Chondrosarcoma of sternal origin is extremely rare. Here, we present the case of a 59-year-old male who presented with gradually increasing swelling and pain over the left sternoclavicular joint which was diagnosed as chondrosarcoma of sternal origin. We also present a review of the relevant literature. Chondrosarcoma of sternal origin is extremely rare. Its incidence is estimated to be only 15% of all chondrosarcomas reported worldwide. The annual predicted incidence of chest wall chondrosarcoma is 60 cases, with sternal origin accounting for 2% of these cases [Soft-tissue sarcomas are mesenchymal-derived tumors that affect muscles, endothelium, cartilage, and supporting tissues but not the blood vessels or the reticuloendothelial system. Less than 1% of all neoplasias are primary malignant tumors of the thoracic wall, which can include a wide range of soft tissue and bone abnormalities .Based on etiology, it can be categorized as primary if the tumor grows from nothing or secondary if it results from single or multiple existing benign osteochondromas and enchondromas. Osteochondromas experience secondary chondrosarcoma in around 80% of instances, with malignant transformation occurring slightly more frequently in solitary exostoses than in multiple exostoses. Isocitrate dehydrogenase 1 and 2 genes are one of the most frequent point mutations. Isocitrate dehydrogenase is a metabolic enzyme that facilitates the conversion of isocitrate to alpha-ketoglutarate through oxidative decarboxylation .Neoplastic involvement of the sternum is extremely rare and considered malignant unless proven otherwise. Computed tomography (CT) with contrast or magnetic resonance imaging (MRI) with histopathological correlation is crucial in confirming the diagnosis of chondrosarcoma, and the treatment is surgery. The prognosis is poor for the axial skeleton. Complete resection leads to acceptable long-term survival for patients with chondrosarcoma.A 59-year-old male presented with complaints of swelling and pain over the left sternoclavicular joint for seven months which was gradually increasing in size. The patient reported no history of fever or trauma. On general examination, the patient was conscious and well-oriented. Systemic examination was within normal limits.On local examination, a relatively well-defined swelling measuring approximately 4.4 × 4.2 cm was noted at the sternal area. It was hard in consistency and immobile. There was no evidence of a rise in local temperature. Moreover, there was no evidence of dilated veins. No movement was noted with deglutition.The patient was advised a chest X-ray. A relatively well-defined lytic lesion was noted over the sternal region and a possible diagnosis of a tumor of skeletal origin was made. The patient was advised to undergo a CT of the chest and an MRI of the thorax.On CT of the thorax, a relatively well-defined hypodense lesion measuring 4.1 × 4.6 × 4.7 cm  was noted over the sternal surface. It showed a chondroid matrix with ring and arch-like calcification.On MRI of the thorax, a relatively well-defined altered signal intensity lesion measuring 4.1 × 4.6 × 4.7cm  was noted at the left sternoclavicular region at the juxta-cortical location involving the manubrium, the proximal body of sternum, medial end of the clavicle, and the first rib on the left side causing cortical bony destruction. The lesion was noted to be involving the adjacent soft tissue component, that is, the involvement of the adjacent pectoralis major muscle with maintained fat planes with a prevascular compartment of the anterior mediastinum. It appeared heterogeneous and predominantly isointense on the T1-weighted image (WI) Figure .On diffusion-weighted imaging (DWI), evidence of restriction was noted Figure .On the post-contrast study, the lesion showed heterogeneous enhancement with few non-enhancing necrotic areas within Figure .The above-mentioned imaging features were highly suggestive of chondrosarcoma. A CT-guided biopsy was done and the result was grade I chondrosarcoma, with the presence of abundant extracellular hyaline matrix and scant cellularity. The patient underwent surgery. Subsequent follow-up visits were unremarkable.Chondrosarcoma of sternal origin is an extremely rare tumor of soft mesenchymal origin. It occurs predominantly in males aged less than 20 years. It is an aggressive tumor, which in this case grew to invade the pleura and adjacent muscles. The clinical manifestation is a palpable mass that is rarely painful, causing respiratory failure and hemothorax. Although chondrosarcomas of sternal origin grow slowly, if not treated timely, they can undergo metastasis .Soft-tissue sarcomas are lobulated, firm masses in gross appearance. Macroscopically, they are usually grayish-pink in color. They may also show hemorrhagic, necrotic, or calcific components within. On microscopy, these characteristically comprise small-to-medium-sized round cells with poor differentiation .For patients with chondrosarcoma to receive successful therapy and have a better prognosis, early diagnosis is essential. Due to its varied clinical presentation, nonspecific symptoms, heterogeneous appearance on imaging examinations, and fluctuating biological behavior, the diagnosis can be difficult. Therefore, a combination of these factors must be taken into account to choose the best course of action. Differentiating between aggressive and more benign lesions is one of the most important variables. Larger size, localization in the pelvis and proximal regions of the limbs, the existence of multiple medullary lesions, and incidence in individuals aged over 50 years are specific characteristics of the lesions that may indicate a higher risk of malignancy .Imaging diagnosis is based on multiple factors, including patient age, the pattern of bone destruction, and matrix mineralization, all of which may confirm the diagnosis in certain cases .CT and MRI are the investigations of choice. CT helps diagnose calcification whereas MRI helps diagnose its soft-tissue extension . MRI hasThe growth and local relapse of thoracic wall chondrosarcomas is usually slow. Late metastases occur if untreated. The biggest factor affecting survival is whether the primary neoplasia is completely under control. A large excision must be performed during the initial procedure to stop local recurrence .Other sarcomas such as synovial sarcomas, osteosarcomas of extraskeletal origin, and malignant fibrous histiocytomas are key differential diagnoses that need to be ruled out. Myositis ossificans is a benign differential that also needs to be considered .Chondrosarcoma of sternal origin is an uncommon tumor of the chest wall. It is diagnosed accurately by contrast-enhanced CT or MRI. Surgery is the mainstay of treatment.


Sarcomas of the head and neck account for about 2% of all head and neck malignancies in adults. The median age at diagnosis is 50–54 years with a slight male predominance. The rarity of these sarcomas and lack of prospective trials make it difficult to reach valid conclusions. A 36‐year‐old woman was referred to our hospital because of an expanding non‐pulsatile mass in the right supraclavicular fossa with associated numbness and paresthesia of the right forearm. The patient reported that the mass had gradually enlarged for the past 5 months. She had no history of trauma or any chronic illnesses. A physical examination revealed a mass measuring approximately 7 cm × 5 cm above the right clavicle with no palpable thrill or bruit. Ultrasound‐guided biopsy was done and the histology report revealed soft tissue cells, fatty cells, and skeletal muscle cells; no tumor cells were identified. Magnetic resonance angiogram studies were made and revealed a highly vascularized supraclavicular mass. Under a multidisciplinary approach, the mass was resected. Head and neck sarcomas are relatively rare tumors and those of the head and neck account for about 2% of all head and neck malignancies and 4%–10% of all sarcomas in adults. The main histologic subtypes are rhabdomyosarcoma, osteosarcoma, chondrosarcoma, and angiosarcoma. The patient presented with an insidious onset with no predisposing factors.Sarcomas of the head and neck account for about 2% of all head and neck malignancies and 4%–10% of all sarcomas in adults. The clinical and histologic makeup of any of these large series of head and neck sarcomas is highly dependent upon the nature of the reporting institution or the clinical practice of the reporting clinician. There are variations and limitations in reporting head and neck sarcomas depending on their demographics, histologic, and anatomical makeup. The median age at diagnosis for all head and neck sarcomas is 50–54 years. Most series report a slight male predominance. Any site within the head or neck can be the primary site for a sarcoma since connective tissue is ubiquitous.Patients generally present with a palpable mass, especially in the neck, skin changes, or subsite‐specific symptoms, for example, hoarseness of voice, epistaxis, dysphagia, nasal obstruction, or cranial nerve deficits.Performing a biopsy to obtain representative tissues for histological evaluation is an important component of the initial evaluation. However, the biopsy method can affect subsequent treatment and thus should be carefully planned in conjunction with the surgeon who will perform the definitive surgery.The rarity of head and neck sarcomas and lack of prospective trials make it difficult to reach valid conclusions.2A 36‐year‐old woman was referred to our hospital because of an expanding non‐pulsatile mass in the right supraclavicular fossa. The patient reported that the mass had gradually enlarged for the past 5 months. She had no history of trauma or any chronic illness; however, she reported numbness and paresthesia of the right forearm. A physical examination revealed a mass measuring approximately 7 cm × 5 cm above the right clavicle with no palpable thrill or audible bruit.Duplex ultrasound scanning confirmed a cyst‐like mass with pericystic fluid in the right supraclavicular fossa; Ultrasound‐guided biopsy was done and the histology report revealed soft tissue cells, fatty cells, and skeletal muscle cells; no tumor cells were identified.We decided to start on three dexamethasone infusions to decompress the mass with 16 mg, each over 4 h.The decompression took 72 h after which the patient registered mild improvement in the numbness and paresthesia of the right hand.Surprisingly, the patient experienced rebound swelling and severe pain, and numbness in the right hand after 72 h. The mass did not respond to dexamethasone decompression infusion.A final decision was made to excise and perform intraoperative studies on the mass.Under general anesthesia, intraoperatively, we found a highly aggressive vascularized mass with tendency of bleeding.Intraoperative images were obtained Figure , and theThe decision to close and obtain magnetic resonance angiogram studies was made. Magnetic resonance imaging and angiography demonstrated a vascular mass compressing the brachial plexus, with no direct communication between the mass, the right subclavian artery and common carotids shown Figures  and 2A.A 3D reconstruction CT scan imaging was done to get proper approach and excision of the mass. The procedure was planned and incorporated a multidisciplinary team.Under general anesthesia, the patient was placed in a beach chair position to obtain an adequate view of the mass. The right clavicle was removed by an orthopedic surgeon to expose the mass.We dissected around the mass carefully so as not to damage the mass or surrounding vessels.We worked from a distal approach on the subclavian artery segment toward the proximal exposure.The feeding arteries were detected and divided with ligation which resulted in a decrease of pressure in the mass.The mass had spread in most places and about 90% was resectable. The residual tissues could not be resected as they were far adhered to the major neck vessels.Finally, the drainage veins were clamped after which the right clavicle was reconstructed with a plate by the orthopedic surgeon.The histology report (H/8244/22) under H&E staining revealed the tumor is hypercellular and is composed of plump spindle cells with moderate pleomorphism. Mitotic count is 15–18/hpf and foci of necrosis are present. No residual normal tissue seen Figure .The immunohistochemistry studies revealed CD34‐positive markers and composition of spindled to epithelioid cells with abundant eosinophilic cytoplasm with unusual glassy appearance Figure .The patient was put in the intensive care unit for monitoring. The operation time was 4 h, and the estimated blood loss was 1000 mL.3Head and neck sarcomas are relatively rare tumors and those of the head and neck account for about 2% of all head and neck malignancies and 4%–10% of all sarcomas in adults.Sarcomas are malignant tumors arising from skeletal and extraskeletal connective tissues including the peripheral nervous system. Approximately 76% arise in soft tissue and the remainder in bone.The main histologic subtypes are rhabdomyosarcoma in children, osteosarcoma, chondrosarcoma, and angiosarcoma.The median age at diagnosis for all head and neck sarcomas is 50–54 years. Any site within the head or neck can be a primary site for a sarcoma, since connective tissue is ubiquitous.There is no clearly defined etiology in most cases of soft tissue sarcoma, but several associated or predisposing factors have been identified. These include a genetic predisposition, gene mutations, radiation therapy (RT), chemotherapy, chemical carcinogens, chronic irritation, and lymphedema. In addition, an association between viral infection and sarcoma has been shown for HIV and human herpesvirus 8 in Kaposi's sarcoma, and for Epstein–Barr virus and smooth muscle tumors in immunocompromised patients.The genetics of sarcomas segregate into two major types: those with specific genetic alterations and usually simple karyotypes, including fusion genes due to reciprocal translocations  or specific point mutations , and those with nonspecific genetic alterations and complex, unbalanced karyotypes, reflected by numerous genetic losses and gains .There is a high incidence of acquired (somatic) gene alterations in soft tissue and bone sarcomas. Somatic mutations in specific genes vary across histological subtypes of soft tissue sarcoma. Frequently mutated genes included the p53 tumor suppressor gene, NF1, and PI3KCA. DNA amplifications of chromosome 12q have been observed in 90% of patients with dedifferentiated liposarcomas.The CD34 protein, the product of the CD34 gene , is expressed on the tumor cells of dermatofibrosarcoma protuberans (DFSP), but only on the vascular cells of malignant fibrohistiocytic lesions.The expression of the HER2 (c‐erbB‐2) oncogene and the epidermal growth factor receptor is frequently and independently increased in bone and soft tissue sarcomas.Several other genes have been associated with soft tissue sarcomas.3.1The commonly used immunohistochemical markers for differential diagnosis of spindle cell neoplasms are smooth muscle actin, desmin, CD 34, S100 protein, endothelial markers, and melanocytic markers. The recognition of the spindle cell tumor‐like lesions  and tumors  is crucial to avoid confusion with morphologically similar but more aggressive tumors like myofibroblastic sarcoma and dermatofibrosarcoma protuberans.Some very rare tumors like epitheloid hemangioendothelioma (EHE) is a rare vascular neoplasm of intermediate malignant potential, which commonly involves lungs, liver soft tissue, and bone. They usually present as an asymptomatic mass. Microscopically, they exhibit proliferation of epithelioid cells and spindle shaped endothelial cells. Epithelioid cells show cytoplasmic vacuoles with few cells containing RBCs.A 34‐year‐old male presented to our institution with the chief complaint of swelling on the base of the tongue from 8 months. Surgical excision was done. An extensive workup of immunohistochemistry was done using different markers including CD 31, CD 34, Ki 67, Factor VIII, and BCL2. Correlation of histopathology and immunohistochemistry below confirmed the diagnosis of EHE . The actuarial frequency at 15–20 years is approximately 0.5% for RT of normal bone and soft tissue in adults treated with RT alone to full doses and without chemotherapy.3.3Secondary sarcomas have a poorer prognosis than do de novo sarcomas. As an example, in a comparison of 130 patients with radiation‐associated soft tissue sarcomas with a matched cohort of sporadic sarcomas, patients with a secondary sarcoma had significantly worse disease‐specific survival . For MFH, 5‐year disease‐specific survival was 44% for patients with radiation‐associated sarcomas compared to 66% for patients with sporadic MFH.4Head and neck sarcomas are relatively rare tumors and those of the head and neck account for about 2% of all head and neck malignancies and 4%–10% of all sarcomas in adults. The median age at diagnosis for all head and neck sarcomas is 50–54 years. The main histologic subtypes are: rhabdomyosarcoma, osteosarcoma, chondrosarcoma, and angiosarcoma.Several gene mutations, radiation therapy, chemotherapy, and viral infections contribute to sarcomagensis. The biopsy method can affect subsequent treatment and thus should be carefully planned in conjunction with the surgeon who will perform the definitive surgery.Positive surgical margins are an independent predictor of poor survival. Negative margins are difficult to achieve in the region of the head and neck because these sarcomas tend to grow in tight anatomical confines and in close proximity to vital neurovascular structures.The rarity of head and neck sarcomas and lack of prospective trials make it difficult to reach valid conclusions.The patient's perception is that the swelling was something that might be related to use of local herbs that she was using to treat cough. She also reported that the swelling was secondary to the wound she had on the right thumb that was treated by local herbal medicine.Kato Ronald: Conceptualization; investigation; methodology; resources; supervision; validation; writing – original draft; writing – review and editing. Solomon Kibudde: Formal analysis; supervision; validation. Yusuf Mwondha: Investigation; project administration. Starlin Farah: Formal analysis; resources; writing – review and editing.There was no funding or any financial assistance that was contributed toward this manuscript.There is no any conflict of interest amongst authors and all our institutions with regard to the publication of this report.Written informed consent was obtained from the patient to publish this report in accordance with the Journal's patient consent policy.


Small bowel obstruction is a common surgical pathology encountered in the emergency department. The most common cause of small bowel obstruction is adhesions secondary to previous abdominal surgery. While strangulated external hernias are also a common cause of obstructions encountered, internal hernias leading to obstruction are rare. We present a 76-year-old male who presented with an acute abdomen and was later diagnosed with an internal hernia underneath his right external iliac artery. Internal herniation underneath the iliac vasculature is a recent phenomenon encountered very rarely after the natural anatomy has been disturbed in patients who have undergone pelvic lymph node dissection. Patients with a previous history of pelvic lymph node dissection should be suspected of having an internal hernia if they present with an acute abdomen. Closure of the peritoneum should also be considered in these patients as it may help prevent herniation. Internal hernias were previously considered a rare cause of small bowel obstruction, but their incidence has been increasing in the past two decades . This isA 76-year-old gentleman presented to the emergency department with rapid-onset severe constant abdominal pain after eating. It migrated from the umbilical region to the right iliac fossa (RIF). He had opened his bowels in the morning and did not complain of any vomiting, nausea, or fevers. Whilst very active and lean, he took apixaban for atrial fibrillation and, three years previously, had undergone neoadjuvant chemotherapy and robot-assisted cystoprostatectomy with the formation of an ileal conduit urostomy for an invasive bladder transitional cell carcinoma with an incidental prostate carcinoma. He is a non-smoker with no history of chronic cough or other risk factors for herniation. He had tenderness in the umbilical region and RIF with rebound tenderness. The urostomy was working. Though his pulse and inflammatory markers were within normal range, his serum lactate was 5.6mmol/L. A contrast-enhanced CT scan of the abdomen and pelvis showed dilated small bowel loops, a portion of which were poorly enhanced, suggesting a closed loop small bowel obstruction Figure . The radHe was resuscitated with intravenous fluids and broad-spectrum antibiotics and had a diagnostic laparoscopy. The findings were necrotic small bowel and haemorrhagic fluid but no obvious cause was found. A decision was made to convert to a lower midline laparotomy. The ileal conduit and ureters were found to be intact and patent. Approximately 40 cm of ileum herniated from lateral to medial between the pelvic brim and a very tight, thick cord-like band. The bowel was necrotic and contained a large amount of bloody fluid. Only after a very awkward reduction of the necrotic bowel did the “band” become appreciably pulsatile; it was a looping right skeletonized external iliac artery. The necrotic small bowel was resected, and bowel continuity was established with a stapled side-to-side anastomosis. The hernia defect Figure  was closInternal herniation of small bowel loops underneath the iliac arteries is a rare phenomenon that has been reported in a few previous case reports -14. The Pelvic lymph node dissection is the most effective method of detecting lymph node metastasis in several pelvic malignancies . HarvestAfter the reduction of the herniating content, we found a large hernial defect underneath the external iliac artery Figure . AddressInternal herniation underneath the iliac vasculature in a rare phenomenon that occurs after skeletonization of these vessels due to pelvic lymph node dissection. This diagnosis should be considered in patients presenting with symptoms of bowel obstruction following pelvic surgery, especially where there are tortuous iliac vessels. Closure of peritoneum could be considered to potentially avoid its complication. More studies are needed to understand the true incidence of internal hernias after pelvic lymph node dissection.


Teratomas are a type of germ cell tumor that may contain several different types of tissue. Neurofibroma is a benign peripheral nerve sheath tumor with the plexiform type being pathognomonic for neurofibromatosis type 1. We report a case of a 33-year-old woman with a background of Neurofibromatosis type 1 who presented with left-sided chest pain and shortness of breath. She was diagnosed with a large mediastinal mass which was confirmed from a CT-guided biopsy as neurofibroma. Following a multidisciplinary team discussion, she underwent mediastinal mass resection and the final histopathology report revealed mediastinal mature teratoma. Neurofibromatosis type 1 (NF1) is a hereditary disorder that is either inherited in an autosomal dominant pattern or by de novo mutations. It is caused by mutations or deletions to the NF1 gene which is located on chromosome 17 and encodes the tumor suppressor protein neurofibromin -4.The patient was a 33-year-old Caucasian woman who presented with left-sided chest pain and shortness of breath which progressively worsened over 12 hours. She was experiencing intermittent and brief episodes of left-sided chest pain and dyspnoea over the last year which did not cause her any immediate concerns as they were self-terminating. During the same period, she noticed increasing hair loss throughout her body. Furthermore, she developed a subcutaneous nodule below her right breast which reached dimensions of 6.5 x 5 cm within a year. On clinical examination, she had reduced air entry on the left base during her chest auscultation, café-au-lait spots throughout her body, some larger than 15mm, and bilateral inguinal freckles. Her medical history was comprised of the excision of two subcutaneous nodules 10 years ago (located at the ulnar side of her left forearm and the posterior triangle of her right neck) which led to her NF1 diagnosis. Thoracic imaging revealed a large left-sided pleural effusion and a large mass in the anterior mediastinum and therefore, she was subsequently referred to our department. The size of the mass on the computer tomography  Figures , 2G. FocBenign teratomas in the mediastinum are a rare diagnosis that accounts for 3%-12% of mediastinal tumors . HoweverNF1 that encodes neurofibromin. This is a protein that acts as a GTPase that down-regulates the RAS pathway [NF1, results in the formation of neurofibromas has not yet been clearly defined.NF1 is a rare disease with an incidence of approximately 1:3,000 people . Patient pathway . The pat pathway . The mos pathway . Evidenc pathway . TherefoMature teratomas are derived from all three embryonal germ cell layers . The antIn our patient, the CT scan revealed a lobulated mass with soft and fat tissue densities with no evidence of teeth which would have supported the diagnosis of mature teratoma preoperatively. In compliance with the histological criteria for fibroadenoma diagnosis, the incisional biopsy from the chest wall mass in our patient demonstrated spindle cell proliferation with positive staining for S-100 and CD34 Figure -2C 15-1-115-17. To our knowledge, this is the first case of teratoma diagnosis in the anterior mediastinum in a patient with NF1. Anterior mediastinal tumors in NF1 patients are usually either phrenic neurofibromas or malignant peripheral nerve sheath tumors (MPNSTs) which are rare sarcomas ,19. OnlyFurthermore, apart from a unique diagnosis our report also presents an additional valuable feature for the medical literature, as the initial CT-guided biopsy of the anterior mediastinal mass was not in agreement with the final histopathology.Neurofibromatosis type 1 is a rare autosomal disease. Its most commonly reported clinical manifestation of the anterior mediastinum is either phrenic neurofibromas or malignant peripheral nerve sheath tumors. The patient in our study, despite she had also developed subcutaneous neurofibromas, her mediastinal mass was confirmed as predominantly mature teratoma. This case report aims not only to highlight the first case of teratoma diagnosis in the anterior mediastinum among patients with NF1 but also to raise awareness among clinicians that a mature teratoma could mimic neurofibroma in a CT-guided biopsy.


A ciliated hepatic foregut cyst (CHFC) is a very uncommon cystic hepatic lesion that arises from an embryonic remnant of the foregut epithelium. CHFC is predominantly asymptomatic and is found incidentally. However, it can show various clinical presentations such as pain and weight loss. We present the case of a 17-year-old female who came to our hospital with complaints of right subcostal pain and abdominal discomfort and was diagnosed with CHFC by biopsy. Successful laparoscopic resection was performed due to the possibility of malignant transformation. Even though the majority of the patients are asymptomatic and cysts are commonly found incidentally, when the lesion has concerning features, they may need follow-up or resection due to rare reported cases of malignant transformation. A ciliated hepatic foregut cyst (CHFC) is a rare benign hepatic lesion and is commonly considered a result of the evagination of the embryonic remnants of the aberrant foregut epithelium. The term was first coined by Wheeler and Edmonson in 1984 . CHFC isA 17-year-old female presented to the clinic with a history of severe right upper quadrant pain and abdominal discomfort. The blood workup including liver function tests was found normal. Abdominal computed tomography (CT) scan showed a 2.4 x 2.8 cm precisely contoured hypoattenuating lesion in the right periportal region of the liver. The lesion was circular with a cystic structure filled with dense fluid and was located close to the posterior wall of the right hepatic artery, resulting in compression of the right portal vein. The lesion was further characterized by contrast-enhanced abdominal magnetic resonance imaging (MRI) . Histopathological examination revealed the presence of a cyst lined by ciliated pseudostratified epithelial cells, consistent with CHFC , unilocular, and avascular lesions generally found in the medial segment of the left hepatic lobe (segment IV A and IV B), with various elements of the cyst, including clear serous to white or brown material with various densities ,6-9. CHFManagement of CHFC is controversial because most of the lesions are found incidentally, and patients are generally asymptomatic. Some recommend only observation , while oSince it determines the prognosis and management of the patient, a biopsy should be recommended for suspicious lesions that are detected incidentally on systemic screening . SimilarCHFC is a rare lesion located in the liver. Even though the majority of the patients are asymptomatic and cysts are commonly found incidentally, when the lesion has concerning features, they may need follow-up or resection due to rare reported cases of malignant transformation.


Benign vascular tumors known as hemangiomas usually appear in early childhood and adulthood. It rarely occurs in the oral cavity and is most frequently observed in the head and neck area. Oral hemangiomas are always clinically significant and need to be diagnosed as soon as possible and treated appropriately. Because the tongue is a highly mobile muscular organ and is, therefore, more prone to trauma and associated consequences, tongue hemangiomas pose a significant risk to patients. We are presenting a case of hemangioma on the dorsal surface of the tongue in a female patient of two years of age. The case report describes the lesion's diagnostic features and available treatment options while highlighting the importance of color Doppler ultrasonography, particularly for diagnosis and treatment. Tongue hemangiomas are benign vascular tumors that are seldom encountered and can cause bleeding, pain, trouble breathing, difficulty biting, and difficulty speaking . About 6A two-year-old pediatric female patient reported at the dental hospital with a complaint of painless swelling on the dorsal surface of the tongue since birth. This painless swelling was gradually increasing in nature. The initial lesion was a bluish patch and gradually increased to a present size of approximately 3X3 cm. There was no history of bleeding or discharge from the swelling. Additionally, no history of lip biting or trauma was reported. The patient's past medical and dental histories were not significant. During the intraoral examination, a lobulated, bluish-red soft tissue swelling with a diffuse periphery was observed on the dorsal surface of the tongue, specifically in the middle one-third of the tongue, with a size of approximately 3x3 cm, as shown in Figure Hemangiomas are known to be more common in women. The face, lips, tongue, oral mucosa, and trunk are the most often afflicted areas of the head and neck . They maPyogenic granuloma, chronic inflammatory gingival hyperplasia, telangiectasia, and squamous cell carcinoma are among the conditions that can be seen in the differential diagnosis of hemangiomas. Pyogenic granuloma, a reactive lesion that bleeds readily, grows quickly, and is typically accompanied by inflammation and ulceration, is frequently confused with hemangiomas. Clinically, it is frequently reddish-purple, pedunculated, lobulated, and perhaps hormone-sensitive . FurtherThe tongue, being a highly mobile muscular organ, is more susceptible to trauma and its associated consequences. Conversely, oral soft tissue hemangiomas can resemble other lesions both histologically and clinically. In the case mentioned, the female child had a hemangioma on the tongue, which posed a significant risk for trauma and its related consequences. Early diagnosis and biopsy are crucial to ascertain the lesion's clinical behavior and any repercussions, leading to an accurate prognosis and diagnosis of the specific vascular abnormality for better treatment approaches. Therefore, it is important to diagnose and treat hemangiomas early.


Inflammatory pseudotumor is rare observed in renal immunoglobulin G4-related disease.A 65-year-old female presented with a mass in the right kidney which was found in physical examination.Based on the imaging findings and clinical manifestations, we preliminarily judged that the mass of the right kidney was renal cell carcinoma.The patient finally underwent total nephrectomy.The final result of microscopic pathological examination is renal inflammatory pseudotumor.There are some characteristics on magnetic resonance imaging of renal inflammatory pseudotumor, which can improve diagnosis rate by combining with medical history and clinical manifestations. At present, there are many causes of RIP have not yet been elucidated, IgG4-RD may be one of its causes. Correct preoperative diagnosis can avoid total nephrectomy. However, the preoperative imaging findings mostly suggest malignant behavior and urologists often pick up the wrong treatment because of misdiagnosis. From 1999 to 2022, we retrieved 49 English cases of RIP in the Pubmed database. And our case was to summarize characteristics of RIP from 3 perspectives including history and clinical manifestation, imaging findings and histopathology.Clinically, the renal inflammatory pseudotumor (RIP) in renal immunoglobulin G4-related disease (IgG4-RD) is very rare.Previous cases described 37 cases of computed tomography (CT) and 16 cases of magnetic resonance imaging (MRI) imaging findings. Few literatures summarized the MRI imaging features of RIP. So we hope that we can provide favorable diagnostic clues by digging deeper into MRI characteristics through literature review by combining our case.A 65-year-old female presented with a mass in the right kidney which was found in physical examination. No abnormalities in clinical manifestations. Increased C-reactive protein , gamma globulin  and accelerated erythrocyte sedimentation rate  detected in laboratory.T1 and T2, and the signal was uniform. The diffusion-weighted imaging (DWI) showed slightly high signal and the apparent diffusion coefficient (ADC) value (b = 800) is about 1.0. The mass was slightly enhanced in the arterial phase and increased in the venous phase and delayed phase ,,5,13–17 Adamantiades-Behçet’s Disease, infection by Histoplasma capsulatum and Epstein-Barr virus, chronic pachymeningitis, primary amenorrhea, chronic Hepatitis B and Raynaud’s disease,,21 ipsilateral perinephric and periureteric fibrosis, rheumatoid arthritis, Wegener’s granulomatosis  and gout.So it was not difficult to find that immune system abnormalities including infection and autoimmune diseases had a potential relationship with RIP.We conducted a summary of 49 cases about their history and clinical manifestations in Table To sum up, we have found that patients with RIP may have inflammation-related clinical manifestations or experimental abnormalities and abnormal immune indicators.Otherwise, there are certainly some reasons for rearrangements involving anaplastic lymphoma kinase gene that the literature appears to support.,25 Grossly, the presentation of mass, especially the formation of vessels, depends on weak or strong inflammatory response. Inflammation lasting for a long time can induce angiogenesis which is vulnerable and easy to bleed. Under the microscope, the histologic examination of most cases reveals the bulk of the mass to contain spindle cells admixed with collagen, lymphocytes and plasma cells which it is also known as inflammatory myofibroblastic tumor. The spindle cells which have myofibroblastic features and are of fibroblastic or myofibroblastic origin express Vimentin and SMA. However, the histologic examination of few cases revealed lymphoplasmacytic infiltration without spindle cells. Either way, the mass is the inflammatory, fibrosis will be the end of chronic inflammatory reactions.The initial cause of the RIP is likely to be the renal immune complex deposition in most cases.In any case, the mass always has the characteristics of fibrosis, which is also the pathological basis for determining the characteristics of imaging findings.Even though the mass could be either solid, cystic or solid–cystic in nature, the most case all mentioned the solid tissue of mass presented mild enhancement during the arterial for existence of fibrous components.There was 16 cases received routine MRI examinations and we conducted a summary in Table T2 for which the mass have spindle cells. Second, RIP all presented delayed enhancement which was probably due to an accumulation of extravascular contrast media in the fibrotic component of the lesion. Finally, there were 2 cases mentioned that diffusion-weighted imaging  of IPT showed slightly hyperintensity.,16 Our patient’s case was mostly same as mentioned above. So we thought RIP should be suspected when the above 3 characteristics appeared in MRI, especially the DWI and ADC. Diffusion MRI studies yielded significantly different ADC between benign and malignant renal masses but few case reports described it. The ADC value (b = 800) of our case was about 1.0. Thus, we appeal to radiologists to report more MRI findings of RIP so that we can find features and make accurate diagnosis.Among these 49 cases, 37 received routine CT examinations. On CT scans, RIP presented low density, isodensity or high density due to the weak or strong inflammatory response.T2.The differential diagnosis of RIP may include malignant tumors such as papillary renal cell carcinoma, transitional cell carcinoma, inflammatory fibrosarcoma, malignant fibrous histiocytoma and nonmalignant tumors such as angiomyolipoma, xanthogranuloma pyelonephritis and plasma cell granuloma because of low signal on We find many common characteristics in literature review and summary about RIP. First of all, the immune system of more patients is abnormal or they suffer from immune-related diseases and the relevant inflammatory indicators and immunological indicators are also abnormal. Second, the presence of spindle cells is the most important feature of RIP, which is the basis of imaging findings. Finally, there are some characteristics on MRI of RIP, which can improve diagnosis rate by combining with medical history and clinical manifestations.Conceptualization: Guoqiang Yang, Jiangfeng Du, Yan Tan.Funding acquisition: Hui Zhang.Investigation: Yang Han.Methodology: Yang Han.Resources: Guoqiang Yang.Software: Jiangfeng Du.Supervision: Jiangfeng Du.Validation: Yang Han.Visualization: Yang Han.Writing – original draft: Yang Han.Writing – review & editing: Yan Tan, Hui Zhang.


Deficiency of smooth muscle cells can lead to dysfunction and engorgement of blood vessels termed as hemangioma, arteriovenous malformations, and venous malformations (VMs). Anorectal VM is a rare disease. It can present with massive hematochezia. An optimal treatment of anorectal VMs has not been defined. Surgery is an option if the lesion can be resected completely. Endoscopic injection sclerotherapy has been reported to be effective in treating small colorectal VMs. However, it has rarely been described in the treatment of large VMs. In this study, we describe a rare case of large anorectal VMs treated with microfoam sclerotherapy. VM occurs mainly in the alimentary tract, but it also affects the urogenital tract and other parts of the body. Multiple organ involvement is usually seen in Klippel-Trenaunay syndrome, blue rubber bleb nevus, and Osler-Weber-Rendu syndrome. VMs can cause serious problems due to acute or chronic bleeding, obstruction, and compression.2 Clinical features include minimal to massive hematochezia.4 Visualization of bluish red or red purple elevated lesions in colonoscopy is the diagnostic feature of VMs. The differential diagnosis includes hemangioma and arterial-VM. The absence of pulsation differentiates VMs and arteriovenous malformations. Biopsy is not recommended. Intravascular calcifications known as phleboliths are a specific finding of VMs seen on cross-sectional imaging. An optimal treatment of anorectal VMs has not been clearly defined.3 In this study, we describe a rare case of large anorectal VMs treated with microfoam sclerotherapy.Anorectal VM is a rare disease.A 42-year-old man presented with a 2-month history of hematochezia. He required 5 units of packed red blood cell transfusions. Examination showed pallor. Laboratory tests revealed a hemoglobin of 7.0 g/dL. Colonoscopy showed bluish red elevated vascular lesions occupying the complete circumference of the anorectum extending up to 14 cm of the anal verge  connected by a 3-way stopcock (modified Tessari technique). Two 20 mL plastic syringes were connected by a 3-way stopcock. The foam was formed by mixing polidocanol (1%)  with CO2 (polidocanol and CO2 were in a 1:4 ratio) between the 2 syringes. Polidocanol and CO2 were mixed back and forth at least 20 times between the 2 syringes. Foam injection was started from the proximal rectum to the distal rectum. The anal canal inferior to the pectinate line is sensitive to pain because of somatic innervation. Caution was exercised in the anal canal near the pectinate line. One to 2 mL of foam was injected per puncture. A total of 12 mL of the sclerosant was injected at each session , and a remarkable improvement in MRI and colonoscopy images. Follow-up colonoscopy showed remarkable sclerosis of engorged veins  can be converted into microfoam using COIn conclusion, anorectal VM is a rare disease. Endoscopic foam sclerotherapy seems to be a safe alternative to surgery for the treatment of large anorectal VMs.Author contributions: A.K. Jha and A. Suchismita were involved in designing and writing the manuscript. V.M. Dayal assisted in the review of the literature. All authors read and approved the final manuscript. A.K. Jha is the article guarantor.Financial disclosure: None to report.Informed consent was obtained for this case report.


A bifid ureter is an uncommon congenital anomaly. It develops through abnormal branching of the ureteric bud in utero and represents incomplete duplication of the collecting system. However, a bifid ureter with a blind-ending branch is a rare variant.We present the case of a 26-year-old female who presented with recurrent urinary tract infections and an episode of pyelonephritis. Radiological imaging revealed a blind-ending branch of a bifid ureter with Yo-Yo reflux.This report demonstrates laparoscopic evidence of the reflux and management of this rare congenital anomaly. A bifid ureter is a congenital abnormality characterized by a Y-shaped bifurcation in the urinary collecting system . If one Most of the cases are asymptomatic and discovered incidentally; therefore, the exact incidence cannot be determined. However, some cases present with recurrent urinary tract infections (UTIs) and nonspecific abdominal pain . The refWe present a case with a blind-ending branch of a bifid ureter requiring laparoscopic removal. Yo-Yo reflux was demonstrated in this case.A 26-year-old female who was diagnosed with bilateral duplex systems as a child was referred for recurrent UTIs and a recent episode of right-sided pyelonephritis. She reported symptoms of dysuria, frequency, severe fatigue, and right-sided flank pain.She underwent several investigations, including a computed tomography (CT) urogram and a right retrograde pyelogram.The CT urogram revealed bilateral duplex kidneys, with the left ureters appearing to join together at the level of the iliac vessels. However, the right ureter showed a blind-ending branch that went up to the level of the kidney but did not fuse with the renal parenchyma Figure . The preThe retrograde pyelogram confirmed duplication of the right ureter at the level of iliac vessels with a medial blind ending branch Figures -3. RefluManagement options were discussed with the patient, including conservative approach and surgical removal of the blind-ending branch. As the patient was complaining of recurrent symptoms, she preferred the surgical approach. Laparoscopic ureterectomy of the blind-ending branch was offered and explained in detail. Risks of the operation was explained, including the risk of having no benefit as the occurrence of recurrent UTI could be linked to other reasons. The patient agreed to proceed with the operation.During the operation, the right duplex ureters were identified and followed down to the Y junction at the level of iliac vessels. Interestingly, Yo-Yo reflux was detected by noticing the peristalsis moving from the normal ureter to the medial blind-ending ureter. The blind-ending ureter was excised at the level of bifurcation, leaving the upper normal ureter in continuity with the distal ureter.Postoperatively, the patient recovered well. On subsequent follow-up, the patient reported improvement of her persistent loin pain and fatigue with no recurrence of UTIs.The case highlights the rare anomaly of a blind-ending branch of a bifid ureter with observed evidence of Yo-Yo reflux. A bifid ureter is a relatively uncommon condition resulting from abnormal branching of the ureteric bud during embryonal development. In most cases, both branches of the bifurcation join the metanephric mesenchyme and fuse with the renal pelvis, forming a Y-shaped structure. However, when one branch fails to reach the metanephric mesenchyme, a blind-ending branch is formed . The firThe clinical presentation varies. Some patients remain asymptomatic, others may experience recurrent UTIs, pyelonephritis, and flank or abdominal pain . The refYo-Yo reflux has been described in literature to occur as a result of abnormal peristalsis propagation from the functional branch to the blind-ending branch or due to the difference in the pressure gradient between the two branches .It is quite challenging to demonstrate Yo-Yo reflux radiologically. In our case, however, the radiological imaging has demonstrated the evidence of the reflux. The CT urogram showed the presence of the contrast in the blind-ending branch, and the retrograde pyelogram demonstrated reflux of the contrast from the lateral functional branch to the medial blind-ending branch.The presence of Yo-Yo reflux was not only confirmed through radiological imaging but also directly observed and recorded during the laparoscopic procedure. The peristaltic movement of urine from the functional branch to the blind-ending branch was visually identified Video .Laparoscopic ureterectomy of the blind-ending branch was performed successfully Video . During A bifid ureter with a blind-ending branch is a rare variant of ureteric duplication. The demonstration of Yo-Yo reflux into the blind-ending branch is unusual. It can be challenging to prove the reflux. Our case demonstrates a radiological and a visual evidence of the reflux during laparoscopy.Asymptomatic cases may not need treatment; however, surgical intervention might be required in symptomatic cases. Our case provides evidence of the effectiveness of laparoscopic ureterectomy as a management option for this rare anomaly.


Inflammatory pseudotumors (IPT) are rare benign tumors that can develop in various regions of the body. Notably, IPTs have been uncommonly described in the Genitourinary system including occasional reports from the paratesticular region. This origin from this area is significant because of the ambiguity in differentiating this pathology from malignant lesions arising from the testis. We would like to report a case of a 32-year-old male who presented with a painless left scrotal mass for two years. Ultrasonography was done followed by a radical orchidectomy and histopathological examination of the excised lesion showed features suggestive of inflammatory pseudotumor from the paratesticular region. We feel this case merits reporting owing to the rarity of IPT occurring in the paratesticular region and the essential need for increased awareness and differentiation from the malignant counterparts. Inflammatory pseudotumors (IPT) are benign tumors that can originate from various organs in the body ,2. ThougA 32-year-old male patient presented to us with complaints of a painless left scrotal mass for two years. The scrotal mass was insidious in onset, progressive in nature, and hard in consistency with no history of any antecedent trauma or recurrent infections. Clinical examination revealed a hard, non-tender mass of size 7 x 5 x 3 cm in the left hemi-scrotum which could not be palpated separately from the testis. The mass was not adherent to the overlying scrotal skin and there were no other swellings in the groin or other regions of the body. Ultrasonography was done and this showed a heterogeneous mass of size 6 x 6.5 x 2.5 cm in the left scrotum. Serum tumor markers namely alpha-fetoprotein (AFP), beta human chorionic gonadotropin (hCG), and lactate dehydrogenase (LDH) were found to be within normal limits. This was followed by a radical orchidectomy and a gross examination of the specimen showed a 7.5 x 7 x 3.5cm vaguely nodular, capsulated mass attached to the testis and cord, which on cross-section was greyish white, firm, and whorled Figure .The histopathological examination (HPE) of the specimen demonstrated spindle-shaped cells with elongated slender nuclei with eosinophilic cytoplasm arranged in whorls and fascicles Figure . The tesThe intervening areas show extensive hyalinization and inflammatory cell infiltration composed of plasma cells, lymphocytes, and eosinophils Figures , 4.These features directed us to a conclusion of the Inflammatory Pseudotumor of the paratesticular region. The patient was followed up at six months and he was asymptomatic with no evidence of any recurrence.Paratesticular tumors are lesions that constitute approximately 5% of the overall intrascrotal neoplasms. Among these, approximately 75% of these tumors arise from the spermatic cord . In the It is thought to be a consequence of spindle cell proliferation but the exact underlying etiopathogenesis has not been fully understood . HoweverThe definitive management of IPT is the complete excision of the lesion . ConsideIPT are unusual tumors whose clinical presentation may resemble that of malignancy and hence careful evaluation of the lesion is essential to tailor the management individually which may vary from a testicular sparing approach to a radical orchidectomy. Though these tumors are benign in nature, due to the rarity and limited literature availability, these patients are to be advised to be kept under a periodical follow-up, especially if a testicular sparing surgery is done. Due to its rarity, we find it imperative to report this case as it can contribute important information to the existing IPT literature and might fill a gap in our understanding of this condition.


Plexiform schwannoma is a rare subtype of schwannoma. In this report, we present a case of plexiform schwannoma arising from the sciatic, tibial, and peroneal nerves. A 54-year-old man presented with a painful palpable mass extending from the left posterior thigh to the calf. Magnetic resonance imaging showed multiple bead-like nodular structures along the sciatic, tibial, and peroneal nerve pathway. The nodular lesions showed uniform signal intensity on T1-weighted imaging. On T2-weighted imaging, each nodule showed an eccentric area of relatively low signal intensity surrounded by an area of higher signal intensity and a low-intensity rim. Plexiform schwannoma or neurofibroma was considered as the preoperative diagnosis. Because of the patient's severe symptoms and strong desire for relief, tumor enucleation of the largest painful nodule was performed, and plexiform schwannoma was confirmed pathologically. Schwannomas are benign tumors derived from Schwann cells of peripheral nerve sheaths. Plexiform schwannoma is a subtype of schwannoma that exhibits a characteristic morphological bead-like or multinodular appearance. This subtype is extremely rare, accounting for less than 5% of all schwannomas ,2. FurthA 54-year-old man presented with a painful palpable mass extending from the left posterior thigh to the calf. He was referred to our orthopedic department for further investigation and treatment. The patient had a history of lumbar intervertebral disc herniation 4 months previously. Blood biochemical tests revealed no significant findings. The patient had no noteworthy family history.MRI revealed multiple well-defined nodular structures in the left lower limb, extending from the anterior aspect of the quadriceps femoris muscle to the popliteal fossa and proximal lower leg. The nodular structures exhibited a bead-like pattern and measured up to 1.8 × 1.7 cm in size , Fig. 2.Because of the patient's severe pain corresponding to a portion of the tumor in the left calf and his strong desire for relief, the largest tumor in the calf was surgically excised. Intraoperatively, the nerve fibers were observed to partially surround the tumor, and tumor enucleation was performed to preserve the nerve function.Gross examination revealed a smooth-surfaced tumor with a yellowish-white appearance. Microscopically, the tumor had a fibrous capsule and was composed of densely clustered spindle-shaped cells arranged in a palisading pattern (Antoni A areas) , and arePlexiform schwannoma is a rare subtype of schwannoma that proliferates in a bead-like or plexiform pattern along a nerve and accounts for 2%-5% of all schwannomas ,2. It wa50s presented with multiple nodular lesions in the left lower limb, and tumor enucleation was performed for the largest nodule. Multiple nodular lesions arranged in a bead-like pattern along the pathway of the sciatic, tibial, and peroneal nerves were found on preoperative MRI, and the enucleated tumor showed typical pathological findings of schwannoma consisting of Antoni A and B areas. Although the tumors were located along the peripheral nerve trunk, a diagnosis of plexiform schwannoma was made based on both radiological and pathological findings.Plexiform schwannoma commonly occurs in individuals aged 20-50 years, and there is no sex predilection Plexiform neurofibroma is a tumor with a morphology similar to that of plexiform schwannoma –10. PlexOn MRI, plexiform schwannoma and neurofibroma show multiple bead-like nodular lesions. Generally, schwannomas have a low-intensity rim reflecting a fibrous capsule at the periphery on T2WI. By contrast, a low-intensity rim on T2WI is less common in neurofibromas ,12. BothWe experienced a case of plexiform schwannoma arising from the sciatic, tibial, and peroneal nerves. The occurrence of plexiform schwannoma in a peripheral nerve trunk is rare; however, when a bead-like multinodular tumor is present along a nerve pathway, the possibility of plexiform schwannoma should be considered. An eccentric target-like appearance on T2-weighted MRI might be crucial for distinguishing plexiform schwannoma from plexiform neurofibroma.All authors provided final approval of the submitted version.Informed consent was obtained from the patient for the publication of this report and any accompanying images.


Small bowel obstruction is a frequently encountered surgical condition in adults. Its most prevalent causes include adhesions resulting from prior abdominal surgery or peritoneal infection. However, cases of small bowel obstruction caused by omental bands in elderly individuals with no prior abdominal surgeries are exceedingly rare, with only a few reported in the literature. Here, we report a case of an elderly patient with small bowel obstruction caused by internal herniation through an omental band, without prior abdominal surgery or trauma. The initial impression was mesenteric ischemia, which posed a diagnostic dilemma as the patient did not exhibit any clinical risk factors for mesenteric ischemia with absent history of previous trauma or abdominal surgery. A computed tomography (CT) scan was performed, revealing clustering of small bowel loops in the right hemiabdomen with mild dilatation and a close loop configuration indicative of an internal hernia. Internal hernias are rare and challenging to diagnose clinically as they lack specific signs and symptoms. In this case, CT played a crucial role in enabling preoperative diagnosis of an internal hernia and guiding early management.  Small bowel obstruction in adults can result from various factors, including adhesion, hernias, and neoplasms. Among them, internal hernias account for 0.6 to 5.8% of all small bowel obstructions . AdhesioA 76-year-old Malay gentleman with no known medical illnesses presented with acute symptoms of vomiting and periumbilical pain radiating to the epigastric region for two days. The abdominal pain was cramping in nature, and the pain score was graded as 10. Notably, the patient had experienced constipation for the past three days but had no constitutional symptoms or family history of malignancy. Vital signs showed a slightly hypertensive state with a blood pressure of 145/86 mmHg and an irregularly irregular heart rhythm but not tachycardic. Physical examination revealed a distended abdomen with tenderness over the epigastric and right hypochondrium while hernial orifices remained intact and no mass was detected during digital rectal examination. Laboratory findings indicated a white blood cell count of 11.0x 109/L, a hemoglobin level of 14.1 g/dl, and normal blood urea and electrolyte values. Amylase showed 103 U/L and venous blood lactate levels were elevated at 4.6 mmol/L. Electrocardiogram was performed and revealed atrial fibrillation. Chest X-ray revealed no air under the diaphragm. The presence of sentinel loops in the epigastric and paraumbilical regions on plain abdominal X-rays prompted further investigations. A subsequent computed tomography (CT) abdomen scan provided crucial insights, revealing clustered C-shaped loops of the distal ileum converging toward a mesenteric defect in the right paramedian region as shown in Figure The diagnosis of internal herniation through an omental band leading to ileal ischemia was confirmed during emergency laparotomy as shown in Figure Omental band adhesion resulting in acute obstruction of the small bowel within the peritoneal cavity is a recognized condition. The formation of omental bands can be attributed to factors such as congenital factors, previous surgeries, or inflammation . StranguIn our case, the most plausible explanation considering the patient's age and the absence of previous abdominal surgeries or inflammatory conditions is a congenital condition. It is worth noting that omental bands can occasionally lead to the formation of defects, serving as potential spaces for herniation of the intestines, as observed in our case. This narrow space acts as a constriction point, resulting in strangulation. A significant portion of the ileal loops had herniated through this space, highlighting an unusual cause of bowel strangulation, where the constriction is due to an omental band adhesion causing closed loop small bowel obstruction and gangrene.While there are various causes of small bowel obstruction, the clinical presentation rarely provides a definitive etiology. CT has proven to be valuable in identifying the location, level, and cause of the obstruction. Identifying adhesions as the cause of small bowel obstruction remains a diagnosis made by excluding other causes, relying on the observation of a sudden change in bowel caliber without evidence of alternative obstructive causes . CT featIn conclusion, an adhesional omental band with small bowel obstruction in an elderly patient with a virgin abdomen presents a unique clinical scenario. The underlying mechanisms of this condition in the absence of prior abdominal surgeries remain uncertain, potentially involving age-related changes in the omentum or other contributing factors. Imaging techniques, particularly CT, play a vital role in diagnosing and managing such cases. Increased awareness and consideration of congenital bands causing herniation of bowel loops are crucial for accurate diagnosis and timely intervention in patients with small bowel obstruction and no previous abdominal surgeries.


Osteoid osteomas of the talus are rarely seen. They can easily be misdiagnosed. In this case report, we present a 21-year-old man with an osteoid osteoma in the talar neck whose pain onset coincided with an ankle injury. The latter was deemed a misleading factor when making a diagnosis. Eventually, the patient was treated with surgical excision of the osteoid osteoma. The gap that resulted after the excision was filled with an autologous bone graft. A year after his operation, the patient returned to his daily activities and remained pain-free. A high index of suspicion and an appropriate imaging examination are mandated for the early diagnosis of such entities. Osteoid osteomas are benign, self-limited, osteogenic bone tumours commonly found in the diaphysis and metaphysis of long bones. The proximal femur is the most distinctive site where osteoid osteomas occur, followed by the humerus, tibia, phalanges, and vertebral arch .Even though osteoid osteomas are well identified on radiographs as radiolucent lesions, computed tomography is considered the diagnostic modality of choice for their diagnosis. The presence of a nidus is a typical finding in the former. Moreover, an abundance of bone oedema around these lesions is evident in MRI scans .Depending on the location of the nidus, osteoid osteomas may be periosteal, intracortical, spongiosal, or subarticular . Their dThe occurrence of osteoid osteomas in other sites is rare. Hence, when they present in atypical locations, they can be easily misdiagnosed, neglected, or treated with delay. In this case report, we present a 21-year-old man with an osteoid osteoma of the talus.A 21-year-old man visited our outpatient department complaining of chronic pain in his right ankle. He described that his symptoms started two years ago when he fell down the stairs and sustained an ankle injury. Two months later, his pain did not improve. He, therefore, sought orthopaedic consultation. The orthopaedic surgeon who initially assessed him suggested that, apart from plain radiographs, further investigation was needed and asked for an MRI scan. The latter revealed bone oedema around the talar neck and concomitant soft tissue inflammation , and occasional consumption of analgesics.Since his pain persisted, a third MRI scan of the ankle was advised. Bone marrow oedema was evident once again. Moreover, the MRI indicated a fracture line spanning from the anterosuperior to the posteroinferior part of the talar neck and a nidus in the talar neck. In contrast, plain radiographs showed no fracture of the talus Figures -4.A scheme of intra-articular corticosteroid injections commenced that kept the patient pain-free for a short period of time. However, after a few months, weight-bearing became gradually painful, and a progressively worsening nocturnal pain developed in the ankle.Two years after the onset of his symptoms, the patient was referred to our clinic for further assessment. A CT scan of his right ankle verified the presence of an osteoid osteoma in the superior surface of the talar neck Figure .The patient was given aspirin for pain management and agreed to undergo surgical excision of the osteoid osteoma.In the operation theatre, under spinal anaesthesia, the patient was positioned supine and a thigh tourniquet was applied. His right leg was prepped and draped, and then the tourniquet was inflated. A dorsal approach to the ankle was used. With the patient supine, a skin incision was made over the anterior ankle and lateral to the tibialis anterior. After the extensor retinaculum was incised, an interval between the tibialis anterior and the extensor hallucis longus was used to gain access to the ankle joint. A well-defined mahogany-coloured lesion with an approximate size of 0.9x0.8x.07 cm was then identified and curetted uneventfully. The specimen was sent to pathology for examination. The tumour bed was debrided, and the gap was filled with an autologous bone graft harvested from the distal third of the tibial diaphysis. The wound closure was performed in a standard fashion. The histopathology report confirmed that the lesion was indeed an osteoid osteoma Figure .His rehabilitation was uneventful. On his six-month follow-up, the patient reported that his pain had fully resolved a week after his operation and remained pain-free. A year after his operation, the patient was reviewed. He had fully recovered, returned to his daily activities, and reported no discomfort when participating in sports Figure .Osteoid osteomas were first described by Jaffe in 1935 [According to the Enneking classification, they are latent benign tumours that do not spread locally and have a low potential to become malignant . Long boPain is the most common symptom seen in osteoid osteoma patients. It is described as blunt, constant, and progressive and deteriorates at night and after alcohol consumption. Its presentation is associated with the increased number and size of unmyelinated nerve fibres within the nidus. Moreover, it is linked with the increased concentration of prostaglandins PGE2 and PGI1 and the expression of cyclooxygenases (COX-1 and COX-2) in osteoid osteoma tissue . When osRadiographic assessment with plain X-rays indicates an intensely reactive bone around a small, round, radiolucent nidus. This sclerotic area around the nidus may differ depending on the tumour’s location. For example, in subperiosteal osteoid osteomas, this reactive zone is barely visible, thus making it difficult to tell them apart from soft tissue lesions. The detection rate of osteoid osteomas with plain radiographs is only 66% . Thin-slThe generic symptoms of osteoid osteomas can lead to a misdiagnosis. Foot osteoid osteomas may be mistaken for tibiotalar impingement syndrome. The latter is characterised by anterior ankle pain, joint oedema after activity, and occasionally reduced ankle dorsiflexion. The pain is caused by synovial tissue interference between the talus and the ankle mortise. In addition, the decreased tibiotalar arc of motion caused by spurs or osteophytes has also been implicated in this process. The diagnosis of anterior impingement is mostly based on clinical examination. Its most common symptom is local pain, exacerbated during palpation. Standard anteroposterior and lateral radiographs are required to detect the presence of osteophytes. However, the latter may not be identified radiographically due to the superposition of the more prominent anterolateral border of the distal tibia. The mainstay of treatment for tibiotalar impingement syndrome is activity modification, NSAIDs, and corticosteroid injections. Surgical management is indicated in patients with progressive symptoms who fail nonoperative management . SimilarHowever, there are cases, such as osteoid osteomas of the distal phalanges, where the results of conservative treatment are not acceptable. In cases where conservative management fails, more invasive options are taken into consideration. These consist of open or arthroscopic surgical excision, as well as less invasive procedures like CT-guided percutaneous excision, radiofrequency ablation, laser photocoagulation, and MR-guided high-intensity focused ultrasound (MR-HIFU) . During Osteoid osteomas of the talus are rarely seen and therefore can be easily misdiagnosed. A high index of suspicion and an appropriate imaging examination are mandated for an early diagnosis. Computed tomography is the imaging modality of choice to investigate such entities. There are numerous treatment options, all of which offer good results when indicated. The surgical treatment of osteoid osteomas with curettage offers a success rate close to 97%.


Background: Wilms tumor (WT) is the most frequent renal tumor in children. The SIOP-UMBRELLA Guidelines allow for nephron-sparing surgery (NSS) in syndromic patients, as well as in cases of small (<300 mL) non-syndromic unilateral WTs, without lymph node involvement, and with a substantial expected remnant renal function, following neoadjuvant chemotherapy. We present a case of prechemotherapy transperitoneal robot-assisted partial nephrectomy (RAPN) for a unilateral, non-syndromic Wilms tumor. Methods: A four-year-old child presented with a solid mass measuring 3.6 cm in diameter involving the upper right renal pole, incidentally detected during an abdominal echotomography. CT scan and abdominal MRI revealed no local infiltration or lymph node involvement, suggesting that the exophytic mass could be easily resected via an NSS robotic approach. Preoperative imaging did not strongly suggest WT. A virtual 3D reconstruction of the tumor was performed. Results: After the oncologic board approval, a robot-assisted partial nephrectomy with an intraperitoneal approach was performed. Histopathological analysis confirmed the diagnosis of WT. The patient subsequently received 10 doses of vincristine as adjuvant chemotherapy. A 28-month follow-up showed no tumor recurrence. Conclusions: Intraperitoneal RAPN may be an option for selected WT and warrants consideration as a challenging but advantageous approach. Wilms tumor  is the second most common solid tumor and the most prevalent renal tumor in children . It typiWT mostly presents as a painless mass in the upper abdominal quadrant, while hematuria is observed only in fewer than 20% of cases . ComputeWhen dealing with suspected WT, it is important to fully evaluate differential diagnosis with neuroblastoma for the following reasons: (1) neuroblastoma commonly presents calcifications, a feature less frequently seen in WT; (2) neuroblastoma tends to encase vascular structures without invading them, whereas WT may extend into the renal vein and inferior vena cava; (3) neuroblastoma is not typically well circumscribed, as it often exhibits more diffuse or infiltrative growth patterns; (4) neuroblastoma frequently crosses the midline, extending beyond its original location, and can involve the diaphragm and the spinal canal; (5) neuroblastoma is often associated with retroperitoneal lymph node involvement, a characteristic less commonly observed in WT .Additionally, there are less frequent differential diagnoses to consider: (1) cystic partially differentiated nephroblastoma, a condition that presents as a multicystic unilateral lesion, usually without solid components; (2) renal rhabdoid tumors, often displaying tumor lobules mixed with necrotic or hemorrhagic areas, subcapsular fluid collections, more calcifications than WTs, and a higher tendency to invade nearby vessels or structures; (3) clear cell sarcoma, which can be distinguished from other tumors when concurrent skeletal metastases are present; and (4) childhood renal cell carcinoma, which is extremely rare and appears as a solid mass with cystic areas or calcifications, and may show contrast media uptake.In very rare cases, WT can be confused with benign conditions, including pediatric cystic nephroma  , renal aOnce the diagnosis of WT has been established, surgery is the crucial step. The Children’s Oncology Group (COG) and the International Society of Pediatric Oncology (SIOP) differ on the surgical timing: the first recommends adjuvant treatment while the second dictates neoadjuvant chemotherapy . Both CODifferent from renal tumors in adults, nephron-sparing surgery (NSS) is not recommended in children, unless in very selected cases. COG guidelines accept NSS in patients with a solitary kidney or a horseshoe kidney and in patients with genetic syndromes prone to oncological recurrences . SIOP guidelines also permit NSS for non-syndromic unilateral WT with a small volume (<300 mL) with an expected average remaining kidney function and when lymph nodes have not been involved , althougOver the last 30 years, minimally invasive surgery (MIS) has seen renewed use in pediatric and urology surgery, from standard laparoscopic to robotic techniques, but only recently has MIS gained ground in pediatric urologic oncology with a few described applications to renal tumors .In particular, a few cases of RAPN for WT have been described, all limited to syndromic patients prone to recurrent malignancies ,13,14.The aim of this paper is to present a case of a 4-year-old child treated with prechemotherapy RAPN for a unilateral WT.A four-year-old girl was admitted to our emergency department with a fever, abdominal pain, and diarrhea persisting for two days, which responded to acetaminophen.The patient’s family and clinical history were uneventful.Upon physical examination, the child was in good general condition, weighing 14 kg and measuring 107 cm in height. The abdomen was soft and painless, with no palpable masses, and all other findings were normal. She had fever, with a body temperature of 38.5 °C, oxygen blood saturation of 98% (in ambient air), no signs of dyspnea, and regular heart rate.Urine and blood tests came back normal, except for a C-reactive protein level of 200 mg/L . Thoracic ultrasonography (US) revealed scattered B-lines and an irregular bilateral basal pleural line. The left lung showed signs of consolidation with an associated 7.7 mm × 10 mm (posterior × axillary) pleural effusion.Abdominal US displayed an echogenic solid roundish mass of 3.6 cm diameter in the hepatorenal space. The mass was localized at the upper right renal pole, partially exophytic, with a hypoechoic homogeneous structure and a claw sign; no renal vein involvement was seen and the remaining organs were unharmed .A broad-spectrum antibiotic therapy was initiated , leading to a rapid improvement in body temperature, relief of abdominal pain, and normalization of blood test results.The abdominal CT confirmed an expansive neoformation of 41 mm × 37 mm × 41 mm, with regular margins. It appeared hypodense and minimally uneven, with a density of 35–40 Hounsfield Units (HU). Some lateral septa were observed, and no calcifications were present. The neoformation exerted pressure on the caudal hepatic lobe and displaced the kidney inferiorly, without any signs of infiltration .The MRI revealed a hypointense lesion in T1-T2 sequences, displaying no intralesional contrast enhancement in both early and late phases. Only mild contrast enhancement along its margins was observed. Diffusion-weighted imaging (DWI) sequences showed reduced tissue diffusion. In all imaging studies, lymph nodes were found to be uninvolved .The tumor presented in this case exhibited lower intensity and heterogeneity compared to the typical presentation of WTs. Our radiology team did not univocally provide for a WT diagnosis. The case was discussed at the hospital’s oncology board, and the approved treatment plan involved NSS with a right partial nephrectomy. After an in-depth discussion with the parents regarding the risks and benefits of both MIS and open techniques, as well as the advantages of MIS over the open technique, and the choice between total nephrectomy and NSS, informed consent was obtained for a RAPN.©, Moncalieri, Turin, Italy)  .® XI Surgical System was then docked  Guidelines . Two addn docked .After performing the Kocher maneuver to expose the right kidney, the tumor was located and carefully separated from the adrenal gland, which showed no signs of infiltration. Hilar vessels were prepared and secured with vessel loops, but not clamped. Using the superior 3D virtual reconstruction as a guide, only the superior branch of the renal artery supplying the tumor was clamped using a single laparoscopic bulldog clamp . Indocyanine green injection confirmed proper tumor ischemia, with a well-preserved vascularization of the lower two-thirds of the kidney. The partial nephrectomy was executed safely using a monopolar, leaving a margin of healthy renal parenchyma around the tumor .® , with perirenal fat intersposed.Hemostasis of the tumor bed was obtained with 5-0 PDS running suture. The cortical was closed with 4-0 vicryl suture and Hem-o-Lock clipsThe total operative time was 180 min, including the time for robot docking, while console time was 150 min. No warm ischemia time was required, and the estimated blood loss was 20–30 mL. The low body weight did not impede the procedure, which was uneventful, and there was no crashing of instruments.The post-operative course was uneventful. Early bowel movements began on post-operative day (POD) two, and oral feeding resumed shortly after. The patient was discharged home on the fourth POD due to her constant refusal to mobilize.Histopathology revealed a WT with central spontaneous necrosis, accounting for 40% of the tissue, and a mixed composition of blastemal (85%) and epithelial (15%) components, without anaplasia. The tumor was completely enclosed by a fibrous tumoral pseudocapsule, with negative surgical margins, classifying it as stage I—intermediate risk.Following surgery, the patient underwent a 10-cycle adjuvant chemotherapy regimen with vincristine, according to the UMBRELLA SIOP 2016 protocol, regimen 1, for intermediate-risk cases excluding focal anaplasia (post-operative chemotherapy for tumors having primary excision).One year after surgery, a chest X-ray revealed a suspicious area in the right lung base, which a CT scan determined to be a hilar vessel. Abdominal US displayed normal findings.As of the date of this work, the follow-up has reached 28 months. The girl remains in good health, with no signs of tumor recurrence.The standard surgical treatment for unilateral WT remains radical nephrectomy along with lymph node sampling, utilizing a laparotomic transperitoneal approach .According to the UMBRELLA SIOP Protocol, NSS is recommended only in specific cases following neoadjuvant chemotherapy: bilateral, syndromic (for genetic predisposition—less than a year old), nephroblastomatosis , high riNSS techniques hold particular appeal for use in children. Both radiotherapy and chemotherapy carry nephrotoxic effects, and the risk of developing hypertension, proteinuria, and chronic kidney disease in patients who have survived childhood cancer is not negligible . From thHistorically, laparoscopic treatment has raised concerns due to the absence of tactile feedback, which can increase the risk of tumor rupture due to the frailty of the tumor capsule, and the potential for incomplete staging due to the inadequate abdominal exploration. However, some successful approaches have been reported even prior to chemotherapy .In recent decades, robotic-assisted NSS has become popular in adult urology and has spurred pioneering experiences in pediatric cases. Preoperative imaging plays a crucial role in surgical planning. Based on CT and MRI imaging, three-dimensional (3D) reconstruction enhances the topographic view of the tumor and adjacent structures , therebyPrevious experiences of RAPN for pediatric WTs are limited, and they are summarized in Blanc et al. described two syndromic patients who, after receiving neoadjuvant chemotherapy, underwent robotic retroperitoneal partial nephrectomy for WT through a retroperitoneal approach. There was no disease recurrence at 6- and 16-month follow-up. . More reWhen the current patient was discussed, several key considerations were factored into the decision-making process.Firstly, WT typically exhibits MRI heterogeneity and lobules, usually presenting as T1-hyperintense/T2-hyperintense; following intravenous paramagnetic gadolinium administration, it tends to display lower signal intensity compared to the renal cortex . In thisSecondly, both MRI and CT imaging indicated a confined and endophytic mass, displaying an unaltered renal anatomy with a low estimated risk of rupture. Given the small size, upper pole location, exophytic nature, and the absence of lymph node involvement, considering NSS was deemed advantageous over radical nephrectomy. Similarly, a biopsy of the mass was not chosen.Thirdly, the location of the lesion, situated on the anterior aspect of the right kidney, nestled between the inferior vena cava and liver, rendered the robotic approach particularly appealing. This was owing to the enhanced magnification and clearer visualization of the anatomy it offered.NSS was considered feasible, due to a conjoined adult and pediatric urologic surgical team . While pUltimately, the 3D reconstruction enabled the preoperative identification of the vessel supplying the tumor and allowed for intraoperative selective arterial clamping, differently from the cases previously described in the literature ,13,14. WTo the best of our knowledge, this is the first reported case of a non-syndromic unilateral WT treated with a transperitoneal RAPN without neoadjuvant chemotherapy and managed surgically with selective arterial clamping. Despite the limited follow-up of 28 months, this approach was successful, resulting in complete excision of the tumor and obviating the need for radiotherapy.Considering that children with WTs now have a longer life expectancy, and increased risk of long-term sequelae such as hypertension and chronic renal failure is evident, NSS should be the preferred surgical option for WTs when feasible . In thisRAPN presents a challenging option for managing Wilms tumor. While current experiences are predominantly limited to syndromic WTs, our case suggests a potential role for prechemotherapy RAPN in selected patients with non-syndromic unilateral forms. Additionally, this case implies that the transperitoneal approach can be a viable choice when the tumor is estimated to have a low risk of rupture. The use of 3D virtual reconstruction allows for selective arterial clamping, ensuring intraoperative safety and avoiding complete kidney ischemia.As current guidelines do not yet define appropriate criteria for combining NSS and MIS in WTs management, study protocols for surgery in pediatric renal oncology are warranted to conduct procedure-related risk assessments and compare them with the traditional surgical strategies currently in use.


Osteoid osteoma (OO) is a common benign tumor that tends to affect children and young adults. Patients typically present with nocturnal pain that is relieved with non-steroidal anti-inflammatory drugs (NSAIDs) and a unique round or oval radiolucent area with surrounding sclerotic bone on X-ray. The cortex of the diaphysis or metaphysis of long bones is the usual anatomical location, with only 4% of cases localizing to the foot and ankle. Treatment options include medical management, surgical excision, and less invasive techniques such as radiofrequency ablation (RFA). We present a case report of a 21-year-old female with an osteoid osteoma of the calcaneus, a rare presentation for this type of tumor. She was successfully treated with RFA and had an excellent functional outcome. Osteoid osteoma (OO) is a common benign tumor that accounts for 11% of benign tumors and 5% of all bone tumors . A distiThe current case report describes a 21-year-old female with an osteoid osteoma of the calcaneus, a rare presentation for this type of tumor. She was successfully treated with RFA and had an excellent functional outcome.A 21-year-old female college student presented with a three-year history of moderate pain in her heel with no previous history of trauma. The onset was insidious, and she had intermittent pain over the past three years. Her pain became more severe and persistent over months after a history of ankle sprain. The initial radiograph of her first presentation Figures  after heOn physical examination, the patient had a normal gait and mild swelling over the lateral aspect of her ankle with no overlying erythema. Bony tenderness was experienced by the patient upon palpation of the lateral aspect of the heel. She had a painless full range of motion of the ankle and subtalar joint and an intact distal neurovascular examination. The American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Rating System was used to assess the clinical status of the ankle-hindfoot in this patient ,7. A scoBased on clinical examination and radiographic findings of osteoid osteoma, treatment options were fully explained to the patient, which included surgical resection and RFA. After further discussion, she opted to undergo RFA. Under general anesthesia, the patient was placed on the CT table. The lesion was imaged, and a bone biopsy needle was percutaneously introduced to obtain a tissue sample. A cortical bone and bone dust was reported by the pathologist, which was consistent with osteoid osteoma. The patient was kept non-weight-bearing immediately after the procedure for two weeks. At her one-month follow-up, she reported a complete resolution of pain. At a three-month follow-up, she had no evidence of recurrence and was pain-free. At one-and-a-half-year follow-up, the AOFAS Ankle-Hindfoot Rating was re-calculated, which was 100 out of 100, indicating good clinical status of the ankle and hindfoot postoperatively. Figures Osteoid osteomas (OOs) are benign solitary lesions affecting predominantly long bones, causing cortical thickening. OOs comprise 10% of all benign bone tumors and 3% of all primary bone tumors affecting young adults and children with a male predominance with a 3:1 ratio ,8,9.Usually, osteoid osteomas are found in the femur, which is considered the most common location for it, followed by the spine, mainly in the posterior column , with onOsteoid osteoma patients have nocturnal pain in most cases, with unknown mechanism(s); pain is hypothesized to occur due to autonomic nerve fibers that run through the nidus, which are sensitive to vascular pressure changes . It can In this case, the patient’s symptoms have proceeded the finding of nidus and reactive sclerosis with other osteoid osteoma characteristics, and it was absent in X-ray, which usually happens and has been mentioned in the literature, especially if it is intra- or juxta-articular, with one case report mistakenly diagnosed mimicking os trigonum syndrome . Such unOn magnetic resonance imaging, the nidus may give a low or intermediate T1 signal and variable T2 signal and enhancement with contrast . Yang etIn general, treatment of osteoid osteomas ranges from conservative as self-limiting to surgical intervention, including RFA. Many studies have reported the need for treatment of osteoid osteomas in the calcaneum due to failed conservative management, whether it was RFA, arthroscopic surgery, or surgical excision for osteoid osteomas, and it has shown to yield good results -25.The necessity of complete excision of osteoid osteomas to relieve pain has made open surgical resection a favorable treatment choice for many years . HoweverRFA is an alternative method used to treat osteoid osteoma patients. Cantwell et al. conducted a study that included 200 patients with osteoid osteomas treated with RFA and showed success rates of 76%-100% . AnotherIn conclusion, calcaneal osteoid osteomas can be challenging to diagnose and treat as they might not present with classical nocturnal pain and radiographic reactive sclerosis. Thus, a high index of suspicion should be maintained for those who present with chronic pain and swelling and do not respond to conservative treatment. Percutaneous RFA is considered safe and effective for osteoid osteomas of the hindfoot and is associated with a shorter recovery period with similar results to surgical options.


Splenogonadal fusion in female patients is seldom reported. We describe a 6-month-old girl who represents the youngest living female with splenogonadal fusion reported to date. The lesion was diagnosed as an incidental finding during screening abdominal ultrasonography performed for a vulvar infantile hemangioma. A tail-like structure with splenic echotexture connecting a normally located spleen and the left ovary was detected and better characterized by MRI. We also reviewed the pertinent literature on managing this usually asymptomatic condition, especially in female patients. Greater professionals’ awareness of this benign anomaly is paramount to avoid the unnecessary removal of an otherwise normal gonad. Written informed consent was obtained from parents for publication of this manuscript and any accompanying images.1Herein, we report the youngest living female ever to be diagnosed with splenogonadal fusion, and provide an overview of current literature on the management of this usually asymptomatic condition, which has essentially a benign course, especially in female patients.The fusion between splenic and gonadal tissue is a rare congenital anomaly. Medical literature consists primarily of case reports that have been first extensively reviewed in 1956 by Putschar and Manion, who detailed 30 clinical cases and coined the current classification system.2A 6-month-old female infant was referred to our clinic for evaluation of an ulcerated infantile vulvar hemangioma . RequestOn physical examination, she was otherwise healthy, except for a large hemangioma involving the right labium majus of the vulva, with initial signs of ulceration. Following also a negative cardiac workup, treatment was started with oral propranolol at a dosage of 0.5 mg/kg twice daily, increased to 1 mg/kg twice daily after one week. Propranolol administration induced an effective slowdown of the hemangioma growth and progressive regression of the vascular lesion. At 10 months of age, an abdomen MRI was requested to better characterize the abnormality ultrasonographically detected . The mul3Splenogonadal fusion is a rare malformation in which the spleen is abnormally connected to the gonad, or, more rarely, to a derivative of the mesonephros.Splenogonadal fusion may occur as an isolated condition or with other malformations, which are usually more frequently encountered in the continuous form.Sex distribution strongly favors males, with a reported sex ratio ranging from 16.6:1,,,,Therefore, to our knowledge, the present case represents the youngest living female to be diagnosed with splenogonadal fusion reported to date.Nevertheless, splenogonadal fusion female cases are undoubtedly underrepresented or underreported. We counted a total of 14 cases previously reported. Of these, nine had severe associated malformations and were all discovered by perinatal autopsy.Although the association between facial hemangiomas and splenogonadal fusion has been previously reported,,we speculated that the co-occurrence of two rare conditions, i.e vulvar hemangioma and splenogonadal fusion, was most likely coincidental.The co-existing genital infantile hemangioma, which accounts for 1 % of all infantile hemangiomas,From a diagnostic standpoint, ultrasonography should easily recognize the typical homogenous smooth echotexture of the involved splenic tissue, which may be further characterized by a variety of second-line imaging modalities, including MRI and scintigraphy.As far as management is concerned, a conservative treatment seems the most appropriate option. Therefore, surgical treatment for splenogonadal fusion should be kept as a last resort, especially if the diagnosis can be made prior to or during surgery. But in all circumstances, surgery should be primarily aimed at preserving the gonad function, thus consisting of merely severing the obstructive band (continuous type) or removing the splenic tissue attached to the gonad (discontinuous type). In the majority of cases, the splenic tissue may be successfully excised without injury to the gonad. However, if splenic and gonadal tissue is intimately fused, there is a serious risk that the gonad is going to be unnecessarily sacrificed.,In males, anecdotal reports have described the association between splenogonadal fusion and testicular germ cell tumors. However, rather than bearing a causal relationship, we concur that such association is merely related to the delayed treatment of a co-existing cryptorchidism.Another potential indication for surgery may be bowel obstruction secondary to extrinsic compression exserted by a continuous splenogonadal fusion form. However, given that the splenic band usually runs along the left paracolic gutter, as also shown in our case, this occurrence seems very unlikely. Nonetheless, Hines and Eggum4Splenogonadal fusion is a benign congenital abnormality. Greater awareness among health professionals is paramount to increase splenogonadal fusion identification and, therefore, to prevent unnecessary removal of the involved, but otherwise normal, gonad.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.