was navigated into the left cavernous ICA. At this time, it was noticed the microwire was unable to navigate beyond the proximal segment of the device. Further, inspection revealed the FRED did not completely open and, instead, appeared to be distorted in the left cavernous ICA  was inserted into the microcatheter to engage the proximal anchors of the device Video . The devPost-retrieval left ICA angiogram did not demonstrate any evidence of vessel injury. At this time, the decision was made to proceed with aneurysm treatment using a Pipeline Embolization Device . A Phenom-27 microcatheter  along with a Synchro-2 microwire was inserted into the 8F Cerebase. The microcatheter was advanced over the microwire into the left distal ICA. A 5.0mm x 20mm PED was deployed across the neck of the clinoidal aneurysm Figure -3B. PostThe case we present details a complication with device deployment that is likely related to a combination of incomplete opening of the flow diverter and foreshortening of the device after deployment. We postulate that the tortuosity in the proximal segment of the cavernous ICA and superimposed mild parent vessel stenosis in the proximal cavernous ICA provided the environment for incomplete opening of the flow diverting device. Additionally, the foreshortening of the device resulted in inadequate coverage of the aneurysm’s neck. In an attempt to provide adequate coverage of the aneurysm’s neck, the decision was made to place another FRED device distally. However, upon attempting to navigate the microwire through the FRED, we were unable to obtain distal access due to proximal distortion of the FRED. Successful retrieval of the flow diverter was performed with the utilization of a microsnare without injury to the parent vessel or aneurysmal rupture. This complication related to this flow diverter has not been reported in the literature previously and has only been reported once with the Pipeline Embolization Device , making it an exceedingly rare complication with potentially disastrous thromboembolic complications. There is insufficient experience, and therefore evidence or commentary, to discuss the benefits of the distal and proximal radiopaque markers of FRED, as well as the greater fluoroscopic visibility of the tantalum coated interwoven wires of the stent, versus the potential difficulty in deployment and risk of developing this complication. Retrieval of retained endovascular devices has been successfully reported in the literature by the use of stent retrievers and microsnares for retained low profile intracranial stents, stent retrievers, flow diverting stents, microcatheters, coils, and the Woven Endobridge device  -10. MitcWe report, to our knowledge, the first case of microsnare retrieval of a distorted FRED. This case serves to document this complication with this flow diverting device, as well as to further document the utility of microsnares in the retrieval of endovascular devices. Incomplete opening of the FRED should prompt immediate treatment to decrease the risk of thromboembolic complications.


Radioiodine (I-131) whole-body scintigraphy (WBS) is a useful modality for identifying functionally preserved thyroid tissue and metastases from differentiated thyroid cancer (DTC); however, the specificity of I-131 uptake is limited, and its accumulation in the pancreas has not been well described.18F-FDG) during subsequent 18F-FDG-positron emission tomography. A diagnosis of pancreatic metastasis from the DTC could not be excluded; therefore, local resection was performed for diagnostic certainty and treatment. Histopathology confirmed the mass to be an exophytic lymphoepithelial cyst (LEC) of the pancreas. The patient also had a transient pancreatic leak which spontaneously resolved after surgery, and he was discharged from the hospital on postoperative day 8.A 70-year-old male patient with DTC who had previously undergone total thyroidectomy (pT3N1bM0 Stage IV) received radioiodine treatment at our facility. After treatment, an I-131 WBS revealed abnormal I-131 uptake in the head of the pancreas. Computed tomography identified a round hypodense mass (10 × 20 mm) adjacent to the pancreas head that was impervious to fluorodeoxyglucose (To the best of our knowledge, this is the first reported case of an exophytic pancreatic LEC producing a false-positive result during I-131 WBS. Knowledge of all potential I-131 false-positive findings may help improve the management of patients with DTC and circumvent misdiagnoses. Radioiodine I-131) whole-body scintigraphy (WBS) is routinely used to detect remnants of functioning thyroid tissue, recurrent neoplasia, or distant metastases in patients with differentiated thyroid cancer (DTC) after undergoing postoperative radioiodine therapy 31 whole-. DTC hasIn the present case, a routine I-131 WBS of a 70-year-old patient previously diagnosed and treated for DTC revealed abnormal uptake of radioiodine in the pancreas. A hypodense mass identified near the pancreas head could not be excluded as a pancreatic metastatic neoplasm; however, pathological examination of the tumor tissue after resection confirmed a final diagnosis of pancreatic lymphoepithelial cyst (LEC). The patient recovered well with minimal surgical management. This case has been reported in line with the SCARE criteria .18F-FDG-PET). Retrospectively reviewed, the preoperative CT images before thyroidectomy showed the same lesion with slightly small size (10 × 18 mm). Serum levels of thyroglobulin (Tg) and CA 19-9 were normal . However, open surgical examination was decided to either confirm or exclude the possibility of metastasis from the original DTC.The patient in this case is a 70-year-old man who had previously undergone total thyroidectomy for papillary thyroid cancer with a pathological staging of pT3N1bM0 (stage IV). Treatment with I-131 (13.7 Gbq) commenced 11 months after initial surgery. After treatment, a routine I-131 WBS showed focal uptake in the thyroid bed and near the head of the pancreas Fig. , but no Intraoperative visual inspection revealed the cyst to be adhered to the pancreatic head. Tumor enucleation was performed, and the tumor was filled with cheesy, granular, and yellowish-white contents Fig. . The tumRadioiodine WBS is routinely used to screen for local or distant metastases in patients with DTC after having undergone thyroidectomy and subsequent radioiodine therapy . The scaThere are various possible causes of false-positivity on I-131 WBS after thyroidectomy for DTC: functional sodium iodide symporter expression in normal tissue, benign and malignant tumor, metabolism of radioiodinated hormone, retention of radioiodinated body fluids associated structural change, retention and uptake of radioiodine in inflamed tissue, contamination by physiologic radioiodine uptake , 12. Fal18F-FDG-PET [18F-FDG-PET avidity [The preoperative findings of abnormal I-131 uptake in the pancreas suggested the possible occurrence of metastatic DTC. Patients with DTC are known to experience unusual metastases; however, DTC metastasis to the pancreas is extremely rare, and only 24 cases have ever been reported in the literature . Several-FDG-PET . Relatin avidity . NeitherEctopic thyroid tissue in the pancreas may be a differential diagnosis based on the I-131 WBS findings. However, such an occurrence is exceedingly rare, and only 3 cases of intra-abdominal ectopic thyroid tissue have ever been reported at sites including the adrenal gland, gall bladder, porta hepatis, mesentery, liver, spleen, retroperitoneum, duodenum, and jejunum. Surgical resection is also commonly applied to ruling out malignancy when this rare occurrence is encountered in clinical practice –29. OverPancreatic LECs are relatively rare benign tumors; since first being described by Luchtrach and Schriefers in 1985, over 200 cases of pancreatic LECs appear in the literature, thereby accounting for approximately 0.5% of all pancreatic cysts . LECs mo18F-FDG-PET findings. Considering clinical policy for addressing pancreatic lesions, surgical resection was deemed necessary to rule out all possibilities of malignancy [Preoperative attempts at cytopathologic assessment usually involve endoscopic ultrasound-guided fine-needle biopsy (EUS-FNA) . The senlignancy , 41. In lignancy , 43. On In conclusion, we present a rare case of pancreatic LEC which produced false-positive radioiodine uptake during routine WBS of a patient previously diagnosed with DTC who had undergone total thyroidectomy and subsequent radioiodine treatment. A better understanding of the false-positivity patterns associated with I-131 WBS is critical for the proper management of patients with DTC.


A sixty-year-old man with ulcerative colitis and polymyalgia rheumatica, for which he was receiving prednisolone, visited the emergency department complaining of a gradual worsening of pain in the right buttock. Physical examination revealed mild redness and tenderness at the right side of the anus. Ultrasound revealed an approximately 38-mm long, avascular subcutaneous collection with heterogeneous echogenicity in the tender region. A perianal abscess was diagnosed, the lesion was punctured, and pus was drained, after which the pain improved. Point-of-care ultrasonography was effective in the prompt diagnosis and subsequent treatment of this patient’s perianal abscess. The prevalence of perianal abscess is estimated to be greater than 16.1 per 100,000. Risk factors include inflammatory bowel disease, smoking, human immunodeficiency virus infection, and Crohn's disease [The diagnosis of a perianal abscess is often difficult and time-consuming . PatientWe report the usefulness of point-of-care ultrasonography (POCUS), which can be used as a marker for rapid diagnosis and treatment of perianal abscesses.A sixty-year-old man with ulcerative colitis and polymyalgia rheumatica, for which he was routinely taking 20 mg prednisolone and 2000 mg mesalazine, started complaining of pain in the right buttock for five days. The patient had a history of heavy smoking. Because of the gradual worsening of his pain, he visited the emergency department of our hospital.The patient was in a recumbent position and unable to sit because of pain. The patient’s vital signs showed mild tachycardia (heart rate 108/min) and a temperature of 36.7°C. Physical examination revealed mild redness and tenderness around the anus Figure .The abscess was punctured and drained, and the patient’s pain improved promptly. He was diagnosed with a perianal abscess based on ultrasound findings and drainage of the abscess and was prescribed a daily dose of 1500 mg amoxicillin and 375 mg clavulanic acid for four days. The pain disappeared within four days. POCUS was effective in the prompt diagnosis and treatment of a perianal abscess.A perianal abscess occurs commonly in immunocompromised patients such as those with diabetes or those taking immunosuppressive medication for autoimmune conditions. Patients with a perianal abscess often lack specific physical examination findings such as erythema and tenderness of perianal skin, which makes it difficult to promptly diagnose and treat. A delayed diagnosis can lead to sepsis and fistula formation. Although perianal abscess is a disease that requires prompt diagnosis and treatment, its diagnosis is time-consuming and costly.Imaging is the first and most obvious choice of investigation for perianal abscess. Computed tomography (CT) and magnetic resonance imaging (MRI) have limitations in terms of radiation exposure and cost, whereas ultrasound has the advantages of being inexpensive and noninvasive and enabling prompt diagnosis. Compared with ultrasonography, MRI or CT costs approximately three to five times more in Japan. Therefore, our case shows that POCUS can become a popular diagnostic tool, especially in situations where CT may be inaccessible, such as in ambulatory clinics or during home visits.POCUS includes percutaneous and transanal scanning, and the latter is reported to be effective in diagnosing perianal abscesses ; howeverUsing POCUS, a perianal abscess can be diagnosed by following the methods and identifying the features mentioned below ,6. A linHowever, POCUS is limited by the difference in reproducibility and subjective difference in the level of ultrasonic procedure acquisition. Some training may be required to perform these diagnostic POCUS and therapeutic procedures accurately. However, it is much simpler than transanal ultrasound, and in this case, the ultrasound procedure was performed by a novice doctor.This case shows that POCUS is an effective diagnostic tool for perianal abscess. Therefore, with the widespread availability and cost-effectiveness of POCUS, clinicians should consider using it for the diagnosis and treatment of perianal abscesses.


Granular cell tumours of the scalp are rare. Malignant transformation of these tumours is even more uncommon, making the diagnosis exceedingly difficult. The recommended treatment of surgical excision with negative margins is not easily achieved in this location, given the anatomy of the scalp. Granular cell tumours (GCTs) are a rare form of neural derived neoplasm usually arising from Schwann cells . These tA 60-year-old man presented to a hospital with swelling on his occipital scalp in 2012. He underwent wide local excision of the mass, including the pericranium, with immediate reconstruction using a local scalp flap and a split-thickness skin graft to the donor area of the flap.Histopathological examination of the mass demonstrated features consistent with a malignant GCT: surface ulceration, dermal nests and sheets of round, polygonal and spindled cells with abundant granular eosinophilic cytoplasm with nuclear hyperchromasia and pleomorphism. Importantly, the tumour was noted to have invaded the pericranium.The patient was lost to follow-up and re-presented 3 years later with a massive fungating scalp mass . An inciIn addition to the obvious large fungating mass of the scalp, physical examination also revealed multiple cervical nodes in zones II-V on the right side; the left side was not amenable to palpation due to the presence of the mass .A staging magnetic resonance imaging study showed a heterogenous soft tissue mass in the occipito-cervical region measuring 16 × 21 cm, with no evidence of intracranial extension. A plain chest radiograph showed multiple lesions of variable sizes in both lung fields indicative of metastatic disease. An abdominal ultrasound revealed a targetoid 2.3 × 2.0 x 1.9 cm hypoechoic lesion in segment VII of the liver, suspicious for metastasis.An assessment of unresectable, terminal metastatic malignant GCT of the scalp was made and the patient recommended for palliative care.GCTs are localised mainly in the dermis, subcutis or submucosa of various locations—respiratory, digestive or urinary tract. They are predominantly benign, with only 1–2% undergoing malignant transformation .et al. include the following six findings—(i) necrosis, (ii) cellular spindling, (iii) vesicular nuclei with large nuclei, (iv) increased mitotic activity, (v) high nuclear to cytoplasmic ratio and (vi) pleomorphism [Histological features of malignant change, as proposed by Fanburg-Smith morphism , 6. A mimorphism , 6. Immumorphism .de novo or from the transformation of benign lesions is still unsettled. Chen et al. [de novo and postulated that benign lesions can undergo malignant transformation.The question as to whether GCTs arises n et al.  challengClinically, it has been noted by some authors that malignant GCTs behave in a very aggressive manner, similar to high-grade sarcomas .Malignant GCTs typically grow rapidly, often ulcerate, invade locally and tend to spread with extensive metastases; mainly to the lymph nodes, lungs and bones and rarely to the intestines, liver and brain. The aim of treatment for malignant GCT is complete surgical excision, where possible. There is no established role for chemotherapy or radiotherapy .In the index case with the extent of the scalp mass and metastases to the lymph nodes, lungs and liver, the treatment option was only one of palliation. After review by a multidisciplinary tumour board, we accepted the view of the oncologist that we attempt palliation as is done for sarcomas, which these tumours mimic in behaviour. The patient was therefore started on a course of pazopanib, a potent and selective multi-targeted receptor tyrosine kinase inhibitor that blocks tumour growth and is approved for soft tissue sarcoma treatment. However, there was no response to the drug and the patient soon demised.Malignant transformation of GCTs is exceedingly rare with less than a hundred cases reported in the literature. In addition, the scalp is a rare anatomical site for GCTs in general with only one other case reported in the literature which was benign . This reNone declared.None.


Introduction: Benign cardiac tumors and tumor like conditions are a heterogeneous collection of mass lesions that vary widely in their characteristics, such as presentation, size, and location. In some instances, these tumors are found incidentally, and therefore a broad differential diagnosis should be considered.Case: An elderly male with significant unintentional weight loss and a high risk for cancer presented with an incidental valvular cardiac mass. The mass was thought to be a non-bacterial thromboendocarditis on initial clinical evaluation. After multiple imaging modalities, the mass was suspected to be a papillary fibroelastoma (PFE), which was resected due to high stroke risk and multiple previous chronic infarcts on brain MRI.Conclusion: This case highlights the need for a comprehensive cardiac evaluation of a valvular tumor to discern the etiology and rule out other underlying pathophysiological processes that may require alternative interventions to cardiac surgery. Benign cardiac tumors and tumor-like conditionsare a heterogeneous collection of mass lesions that vary widely in location, appearance, size, and presentation. In some instances, the presentations are similar and therefore, a comprehensive assessment would be needed to discern the exact etiology and rule out other etiologies that may require alternative interventions to cardiac surgery.Written informed consent was obtained from the patient for the publication of any potentially identifiable images or data included in this article.A 73-year-old male smoker presented for the evaluation of a cardiac mass that was diagnosed incidentally on a CT abdomen and thorax. The CT was originally ordered as part of a workup for unintentional 35-lb weight loss over 4 months (240–205 lb). The CT reported an 8-mm polypoid aortic valve along with moderate emphysematous changes in the lungs and several pulmonary nodules (3 mm in size).He denied any loss of appetite, change in diet, fever, chills, sweating, or other constitutional symptoms. The patient reported adequate functional capacity, exercising twice per week. He also denied any symptoms. The patient provided consent for this case report.The patient had a history of hereditary hemochromatosis, right carpal tunnel syndrome (treated by surgery), and recently resected early-stage bladder cancer. He also reported a history of severe osteoarthritis treated by surgery and a remote history of basal cell carcinoma on his upper lip that was also resected. Colonoscopy 2 years ago was normal.Papillary fibroelastoma (PFE), healed vegetation, subacute bacterial endocarditis, myxoma, multiple large lambl's excrescences, or non-bacterial thrombotic endocarditis (NBTE) due to occult malignancy or antiphospholipid syndrome.Laboratory testing revealed mildly elevated hsCRP levels 4.6 ml/L , ESR 38 mm/h, NT-Pro BNP 270 ng/ml , and D-dimer 522 ng/ml . Other blood studies, such as complete blood count, basic metabolic panel, coagulation studies , and alpha-fetoprotein were normal. Blood cultures were also negative. The antiphospholipid antibody, B-2 glycoprotein, and special coagulation studies were all negative.On TEE done at our institution, we identified one large (1.7 × 1.1 cm) mass on the aortic side of the aortic valve, between the non-coronary and left cusp at the base, that is attached by a stalk , likely Brain MRI showed focal encephalomalacia with surrounding FLAIR/T2 hyperintensity that likely reflects gliosis involving the posterior inferior right cerebellar hemisphere, most consistent with effects of chronic infarction, and multifocal chronic-appearing lacunar infarcts involving the cerebellar hemispheres and right parietal lobe.With the patient's extensive cancer history and to rule out possible lung cancer, an FDG-PET was performed. The study was normal, and no uptake was seen to correlate with the cardiac masses.Pre-operative CT cardiac angiogram with contrast confirmed the presence of the lobular mass and its stalk on the non-coronary cusp, also revealing a more subtle thickening of the left aortic cusp with a more subtle nodule along its ventricular surface, and some thickening more prominent along the ventricular surface of the non-coronary cusp . 3D recoGiven the high suspicion of NBTE and even after the negative workup for cancer, the patient was given 6 weeks of apixaban 5 mg BID to see if the masses would regress, which they did not, based on the follow-up echocardiographic assessment. After discussion with the patient and given the presence of a highly mobile mass on the aortic valve combined with the suspicion of silent emboli on brain MRI, the decision was to excise the mass.Pre-bypass TEE confirmed the presence of the mass (no change in size). During surgery, there was one large mass attached to the non-coronary cusp which was about 1.1 cm in diameter. There was a medium size mass attached to the non-coronary cusp which was 2 mm . There wGross and microscopic images are shown in This case makes the important point, that suspected PFE has a differential diagnosis that includes thrombus, and in this age group, NBTE related to cancer is raised as associated with lupus and or antiphospholipid antibody syndrome, and subacute endocarditis. Moreover, it emphasizes how judicious use of imaging can be critical in planning a successful intervention with valve preservation.The current report describes the case of an elderly male with high cancer risk, due to cancer history and smoking, presenting with weight loss and a cardiac mass. The differential diagnosis for a cardiac mass/vegetation is broad, but only NBTE was previously associated with cancer. However, as we show in this case report, it is important to keep a broad differential until further investigations are done since neither of the differentials is a clinical diagnosis.Papillary fibroelastoma is being recognized as the most common primary cardiac tumor , 2. EdwaT. whipplei. In our patient, a PET was also done to exclude underlying malignancy. Treatment of NBTE usually consists of systemic anticoagulation and treating the underlying condition. Excision of the vegetation may have a role in some patients who do not have advanced malignancy.Non-infectious lesions of heart valves, first described as Libman-Sacks, goes by multiple other names, such as NBTE, verrucous endocarditis, or marantic endocarditis . It descCardiac imaging workup for the two pathologies is similar. A TTE is the mainstay imaging modality to describe the vegetation/mass. A TEE should also be considered to discern the details of the vegetations/mass, especially for smaller masses (<5 mm). Papillary fibroelastoma has a typical look of a pedunculated mass with small fronds and a stalk. Non-bacterial thromboendocarditis are usually broad, small (<1 cm), and irregular. In certain cases when the stalk is not visible, or not found, the PFE may look like an NBTE, warranting a TEE or another modality. CT or MRI may also be used to further assess the mass and plan the surgical approach. However, the utility of MRI for cardiac mass work up is not established in literature and echocardiography is still the gold standard due to the high mobility of these masses.Conclusive diagnosis of either disease is only done through pathological examination of the surgical specimen. A PFE mass is white and fibrous, consisting of endocardial fronds surrounding an avascular collagenous core. An NBTE vegetation consists mainly of immune complexes, mononuclear cells, fibrin, and platelet thrombi.This case highlights the need for a comprehensive cardiac evaluation of a valvular tumor to discern the etiology and rule out other underlying pathophysiological processes that may require alternative interventions to cardiac surgery.To be able to consider the wide differential diagnosis of valvular masses.To learn multiple possible steps in approaching a valvular tumor.The original contributions presented in the study are included in the article/Written informed consent was obtained from the patient for the publication of any potentially identifiable images or data included in this article.AAh, EE-A, and RK, were involved in collecting the data, analyzing them, and writing the report. AAr, TF, and KK were involved in patient care, supervising the case report, and providing a critical review of the written case report. TF was involved in the construction of the 3D model provided in the case. All authors contributed to the writing and revision of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Chondrosarcoma of the cranium is a rare malignancy. The result of treatment is challenging to assess because the slow-growing rate means that there is a long interval previously discovering the recurrence and last long time to diagnosis of recurrence. This report describes a 38-year-old man who presented with a generalized seizure 2 months before his referral. The patient underwent excisional surgery. The histological examinations revealed a cartilage developing tumor compatible with chondrosarcoma. The radiologic and histologic correlation established the diagnosis. But, the patient had two episodes of recurrence after surgery. We determined that intracranial chondrosarcoma must be comprised in the differential diagnosis of a mass with calcification on cranial imaging. Accurate diagnosis is obligatory for supplementary patient managing, and a recurrence is more common in patients only treated by surgery. Chondrosarcoma is the second common primary malignancy of bone, ascending from chondrocytes origin through the axial and appendicular skeletal system . The patA 38-year old male was referred to the department of neurosurgery in Sina hospital affiliated with Tehran University of Medical Sciences, Tehran, Iran, with a history of generalized seizure from 2 months before his referral. At first, outpatient examination findings were unremarkable. The patient’s family history and past medical history were none. General examination was negative. Routine laboratory investigations were the normal limit. The patient underwent a brain computed tomography (CT) scan, which showed a heterodense mass with a calcified component in the right frontoparietal region, causing erosion of frontal bone on non-contrast imaging . The posDiagnosis needed histopathologic investigation. The patient underwent excisional surgery. Through the pathology description, it was discovered that neoplastic tissue consisted of a well differentiated chondroid component with lobular architecture. Also, there were no mitotic figures and necrosis . The finThe occurrence of benign bone and cartilage neoplasms is mainly unclear due to the lack of reporting as well as failure to present clinically . Three sThe current basis of handling is surgical resection which is well surveyed by adjuvant radiation therapy. Chemotherapy has been predominantly ineffective for chondrosarcoma because there is a deficiency of targeted therapies . Re-growChondrosarcoma in the cranial area is rare, but they must be careful in the differential diagnosis of various cranial masses. Difficulties in the differential diagnosis might occur in connection with an extraordinary setting. They reveal common unexpected clinical signs that, to conclude, lead to inadequate treatment. It is our hope that with such reports, we are able to reduce the effects of individual surgeons and individual foundation bias on the outcome of these patients, in that way making a more independent protocol for physicians and patients in the future management of these tumors.None.None.


Enteric duplication cysts are rare congenital anomalies that present with a vague constellation of symptoms such as vomiting and abdominal distension. Of these, cystic nontubular jejunal duplication cysts comprise an exceedingly small subset. Here, we delineate the case of a two-month-old female baby who presented with symptoms suggestive of acute intestinal obstruction. Radiological workup divulged a cystic lesion, which was subsequently confirmed to be a cystic nontubular jejunal duplication cyst with extensive intestinal wall sharing. Surgical excision was planned but posed a remarkable surgical challenge due to intestinal wall sharing and the cyst’s exceedingly fibrotic nature. Gastrointestinal (GI) tract duplication cysts are rare congenital malformations that can occur anywhere within the GI tract. Their prevalence is noted to hover around one in 25,000 deliveries . The dupA two-month-old female baby presented to the emergency department with a two-day history of bilious vomiting, constipation, and abdominal distension, suggesting possible intestinal obstruction. This presentation was on a background of intermittent episodes of bilious vomiting and a prior neonatal abdominal ultrasound remarkable for an underlying ovarian cyst, obscuring the current diagnosis. At the time of presentation, her symptoms included bilious vomiting, colic, constipation, and abdominal distension. Physical examination revealed a dehydrated and lethargic child who was underweight and visibly anemic. Pertinently, the abdomen was noted to be distended and a mass was palpable predominantly within the left hemiabdomen. The mass appeared mobile and nontender upon palpation. Based on the clinical picture and the patient’s past history of an ovarian cyst, a differential diagnosis including an ovarian cyst, duplication cyst, and mesenteric cyst was deemed plausible.An abdominal radiograph was performed that showed a distended proximal bowel, with a generalized haziness in the abdomen. A subsequent CT scan revealed an exorbitant left-sided cystic lesion, obstructing the proximal intestine, the origin of which could not be ascertained Figure .The patient underwent resuscitation and blood transfusion, followed by an exploratory laparotomy performed through a left supraumbilical transverse incision. Upon laparotomy, a huge cystic lesion along the jejunal wall, about 25 cm from the duodeno-jejunal junction, was appreciated (Figure Imperatively, the cyst was noted to share the jejunal wall, thereby causing jejunal obstruction and posing a remarkable surgical challenge as the adjacent wall had to be sacrificed. Therefore, an intraoperative diagnosis of a jejunal duplication cyst was made. Due to the extensive wall sharing and the fibrotic nature of the cyst, resection of the cyst and the adjacent jejunum was performed Figure .Thereafter, an anastomosis of the jejunum was performed simultaneously using a longitudinal GI anastomosis stapling device Figure .The baby demonstrated a smooth postoperative recovery. She was kept on total parenteral nutrition for four days, after which the transition to oral nutrition was made. Her bowel function remained intact. She was discharged on the seventh postoperative day and continues to do well to date.GI tract obstruction remains one of the most frequent causes of postnatal admission to pediatric surgery units, with the most common causes being anorectal malformations, esophageal obstruction, and duodenal obstruction, with incidence rates hovering at 41%, 24%, and 20%, respectively . A myriaWhile the pathophysiology underlying jejunal duplication cysts remains esoteric, it is generally thought that these cysts represent a structure closely tethered to the jejunum with surrounding smooth muscle and an epithelial lining . Due to EUS is the diagnostic tool of choice for the investigation of all duplication cysts, and in some cases, is combined with fine needle aspiration of the cyst to obtain a definitive diagnosis and rule out other more serious pathologies, including potential underlying malignancies . Other dIn our case, the jejunal cyst was noted to share a common intestinal wall, rendering it a considerable surgical challenge to safely resect the cyst alone. Furthermore, upon deflation, the cyst appeared exceedingly fibrotic, necessitating the excision of the adjacent jejunal wall. A complete resection and side-to-side anastomosis was thus performed. As duplication cysts amplify the chances of late malignant transformation, complete excision should be ensured . HoweverCystic nontubular jejunal duplication cysts are an exceedingly rare subdivision of enteric duplication cysts and can sometimes share a common wall within the GI tract. In such instances, complete resection can be a considerable surgical challenge, often necessitating the excision of the adjacent intestinal tissue. Due to their malignant potential and symptomatic presentation, complete excision remains necessary but exceedingly difficult in the context of preserving normal bowel function.


We report the case of a patient with recurrent episodes of disturbed memory suggestive of transient epileptic amnesia, and a focal hippocampal lesion typically associated with transient global amnesia. We argue how careful consideration of clinical, electrophysiological and imaging findings can resolve this apparent contradiction and lead to a diagnosis of early symptomatic post-stroke seizures that links brain structure to function in a new, clinically relevant way.A 70-year-old patient was identified in clinical practice in our tertiary care centre and was evaluated clinically as well as by repeated electroencephalography and magnetic resonance imaging. The presenting complaint were recurrent episodes of short-term memory disturbance which manifested as isolated anterograde amnesia on neurocognitive evaluation. EEG and MRI revealed predominantly right frontotemporal spikes and a punctate diffusion-restricted lesion in the left hippocampus, respectively. Both symptoms and EEG changes subsided under anticonvulsant treatment with levetiracetam.Our report contributes to the current discussion of clinical challenges in the differential diagnosis of transient memory disturbance. It suggests that focal diffusion-restricted hippocampal lesions, as seen in TGA, might be ischemic and thus highlights the importance of considering post-stroke seizures as a possible cause of transient memory disturbance. Differential diagnoses for atraumatic temporary memory loss include cerebral ischemia, transient epileptic amnesia (TEA), and transient global amnesia (TGA). Diagnostic criteria for TEA are recurrent short episodes of disturbed memory; sparing of other cognitive domains; and clinical or electroencephalographic (EEG) evidence of seizure activity or response to anticonvulsant medication . Memory 1-hypointense and rather hyperintense in FLAIR images  revealed a persistent anterograde amnesia with no further cognitive impairments (score 26/30). Routine blood tests and computed tomography of the head were unremarkable. Initial electroencephalography after spontaneous resolution of symptoms showed intermittent right frontotemporal spikes followed by slow waves. They were preceded by intermittent beta waves and low-amplitude spikes in the left temporal region Fig. A; diffusDespite their definition as distinct phenotypes of transient memory disturbance, differentiation between TGA and TEA can be challenging. When clinical features are inconclusive, diffusion imaging and EEG may aid diagnosis. Their usefulness is limited, however, by the facts that the appearance of characteristic lesions in the hippocampus in TGA is often delayed  and thatConflicting positive findings, on the other hand, also present challenges. Arguing that the lesion in our patient was too circumscribed to be a postictal phenomenon, and ignoring the possibility of a coincidental finding, it follows that it played a causal role for his symptoms. While TEA is usually idiopathic, a small number of symptomatic cases caused by focal lesions in the temporal lobe have been reported previously . Diffusi1-intensity are unusual for TGA. Considering the high frequency of recurrent amnesic episodes and consistent EEG changes thus led us to the diagnosis of early post-stroke seizures.In the presented case, imaging was consistent with both a recent ischemic infarct and a TGA lesion, although the posterior location in the hippocampus and low TWe suggest that this differential be considered in cases of transient amnesia with a suspicious lesion in the hippocampus, especially if symptoms recur or are associated with epileptiform discharges on EEG, as it might inform secondary prevention and influence the medical management of the patient.


Case Description. A 7-month-old, previously healthy male presented with a thoracic scoliosis and an asymptomatic right midupper thoracic spinal prominence present since birth. MRI revealed an extensive heterogenous mass in the right epidural space from T5-T6 and the right paravertebral space, resulting in severe spinal stenosis. Outcome. Complete resection of the tumor, including a three-level neurotomy, was achieved by posterior decompression/laminectomy. The final tumor was consistent with a mature teratoma. The surgical resection was performed without any immediate complications.  Teratomas in the pediatric population are most commonly found in the sacrococcygeal region. Pediatric intraspinal teratomas, however, are an exceedingly rare central nervous system (CNS) neoplasm. The clinical presentation of these intraspinal neoplasms can vary significantly and thus can be difficult to identify in infants less than one year of age where verbal expression and motor development are still lacking.  Extramedullary epidural teratomas are exceptionally rare tumors in the pediatric population. Clinical presentation can be ambiguous, particularly in an infant. MRI was useful in suggesting a teratoma as a potential diagnosis and for postoperative surveillance for recurrence. However, histopathological analysis remains the gold standard for definitive diagnosis. Surgical resection is the mainstay of treatment, especially in the setting of cord compression and progressive loss of motor function. Close follow-up is crucial to monitor for progressive spinal deformity or recurrence. Neoplasms of the central nervous system (CNS) are the second most common malignancy in the pediatric population . HoweverOf the various histological subtypes comprising spinal cord neoplasms, spinal teratomas account for a relatively small percentage. In general, teratomas are germ cell tumors that are an amalgamation of highly differentiated, mature tissues—these frequently contain all three germ cell layers . Most coIntraspinal teratomas can be found in both extramedullary and intramedullary locations of the spinal cord. Various studies have described intramedullary and extramedullary intradural teratomas in the pediatric population. However, fewer studies exist examining spinal teratomas in epidural locations . Here, wA 7-month-old, previously healthy male was referred for an initial consultation and evaluation to the neurosurgery clinic of a large children's hospital for a congenital deformity of the spine and an asymptomatic right midupper thoracic spinal prominence present since birth. All subsequent care, including imaging, biopsy, histology, and surgery, was performed at the same institution. He was delivered at term via cesarean section secondary to breech presentation. The patient had met all developmental milestones with no noticeable complaints of pain or neurological deficits.His neurological exam revealed no motor or sensory deficits in the upper or lower extremities bilaterally. Cranial nerve testing, muscle tone, and deep tendon reflexes were intact. Visual inspection was significant for slight curvature of the spine with no spinal dysraphism or midline stigmata.Imaging was subsequently performed to evaluate the spinal prominence noted on physical exam. Plain films of the thoracic spine demonstrated levoscoliosis and an additional osseous projection from the right posterior aspect of the midthoracic rib segment .Magnetic resonance imaging (MRI) of the cervical, thoracic, and lumbar spine revealed a multilobulated, partially cystic, calcified, heterogenous mass centered at the right (T5-T6) paravertebral space extending anteriorly into the dorsal aspect of the intrathoracic cavity , right dThe patient underwent open tumor excision and posterior decompression/laminectomy (T3 to T10) due to tumor magnitude. Neuromonitoring was used throughout the case; baseline motor signals were absent at the beginning of the case. During the procedure, three nerve rootlets  on the right were found penetrating through the tumor, and a three-level neurotomy was performed. The rest of the tumor was gently teased from the dura. Additionally, there was some retropleural extension into the right chest cavity. This was resected as well. Given the location of the tumor, biopsy results, and clinical picture, goals of surgery were to obtain as close to negative margins as possible. During the procedure, multiple specimens from various sites were sent for frozen histopathological analysis. These all came back consistent with mature teratoma, without any malignant features. As the tumor itself was teased off the dura, pleura, and other surrounding structures, true negative margin surgery would have been associated with significantly more morbidity. Considering benign histology, the decision was made to preserve as much function as possible and to proceed to closely monitor for recurrence post-operatively.Histologically, the tumor revealed skin with adnexal structures and keratinous debris, cystic spaces lined by ciliated and mucinous epithelium, neuroglial tissue, bone with bone marrow, cartilage, and mature fibro-adipose soft tissue. Mature fibrovascular soft tissue, granulation tissue, and a few bone foci were noted at the inked margins of excision. The final pathological diagnosis was consistent with a mature teratoma Figures  and 4.At the end of the surgical procedure, neuromonitoring reported a partial return of motor activity from a baseline of no activity. The patient tolerated the procedure well and was transferred to the pediatric intensive care unit (PICU) postoperatively for further management. He was transferred to the floor on postoperative day 1 and discharged on postoperative day 2. He returned for a follow-up visit at 1.5 weeks in a thoracic-lumbar-sacral orthosis (TLSO) brace and received full-length plain radiographs . His motAt his 8-week postoperative visit, he remained in a thoracic lumbar sacral orthosis (TLSO) brace and continued to show improvement in lower extremity strength and ability to maintain posture. At his 6-month and 1-year postoperative visits, the patient was doing well and had progressed to crawling, cruising, and walking. He demonstrated 5/5 strength in both upper and lower extremities throughout all muscle groups. No recurrence of the tumor was noted on repeat plain radiographs, nor at one- or two-year follow-up MRI. At 1- and 2-year follow-up, he had 20-degrees of scoliosis, without any residual neurological deficits. The plan will be for continued bracing, likely until skeletal maturity to slow curve progression. He will continue to have annual follow-up through adolescence to monitor for progressive spinal deformity with plain radiographs, as well as yearly surveillance MRI through 5-year follow-up, and then will decrease frequency to every 2-3 years.Intraspinal teratomas within the pediatric population represent an exceptionally rare clinical entity. While several case reports and studies documenting intraspinal teratomas have accumulated over time, the large majority of these tumors have been observed in intramedullary or extramedullary intradural locations –16. AccoThe clinical presentation of intraspinal tumors can vary significantly and can be difficult to identify in the pediatric population, since complaints are often vague and symptoms nonspecific. Pain is a common presenting symptom of intraspinal tumors, followed by weakness and gait disturbance , 3. HoweBased on heterogenous composition of tissue types within teratomas, several imaging findings are suggestive of a spinal teratoma. MRI of the spine performed in our patient displayed a heterogenous tumor, which was multilobulated, partially cystic and calcified. Despite these findings and advancements in imaging technology, distinguishing between tumor types on imaging studies is unreliable , 18. HisThe primary treatment of intraspinal tumors is surgical resection. In particular, microsurgical dissection, involving laminectomy or laminotomy with tumor resection and nerve root and/or spinal cord decompression, is the standard means for surgical treatment of intraspinal tumors . DependiManagement after resection will involve close clinical and radiologic follow-up and continued bracing, as the authors have concern for the long-term development of a progressive deformity. A recent retrospective review of 272 cases of intracanal tumor resection found the incidence of postoperative progressive spinal deformity to be 15.8% . This ocExtramedullary epidural teratomas are exceptionally rare tumors in the pediatric population. Clinical presentation can be ambiguous, particularly in an infant. MRI was useful in suggesting a teratoma as a potential diagnosis and for postoperative surveillance for recurrence. However, histopathological analysis remains the gold standard for definitive diagnosis. Surgical resection is the mainstay of treatment, especially in the setting of cord compression and progressive loss of motor function. Close follow-up is crucial to monitor for progressive spinal deformity or recurrence.