The sellar region represents a complex anatomical area, composed of multiple structures of different embryological derivation, including the skull base and the pituitary gland, along with vascular, nervous, and meningeal structures. Masses arising in this region include benign and malignant lesions arising from the pituitary gland itself, but also from vestigial embryological residues or surrounding tissues, that may require different therapeutic approaches. While assessing sellar region masses, the combination of clinical presentation and imaging features is fundamental to define hypotheses about their nature. MR represents the imaging modality of choice, providing information about the site of the lesion, its imaging features, and relation with adjacent structures, while CT is useful to confirm the presence of lesion calcifications or to reveal tumor invasion of bony structures. The aim of this pictorial review is to provide an overview of the common neoplasms and tumor-like conditions of the sellar region, according to the 2021 WHO Classification of Tumors of the Central Nervous System (fifth edition), with an emphasis on the radiologic-pathologic correlation. After a brief introduction on the anatomy of this region and the imaging and pathological techniques currently used, the most relevant MRI characteristics, clinical findings, and pathological data, including histologic and molecular features, will be shown and discussed, with the aim of facilitating an appropriate differential diagnosis among these entities. The sellar region represents a complex anatomical area that includes the bony framework of the central skull base, the pituitary gland, and a series of vascular, nervous, cerebrospinal fluid (CSF), and meningeal structures surrounding it. Therefore, a neoplastic or tumor-like mass in this region can originate from any of these elements, and this explains the wide variety of differential diagnoses that can be postulated.The classification of sellar region tumors is constantly evolving, with the current reference , that introduces some changes to previous editions . DiagnosGiven the relative anatomical complexity of this region, and the recent release of the latest classification of CNS tumors, the aim of this review is to provide a review of the anatomy, imaging techniques, and most relevant MRI characteristics of neoplasms and tumor-like lesions involving the sellar region, together with clinical findings and pathological data, to help neuroradiologists in achieving an appropriate differential diagnosis among these entities.The sella turcica is a saddle-shaped depression on the basisphenoid. The borders of this anatomical structure are defined anteriorly by the middle clinoid processes , while the posterior border is formed by the dorsum sellae which ends at its superior angles with the posterior clinoid processes Fig. . The selThe sella turcica harbor the pituitary gland, a bean-shaped gland with two distinct lobes: the anterior lobe, also called the adenohypophysis, and the posterior one named neurohypophysis Fig. . The antThe gold-standard imaging modality for sellar region assessment is undoubtedly MRI, that should be performed on high-field scanners (1.5 T or higher) with a multi-channel head coil allowing for parallel imaging. Standard MR protocol should include turbo spin echo (TSE) T1- and T2-weighted sequences acquired on both the sagittal and coronal planes, using a small (13–18 cm) field of view (FOV) with a slice thickness less than or equal to 3 mm, with axial images that might provide additional information on lesion morphology and extension in selected cases.Gadolinium-based contrast agent administration is always recommended in the characterization of neoplasm or tumor-like lesions of the sellar region, followed by TSE T1-weighted sequences similar to those acquired prior to the contrast administration; furthermore, in a few conditions, it may not be necessary, such as the growth and puberty disorders (GPD) in the pediatric population . DynamicOptional sequences that can be acquired for the study of the sellar region include diffusion-weighted imaging (DWI), susceptibility-weighted imaging (SWI), volumetric high-resolution T1- and T2-weighted sequences, and MR angiography (MRA). In particular, DWI provide information about lesion cellularity, by measuring water molecule diffusion movements, and recent studies have shown that apparent diffusion coefficient (ADC) values correlate with tumor consistency and proliferative index in PAs, even if these data require further validation , 12. NevPerfusion-weighted imaging (PWI) can provide additional information helpful in differential diagnosis of sellar/parasellar tumors. Indeed, although both PAs and meningiomas are lesions with a significant vascularization, meningiomas show significantly higher relative cerebral blood volume values compared to PAs . FurtherAlthough MRI represents the imaging gold-standard for the diagnosis of sellar lesions, CT might provide supportive information regarding the anatomy of the sphenoid bone and sinus, also revealing and depicting the degree of tumor invasion of adjacent bony structures. Furthermore, the acquisition of CT images might confirm the presence of lesion calcifications suspected using SWI sequences. Finally, CT angiography might help in better describing the relationships between intracranial arteries and the lesion, and a CT of the brain may still be helpful in the emergency room to exclude the presence of an acute pituitary hemorrhage.The first and probably most important question a pathologist should answer is whether the observed sample contains tissue from a normal pituitary gland or not. Although in typical cases PA morphology is straightforward, and is therefore relatively easy to achieve a correct diagnosis, unusual morphological patterns might be present for other lesions  and might therefore cause diagnostic concerns . In theA particular setting is the evaluation of a lesion immunonegative for all the pituitary markers such as hormones and transcription factors, but positive for neuroendocrine markers, raising the possibility of a differential diagnosis between a null cell adenoma and metastatic neuroendocrine carcinoma. In those cases, lesion morphology, mitotic activity, and lineage differentiation markers  might help in making a correct diagnosis. However, it must be kept in mind the possibility of the presence of relatively rare and highly debated entities such as the primary intracranial neuroendocrine carcinoma arising in sellar region (which is TTF1−) or the small cell carcinoma of unknown primary  .Finally, lesions purely cystic or with some cystic components  rarely represent a diagnostic dilemma from a pathological standpoint, given the relation between their clear morphology and typical radiological features. In this light, it is noteworthy to stress that the cystic appearance is a phenomenon clearer to neuroradiologist rather than to pathologist.PAs, that following the 2021 WHO Classification of Tumors of the Central Nervous System are now known as PitNETs, represent the most common masses of the sellar region in adults arising from the adenohypophysis , with a In the revised 2021 classification based on cell lineage, immunohistochemical analysis and transcription factors, PitNETs can also be classified arising from three cell lineages: TPIT (corticotroph), PIT1 , and SF1 (gonadotroph) lineage tumors, which can be clinical functioning or silent . PIT1 isOn MRI, PAs generally present as sellar or intra- and suprasellar masses not clearly separated from the pituitary gland Figs.  and 3. GLow T2-weighted signal intensity is typical of densely granulated somatotroph adenomas, that are more responsive to somatostatin analogs . EctopicHistological examination reveals a tumor with solid growth pattern, in some areas composed of elongated cells arranged in a perivascular fashion. True papillae with fibrovascular core can also be appreciable.Common differential diagnoses of PAs include pituitary hyperplasia, meningioma, metastasis, craniopharyngioma, and hypophysitis.Furthermore, in some cases, the enlargement of the pituitary gland due to intracranial hypotension syndrome might be misinterpreted as a PA . With reAdvanced imaging techniques, such as MR elastography and textural analysis, have shown potential in predicting tumor consistency and treatment response before surgical resection . The thePituitary blastoma is a rare embryonal neoplasm arising from the fetal adenohypophysis, recently added as in the new 2021 WHO classification . From anCraniopharyngioma (CP) is a benign slow growing (WHO grade 1) sellar/suprasellar neoplasm that arises from the epithelial remnants in the anterior part of Rathke pouch at the infundibular stalk juncture with pituitary gland . AccordiACP is significantly more common than PCP , and is usually more prevalent in children, although a bimodal age distribution has been observed with a first peak incidence between 5 and 15 years of age and the second ranging from 45 to 60 . It freqOn imaging, ACP typically presents as a multilobulated mixed cystic-solid lesion, partially calcified, usually with supra- and/or infradiaphragmatic extensions and finger-like projections into neighboring structures . Cystic On histology, the hallmarks of ACP are keratin deposits , surrounded by loose textured cells known as “stellate reticulum,” thought to derive from degeneration of internal cells. The cords and islands of well-differentiated squamous epithelium surrounded by palisading columnar epithelium are distinctive and diagnostic features of ACP . In somePCPs occur almost exclusively in adults at 45–60 years of age, with symptoms similar to those described for ACPs and mainly related to their mass effect such as headache, visual disturbance and hydrocephalus, as well as endocrine deficit . On MRI,Pathological examination shows the presence of a well differentiated squamous, non-keratinizing epithelium, lining a fibro-vascular core .For both ACP and PCP, surgical resection with open or endoscopic endonasal approaches represents the primary treatment . A cyst Intracranial germ cell tumors (IGCTs) are a heterogeneous group of rare pediatric neoplasms, with peak presentation at 10–14 years of age and a peculiar predilection for the midline, with pineal, and suprasellar region involvement . The firOn the other hand, NGGCTs are usually larger than germinomas, often causing obstructive hydrocephalus, and show the presence of spontaneous T1-hyperintense foci with a moderate lesion enhancement. On CT, germinomas are uniformly hyperdense, while NGGCTs appear more inhomogeneous, with particular reference to mature teratomas that appear as mixed density lesions with large cysts and areas of calcification.In the presence of a pineal mass, the differentiation between IGCTs and pineoblastoma is not easy, because of their similar density and signal intensity, as well as the shared presence of cystic components. Nevertheless, the bifocal presentation is highly suggestive of IGCTs.On histology, germinoma appears as a neoplasm composed of large-size, polygonal cells arranged in lobules or “sheets,” with vesicular nuclei having conspicuous nucleoli. A chronic lymphoplasmacytic infiltrate can be visible, especially in perivascular areas, with tumor cells are immunoreactive for PLAP, c-KIT, and negative per CK-pan and S100 protein .With reference to treatment, germinomas are significantly radiosensitive and responsive to chemotherapy treatments . Mature Primary posterior pituitary tumors (PPTs), in the revised definition of the 2021 WHO classification, are rare slow-growing neoplasm (WHO grade 1) of middle-aged adults, that arise from different morphological variants  of the pituicytes of infundibular stalk and neurohypophysis and representing a spectrum of the same entity. They typically show immunopositivity for the thyroid transcription factor-1 (TTF-1) and include pituicytoma (PC), spindle cell oncocytoma (SCO), granular cell tumor (GCT), and sellar ependymoma (SEP) .The main clinical manifestations resemble that of NFPAs and include visual defects, hypopituitarism, and headache. Diabetes insipidus is uncommon. Acute presentation with pituitary apoplexy is extremely rare . CT usuaPC is predominantly composed of bipolar spindle cells arranged in solid sheets and short fascicles, with elongated nuclei and abundant cytoplasm, often organized in fibrillary, anucleate areas. In some areas can be present more epithelioid cells with clear-cell cytoplasm. The strong and diffuse S100 immunoreactivity can lead to a misdiagnosis of schwannoma (TTF1−). SCO has a solid architecture, composed of interlacing fascicles of fusated and epithelioid cells, with mild pleomorphic nuclei, prominent nucleoli, and eosinophilic to oncocytic cytoplasm. On immunohistochemistry tumor cells are S100+, TTF1+, vimentin+, EMA−, GFAP−, and negative for all pituitary hormones.PPTs are often misdiagnosed before surgery and the most common radiological preoperative diagnosis is a PA. Differential diagnoses also include CP, germinoma, lymphocytic hypophysitis, histiocytosis, neurosarcoidosis, and metastases.Complete resection is important to prevent tumor recurrence but is often challenging due to the fibrous and vascular nature of these tumors, and most patients require revision surgery and/or adjuvant radiotherapy. The optimal management strategy includes therapeutic presurgical angiography with tumor feeders’ embolization to reduce intraoperative bleeding, and subsequent gross total resection via craniotomy or endoscopic transsphenoidal surgery. Anti-VEGFR therapy and somatostatin analogs could be a potential option for the treatment of PPTs .Hypothalamic hamartomas (HHs) represent nonneoplastic congenital gray matter heterotopia arising from the tuber cinereum, a hypothalamic region located between the mammillary bodies and the infundibulum. It is related to neuronal migration abnormalities which probably occur between gestational days 33 and 41 . The sizMR imaging accurately depict this entity, showing a sessile or pedunculated mass mainly isointense to the gray matter centered in the tuber cinereum region, without contrast enhancement Fig. .Fig. 13HThe major differential diagnosis is represented by hypothalamic-chiasmatic glioma, which tends to be T1-hypointense and T2-hyperintense, often showing contrast enhancement.HHs management may require surgery in drug-resistant seizures. Central precocious puberty is successfully treated with pharmacological therapy as luteinizing hormone-releasing hormone agonists.Rathke cleft cyst (RCC) is a benign lesion located within or above the pituitary gland, arising from remnants of the fetal Rathke pouch . These lCT is useful for diagnosis, showing a well-demarcated round or ovoid intrasellar-suprasellar mass located at the midline between the anterior and posterior pituitary lobes. RCCs usually appear homogeneously hypodense (75% of the cases), less frequently mixed hypo-isodense (20%) and hyperdense (10%), without calcifications. They may show ring-like or capsular enhancement. MR signal depends on the cyst content. On T1-weighted images, RCCs may present both hypo- or hyperintense; on T2-weighted sequences, about 70% appear hyperintense while 30% are iso-to-hypointense . An almoOn histology, RCC shows small fragments of fibrovascular stroma, partially lined from pseudostratified columnar epithelium, resembling that of respiratory tract, with intermingled goblet cells.Main differential diagnoses include CPs and PAs. CPs often show enhancing solid components and calcifications, not present in RCCs. On the other hand, intracystic nodule, midline location within the gland, no fluid-fluid level, and no septation may help differentiate RCCs from PAs.RCCs are usually stable “leave me alone” lesions with a good prognosis. Surgical treatment may be required in case of symptomatic lesions or diagnostic doubts.Arachnoid cysts (ACs) represent the most common off-midline extra-axial cysts and are usually located within the subarachnoid spaces, including the suprasellar cistern.Also known as meningeal cysts, they are CSF filled lesions lined by a layer of flattened arachnoid cells. ACs are sometimes in communication with subarachnoid cisterns.Most ACs are primary and due to meningeal development anomalies (embryonic endomeninges fail to merge and remain separated). On the other hand, inflammation, tumor, trauma, or hemorrhage may give rise to secondary ACs .Although ACs are generally asymptomatic, some patients may experience a wide variety of symptoms related to the location and size of the lesion. Nevertheless, the most frequent clinical presentation is headache. Subdural hematoma may represent a rare complication of ACs after minor trauma .On CT, uncomplicated ACs show CSF density and do not enhance. Intrathecal instillation of contrast agent (CT cisternography) may be helpful in documenting communication with the subarachnoid space. ACs also follow CSF signal on all MRI sequences Fig. . They doHistological examination show a delicate fibrous tissue forming cyst wall (arachnoid laminar connective tissue) lined by an attenuated meningothelium. Stroma is edematous with lymphocytic infiltrate.The main differential diagnosis is the epidermoid cyst which however shows higher signal than CSF on FLAIR sequence and diffusion restriction.Asymptomatic ACs do not require treatment . When treatment is required, surgical options include fenestration, endoscopic resection, marsupialization, or cysto-peritoneal shunting with a programmable valve.Hypophysitis is a rare inflammatory disease of the pituitary gland and its stalk that can be classified based on the anatomical extension , its etiology , and histopathology . LymphocHistological examination shows fragment of fibrotic tissue with lymphoplasmacytic infiltrate and a hemorrhagic background with pigmented macrophages.Differential diagnoses include NFPAs, CPs, metastases, RCC, IGCTs, lymphoma and, in the post-partum period, Sheehan’s syndrome. The management of hypophysitis consists of high-dose glucocorticoid administration and hormone replacement therapy . MoreovePituitary abscess represents a rare but life-threatening condition, with immunosuppression, surgery, and infections that are known predisposing factors . The cliLymphoma of the sellar region is a rare entity that may origin from the infundibulum, pituitary gland, or the hypothalamus, with a diffusely infiltrative growth and a propensity for perineural spread. Diffuse large B cell lymphoma represents the most common type 90%), and usually occurs in immunodepressed patients with a mean age of 30–40 years. However, in the last years, its incidence has been increasing in immunocompetent patients, with a peak presentation in the sixth decade of age and male predilection . The typ%, and usOn hematoxylin-eosin staining, these tumors are composed of medium to large-sized cells, arranged in a discohesive pattern, and show an immunohistochemical profile consistent with a high-grade B cell lymphoma.Differential diagnoses include infections, metastases, and PAs. The role of surgery is generally restricted to stereotactic biopsy. The management of lymphomas is based on multimodal treatment, which includes high-dose methotrexate, other chemotherapeutic agents and radiotherapy . UnfortuMeningioma is the second most common tumor of the sellar region in adults, with an incidence peak between the sixth and the seventh decade of life and female predominance. Meningiomas of this region may arise from the tuberculum sellae, clinoid processes, or cavernous sinus walls. Clinical presentation is related to compression of the surrounding structures, such as visual impairment, endocrine dysfunction, or cranial nerve deficits. On MRI, meningioma appears as a well circumscribed, round or lobulated, extra-axial dura-based mass. It enhances homogenously and brightly . T2-hypeOn histological examination, atypical meningiomas show loss of lobular architecture (“sheeting”) and hypercellularity. In some field, cells with high nuclear/cytoplasmatic ratio  can be visible, along with nodular areas composed of clear cells. Immunolabeling with Ki67 shows a proliferative index near to 30%. Tumor cells are EMA+, and nuclear staining for progesterone receptor is nearly 30%.Differential diagnoses of sellar/parasellar meningiomas include metastasis, lymphoma, PA, and cavernous sinus venous malformation. Surgery is the therapy of choice in symptomatic or growing lesions. However, the proximity of these tumors to the optic nerve, cavernous sinus, and internal carotid artery often precludes safe, complete resection. Adjuvant radiotherapy and stereotactic radiosurgery can be used in selected cases of macroscopic residual after surgical resection. Cavernous sinus invasion is one of the main factors limiting the extent of resection.Cavernous hemangiomas of cavernous sinus are not true neoplasms and are better described as venous malformations (VMs) according to the International Society for the Study of Vascular Anomalies (ISSVA) 2018 classification. VM is a rare congenital vascular anomaly containing endothelial-lined sinusoidal spaces filled with slow-flowing or stagnant blood. Although all VMs are present at birth, they may not manifest until late childhood or young adulthood, occurring more commonly in middle-aged women. Clinical manifestations include headache, visual impairment, and cranial nerve palsies. VMs of the cavernous sinus tend to grow as asymmetrical dumbbell-shaped mass extending into the sellar region or middle fossa with three patterns of growth: endophytic lateral growth, with extension into the middle cranial fossa, endophytic medial growth, with medial extension into the sella or anterior extension into the superior orbital fissure, and exophytic growth from the sinus wall . On MRI,On microscopy, VMs show different sized, ectasic, vascular channels, often back-to-back arranged, densely packed. Vessels are lined by flattened, benign-appearing endothelium. The immunostaining for CD31 is typical.Differential diagnoses include PA, meningioma, and schwannoma. Total removal of these highly vascular lesions is often very difficult due to the risk of severe intraoperative bleeding and the presence of critical neurovascular structures within the cavernous sinus. Stereotactic radiosurgery has been shown to be a successful primary or adjuvant strategy to decreasing lesion volume.Pituitary metastases are rare  . Lung anThe histologic findings vary according to the histotype of the primary tumor.Differential diagnoses include LHy, lymphoma, Langerhans cell histiocytosis, and neurosarcoidosis. Treatment and prognosis depend on the primary tumor. Surgical decompression and radiotherapy can be considered in symptomatic patients.Optic pathway gliomas (OPGs) are rare low-grade gliomas (WHO grade 1) that arise from the optic pathway  or hypothalamus, most frequently in children with a mean age of 4–5 years. The main histological subtypes are pilocytic astrocytoma and pilomyxoid astrocytoma. Pilocytic astrocytoma is often bilateral, arising from the optic nerve, and is frequently observed in patients affected by neurofibromatosis type 1 (NF1), while other subtypes are mostly sporadic and located posteriorly. Pilomyxoid astrocytoma may have an aggressive behavior, with a tendency to metastasize via CSF. OPGs in children with NF1 usually have a better prognosis. Onset symptoms are insidious and include visual impairment, pituitary/hypothalamic dysfunction, or hydrocephalus. For this reason, OPGs are often diagnosed late, noticing a visual disturbance progression or exophthalmos for tumors arising from the orbital segment of optic nerve, or nystagmus for OPGs involving the optic chiasm or hypothalamus . On MRI,On histopathology, pilocytic astrocytomas show round to spindled nuclei and dendrite-like cytoplasmic processes, often paired with Rosenthal fibers.The main differential diagnosis is optic nerve meningioma, that is frequently calcific. OPGs in patients with NF1 sometimes show a spontaneous regression . ManagemAneurysms arising from anterior communicating arteries (ACoA) can mimic a suprasellar or parasellar mass. Saccular aneurysms are the most common type. Peak presentation is between 40 and 60 years of age, with a female predominance. Typical manifestations are related to mass effect and include visual impairment due to optic chiasm compression. Giant aneurysms (> 2.5 cm) may extend into the sellar cavity mimicking pituitary tumors and resulting in hypopituitarism, due to pituitary/pituitary stalk compression . ACoA anDifferential diagnosis of neoplasms and tumor-like lesions of the sellar region may not always be easy because of the plethora of entities possibly involving this anatomical region, some of which presenting with similar findings on MRI. The radiologist must be aware of the presence of this wide range of differential diagnoses for proper diagnostic framing. In addition, knowledge of the latest updates on their classification and related pathologic findings contributes to a better understanding of these entities and to appropriately interface with other specialists within the multidisciplinary team assessment.


This case report of a rare condition involving situs inversus partialis, wandering spleen, and a single atrium. Situs inversus partialis is a congenital developmental defect in which the abdominal or thoracic organs are reversed to the opposite side of the body across the sagittal plane. The case report highlights the congenital developmental anomaly and the diagnostic and management complexities associated with this condition. The patient in this case has survived to the age of 24, despite the presence of a single atrium. In the existing literature, situs inversus is a known congenital condition, but partial situs inversus is less common. A wandering spleen is also a rare condition characterized by splenic hypermobility. The combination of situs inversus partialis, a wandering spleen, and a single atrium is particularly unusual and has limited reported cases. Therefore, this research contributes to the existing literature by providing a unique case report and highlighting the challenges associated with diagnosis and management in such cases. Situs inversus is divided into two types, complete situs inversus, also known as situs inversus totalis, and partial situs inversus, also known as situs inversus partialis, in which some organs are inverted and others are as they are [The term they are . Almost they are ,3.The spleen is generally located in the left upper quadrant of the abdomen and is kept in position by various suspensory ligaments. A floating spleen, or wandering spleen, is an unusual condition in which there is splenic hypermobility due to elongations or maldevelopment of the spleen's suspensory ligament .A single atrium, or common atrium, is a rare congenital anomaly in which there is a complete absence of the atrial septum. It leads to an arterial and venous blood mixture in the common atria, which usually causes palpitations, dyspnea, and cyanosis .This case report aims to highlight the clinical presentation, diagnostic difficulties associated with partial situs inversus, and management challenges associated with this rare combination of conditions. A 24-year-old female presented to the outpatient department of medicine with complaints of breathlessness and palpitations for several months. She was also having off-and-on epigastric pain, nausea, and vomiting. The pain was dull and aching, which the patient narrated as wandering-type from the epigastric region to the right upper quadrant of the abdomen. These episodes were of mild intensity, and every time for these symptoms, she sought treatment from a general practitioner and got relief. For persistent breathlessness and palpitations, she was referred to this hospital.2, was afebrile, had a pulse rate of 120 beats per minute, a blood pressure (BP) of 90/60 mmHg, a respiratory rate of 24 breaths per minute, and had SpO2 of 85% in room air. The patient had peripheral cyanosis. The liver was palpable 7-8 cm further along the midsternal line on abdominal examination. The spleen was not palpable. A nontender palpable mass was identified in the right iliac fossa. The cardiovascular system examination was not remarkable except for peripheral cyanosis. A respiratory system examination revealed bilateral basal crackles.On general examination, the patient was less than average built, had a body mass index of 18 kg/m-3, and a platelet count of 16,000. All other parameters have been given in Table Her laboratory parameters showed hemoglobin of 13.7 g/dL, white blood cells of 12,100 mmUltrasonography (USG) of the abdomen and pelvis revealed a large central liver extending from the right hypogastrium to the left hypogastrium and a mass-like lesion in the right iliac fossa. The spleen was not visualized. Computed tomography (CT) angiography showed a well-defined homogeneously enhanced splenunculi structure in the right iliac region with stretched splenic vessels suggestive of the wandering spleen with an accessory splenic artery directly arising from the abdominal aorta at the T11 level and measuring 1.8 mm at the origin Figures . The lefThe patient was managed symptomatically with oxygen therapy. A consultation with a cardiac surgeon was conducted, and the patient was counseled on non-surgical management due to complicated surgery with a poor prognosis and multiple risks. The prognosis was explained to the patient and relatives, and they were advised to follow up for further symptomatic management.Situs inversus partialis is an extremely rare condition, and it is less common as compared to situs inversus totalis, both conditions are inherent as autosomal recessive defects ,5. SitusA wandering spleen is distinguished from the normal spleen by the absence of fixation and an excessively long splenic pedicle. As a result, the spleen can move and migrate from its typical location in the left hypochondrium. Gastrosplenic and splenorenal ligaments fix the spleen in its normal position; failure of the development of these ligaments congenitally leads to a wandering spleen .The spleen grows in the dorsal mesogastrium and shifts posterolaterally to the left when the gut rotates. The lienorenal ligament is formed when the dorsal mesogastrium connects with the left kidney and the posterior abdominal wall. It contains the pancreatic tail and the splenic artery. Failure to fuse results in an excessively long pedicle.A single atrium is a very rare condition characterized by an embryologically deficient interatrial septum. The morphology of the right atrium  is in the dextral part of the common atrium, while the sinistral part has the morphology of the left atrium  ,6,7,8. TIn this case report, the patient has survived to the age of 24, despite the presence of a single atrium with neither palliative surgery nor medical evaluation. In the existing literature, situs inversus is a known congenital condition, but partial situs inversus is less common. A wandering spleen is also a rare condition characterized by splenic hypermobility. The combination of situs inversus partialis, a wandering spleen, and a single atrium is particularly unusual, and not a single case has been reported in the literature.Situs inversus partialis of the stomach with a wandering spleen having a single atrium is an extremely rare presentation. This is a congenital developmental anomaly wherein the abdominal organs or thoracic organs alone are reversed to the opposite side of the body through the sagittal plane. Partial situs inversus is of clinical importance due to the technical and diagnostic difficulty. In our case, the patient was still surviving with only mild symptoms at the age of 24 even after a single atrium. Surgical intervention was not possible as there were many risk factors. This case highlights about importance of awareness and early detection of such conditions to guide appropriate management strategies if feasible.


Epstein-Barr virus (EBV)-positive plasmacytoma is a rare and unique plasma cell neoplasm that could arise in immunocompetent individuals. Given the molecular and immunohistochemical similarity of EBV-positive plasmacytomas to their significantly more aggressive counterpart, plasmablastic lymphoma (PBL), providers must distinguish between the two neoplasms. This case elucidates a presentation of EBV-positive plasmacytomas in a healthy, immunocompetent individual originating in the C4/C5 cervical neck region. The patient's clinical presentation, in combination with the surgical pathology from the mass biopsy, pointed toward EBV-positive plasmacytoma. Factors such as cellular proliferation rate, cellular atypia, and immunohistochemical staining help differentiate the two diseases. This case will further help providers in the oncologic world to identify these masses.  Epstein-Barr virus (EBV) is a known oncogenic virus that has been the causative agent for various malignancies, including Burkitt's lymphoma, Hodgkin's lymphoma, and gastric carcinoma subtype . OccasioA 54-year-old male with no significant past medical history besides tobacco use was admitted for ongoing cervical neck pain and myelopathy. Vitals on admission were within normal limits except for some tachycardia. CT cervical spine (C-spine) on admission depicted an aggressive-appearing soft tissue mass in the C5/C6 vertebra, causing complete destruction of the fifth and sixth cervical vertebra Figure . He undeThis case depicts another unique presentation of EBV-positive plasmacytoma in an immunocompetent individual. Plasmacytomas are rarely EBV-positive, especially in patients with no history of immune deficiency. To accentuate the rarity of this pathology, MD Anderson Cancer Center recently analyzed EBV-positive immunocompetent patients in their database and identified only four cases . The patPlasmacytomas generally have morphological features which overlap with PBL, such as cellular atypia, with some cells appearing plasmablastic and, of course, EBV positivity. However, some pathological differences can help differentiate the two disease states. Plasmacytomas usually have a low Ki67 proliferation rate with less atypia, while PBLs have a high Ki67, with most cases being greater than 70%. To further appreciate this difference, the cases reported at MD Anderson had an average Ki67 proliferation rate of 25% for plasmacytomas ,6,7.Our patient met many criteria suggesting EBV-positive plasmacytoma, including low Ki67, light chain restriction, no necrosis, and, as mentioned before, immunocompetent status. Plasmacytomas are relatively indolent; treatment usually comprises radiation therapy or minimal chemotherapy . PBL, onGiven the rarity of EBV-positive plasmacytomas, this report adds another case to the body of growing medical research literature about this unique disease. This report aims to augment the reported cases of EBV-positive plasmacytomas and emphasize the importance of differentiating between PBL and EBV-positive plasmacytoma. More such cases need to be reported in order to increase provider suspicion of plasma cell neoplasm in the presence of EBV positivity.


Neurofibroma (NF) is a common benign peripheral neurogenic tumor that is rarely encountered in the paranasal sinus tract. In this report, we present a 55-year-old female who serendipitously discovered a maxillary sinus NF during a medical examination for a pulmonary nodule. The purpose of this article is to enhance medical practitioners' comprehension of paranasal sinus solitary NF by exploring cases, summarizing occurrences located in the paranasal sinus tract and conducting an organized review of paranasal sinus tract NF. The patient was a 55-year-old female. Four weeks prior, she had presented with left neck pain and palpable mass similar to that of a broad bean, unaccompanied by local redness or swelling. She was also accompanied by cough, scanty white sputum, no fever, no sore throat, no chest pain, and no chest tightness or discomfort.At first, the patient was diagnosed with cervical lymphadenopathy via outpatient ultrasound, and then a chest CT scan at our hospital revealed a tumor lesion in the left lower lobe. Subsequently, non-contrast-enhanced MRI of the brain  showed aSubsequently, biopsy of cervical lymph nodes indicated metastatic adenocarcinoma, thus she was diagnosed with lung adenocarcinoma and lymph node metastasis, presaging her poor prognosis.In accordance with imaging diagnostics, the nasal sinus mass was thought to be benign. A dialogue with the patient regarding further management ensued, eventually resulting in her consent for priority surgery of maxillary sinus masses. Postoperative complications were not observed. The patient was discharged ten days after surgery. An MRI scan conducted five months post-surgery revealed no recurrence. For the treatment of lung cancer, the patient underwent gene detection and targeted chemotherapy successively; however, the latest follow-up displayed lacklustre efficacy and CT displayed metastases of liver, lung and spine.Since the nasal sinus mass may have been benign, endoscopic resection of the left maxillary sinus mass was performed immediately; pathological results indicated paranasal sinus tract neurofibroma (NF) . So far, fewer than 100 cases have been reported in the literature around the world, mostly as individual case reports. It is mainly seen in individuals between 10 and 70 years old, with a peak age of onset at 30 years old; it is slightly more common in females than males. Most paranasal sinus NFs are primary solitary lesions (90%), with only a few related to type I neurofibrosis (10%).NF is a common benign neurogenic tumor, which rarely occurs in the paranasal sinus.A case of paranasal sinus NF in the maxillary sinus is reported here. Although she has lung adenocarcinoma with cervical lymph node metastasis, there is no evidence of association among them. Of these cases, three were related to neurofibromatosis type I and the other 12 were primary solitary NFs. Including this case reported here, there was a 1:2 male-to-female ratio among these 16 reports; onset age ranged from 10 to 79 years old with a median age of 45 years old.Only 15 cases of NFs involving paranasal sinuses were found by searching literature and summarised in  invading alveolar bone can lead to tooth loosening or abnormal occlusion, and invading brain tissue can cause headaches. Solitary NFs differ from NF1 related ones due to lack of common skin coffee spots or family history associated with them.Clinical manifestations of sinus NF lack specificity and vary depending on location. Common clinical manifestations include local swelling, pain, nasal congestion or runny nose as well as epistaxis or facial discomfort; occasionally invading the orbit can lead to exophthalmos and visual impairment, which was consistent with our findings. NF1-associated tumors often present multiple lesions involving multiple sites simultaneously. (3) On X-ray paranasal sinus, NFs usually manifest by decreased transparency within affected area sometimes accompanied by dilated Sinuses. Whereas CT usually shows heterogeneous solid mass inside nasal cavity, sometimes cystic too, when small tumor size does not change size within affected area; however, large tumors may expand said cavity or even cause local bone absorption/breakage through its walls into orbital/intracranial/pterygomaxillary fossa areas, respectively; contrast enhancement showed mild up to obvious enhancement which may be linked toward tissue components within said tumor. While MRI showed medium low signal on T1WI, heterogeneous medium signal/high signal on T2WI, without limited diffusion on DWI. (4) Despite invasive nature potentially leading up toward malignant NF recurrence after surgical resection almost non-existent.The imaging findings for paranasal sinus NFs show nonspecific changes but understanding certain characteristics may help prompt diagnosis: (1) Paranasal sinus NFs is most commonly found in maxillary sinuses followed by frontal ones while ethmoid and sphenoid are rarer; out of 20 cases summarised here 13 were located in maxillary while four were located at frontal ones and one at ethmoid; other cases involved both ethmoid and sphenoid but all part of nasal NF. (2) Paranasal sinus NFs are more commonly seen as solitary lesions than NF1-related ones; only 3 of 16 cases (18.75%) being NF1-related. Whereas 90% being solitary lesions according to Azani et al,The differential diagnosis of paranasal sinus NFs includes cysts, schwannomas, solitary fibroid tumors, inflammatory pseudotumors, fungal granulomas, inverted papillomas, ectopic meningiomas, ossifying fibroids, leiomyosarcomas, lymphomas, metastasis and so on. If low density or cystic components are found inside the tumor, maxillary sinus cysts/schwannomas should be differentiated. When solid tumors with delayed enhancement are manifested, solitary fibromas, inflammatory pseudotumors, fungal granulomas, inverted papillomas, and ectopic meningiomas need be distinguished, while calcification is detected, ossifying fibromas would be differentiated first. Once bone walls and surrounding tissues are invaded, leiomyosarcoma, lymphoma, and metastatic tumor should be identified.Surgery is currently the main treatment option for paranasal sinus NFs. Although slow progression and good prognosis are common, radiotherapy and chemotherapy may be performed while malignant lesions are detected.In conclusion, paranasal sinus NFs is a rare benign neurogenic neoplasms, which expressed either isolation or NF1 correlation. Despite there is non-specific in-clinical presentation and imaging features of it, consideration should be given to the possibility of paranasal sinus NFs when diagnosed benign masses and solid tumors of the paranasal sinus by imaging, especially in those with NF1.Paranasal sinus solitary NFs are a rare type of tumor mainly occurring within the maxillary sinuses.The clinical manifestations of paranasal sinus solitary NF are nonspecific in nature. Commonly observed symptoms include localised swelling, pain, nasal obstruction, rhinorrhea, and epistaxis.When imaging reveals a heterogeneous solid mass in the paranasal sinus accompanied by mild delayed enhancement or obvious enhancement, consideration should be given to the potentiality of NF, regardless of the presence of bone destruction.The imaging manifestations of paranasal sinus NFs are non-specific making it difficult to differentiate from other conditions. The diagnosis primarily relies on tissue biopsy.


Pancreaticoduodenectomy in patients with CA stenosis due to median arcuate ligament often required carefully collateral pathways management to avoid hepatic ischemic complications.Case 1: A 63-year-old man was referred to our department because of jaundice with distal common bile duct tumor. Pancreaticoduodenectomy with left posterior SMA first approach and circumferential lymphadenectomy was performed. Case 2: A 48-year-old man was referred to our department because of right-upper-quadrant abdominal pain with Vater tumor. Laparoscopic pancreaticoduodenectomy with left posterior SMA first approach and circumferential lymphadenectomy was performed. Postoperatively, in all two cases, three-dimensional reconstruction images showed developed collateral pathways around the pancreatic head, and the CA was stenosis in 75% and 70% due to MAL, respectively. Intraoperatively, in all two cases, we confirmed poor blood flow in the common hepatic artery (CHA) by palpation and observation. So that in the first case, we have decided to proceed a no-touch technique of GDA segmental resection en bloc with the tumor and reconstructed with an end-to-end GDA anastomosis; in the second cases, we have decided to proceed gastroduodenal collateral preservation. When preserving these collateral pathways, we confirmed that the PHA flow remained pulsatile as an indicator that the blood flow was adequate.Celiac axis stenosis was a rare but difficult-to-managed condition associated with pancreaticoduodenectomy. Collateral pathways management depends on variety of collateral pathways.The online version contains supplementary material available at 10.1186/s12957-023-03096-5. Hepatic ischemic complication is one of main causes that lead to lethal outcome after pancreaticoduodenectomy . And mosMedian arcuate ligament syndrome (MALS) is the most common cause of celiac axis (CA) stenosis . Due to A 63-year-old man was referred to our department with a distal common bile duct tumor. He had a history of 3-year diabetes with no surgical history. There was no family history of pancreatic cancer or genetic disorders. The patient’s appetite was normal, and he had no weight loss or abdominal pain, but jaundice increased in 2 weeks. Stool was normal with no history of constipation or diarrhea. Laboratory results included an elevated carbohydrate antigen 19–9 (CA19-9) level of 743.6 U/ml, but the carcinoembryonic antigen (CEA) level was normal. Other results, including diabetes indices such as HbA1c levels, and bilirubin levels, were elevated with a level of 308.1 μmol/l of total bilirubin and 173.7 μmol/l of directed bilirubin. Liver enzymes were also elevated, with alanine transaminase (ALT) and aspartate transaminase (AST) levels were 270 U/l and 111 U/l, respectively. In imaging examinations, gadoxetic acid-enhanced magnetic resonance imaging (MRI) revealed a strict distal common bile duct with enhancement in the early phase  due to decreased gastric blood flow did not occur, and the patient was able to resume eating 4 days after the surgery . The patA 48-year-old man was referred to our department with a Vater tumor. He had a history of 3-year diabetes with no surgical history. There was no family history of periampullary cancer or genetic disorders. The patient’s appetite was normal, and he had no weight loss or jaundice, but right-upper-quadrant abdominal pain increased in 2 weeks. Stool was normal with no history of constipation or diarrhea. Laboratory results included an elevated carbohydrate antigen 19–9 (CA19-9) level of 500.6 U/ml, but the carcinoembryonic antigen (CEA) level was normal. Other results, including bilirubin levels, were elevated with a level of 80.1 μmol/l of total bilirubin and 53.6 μmol/l of directed bilirubin. Liver enzymes were also elevated, with alanine transaminase (ALT) and aspartate transaminase (AST) levels were 172 U/l and 61 U/l, respectively. In imaging examinations, gadoxetic acid-enhanced magnetic resonance imaging (MRI) revealed a Vater tumor of diameter 15 × 9 mm with enhancement in the early phase  due to decreased gastric blood flow has occurred, and the patient was able to resume eating 4 days after the surgery. The pathological diagnosis was pancreatic adenocarcinoma, pT2N0M0 , and the cancer was stage IIA based on the eighth edition of the UICC-TNM classification . No viabCeliac axis (CA) stenosis was reported to be found in about 5–10% of patients who underwent PD , 13. In Along with atherosclerosis, compression by the MAL is accounted for about 90% cause of severe CAS . The medThe CA stenosis usually led to collateral pancreatoduodenal arteries to supply hepatic blood flow. According to a systematic review by Giovanardi, Lai, Garofalo, Arroyo Murillo, Choppin de Janvry, Hassan, Larghi Laureiro, Consolo, Melandro, and Berloco, in totally 87 cases of patients who underwent pancreaticoduodenectomy with CAS syndrome that they could found in English literature, PDAs abnormalities were reported in 73 cases (83.9%). And among them, 67 cases had a real anterior and/or posterior arcade between GDA and SMA, but enlarged GDA was observed in only four cases [Due to the failure of MAL division can only be determined intraoperatively, and in these situations, surgeons must make a choice, with complex revascularization or abandonment of the surgery. However, with the development of diagnostic imaging therapies preoperatively like CT with routine three-dimensional arterial reconstruction or preoperative endovascular intervention, the colleterial arterial pathways can be determined very clearly. So that, it is not impossible for surgeons to determine the ability of radical resection with collateral pathway management without impairing the curativeness of cancer. In some research, authors have chosen a preoperative management of CAS, and one of the most popular choice was CA preoperative endovascular stenting , 18, butIn our two cases, a collateralization of GDA dilation with SMA was determined preoperatively, and we have not chosen CA preoperative endovascular stenting with these above reasons. Intraoperatively, after GDA clamping and MAL division, the hepatic arterial flow through CHA has not recovered, so we have decided to resect a GDA segment that infiltrated to the tumor and proceeded end-to-end GDA anastomosis. Postoperatively, patient was administered by continuous intravenous (IV) infusion unfractionated-heparin therapy following the American Heart Association (AHA) guideline . One of Celiac axis stenosis was a rare but difficult-to-managed condition that can occur in patients who underwent pancreaticoduodenectomy. If median arcuate ligament division does not restore hepatic arterial flow, gastroduodenal collateral arcade reconstruction and preservation are needed. Collateral pathways management depends on variety of collateral pathways; in some cases, gastroduodenal artery resection and reconstruction with end-to-end anastomosis with a no-touch technique were recommended to minimize risks of complicated revascularization.Additional file 1: Video 1. Laparoscopic pancreaticoduodenectomy with left-posterior SMA first approach and circumferential lymphadenectomy was performed .


Congenital hepatoblastoma, a rare malignant liver tumor in infancy, typically presents with abdominal distension or mass. Tumors detected antenatally or during the first three months of age are considered congenital hepatoblastoma. Hepatic arteriovenous fistulas (HAVF) are associated with high mortality in the neonatal period and can be caused by many secondary factors. This case report focuses on a patient with congenital hepatoblastoma accompanied by HAVF, highlighting the clinical and imaging characteristics and management strategies.A term infant presented with sudden tachypnea and heart failure on his first day of life. A cystic-solid mixed lesion in the fetus’s liver was detected by an antenatal ultrasound scan. Postnatal digital subtraction angiography confirmed the presence of arteriovenous fistulas, which were treated with trans-arterial embolization. However, despite the intervention, the patient’s heart failure did not improve. The patient underwent a left hepatectomy, and hepatoblastoma was discovered by histology of the resected hepatic lobe. Unfortunately, metastases were later discovered in the intracranial and ocular regions. Ultimately, the family decided to discontinue further treatment.Congenital hepatoblastoma presenting with hepatic arteriovenous fistulas has not been previously described. Hepatoblastoma should be considered when alpha-fetoprotein levels show a significant elevation in newborns. Prenatal diagnosis may improve pre- and postnatal management. Congenital hepatoblastoma detected antenatally or during the first three months of age accounts for less than 10% of all pediatric hepatoblastomas. Congenital hepatoblastoma is associated with a worse prognosis, as it tends to have a higher incidence of pure fetal histology and a higher probability of metastasis . The cli2.A male infant was admitted to NICU at 19 h of life due to jaundice and tachypnea. The boy was 38 + 2 weeks of gestation. The birth weight was 2,290 g (less than the 5th percentile), and the length was 44 cm. Apgar scores were 10 and 10 in the 1st and 5th minutes. The mother was 37 years old with antiphospholipid antibody syndrome and a history of retroperitoneal tumor resection. An ultrasound taken at 28 weeks of gestation revealed the hepatic space-occupying lesion to be 3.6 cm × 3.6 cm × 3.0 cm . At 29 w3.HAVF is a rare condition with a low incidence rate and is often misdiagnosed. It was first reported by Goodhart et al. in 1899 and is classified into hepatic artery-portal vein fistula (HAPVF) and hepatic artery-hepatic vein fistula (HAHVF) . The cliIn the present case, the infant rapidly presented with respiratory distress and heart failure. Considering the prenatal ultrasound findings, we suspected that an intrahepatic space-occupying lesion caused congestive cardiac failure. Meanwhile, enhanced CT and digital subtraction angiography (DSA) were performed to confirm the diagnosis. The current main treatment options for HAVF include interventional embolization, hepatic artery ligation, and hepatic lobectomy . InterveCompared with HAVF, hepatoblastoma is more common in infant, however, it remains a rare disease with an incidence is 11.2 per million . GeneralThe relationship between the two diseases must be considered, and on the basis of monism, we hypothesized that hepatoblastoma led to the development of HAVF. First, HAVF is common in primary hepatocellular carcinoma with an advanced stage, frequently involving the hepatic venous and/or portal venous system . HepatobWith the increasing availability of prenatal examinations, prenatal diagnosis plays a crucial role in detecting fetal hepatic tumors and allows for appropriate perinatal care and definitive treatment. The evaluation methods for fetal hepatic tumors include fetal ultrasound and MRI. The characteristic sonographic findings of hepatoblastoma revealed a large, hypoechoic solid lesion in the liver with focal hemorrhage, necrosis, and calcification . MRI shoAlthough our patient had a poor outcome, we believed that early antenatal diagnosis of hepatoblastoma and HAVF in other cases could lead to more favorable outcomes. Prenatal diagnosis allows for timely intervention and appropriate management, ultimately improving the prognosis for affected infants.4.We reported a case of a rare hepatoblastoma presenting with HAVF in an infant. The patient presented with heart failure and was ultimately diagnosed through DSA and histological examination. The present case highlighted the significance of radiological features and AFP levels in the early detection of hepatoblastoma. A timely diagnosis permits consideration of prompt treatment and may lead to better outcomes.


Lipoma is a benign, rare, mesenchymal tumor found in the head and neck region, especially in the parotid gland. It thus requires a careful and precise examination to establish a diagnosis. A surgical procedure of the parotid gland is challenging due to the associated risk factor of facial nerve injury. We report a rare case of head and neck region lipoma between the superficial and deep lobe of the parotid gland. A 44-year-old female patient was presented with the chief complaint of a painless lump on the left front ear to the left cheek for about 1 year. There were no complaints of tooth pain before the lump appeared, and there were no lumps in other regions. A fine-needle aspiration biopsy, ultrasonography, and magnetic resonance imaging were all performed to establish the preoperative diagnosis and to plan the correct surgical approach. Lipoma was the initial clinical diagnosis, and a surgical excision with superficial parotidectomy and facialis nerve preservation was performed. Follow-up examinations were conducted to assess any facial nerve injury complications. Conclusion Lipoma rarely grows in the parotid gland. Careful diagnosis should be performed to establish a precise surgery for parotid dissection and facial nerve preservation. Lipoma is a benign mesenchymal tumor that can be found anywhere in the body where fat is normally present, but it is rarely found in the head and neck region, even less so in the parotid region.Due to the rarity of lipoma in the parotid gland regions, an accurate diagnostic method is required to make a conclusive diagnosis. A more accurate diagnosis of these tumors have been made possible by improved preoperative evaluation tools including magnetic resonance imaging (MRI) and fine-needle aspiration biopsy (FNAB).A 44-year-old female patient with a lump on the left front ear to the left cheek for 1 year was presented to our department. The swelling was painless and had progressively increased during the previous year. There were no complaints of tooth pain, and no lumps were found in other regions. A physical examination showed a solitary mass on the left preauricular region, with a size within 4 × 3 × 2 cm, firm in consistency, and not compressible on palpation. The skin over the swelling appeared normal. There were no other head and neck masses that could be felt .The patient's past medical history and psychosocial data presented no related information with the swelling. There was no family history of tumors, especially in the head and neck regions. An examination and therapy related to the swelling had never been performed on the patient. FNAB, ultrasonography (USG), and MRI were performed sequentially to establish a preoperative diagnosis and to plan the best surgical approach.The FNAB report revealed a distribution of epithelial cells with round-oval nuclei, fine chromatin, broad cytoplasm, and eosinophilic color with the background consisting of a distribution of erythrocyte cells, a few inflammatory lymphocyte cells, and fat droplets. The report also showed that there were no malignant cells, and it was suspected that the swelling was a benign lesion mass suggestive of lipoma . An USGUsing the classic Blair's incision, a surgical lipoma excision, facial nerve dissection, and superficial parotidectomy were performed . DuringDuring the hospital stay, the patient was given antibiotics to prevent postoperative infection, nonsteroidal anti-inflammatory drugs, and corticosteroid anti-inflammatory drugs to reduce postoperative inflammation. The patient was discharged 3 days after the operation with a good prognosis assessment. Follow-ups were performed 3 months, 6 months, 1 year, and 2 years after the operation to observe any disease recurrence and facial nerve functions. There was no recurrence during the follow-ups. Facial nerve function was checked clinically by asking the patient to wrinkle the forehead to observe any asymmetry, close the eyes tightly to observe lid closure competence, smile to observe asymmetry of the nasolabial fold, and contract the mouth to observe orbicularis oris functions. There was no facial nerve dysfunction found during the examination .The most common benign mesenchymal encapsulated tumors that resemble mature adipose tissue histologically are lipomas. Adipose tissue is known to exist in salivary glands; however, lipomas, particularly those of the parotid gland, are quite uncommon.Numerous etiological factors were explored, such as inherited factors, trauma, diabetes, endocrine problems, corticosteroids, obesity, and radiation.Despite having a histological resemblance to mature adipose tissue, a fibrous capsule helps to identify lipoma from simple, normal fat aggregation.Nowadays, a histopathological examination and preoperative imaging play crucial roles in correctly diagnosing the nature and location of lesions. Their primary purpose is to remove extraparotid subcutaneous lesions, and second objective is to confirm the lipoma diagnosis.An essential diagnostic technique for identifying parotid tumors is a FNAB. However, its accuracy is only approximately 50% in most parotid tumor cases.Preoperative imaging for a case of lipoma usually comprises either a USG or MRI scan.The MRI results showed a mass with the intensity of fat growing on the left parotid region. An MRI can be useful in providing details about a tumor's clinical characteristics and in identifying the tumor's location and relationship to significant anatomical structures. Higher soft tissue contrast, enhanced lesion definition, and the absence of ionizing radiation are some of the benefits of an MRI.Deep parotid lobe lipomas are highly uncommon and difficult to treat; this requires meticulous dissection of the facial nerve's branches.Facial nerve dysfunction, Frey's syndrome, facial scars, or an asymmetrical contour are a few potential postoperative morbidities that could arise and should be discussed with the patient.It is preferable not to postpone the surgery for too long, as a local mass effect may be complicated with facial nerve palsy or even airway obstruction if parapharyngeal space is involved.In this case, excision of the lipoma and superficial parotidectomy were performed with appropriate facial nerve dissection so that the entire lipoma could be excised without injuring the facial nerve. This is important to prevent postoperative facial nerve dysfunction. However, this case has some limitations, follow-up of the patient was affected by the coronavirus disease 2019 pandemic, so patient evaluation could not be routinely conducted. Postoperative evaluation was done by clinical examination rather than postoperative MRI, as the tumor was well-capsulated with a low risk of recurrence, and a superficial parotidectomy was performed to ensure that no tumor tissue remains.Lipoma of the parotid gland is uncommon and can be clinically deceptive. An accurate clinical assessment is required, followed by preoperative imaging and a histopathological examination to facilitate in the diagnosis of parotid gland lipoma. For the histopathological examination, an FNAB is highly accurate for the diagnosis of lipomatous tumors. For the purpose of facilitating the identification of lipoma, preoperative pictures from a USG and MRI are highly useful in evaluating its location and its relationship to significant anatomic structures. The best tool for both diagnosis and surgical planning remains to be an MRI.Due to the possibility of a facial nerve lesion, surgical management of parotid region lipomas is difficult and should only be performed by skilled surgeons. Postoperative functional and esthetic outcomes should be the main objectives, and in all cases, a superficial parotidectomy and blunt dissection of facial nerve trunks are required.


Teaching Point: Pelvic inflammatory disease (PID) is the most frequent gynecologic cause of emergency visits. Because of its prevalence and non-specific symptoms, the radiologist may encounter this pathology and its complications on all imaging modalities and should carefully assess PID signs to avoid delay in management, late complications, and unnecessary surgery. A 32-year-old female patient hospitalized for treatment of a B-cell lymphoma presented fever for a week and abdominal pain for two days with pelvic and right iliac fossa tenderness. Blood tests revealed signs of infection (leukocytosis and elevated CRP). The patient first underwent abdominal ultrasound  showing Magnetic resonance imaging (MRI) confirmed the diagnosis of tubo-ovarian abscess. Axial and sagittal T2 weighted images  showed bA week later, the patient presented to the emergency room while under antibiotherapy for persistent pelvic pain. A computed tomography (CT) scan was performed and revealed a persistent tubo-ovarian abscess with extension to the recto-uterine pouch  was found to have specificity of 95% for PID. Early detection of PID can reduce the risk of tube-related infertility, ectopic pregnancy, and pelvic chronic pain due to adhesions [Ultrasonography is considered the first-line imaging modality in the evaluation of suspected salpingitis showing free fluid in the cul-de-sac and thickening and wall enhancement of the fallopian tubes .In advanced cases of PID, MRI is more sensitive for the detection of ovarian involvement, differentiation between pyosalpinx and hematosalpinx, and the differential diagnosis with ovarian malignancy .


Introduction: The adrenocortical oncocytic neoplasms (AONs) are rare tumors of the adrenal gland, classified as oncocytoma (AO), oncocytic neoplasm of uncertain malignant potential (AONUMP) and oncocytic carcinoma (AOC). The aim of this study was to perform a review of the literature, in order to evaluate the prognosis of these rare cancers. We also reported the oldest patient with AON. Methods: A comprehensive literature review using as key words “adrenal oncocytoma”, “adrenal oncocytic neoplasm”, and “adrenal oncocytic carcinoma” was performed. Report of the case: We report the case of an 88-year-old woman receiving a left open adrenalectomy for an AON (15 × 10 × 8 cm). The considerable size and weight together with the presence of necrosis were indicative for a lesion with an uncertain potential for malignancy, according to Weiss modified criteria. After two years, the patient was free from any sign of recurrence. Results: Only 287 AONs were detected in the scientific literature, exploring OVID, MEDLINE, PubMed and SCOPUS as dataset. These tumors are usually incidentalomas with an unpredictable malignant potential. Surgical resection remains the mainstay of treatment for AON. Conclusion: AO and AONUMP have an excellent prognosis and a low mortality rate, with only three cases of recurrence reported in the literature and one metastatic case four years after first adrenal surgery. In contrast, AOC carries a high risk of local relapses, distant metastasis, and a significantly higher mortality rate (30%). Surgical resection remains the primary treatment for adrenal oncocytic neoplasms. Oncocytes are large polygonal or round cells with abundant granular and eosinophilic cytoplasm that are demonstrably packed with mitochondria on ultrastructural examination. Foci of oncocytic change are not uncommon in conventional adrenocortical neoplasms. Hamperl first used the term oncocytosis in 1931 ,3.Oncocytic neoplasms (ONs) are, by definition, composed exclusively or almost exclusively of oncocytes . ONs canKakimoto S et al. described in 1986 the first case of adrenocortical oncocytic neoplasms (AONs), as a rare tumor of the adrenal gland . It is iThere is no single parameter to discriminate between benign and malignant AONs, and they are classified regarding their biological behavior by a combination of histological features according to the Lin–Weiss–Bisceglia system (LWB) .AONs are classified, regarding their malignant potential, as oncocytoma (AO), oncocytic neoplasm of uncertain malignant potential (AONUMP), and oncocytic carcinoma (AOC) .The aim of this study was to perform a review of the literature, in order to evaluate the prognosis of these rare cancers. Furthermore, we present the case of adrenal oncocytoma in the oldest patient in the literature.Using the PubMed database, a systematic review of the current literature was carried out, up to May 2023. The Medical Subject Headings (MeSH) search terms used were oncocytic neoplasms, adrenocortical oncocytic neoplasms, adrenal tumors, adrenocortical oncocytomas. The authors observed that the adrenal AONs were rare. The keywords “oncocytic neoplasms”, “adrenocortical oncocytomas” and “adrenocortical oncocytic neoplasms” were used for the research. Several combinations of the keywords were utilized. The last research was concluded in May 2023. No language restrictions were imposed. The final article was realized in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines . MoreoveThe study’s inclusion criteria involved patients with a confirmed histopathological diagnosis of adrenocortical oncocytic neoplasm.A total of 138 articles were identified (118 full-text publications and 20 abstracts containing a complete description). Fifteen were case series, and all others single clinical cases; two abstracts were excluded due to the absence of information.An 88-year-old woman, diagnosed with pulmonary hypertension and experiencing difficulty walking following hip replacement surgery, underwent an abdominal ultrasound due to constipation and abdominal swelling, in the absence of other symptoms. The ultrasound revealed evidence of a small adrenal mass measuring less than 5 cm. A subsequent CT scan  performeEndocrine function tests did not show any abnormalities, confirming the suspicion of a non-functioning adrenal mass. Due to the tumor’s significant size and rapid growth, a left open adrenalectomy, with complete excision of the mass and preservation of the spleen and kidney, was performed. The postoperative course proceeded without complications; the patient was mobilized on the first day and discharged on the fifth. After two years of follow-up, she was disease-free.Macroscopic examination revealed a rounded, smooth mass measuring 17 × 13 × 10 cm and weighing 730 g. The cut surface exhibited lobulated areas with yellowish and brownish regions, enclosed by a thin fibrous capsule .Microscopic findings indicated a well-circumscribed, partly encapsulated tumor composed of nests and trabeculae of large polygonal cells with abundant eosinophilic granular cytoplasm. No venous invasion, high mitotic rate, or atypical mitoses were observed. While there were focal areas of necrosis, there was no evidence of capsular or sinusoidal invasion .Immunohistochemical studies  revealedThe morphological features were typical of an AON. The substantial size and weight of the tumor, along with the presence of necrotic areas, were factors considered indicative of a lesion with uncertain potential for malignancy, in accordance with the Weiss modified criteria .Currently, two years after the resection of the adrenal mass, there are no signs of recurrence.Data of 136 articles were included in the review, comprising 287 cases of AONs, including our case. Demographic data of patients with AONs are shown in The masses had an average diameter of 8.9 cm (range 2–28 cm) and an average weight of 467 g (range 8–5720 g) ,23. TheyAs shown in Moreover, of the 278 cases in which the Lin–Weiss–Bisceglia system was applicable, , 42% werThe follow-up , reportePercentages were calculated for those 135 cases with available follow-up information.In the followed-up cases, mortality was absent in the AO group; only two deaths 4.2%) were reported in the AONUMP group, and nine deaths (30%) in the AOC group.The average age was 48 years, with eight females and three males. Eight cases involved the left adrenal gland, while only three were located on the right one. The average size and weight of the tumors were 14.5 cm and 1067 g, respectively. Only two were functional neoplasms, associated with conditions such as hyperandrogenism or Cushing syndrome. According to LWB criteria, two were oncocytic neoplasms of uncertain malignant potential, and the other nine were carcinomas. The average follow-up of these patients was 2 years; only in one case, death was reported within 1 month of surgery.Adrenocortical oncocytic neoplasms (AONs) are exceptionally rare tumors. Differently from the previously described analysis—where only about 160 cases have been reported in the literature—we have identified 287 AON cases . AONs weIn terms of location, AONs were found to have a slight prevalence on the left side (L/R: 1.4/1), which was lower than previously reported in the literature L/R 3.5/1) . In nine.5/1 . InMost oncocytic tumors arising from endocrine organs were nonfunctional, as in our case, and often asymptomatic. In agreement with literature reports, about 30% were functional (32%). Hyperandrogenism and Cushing syndromes were the conditions most frequently associated with AONs; the simultaneous presence of virilization and subclinical Cushing was described in three of the functioning tumors ,41,42.Goel T et al. in 2007 first described a case of a 48-year-old male with oncocytic left adrenal mass who presented with hypertension and high urinary catecholamines; they concluded that functional adrenal oncocytoma mimicking pheochromocytoma should always be considered a possibility . SubsequPeynirci H. et al. described two cases of primary hyperaldosteronism (Conn syndrome) among functional oncocytomas (0.7%) ; in contWong et al., in their series, described a case of a male with gynecomastia associated with elevated serum prolactin and estradiol . MoreoveIn 2017, the World Health Organization first recognized and classified the oncocytic variant as a distinctive subtype of ACCs . In our Juliano JJ et al. reported a case of recurrent metastatic adrenal oncocytoma with the longest follow-up of about 15 years . MetastaAs demonstrated by Renaudin K. et al., malignant oncocytic adrenocortical tumors appeared to have a better prognosis than conventional adrenocortical carcinomas, but the corresponding hazard ratio did not reach statistical significance ) ; similarThe imaging characterization of adrenal tumors relies on CT and MRI criteria, which include tumor size, morphological features, pre- and post-contrast CT densitometry, as well as MRI pre- and post-contrast signal intensity characteristics. When CT and/or MRI images present uncertainty in tumor characterization, functional radionuclide modalities such as 2-(18F) FDG PET/CT or PET-MRI hybrid imaging may be employed. It is important to note that imaging findings alone, even with the addition of more advanced imaging techniques, may not be sufficient to characterize adrenal oncocytomas. It is recommended to use integrated morpho-functional imaging to characterize adrenal tumors. However, since adrenal oncocytomas can sometimes exhibit 2-(18F) FDG uptake, there is a risk of overestimating malignancy. As FDG-avid masses, adrenal oncocytomas are known to be causes of false-positive PET results ,49,50,51The therapy of oncocytic adrenocortical neoplasms mainly relies on surgical resection. With the development of laparoscopic techniques, laparoscopic surgery is becoming more and more popular . It was Macroscopically, most of them were large, rounded, encapsulated, and well circumscribed tumors. On cut section, they were yellow brownish; some may have exhibited areas of hemorrhage or necrosis. The section of benign tumors was usually golden or brownish yellow, and the malignant tumors were mostly ash red or fish-meat-like. Microscopically, they were composed of large eosinophilic and granular cytoplasm cells with a central pyknotic nucleus, with a solid, trabecular, tubular, or papillary growth pattern.The immunohistochemical pattern proved challenging to establish in many reported cases, as it had not been well-documented. Generally, these tumors are positive for vimentin, melan-A, synaptophysin, and alpha-inhibin, while they test negative for chromogranin.Among the various molecular and cytological markers that could aid in the differential diagnosis of adrenocortical carcinoma, cell proliferation markers like Ki-67 and the oncoprotein p53 can be particularly valuable. Unfortunately, their role as definitive biomarkers remains uncertain due to the limited availability of these tumors .However, as per Mearini et al., the Ki-67/MIB1 index is a practical tool for distinguishing between benign masses and carcinomas in the differential diagnosis .The current study presented a limitation. Since eosinophilic cytoplasm may be caused by the prominence of a number of cytoplasmic organelles other than mitochondria (as occurs in oncocytic tumors), whether the oncocytic nature of the tumor cells comes from mitochondria should be confirmed. Therefore, nowadays, diagnosis also makes use of IHC with antimitochondrial antibody mES_13 in more than 90–95% of the tumor cells and/or electron microscopy. The definitive pathology in the current study  was performed in a conventional way, and the diagnosis was reached by exclusion.Adrenal oncocytic neoplasms are indeed rare tumors, with approximately 287 cases documented in the literature. They tend to be more prevalent in young women, often occurring in the fourth and fifth decades of life. Furthermore, they show a higher frequency in the left adrenal gland, and approximately 68% of cases are non-functional.Regarding prognosis, oncocytoma (AO) and oncocytic neoplasm of uncertain malignant potential (AONUMP) generally have an excellent prognosis. In contrast, adrenal oncocytic carcinomas (AOCs) have a considerably higher risk of local relapse (5.1%), distant metastasis (3.7%), and mortality (7.4%). Effective management relies on a combination of biochemical, histopathologic, radiologic, and clinical features. However, surgical resection remains the primary treatment for adrenal oncocytic neoplasms. Surgical decisions should take into account the mass’s imaging characteristics, the patient’s age, and any concurrent medical conditions.In general, the available data are of limited guidance in deciding when surgery is necessary. At diagnosis, in fact, oncocytomas are typically large, with a median size of 8.75 cm, possibly because they do not produce hormones and are difficult to distinguish from malignant adrenal tumors using imaging methods like CT or MRI. The usual density cutoff of <10 Hounsfield units (HU) to identify benign lesions on CT scans is inadequate for identifying benign adrenal oncocytomas, which have an average density of 14 HU. Additionally, the characteristic loss of signal on MRI out-of-phase images, often seen in benign adrenal lesions, is frequently absent in non-malignant oncocytomas. Consequently, most adrenal oncocytomas would be considered for surgery due to their indeterminate preoperative imaging characteristics. However, it is advisable to consider adrenalectomy if the adrenal mass reaches a diameter of 6 cm or more, if the mass increases by 1 cm or more during the observation period, or if there is evidence of autonomous hormonal secretion. During surgical procedures, the primary goal is to achieve complete resection of the adrenal gland without disrupting the adrenal capsule. Experienced pathologists play a crucial role in the pathological examination, allowing for the classification of tumors based on their biologic potential and providing insights into the patient’s prognosis.


Dorsal agenesis of the pancreas is an exceedingly rare congenital anomaly where the dorsal part of the pancreas fails to develop properly during embryonic development. We report a case of partial agenesis of the dorsal pancreas in a 27-year-old female who presented with progressively worsening abdominal pain, nausea, vomiting, generalized weakness, easy fatigability, and dizziness. Physical examination revealed fair general condition with stable vital signs and normal abdominal and other system findings. Laboratory evaluations and abdominal computed tomography scan revealed an absence of the pancreatic body, tail, and duct of Santorini, confirming the diagnosis of partial agenesis of the dorsal pancreas. Only around 100 cases have been reported in the literature, making it a diagnostic challenge. Our case illustrates the rarity and challenges in diagnosing dorsal agenesis of the pancreas. Further research is needed to fully understand its causes and associations. The dorsal bud either never forms or totally degenerates in cases of dorsal pancreas agenesis.2 Fewer than 100 cases have been reported in the literature so far.1 ADP may be discovered when evaluating conditions arising from anomalies like pancreatitis and diabetes mellitus. Here, we report a case of a 27-year-old female with partial agenesis of the dorsal pancreas.Agenesis of the dorsal pancreas (ADP) is a rare congenital anomaly in which the dorsal part of the pancreas fails to develop properly during fetal development.A 27-year-old female presented to the Outpatient Department with a 5 day history of progressively worsening abdominal pain. The pain was mainly localised over the epigastrium and left flank and was relieved only after receiving intravenous medications. She also experienced multiple episodes of vomiting that contained food particles and were not bile-or blood-stained. The patient reported a decrease in appetite, generalised weakness, easy fatigability, anddizziness. Additionally, she complained of retrosternal discomfort and a foreign body sensation in the upper one third region of the chest. The patient had a history of altered bowel habits, with alternating constipation and diarrhoea. She had been admitted to the hospital twice before for the same complaints, and each time, the symptoms were managed conservatively. Upon examination, the patient appeared to be in fair general condition with stable vital signs. Her heart rate was 84 beats per minute, her respiratory rate was 22 breaths per minute, her blood pressure was 120/80 mmHg, and her oxygen saturation was 99% in room air. An abdominal examination revealed a soft, non-tender abdomen with normal bowel sounds. Other system examinations, including chest and cardiovascular findings, were unremarkable.3, haemoglobin 12.46 g/dL, platelet count of 261,500/mm3, serum albumin 3.5 g/dL, aspartate aminotransferase 30 U/L, alanine aminotransferase 26 U/L, and alkaline phosphatase 67 U/L. The total bilirubin was 0.4 mg/dL with a 0.2 mg/dL direct fraction. Serum amylase and lipase were within the normal range. An abdominal computed tomography (CT) scan showed a normal-appearing pancreatic head and the complete absence of the neck, body, and tail  and uncinate process and gives rise to the Wirsung duct/main duct which drains through the major papilla. The dorsal pancreatic bud forms the body and the tail of the pancreas and gives rise to the accessory pancreatic duct (Duct of Santorini) which drains through the minor papilla.4 In a few instances, dorsal pancreatic agenesis remained a diagnostic challenge in the evaluation of abdominal pain.5 The exact genetic pathogenesis of ADP is still unknown. Some literature suggests that Hepatocyte Nuclear Factor 1-beta and GATA Binding Protein 6 genes were proven to be correlated with the embryogenic development of the pancreas.6 However, experiments in mice showed that mutation in retinaldehyde dehydrogenase 2  and gene H1xb9 or deficiency of retinoic acid resulted in ADP.7ADP is mostly asymptomatic, but common presenting symptoms include diabetes mellitus, abdominal pain, pancreatitis, enlarged pancreatic head, and, in a few cases, polysplenia.8 However, our patient did not report any symptoms of chronic pancreatitis. In a case of dorsal pancreatic agenesis, in a woman with diabetes mellitus and both of her sons, the pattern of genetic transmission for this anomaly was either autosomal dominant or x-linked dominant.9 However, in our case, there was no associated family history with the patient. As indicated in the literature, dorsal pancreatic agenesis has been linked to various organ anomalies such as multiple splenic malformations, Kartegener syndrome, polycystic kidney disease, congenital choledochal cysts, and biliary atresia.10 Furthermore, neither of the other anomalies was found in our case. In our case, the finding of dorsal pancreatic agenesis is incidental. The patient does not have any other findings or associated comorbidities, as mentioned in the literature. The rigid association has not yet been proved, despite the fact that a small number of research link genetic pathways to its development.A few cases of dorsal pancreatic agenesis that presented with chronic pancreatitis are also reported.Thus, as noted in the earlier literature, our case demonstrates that the dorsal pancreatic agenesis may be an incidental finding with no accompanying characteristics or an odd presentation and further research on its causation and connection is required to fully establish the pathogenesis.


Here, we present a case report on internal carotid artery pseudoaneurysm (ICAP) which highlights a rare but potentially life-threatening complication of transsphenoidal pituitary surgery. A 32-year-old male underwent resection of a pituitary tumor and developed a large cerebrospinal fluid (CSF) leak during surgery, which was reconstructed with a fat graft and nasoseptal flap. Postoperatively, he was recovering well and discharged without complications; however, eight days after surgery he returned with massive epistaxis and hematemesis. This was initially managed with endoscopic exploration, nasal packing, and transfusion of blood products. Imaging revealed a pseudoaneurysm on the right internal carotid artery. The patient was started on aspirin and clopidogrel, and a flow diverter stent was placed without complications. Our case emphasizes the importance of prompt recognition and management of vascular injuries such as an internal carotid pseudoaneurysm after transsphenoidal pituitary surgery to prevent catastrophic outcomes. Transsphenoidal pituitary surgery is a common approach for the treatment of pituitary tumors. However, it carries the risk of internal carotid artery injury, which can result in serious complications. Internal carotid artery pseudoaneurysm (ICAP) is one of the rare but potentially fatal complications that can occur after transsphenoidal surgery . It is aA 32-year-old male presented to our hospital's emergency department with a 2-month history of vision changes and a known pituitary tumor. On examination, he had decreased peripheral vision, with the right side being worse than the left. The MRI pituitary and brain Figures , 2 showeOn the evening of POD 8, he returned to the emergency department with large-volume nasal bleeding and hematemesis. The epistaxis was high flow, high volume, and the bleeding occurred around and through the packing, on the right side. A large amount of oxymetazoline was used on the packing in both nostrils, and dissolvable packing was placed by the on-call otolaryngology team. The patient was noted to be pale and found to be tachycardic to 120s. Due to the large volume of epistaxis, the decision was made to take the patient emergently to the operating room (OR) to explore the possibility of arterial bleeding. Type & screen and three units of blood products were held for the OR. While being transported to the OR, he had right-sided epistaxis around the packing again. He was intubated through rapid sequence induction and the packing was endoscopically removed from the right side of the nasal cavity. During the nasal cavity exploration, a large volume of blood was noted to pool from the right sphenoid sinus above the CSF leak repair site. Packing with gauze was necessary to control the bleeding. The patient was transfused with red blood cells while he was taken emergently to interventional radiology.A carotid artery angiogram was performed which revealed a pseudoaneurysm on the right side of the internal carotid artery around the level of the cavernous sinus Figures , 6. The Transsphenoidal pituitary surgery is a common procedure used to treat pituitary tumors located at the base of the brain. Despite being a minimally invasive approach, it carries the risk of complications, including vascular injury. Here we presented a case of ICAP after transsphenoidal surgery. This is a rare, but potentially fatal vascular complication. ICAP occurs when there is a disruption of the arterial wall that leads to a sac-like structure filled with blood outside the arterial wall. In this paper, we will discuss the management and treatment options for ICAP after transsphenoidal pituitary surgery, including endovascular and surgical techniques.The reported incidence of ICAP in skull base surgery ranges from 0.4% to 7.4% -4. The tPrompt diagnosis and management are essential to prevent catastrophic outcomes. The gold standard for the diagnosis of ICAP is digital subtraction angiography (DSA) . In hemoThe use of flow diverters provides an excellent option for the endovascular treatment of intracranial pseudoaneurysms; however, their use does not come without risks. Complication rates have been reported around 17% with permanent morbidity rates and mortality rates of 3.7% and 2.8%, respectively . Rates oIt is fortunate that the authors were in a situation where gauze was able to control the bleeding from the ICAP. In other situations, this may not be the case and more rapid and aggressive treatments may be needed. We also were fortunate to have a neuro-interventional radiologist readily available, which is not the case at all institutions. It is important to treat each ICAP on a case-by-case basis and also consider what treatment pathways are available within your hospital system. Figures Overall, ICAP is a rare but potentially fatal complication of transsphenoidal pituitary surgery. The risk factors for ICAP should be carefully considered preoperatively, and prompt diagnosis and management are essential to prevent catastrophic outcomes. The initial focus in a bleeding patient should be control of bleeding which can best be accomplished by packing with non-absorbable materials. Endovascular management with balloon occlusion, embolization, flow diverter stent, or pipeline embolization device has been reported as a safe and effective treatment for ICAP, and surgical management with arterial ligation or revascularization may be necessary in some cases. Following treatment, packing should be removed in the OR or interventional radiology suite as bleeding can occur. A multidisciplinary approach involving neurosurgery, interventional neuroradiology, otolaryngology, and vascular surgery is essential for the optimal management of ICAP.


Recently recognized as a distinct entity, a myxoid glioneuronal tumor (MGNT) is a rare, low-grade central nervous system tumor. MGNTs are commonly located at the septum pellucidum or in the third ventricle, increasing the likelihood of tumor or treatment-related damage to adjacent structures critical for memory, such as the fornix. Though there have been a handful of case reports of neurosurgical and oncological outcomes of MGNTs, memory outcomes following resection of MGNTs adjacent to the fornix have not been previously reported.We present a case of a high functioning female for whom an MRI revealed an incidental finding of an intraventricular tumor adjacent to the fornix bilaterally. The patient underwent resection of the tumor followed by MRI surveillance without additional oncologic intervention. Due to reported cognitive problems, the patient was referred for serial neuropsychological evaluations.Post-operative MRI following resection revealed cytotoxic edema followed by selective, progressive atrophy of the bilateral anterior fornices. Post-surgically, the patient developed an isolated verbal memory impairment, which persisted one-year post resection with minimal improvement. The memory impairment impacted the patient’s everyday functioning, including the ability to work in a cognitively demanding job.This unique case demonstrates the critical role of the bilateral fornix in verbal memory and underscores the importance of a careful risk/benefit analysis when considering neurosurgical intervention to MGNTs and other intracranial lesions adjacent to this structure during neurosurgical planning. Myxoid glioneuronal tumor (MGNT) is a rare central nervous system tumor, first described in 2018 , 4. TherIn humans and animals, the fornix is a critical structure supporting episodic memory , 6. DamaWe present a patient diagnosed with an intraventricular MGNT adjacent to the fornix bilaterally who developed a selective verbal memory impairment following an uncomplicated transcallosal resection. Subtotal resection was carried out, with no disruption to the tumor adjacent to the fornices. There was no significant bleeding, and no macroscopic blood vessels were encountered. The patient developed post-operative cytotoxic edema followed by atrophy of the bilateral fornices. Neuropsychological testing demonstrated anterograde verbal memory impairment, which corresponded to the loss of forniceal function. We highlight the role of the fornix in memory and discuss implications for clinical management of similar patients.An otherwise healthy right-handed female in her 30s with 20 years of education presented to the emergency department after a motor vehicle crash in which she was the driver and was hit head-on by another driver. A full trauma evaluation revealed orthopedic injuries, with no evidence of head injury, loss of consciousness, or focal neurological symptoms. A CT revealed an incidental brain mass, which led to referral for MRI that demonstrated a non-enhancing lesion measuring 2.2 cm centered at the right aspect of the septum pellucidum . She completed speech therapy and cognitive rehabilitation which helped her to employ compensatory strategies, including using a detailed daily journal and calendar reminders.The patient completed a neuropsychological evaluation 4- and 12-months post-resection. We present the unique case of a young high functioning woman who suffered a new-onset verbal memory impairment following transcallosal resection of an intraventricular MGNT that impinged upon the fornix bilaterally. Notably, the memory impairment persisted one-year following surgery. This serves as strong evidence that isolated damage to the bilateral anterior fornices can produce a selective and sustained memory impairment similar to hippocampal lesions . This isdiffuse damage, such as thiamine-deficient Korsakoff syndrome  given its narrow size, sharp bending angle, and close proximity to the ventricles leading to a high susceptibility to partial voluming and effects of crossing fibers  for the publication of any potentially identifiable images or data included in this article.AS: Conceptualization, Data curation, Writing – original draft. EK: Conceptualization, Writing – review & editing. JR: Conceptualization, Formal Analysis, Visualization, Writing – review & editing. JK: Data curation, Writing – review & editing. NF: Conceptualization, Data curation, Visualization, Writing – review & editing. VG: Data curation, Visualization, Writing – review & editing. MS: Conceptualization, Writing – review & editing. JS: Conceptualization, Writing – review & editing. CM: Conceptualization, Supervision, Writing – review & editing.