Osteoblastoma (OB) is a rare benign bone tumor, representing less than 1% of all bone neoplasms. In contrast to the typical OB, a smaller subset known as ‘epithelioid osteoblastoma (EO)’ exhibits a distinctive inclination for local invasion and recurrence. This rare variant can pose diagnostic challenges, particularly due to its unclear clinical and radiological presentation.This study details a clinical case of a 12-year-old boy experiencing pain from a lytic bone tumor located in the thoracic vertebrae (T3–T4), initially suggesting malignancy. Following extensive curettage, histopathological analysis confirmed the diagnosis of EO through immunohistochemical staining. Subsequent follow-up at 3 months revealed the absence of no pain or recurrence of the lesion.Distinguishing EO from a malignant tumor requires a multidisciplinary approach, considering clinical, radiographic, and histological features that differentiate the two entities.The goal of this case presentation is to increase awareness regarding this recurrent tumor variant, which poses diagnostic challenges, particularly in distinguishing it from malignant tumors, including osteosarcoma. HighlightsEpithelioid osteoblastoma (EO) is a rare and aggressive type of osteoblastoma due to its tendency to invade locally and its high recurrence rate.The diagnosis and treatment of EO require careful assessment of clinical, radiographic, and histopathological findings, as these often exhibit overlapping features with low-grade osteosarcoma (LG-OS) and EO.EO is characterized by rounded, well-defined contours, discernible boundaries, and associated expansive growth patterns.The most effective treatment strategy for EO entails either extensive curettage or en bloc resection.1. Epithelioid osteoblastoma (EO), specifically, is an uncommon and highly aggressive variant of OB, primarily recognized for its tendency to local invasion and a notably elevated recurrence rate. It derives its name from the distinctive presence of enlarged epithelioid osteoblasts2. This bone-forming tumor predominantly affects young adults, with a higher prevalence among males, particularly in patients under the age of 25. It notably tends to manifest in the vertebral column and sacral region3.Osteoblastomas (OBs) account for 1% of all benign bone tumors4. Furthermore, some cases may present with pathological fractures if the tumor weakens the bone structure. Given its rarity, recognizing these clinical signs and symptoms is crucial for timely diagnosis and appropriate management of EOs5. In radiographical findings, EO on computed tomography (CT) imaging typically appears as a well-defined osteolytic lesion with irregular margins and areas of cortical thinning. Additionally, MRI can provide valuable information about the tumor’s extent, including its relationship to adjacent structures and the spinal cord if it involves the spine6. Histopathologically, EO is characterized by an abundance of large epithelioid osteoblasts that encircle the tumor’s periphery. Occasionally, it can exhibit a more aggressive local growth pattern, which may lead to cortical destruction and the development of secondary aneurysmal bone cysts. The diagnosis of OB relies on histological findings, specifically the presence of a bone-forming tumor characterized by trabeculae of remodeled woven bone surrounded by well-developed, plump osteoblasts within a vascularized background6.Clinical manifestations of EO vary depending on the tumor’s location and size. Common symptoms include localized pain, which can be severe and persistent, as well as swelling or palpable masses in the affected area. In cases where the tumor involves the spine, patients may experience neurological deficits such as weakness, numbness, or altered bladder and bowel function due to compression of the spinal cord or nerve roots7. This report focuses on the case of a 12-year-old boy diagnosed with thoracic spine EO. The patient initially presented with persistent, localized pain in the thoracic spine region, which raised concerns about malignancy.The diagnostic challenge associated with OB is further complicated by the spectrum of lesions it can manifest, especially when more severe forms are identified by the presence of epithelioid osteoblasts. Consequently, some pathologists have chosen to classify OB into subcategories, using each distinct feature as a foundation for differentiation. It is imperative for a skilled pathologist to effectively distinguish this specific lesion from conditions like low-grade osteosarcoma (LG-OS) or benign bone tumors such as osteoid osteoma, as their prognosis and clinical implications differ significantly8.This work has been reported in line with the SCARE criteriaA 12-year-old boy was referred to the neurosurgery department of our hospital with a 5-month history of persistent moderate pain in the upper thoracic spine, with no associated trauma. On examination, he exhibited a painful, firm, and tender mass in the T3–T4 region of the spine. However, there were no observed weaknesses, sensory impairments, or abnormal reflexes. Notably, the pain exhibited minimal response to non-steroidal anti-inflammatory drugs (NSAIDs). Moreover, the patient denied experiencing fevers, night sweats, or weight loss. The constellation of clinical signs and symptoms prompted further investigation, including radiological imaging. MRI and CT scan revealed an aggressive lytic lesion 2.2×2×2 cm in size that was causing expansion and scalloping of the posterior pedicles of the thoracic vertebrae, specifically at the T3–T4 level .Written informed consent was obtained from the patient’s parents/legal guardian for publication and any accompanying images. A copy of the written consent is available for review on request.Parental Consent for Minors: Written informed consent was obtained from the patient’s parents/legal guardian for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.No funding was received.All authors contributed equally to this work.There are no conflicts of interest.https://www.researchregistry.com/browse-theregistry#home/registrationdetails/65251d0e857b85002aa669e0/Nooshin Zaresharifi and Zoheir Reihanian are the Guarantors for this study and accept full responsibility for the work and the conduct of the study, had access to the data, and controlled the decision to publish.Datasets generated during the current study are available upon reasonable request.Not commissioned, externally peer-reviewed.


It is uncommon for soft tissue sarcomas to develop after adenocarcinoma of the rectum. In a treated rectal adenocarcinoma patient, we encountered a huge malignant quadriceps tumor as leiomyosarcoma and salvaged the limb.A 49-year-old male known case of treated moderately differentiated adenocarcinoma of the rectum presented in the Orthopedic Clinic with a new swelling in his left thigh. MRI of the left lower limb was obtained, and it demonstrated a large 15.8 x 13.2 x 30 cm well-defined mixed solid cystic lesion in the anterolateral aspect of the left mid-thigh without the involvement of adjacent bony cortex. Limb salvage surgery with wide local excision of the tumor was done. The patient was ambulated full weight from the very next day with a Musculoskeletal Tumor Society Score (MSTS) score of 20.Despite the massive size of the tumor, limb salvage was attempted successfully and achieved good functional status. Extremity soft tissue sarcomas are uncommon, heterogeneous malignant tumors that make up less than 1% of all cancers . HistoriA 49-year-old male known case of treated moderately differentiated adenocarcinoma of the rectum presented in the Orthopedic Clinic with a new swelling in his left thigh. Before this presentation, the patient had received neoadjuvant chemotherapy followed by laparoscopic anterior resection and adjuvant chemotherapy. The patient was disease-free and on regular oncological follow-up for one year when he noticed a new swelling and pain in his left thigh. MRI of the left lower limb was obtained, and it demonstrated a large 15.8 x 13.2 x 30 cm well-defined mixed solid cystic lesion in the anterolateral aspect of the left mid-thigh without the involvement of adjacent bony cortex. This lesion involved the vastus intermedius, vastus lateralis, vastus medialis, and rectus femoris, and had several thin internal septations with an internal hemorrhagic component. Figures The neurovascular bundle was intact. No size-significant inguinal or popliteal lymphadenopathy was noted. No other lesion was noted.A Trucut biopsy of the thigh lesion was performed, and it was revealed to be leiomyosarcoma Grade 2 as a second malignancy. The case was discussed in our routine clinic-pathological conference and the decision was taken to perform a wide local excision of the tumor with intent of limb salvage. Elective surgery of the patient was planned after counseling him about the potential loss of limb extension.An elliptical incision was made over the swelling extending from the anterior superior Iliac spine to the lateral border of the patella Figure . Skin anThe profunda femoris artery was ligated and an en bloc-wide local excision of the whole tumor was performed. Superiorly quadriceps muscle attachments from the iliac bone were separated and inferiorly muscles were resected at the level of quadriceps tendon attachment on the patella. The tumor was attached to the femur and excised along with its periosteal attachments Figure . The lenThe patient was ambulated full weight-bearing with the help of a knee brace from the first postoperative day. Post-operative histopathology showed it to be grade 3 leiomyosarcoma as per Federation Nationale Des Centres De Lutte Control Le Cancer (FNCLCC)  with cleThe case was re-discussed in a clinic-pathological conference and a decision of adjuvant radiotherapy was made. The patient received adjuvant radiotherapy 66 Gray, 33 fractions, three weeks after surgery.At 14 months follow-up the patient is completely pain-free and ambulates with the help of a knee brace. The Musculoskeletal Tumor Society Score (MSTS) of the patient is 20 .Soft tissue sarcomas are a heterogeneous group of sarcoma with above 50 subtypes. Leiomyosarcoma is one of the most common subtypes. The treatment of leiomyosarcoma is particularly difficult due to the variability of its biological origin, clinical behavior, and chemosensitivity, as well as the dearth of effective clinical studies . For thiThis kind of cancer has an unknown etiology, and the risk factors have not yet been discovered. Cancer symptoms can vary depending on the cancer's location and stage, but common ones including fatigue, fever, and weight loss are frequently observed. Although swelling or a lump is frequently recognized because tumors typically grow extremely quickly, local pain is rare ,5. The tModalities like CT scan and MRI are being used to diagnose leiomyosarcoma of the thigh with multiple distinguishing features  but the Soft tissue leiomyosarcomas are quite aggressive tumors. Patients with leiomyosarcoma have only a chance of 50% three-year survival . CombineLeiomyosarcoma can present in a variety of locations with an array of symptoms. Leiomyosarcomas presenting as a second malignancy in rectal adenocarcinoma patients is rare. Even the primary cases of thigh leiomyosarcomas that have been reported are rare. There has been no well-defined treatment protocol for such a patient. Nevertheless, an attempt should be made to salvage the limb involved with leiomyosarcoma through surgical resection with wide margins. Despite being a massive tumor involving the whole quadriceps muscle, we salvaged the limb and achieved good functional status on ambulation with a knee brace. Although multiple reconstruction options are considered with muscle flaps to restore the function of the excised limb compartment, any such intervention in a patient with multiple malignancies would have increased the morbidity and an equivalent functional outcome has been achieved with the knee brace. We conclude that such tumors shall be treated with limb salvage surgeries whenever possible, as this improves the functional outcome and survival of the patient.


Echinococcus granulosus endemic to areas with considerable pastoral farming and animal husbandry. Typical presentations include hydatid cyst formation in the liver, lungs, brain, kidneys, or bones. An isolated splenic hydatid cyst is an extremely rare occurrence, accounting for only 0.5%-4% worldwide incidence rates, and recurrent cases are even more infrequent. Globalization, cross-border travel, and altered immigration patterns over time have shifted some of the burden of CE from the developing to the developed world, making the diagnosis challenging for these nonendemic areas. Judicious use of imaging modalities for prompt diagnosis and effective intervention is necessary to treat the initial disease and prevent a recurrence. Herein, we present the case of a 13-year-old male with recurrent isolated splenic hydatid cyst. The patient presented with chronic and nonradiating pain in his left hypochondrium. Physical examination revealed splenomegaly. Ultrasonography showed multiple cysts. Computerized tomography (CT) scan showed cystic lesions in splenic parenchyma with numerous internal enhancing septae. Surgical evacuation was performed for the management of disease.Cystic echinococcosis (CE), or hydatid disease, is a parasitic infection caused by  Echinococcus granulosus. Sheepdogs are the definitive hosts, while sheep, goats, cattle, and pigs are intermediate hosts Cystic echinococcosis (CE), or hydatid disease, is a parasitic infection caused by The rarity of splenic hydatid cysts and the sparsity of available literature poses a diagnostic challenge for endemic and nonendemic countries alike. It may cause disease progression to life-threatening complications like anaphylactic shock A 13-year-old male presented to the emergency department of hospital with a compliant of abdominal pain. The patient reported chronic and nonradiating pain in his left hypochondrium which was progressive for over a year. Splenomegaly was evident on physical examination. His family history was unremarkable.Echinococcus granulosus infection thus confirmed the diagnosis of splenic hydatid cyst. The patient was then scheduled for a cystectomy and partial splenectomy. Although the surgery was successful, USG revealed recurrence during the early postoperative follow-up period. The recurrence was managed through surgical evacuation of the splenic cysts.All the routine laboratory tests of the patient were unremarkable. Ultrasonography (USG) of the abdomen was done which showed multiple cysts in the spleen. The patient was then referred to the pediatric surgery department where he was kept under observation. A CT scan was advised which revealed multiple cystic lesions in splenic parenchyma inferiorly displacing the left kidney along with numerous internal enhancing septae. The ultrasonography features are shown in The differential diagnoses of splenic hydatid cyst include pseudocysts, epidermoid cysts, splenic abscesses, cystic neoplasms, and hematomas of spleen.Echinococcus granulosus infections Hydatid disease is a serious public health concern, particularly in cattle and sheep-raring countries like Pakistan, the Middle East, South America, Australia, and North Africa, where the disease is endemic. The spleen serves as the site of 4 main types of cysts; epidermoid cysts, post-traumatic pseudocysts, intrasplenic pancreatic pseudocysts, and hydatid cysts due to Clinical presentation is variable and depends on the number and size of the cysts. Splenic hydatid cysts are predominantly asymptomatic; however, compression of adjacent viscera through an increase in the size of the cyst causes pain, usually in the right hypochondrium. The patient may also present with a rupture of the splenic cyst and spread of infection to other organs or systemic hypertension resulting from renal artery compression The appearance of hydatid cysts on radiographic examination is variable and dependent on factors like location and age. Moreover, complications like infection and rupture make diagnosis difficult. Splenic hydatid cyst poses a diagnostic challenge, particularly in nonendemic areas, owing to shared similarities with other cystic lesions of the spleen on sonography and CT scan. It should be included in the differential diagnosis of any cystic lesion of the spleen, especially in endemic areas ,12. CT sThe increasing globalization, cross-border travel, and changing immigration patterns have shifted some of the disease burden from the developed to the developing world, making isolated splenic hydatid cyst a global health challenge. Moreover, the disease is difficult to diagnose and a delay in treatment leads to serious life-threatening complications. The sparsity of available literature further adds to the challenge, making adequate diagnosis and intervention for isolated splenic hydatid cysts a persistent problem for endemic and nonendemic areas alike.An isolated splenic hydatid cyst is an extremely rare occurrence, with a worldwide incidence rate of 0.5%-4%. The appearance of hydatid cysts on radiographic examination is variable and dependent on factors like location and age. Moreover, complications like infection and rupture make diagnosis difficult. The difficulty of diagnosis and scarcity of available literature make prompt, effective diagnosis and intervention challenging. CT scan is the diagnostic modality of choice and aids treatment. This unique case highlights the importance of proper preoperative imaging diagnosis, which guides the choice of treatment and reduces the risk of disease complications and recurrence.Not required as we have acquired consent from the patient.1.Name of the registry: NA2.Unique Identifying number or registration ID: NA3.Hyperlink to your specific registration (must be publicly accessible and will be checked): NANot commissioned, externally peer reviewed.All authors contributed equally.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.


In the case of endodontic infection, the presence of furcation canals can be atthe origin of a periodontal lesion located in the furcation. The furcation beingvery close to the marginal periodontium, this type of lesion can be favorable tothe genesis of an endo-periodontal lesion. These furcation canals are lateralcanals located on the pulp chamber floor and constitute one of the manyphysiological communication pathways between endodontic and periodontal tissues.These canals are most often difficult to localize, shape, and to fill because oftheir small diameter and length. The disinfection of the pulp chamber floor withsodium hypochlorite solution may contribute to the disinfection of furcationcanals when they are not identified, shaped, and/or filled. This case seriesillustrates the endodontic management of visible furcation canals associatedwith an endo-periodontal lesion. These furcation canals had a large diameterwhich allowed their identification during the endodontic treatment. Studies evaluating the success rate of endodontic treatments often revealdisappointing results in general practice ,Furcation canals are classified as lateral canals located at the pulp chamber flooror on the coronal aspect of a root canal of premolars and molars A 50-year-old non-smoking woman with no past medical/surgical background (ASA 1)was referred for endodontic treatment of the right mandibular second molar(#47). Her dentist had initiated the endodontic treatment 5 months earlier. Thetooth presented an irreversible pulpitis following a secondary tooth decay undera composite restoration and a coronal fracture of the lingual aspect. Theendodontic treatment had not been completed following the fracture of anendodontic file in the mesiobuccal root canal.Clinical examination revealed negative tests of axial and lateral percussion,lingual palpation, and bite. However, vestibular palpation was painful.Periodontal probing revealed an attachment loss that involved the entire buccalsurface and the mesial buccal angle of the distal root, with a pocket depth (12mm) reaching the apex root. The examination showed the presence of a class 2inter-radicular lesion After local anesthesia, the root surface was inspected under an operatingmicroscope  and revealed no evidence ofroot fracture. A rubber dam was set up, isolating the second and first rightmandibular molar. The provisional crown was removed, and the rubber dam wassealed. The endodontic treatment was performed following the usual steps of rootcanal localization, scouting, cleaning, and shaping  under abundant and renewedflushing of a 3% sodium hypochlorite solution . Theseparated file could be "bypassed" and removed during irrigation. The inspectionof the pulp chamber floor, using the operating microscope, revealed a foramen inits middle. A 06-size K-file  was inserted into the foramen. The useof an electronic apex locator confirmed the patency of this canal with the periodontium B and 1C.At three months postoperatively, the tooth was asymptomatic, and the clinicalexamination was normal. The periapical radiological bone lesion at the distalroot decreased in size. Periodontal probing had decreased to 3 mm without agingival recession. The periodontal lesion showed signs of clinical andradiographic healing F. At eigA 45-year-old non-smoking woman with no past medical/surgical background (ASA 1)was referred for endodontic treatment of the right mandibular second molar(#47). A composite restoration was set 7 months ago. The patient complained ofswelling facing tooth #47, 2 months after the restorative procedure.Clinical examination revealed the presence of a sinus track facing the buccalmucosa of the tooth #47. The pulp sensitivity with cold and electrical tests wasnegative. Percussion and palpation tests were also negative. Periodontal probinggave a periodontal pocket of 5 mm attachment loss facing the buccal aspect ofthe mesial root, with bleeding on probing. The gingival plaque index All the endodontic management procedures of isolation, access cavity, shaping,cleaning, and obturation were performed following the same protocol as describedin the Case #1.During treatment, the pulp chamber floor was inspected under the operatingmicroscope and revealed a foramen on the pulp chamber floor. This foramen waslocated in a mesial position on the pulp chamber floor. A 06-size K-file was glided into the foramen B to 2D. At two weeks postoperative, the sinus track disappeared. At six monthspostoperative, the tooth was asymptomatic. The periodontal probing and theclinical examination were normal. It was then decided to make the final ceramicprosthetic restoration . Theradiographic examination showed a complete endo-periodontal healing at twelvemonths postoperative F.,Furcation canals are physiological communication pathways between the pulp and theperiodontium at the furcation level. They are often incriminated when aninter-radicular radiolucency of endodontic origin is observed in multi-rooted teeth.Their presence, incidence, location, and diameter are well reported in experimentalstudies The floor of pulp chamber has foramina ranging from 7 to 34 µm in diameter ,Another ex vivo study observed that 2.8% of mandibular molars and 0.3% of maxillarymolars have furcation canals communicating between the pulp chamber floor and thefurcation area ,,When there is a single furcation canal, its foramen is located in the center of thepulp chamber floor (57.1%) but may also have a more mesial position (28.5%) on thefloor and more rarely a distal position (14.4%). The average length from the pulpchamber floor to the furcation region is 3.9 mm ,,The observed foramen on the pulpal chamber floor in ex vivo studies did not containany vessels, nerves, or connective tissue after 5 minutes of action of sodiumhypochlorite solution Several methods have been suggested for the filling of furcation canals afterchemical disinfection: by compressing ZnO-eugenol cement with a cotton pellet A coronal sealing by bonding or sealing a coronal-root restoration is mandatory toprevent leakage of the endodontic system. In addition, attention should be paid toproperly cleaning the pulp chamber after the root canal obturation due to thenegative interaction of all endodontic sealers with bonding protocols In these clinical cases, the important diameter of the furcation canal allowedexceptionally to highlight it during the treatment, to carry out a chemo-mechanicaldisinfection, and to fill it with gutta-percha and endodontic sealer like any rootcanal. Healing was obtained without the need for local periodontal therapy due tothe endodontic origin of the endo-periodontal lesion.Furcation canals play a significant role in the rate of success or failure ofendodontic treatment. The chemical cleaning of the pulp chamber floor and thecoronal sealing are important to prevent infection of endodontic origin.


Meningiomas are relatively common primary adult brain tumors. They are slow-growing, highly vascular, and graded according to histology, phenotypic and genotypic features.We present a case of a 66-year-old male with a history of tongue squamous cell carcinoma, which presented multiple risk factors for cardiovascular and thromboembolic events. A brain lesion was initially detected on a computed tomography (CT) scan and later characterized by magnetic resonance imaging (MRI). The multidisciplinary team decided to maintain surveillance due to the lack of associated symptoms. Upon expansion in size and acute intralesional hemorrhage seen on follow-up imaging, the patient was submitted to surgical excision. The histopathological testing determined it to be an atypical meningioma. Two months later, the patient received stereotactic radiotherapy, and a post-surgical MRI showed no evidence of tumor recurrence.This case report describes a rare occurrence of intratumoral hemorrhage in a meningioma during surveillance, highlighting the importance of vigilant monitoring and consideration of potential risk factors for hemorrhagic events. Meningiomas account for 20 to 30% of all primary adult brain tumors. They are slow-growing and highly vascular tumors, commonly found in the supratentorial convexity. They can be classified into different subtypes, each with a specific grade based on the 2016 World Health Organization (WHO) classification. From 2021 according to the new WHO classification, grading will be based on phenotypic and genotypic features. If the following mutations, such as TRET promoter mutation or homozygous deletion of CDKN2A and/or CDKN2B are present, a neoplasm that was previously classified as Grade I would now be a Grade III. A Grade I is considered benign and Grade III malignant according to the 5th WHO classification [Around 4% of all brain tumors will present with spontaneous intracranial hemorrhage, mostly in pituitary adenomas, highly vascularized tumors such as medulloblastoma, neuroblastoma, ependymoma, oligodendroglioma, or metastatic tumors. Hemorrhage is a rare complication of meningiomas, with a reported incidence of 0.5 to 2.4%. Most reported intracranial hemorrhages associated with meningiomas are found in the subarachnoid and subdural spaces. Purely intratumoral hemorrhage is a much rarer event -5.In this report, we present a case of a meningioma presenting with intratumoral hemorrhage on surveillance.This is a case of a 66-year-old male followed at an oncologic institution due to a squamous cell carcinoma of the tongue since 2020. The patient had multiple risk factors for a cardiovascular or thromboembolic event, such as heavy smoking habits, diabetes mellitus, dyslipidemia, hypertension, past alcoholic use disorder, and a past embolic event in the right internal jugular vein associated with an implanted central venous catheter used for the treatment of the tongue tumor, managed with anticoagulants.In January 2021 a computed tomography (CT) of the neck to assess the response of the tongue tumor to neoadjuvant chemotherapy, an intracranial space-occupying lesion was found with no associated symptoms. For a better characterization of the lesion, a brain magnetic resonance imaging (MRI) was performed, which revealed a left fronto-opercular extra-axial lesion with a diameter of 31x20x26 mm and well-defined borders without associated edema , suggesting intralesional acute hemorrhage. At this time, vasogenic edema was observed along the left frontal lobe causing a mass effect on surrounding structures, which promotes left lateral ventricle compression  Figure . Since tDue to histological features, the patient was submitted two months after surgery to stereotactic radiotherapy, with a total dose of 54 Gy in 27 daily fractions (2Gy/fraction), using volumetric modulated arc therapy (VMAT) with 6MV photons. The predicted tumor volume (PTV) included the tumor bed, possible residual lesion, dural resection bed, and a safety margin. The dosimetric evaluation showed coverage of the target volume (PTV) with D98 of 95%, D95 of 96.6%, and D2 of 104.9%. The maximum dose to the left optic nerve was 51.6Gy, 22Gy to the brainstem, and 19.7Gy to the pituitary gland.The recovery was uneventful and post-surgical MRI showed no signal of tumor recurrence or growth.With the advances in imaging diagnostic methods, there has been an increase in incidental findings of brain tumors, namely meningiomas which represent one of the most common benign brain tumors . In this case report, we had the opportunity to see, on imaging, signs of intratumoral bleeding in a previously solid mass, emphasizing that the patient remained asymptomatic.Hemorrhagic events are usually associated with gliomas and metastatic tumors, being rare in meningiomas. The hemorrhagic events associated with meningiomas can be classified as subarachnoid, intracerebral, subdural, or intratumoral hemorrhage. Most bleeding meningiomas often present with extra-tumoral bleeding or even a combination of extra-tumoral and intratumoral bleeding, with only a few cases of exclusively sustained intratumoral meningioma bleeding reported in the literature.Bosnjak reviewed 145 cases of presumptive preoperative diagnosis of hemorrhagic intracranial meningioma and identified that bleeding propensity is higher in patients older than 70 years and younger than 30 years, and in the fibrous, malignant, and angioblastic histological types of meningiomas [The exact mechanism of spontaneous intra-tumoral hemorrhage is not yet understood, but some possibilities have been postulated -10. UsuaEven though meningiomas rarely present with a hemorrhagic event, this scenario should never be discarded. In our case, the patient had several risk factors for a hemorrhagic event, namely hypertension, diabetes mellitus, and antithrombotic medication, besides the tumor location in the convexity. Although the patient had no symptoms regarding the meningioma, tight control of the lesion was revealed to be of utmost importance in the early identification and fast-acting management and good prognosis of the patient.


Adrenal incidentalomas are radiologically discovered tumors that represent a variety of pathologies, with the diagnosis clinched only on surgical pathology. These tumors may be clinically monitored, but triggers for surgery include size > 4 cm, concerning features on radiology, or hormonally functioning. Adrenal oncocytic neoplasms (AONs) are notably rare and typically nonfunctional tumors that are discovered as incidentalomas and exist on a spectrum of malignant potential.We discovered an exceptionally large (15 cm in the greatest dimension) incidentaloma in a 73-year-old man with left back pain and he was treated with robotic-assisted adrenalectomy. Surgical pathology was consistent with AON of borderline uncertain malignant potential; adjuvant mitotane and radiation were omitted based on shared decision-making.Large AONs are rare, usually benign tumors that can be safely treated with robotic-assisted adrenalectomy. Surgical pathology is the crux of diagnosis and post-operative management, as it informs both the initiation of adjuvant therapy and the stringency of post-operative surveillance.The online version contains supplementary material available at 10.1186/s12894-023-01238-1. Oncocytic adrenocortical neoplasms (OANs) are rare tumors of the adrenal gland that span the clinical continuum from benign to malignant. Large (> 4–6 cm) OANs are indistinguishable from adrenal cortical carcinomas preoperatively and are only diagnosed via surgical pathology following open, laparoscopic, or robotic adrenalectomy.Given aggressive features on pathology, adjuvant treatment with mitotane, chemotherapy, and/or radiation is considered. In the absence of high-risk pathology, surveillance is an option with CT scans every 3 months for up to 5 years.The online version contains supplementary material available at 10.1186/s12894-023-01238-1. Adrenal incidentalomas larger than 4 cm are at risk of being poorly differentiated adrenal cortical carcinomas (ACCs) and treatment is recommended with either open, laparoscopic, or robotic adrenalectomy . InfrequA 73-year-old man was diagnosed with a left adrenal mass that measured 14.8 × 11.2 × 9.8 cm following a contrast-enhanced abdomen/pelvis CT scan obtained to evaluate left back pain. He reported no flushing, sweating, palpitations, headache, weight changes, or proximal muscle weakness. Subsequent basic metabolic panel, renin and aldosterone, random plasma cortisol and low-dose dexamethasone (1 mg) suppression test, 17-hydroxyprogesterone, testosterone, deoxycorticosterone, androstenedione, adrenocorticotropic hormone, and plasma metanephrines were within normal limits; dehydroepiandrosterone sulfate level was mildly elevated to 474 µg/dL . 18 F-fluorodeoxyglucose positron emission tomography (FDG-PET) scan  system, reticulin algorithm, or the Helsinki scoring system , 10. TheIf an AON is classified as malignant or BUMP, adjuvant mitotane chemotherapy and adjuvant radiation therapy is considered based on extrapolated data from patients with ACC. The European Society of Endocrinology clinical guidelines recommends against use of adjuvant radiation therapy for stage I and II disease with negative surgical margins. Recommendation for adjuvant mitotane is limited to ACC patients with high risk of recurrence based on data from retrospective analyses that demonstrated improved recurrence-free and overall survival . IndicatThere are no standard post-operative surveillance recommendations for AONs. Given AON with BUMP, we opted for CT scan every 3 months for up to 5 years informed by clinical guidelines for ACC follow-up . HoweverWe present a case of a 15 cm AON with borderline uncertain malignant potential treated with robotic surgery and review the post-operative decision-making management criteria. AONs are rare, typically benign tumors that can be safely treated with robotic-assisted adrenalectomy. Surgical pathology is part and parcel of diagnosis and determines then neoplasm’s malignant potential, which may inform both the initiation of adjuvant therapy and the post-operative surveillance regimen.Additional file 1. Video recorded robot-assisted adrenalectomy including the following steps: (1) dropping the colon and gaining access to retroperitoneum (2) retracting the adrenal mass up and creating the plane beneath the mass (3) dissecting the plane between pancreas (on the left) and the adrenal mass (on the right) (4) identifying renal and adrenal vein, clipping and cutting the adrenal vein (5) dissecting the plane between splenic artery and adrenal mass (6) dissecting the plane between adrenal mass and left kidney (7) cutting the final attachments (8) complete detachment of the mass.


Extraskeletal occurrence is less frequent and primary adrenal involvement is an even rare presentation. We present such a case of a 7-year-old boy diagnosed with adrenal EWS with associated venous thrombosis and pulmonary embolism detected on Although rare, primary extraosseous EWS has been reported involving chest wall, paravertebral and retroperitoneal region, and even rarer occurrence of organ involvement .18F-FDG PET-CT scan to further characterize the lesion and evaluate the disease extent. The scan taken after 1 hour of 4 mCi of18F-FDG injection. PET-CT scan showed high-grade FDG avid large, lobulated, heterogeneously enhancing left adrenal mass lesion  with hypodense necrotic areas within and associated thrombus in left suprarenal vein, extending in both renal veins, and IVC reaching upto right atrium, with heterogeneous components within showing mild FDG uptake suggesting tumor thrombus. In addition, bilateral pulmonary thromboembolism was detected  abdomen done at another center suggested a large left suprarenal mass lesion raising possibility of neuroblastic tumor. Laboratory investigation revealed normal plasma cortisol, plasma-free metanephrine and normetanephrine, and urinary metanephrine levels. Patient was referred to our department foretected . No lymmbolism . PatienEWS is the second most common skeletal malignancy affecting adolescents after osteogenic sarcoma.


Primary hepatic Burkitt lymphoma (PHBL) in children is an extremely rare hepatic malignancy with a dismal prognosis, unless it is detected and treated promptly.An 11-year-old child with abdominal pain was admitted to our hospital. No notable abnormalities were found during his physical examination or laboratory workup, but the abdominal computed tomography and magnetic resonance imaging both indicated a malignant hepatic mass measuring 9.2 × 7.1 × 7.5 cm in size. His postoperative pathology revealed an unexpected primary hepatic Burkitt lymphoma following a laparoscopic liver lobectomy. He then received rituximab and intense multi-agent chemotherapy as treatment. Despite post-chemotherapy bone marrow suppression, the patient eventually made a full recovery and had a good overall state.In this study, we describe a rare case of pediatric primary hepatic Burkitt lymphoma and review the literature on clinical features, diagnosis, and treatment for primary hepatic Burkitt lymphoma in children. We stress that this diagnosis should be taken into account in the absence of other single hepatic lesions or primary tumors of hematological disorders, particularly when there is a normal AFP level. Primary hepatic lymphoma (PHL) is a rare cancer that accounts for less than 10% of all focal hepatic lesion . The difAn 11-year-old child who had been complaining of right upper quadrant ache for 10 days was hospitalized to our hospital. A large lesion that the local hospital discovered during a CT scan of his abdomen led them to believe that he most likely had liver cancer. He had no history of hypertension, coronary heart disease, diabetes, or infectious disease. His grandfather passed away from liver cirrhosis in the past, and his father carried the hepatitis B virus. Physical examination revealed that his belly was soft, flat, and lacking any abdominal mass or rebound pain.Laboratory workup for tumor markers, liver function, coagulation, blood routine, and liver function did not reveal any notable abnormalities. Our hospital’s abdomen enhanced CT scan revealed that the lesion, which measured 9.2 × 7.1 × 7.5 cm, was located in the hepatic segments V and VI. Additionally, it implied that the lesion might mostly be malignant. Moreover, hepatic MRI did not reveal any mesenteric or retroperitoneal lymphadenopathy, calcification, or necrosis  was made. This is an uncommon hematologic cancer of the liver. Consequently, after he was discharged from our hospital, we advised that he continue his treatment in a children’s specialty facility.He received rituximab continuously along with chemotherapy in accordance with BFM Collaboration Group protocol. But frequent chemotherapy caused severe post-chemotherapy bone marrow suppression, which reduced the production of platelets, red blood cells, and white blood cells. He subsequently experienced recurrent fever and rash, although these symptoms were managed by symptomatic therapy such anti-infection, gamma globulin infusion, and blood transfusion. In the end, he successfully finished five rounds of chemotherapy within 4 months of the operation.We conducted a systematic follow-up on the patient 16 months following the operation. He made a good recovery and showed no signs of fever or redness. His laboratory tests also return to normal. And his PET-CT scan results indicate that there are no signs of recurrence, which is considered achieving complete remission (CR).Although secondary liver involvement in non-Hodgkin lymphomas is frequently observed in their advanced stages, primary hepatic lymphoma (PHL) is a rare type of cancer. According to previous study, man in their middle years are most frequently affected , 14.PHL Taking this present case into account, their median age was 8.4 years . The clinical manifestations of PHBL are non-specific and include nausea, exhaustion, weight loss, and abdominal pain. The child only ever displayed clinical illness and symptoms of liver failure in one instance. Two cases in particular were complicated with acute pancreatitis and hepatectomy eased the symptoms. It was hypothesized that the extrinsic tumor compressing the ampulla of Vater was partially blocking the pancreatic outflow. Physical examination of PHBL may also exhibit no abnormalities. Nevertheless, common positive indications include hepatomegaly, with some instances also showing jaundice or lymphadenopathy. Corresponding with adult data , 14, allDespite individuals with PHL being discovered to be related with a number of diseases, such as EBV, HBV, HCV, or HIV infections, liver cirrhosis, systemic lupus erythematosus, and immunosuppressive medication, the pathogenesis of PHL has not yet been thoroughly elucidated , 15. OnlOwing to its rarity, PHBL may be difficult for doctors and pathologists to diagnose. Primary hepatic tumors and metastatic lesions are included in the initial differential diagnosis made only on the basis of a physical examination. It is important to distinguish primary hepatic tumor from hepatoblastoma, hepatocellular carcinoma, hepatic adenoma, and other related conditions. The diagnosis of hepatoblastoma and hepatocellular carcinoma in our patient was not supported by the normal AFP. Hepatic adenomas often appear during puberty and are linked to androgen use , which wHistopathology provides the foundation for the PHL diagnosis in its entirety. It is acceptable to diagnose liver tumors using ultrasound-guided core-needle biopsy, but malignant tumors run the danger of metastasizing along the needle tract. Laparotomy also offers the additional advantage of allowing for a better examination of the abdominal cavity to rule out the presence of extra hepatic masses. Although the histological type of the mass was unclear, we performed a laparoscopic exploration and planned biopsy since it was possible that the tumor was malignant. Upon entering the abdominal cavity, we found that the liver tumor was huge, accompanied by the appearance of spontaneous rupture and bleeding Fig. D, which According to Table There is currently no agreed-upon treatment for this rare case, and reports of sole surgical therapy, sole chemotherapy, or combined therapy exist. According to recent research and our case, complete surgical resection would be the preferred choice of treatment for patients with a single tumor restricted to one side of the liver when the histologic diagnosis is unknown. According to Table In conclusion, there is little knowledge about the causes and processes of pediatric PHBL, which is highly uncommon in kids and predominantly affects boys and kids in school. As a result, no established consensus treatment protocols exist at this time. It is also simple to make a mistaken diagnosis because PHBL’s clinical signs and laboratory tests are not specific, and the final diagnosis is still determined by pathology. Therefore, this diagnosis should be taken into account in the absence of other single hepatic lesions or primary tumors of hematological disorders, especially when the AFP level is normal.


Cutaneous squamous cell carcinoma (cSCC) is a common malignancy in the head and neck region. Although rarely metastatic, it has the potential to become locally aggressive and invade surrounding structures. The involvement of the scalp with cSCC presents a unique surgical challenge given its proximity to vital structures. We present a case of locally advanced cutaneous scalp squamous cell carcinoma with involvement of the skull and dural involvement not previously demonstrated on imaging. This case required complex multidisciplinary surgical management from both neurosurgery and head and neck surgery for treatment, preservation of essential tissues, and cosmesis. Cutaneous squamous cell carcinoma (cSCC) represents 20-50% of all skin cancers -3. This The case subject was a 65-year-old male who presented with a large ulcerative lesion on his scalp. The lesion appeared three years prior to his presentation; however, the patient did not seek medical evaluation until he had a fall that resulted in a laceration. At the time of his fall, a biopsy was performed and revealed invasive cSCC. Unfortunately, the patient was lost to follow-up and was unable to be notified of his diagnosis. Ten months after this encounter, his family requested a welfare check due to an unexpected lapse in communication, at which point first responders noted the large scalp lesion and brought him to his local emergency department for evaluation. A head CT scan revealed a large scalp lesion invading the skull Figure . He was A review of systems was notable for a 10-pound unintentional weight loss over the last year. Other past medical history included tobacco and alcohol use, but he otherwise had no diagnosed comorbid conditions. His physical exam was notable for a 10 cm circumferential, ulcerative, necrotic lesion at the midline vertex of the scalp with rolled edges and a pale complexion Figure . His exaKlebsiella and Proteus. The final pathology of the biopsy confirmed poorly differentiated invasive cSCC. Positron emission tomography (PET) imaging revealed scattered nodes with low-grade metabolic activity in a left 0.9 x 0.5 cm suboccipital node with a maximum standardized uptake value (SUV max) of 2.2 and a left 1.2 x 0.9 cm supraclavicular node with an SUV max of 1.8. There was no evidence of distant metastatic disease. The case was reviewed at our institution’s multidisciplinary head and neck tumor board. This tumor board consists of head and neck surgeons, radiation oncologists, medical oncologists, dentists, radiologists, and pathologists. Given that the tumor was slightly deviated to the left side of the scalp and that imaging did not demonstrate dural involvement, the tumor board recommended wide local excision, craniectomy, left posterolateral and bilateral suboccipital neck dissections, cranioplasty, and reconstruction with a free flap. For reconstruction, a latissimus dorsi free flap was recommended due to the large defect area that would need to be covered. Other flap options for reconstruction were considered but felt to be insufficient for the size of the defect. Neoadjuvant treatment was not recommended in this case as surgery was considered to be curative for this patient and he did not have comorbidities making him a poor surgical candidate.Empiric ampicillin/sulbactam 3000 mg IV every six hours was started and was later narrowed to amoxicillin/clavulanate 875-125 mg tablet every 12 hours after cultures grew On the day of surgery, the patient underwent a left level II, III, V, and bilateral suboccipital neck dissections, wide local excision of the scalp cSCC, and biparietal craniectomy. Although dural involvement was not previously demonstrated on imaging, during the resection, the dura appeared to be involved with the tumor. The tumor was resected from the dura to the level of the superior sagittal sinus. Further disease resection was determined to carry too high of a risk of mortality and stroke and was thus limited. The final defect measured 13 x 12 cm. He received a polyetheretherketone (PEEK) cranioplasty and left latissimus dorsi myofascial free flap with anastomosis to the superficial temporal artery and vein. A split-thickness skin graft from the left thigh was used to cover the flap (Figure The patient’s postoperative hospital course was uneventful. His length of stay was 14 days for coordination of discharge needs as he required a skilled nursing facility for wound care. Wound care consisted of routine split-thickness skin graft care with a Xeroform dressing and drain care. After discharge, he received care in a long-term acute care facility for 18 days for rehabilitation and wound management. At his last office visit, he was doing well with expected postoperative changes and adequate healing of the skin graft, free flap, and donor site. Due to the positive deep margin at the dura, the tumor board recommended he receive cisplatin-based adjuvant chemoradiation. Unfortunately, the patient was followed for only two months postoperatively and was again lost to follow-up and attempts to contact him have failed.cSCC affects 41 of every 100,000 North Americans annually . There aGiven its association with UV exposure, cSCC most commonly affects the head, neck, hands, and forearms  with heaGiven its high exposure to UV light, the scalp is a site frequently affected by cSCC . cSCC ofClosure of the scalp defect presents a unique challenge as the skin tends to be inelastic and may hold high levels of tension ,9. TheseIn patients with poor local tissue, large defects, or in need of adjuvant radiation therapy, a latissimus dorsi regional or free flap may be a preferred option for reconstruction . A latisThese considerations heavily impacted the surgical approach in this case study. Given how locally advanced this tumor was, the patient would need adjuvant radiation therapy. This, in addition to the size of the final defect, made reconstruction with a latissimus dorsi myofascial free flap the preferred option. The involvement of the skull and the dura also posed a reconstructive challenge, necessitating a PEEK cranioplasty. Multidisciplinary collaboration between surgical and medical specialties allowed a complete resection and reconstruction that will withstand future radiation therapy to provide local and regional disease control.cSCC is often managed surgically. Scalp involvement with cSCC presents challenging resection and reconstruction. This challenge is further magnified in the case of large, locally advanced cases. These cases require a multidisciplinary collaboration between different surgical and medical teams to provide complete resection of the tumor and prevent or decrease the local and regional risk of recurrence with adjuvant treatment.


Both musculoskeletal gossypibomas and chronic expanding hematomas have been rarely reported; the reports that do exist are usually case reports. Our objective is to demonstrate problematic imaging diagnostics of an unusual presentation mimicking a malignant lesion. We report the case of a 47-year-old man who underwent bone graft harvesting from the iliac crest for spinal fusion due to scoliosis at 18 years of age, and 29 years later, he developed a growing, painful tumor at the original donor site (a bone defect in the iliac crest). It was challenging to differentiate a hematoma from a malignant tumor based solely on clinical and radiological workup, including an ultrasound-guided needle biopsy focused on viable tissue. The definitive diagnosis of a gossypiboma with a chronic expanding hematoma was based on histopathological assessment after wide surgical resection—a chronic expanding hematoma with multiple foamy macrophages and giant cells engulfing foreign material . A 47-year-old man presented to our outpatient department with a growing, painful tumor in the region of the left iliac bone. He sustained bone graft harvesting from the iliac crest for spinal fusion due to scoliosis 29 years ago, and he had not had any problems in the past. Therefore, no imaging method was available for comparison. He stated he did not have any history of trauma, and he had observed the tumor for one year. The patient had already undergone an inconclusive diagnostic checkup at a different hospital, with an open biopsy only yielding nonspecific findings of tissue necrosis. Imaging methods were used .The combination of aggressive bone destruction, lesion extending into the pelvis, and a non-aggressive sclerotic margin with a narrow zone of reactive osteosclerosis were considered controversial. A significant portion of the lesion infiltrated the gluteal muscles, displaying subtotal central necrosis and a thin viable (enhancing) rim preserved in the periphery. Calcification of an unusual morphology was visible in the center of the lesion. Bone destruction associated with soft tissue mass and an irregular tumor shape suggested a malignant lesion. Ultrasound assessment and ultrasound-guided needle biopsy followed .The histological findings from the ultrasound-guided needle biopsy were considered nonspecific and inconclusive. No tumor was identified, and a recommendation was made to exclude histiocytosis or Erdheim–Chester disease .These diagnoses were subsequently excluded based on a hematologic workup and a bone scan. At angiography, the mass was hypovascularized and thus unsuitable for therapeutic embolization. We therefore decided to perform a wide surgical excision and histologic assessment of the whole mass. We performed an incision along the iliac crest. Beneath the gluteal muscle, we found a tumorous mass 10 × 10 cm adjacent to the original site of bone graft harvesting. It consisted of a fibrous pseudocapsule, an old hematoma, and necrotic tissue. After wide resection, we sent this mass for histologic assessment. We found remnants of a foreign material near the iliac bone similar to a textile .The donor site of the iliac crest had smooth margins without macroscopic changes from recent destruction. The procedure revealed that the iliac bone defect was the original donor site, not new osteolytic destruction. Finally, we refixed the gluteal muscle by via a transosseous suture to the iliac crest. We sent the tumorous mass for histopathological assessment .The final diagnosis corresponded to a gossypiboma with a chronic expanding hematoma.Non-weight-bearing with crutches was recommended after surgery for six weeks due to the healing of the refixed gluteal muscles. We have not observed any complications or relapses during follow-up for five years.A chronic expanding hematoma is a rare entity resulting from trauma, surgery, and bleeding disorders and has been mentioned infrequently in the literature with various presentations ,2,3. It Similarly, Sakamoto and Matsuda described a chronic expanding hematoma as a late complication from 24 to 45 years after thoracoplasty . The expIn conclusion, both musculoskeletal gossypibomas and chronic expanding hematomas have been rarely reported; they can develop for months, but sometimes with a latency of decades; they can also mimic a malignant lesion. The consideration of these subjects in differential diagnosis and the importance of bringing them to medical attention should be emphasized.


Dermatofibrosarcoma protuberans (DFSP) affecting the scalp often disfigures the shape of the head but is also known to extend intracranially to cause neurologic symptoms if not addressed in time.We describe the case of a 6-year-old girl with DFSP of the scalp, involving the periosteum, which was treated with a single-stage surgery involving a multidisciplinary team comprising of a Mohs micrographic surgeon, pediatric neurosurgeon, and pediatric plastic surgeon.A). It was initially noticed at birth as a depression in the skin a few millimeters in diameter. However, at the age of 3 years, the patch grew, prompting an ultrasound scan, which showed normal underlying bone. By the age of 5 years, the lesion had grown precipitously, becoming nodular and painful, with secondary local satellite lesions. The patient did not have any neurologic symptoms. Multiple punch biopsies showed spindle cell proliferation, consistent with DFSP. Platelet-derived growth factor translocation was notably negative. A chest x-ray was performed and did not show any concern for metastatic disease. There were no other symptoms or signs suggestive of metastatic spread.A 6-year-old girl presented with a tender midline lesion, measuring 5 × 4 cm, on the vertex , A. It wB). These findings raised our suspicion for possible periosteal and/or underlying bone involvement. To holistically address the diagnosis, a multidisciplinary team of a Mohs micrographic surgeon, pediatric neurosurgeon, and pediatric plastic surgeon was formed for excision of the mass and reconstruction of the calvarium and scalp.Computed tomography and magnetic resonance imaging of the head revealed a 3.5 cm × 4.7 cm × 7-mm region of ill-defined soft tissue involving the skin and subcutaneous tissue, interdigitating with the underlying musculature. Although there was no obvious intracranial extension, it was noted that there was bilateral smooth osseous thinning of the bilateral frontal and parietal bones overlying the sagittal venous sinus , B. ThesA). Because of periosteal involvement of the tumor, a craniotomy was performed by the neurosurgeon. The bone flap started at the bregma and extended posterior over the midline. This was completed without complication, and no dural tears were made (B).Mohs micrographic surgery proceeded initially with the patient under general anesthesia. Cutaneous free margins were obtained after the fourth excision. The tumor was noted to have subclinical and microscopic extension within the galea and periosteum . The calere made , B.Fig 2A). Galeal scoring and circumferential subgaleal undermining allowed advancement of the scalp toward the midline. Two back cuts in a yin-yang fashion allowed further advancement. Intraoperative tissue expansion was performed by placement of tissue expanders on both sides, resulting in a gain of at least 1 cm on each side, allowing tension-free approximation across the midline. A segment of the scalp tissue that was missing galea was excised to allow continuity in the galea (B).Following these procedures, a full-thickness scalp defect measuring 8 × 12 cm and a bone defect measuring 8 × 11 cm were noted. A titanium mesh spanning the cranial defect was placed and secured in place using screws , A. Galehe galea , B.Fig 4The patient recovered from the operation uneventfully and was discharged on postoperative day 4. Final soft-tissue pathology showed margin-free excision and a grossly indented calvarium bone but no obvious evidence of bony DFSP invasion. There were no wound healing issues, and the patient remained disease free at her 19-month follow-up visit, as determined based on clinical examinations. Given the high confidence in complete resection, no additional follow-up has been scheduled or arranged.Dermatofibrosarcoma of the scalp has historically shown potential for periosteum invasion. Although only a few cases of this have been reported, craniectomy is typically required for establishment of margin-free resection.,Because calvarial growth is usually complete at ∼5 years of age, titanium implants and other prosthetic materials should not affect calvarial growth.Despite preoperative imaging and gross appearance of the bone at the time of resection raising suspicion for underlying calvarium involvement, the final pathology did not show any bone invasion. The authors believe that pursuing craniectomy was critical in achieving the optimal outcome for our patient even if the final pathology did not confirm bony involvement. With this approach, we have high confidence in our surgical margins in a disease that is notorious for a high recurrence rate. Furthermore, resection and reconstruction were conducted under a single session of general anesthesia and limited additional trips to the operating room.The formation of the multidisciplinary team was instrumental for the management of this patient. The recurrent nature of the lesion, location being in a sensitive spot over the dural sinuses, and desire for single-stage hard- and soft-tissue reconstruction necessitated the expertise of each member of the team. Therefore, we believe that multidisciplinary referral to a tertiary center with the availability of a Mohs micrographic surgeon, pediatric neurosurgeon, and pediatric plastic surgeon is advised to allow single-stage, margin-free resection and immediate reconstruction.None disclosed.


Common carotid artery occlusion is rare. Bilateral common carotid artery occlusion is extremely rare and, to our knowledge, has hardly ever been reported. This report describes a case of fatal stroke with acute simultaneous bilateral common carotid artery occlusion presenting as sudden coma. A 90-year-old woman was transferred to our hospital by ambulance with a sudden coma. She had a history of atrial fibrillation but had not taken any oral antithrombotic medication in recent years. She had been receiving house calls for dehydration in the previous week. Magnetic resonance imaging showed extensive cerebral infarcts in both cerebral hemispheres, and magnetic resonance angiography revealed bilateral common carotid artery occlusion. Acute recanalization therapy was not performed because of the extensive cerebral infarction, the patient's advanced age, and her poor ability to perform activities of daily living. On the day after onset, she died of massive cerebral infarction and marked brain swelling. Common carotid artery (CCA) occlusion is rare, accounting for less than 1% of all strokes The case was a 90-year-old woman who had been receiving house calls for dehydration during the previous week and was transported by ambulance to our hospital after the sudden onset of a coma. She had a medical history of hypertension, diabetes, atrial fibrillation, congestive heart failure, and Parkinson's disease and needed assistance with activities of daily living . She had taken antithrombotic medications in the past but not in recent years. Upon emergency arrival, she had severe neurological deficits, including deep coma  and tetraplegia  but no unilateral symptoms, such as conjugate deviation or hemiparesis. Magnetic resonance imaging at 105 minutes after onset revealed extensive infarcts in both cerebral hemispheres, with only the right posterior cerebral artery territory being spared . MagnetiWe have encountered an extremely rare case of acute simultaneous bilateral CCA occlusion that resulted in a fatal stroke. Occlusion of the CCA is rare, and bilateral CCA occlusion is even rarer Our patient presented with a sudden coma. Coma is one of the most common symptoms of onset of ischemia in the posterior circulation. Anterior circulation ischemia often presents with unilateral cerebral hemispheric symptoms, but bilateral occlusion of the internal carotid artery (ICA) has also been reported to cause coma, albeit rarely Furthermore, a case with bilateral CCA occlusion would have a large volume of causative thrombus. In our patient, the following 2 points may have played an important role in thrombus formation: first, the patient was not taking anticoagulants despite having atrial fibrillation and congestive heart failure; second, she had been dehydrated for about a week before onset. A case of extensive thromboembolism of the innominate trunk, right subclavian artery, and bilateral CCA, as well as pulmonary embolism, has been reported This report describes a rare case of fatal stroke with acute simultaneous bilateral CCA occlusion that presented as sudden coma. Acute simultaneous bilateral CCA occlusion is extremely rare but can occur. Bilateral anterior circulation stroke presenting with sudden coma is rare, but indicates critical cerebral ischemia and requires prompt and appropriate imaging.All procedures performed in studies involving human participants were in accordance with the ethical standards of the institution and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The study was approved by the Ethics Committee of Nakamura Memorial Hospital (No. 2023102601).Written informed consent was obtained from the patient's daughter.Yuki Koike: Validation, Writing – review & editing. Hideki Endo: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Resources, Data curation, Writing – original draft, Writing – review & editing, Visualization, Project administration. Tomoki Fuchizaki: Validation, Formal analysis, Investigation, Resources, Writing – review & editing. Kenji Kamiyama: Supervision. Toshiaki Osato: Supervision. Hirohiko Nakamura: Supervision.


While Non-Hodgkin Lymphoma (NHL) often involves the ovaries at time of autopsy, it is rarely present at the time of diagnosis. Here we present a case of a 20-year-old who presented with a large adnexal mass and elevated B-HCG, CA-125, and LDH. The patient underwent exploratory laparotomy, and frozen section of the left ovarian mass was suspected to be a dysgerminoma. Final pathologic diagnosis was Ann Arbor stage IVE Diffuse Large B-Cell Lymphoma, germinal center subtype. Patient is currently undergoing chemotherapy and has received the 3 of a planned 6 cycles of R-CHOP. The term ‘primary ovarian lymphoma’ denotes an extranodal lymphoma identified in one or both ovaries without evidence of involvement of any other lymph node region or extra-lymphatic organ. The pathogenesis of ovarian lymphoma is debated due to the lack of lymphatic tissue in the ovary. It is hypothesized to arise from reactive lymphocytic infiltrates in the setting of pelvic inflammatory disease, endometriosis, benign ovarian cysts, or other inflammatory conditions . Primary2A 20-year-old healthy woman presented to the emergency department at a tertiary care center with abdominal pain and distension. She reported a growing, firm pelvic mass over the last several months. On abdominal exam, she had a firm, mildly tender pelvic mass extending to the level of the umbilicus. B-HCG was 62.6 mIU/mL on initial presentation, but no intrauterine pregnancy (IUP) or ectopic pregnancy was visualized on transvaginal ultrasound. The pelvic ultrasound did reveal a 14 × 9 × 12 cm left heterogenous adnexal mass with cystic areas and vascularity, and the final radiology report suggested concern for an ovarian dysgerminoma. Tumor markers were collected: CA-125 was elevated to 202 U/mL, CA 19–9 was < 0.6 ng/mL and CEA was 0.9 U/mL. She was referred for outpatient gynecologic oncology follow up.Three weeks after initial presentation, she returned to the ED with worsening abdominal pain, distension, and lethargy. Beta-HCG had increased to 47,307 mIU/mL. Repeat TVUS demonstrated a viable IUP. The large, heterogenous left adnexal mass was also again visualized. Additional tumor markers were obtained including AFP, LDH, testosterone, and Inhibin B. Testosterone was 55 ng/dl (First trimester reference range 26–211 ng/dl)  and inhiAt day ten post-termination, the patient presented again to the ED with three days of constant, severe pelvic pain that suddenly worsened the night before presentation. Pain was associated with subjective fever chills, bloating, yellow, non-malodorous vaginal discharge, and constipation. She became febrile to 39.2 degrees Celsius, tachycardic, and had a leukocytosis to 11,200/mcL. On physical exam, her abdomen was diffusely tender to palpation with guarding but no rebound tenderness. Pelvic exam was limited due to the patient’s discomfort. The cervix was unable to be visualized on speculum exam, and bimanual exam demonstrated cervical motion tenderness.para-aortic lymph nodes measuring up to 1.3 cm, and small volume ascites with mild nodular stranding of the greater omentum 3Ovarian lymphoma has variable presentation, and can include symptoms typical of ovarian malignancy such as pelvic pain, bloating, pelvic mass, or ascites. Fevers, night sweats, fatigue, and weight loss (B symptoms) are frequently reported. CT imaging typically demonstrates homogenous masses with uniform enhancement and without cystic components, papillary projections, hemorrhage, necrosis, or calcifications .Extranodal NHL is typically diagnosed by incisional or excisional biopsy or fine needle aspiration, and primary treatment typically involves systemic chemotherapy with or without local radiation rather than surgical resection . OvarianOn initial presentation, the differential diagnosis for the patient was very broad. This patient initially presented with elevated CA-125 and LDH. CA-125 is the most commonly used blood test for ovarian cancer surveillance but has limited use as a screening tool due to unacceptably high false-positive and -negative rates . ElevateIn this case, CA-125 and LDH elevation, patient age, heterogeneously enhancing pelvic mass on CT, and the finding of malignant neoplasm with small round cells on intraoperative frozen section highly favored the diagnosis of dysgerminoma. Histologically, NHL can resemble dysgerminoma, granulosa cell tumor, small cell neuroendocrine carcinoma, small cell carcinoma of hypercalcemic type, and undifferentiated carcinomas . As suchMenstrual recovery and spontaneous pregnancy have been frequently observed in reproductive-aged women receiving chemotherapy for NHL . Both ov4Although primary ovarian lymphoma accounts for a very small proportion of ovarian tumors, it should be a part of a differential diagnosis for adnexal masses suspicious for malignancy. Ovarian lymphoma is difficult to distinguish from a primary ovarian malignancy by imaging, tumor biomarkers, or histology. Maintaining ovarian lymphoma on the differential for an adnexal mass suspicious for malignancy may promote fertility sparing treatment and minimize unnecessary surgical interventions.5Written informed consent was obtained from the patient for publication of this case report and all included images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.Charlotte Gerrity: Writing – original draft. Alyssa Mercadel: Writing – review & editing. Abrar Alghamdi: Writing – review & editing. Marilyn Huang: Writing – review & editing, Supervision.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Pneumatosis intestinalis (PI)—the presence of intramural bowel gas—is an uncommon radiological finding, the severity of which depends on the underlying pathological process, ranging from benign disease to life-threatening ischaemia and intra-abdominal sepsis. PI has been described in systemic sclerosis and mixed connective tissue disease; however, few cases have been reported in Sjogren’s syndrome (SjS). The exact pathogenesis of PI in systemic connective tissue disorders is not fully understood and likely multifactorial. We have described a unique case of PI without evidence of peritonitis in a stable patient with long-standing SjS managed non-operatively. An awareness of such benign PI, particularly amongst patients with systemic connective tissue disease, is crucial for diagnostic accuracy and safe patient care, particularly in preventing unnecessary surgical intervention. Pneumatosis intestinalis (PI)—the presence of intramural bowel gas—is an uncommon radiological finding, the severity of which depends on the underlying pathological process, ranging from benign disease to life-threatening ischaemia and intra-abdominal sepsis . Benign 9/L, haemoglobin 130 g/L, C-reactive protein level 6 mg/L and lactate 1.0 mmol/L. Dual contrast abdominal CT scan (An 84-year-old male with untreated primary SjS was referred to the emergency department with acute abdominal pain, distension and vomiting. He presents on the background of oesophageal dysmotility, sinus bradycardia and previous appendicectomy. On this presentation, he was clinically well, haemodynamically stable and afebrile. His abdomen was distended but otherwise soft and benign to examination. Laboratory findings were as follows: white cell count 5 × 10 CT scan  demonstrThe exact pathogenesis of PI in systemic connective tissue disorders is not fully understood and likely multifactorial. Of note, bacterial overgrowth and increased intra-luminal hydrogen may compromise mucosal integrity and facilitate the intramural translocation of gas, with rupture of resulting sub-serosal gas blebs by causing an associated benign pneumoperitoneum . The mecIrrespective of the pathophysiology, the clinical importance of benign PI is the risk of misdiagnosis leading to unnecessary operative intervention . DiscernHere, we have described a unique case of PI without evidence of peritonitis in a stable patient with long-standing SjS managed non-operatively. An awareness of such benign PI, particularly amongst patients with systemic connective tissue disease, is crucial for diagnostic accuracy and safe patient care, particularly in preventing unnecessary surgical intervention.