Solid pseudopapillary neoplasms (SPNs) of the pancreas are rare tumors, comprising about 1 % of pancreatic tumors. They primarily affect females during their reproductive phase and have a favorable prognosis. SPNs are usually asymptomatic or present with mild symptoms. The exact histopathogenesis of SPNs remains unknown. Surgical resection is curative, and central pancreatectomy is a pancreas-sparing surgical technique.A 33-year-old female presented with epigastric pain, vomiting, and infertility. Imaging revealed a mass in the pancreas. Exploration confirmed the mass, and central pancreatectomy was performed. Histopathology confirmed the diagnosis of SPN. The patient's recovery was uneventful, and follow-up CT scans showed no recurrence.This case involves a 33-year-old female presenting with epigastric pain and vomiting, revealing a cystic mass with a solid component in the pancreas. While generally benign, SPNs can become malignant in 15 % cases, with a favorable prognosis. Histopathologically, SPNs remain distinct, with CD99 and CD10 staining confirming the diagnosis. Diagnostic imaging, particularly CT scans, aids in identifying SPNs. Surgical resection, such as central pancreatectomy, is effective, preserving organ function. The case's positive outcome aligns with an overall 5-year survival rate of 95–97 %, highlighting the overall favorable prognosis of SPNs. The procedure's balance between tumor removal and organ preservation offers clinical advantages.This case underscores the successful management of an SPN using central pancreatectomy. It highlights the importance of early diagnosis and surgical intervention, as well as the favorable prognosis associated with SPNs, even in cases of metastasis. Central pancreatectomy offers organ preservation and reduces long-term complications. Continued reporting and research on such cases contribute to refining treatment strategies for SPNs. •This report innovates SPN management via central pancreatectomy and pancreaticogastrostomy, showcasing its feasibility.•Rare SPNs mainly impact young females, stressing early diagnosis and ideal treatment for a promising prognosis.•A 33-year-old female with epigastric pain revealed a mass at the pancreatic neck-body junction, emphasizing the need for careful evaluation.•Central pancreatectomy preserves organ function, minimizes pancreatic insufficiency risk.•Central pancreatectomy's success and recurrence-free follow-ups highlight its efficacy in managing SPNs SPNs are2A 33-year-old female presented with epigastric pain that extends to both sides, which occurred 3 to 4 h after eating. She also experienced occasional non-projectile vomiting with partially digested food. Additionally, she had a history of oligomenorrhea and primary infertility for the past 12 years. There were no documented instances of weight loss. Her medical history included a past typhoid fever case but no previous surgeries.Upon evaluation, an ultrasonographic scan of her abdomen and pelvis confirmed the presence of cholelithiasis. She was scheduled for a laparoscopic cholecystectomy at a different hospital. Before the procedure, a repeat ultrasonographic scan was performed to confirm the cholelithiasis and examine the pancreas. The ultrasound showed a 27 * 32 mm hypoechoic lesion in relation to the body of the pancreas, while the head and tail were normal after which a CT scan was ordered. The CT scan confirmed these findings, and an EUS showed a well-defined, rounded cystic mass with a solid component at the junction of the head and body of the pancreas. See  MultipleSubsequently, the patient was referred to a tertiary care setting. The necessary blood tests and examinations were carried out. On upper abdominal palpation, mild tenderness was noted in the epigastric region. Other aspects of the physical examination appeared normal. Her hemoglobin level was 12.3 g/dl, and her T. bilirubin, SGPT, and ALP levels were within normal ranges. Renal function tests (RFTs) and coagulation profiles were also normal, and virology results were negative. Based on the above findings and a negative metastatic workup, she agreed to undergo exploration. As a result, she underwent elective exploration using a median approach.During the exploration, a mass was discovered at the junction of the pancreatic neck and body. See  In respoThe resected specimen was sent for histopathological examination, which confirmed the preoperative diagnosis of a solid pseudopapillary tumor of the pancreas. The surgical margins were free of tumors, and immunohistochemistry showed dot-like positivity for CD99 and overall positivity for CD10.The postoperative period was uneventful, with the patient resuming oral intake shortly after the surgery. Regular serum blood glucose monitoring and early mobilization were conducted, and no immediate complications arose. She was discharged from the hospital after a week.The patient attended follow-up visits and underwent CT scans. The most recent CT scan revealed a normal pancreatic body, uncinate process, and tail. The pancreatic duct was draining into the posterior wall of the stomach body, with no evidence of a mass at the anastomosis site, and the anastomosis remained intact. See .Fig. 4CT3Solid pseudopapillary neoplasms of the pancreas are extremely rare, constituting approximately 1–6 % of all pancreatic tumors. Initially referred to as “benign or malignant papillary neoplasms of the pancreas,” these lesions have been designated by various names, including solid and cystic lesions of the pancreas, papillary cystic lesions, and Frantz tumors.  In 1996,SPTs typically present with non-specific symptoms, and they are often discovered incidentally. Some common symptoms include abdominal pain, nausea, vomiting, dyspepsia, weight loss, and the presence of a slowly growing abdominal mass. In some cases, they can also manifest as jaundice, pruritus, asthenia, back pain, and pancreatitis.  In this SPTs are known for their characteristic features and can occur in various locations within the pancreas, though they are most frequently found in the head or tail.  In the pThe primary treatment for SPNs is complete or radical resection, even in cases with advanced disease and metastasis.  Organ prIn this specific case, the patient underwent a central pancreatectomy with pancreaticogastrostomy for the mass located at the junction of the neck and body of the pancreas. Fortunately, SPTs have a favorable prognosis, even in cases of metastasis and local recurrence, with an overall 5-year survival rate of 95–97 %. Local recurrence occurs in less than 10 % of cases and usually happens around 4 years after surgery. ,17 Posto4In conclusion, this case report highlights the successful management of a rare solid pseudopapillary neoplasm (SPN) of the pancreas using central pancreatectomy with pancreaticogastrostomy. SPNs, though rare, predominantly affect young females and can present with non-specific symptoms. Early diagnosis and prompt surgical intervention are essential for achieving favorable outcomes. Central pancreatectomy offers the advantage of organ preservation while maintaining high oncological efficacy and reducing long-term complications. Overall, the patient had an uneventful postoperative period and remained free from recurrence during follow-up visits. This reinforces the generally excellent prognosis associated with SPNs. Continual reporting and research on such cases will contribute to a better understanding of SPNs and aid in refining treatment strategies for optimal patient care. The success of central pancreatectomy in this case underscores its viability as a preferred surgical option for selected SPNs, providing valuable insights for future clinical management.N/AWritten informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.N/A.Not commissioned, externally peer reviewed.There was no conflict of interest to declare.


Scar endometriosis refers to the presence of endometrial glands and stroma at the site of a scar. Hemangiomas, on the other hand, are benign vascular tumors. In this case report, we unravel the clinical enigma around a patient who presented with a painful mass at the previous cesarean section scar site. Initially, we were confident that this was ectopic endometrium presenting as scar endometriosis. However, our journey took an unexpected turn when histopathological findings contradicted our clinical suspicions. Here, we delve into the intricate details of this captivating case, shedding light on the complexities of the diagnosis we faced. Endometriosis is a gynecological disease, characterized by the development and presence of endometrial tissue in places outside of the uterine cavity. The most commonly affected areas include the ovaries (54.9%), followed by the posterior broad ligament 35.2%), anterior cul-de-sac (34.6%), posterior cul-de-sac (34.0%), and the uterosacral ligament (28.0%) . Scar en%, anteriHemangiomas are benign overgrowths of blood vessels and endothelial cells, found either in the outer layers of the skin, deeper layers of the skin, internal organs, subcutaneous tissue, or sometimes in multiple locations simultaneously. Hemangiomas are categorized as capillary or cavernous based on the size of the vascular channels. Capillary hemangiomas have small diameter vascular channels. On the other hand, cavernous hemangiomas have large diameter vascular channels . While hA 34-year-old South Asian female presented to the clinic with chief complaints of swelling and associated pain in the right lower abdomen, specifically over the lateral aspect of the previous cesarean section scar on the right side, which had been bothering her for the past 10 months. The patient has two healthy children delivered via lower segment cesarean section (LSCS). The patient noticed the development of this swelling during her second pregnancy, around the fifth month, over the LSCS scar of the first pregnancy  by the operating surgeon during the delivery of the second baby. But then, it gradually increased in size to measure 3 cm x 2 cm. Throughout the second pregnancy and the initial three months following delivery, the skin over the swelling was normal. However, with the onset of menstruation, the skin over the swelling began to peel off and was accompanied by serous discharge. The swelling also exhibited color changes in relation to the menstrual cycle. It appeared with a bright reddish hue just before the onset of menses and turned pale pinkish after menstruation. It is important to note that the patient did not complain of any bleeding from the swelling.Additionally, the patient noticed that the swelling became harder in consistency during menstruation, compared to its firm state at other times. She complained that the intensity of the pain varied in accord with her menstrual cycle. The pain typically spiked during the time of menstrual blood flow, which usually lasts for about five days in this patient. However, she also reported a period of gradual waxing of pain, for about three days before the onset of menstrual flow, and a subsequent period of waning of pain, for about three days after the passage of menses. The patient also reported experiencing intermittent pricking pain, that lasts for about five minutes per episode, over the swelling at times other than during menstruation.InvestigationsUltrasound ImagingAfter the initial clinical workup was done, she was sent for an ultrasound imaging of the mass. The scan showed a heteroechoic lesion, measuring 2.9 cm x 1.8 cm at the scar site in the subcutaneous plane. Color flow revealed rich vascularity.Magnetic Resonance ImagingFurther imaging studies were considered necessary. So a magnetic resonance imaging (MRI) of the abdomen and pelvis was taken. It showed a well-defined polypoidal, intensely enhancing soft tissue mass with internal hemorrhagic foci and significant vascularity, in the lateral aspect of the postoperative scar site on the right side measuring 3.2 cm x 2.2 cm x 1.8 cm in size, with adjacent skin thickening (Figure TreatmentAfter a proper workup, excision and biopsy of the swelling was planned. Owing to the easy excisability of the lesion, no trial of hormonal drug therapy was tried. The excision and biopsy was performed under local anesthesia and was uneventful without any complications. The excised mass Figure  was sentHistopathologyThe excised mass was sent in for histopathological studies. The cut surface of the mass was noted to be gray-brown in color. A thorough study of sections from the sample, under the microscope, showed fibrocollagenous tissue with dilated proliferating blood vessels, areas of hemorrhage and inflammatory cell infiltrates Figure . EndometFollow-UpAfter two weeks, the patient reported back to the clinic for removal of sutures. The scar site was healthy with no discharge. No residual signs were noted, and the sutures were removed. Telephonic follow-up after one month from the date of the procedure was done. The patient was informed of no residual symptoms.Scar endometriosis typically presents with localized cyclical pain, often occurring in conjunction with menstruation. The pain is characterized as sharp, localized discomfort that intensifies during menstruation, reflecting the influence of hormones on endometrial tissue. Other manifestations include a palpable mass or swelling at the cesarean scar site which may present with tenderness ,6. The eThe clinical presentation of hemangioma depends on its location and depth within the body. The majority present as a single localized cutaneous mass. Hemangiomas most commonly occur on the head and neck region, accounting for 60% of cases. Following that, 25% of the cases are seen on the trunk, as in this case. Although 25% is a significant share, all hemangiomas are commonly observed only in infants and are rare to be seen in adults. Hemangiomas can be superficial, deep, or mixed with components of both superficial and deep layers. Superficial lesions involve the superficial dermis and are raised, lobulated, and bright red. Deep hemangiomas, also called subcutaneous hemangiomas, arise from the reticular dermis and/or the subcutis layer and appear as bluish-hued nodule or plaque. Mixed hemangiomas present with features of both locations . The preHemangiomas may sometimes present with pain. However, it is exceedingly rare for superficial hemangiomas to be painful, especially when the surface is intact. Furthermore, it is even rarer for the pain to follow a cyclical pattern. Only hemangiomas with ulceration and spinal hemangiomas are commonly known to cause pain. There is very little literature providing evidence for hemangiomas presenting with such cyclical features. In the case report by Ortiz-Rey et al. , evidencAlthough there are a few more similar clinical evidence in medical literature -12, to oOur case highlights the diagnostic challenges we faced in differentiating scar endometriosis from hemangioma. While scar endometriosis was our initial suspicion due to its clinical presentation, histopathological examination of the excised tissue was crucial for confirming the diagnosis as hemangioma. Although rare, it is vital to keep hemangioma as a probable differential in our minds when faced with similar clinical situations. The importance of accurate diagnosis in cases like these cannot be emphasized enough. Misdiagnosis can lead to inappropriate treatments, such as hormonal therapies commonly used for endometriosis, being administered for cases of hemangiomas, which would be ineffective in treating them. In contrast, a precise diagnosis enables the implementation of the most appropriate treatment plan. Further research is needed to better understand the clinical and histological characteristics of these conditions, facilitating early and accurate diagnosis and improving patient outcomes.


Perigastric and intramural gastric hematomas rarely occur, with most cases associated with trauma, coagulopathy, and peptic ulcer disease. Furthermore, hematomas in the upper gastrointestinal tract are commonly located in the esophagus and duodenum. In this case report, we describe a hematoma masquerading as a gastric tumor on esophagogastroduodenoscopy (EGD) in a 54-year-old male presenting with melena. Initial computed tomography (CT) imaging suggested gastrointestinal stromal tumor (GIST) as the probable cause. We performed endoscopic ultrasound (EUS) with findings consistent with a perigastric hematoma, which aligned with the patient's diagnosis of splenic vein thrombosis (SVT) and numerous collateral vessels communicating with the hematoma. Interventional radiology (IR) was consulted for further management, although we ultimately chose a conservative approach. Most hematomas observed in the upper gastrointestinal tract are in the esophagus and duodenum. When they occur in or around the stomach wall, they are commonly associated with trauma, coagulopathy, and peptic ulcer disease . In the In this case report, we discuss a 54-year-old male with no relevant medical history who initially presented with abdominal pain and melena. Vital signs were stable, although hemoglobin dropped to a nadir of 5.3 g/dL. After transfusion, he underwent an EGD, which showed a large submucosal, noncircumferential mass without active bleeding in the cardia. Biopsies were taken at this time, although they were inconclusive based on the pathology review. Given the appearance of the mass, a gastric tumor/cancer was suspected. Initial CT imaging showed a large complex gastric mass extending both posterior and anterior to the gastric lumen, including a greater than 6 cm component extending posteriorly and contiguous with the distal body and tail and a greater than 10 cm component extending anteriorly contiguous with the splenic flexure colon (Figures 1It can be challenging to differentiate hematomas from other gastric masses on initial imaging such as EGD and CT scans. The differential can be quite broad and includes tumor/cancer, lymphoma, and abscess. Furthermore, gastric tumors and cancer such as GISTs may also present as intramural gastric hematomas or following rupture with extensive intraabdominal hemorrhage, which can complicate the diagnosis , 3. In aTreatment of SVT is far from standardized and may involve anticoagulation therapy, thrombectomy, other endovascular procedures, management of underlying conditions, such as cirrhosis and pancreatitis, and even surgery if indicated . There iTo date, no definitive diagnostic approach or therapy for intramural/perigastric hematomas has been proposed. Considering the precarious nature of these hematomas, endoscopic procedures may exacerbate bleeding diatheses, particularly with biopsies or submucosal injections. Upon discovery of an intramural gastric hematoma, initial management generally requires appropriate blood and volume resuscitation and correction of any coagulopathy. It appears that most cases are managed conservatively depending on the patient's hemodynamic stability –12. ConsPerigastric/intramural gastric hematomas should be included in the differential diagnosis for patients presenting with gastrointestinal bleeding and found to have a gastric mass, particularly in those with a history of trauma, coagulopathy, and PUD. Patients with known splenic vein thrombosis and varices/collaterals warrant an even higher suspicion for hematoma. EGD and CT imaging are typically part of the initial workup; however, EUS can provide a more definitive diagnosis. In our patient, this revealed a perigastric hematoma secondary to splenic vein thrombosis with continuity to adjacent prominent collaterals. Management is typically multidisciplinary, although conservative management is often chosen, which involves serial monitoring of the hematoma, controlling underlying conditions, blood and fluid resuscitation, and symptom relief.


Spontaneous cerebrospinal fluid (CSF) rhinorrhea develops in patients without any history of trauma. Multiple factors have been theoretically debated. Also, localizing the defect may result in a challenge for the rhinologist. The common locations are the cribriform plate and the lateral recess of the sphenoid. Clival CSF rhinorrhea is rare, and only few cases have been reported so far. A 52-year-old female presented to the otolaryngology clinic with 7 years of history of left-side clear fluid rhinorrhea as a drop, which progressed to be runnier after she had pneumonia with severe cough secondary to COVID-19 infection. CSF was confirmed by a beta-2-transferrin test. During the perioperative evaluation, she developed meningitis which was treated with IV ceftriaxone and IV vancomycin antibiotics. The magnetic resonance imaging (MRI) and computerized tomography (CT) scan showed clival defect with pseudomeningocele which was initially not easy to see on CT. The patient underwent an endoscopic approach to the skull base to repair the defect with a pedicled septal flap. Also, a lumbar drain with intrathecal fluorescein administration was utilized. The postoperative course was uneventful without any complications. There was no evidence of recurrence with a 9-month follow-up postoperatively. Etiologies for CSF rhinorrhea are divided into traumatic and nontraumatic causes; nontraumatic causes are then subdivided based on the intracranial pressure (ICP), either normal or raised . SpontanA 52-year-old female, known to have hypertension and obesity with BMI 33, presented to the otolaryngology clinic complaining of 7-year history of left-sided clear rhinorrhea started as a drop with on and off headaches. Then, 3 months before presentation, she had developed pneumonia secondary to COVID-19, which resulted in severe cough, and at that time, she noticed her rhinorrhea became worse, which aggravated with bending forward. Her clear fluid was tested by beta-2-transferrin which confirmed CSF. Her CT skull base without contrast Figures  showed cThere are multiple factors that could possibly lead to spontaneous CSF leak, anatomical and physiological . AnatomiGiven its rare location, it is considered a challenge in terms of diagnosis and possibly surgical management. There were cases reported as being missed, leading the patient to present with recurrence because they were operated on without knowing the exact location of the defect and assuming the possibility of it being in the common areas . The sta


Uterus didelphys is a congenital anomaly of the female reproductive tract which arises from the abnormal fusion of the Mullerian ducts. We present, the first case to the best of our knowledge, of uterus didelphys with a unicavitary twin gestation to be documented in Ghana, a low-middle income country. A 24-year-old woman, gravida 3, para 0+2 miscarriages, was seen and admitted to our maternity ward due to elevated blood pressure with ++ proteinuria at 36 weeks of gestation. She attended an antenatal clinic regularly during the pregnancy but was mainly seen by midwives. Apart from multiple pregnancy, two 2D ultrasound examinations (one at 25 weeks gestation and another during admission) did not reveal any uterine malformations. At 37 weeks+2 days, she underwent emergency cesarean section on account of pre-eclampsia and a twin pregnancy with the leading twin in breech presentation. After delivering both babies and the placenta, the uterus was exteriorized and inspected, during which a non-gravid bulky left uterus was first found. Each uterus had a normal ovary and fallopian tube on its lateral end. Further postoperative examination revealed a normal-looking vulva, two vaginas, and two cervices. Both babies weighed 1.9 kg, each below the fifth percentile of weight for age. The elevated blood settled postoperatively and the postoperative period was uneventful. The patient and twins were found in a stable condition on review two weeks after delivery and the twins were healthy at 5 years. Despite being a rare presentation, we wish to create awareness among health workers in rural and low-resource settings of such cases and highlight the need to improve prenatal diagnostic capabilities, as this is key to determining the mode of delivery and achieving favorable maternal and fetal outcomes. Twin gestation in uterus didelphys is rare, with an incidence of one in 3000 . It presPatient information: a 24-year-old woman, gravida 3, para 0 + 2 miscarriages, was seen and admitted to the maternity ward of Catholic Hospital, Battor, Ghana on account of elevated blood pressure (BP) with proteinuria of (++) at 36 weeks of gestation . She attended an antenatal clinic regularly during the pregnancy but was mainly seen by midwives. The pregnancy till then had been uneventful with normal BP measurements and unremarkable laboratory test results. She had no family history of congenital anomalies. She had experienced two uncomplicated miscarriages which were not managed in the hospital; thus, she had not been thoroughly examined.Diagnostic assessments: although the patient presented for her antenatal booking visit at 7 weeks of pregnancy, she had only undergone two obstetric ultrasound scans, both of which were 2D and abdominal. Her first obstetric scan was performed at her seventh antenatal visit at an estimated gestational age (EGA) of 25 weeks + 3 days and her second ultrasound scan was performed during the current admission. Apart from a diagnosis of multiple pregnancy, none revealed any uterine anomaly. Transvaginal and 3D abdominal scans were unavailable.Timeline of current episode: on admission, the patient was pale. A complete blood count revealed moderate anemia, with a hemoglobin level of 8 g/dL, which was managed via whole blood transfusion. Bedside ultrasonography showed twin gestation with the leading twin in breech presentation. On day 2 of admission, her BP increased to 170/120 mmHg; thus, treatment with antihypertensives was initiated. She was diagnosed with preeclampsia and managed according to our institutional protocol. At an EGA of 37 weeks + 2 days, she was prepared for an emergency cesarean section on account of pre-eclampsia and a twin pregnancy with the leading twin in breech presentation.Therapeutic interventions: under spinal anesthesia, the abdomen was entered via a Pfannenstiel incision and the right uterus containing both babies was entered through a lower segment transverse incision. A set of dichorionic, diamniotic, live male twins was delivered. The appearance, pulse, grimace, activity, and respiration (APGAR) scores were 9 and 9 at 1 and 5 minutes, respectively, for the leading twin and 7 and 9 at 1 and 5 minutes, respectively, for the second twin. The first twin was in breech presentation while the second twin had a cephalic presentation. The placentas were located in the anterofundal aspect of the right uterus. After delivering both babies and the placenta, the uterus was exteriorized and inspected. It was then that a non-gravid left uterus was first found and observed to be slightly bulky .Patient perspective: the patient was satisfied with the care she received during her antenatal visits and during and after delivery.Informed consent: written informed consent was obtained from the patient for the publication of this case report and its accompanying images.th percentile for their EGA of 37 weeks, indicative of growth restriction. If the leading twin had a cephalic presentation, there would have been the option of induction of labor. In assessing the favorability of the cervix for vaginal delivery, one might confuse which cervix is leading to the uterus carrying the fetuses. This could lead to a diagnosis of an unfavorable cervix, leading to a cesarean section when a vaginal delivery would have been possible. Diagnostic modalities are not readily available at most district facilities and where available, patients may not be able to afford them. In low-resource settings such as ours, many cases likely go undetected due to poor health-seeking behavior and the unavailability of diagnostic equipment. This is particularly true in the largely rural populations of Ghana characterized by prevailing poverty and different forms of obstetric delays. This also implies that women have poor access to care, as seen in our patient, in whom poor health-seeking behavior likely prevented the diagnosis of uterus didelphys as a possible cause of prior miscarriages. For the current pregnancy, in which her level of antenatal care-seeking behavior was considered acceptable, a low index of suspicion and inadequate imaging led to the missed diagnosis of uterus didelphys. Her uterus didelphys went undiagnosed after two previous miscarriages and two 2D antenatal ultrasounds until she underwent a cesarean section for the current pregnancy.Uterus didelphys with twin pregnancy is a very rare presentation. It occurs following abnormal fusion or canalization of the Mullerian ducts during the fetal period. The prevalence of uterus didelphys in Ghana is currently not documented; however, it has a global prevalence of 5.5-6.6% in the general population . These iIn low-resource contexts, the possibility of few reported cases may be attributed to an interplay between having uncomplicated pregnancies or deliveries and the likelihood of missing a diagnosis due to diagnostic limitations. There may also be a low interest among obstetricians to report such rare cases. In the absence of any standard guidelines, the low rate of reporting makes it important to document clinicians´ experiences in managing such cases, particularly given the high incidence of poor outcomes of pregnancies in women with uterine malformations in general. Some researchers have recently called for the continuous publication of case reports pertaining to the management of twin gestation in uterine malformations to broaden the data available on such rare presentations . Others We present a rare case of uterus didelphys with twin gestation, both babies in one uterus, which is rarely reported. Early identification can influence management in pregnancy and after delivery. Despite being a rare presentation, we wish to create awareness among health workers in rural and low-resource settings of such cases and highlight the need to improve prenatal diagnostic capabilities, as this is key to determining the mode of delivery and achieving favorable maternal and fetal outcomes.


Pediatric neck infections and their complications, such as abscesses extending to deep neck compartments, are potentially life-threatening acute conditions. Medical imaging aims to verify abscesses and their extensions and exclude other complications. Magnetic resonance imaging (MRI) has proven to be a useful and highly accurate imaging method in acute neck infections in children. Children and adults differ in terms of the types of acute infections and the anatomy and function of the neck. This pictorial review summarizes typical findings in pediatric patients with neck infections and discusses some difficulties related to image interpretation. Most conventional neck infections can be managed conservatively. However, deep neck infections possess a high risk for serious complications, such as abscess formation, mediastinitis, airway compromise, and venous thrombosis due to the infection spreading along the fascial planes and potential face and neck spaces. These complications are potentially lethal . In chilPediatric acute neck infections arise from common infections originating in the ears, nose, or throat and have the potential to disseminate to the deep neck spaces through direct continuity or lymphatic drainage to the lymph nodes . When adIn clinical practice, these infections have typically been imaged with contrast-enhanced computed tomography (CECT) ,8, whichThe purpose of the current pictorial review is to present typical neck infection MRI findings in children, including the most useful edema patterns and typical abscesses, and underline the potential caveats and complications associated with deep neck infections. We focus on the soft tissue of the neck above and below the hyoid bone. Pediatric non-traumatic emergencies of the orbits, nose, and ear have recently been covered elsewhere .®; Guerbet, Villepinte, France) is routinely used. T2-weighted imaging is useful in assessing the anatomy: fat and water have a bright signal, lymphoid tissue has an intermediate signal, muscles have a low signal, and cortical bone has no signal. Specific edema patterns can be appreciated as bright areas in the fat-suppressed, T2-weighted images. We prefer the Dixon method for fat suppression because it reliably yields homogenous images even with large fields of view. The T1-weighted axial sequence is used to reference post-contrast Dixon sequences and to detect bone marrow fat obliteration in odontogenic neck infections. Pre-contrast T1-weighted sequences are also useful in assessing postoperative hematomas and chronic fluid collections, which may have a high T1 signal intensity. Together with diffusion-weighted imaging (DWI), contrast-enhanced sequences are used for diagnosing and characterizing abscesses. These sequences are important for assessing cystic masses, tumors, and necrotic lymph nodes [2. In the context of neck infections, the DWI serves two functions. First, it is used for demonstrating or excluding diffusion restriction related to purulence in abscesses, and second, it is used for detecting lymphoid tissue in tonsils and lymph nodes. Our MRI protocol is consistent with the protocol suggested by a recent multicenter international consensus paper [We utilized the Philips Ingenia 3 Tesla scanner . Our routine neck infection protocol comprises seven sequences and lasts approximately 30 min . We use ph nodes . The carus paper .MRI has been proven feasible in pediatric patients with suspected neck infections . In our Image quality can be deteriorated by artifacts induced by patient motion or metallic foreign bodies, but the proportion of non-diagnostic MRI scans is low (about 1%) even in the acute setting . EspeciaThe normal anatomy of the pediatric oropharynx is presented in Viral or bacterial infections are the most common causes of acute lymphadenopathy in children . The lymAs lateral lymphadenitis is common in children, the careful analysis of the lymph nodes is essential in looking for suppurative lymphadenitis  which may require surgery or drainage . ChildreThe thymus can often be seen in children as a homogenous mass with smooth margins in the upper mediastinum  and shouIn MRI, we define infection as (1) an abnormal, high signal indicating edema in fat-suppressed T2-weighted sequences or (2) a high signal in fat-suppressed post-contrast T1-weighted sequences indicating pathological tissue enhancement. Abscess MRI criteria include an abnormal isointense or hyperintense collection on T2-weighted sequences with low ADC values and no central enhancement, as well as enhancement surrounding this collection on T1-weighted Dixon post-contrast sequences . In diagReactive, non-suppurative soft tissue edema is common in acute neck infections . While aIn children, two of the most useful edema patterns are retropharyngeal edema (RPE) , and medME is seen in about one-quarter of patients with acute neck infections and can be divided into two categories: anterior and posterior. Anterior ME is commonly a continuum of edema from the visceral and/or anterior cervical spaces, whereas posterior ME is a continuation of RPE caudally. Similar to RPE, ME is encountered as often in children as in adults and is a significant predictor of the length of hospital stay .Tonsillitis (pharyngotonsillitis) is a common oropharyngeal infection. In our previous validation cohort, these types of infections were proportionally less common in children than in adults . MRI finStaphylococcus aureus infections tend to present with lateral lymphadenitis with large infectious mass-like lesions accompanied by widespread soft tissue edema, and careful assessment of both DWI and fat-saturated post-contrast T1-weighted sequences is crucial  in children may be bacterial or viral . In acutIn early lymphadenitis, the lymph node may be necrotic but not yet abscessed. It may be difficult to differentiate between a non-enhancing lymph node with restricted diffusion  and a lymph node with delayed enhancement accompanied by restricted diffusion  . Indeed,Cystic masses, such as branchial cleft cysts, thyroglossal duct cysts, and vascular malformations, comprise the majority of congenital neck masses in children . Some cyGas can be difficult to detect from MRI because the signal void may not be easily distinguished from other areas of low signal . All seqA mediastinal extension is related to a more severe course of illness in both children and adults  Figure . The infMRI findings of mediastinal extension include anterior or posterior edema and/or abscess formation and pleural fluid accumulation . Minor eLemierre’s syndrome has historically been used. With internal jugular vein thrombophlebitis, this syndrome also encompasses bacteremia  secondary to current oropharyngeal infection, resulting in septic emboli [When venous thrombosis in the context of deep neck infection is diagnosed, the eponym c emboli ,37. Lemic emboli  and thusc emboli . The sync emboli .Diagnosing thrombophlebitis is not always simple in MRI, as the thrombus may not be separable from a flow void in T1-weighted sequences . The lacEmergency MRI has been proven to be a feasible imaging method in children with acute deep neck infections. MRI has superior diagnostic accuracy compared to CECT, encouraging more widespread use, especially in younger individuals. The differences between children and adults in anatomic proportions and the distribution of infectious diseases in the neck result in distinctive MRI findings. The subtleties in MRI findings of pediatric deep neck infections require careful assessment and knowledge.To summarize the MRI findings: all acute neck infections cause varying degrees of edema, which is characterized as an abnormally high T2 signal on fat-suppressed images and enhancement shown as a high signal in fat-suppressed post-contrast T1-weighted sequences. For example, edema and post-contrast enhancement of the palatine tonsils and surrounding oropharyngeal mucosa are typical MRI findings in tonsillitis. Abscesses, such as those in peritonsillar, parapharyngeal, and retropharyngeal spaces, exhibit peripheral enhancement and a central, non-enhancing collection of pus, which can be effectively visualized with DWI as low ADC values. The location or extension of the abscess through various anatomical structures  can then be used for proper classification. Careful examination of all MRI sequences is important to avoid various pitfalls. For example, necrotic lymph nodes may be difficult to distinguish from purulent lymphadenitis. Early scans may confuse necrosis and delayed enhancement for non-enhancement, and both can show low ADC values, indicating high cellularity or purulence.


Sinonasal and skull base malignancies are rare tumors which present adjacent to numerous critical anatomical structures. Despite the increased use of endoscopic techniques, many patients still require open surgery. Treatment with surgery requires careful pre-operative planning. Virtual surgical planning and three-dimensional, patient-specific models offer a range of benefits to clinicians in terms of planning tumor resection and reconstruction. In additional, these technologies improve communication with patients, trainee doctors and other colleagues. In this article, we explore the applications of virtual surgical planning in sinonasal and skull base surgery.Sinonasal and skull base malignancies represent a rare, heterogenous group of pathologies with an incidence of 0.556 per 100,000 persons in the population. Given the numerous critical anatomic structures located adjacent to the sinonasal cavity and skull base, surgery for tumors in this region requires careful pre-operative planning with the assistance of radiological imaging and intraoperative image guidance technologies to reduce the risk of complications. Virtual surgical planning (VSP) and three-dimensional models (3DMs) are adjunctive technologies which assist clinicians to better visualize patient anatomy using enhanced digital radiological images and physical stereolithographic models based on patients’ personal imaging. This review summarizes our institutional experience with VSP and 3DMs in sinonasal and skull base surgical oncology. A clinical case series is used to thematically illustrate the application of VSP and 3DMs in surgical ablation, reconstruction, patient communication, medical education, and interdisciplinary teamwork in sinonasal and skull base surgery. Sinonasal and skull base malignancies represent a rare, heterogenous group of pathologies with an incidence of 0.556 per 100,000 persons in the population . DespiteVirtual surgical planning (VSP) and three-dimensional models (3DMs) are adjunctive technologies which assist clinicians to better visualize patient anatomy using enhanced digital radiological images and physical stereolithographic models based on patients’ personal imaging . Three-dWhile the use of VSP and 3DMs has been explored in detail in maxillofacial, orthopedic, and craniofacial surgery, fewer reports have described its application in open or endoscopic sinonasal and skull base surgery. In addition, discussion of its role in guiding ablation in sinonasal and skull base surgery and patient communication for these diseases is more limited. This review summarizes our institutional experience with VSP and 3DMs in sinonasal and skull base surgical oncology. A clinical case series is used to thematically illustrate the application of VSP and 3DMs in surgical ablation, reconstruction, patient communication, medical education, and interdisciplinary teamwork in sinonasal and skull base surgery.n = 280). Cases were excluded where radiological imaging, VSP digital plans, or adequate clinical information were not available. Institutional Review Board approval was granted under an existing protocol to complete this study and written consent was obtained from all patient participants. Patients were staged using the 8th edition of the AJCC [A retrospective review of institutional medical records between 2019 and 2021 was performed to identify cases where 3DMs and VSP were utilized during surgery for sinonasal or skull base malignancies with or without microvascular free flap reconstruction  and magnetic resonance imaging (MRI), with or without positron emission tomography (PET). All cases are discussed at a skull base multidisciplinary tumor board meeting prior to the initiation of treatment.® Maxillofacial, West Chester, PA, USA) or an alternative agent. A formal meeting between the operating surgeons  and a company representative is completed to review the VSP images and design surgical models and cutting guides pre-operatively. In select cases, alternative, reserve cutting guides are designed to permit multiple ablative and reconstructive options based on the intraoperative clinical findings. Reconstructive materials can be digitally superimposed on the model pre-operatively in order to plan precise reconstruction of the surgical defect. A final report detailing the planned cutting guides is presented to the team pre-operatively. In cases where cutting guides for osteotomy are not required, a 3DM may be produced to guide patient communication, education, or planning.The VSP imaging and 3DMs used for surgical planning are created using multiplanar  CT imaging using 0.5–1.25 mm slice thickness, which is converted into de-identified Digital Imaging and Communications in Medicine (DICOM) format with a 0.33 mm × 0.45 mm pixel size. Manufacture of the 3DM is typically completed by DePuy Synthes  involving the lacrimal duct received induction chemotherapy prior to open craniofacial resection incorporating nasal bones and medial maxilla. In illustrative Traditionally, to ensure safe and comprehensive tumor excision, anatomical landmarks based on radiological imaging are used to guide ablation intraoperatively. The surgeon will use two-dimensional (2D) images to understand the anatomic relationships between a tumor and its local anatomy and derive a mental 3D plan. This is combined with the use of intraoperative image guidance to maximize surgical accuracy. The use of VSP and a 3DM permits precise planning and demonstration of incision margins on a physical model based on patient imaging in advance of surgery, which may be particularly useful where anatomy is distorted or obliterated by the tumor. Partial response to induction chemotherapy, pre-operative radiation therapy, and a non-centripetal pattern of tumor response may make recognizing anatomical landmarks more challenging, further strengthening the case for the use of VSP as an aid during surgery. The authors highlight the use of 3DMs to provide precise cutting guides for bony cuts in the midface, which may serve to enhance the quality and accuracy of reconstruction. 3D-printed cutting guides may or may not be used based on tumor location and the ability to affix cutting guides to bone.Case 2 describes an 8-year-old male with a diagnosis of a cT2N0M0 nasopharyngeal embryonal rhabdomyosarcoma treated with chemotherapy and radiotherapy. The patient subsequently developed local recurrence high in the parapharyngeal space closely applied to both the internal carotid artery and external carotid artery branches. In this case, a 3DM and VSP allowed a greater appreciation of the relationship of the tumor and major arteries when communicating the need for preoperative embolization of the proximal internal carotid artery, the internal carotid at the foramen lacerum, and the maxillary branch of the external carotid artery to the patient’s family. This permitted a lip-split approach to en bloc removal of the tumor encompassing the ramus of the mandible, the masticator space, and the parapharyngeal space.Given the rarity and anatomical complexity of tumors in the sinonasal and skull base region, educating patients and their families regarding treatment plans, alternative options, and the associated risks is essential. Frequently, however, this presents a conceptual challenge for patients, who may be presented with 2D radiological imaging during discussion. In this type of case, a 3D rendered image A can be The use of a 3DM in this case assisted understanding of the need for a complex multi-stage treatment process. Improving communication and patient education is one way in which physicians can hope to improve patient satisfaction and outcomes using VSP and 3DMs.Case 3 describes a 69-year-old female who presented with nasal obstruction, facial pain, swelling, and nasal cavity mass. A complete workup confirmed a cT4aN0M0 ethmoid sinus adenoid cystic carcinoma with invasion of the maxillary sinus, sphenoid sinus, and anterior cranial fossa, with abutment of the internal carotid artery (d artery B,C. The Surgical residents and fellows involved in the workup, surgical management, and aftercare of patients with sinonasal and skull base tumors can benefit from the use of VSP and 3DMs A. TraineUsing the 3DM, residents and fellows were able to directly visualize the tumor extent and potential pitfalls of the endoscopic technique employed. This permitted them to assist in complete resection of the tumor with negative margins. Sound anatomical knowledge and competent surgical skills remain the most critical skills for trainees, with VSP and 3DM technology offering great potential to enhance resident and fellow education.Case 4, an 87-year-old female presented with a new diagnosis of a cT4aN0M0 left maxillary sinus SCC. The patient previously underwent multiple surgical resections for an inverted sinus papilloma at outside institutions and presented to our center following rapid expansion of the mass. The imaging highlighted an expansile, multicompartment maxillary sinus tumor measuring 5.5 cm × 3.0 cm, involving the infraorbital nerve and the floor of the orbit, with extraconal orbital spread and infiltration of all the walls of the maxillary sinus (In ry sinus B,C.The patient underwent total maxillectomy with reconstruction with a vertical rectus abdominis myocutaneous free flap and a titanium mesh to reconstruct the orbital floor. VSP and a 3DM were used in this case to demonstrate the anticipated osteotomies and the resulting defect to the reconstructive team in advance of surgery A. Using Use of VSP in this case was focused on assessing the best possible reconstructive options for this elderly patient and reducing the operative time while enhancing the patient’s functional and cosmetic outcomes. Further potential advantages of VSP and 3DMs are the ability to plan prosthodontic rehabilitation pre-operatively as well as applying cutting guides not only for the ablative osteotomies but also the reconstructive osteotomies, for example, in scapular or fibular free flap reconstruction. This patient underwent successful resection and reconstruction without complication.Case 5 describes a 54-year-old female presenting with a cT4aN0M0 spindle cell sclerosing rhabdomyosarcoma involving the anterior skull base, ethmoid sinus, frontal sinus, and orbit (nd orbit A,B. TreaAn open craniofacial resection with skull base reconstruction using a peri-cranial flap, calvarial bone graft, and radial forearm free tissue transfer was ultimately undertaken C. The 3DWe describe the role of VSP and 3DMs in sinonasal and skull base surgery with a thematic clinical case series demonstrating real-world applications in surgical ablation, reconstruction, resident and fellow education, and multidisciplinary teamwork. We particularly highlight the role of 3DMs and VSP in providing potentially more precise oncologic resection and more comprehensive planning for reconstruction. Additionally, the role of VSP and 3DMs in enhancing patient understanding of surgery and improving communication between team members has been discussed as additional benefits of these technologies in the setting of sinonasal and skull base surgery.The role of VSP and 3DMs in mapping tumor extent pre-operatively and to ensure adequate oncologic resection has been established in head and neck surgery, as well as other specialties, but is less completely explored in the skull base field ,8,9. As Precision cutting guides modelled on VSP have been validated in maxillofacial and craniofacial surgery . It is tWe highlight the role of 3DMs and VSP in bony and soft tissue microvascular free flap reconstruction of the skull base. Reconstruction of the skull base typically requires multiple forms of tissue to establish adequate functional reconstruction without CSF leak or other complications. We demonstrate in our series that estimating the size of the ablative defect more precisely using VSP in advance of surgery permits improved reconstruction, as seen in Case 4. We highlight improved bony contact allowing enhanced anatomical reconstruction where VSP/a 3DM is used to plan osteotomies, as well as the possibility to assess nasal anatomy and vasculature for nasoseptal flap reconstruction ,17. OutsThe use of VSP and 3DMs in place of cadaveric specimens has been described in both medical student and resident education . ObtainiNew technologies have also developed in tandem with VSP and 3DMs. Patient-specific instruments designed to conform to a patient’s particular pathology have been described. Manufacture of 3D-printed bone scaffolds which permit bony ingrowth has been reported . The addAs with all new technologies, potential disadvantages exist with VSP and 3DMs. Though some authors have demonstrated reduced costs, the cost of VSP and 3DM technology can be significant . AdditioVirtual surgical planning and 3D modeling offer a variety of benefits in sinonasal and skull base surgery to enhance both the quality of surgical ablation and guide reconstruction in these complex surgeries. In addition to their immediate clinical applications, VSP and 3DMs have potential for use as communication and education tools for both patients and trainees. We highlight 3DMs and VSP as useful tools in the future of the multidisciplinary management of sinonasal and skull base tumors.


Bronchogenic cysts are rare in adults and often remain undetected until discovered incidentally on imaging or during a symptomatic investigation. The possibility of superior vena cava (SVC) compression due to a bronchogenic cyst arises in complex patient presentations. SVC syndrome poses several unique challenges due to the wide range of clinical symptoms and difficulty identifying the cause when symptoms first manifest. This case report examines a 39-year-old male who presented with symptoms resulting from SVC compression caused by a bronchogenic cyst, leading to SVC syndrome. We discuss the various imaging modalities used to assess the severity of the obstruction and the surgical interventions employed to alleviate the symptoms. A surgical intervention provides symptomatic relief and promises an excellent prognosis when performed without complications. Bronchogenic cysts represent a rare congenital condition in adults, resulting from aberrations during embryonic respiratory system development ,2. TheseWe report a unique case of a bronchogenic cyst in a middle-aged man who experienced sudden chest pain, dyspnea, dysphagia, and hoarseness. The patient was found to have a large bronchogenic cyst in the middle mediastinum compressing the SVC, a scenario typically treated through surgical resection. The initial radiographic diagnosis can be challenging due to variable presentation. Imaging studies, including chest X-ray (CXR), CT scan, and MRI, assist in identifying and characterizing these cysts. Histopathology following surgical resection provides a definitive diagnosis.A 39-year-old male with no significant medical history presented to the emergency department with sudden onset of dyspnea, dysphagia, hoarseness, and a sensation of halted blood flow to the brain when bending forward or lifting objects. His symptoms improved with head elevation. Over the previous week, he experienced intermittent chest pain and dyspnea during exertion, accompanied by headaches. A few years earlier, he reported brief, activity-associated episodes of dizziness. He denied experiencing fever, fatigue, anorexia, cough, palpitations, or weight loss and reported no history of chest trauma, smoking, alcohol, or illicit drug use.His vital signs upon examination included a blood pressure of 133/89 mmHg, heart rate of 69 beats per minute, respiratory rate of 14, temperature of 36.9°C, and oxygen saturation of 99% on room air. He was awake, alert, and oriented, without acute distress. His head was normocephalic with no visual field defects. There were no signs of neck swelling or facial plethora. Lung auscultation was clear, and no heart murmurs were detected. His abdomen was soft, nontender, and free of organomegaly. No edema was noted in either the upper or lower extremities, and pulses were present.The patient’s complete blood count, coagulation profile, troponin levels, and renal and liver function tests were within reference ranges. An electrocardiogram indicated a normal sinus rhythm. His CXR revealed an abnormal superior mediastinal contour, suggesting a mediastinal or pulmonary mass. A contrast-enhanced CT scan of the chest Figure  demonstrAn interventional radiologist initially planned to perform a tissue biopsy of the mediastinal mass. However, after consulting with the cardiothoracic surgery (CTS) team, the mass was suspected to be cystic rather than solid. Further evaluation with contrast-enhanced MRI of the chest Figure , 2B confAfter discussions with the patient and his family, a cyst resection via right thoracotomy was performed. Gross and histopathological analysis of the submucosal glands Figure  and ciliBronchogenic cysts, also known as duplication cysts, are congenital malformations that arise from abnormal budding of the embryological foregut during fetal development . They tyObstruction of the SVC can occur due to thrombosis, intrinsic stenosis, or extrinsic compression . This caBronchogenic cysts are usually detected incidentally on CXRs in adulthood  or durinManaging SVC syndrome effectively and promptly necessitates a multidisciplinary team approach. Our priority was to prevent hemodynamic compromise and life-threatening cerebral and upper airway symptoms. Severe SVC obstruction or occlusion can lead to significant morbidity and mortality . ElevatiDiagnosing the cause of SVC obstruction can be challenging without appropriate imaging modalities. Our case underscores the unique presentation of a bronchogenic cyst in the middle mediastinum and the possible complications of such a congenital malformation. In this instance, the cyst’s significant size and location led to SVC obstruction and the patient’s clinical symptoms. Whenever a lesion is discovered, a high index of suspicion for malignancy is crucial, necessitating a swift biopsy to rule out this possibility. The definitive diagnosis of a bronchogenic cyst is usually confirmed by histological examination. Timely and appropriate surgical intervention significantly relieved our patient’s symptoms. This case highlights the importance of a multidisciplinary approach to management, combined with imaging modalities and histological examination, to provide the best possible care for such a treatable lesion.


Gastrointestinal xanthomas are benign, usually sessile, polypoid lesions occasionally incidentally seen in adults, usually in the stomach, but have not been reported in the large intestine in children. We identified xanthomas in the sigmoid colon of the 15-year-old girl confirmed histologically. Our findings suggest that colonic xanthomas may occur as an incidental finding in pediatric patients. They have a characteristic visual and histologic appearance but do not appear to be associated with any symptoms or illness and do not require follow-up. Xanthomas are typically cutaneous lesions demonstrating the accumulation of fatty tissue in the dermis and subcutaneous tissues. These generally appear yellow or white in color and are histologically composed of a dermal infiltrate of lipid-laden foamy histiocytes see Fig. . GastroiHelicobacter pylori gastritis, which required 2 rounds of treatment for the resolution of symptoms and anemia. The patient was subsequently seen 2 years later with a return of abdominal pain and bloating. Because of the family history of inflammatory bowel disease, recurrent anemia, and persistent symptoms, a repeat gastrointestinal endoscopy was performed. The upper endoscopy was normal. Colonoscopy revealed three 1–2 mm smooth yellowish polypoid lesions without any stigmata of bleeding, malignancy, or surrounding gross mucosal abnormalities in the sigmoid colon, while the remaining colon and terminal ileum appeared normal. The lesions appeared inconsistent with any of the common colonic polypoid lesions normally seen in children (see Figs. A 15-year-old female presented to our pediatric gastroenterology clinic with periumbilical, crampy abdominal pain, weight loss, constipation, and bloating. Because of a family history of inflammatory bowel disease, laboratory studies were performed. These demonstrated a hemoglobin of 9.1 milligrams per deciliter, with normal levels of tissue transglutaminase, C-reactive protein, and fecal calprotectin. An upper gastrointestinal endoscopy at that time demonstrated the presence of Gastrointestinal xanthomas in adults are most frequently seen in the stomach and rarely in the esophagus and colon. The mechanism of the development of xanthomas is not known. In the colon, it has been speculated that they may be related to chronic constipation and possibly indicative of prior injury . In thisThis report confirms that colonic xanthomas may occur in children as well as adults, their appearance is somewhat characteristic, and they are likely to be benign and inconsequential. The location of the lesions in our case was inconsistent with the most reported locations in most adults . As thisInformed consent was obtained from the mother before publication.


FNCLCC). The patient is currently under cancer surveillance with no signs of loco-regional recurrence. Spermatic cord liposarcoma is an extremely rare malignancy. It's not easy to identify as it can simulate an inguinal hernia, hydrocele, lipoma, funicular cyst, or testicular tumor. Diagnosis is usually established postsurgery, however, relapses are common and the role of chemo-radiotherapy remains to be defined.Liposarcoma of the spermatic cord is a malignant neoformation so rare that less than 200 cases are reported in the world. It is a tumor that originates from adipose tissue and when it is found in the spermatic cord it can deceptively simulate an inguinal hernia and not be easily identified. The present work describes the case of a 37-year-old man with liposarcoma of the spermatic cord who arrives at our institution with painless swelling of the left testicle. Physical examination revealed a painless swelling in the scrotal sac. The scrotal ultrasound examination revealed a mass, measuring 8 cm  × 5.4 cm  × 8 cm (antero-posterior) and characterized later with a basal CT examination of the abdomen. The patient was subsequently surgically treated with excision of the tumor, plus hernial plastic with plug and mesh. Histological examination revealed a mature adipocyte neoplasm whose morphological and molecular characteristics (amplification of the MDM2 gene) are consistent with the diagnosis of  The inguinal canal in males is a small canal in the lower abdominal wall, that contains the vas deferens, testicular artery and veins, lymphatic vessels, and nerves that make up the spermatic cord. The latter joins the epididymis and testicle within the scrotum and connects to the pelvic cavity. These structures can be involved in a wide range of diseases, including neoplastic, congenital, and inflammatory pathologies, which require a complete anamnesis and physical examination for diagnosis.Spermatic cord liposarcoma is an extremely rare malignancy with fewer than 200 cases reported in world literature ,2. It is■well differentiated, including adipocytic, inflammatory, and sclerosing subtypes;■de-differentiated;■myxoids;■round cell;■pleomorphs.According to the WHO classification ,3 of sofThe histotypes associated with the worst prognosis are the round cell and pleomorphic ones, as they are associated with a higher rate of hematogenous recurrence and metastasis to the lung and bone. In contrast, differentiated and myxoid types are associated with loco-regional relapses ,5.Due to their rare occurrence, spermatic cord liposarcomas are often misdiagnosed as inguino-scrotal hernias, hydrocele, lipomas, funicular cysts, or testicular tumors ,6. RegarUltrasound is chosen as the primary imaging mode for its high sensitivity in characterizing intratesticular and extra-testicular lesions, but also for its ease of execution and availability, and its relatively low cost. Despite suggesting the diagnosis in only about 50% of cases, CT or MRI remain critical tools to guide the diagnosis and surgical planning for suspected malignant lesions within the groin region .Definitive diagnosis through histological, immunohistochemical, and cytogenetic examination remains the gold standard. Classical histology consists of a sarcomatous, nonlipogenic, and usually high-grade cellular component.dediferrentiated liposarcoma variety CO-MINGLED, G2 (sec. FNCLCC)" [. In particular, the examination showed a well-circumscribed nodular proliferation, with peripheral areas of increased cellularity, consisting of mainly mature adipocytes, mixed with elements with cytomorphological characteristics referable to lipoblasts. An abundant myxoid stroma and sometimes branched capillary structures were associated, while no areas of necrosis were found. The sample had the following immunohistochemical characteristics: S100 +, Cd34 -, MDM2 -, Actin ML -, Desmin -, Ki67 5% and mitotic index <1% per field. Currently, the patient is undergoing oncological follow-up by means of an MRI of the abdomen with and without paramagnetic contrast medium and basal CT of the chest, to exclude the appearance of metastasis  Radical orchiectomy, with high bone marrow ligation and large tumor resection, without positive microscopic margins is the essential element in the surgical management of primary spermatic cord neoplasms Given the high risk of postsurgical local recurrence, there is growing evidence that all spermatic cord tumors, regardless of their type and histological grade, are candidates for adjuvant radiotherapy, as they are often resistant to chemotherapy.So spermatic cord liposarcoma is such a rare malignant growth that fewer than 200 cases are reported worldwide in the literature. It is a heteroplastic process that when found in the spermatic cord may not be easily identified by deceptively simulating an inguinal hernia, hydrocele, lipomas, funicular cysts, or testicular tumors. Diagnosis is usually established postsurgery, however, relapses are common and the role of chemoradiotherapy remains to be defined. The patients, therefore, undergo a careful follow-up for the prevention of recurrences, which are very frequent.With this item, we state that informed consent was acquired from our patient for inclusion in the associated study.


Giant hepatic hemangiomas are rare and can cause serious complications that contribute to a high risk of perinatal mortality. The purpose of this article is to review the prenatal imaging features, treatment, pathology, and prognosis of an atypical fetal giant hepatic hemangioma and to discuss the differential diagnosis of fetal hepatic masses.A gravida 9, para 0 woman at 32 gestational weeks came to our institution for prenatal ultrasound diagnosis. A complex, heterogeneous hepatic mass measuring 5.2 × 4.1 × 3.7 cm was discovered in the fetus using conventional two-dimensional ultrasound. The mass was solid and had both a high peak systolic velocity (PSV) of the feeding artery and intratumoral venous flow. Fetal magnetic resonance imaging (MRI) revealed a clear, hypointense T1-W and hyperintense T2-W solid hepatic mass. Prenatal diagnosis was very difficult due to the overlap of benign and malignant imaging features on prenatal ultrasound and MRI. Even postnatally, neither contrast-enhanced MRI nor contrast-enhanced computed tomography (CT) was useful in accurately diagnosing this hepatic mass. Due to persistently elevated Alpha-fetoprotein (AFP), a laparotomy was performed. Histopathological examination of the mass showed atypical features such as hepatic sinus dilation, hyperemia, and hepatic chordal hyperplasia. The patient was ultimately diagnosed with a giant hemangioma, and the prognosis was satisfactory.When a hepatic vascular mass is found in a third trimester fetus a hemangioma should be considered as a possible diagnosis. However, prenatal diagnosis of fetal hepatic hemangiomas can be challenging due to atypical histopathological findings. Imaging and histopathological assays can provide useful information for the diagnosis and treatment of fetal hepatic masses. Congenital hepatic tumors are rare. The three main types of primary congenital hepatic tumors are hemangioma 60.3%), mesenchymal hamartoma 23.2%) and hepatoblastoma 16.5%) [6.5% [1].3.2% and %, mesencA 34-year-old Chinese woman  underwent first- and second-trimester routine ultrasound screening that did not reveal any pathological findings. However, prenatal sonography at 32 gestational weeks revealed a well-defined, solid 2.4 × 2.2 × 2.0 cm-sized mass in the right hepatic lobe that was peripherally hypoechoic and centrally hyperechoic. During fetal breathing movement, the mass showed synchronized movement with the liver. Color Doppler imaging of the lesion revealed prominent vascularity both within the lesion and surrounding it. The peak systolic velocity (PSV) of the feeding artery was 1.35 m/s, and the resistance index (RI) was 0.46 , but no obvious cell atypia. Combined with immunohistochemical results showing CD34 ( +), CD31 ( +), SMA (-), D2-40 (-), ERG ( +), and Glut-1 (-), a diagnosis of congenital hemangioma was ultimately considered Fig. . The patHepatic tumors are rare and account for approximately 5% of all tumors in the fetus and newborn . The mosThis mass combined benign and malignant ultrasonic features. First, in grayscale ultrasound features, it mainly presented as a solid mass without the typical honeycomb-like changes of a hemangioma. We analyzed the imaging observation of a solid mass caused by hepatic cord hyperplasia.This event may have given rise to the dense structure of the mass rather than the “honeycomb” or “grid-like” appearance of typical hemangiomas . Second,We encountered unusual presentations that made it difficult to determine the nature of this mass. The differential diagnosis of fetal hepatic masses was particularly important in this case and included hemangiomas, hepatoblastomas, mesenchymal hamartomas, and metastatic malignant tumors. Fetal hepatoblastoma is a malignant hepatic tumor that arises during in the fetal period, and similarly to hepatic hemangioma, is often detected in late pregnancy. It usually appears as a large, lobulated, and heterogeneous solid tumor . The keyBased on a review of the literature, we find that ultrasound examination can be used to identify several types of fetal hepatic tumors and characterize their location, shape, boundary, composition, vascular distribution, and compressibility as shown in Table In conclusion, the pathophysiological changes of various hepatic masses often present with overlapping imaging features during prenatal imaging. Prenatal ultrasound is a better method for detecting fetal hepatic masses. However, it remains difficult to identify the type of mass based on ultrasound alone. A comprehensive diagnosis should be made based on medical history combined with imaging and clinical data. Finally, ultrasound is a convenient method for follow-up and can guide clinically actionable and effective interventions.


Intestinal obstruction due to adnexal torsion is a rare complication that can be occurred during torsion of an ovarian cyst. A premenopausal woman presented to the emergency department with complaints of abdominal distension, abdominal pain, and obstipation for 2 days. An abdominal radiograph showed signs of large bowel partial obstruction. Hence admission to the surgical department was ordered. Due to deterioration of the patient, a gynaecological evaluation took place. Ultrasonography demonstrated a large ovarian cyst, which was also confirmed by an abdominal computed tomography scan and thus immediate laparotomy was decided. Abdominal hysterectomy with bilateral salpingo-oophorectomy was performed due to torsion of a giant ovarian cyst, which caused intestinal obstruction by compression. The post-operative course of the patient was uneventful. Ovarian torsion should not be eliminated from differential diagnosis when it comes to female patients with clinical presentation relevant to small and/or large bowel obstruction. Ovarian torsion is caused by rotation of the ovary or adnexa with the vascular pedicle on its axes resulting in venous and arterial obstruction . TorsionPatient information: a 47-year-old woman presented to the emergency department with complaints of abdominal distension, abdominal pain and obstipation for 2 days. She also had a history of nausea but no vomiting. She had not visited a gynecologist for annual examination in the past 2 years due to the severe COVID-19 outbreak.Clinical findings: on examination, she was well-built with blood pressure of 110/63 mmHg, pulse rate of 98 bpm and her body temperature was normal. She had mildly distended abdomen though was diffuse tenderness and a mass in her left iliac fossa and suprapubic region. Bowel sounds were present. A digital rectal examination revealed fecal staining in the rectum.Timeline of current episode: an abdominal radiograph showed signs of large bowel partial obstruction. The patient was given 30 ml of gastrografin gastroenteral solution; on the radiograph, the gastrografin appeared to be present in the rectum along with air-fluid levels  findings. I should have never skipped my annual gynecologic examination, due to the pandemic. Fortunately, everything worked out in the end.”Informed consent: written informed consent was obtained from the patient.Ovarian cysts with a diameter of at least 10 cm may cause abdominal pain, swelling and vaginal bleeding . Simple Ovarian torsion should not be eliminated from differential diagnosis when it comes to female patients with clinical presentation relevant to small and/or large bowel obstruction.


This study presents a rare case of hydatid cyst (HC) located in the left thigh, an atypical site for this parasitic infection, which typically affects the liver and lungs. A 22-year-old female presented with a gradually increasing swelling in the anterior aspect of her left thigh over a period of six months. The diagnosis of the thigh HC was established through a combination of imaging techniques, including ultrasonography and magnetic resonance imaging (MRI), and serological tests. The patient underwent surgical removal of the cyst. We also highlight a management strategy for perioperative accidental rupture of the cyst to minimize the risk of dissemination and reduce the likelihood of recurrence. This report emphasizes the need for a careful multidisciplinary approach to ensure effective diagnosis and successful management of HC, particularly when they occur in atypical locations. Echinococcus, a cestode belonging to the Taeniidae family, is the source of hydatid diseases, which are cystic parasitic infestations . The orgA 22-year-old female patient, with no significant medical or surgical history, presented with left leg pain that caused sleep disturbances. She complained of a gradually increasing swelling in the anterior aspect of her left thigh for about six months. The patient consulted her primary care physician due to the onset of sleep-disturbing pain. There was no history of other systemic symptoms.Physical examination revealed a firm, tender, palpable mass at the anterior surface of the left thigh. The lymph nodes were not enlarged, with no other abnormal physical findings. A thigh ultrasound revealed a thick-walled cystic mass deep in the anterior aspect of the proximal part of the left thigh with numerous peripherally arranged internal cysts of various sizes, characteristics suggestive of hydatid disease or a benign neoplastic process. Magnetic resonance imaging (MRI) revealed a thick-walled cystic lesion measuring approximately 8x10x17 cm in the anterior compartment of the thigh  test, which showed a positive result for echinococcus. After confirming the diagnosis, an extensive interrogation was carried out to search for a predisposing cause that led to the development of the lesion. It revealed a history of exposure to dogs during the patient’s childhood, which was around 10 years before the clinical presentation.Before surgery, albendazole 400 mg twice daily was given orally for four weeks. Then, the patient underwent surgery for total cyst removal. Under general anesthesia, with the patient in a supine position, a longitudinal incision was made in the anterior aspect of the left thigh. An accidental rupture of the cyst occurred during the excision. Immediate closure of the cyst wall was performed to prevent further spillage of cyst contents. Subsequently, the surgical site was lavaged with hypertonic saline to reduce the risk of dissemination. In order to minimize the risk of recurrence following the cyst rupture, a decision was made to close the wound and perform a wide resection of the initial incision tract along with the lesion in a monobloc manner Figure . PreservHistopathological reports confirmed thigh hydatid disease with clear margins. Albendazole treatment was continued for three months post surgery with good adherence. Medical follow-ups and consultations were carried on as needed. Post-operative recovery was uneventful, and the patient had no signs of recurrence at the one-year follow-up by CT imaging. The choice of CT imaging for follow-up was made due to the patient's claustrophobia.It has been reported that subcutaneous HCs account for only 2% or fewer cases among all hydatid diseases in the population . HCs undDeep hydatid disease should be diagnosed before surgery, and the sensitivity of serological tests varies depending on the type of hydatid disease . ApproxiHC should be managed based on factors such as size, location, and associated complications. Surgical excision remains the preferred treatment method, and postoperative antihelminthic therapy  is administered to prevent recurrence ,15. IntrThe management of ruptured HCs requires meticulous intraoperative handling and preventive measures to minimize the risk of dissemination and recurrence. In this case, the focus was on the perioperative management of a ruptured HC. Immediate actions were taken following the accidental rupture of the cyst during excision to minimize contamination. The cyst wall was closed to contain the contents and prevent further spillage. Additionally, the surgical field was washed with hypertonic saline solution to decrease the risk of dissemination. To further mitigate the risk of recurrence after cyst rupture, a decision was made to perform a wide resection of the initial incision tract along with the lesion in a monobloc fashion. This surgical approach aimed to remove any potential residual cyst material and reduce the chances of recurrence. Furthermore, the surgical site underwent thorough washing with hypertonic saline and hydrogen peroxide to ensure effective scolicidal action and eliminate any remaining cystic elements before wound closure. By employing these perioperative measures, the surgical team aimed to effectively manage the ruptured HC, minimize the risk of dissemination, and reduce the likelihood of recurrence. As an adjuvant treatment, albendazole was continued for three months postoperatively.The necessity of having a high index of suspicion for HC in individuals with cystic lesions, especially in endemic areas, is highlighted by this case. It is difficult to diagnose a primary HC in the thigh without a combination of imaging techniques and serological tests. For the prevention of complications and the progression of the condition, early diagnosis and effective care are crucial. Having the cyst completely surgically removed along with receiving pre- and postoperative medical care results in a favorable prognosis and considerably lowers the likelihood of recurrence.


Pituitary macroadenomas are rare intracranial tumors. In a few cases, they may present aggressive behavior and invade the sphenoid sinus and nasal cavity, causing unusual symptoms. In this paper, we report an atypical case of pituitary adenoma presenting as a nasal mass.  The patient was a 44-year-old woman who had had amenorrhea and galactorrhea for ten months, with associated nasal obstruction, macroglossia and acromegaly. Both growth hormone and prolactin levels were increased. Magnetic resonance imaging showed a large mass originating from the lower surface of the pituitary gland, associated with sella turcica erosion and tumor extension through the sphenoid sinus and nasal cavity. Histopathological analysis demonstrated a chromophobe pituitary adenoma with densely packed rounded epithelial cells, with some atypias and rare mitotic figures. There was no evidence of metastases.  Macroadenoma invading the nasal cavity is a rare condition and few similar cases have been reported in the literature. This study contributes towards showing that tumor extension to the sphenoid sinus and nasopharynx needs to be considered and investigated in order to make an early diagnosis when atypical symptoms like nasal obstruction are present.  They may occur in different settings of presentation and measure more than 10 mm in diameter. Usually, they exhibit endocrine symptoms and local mass effects that may include compression of the optical chiasm and consequent visual disturbance. In some cases, they become invasive, going beyond the sella turcica to adjacent structures such as the internal carotid and cavernous sinus. In rare cases, they extend to the sphenoid sinus and nasopharynx.,,The reason why certain adenomas behave in a locally aggressive fashion is unknown and, although most cases are benign, these tumors can sometimes show malignant characteristics and so can be defined as carcinomas in the presence of craniospinal and/or systemic metastases.Furthermore, improvements in diagnostic methods such as magnetic resonance imaging techniques and pathological examinations including immunohistochemical and ultrastructural studies provide the possibilities of precisely delimiting the extent of the mass and describing the composition and kind of tumor.A 44-year-old woman who had had amenorrhea and galactor rhea for 10 months, had been noting progressive growth of her face and extremities over the past two and a half years. Over the last six months, she had complained of severe nasal obstruction with respiratory distress and dysphagia due to macroglossia. After referral to our service, which forms part of a tertiary-level uni versity hospital belonging to Universidade Estadual de Campinas (UNICAMP), she started to be followed up regarding endocrinol ogy, neurosurgery and ophthalmology. On physical examination, acromegaly was evident. The blood hormone levels were: growth hormone (GH) 34.20 ng/ml (n = 0.06-5.0 ng/ml), insulin-like growth factor-1 (IGF-1) 726 ng/ml and prolactin (PRL) ranging from 70 to 82.83 ng/ml in three samples (n = 4.79 - 23.3 ng/ml). ACTH, TSH, FSH and LH levels were all normal. Magnetic resonance imaging (MRI) depicted a large mass (3.2 x 4.1 x 3.2 cm) originating from the lower surface of the pituitary gland, which was associated with sella turcica erosion and tumor extension through the sphenoid sinus into the nasal cavity . The selInitially, considering the high levels of GH and that, besides surgery, adjuvant therapy would probably be necessary in order to reduce the tumor, pharmacological treatment with octreotide 30 mg  was administered every 28 days. However, after three months, the blood hormone levels were seen to remain elevated and the symptoms became severe. Therefore, endoscopic surgery was indicated. The surgical procedure was started by setting the speculum at the nostril, so as to reach the tumor through the transsphenoidal route. Because of the volume of the intranasal mass, the procedure was halted due to technical difficulties and only a biopsy was performed. Two months later, it was decided to perform transcranial surgery. Through bifrontal craniotomy, the anterior cranial fossa was accessed and, after drilling the sphenoid surface, the mass was aspirated and removed. Histopathological analysis on the biopsy and the fragments from the hypophysectomy gave rise to a diagnosis of infiltrating pituitary macroadenoma with nuclear atypia. Immunohistochemistry on the samples showed that they were positive for GH and PRL . A visuaTwo months after the surgery, the patient reported that her menstrual cycles had become regular and that her galactorrhea had ceased. Three months later, she noticed that her shoe size had decreased by two sizes. Although her GH and PRL hormone levels showed progressive reduction over this period , IGF-1 maintained high levels (IGF-1 = 455 ng/ml). A postoperative control MRI examination showed evidence of tumor residues . The patEven though pituitary macroadenoma is a rare condition, it exhib its a variety of presentations and manifestations of symptoms when invading the sphenoid sinus and nasal cavity. In the present case, the appearance of some typical signs such as amenorrhea, galactor rhea and growth of the face, tongue and extremities (resulting from increased GH and prolactin levels) contributed towards the inves tigation and aided in making the diagnosis. ,However, in many cases reported in the literature, less exuberance of symptoms was reported. The patients showed nasal obstruction, sometimes with epistaxis and purulent rhinorrhea. In addition, the lack of endocrinal symptoms and the normal levels of pituitary hormones made it more difficult to suspect an adenoma, with a consequent risk of diagnostic delay. In almost all of the cases, the diagnosis was only made after removing the obstructing tissue for microscopic examination.Invasive pituitary neoplasm may occur either as an extension from an intrasellar lesion or as an ectopic tumor. Kikuchi et al. and other authors described similar cases of a large pituitary adenoma consequent to an ectopic focus in the nasal cavity.Although pituitary adenomas are considered to be benign tumors, they can show malignant characteristics when the presentations are atypical, such as in the case reported here. Invasive pituitary tumors are relatively rare, as are pituitary carcinomas. In cases of the latter condition, a pituitary tumor that is either not contiguous with the primary sellar tumor and/or a pituitary tumor that has metastasized to distant sites from the pituitary gland needs to be present.It seems that invasive pituitary macroadenomas do not follow any standard. As shown in Invasive macroadenoma to the nasal cavity is a rare condition with few cases reported in the literature and the reason why some are more locally aggressive is still unknown. The description of this case of atypical presentation and its peculiarities shows that exten sion of the tumor to the sphenoid sinus and nasopharynx needs to be taken into consideration when the usual hormonal manifes tations of adenomas present associations with nasal symptoms. In this manner, early diagnosis and intervention may be facilitated.


Rapunzel syndrome with gastric perforation is an extremely rare presentation of trichobezoars of the stomach. Trichobezoars may vary greatly in presentation ranging from benign symptoms like vague abdominal pain and anorexia to grave complications like perforation peritonitis. A sincere evaluation of any underlying psychiatric illnesses, usually trichotillomania and trichophagia, holds the key to preventing recurrences in patients of trichobezoar. A 15-year-old adolescent female presented with signs and symptoms of enteric perforation with a history of trichotillomania and trichophagia. Exploratory laparotomy of the patient revealed anterior gastric perforation with a huge gastric trichobezoar that extended into the duodenum and jejunum, hence establishing the diagnosis of Rapunzel syndrome. Trichotillomania is defined as an irresistible urge to pull out hair from various parts of one’s body like scalp, eyebrows, and genital regions. It is part of a spectrum of disorders called obsessive-compulsive disorders (OCD) and is thought to be largely related to disorders of anxiety. It most commonly manifests in young adolescent females. There have been studies that have demonstrated genetic anomalies associated with trichotillomania .Trichobezoar is an organized collection of hair and intestinal secretions in the alimentary canal. It most commonly forms in the stomach but can appear in other parts of the gastrointestinal tract as well . UsuallyRapunzel syndrome is a rare entity in which a trichobezoar presents with a long tail of hair that extends into the duodenum, jejunum, ileum, or even colon. The overall incidence of gastric trichobezoars has been estimated to be around 0.4-1% in the general population. Cases of trichobezoar have been reported in literature very infrequently, and Rapunzel syndrome is extremely rare and less than 50 cases have been reported in medical literature to date .This is a case report of a 15-year-old female with Rapunzel syndrome presenting with gastric perforation.A 15-year-old female presented to the emergency department with complaints of sudden onset pain in the abdomen five days back and abdominal distension for the past 15 days, which was gradual in onset and progressive in nature, associated with non-projectile vomiting which was watery. The patient had not been passing flatus or stool for the past three days. She had been experiencing intermittent, indolent pain in the upper abdomen and a gradual decrease in appetite for the past six months. Her mother gave the history of her habit of pulling and chewing her hair since she was five years old, which the patient also confirmed.In the general examination, the patient was found to be anemic and distressed. On abdominal examination, generalized distension and guarding were elicited suggestive of enteral perforation. An immediate X-ray of the chest and abdomen was obtained in which gas under the diaphragm Figure  was seenThe patient was immediately shifted to the operating room with ongoing resuscitation for exploration of the abdominal cavity. Intraoperative findings revealed a 1.5 × 1.5 cm anterior gastric perforation with a strand of hair lying over it Figure . AnterioThe word "bezoar" has been derived from the Arabic word "badzehr" meaning antidote in the context of usage of animal substances and stones to counter poison. These practices were largely abandoned in the nineteenth century but the term "bezoar" carried on and denotes any foreign indigestible substance that accumulates in the gastrointestinal tract .Bezoars can be composed of plant derivatives (phytobezoars), medications (pharmacobezoars), milk (lactobezoars), or hair (trichobezoars). Of these, phytobezoars are by far the most common variant. Several factors predispose to the development of bezoars like impaired motility of gastric musculature (gastroparesis), psychiatric illnesses like pica, trichotillomania, trichophagia, and long-term intake of certain medications like anticholinergics and opiates . Trichobezoars usually present clinically with symptoms of pain in the abdomen, vomiting, decreased appetite and weight loss, or an abdominal lump. Complications from trichobezoars include gastrointestinal obstruction, bleeding, perforation, or nutritional deficiencies. Gastric perforation is a rare presentation of trichobezoars .Diagnosis of such patients is dependent on clinical history and examination supported by radiological and endoscopic evaluation. Although CT scans and sonography have high rates of accuracy in diagnosing such patients, this case was taken to the operating room as soon as evidence of enteric perforation was established on the abdominal X-ray skiagram. Endoscopy has recently gained popularity as a therapeutic tool in upper gastrointestinal bezoars. A retrospective study conducted by Gökbulut et al. and Mihai et al. found 86.5% and 88.7% success rates, respectively, in treating bezoars endoscopically ,10.A multi-disciplinary approach to such cases including a surgeon, gastroenterologist, dietician, and psychiatrist is the right way forward.Rapunzel syndrome with gastric perforation should be managed in lines of any other viscus perforation with special attention to the patient’s psychiatric evaluation in order to avoid recurrences. During the early course of their disease such patients usually present with subtle upper gastrointestinal symptoms, and a careful history taking and attention to any peculiar psychosocial habits, especially in an adolescent female, should urge the physician to consider gastrointestinal bezoars among other probable pathologies.