Gall bladder polyps occur in 0.4% of patients undergoing cholecystectomy, the majority of gall bladder polyps are benign, they are classified into 3 types: epithelial or adenomatous polyps, mesenchymal polyps, and pseudopolyps. Gall bladder polys mostly affect females and those more than 50 years of age. Ultrasound is a very sensitive tool in the diagnosis.An 88-year-old woman presented with epigastric pain and right hypochondrial pain, fever, and vomiting for 1 week. Clinical examination showed jaundice and tenderness at the right hypochondrial region. Investigations showed elevated WBC, bilirubin level and the alkaline phosphatase. MRCP showed multiple gall stones with a large irregular polyp in the fundus of the gall bladder, and dilated common bile duct with multiple stones in the lumen of common bile duct. Cholecystectomy was done with exploration of the common bile duct with extraction of stones, T-tube was placed inside the CBD. At the 14th day T-tube cholangiography was done which showed passage of the dye to the duodenum, the tube was extracted and the patient was discharged home with no postoperative complications. The histopathology showed intracholecystic papillary tubular adenoma of the gall bladder with no evidence of malignancy.The general indications of surgery for gall bladder polyps include the size if more than 10 mm especially if solitary, the presence of associated gall stones, the age if more than 60 years, and if the polyps are causing symptoms. In this patients the large size of the polyp and obstructive jaundice were the two indications for surgery. •Gall bladder polyps are commonly diagnosed and may be associated with gall stones.•Most patients are worried about the possibility of malignancy.•Laparoscopic cholecystectomy can be safely done when there is indication for surgery. It is estimated that polyps occur in 0.4% of patients undergoing cholecystectomy, polyps can be diagnosed in up to 7% of patients before cholecystectomy for gall stones, but the majority are small and diagnosed after cholecystectomy Fig. 1MRCThe majority of gall bladder polyps are benign lesions that may be discovered incidentally or in association with gall stones. There are many pathological types of gall bladder polyps such as epithelial or adenomatous polyps, mesenchymal polyps, and pseudopolyps. Polyps may be primary occurring de novo or secondary association with metachromatic leukodystrophy, Peutz-Jeghers syndrome, inflammatory bowel diseases, primary sclerosing cholangitis or pancreato-biliary malunion .Most cases of gall bladder polys are females, more than 50 years of age and the majority are detected incidentally. Once gall bladder polyps are diagnosed most patients are concerned whether these lesions are benign or malignant and the possibility of their malignant transformation ,5.Ultrasound of the gall bladder is a very sensitive tool in diagnosing gall bladder polyps, polys are differentiated from gall stones by their constant position despite changing the position of the patient during ultrasound examination .The recommended follow up for gall bladder polyps is to perform ultrasound every 3–6 months for the first 2 years, then frequent follow up is probably unnecessary .The work in this case report has been reported in line with the SCARE 2018 criteria [2An 88-year-old woman was presented with epigastric pain and right hypochondrial pain, fever, and vomiting for 1 week. She was admitted to the surgical unit.The patient had history of hypertension and she was on regular medical therapy.Clinical findings: During clinical examination the pulse rate was 95 b/m, the BP was 170/95 mmHg, and the temperature was 38.3, she had jaundice and the adnominal examination showed a scar of previous appendicectomy which was done before several years and tenderness at the right hypochondrial region.Diagnostic Assessment: Investigations showed elevated white blood cell count 14000 cmm, bilirubin level was 2.3 mg/dl and elevated alkaline phosphatase 842 IU/L. Ultrasound and magnetic resonance cholangiopancreatography showed evidence of multiple gall stones with a large irregular polyp in the region of the fundus of the gall bladder, and dilated common bile duct with evidence of multiple stones in the lumen of common bile duct. 2Therapeutic Intervention: The patient was admitted to the hospital and she received parenteral antibiotics and hydration.Surgery was done through right subcostal incision, cholecystectomy was performed with exploration of the common bile duct and extraction of all the stones from its lumen, T-tube was placed inside the CBD. The operation was done by a specialist general surgeon who has the experience in performing biliary surgeries. The family history was negative for malignant diseases and the patient had dementia diagnosed before 5 years.Follow-up and outcome: The patient was admitted to the hospital for 1 week, at the 14th day T-tube cholangiography was done which showed the passage of the dye to the duodenal lumen with no residual stones, the T-tube was extracted and the patient was discharged home with no postoperative complications. The result of the histopathology showed dysplastic biliary epithelium arranged in tubular and papillary pattern, with no evidence of malignancy.No specific post intervention considerations were undertaken.3Most histopathological samples of gall bladder polys show small in size polyps due to the early presentation of most cases and the early surgical intervention by cholecystectomy for this reason cases of very large polyps are rarely reported nowadays .The pathological classification of the gall bladder polyps depends on the tissue of origin, epithelial polyps or called adenomatous polyps are divided into 3 types: tubular polyps, papillary polyps or mixed type when contain both elements, mesenchymal polyps are further divided into: leiomyomas, hemangiomas, and lipomas, and pseudo-polyps which are further divided into: cholesterol polyps, inflammatory polyps, adenomatous polyps, and adenomyomatous polyps .The indications of surgery for gall bladder polyps include the size of the polyp when exceeding 10 mm, solitary polyp, the presence of gall stones with the polyps, the advanced age of the patient when more than 60 years, as these factors are also associated with increased risk of gall bladder cancer. When the clinical symptoms are attributed to these polyps this may be another indication for surgery, polyps near the cystic duct may be the cause of impaired emptying of the gall bladder and hence may cause upper abdominal pain ,9.The greatest concern is when the patients have some of the dyspeptic symptoms, many patients attribute their symptoms to theses polyps and the patients become very aware for the risk of malignant transformation, the problem of patient selection for surgery remains a great issue and many debate is still present between the authors worldwide .Laparoscopic cholecystectomy is one of the most widely performed procedure all over the world, such operation can be done safely for patients when there is a surgical intervention for cholecystectomy .Patient Perspective: The patient was unaware of her complain because she had dementia but the family were concerned about the possibility of malignancy before surgery.Informed Consent: An informed written consent was taken from family for reporting this case and the accompanying images.Provenance and peer review: Not commissioned, externally peer reviewed.No ethical committee approval was needed; consent have been taken from the family to report their findings.No source of funding other than the authors.The surgeon who performed the procedure: Dr Ayad Ahmad Mohammed.Study design, writing, and the final approval of the manuscript: Dr Ayad Ahmad Mohammed.No conflicts of interest present.N/A.Dr Ayad Ahmad Mohammed.


The pure large cell type is a rare variant of primary neuroendocrine carcinoma of the gallbladder. Few reports have mentioned extended survival. Although a multimodal treatment has been described in the treatment of such rare disease, redo liver resection has not yet been mentioned.A 67-year-old lady was found to have poorly differentiated, high grade, pure large cell neuroendocrine tumor of the gallbladder after cholecystectomy for gallstones. After the diagnosis, staging workup showed a lesion in segment IVB/V of the liver, and chromogranin was elevated (982 mcg/L). The patient underwent central inferior hepatectomy and wedge excision of a lesion in segment III (discovered intra-operatively), with hilar lymphadenectomy. Three months after the first liver resection, she developed a new liver lesion II/III and underwent left lateral liver resection. The patient remained disease-free for 4 months following the second liver resection but then developed recurrent liver disease and was started on chemotherapy. Further progression led to multi-organ failure and death at 26 months from initial diagnosis.This is the first reported repeat liver resection in such a rare disease that has led to extended overall survival. We suggest that a group of selected patients with this rare malignancy, and liver-limited disease, may benefit from repeated liver resection. The curarcinoid . A limitarcinoid . With tharcinoid , the manarcinoid . Redo liA 67-year-old lady with no prior comorbidities presented to Hamad General Hospital (HGH) with recurrent dull aching abdominal pain for 6 weeks with no history of weight loss, fever, or upper gastrointestinal (GI) symptoms. Initial abdominal imaging ultrasound (US) showed a distended gallbladder with a wall thickness of 5 mm, multiple stones (largest one measuring 16 mm), no intrahepatic duct dilatation, and no obvious liver lesions. She had an uneventful laparoscopic cholecystectomy with no significant intraoperative findings. The gallbladder was removed intact in an endobag, and there was no bile leak in the abdominal cavity. Histopathology of the gallbladder showed poorly differentiated (high grade) neuroendocrine carcinoma, large cell type, arising in a background of chronic and focally acute cholecystitis with cholelithiasis, intestinal metaplasia, and multifocal low-grade dysplasia. The tumor invaded through the muscular wall of the gallbladder into the surrounding adipose tissue with perineural and angiolymphatic invasion  that showed a hepatic lesion in segment IVB/V and magnetic resonance imaging (MRI) that also confirmed the existence of the same liver lesion in segment IVB/V measuring 28 × 27 × 30 mm  in the liver identical to the primary lesion within the gallbladder. The patient was kept under a rigorous follow-up schedule every 6 weeks. Four months following the first liver resection, a follow-up MRI showed a metastatic liver lesion 2.5 cm in diameter in segment II/III; therefore, a PET/CT scan was obtained to rule out any other metastatic foci, and none were found except the one detected by MRI in segment II Fig. . Hence, Later during follow-up, the patient was found to have a locally recurrent disease on PET CT scan obtained 4 months post-redo (second) liver resection Fig. . The patGallbladder cancer (GBCA) is known for its poor prognosis. A majority of the cases are diagnosed at an advanced stage. It is considered the most common malignancy of the biliary system and the fifth most common malignancy in the GI tract . PrimaryPure large cell neuroendocrine carcinoma (LCNEC) has been first described in 2000 by M. Papotti et al. , who repIn principle, complete surgical resection (R0) remains the gold standard for primary control of GBCA (T1/T2), the magnitude of which depends on the stage of the disease and may reach up to major liver resection. In the presented case, primary diagnosis of LCNEC was first reported post-cholecystectomy, which was confirmed later post-first liver resection. Completion surgery for LCNET is advocated in the absence of metastatic disease elsewhere. The spectrum of previously reported primary surgery for LCNEC started from simple cholecystectomy for T1a tumors and extended to hepatic resection and lymphadenectomy . The pre2 and hence it becomes more challenging when deciding on the best management plan for LCNEC especially the surgical candidates as to whether concomitant adjuvant therapy is essential. Few reports have shown a limited survival benefit in those candidates receiving chemotherapy post-surgery [Pure LCNEC has been rarely mentioned (eight cases as of April 2016)-surgery  and for -surgery . The inf-surgery , 15. We The longest reported survival of such cases was 69 months, as reported by Shimono et al. . In theiGenerally, the prognosis of NETs of the gallbladder depends on the grade of the tumor and the presence of hepatic metastasis. Most of the high-grade lesions are metastatic at diagnosis and only a few are resectable, and if we exclude the case reported by Shimono et al, the median survival is about 10 months . Our patRedo liver resection has hardly been described in LCNEC of the gallbladder. This is the first reported repeat liver resection in such a rare disease that has led to extended overall survival. We can only speculate that a group of selected patients with such rare disease may benefit from a repeated liver surgery in the absence of extrahepatic disease.


Surgical resection remains the standard treatment for adrenocortical carcinoma. Higher rates of local and peritoneal recurrence have been reported with the laparoscopic approach compared to open resection, although the evidence is limited. A dilemma occurs when tumors appear benign in nature, measure >5 cm, or when patients request a minimally invasive surgical approach. We describe the first reported case to date of successful robot-assisted laparoscopic adrenalectomy for myxoid variant adrenocortical carcinoma.  A 38 year old female presented with a large 8.0 cm enhancing left adrenal mass concerning for pheochromocytoma, given refractory hypertension and symptoms of palpitations and headaches. Functional work up was negative. The patient underwent robot-assisted laparoscopic left adrenalectomy after appropriate alpha and beta blockade. Histological sections demonstrated a cortical neoplasm with prominent myxoid changes consistent with myxoid adrenocortical carcinoma. The patient's symptoms resolved and serial imaging demonstrated no recurrence three and nine months, post-operatively.  Myxoid adrenocortical carcinoma is a rare and aggressive entity best managed with surgical resection. Though open resection for invasive adrenal cancer remains the gold standard, minimally invasive approaches are being increasingly used, whether deliberately or not. We describe the first reported robot-assisted laparoscopic adrenalectomy for invasive myxoid adrenocortical carcinoma. Surgical resection remains the standard treatment for adrenocortical carcinoma (ACC). Open adrenalectomy has historically been used for large invasive tumors concerning for ACC, but laparoscopic adrenalectomy has been used for smaller lesions given potential advantages of decreased post-operative pain, shorter hospital stay, and faster recovery. Higher rates of local and peritoneal recurrence have been reported with the laparoscopic approach compared to open resection, although the evidence is limited. A dilemma occurs when tumors appear benign in nature, measure >5 cm, or when patients request a minimally invasive surgical approach. We describe the first reported case-to-date of successful robot-assisted laparoscopic adrenalectomy for myxoid variant ACC, a rare tumor of which only 42 cases have been reported worldwide.A 38 year old female presented with a history of hypertension refractory to medical therapy. Given concerns for renovascular hypertension, she underwent abdominal ultrasound demonstrating a left adrenal mass. She was referred to urology for further work up and management. The patient denied any associated flank or abdominal pain, however, she did report experiencing palpitations and headaches with elevated blood pressure measurements. She denied diaphoresis, flushing, chest pressure, or visual disturbances. The patient denied any family history of Multiple Endocrine Neoplasia Syndrome (MEN) disorders, pheochromocytoma, or markedly elevated blood pressure. She had no personal history of diabetes or recent symptoms to suggest Cushing's syndrome. She denied any family history of adrenocortical carcinoma.2. General appearance was normal without evidence of truncal obesity, moon facies, nuchal fat pad. Skin exam did not reveal violaceous striae or facial flushing. Cardiac, lung and abdominal exams were unremarkable without palpable mass or CVA tenderness. Neurologic and musculoskeletal exams were normal.She was noted to have a blood pressure of 170/100 mmHg without tachycardia. Body mass index was 36.8 kg/mLaboratory evaluation demonstrated normal serum electrolytes, including normal serum potassium. She underwent work up for metabolic function of the adrenal lesion with normal serum catecholamines  and normal 24 urine collection for free serum cortisol .Imaging work up was performed including computed tomography (CT) scan with intravenous contrast revealing a large enhancing left adrenal mass measuring 7.4 × 7.3 × 8.0 cm with no washout on delayed imaging . MagnetiLeft adrenal mass measuring 8.0 cm in greatest dimension, suspected pheochromocytoma based on MRI characteristics, with negative functional work up. No biopsy was performed given underlying concern for pheochromocytoma.en bloc with the adrenal mass to ensure complete resection. As is our standard practice with all extirpative surgeries, the specimen was extracted intact using an impermeable laparoscopic bag through an extended port-site. The adrenal tumor measured 9.0 × 8.0 × 7.5 cm (260 grams). Histological sections showed a cortical neoplasm with prominent myxoid changes , and urinary free cortisol level. Confirmatory testing can be performed as needed. Aldosterone and renin levels are recommended in patients with hypertension and/or hypokalemia. Our patient with myxoid ACC did not have any evidence of endocrine function on initial functional testing, however her presenting symptoms and the tumor characteristics on magnetic resonance imaging were concerning for pheochromocytoma. A biopsy was therefore not performed for fear of triggering a catecholamine crisis.Myxoid ACC has a prognosis reported to be either similar or worse than that of conventional ACC. In one case review involving follow up of four patients with myxoid ACC, all four patients had a disease specific mortality between 11 and 69 months . The WeiBecause of the rarity of myxoid ACC there are no clear management recommendations. Treatment of conventional ACC is based on nonrandomized trials or retrospective cohort studies. Surgical resection is the only curative treatment for ACC, although the incidence of postoperative recurrence is high even in nonmetastatic disease, which is postulated to be caused by micrometastases at the time of surgery. Some retrospective studies have shown increased recurrence rates, faster time to recurrence and higher incidence of positive margins with laparoscopic adrenalectomy . Robot-aDue to the high rates of recurrence, adjuvant chemotherapy in the form of mitotane can be considered, however the current data is limited to retrospective studies in higher risk patients. It is unclear if adjuvant mitotane therapy is beneficial in low to intermediate risk patients. The ADIUVO trial, with planned completion date in 2020, hopes to answer this question.In general, post-operative management for conventional ACC includes surveillance CT imaging every three months for the first two years. Imaging intervals can be extended after two years and follow up is recommended for a minimum of ten years post resection . If pre-Myxoid adrenocortical carcinoma is a rare and aggressive entity managed with surgical resection. Though open resection for invasive adrenal cancer remains the gold standard according to most surgical associations, minimally invasive approaches are being increasingly used, whether deliberately or not . We desc


Tumor lysis syndrome is an oncologic emergency that can present with variable symptoms and is truly a laboratory-based diagnosis without pathognomonic clinical findings. The classical teaching is to consider this diagnosis in cancer patients undergoing chemotherapy. We present the case of a 66-year-old female with newly diagnosed metastatic liver adenocarcinoma, not on chemotherapy, who was diagnosed with spontaneous tumor lysis syndrome. Cognizance of this syndrome and associated laboratory findings are paramount to diagnosis and rapid intervention. Tumor lysis syndrome (TLS) is an oncologic emergency seen in patients with rapidly proliferating hematologic malignancies following exposure to systemic chemotherapy. It is a metabolic disorder characterized by hyperuricemia, hyperkalemia, hypocalcemia, and hyperphosphatemia, which can result in acute kidney injury, cardiac arrhythmias, and central nervous system toxicity. Spontaneous TLS (STLS) is rare and occurs in the absence of cytotoxic therapy. It is characterized by spontaneous cellular death in rapidly proliferating malignancies. STLS in patients with solid cancers is associated with a high mortality.A 66-year-old female with past medical history of hypertension, hyperlipidemia, and diabetes mellitus presented to the emergency department (ED) with subacute weakness and dyspnea. Five weeks prior to this presentation, she was seen in the ED for abdominal pain and dyspnea and was found to have large, bilateral pleural effusions and anemia. Extensive further work-up revealed a diagnosis of stage IV, poorly differentiated adenocarcinoma of the transverse colon. Imaging revealed diffuse large lymphadenopathy throughout the abdomen, retroperitoneum, and mediastinum with multiple pulmonary nodules. She underwent an open extended right hemicolectomy with ileostomy as well as resection of the jejunum due to tumor invasion. Thoracentesis was performed and she was eventually discharged home to follow up with oncology for discussions about immunotherapy or chemotherapy.At the current ED visit, the patient’s vitals were as follows: blood pressure 121/39 millimeters of mercury, pulse rate of 88 beats per minute, respiratory rate of 20 breaths per minute, and an oxygen saturation of 98% on three liters of oxygen via nasal cannula. Physical examination was pertinent for an ill-appearing female with mild jaundice, abdominal distention with mild tenderness, and decreased breath sounds with rales in the bilateral lower lung fields. A chest radiograph showed bilateral pleural effusions. The complete blood count was unremarkable. The complete metabolic panel demonstrated hyponatremia, hyperkalemia, uremia, acute kidney injury, and transaminitis . Given tA diagnosis of STLS was made in this patient with metastatic, poorly differentiated adenocarcinoma, who had not been initiated on systemic chemotherapy. Intravenous crystalloids, rasburicase, and treatment for acute hyperkalemia with calcium gluconate, insulin, dextrose, kayexalate, and sodium bicarbonate were initiated. After consulting the renal and oncology teams, the patient was admitted. Given the poor prognosis, the patient declined dialysis and further invasive measures. Her status was changed to comfort measures only and she died two days later.TLS can be therapy-related (cytotoxic therapy) or spontaneous (no exposure to cytotoxic therapy). TLS is more commonly seen in patients with hematologic malignancies compared to solid malignancies, due to increased proliferation rates and sensitivity to cytotoxic therapy.One retrospective review found that STLS occurred in 1.1% of patients with hematologic malignancy and acute renal failure.4There is a 20–50% mortality rate in TLS occurring in solid tumors if undiagnosed, or diagnosed too late.What do we already know about this clinical entity?Tumor lysis syndrome (TLS) is an oncologic emergency identified by lab abnormalities: hyperkalemia, hyperphosphatemia, hyperuricemia, hypocalcemia, and acute kidney injury.What makes this presentation of disease reportable?TLS may occur spontaneously, but typically it occurs in the setting of hematologic malignancies. Spontaneous TLS in solid tumors is rare.What is the major learning point?The classic lab abnormalities of TLS should prompt consideration of this complication in any oncology patient, regardless of concomitant chemotherapy.How might this improve emergency medicine practice?Early recognizance of TLS can lead to rapid management, mitigation of complications, and improved emergency medical care.Our patient had been recently diagnosed with metastatic colon adenocarcinoma with diffuse metastases. We believe the heavy tumor burden and rapid proliferative rate increased her risk of developing STLS.Consideration of a diagnosis of TLS was historically reserved for patients with the classic lab abnormalities who were undergoing chemotherapy. Reports of STLS in both hematologic and solid malignancies are increasing in the literature. Many of these patients will first present to the ED and it is pertinent for the emergency physician to recognize this oncologic emergency. Striking electrolyte imbalances and acute kidney injury in any cancer patient ought to prompt consideration of STLS, as the associated complications can be life-threatening.


Background: Glioblastoma is a malignant brain tumor with poor prognosis requiring early diagnosis. Secondary glioblastoma refers to cases that progressed from low-grade glioma. Evidence shows that timely resection correlates with increased survival.Case presentation: We describe a case of a patient with secondary glioblastoma who was mistakenly diagnosed with Angiostrongylus cantonensis infection until 7 years after disease onset. The patient presented with non-specific clinical manifestations at disease onset. A conventional magnetic resonance imaging (MRI) in the primary survey provided insufficient information, and thus failed to identify the malignancy. During follow-up, unfortunately, clinicians were misled by the patient's raw food diet, a positive serum parasite antibody and a result of low glucose metabolism on Fluorodeoxyglucose-positron emission tomography-computed tomography (FDG-PET-CT). The patient was diagnosed with parasitosis. However, his condition kept getting worse under antiparasitic treatment. Preoperative magnetic resonance spectroscopy (MRS) and diffusion tensor imaging (DTI) failed to reverse the mistaken impression. Final diagnosis was confirmed until intraoperative and postoperative pathological findings indicated glioblastoma.Conclusion: We ascribe the incorrect diagnosis to insufficient understanding on imaging manifestations of brain neoplasm as well as clinical features of parasitosis. Thus, we review the MRI, FDG-PET-CT, MRS, and DTI data of this case according to the timeline, refer to relevant studies, and point out the pitfalls. With a long course of slowly progressing, this was a rare case of secondary glioblastoma with the absence of isocitrate dehydrogenase 1 (IDH1) gene mutation. Angiostrongylus cantonensis infection, which affected our ability to properly treat the patient.Glioblastoma is the most common type of malignant brain tumor. The overall survival of patients with glioblastoma is extremely poor, with a survival rate of 42.4% at 6 months, 17.7% at 1 year, and 3.3% at 2 years  scan that was unremarkable, except for the presence of small patchy areas in the left frontal lobe . The patIn October 2017, however, his headache returned, and the pain was more severe. He underwent another MRI scan, revealing a cystic lesion with rim enhancement at the same location .A. cantonensis antibodies in the serum, but not in the cerebrospinal fluid. However, DNA test for A. cantonensis by polymerase chain reaction (PCR) was negative. The patient was prescribed albendazole, a broad-spectrum anthelmintic, and his condition improved after five courses. Unfortunately, he began to complain of right leg weakness. An MRI scan performed in March 2018 showed an enlarged cystic lesion in the left frontal lobe (figure not shown).Fluorodeoxyglucose-positron emission tomography-computed tomography (FDG-PET-CT) showed low metabolism , and couThe diagnosis of parasitosis was confirmed at follow-up, and the patient was prescribed one course of praziquantel, which was ineffective. The headache worsened, and after 3 months, the patient was admitted to our hospital.Upon admission, a physical examination showed weakness of the right leg, which was worse in the distal (0/5) than in the proximal (4/5) muscles, with an ipsilateral hyperactive knee reflex and positive Chaddock's sign. An MRI scan revealed further enlargement of the lesion , and magWe performed lesion resection under an intraoperative electrophysiological monitor to protect the adjoining precentral gyrus . SwellinThe postoperative pathological findings indicated glioma, classified as glioblastoma, WHO IV according to 2016 World Health Organization (WHO) Classification of Tumors of the Central Nervous System. Histological analysis showed an absence of mutation of the isocitrate dehydrogenase 1 (IDH1) gene .Written consent for publication of this case report was obtained from the patient.We describe a case of a patient with secondary glioblastoma who was mistakenly diagnosed with parasitosis and received inappropriate treatment. In view of the slow progression of the disease, an early diagnosis would have resulted in a better prognosis. There were several reasons for the incorrect diagnosis: inadequate attention to the initial abnormality on the MRI scan; insufficient knowledge on the clinical features of different parasitosis; and being misled by the patient's raw food diet, serological antigen positivity and FDG-PET results.The first MRI scan was conducted in 2013, ~2 years after the onset of disease. This scan showed an abnormal signal in the left frontal cortex that was barely discerned in the absence of enhancement.Conventional MRI, which includes T2-weighted and pre- and post-gadolinium contrast-enhanced T1-weighted images, can provide sufficient anatomic details. It is often used in the diagnosis of brain tumors , 4. In tAl-Okaili et al. histologically confirmed the effectiveness of a multimode MRI-based approach  in diffeIn our case, the patient underwent only conventional MRI and was followed-up for the abnormal signal. Although this decision seemed reasonable at the time, we should have handled the case with higher vigilance and requested more frequent follow-ups, instead of a 4-year gap without re-examination.The second MRI scan was conducted in 2017. The scan revealed a cystic lesion at the same region, which presented as a low signal on T1-weighted image, a high signal on T2/T2-FLAIR with surrounding edema, and a low signal on DWI. Post-contrast T1-weighted image revealed rim enhancement. A third MRI scan was conducted in 2018, and the image was identical to the scan from 2017, except that the lesion was further enlarged.In general, gliomas are solid tumors with or without enhancement . The forNevertheless, the DWI provided us with critical information. Previous studies –17 have A. cantonensis infection, as discussed blow.At the time of diagnosis, however, the patient's special diet, relative atypical enhancement pattern and PET-CT results were misleading, and the MRI results were mistaken for cystic parasitosis with central necrosis. It must be noted that liquefactive necrotic area can also exhibit hypointense lesions on DWI with increased ADC, reflecting the process of encephalomalacia with unrestricted water motion , but rimMRS revealed a heightened Cho peak and a weakened NAA peak, with a Cho/NAA ratio of 4.9. The level of Cho/NAA ratio helps distinguish different grades of glioma . It is sA DTI scan, which helped us to understand the relationship between the tumor and the ipsilateral pyramidal tract, was performed 9 days before the surgery. DTI is based on diffusion measurements, and its parameters  reflect the integrity of the white matter and tumor infiltration , 22. DueWe measured the FA value in the non-enhancing tumor core, edematous brain, and contralateral normal white matter  and founA PET-CT scan was conducted in October 2017, <1 month after the second MRI scan. The report revealed “decreased glucose metabolism, consistent with a primary benign lesion.” Combined with the patient's history of eating raw meat and the positive serological findings, clinicians arrived at an incorrect diagnosis, which affected the treatment protocol.Low-grade gliomas tend to exhibit low uptake of glucose, whereas high-grade gliomas tend to exhibit high uptake of FDG compared with normal gray and white matter , 29. BasStudies have reported that FDG-PET can reveal hypo- or iso-metabolism in high-grade gliomas , 31. The11C]methionine ([11C]MET) (18F]fluoroethyl-L-tyrosine ([18F]FET)  , 33 and 18F]FET) , are ideAccording to a previous study, FET sensitivity was 93%, specificity 100%, accuracy 96%, positive predictive value (PPV) 100% and negative predictive value (NPV) 91% for detecting malignant brain tumors, while FDG sensitivity was 27%, specificity 90%, accuracy 52%, PPV 80%, and NPV 45%. Other sThe patient's history of eating raw meat led the attending physician to screen for a parasitic infection.Most cases of cerebral parasitosis derive from cerebral cysticercosis, whose imaging features are variable , 39. SolA. cantonensis IgG instead of cysticercosis. A. cantonensis infects humans through third-stage larvae from snails, slugs, or contaminated, uncooked vegetables  without radiological or histological evidence of a less malignant precursor lesion, account for 94.7% of all glioblastomas. Our patient was 46 years old at disease onset, which is close to the mean onset age  of secondary glioblastoma, whereas primary glioblastomas develop in older patients, with a mean age of 62 years  Classification of Tumors of the Central Nervous System . Based oWhat is remarkable is that, despite a clinical slow-growing feature, the tumor turned out to be IDH-wildtype, which is a minority in secondary glioblastomas and might imply a distinct histological origin  from theThe patient underwent normative resection and complementary treatment immediately after confirmation of the pathology. We also arrived at several important considerations after all these twists and turns.Firstly, early stage malignant gliomas can manifest neither specific clinical signs such as epileptic seizure or focal neurological deficits, nor imaging signs of necrosis or significant enhancement . A comprSecondly, a low glucose metabolism is not always indicative of a benign lesion. It is critical for clinicians to recognize the limitations of FDG-PET in cerebral imaging.A. cantonensis infection, it is important to fully understanding its manifestations and carefully gather clues.Thirdly, when trying to make a diagnosis of a rare disease, such as brain Last but not least, consecutive follow-ups are indispensable in such cases. A comparative research in 2012 proved that early resection of LGGs was associated with better overall survival compared to the “biopsy and watchful waiting” strategy . SupposiAll datasets generated for this study are included in the manuscript/supplementary files.CL: collected and analyzed patient information and wrote the manuscript. WX: performed the surgery. PL: analyzed and rebuilt DTI. YW: performed the surgery and reviewed the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The corkscrew aorta is a variant of the normal anatomical course of the aorta. This rare condition is characterized by a marked tortuosity of the aorta. In our experience it concerns the tract of subrenal aorta, that is an unusual condition, since there are no other cases in the literature. It is characterized by the presence of at least two kinking, and a coiling interposed among them. It is diagnosed by Angio-CT and its response is incidental, being from an asymptomatic clinical point of view. The “corkscrew aorta” is a variant of the normal anatomical course of the aorta. This is a rare condition of which there are no cases in the literature in reference to the abdominal aorta, having been described only in the cervical and thoracic district, mostly in the pediatric age. In particular, it was found tortuous course of the aortic arch with corkscrew appearance, sometimes in association with other vascular anomalies , 2. The A 79-year-old man, with a history of HCV-related cirrhosis, arrives in our operative unit to perform an abdominal ultrasound in which biliary tract dilatation is observed.For this reason we make a Colangio-RMN  with T Ip/Op, T2 Ssh, SPAIR, DWIBS and images acquired according to the axial and coronal planes, integrated with MRCP 2D, 3D, where the abnormality of the abdominal aorta was accidentally detected. Therefore, to evaluate the presence of further abnormalities of the thoracoabdominal aorta, we make an Angio-CT  with contrast medium (iomeprol 400: volume administered: 90 ml: infusion speed: 4.5 ml/sec), with three dimensional and multi-planar reconstructions in postprocessing  two kinking and coiling interposed among them were appreciated, without any significant stenosis or pathological dilation. The emergence of downstream vessels, the superior and inferior mesenteric artery, was typically without variations.The aorta regained regular course at the bifurcation with regular iliac axes by size and course.The patient was then subjected to clinical and instrumental supervision with an ultrasound examination on the 3rd and 6th months and Angio CT on the 12th month to evaluate any changes or appearance of clinical signs.The corkscrew aorta is a variant of the normal anatomical course of the aorta. This is a rare condition of which there are no cases in the literature referring to the abdominal aorta, having been found in the cervical and thoracic district , 2. It iThe diagnosis is incidental, carried out exclusively with diagnostic images, particularly with Angio-CT. This demonstrates the presence of at least two kinking , 4, defiIn our experience this condition did not determine any symptoms , 6.Among the complications cannot be excluded are the formation of stenosis or narrowing, due to the presence of multiple angles, as it happens on other vascular districts, which could determine hypoinflux to the lower limbs, but in our work this possibility did not occur since the morphological picture remained unchanged and iconographic after a year. If complications had occurred, the only treatment available would have been aorto-aortic grafting, since the tortuosity of the vessel contraindicates endovascular treatment.The corkscrew aorta, defined as a variant of the normal anatomical course of the aorta, is incidental, confirmed by Angio-CT, being from an asymptomatic clinical point of view.


Lateral periodontal cyst (LPC) is an uncommon developmental odontogenic cyst arising on the lateral surface of tooth roots. Commonly reported in mandibular canine-premolar or maxillary anterior regions, it presents as a well-circumscribed or tear drop-shaped radiolucency with a sclerotic border. Associated teeth are asymptomatic and vital, and roots may be displaced without resorption. Histopathologically, cystic lining resembles reduced enamel epithelium along with glycogen-rich clear cells and epithelial plaques. Unilateral variant of LPC has low recurrence and is managed by enucleation. A 43-year-old male patient reported with asymptomatic swelling in the left mandibular canine and first premolar region. Both teeth were vital, and radiographs revealed well-circumscribed radiolucency between the roots. Following consent, surgical enucleation and guided bone regeneration (GBR) with xenograft and resorbable collagen membrane were done under local anesthesia. The immediate postoperative period was uneventful, and complete bone fill of cystic cavity and healing of periodontal tissues was observed after a one-year follow-up. Histopathologic examination confirmed the diagnosis. LPC should be a differential diagnosis in cystic lesions lateral to the surface of a tooth and without any associated inflammation. Based on this case report, unicystic LPC can be successfully managed through surgical enucleation with GBR for better periodontal healing. Lateral periodontal cyst (LPC) is a relatively rare odontogenic pathology, representing about 0.4% of all odontogenic cysts –4. It haAccording to the World Health Organization (WHO) classification of odontogenic tumors and cysts , LPC is classified as an odontogenic cyst of developmental origin  [7]. CliAlthough untreated odontogenic cysts could cause root resorption in adjacent teeth, it has not been reported in association with LPC , 8. MoreTreatment of LPC, which provided that the lesion is unilocular on radiological examination, is by conservative surgical enucleation and following up the patient over a period of six months to one year, in order to monitor for recurrence , 12. NevThe aim of this paper is to present a case of LPC treated with surgical enucleation and primary bone defect repair using GBR with xenograft and resorbable collagen membrane, along with a recurrence-free follow-up period of one year. In addition, this case is being reported for the similarities in clinical and radiographic presentation between LPC and other odontogenic lesions and a proposed modality towards definitive treatment.A 43-year-old Saudi male patient reported to the oral surgery outpatient clinic at the College of Dentistry and Dental University Hospital, King Saud University, with a complaint of painless swelling in the left mandibular premolar region. Although the history revealed a presence of the swelling for more than one year without any associated symptoms, the patient preferred to obtain clinical consultation as he was concerned about the swelling. The patient had no previous history of dental treatment except for periodic oral prophylaxis and reported no systemic comorbidities.Upon clinical examination, a well-circumscribed and fluctuant swelling, measuring about 9-12 mm in diameter, was observed at the junction of the buccal attached and free gingival margins in between the left mandibular canine (33) and premolar tooth (34) . The sweRadiographic examination (orthopantomogram (OPG)) of the left mandibular body region revealed a well-circumscribed radiolucency, with a sclerotic border in between the roots of teeth 33 and 34. The radiolucency measured approximately 1.5 cm superior-inferiorly and 1.2 cm mesiodistally. Although the roots of the associated teeth (33 and 34) were displaced, there was no discernible loss of the lamina dura in them. Cone beam computed tomography (CBCT) of the region of interest revealed a cystic lesion between the roots of the left mandibular canine and premolar, along with resorption of both the buccal and lingual cortical plates .Based on a clinical and radiographic diagnosis of a lateral periodontal cyst, the patient was consented for enucleation and curettage of the cystic lesion and primary reconstruction of the defect site using guided bone regeneration. Following informed consent, under local anesthesia, the lesion was surgically approached through a gingival crevicular incision extending from tooth 32 to tooth 35. After mucoperiosteal flap elevation, an anterior vertical releasing incision was provided for optimum visualization and sharp dissection using a pair of scissors was done superficial to the cystic wall in order to separate the mucoperiosteal flap without compromising its integrity. While the cystic lesion was identified and enucleated in total, mild adhesions to the lingual mucoperiosteum were released through blunt dissection using the surgical curette .Following enucleation and curettage, the cystic cavity was thoroughly irrigated with sterile normal saline. Clinical examination revealed a bony wall with intact mucoperiosteum on the lingual aspect, and there was no resorption of the roots of the tooth mesial and distal to the lesion. The residual defect left behind by the cystic lesion was then filled with a xenograft bone  soaked in sterile normal saline and covered by a resorbable collagen membrane (RCM) . The mucoperiosteal flap was reapproximated and closed with Vicryl 4-0 interrupted sutures  . PostopeThe excised soft tissue specimen was immediately fixed in 10% neutral buffered formalin and was sent for histopathology examination (HPE). HPE of the excised specimen revealed a cystic lesion lined in most areas by a thin epithelial lining composed of one or two rows of cuboidal or flattened epithelial cells. Focal areas of epithelial thickenings, with a few duct-like spaces rimmed by cuboidal cells and areas of swirling orientation of the cells, were also noted. Occasional clear cells in the lining along with odontogenic epithelium in the cyst wall were also seen. Based on HPE and clinicoradiological correlation, a diagnosis of lateral periodontal cyst was established. Considering the low risk of recurrence associated with the lesion, it was decided to follow up the patient closely .In this report, a case of LPC has been presented along with its corresponding clinical, radiographic, and histopathologic findings, in addition to its primary management with GBR. The first documented report of LPC in the literature was as early as 1958 by Standish and Shafer , who repIn spite of its distinguishing radiographic and clinical presentation, it is considered prudent enough to confirm the diagnosis of LPC through HPE . The chaIt must however be noted that a HPE finding similar to LPC is also reported in the botryoid odontogenic cyst (BOC) , 9. In cTreatment of unicystic LPC usually involves conservative surgical enucleation of the cyst and curettage of the cystic cavity to eliminate any remnants. In the majority of the cases, the associated teeth remain vital and are neither extracted nor endodontically treated , 5, 12. Even though managed conservatively, enucleation of LPC leaves behind a significant bone cavity and dead space, which in the long term might affect the periodontal health of associated teeth . SeveralAlthough LPC is an uncommon developmental odontogenic cyst, it should be considered a differential diagnosis in case of cystic lesions lateral to the surface of a tooth and without any associated inflammatory processes or symptoms. Unicystic LPC clinically and radiographically diagnosed based on the previously mentioned characteristic features can be managed with conservative surgical enucleation and GBR. However, further long-term clinical studies in larger sample sizes should be mandated to ascertain the efficacy of this treatment modality. Nevertheless, the role of HPE after surgical enucleation should not be discounted and histopathological confirmation of diagnosis serves as the benchmark for a recurrence-free follow-up period.


The presence of a cartilaginous mass on the bony external auditory canal is an unusual finding. Currently, two different diagnoses have been used to describe this type of mass: chondroma and cartilaginous choristoma. There is currently no consensus on which diagnosis is appropriate for this type of lesion. Choristoma is defined as a tumor-like growth of normal tissue occurring in an abnormal location. Histological examination alone cannot be used to distinguish between cartilaginous choristoma and chondroma, as both lesions comprise normal mature hyaline cartilage. To diagnose a mass as cartilaginous choristoma on the bony external auditory canal, it is necessary to confirm that it does not originate from the underlying periosteum. Here, we present the cases of two patients with typical cartilaginous masses on the bony external auditory canal, in which the surgical findings showed that the masses were not in contact with the underlying periosteum, indicating that cartilaginous choristoma—not chondroma—is an appropriate diagnosis for these mass lesions. The clinical findings (characteristic appearance and location) reported here may aid clinicians in the diagnostic and surgical management of these cartilaginous masses. Previ reports , 2, 4, 7ondromas ; thus, tondromas , 9. Therondromas , salivarondromas , and ossHere, we report the cases of one 73-year-old woman (Case 1) and one 55-year-old man (Case 2). Both patients did not have a history of swimming in cold water or taking saunas. They each presented with a mass, discovered incidentally on routine examination, at the medial portion of the anterior wall of the bony EAC just in front of the short process of the malleus Figures . The masOnly 53 cases of a cartilaginous mass on the bony EAC have been documented in the literature –7. HowevChondromas can be classified into several types, depending on the sites in which they originate. When a cartilaginous mass is found at the surface of the bony EAC, just as in our cases, “periosteal” chondroma is considered in the differential diagnosis of CC . PeriostThe pathogenesis of CC is thought to be due to the migration of embryological cartilage cells . It is sWhen the lesion occurs at the typical site , the differential diagnosis can be narrowed by first categorizing the lesion into two groups: soft mass  or firm mass . This step could be easily achieved by palpation of the mass using a tool, such as a Rosen needle. If the lesion is found to be a firm mass, a CT scan could be useful in distinguishing between CC, periosteum chondroma, and a malignant tumor; the characteristic radiographic feature of periosteum chondroma is erosion of the underlying cortex . In bothIn the literature, the majority of reported CCs on the bony EAC were removed surgically; however, several authors have described that CCs have low growth potential and have not been reported to undergo malignant transformation. In consideration of this, observation is an appropriate strategy. Nonetheless, one study reported that a single CC enlarged in size and touched the tympanic membrane, resulting in conductive hearing loss . FurtherIn this case study, the cartilaginous masses on the bony EAC were appropriately diagnosed as CC and not chondromas. Preoperative examination, which included palpation and CT imaging, and intraoperative findings were useful in obtaining a proper pathological diagnosis for these lesions.


Background: Childhood asymmetry labium majus enlargement (CALME) is an uncommon, benign condition that occurs in pre- and early pubertal girls and is characterized by a painless, fluctuating, non-tender labial swelling with normal overlying skin. Recognition of this benign condition is essential. Differentiation with several other diseases that mimic CALME and require different diagnostic and therapeutic approaches is mandatory. Two cases of CALME are described in this report. Differential diagnoses and therapeutic approaches are highlighted. Case presentation: The first case was an 11-year-old Caucasian girl referred to our hospital for the evaluation of right labium majus, which showed a palpable, painless, soft, non-tender, non-erythematous enlargement measuring approximately 2 cm with indistinct borders. Ultrasound showed a mass 23 × 18 × 12 mm in diameter. Surgical excision of the mass was performed and in the histopathological evaluation, the tissue specimens were composed of haphazardly arranged vascular channels, adipose tissue and nervous elements that were components of the vulvar soft tissue and were compatible with the diagnosis of CALME. Case 2 was a 6-year-old Caucasian girl who presented a post-traumatic painless mass of left labium majus swelling that progressively increased in volume. Ultrasound study evidenced an ill-defined heterogeneous echotexture mass 26 × 15 × 10 mm in diameter and magnetic resonance imaging confirmed these findings. Histopathological examination was performed after bioptic sampling evidencing normal constituents of vulvar soft tissue, including fibroblast, collagen, adipose tissue, blood vessels and nerves compatible with CALME. Conclusions: CALME is a particular clinical condition that occurs mainly in pre-pubertal girls and has a benign course but poses numerous problems in differential diagnosis that can be solved only with careful clinical observation and with a careful use of radiological imaging techniques. Our cases, in agreement with recent literature, suggest that radical excision is not recommended and that surgical biopsy should be taken into consideration only in cases of doubt. Childhood asymmetry labium majus enlargement (CALME) is an uncommon, benign condition that occurs in pre- and early pubertal girls and is characterized by a painless, fluctuating, non-tender labial swelling with normal overlying skin . The lesThe term CALME was coined in 2005 by Vargas et al. to describe a disease with the previously cited characteristics, but it is highly likely that it was discovered some years before, although identified with different names . Cases rChildren’s parents gave their written informed consent for management of their daughter and for publication of the clinical case. Ethics Committee of Santa Misericordia Hospital in Perugia, Italy, was informed about management and publication of these two cases (project identification code n. WAidid2017_02).An 11-year-old Caucasian girl was referred to our hospital ward for the evaluation of right labium majus swelling. History of illness, systemic disease or trauma was denied. On admission, her vital parameters were normal. In her physical examination, there was no abnormality except for the right labium majus, which showed a palpable, painless, soft, non-tender, non-erythematous enlargement measuring approximately 2 cm with indistinct borders. The vaginal introitus and external meatus were normal, with no evidence of clitoral hypertrophy. Laboratory investigations revealed normal complete blood count, liver and renal function tests. Serum levels of acute phase reactants were within normal limits, such as serum levels of FSH, LH, estradiol, total testosterone, and thyroid hormones. Ultrasound showed a mass 23 × 18 × 12 mm in diameter characterized by an increased amount of labial soft tissue on the affected side with a similar echogenicity to the contralateral side.Surgical excision of the mass was performed. In the histopathological evaluation, the tissue specimens were composed of haphazardly arranged vascular channels, adipose tissue and nervous elements that were compatible with the diagnosis of CALME . HoweverFollow-up was performed at 1, 6 and 12 months without evidence of recurrence.A 6-year-old Caucasian girl presented a post-traumatic painless mass of left labium majus swelling that progressively increased in volume . A careful clinical examination was made, with no evidence of other alterations. As in Case 1, laboratory tests revealed no signs of a chronic or neoplastic condition and no endocrine abnormalities. Ultrasound study evidenced an ill-defined heterogeneous echotexture mass 26 × 15 × 10 mm in diameter . The area of enlargement blended into the normal labial tissue, and there was no definable capsule. Magnetic resonance imaging (MRI) confirmed these findings, namely, asymmetrical mildly enlarged labial tissue composed of homogeneous hypointense signal on T1-weighted imaging and hypo- to isointense to muscle on T2-weighted images. Histopathological examination was performed after bioptic sampling evidencing normal constituents of vulvar soft tissue, including fibroblast, collagen, adipose tissue, blood vessels and nerves compatible with CALME . The immCALME is a clinical condition whose origins are unknown. The most accepted hypothesis considers CALME to be the effect of a hormonal response, as occurs during breast development. The vulva is responsive to sex hormones and, at puberty, it undergoes profound changes. The labia become gradually larger, thicker, and wrinkled . AsymmetThe two cases reported here have clinical, radiological, and histological findings that strongly support the diagnosis of CALME. Diagnosis was suspected based on clinical signs and symptoms and sonography/MRI results and was later confirmed by histologic findings. However, several differential diagnoses were considered before deciding to perform confirmatory tissue biopsy; mimicking lesions, inguinal hernia, vascular malformations, lipoma, neurofibroma, rhabdomyosarcoma, angiofibroblastoma, Bartholin’s duct cyst or abscess, and labial hypertrophy were also taken into account. Due to its fluctuating nature, CALME should be considered in a differential diagnosis with inguinal hernia , but in Confirmation of the diagnosis is usually based on biopsy and histological evaluation of the enlarged tissue. For therapy, when CALME is described, surgical excision is considered the best solution . In bothCALME is a particular clinical condition that occurs mainly in pre-pubertal girls and has a benign course but poses numerous problems in differential diagnosis that can be solved only with careful clinical observation and with a careful use of radiological imaging techniques. Our cases, in agreement with recent literature, suggest that radical excision is not recommended and that surgical biopsy should be taken into consideration only in cases of doubt.


A 72-year-old man living in a mountain region presented with a painful giant tumor in the right laterocervical area, which had been observed 2 years previously and had started to grow rapidly over the past 6 months. The patient had a past history of heavy tobacco intake and suffered from arterial hypertension and diabetes mellitus. The physical examination revealed a bulky, exophytic tumor measuring 20 cm in length across the major axis, with a large ulcerated area, which bled easily and multiple fistulae discharged a malodorous secretion. The adjacent dermis was also infiltrated over several centimeters beyond the visible borders of the lesion. A biopsy of the tumor was performed. Histopathological examination revealed a well-differentiated squamous cell carcinoma. The computed tomography (CT) scan showed a heterogeneous mass in the right lateral region of the neck with irregular contours, a necrotic center and an infiltration of the internal jugular vein. The tumor appeared to adhere to the sternocleidomastoid muscle, the paralaryngeal soft tissues, the submandibular region, the parapharyngeal space and the parotid. No local adenopathy or distant metastatic disease was noted. The tumor was considered unresectable. The patient had an ECOG performance status rating of 2 and a normal renal function. Neoadjuvant chemotherapy with cisplatin and 5-fluorouracil was initiated. After the third cycle, the CT scan showed a progression of disease with increased-neck-mass size and appearance of pulmonary metastases. The general condition of the patient did not allow second-line chemotherapy and he died 1 month later.


The clinician should always consider extracranial metastases in glioblastoma. Increased risk factors are young age at diagnosis, histology of gliosarcoma, and prior intracranial tumor surgery. Clinical guidelines are needed for this rare event, including consideration for prophylactic intervention. Here, we present two case stories with metastasis to the spinal cord and the neck musculature, respectively. They both had clinical and histopathological features corresponding to an increased risk of extracranial spread. Clinical guidelines are needed for this rare event.Glioblastoma, WHO grade IV, is the most aggressive primary brain tumor in adults and has a median overall survival of <15 months despite optimal available treatment.2A 30‐year‐old male was brought to the department of neurosurgery due to a history of confusion, headaches, nausea, seizures, and insomnia which had accelerated during the last 30 days. The patient had a history of systemic infection with Epstein‐Barr virus (EBV) 5 years previously which had been treated conservatively. At admission, a Glasgow Coma Scale (GCS) of 11 was noted . A magnetic resonance imaging (MRI) of the brain .The primary tumor involved the right frontal horn in the lateral ventricle and had spread to the fourth ventricle at progression. The ventricles communicate to the spinal cord and this could represent the metastatic route. Metastases to the bone are found in approximately 31% of all extracranial metastases but when it occurs, the most common site is the vertebrae (73% of cases).The role of IDH has been known since 2008 and was implemented at our institution in 2009. But IDH status was not integrated into the World Health Organization (WHO) classification before 2016For the patient in case story 2, the tumor in the neck was not seen until after surgery, confirming the increased risk of extracranial metastases after surgery with iatrogenic seeding. The patient had a GS described to be associated with increased risk for development of extracranial metastases.When the tumor in the neck was diagnosed with the same histology as the primary tumor, the patient was offered palliative radiotherapy against the neck since he was not a candidate for systemic treatment, but he declined. This underlines the discussion for which palliative strategies to turn to since patients at the time of diagnosis of extracranial metastases in general have limited lifespan left of a few months.Although rare, the incidence of extracranial metastasis from malignant gliomas is increasing,5The presented cases in this study support young age at diagnosis, prior intracranial brain tumor surgery, and GS components in the tumor as risk factors for the development of extracranial metastases. We suggest that more extensive radiation fields should be considered in the case of GS tumors to minimize extracranial spread. Moreover, we find a need for the development of clinical guidelines to detect extracranial spread in malignant glioma to improve treatment and to better understand this phenomenon.None declared.DSN, HSP, and UL: Concepted the study. DSN and SRM: Evaluated the case materials and wrote the manuscript. HB: Contributed to the histological evaluation. SM: Contributed to the imaging evaluation. All authors participated in critical review and revision of the manuscript and gave approval of the final manuscript.The project has been approved by the Danish Data Protection Agency with the journal number: VD‐2018‐459.


Villar’s nodule is an umbilical endometriosis without anterior or ongoing pelvic endometriosis. The primitive location of this nodule at the umbilical level is rare. Its etiopathogenesis remains unclear.We report a case of umbilical endometriosis with unusual clinical expression in a woman in the reproductive years with no surgical history and no known history of endometriosis. Endometriosis manifested as progressive transformation of the normal umbilicus into several small nodules, with bleeding coinciding with the menstrual cycle. The diagnosis was confirmed by histology and surgical treatment consisted of omphalectomy.Umbilical endometriosis is a rare disease that occurs naturally in patients with pelvic endometriosis. Etiopathogenesis of the disease is still unclear. In our patient, the appearance of the nodule was impressively, by a gradual transformation of the normal aspect of the umbilicus, into several small, slightly pigmented, firm, painful and concomitantly bleeding nodules during periods of menstruation. In the literature, this multinodular or budding form would be of exceptional observation.The characteristics of the umbilical tumor, associated with the cyclical nature of tumor bleeding in a patient without previous history of endometriosis, strongly suggest the diagnosis of Villar’s nodule, but the confirmation is still histological. The treatment is always surgical and recurrence is very rare. Villar in 1886. He then defined it as the presence of endometrial glands in the umbilicus in a woman without a history of pelvic endometriosis . It requ1.1A 43 years old patient with history of four pregnancies resulting in three parties and a miscarriage, was received in surgery consultation for abdominal pain associated with tender umbilical swelling. The symptoms have evolved about six months with a gradual transformation of the umbilicus originally normal appearance into several small nodules. This swelling flared up during the menstrual cycle, with a recrudescence of pain during these periods. There was no history of metrorrhagia, dysmenorrhea, or dyspareunia. The menstrual cycle was regular. This mass would have motivated a traditional treatment without success. On clinical examination the patient was in good general condition and there were no signs of clinical anemia. There was a multinodular umbilical tumor about 2 cm in size, coarsely pigmented, painful, firm in consistency and letting a bloody liquid flow under pressure. The mass was irreducible, non-pulsating, and not expansive to coughing. Clinical examination reported normal findings. The abdominopelvic Doppler ultrasound had noted a hypoechoic, well-vascularized mass around the navel measuring 2.5 × 2 cm . The uteThere were no abnormalities of the abdominal-pelvic contents. The histology of the operative specimen noted macroscopically a piece of 4 × 3 × 3 cm, with the presence of budding nodule partially covered with a skin coating.At microscopy, it was an epidermal coating without atypia, on fibrous connective tissues, with glandular formations of endometrial type without atypia. These endometrial glands were dilated, distended and hemorrhagic, on a scanty chorion without atypia. The resection margins were normal in appearance. The diagnosis of umbilical endometriosis was made. The patient underwent a mini laparotomy omphalectomy . The exp2Umbilical endometriosis is a rare disease that occurs naturally in patients with pelvic endometriosis . The VilThe Villar’s nodule in this case can therefore pose a problem of differential diagnosis with the Sister Marie Joseph’s nodule. Indeed, the sister Marie Joseph’s nodule is a skin manifestation in the umbilicus, an intra-abdominal malignancy ,9. MagneThe post-therapeutic evolution is generally favorable with a very low risk of recurrence or very low cancer transformation ,10,11,142.1The characteristics of the umbilical tumor, associated with the cyclical nature of tumor bleeding in a patient without previous history of endometriosis, strongly suggest the diagnosis of Villar’s nodule, but the confirmation is still histological. The treatment is always surgical and recurrence is very rare.The authors declare that they have no competing interests regarding the publication of this manuscript.No sponsors to declare.Ethical approval is not needed for this case report as patient consent and we are not trialing a new device.We obtained consent to publish this case presentation from the patient.Case report concept and design: OUEDRAOGO NLM, IBOUDO S, SIMPORE J, TRAORE SS. Acquisition of data: OUEDRAOGO NLM, IBOUDO S. Statistical analysis and interpretation of data: OUEDRAOGO NLM, OUATTARA AK, SIMPORE J. Drafting of the manuscript: OUEDRAOGO NLM, OUATTARA AK, SIMPORE J. Critical revision of the manuscript for important intellectual content: OUEDRAOGO NLM, IBOUDO S, OUATTARA AK, OUEDRAOGO AS, ZIDA M, ZONGO N, OBIRI-YEBOAH D, OUANGRE E, SIMPORE J, TRAORE SS. All authors approved the final version of this publication.N/ADr Nabonswinde Lamoussa Marie OUEDRAOGOProf. Jacques SIMPORENot commissioned, externally peer-reviewed.


Inflammatory myofibroblastic tumor (IMT) of the lung is rare. This disease often shows neoplastic features with anaplastic lymphoma kinase positiveness as well as inflammatory features, such as steroid-responsive immunoglobulin G4 (IgG4)-related sclerosing disease. Since many cases have been reported as advanced, various treatment strategies should be considered based on clinical and biological features of each case.We report a 49-year-old male with IMT, which seemed invading the left atrium from preoperative imaging modalities. Serological and pathological examinations from the biopsy specimen revealed high expression of anaplastic lymphoma kinase expression in the tumor. On the other hand, IgG4/IgG ration in the tumor was small, where a therapeutic effect of steroid was not expected, leading to surgical treatment rather than a steroid administration. The tumor was completely resected en bloc with the right lower lobe of the lung and a part of the left atrium. The postoperative course of the patient was uneventful. The patient has remained recurrence free over 5 years from the surgery.In this case, preoperative biological assessment prior to the treatment led to a good clinical course. We believe that molecular biological examination is important in the determination of treatment strategy for this rare disease as well as imaging modalities. Inflammatory myofibroblastic tumor (IMT) of the lung is rare and has been called a variety of names, such as inflammatory pseudotumor, plasma cell granuloma, and histiocytoma , 2. It hIn this report, we present an asymptomatic but invasive IMT case. We assessed the biological features of the tumor preoperatively and surgical treatment was selected. The postoperative course was uneventful.A 49-year-old man was first referred to a local hospital due to a mass on the right hilum found by plain chest computed tomography (CT) during medical check-up. The tumor seemed to be invasive to the left atrium. Therefore, only excisional biopsy by video-assisted thoracoscopic surgery was performed. He was referred to our institution for treatment. His past medical history was unremarkable.Enhanced chest CT showed a 4-cm mass, with a heterogeneous enhancement Fig. a. EnhancThe patient underwent thoracotomy after an isolation of the right femoral artery and vein in preparation for a case of the cardio-pulmonary support that would be needed. The tumor lesion was palpable around the right hilum, surrounding the inferior pulmonary vein (IPV). After resection of the A6, basal artery, and the lower bronchus, the pericardium was opened and the superior and inferior pulmonary veins were isolated in the pericardium. The tumor lesion was revealed to localize at the IPV in the pericardium. Thus, we clumped the left atrium and resected the tumor en bloc with IPV and a part of the left atrium without cardio-pulmonary support. After removal of the tumor, the left atrium was sutured by over and over running suture.Pathological examination demonstrated the proliferation of spindle cells and collagen fibers. It also revealed the infiltration of plasma cells and lymphocytes Fig. a. No eviThe postoperative course of the patient was uneventful. Currently, the patient remains free of disease over 5 years after surgery.An IMT of the lung is rare, with an incidence of 0.04% . Gender,It is unclear whether the etiology of an IMT is the result of non-specific inflammatory reaction or neoplastic change. There were some cases where expression of the ALK gene elevated  and otheThe 5-year survival rate of IMT was reported 74–91%  and chemRecently, clinical trial of crizotinib for ALK-positive IMT was reported . In thatWe reported an asymptomatic but invasive IMT case, which demonstrated the high expression of ALK without IgG4. Because we contradicted the possibility of the IgG4SD beforehand, we chose the operation over other therapies. We believe, to determine the therapeutic strategy and prospect prognosis, analysis of IgG4 and ALK for IMT along with existing imaging modalities may prove useful.


Paclitaxel is a chemotherapy drug commonly used in the management of ovarian cancer. Colonic perforation is an extremely rare complication of paclitaxel administration with few case reports in the medical literature. We report a case of a patient with advanced ovarian cancer who had a rectal perforation following administration of paclitaxel. There has only been one other case report of rectal perforation in the medical literature following paclitaxel therapy.A 55-year-old Caucasian woman with advanced ovarian cancer awaiting elective debulking surgery for her tumor presented to our emergency department with abdominal pain, vomiting, and diarrhea. She was admitted to hospital for neoadjuvant chemotherapy and management of her systemic symptoms. She became acutely unwell following one cycle of chemotherapy with paclitaxel. A computed tomography scan of her abdomen showed typhlitis of her descending colon and a corresponding rectal perforation. Surgical intervention was deemed inappropriate as she had a heavy burden of disease and neutropenia. She died following a period of conservative management with strong intravenously administered antibiotics.This case highlights the importance of recognizing gastrointestinal complications following chemotherapy and the need to be aware of the possibility of bowel perforation. Prompt surgical review and intervention must be requested in patients with acute abdominal pain and persistent gastrointestinal symptoms such as diarrhea and vomiting. Paclitaxel  is a biosynthetic form of the natural product taxane, which is derived from the bark of Pacific yew trees . It is aPaclitaxel is widely used as a first-line agent in combination with carboplatin for the management of advanced ovarian cancer . Common A 55-year-old Caucasian woman with a 5-month history of abdominal pain and vomiting was diagnosed as having a probable high-grade ovarian malignancy with a large volume of peritoneal disease. She had a prior ultrasound of her pelvis which demonstrated a 17 cm large irregular solid vascularized mass in her right ovary. Her comorbidities included obesity (body mass index of 33), asthma, and she had previously undergone a laparoscopic cholecystectomy. There was no significant family history. She did not smoke tobacco and she drank alcohol occasionally. She was scheduled for debulking surgery; however, she presented to our emergency department with worsening abdominal pain, vomiting, and diarrhea. A physical examination showed dry mucous membranes, capillary refill < 3 seconds, and jugular venous pressure of 4 cm. Her chest was clear on auscultation with dual heart sounds. Her abdomen was distended with generalized tenderness but no guarding or signs of peritonism. Bowel sounds were present. A computed tomography (CT) scan of her abdomen and pelvis was performed which demonstrated the large right ovarian tumor, peritoneal tumor deposits, and ascites. There was extrinsic compression of her sigmoid colon due to the tumor without radiological signs of large bowel obstruction. There were no other abnormalities of her bowel. She received intravenously administered fluids for rehydration, anti-emetics for nausea, and intravenously administered morphine for abdominal pain. She remained overnight in our emergency department for treatment. She was reassessed the following morning after resolution of her symptoms and was found to be hemodynamically stable and subsequently discharged home.She re-presented 1 week later with similar symptoms and was admitted to hospital for further management. Following multidisciplinary discussion, she was recommended for neoadjuvant chemotherapy prior to surgical debulking. An urgent core biopsy of the mass confirmed the likely diagnosis of ovarian malignancy. This biopsy indicated a high-grade serous adenocarcinoma. The histology and CT findings were consistent with an International Federation of Gynaecology and Obstetrics (FIGO) stage III ovarian cancer. She was appropriately counselled as to the benefits and risks of chemotherapy prior to commencing treatment.2 and carboplatin 385 mg/body to achieve area under the curve (AUC) of 5 using the Calvert formula. The results of her pre-chemotherapy blood tests were within acceptable ranges. Specifically, her white cell count (WCC) was 10.1 × 109/L  and neutrophils were 8.5 × 109/L . She reported feeling better 1 day after chemotherapy. However, 3 days following the commencement of chemotherapy, persistent diarrhea developed. Stool cultures were negative for stool pathogens including Clostridium difficile. On the sixth day post-chemotherapy, she became febrile and acutely unwell with severe abdominal pain. Blood tests at the time revealed a WCC of 0.6 × 109/L and neutropenia of 0.1 × 109/L. A repeat CT of her abdomen and pelvis showed a thickened descending colon and rectal pneumatosis with perforation into the mesorectum (Figs. Escherichia coli and meropenem was commenced. She was transferred to our intensive care unit for hemodynamic support due to septic shock. A surgical assessment was conducted but immediate surgical intervention was deemed inappropriate due to high predicted mortality. She was administered granulocyte colony-stimulating factor but her white blood cell counts did not improve and her respiratory function deteriorated. She died 9 days after the administration of the first dose of chemotherapy. An autopsy was not performed due to the wishes of our patient’s family.She was commenced on a first cycle of the commonly used platinum-based two-drug chemotherapy regime of paclitaxel and carboplatin . The dosGastrointestinal complications from chemotherapy range from common side effects such as vomiting and diarrhea to rarer complications such as neutropenic enterocolitis. Vomiting and diarrhea are common side effects of paclitaxel therapy. There are few case reports of neutropenic enterocolitis and reports of bowel perforation are even rarer following paclitaxel therapy.et al. were the first to describe bowel perforation as a potential complication of paclitaxel therapy [Seewaldt  therapy . They po therapy . Rose an therapy . Of inte therapy . Bowel p therapy , 5. Conc therapy . Tumor l therapy .The case described here had descending colon colitis as well as a more distal perforation in her rectum both of which looked normal on earlier imaging prior to the administration of chemotherapy. It is unusual for the rectum to develop ischemia and subsequent pneumatosis due to its excellent blood supply from the inferior mesenteric, internal iliac, and median sacral arteries. The perforation in this case was not due to tumor lysis as there was no rectal invasion by the tumor. There were also no other postulated risk factors for intestinal perforation such as concurrent corticosteroid use.It is likely that paclitaxel has several mechanisms of action. One mechanism of action of paclitaxel has a direct effect on gastrointestinal mucosa: it arrests cellular division and promotes cell death, which leads to perforation. This was suggested by Hruban and colleagues who showed the presence of gastrointestinal mitotic arrest in autopsy-derived gastrointestinal specimens following paclitaxel treatment . There iClinicians need to be aware of the risk of gastrointestinal necrosis and perforation that occurs following treatment with paclitaxel, especially on the first cycle. An analysis of these complications is important in order to identify future patients at risk of these complications. The management of gastrointestinal necrosis and perforation requires early referral to the surgical team. Surgeons need to be aware of gastrointestinal complications that occur with paclitaxel treatment and with other chemotherapy agents, including the high morbidity and mortality risks associated with these complications in what are often critically unwell patients. Treatment options need to be discussed early with the patient and in a multidisciplinary setting to ensure management is not compromised. Patients also need to have an understanding of the risks of therapy.


Percutaneous needle biopsy has been found to be a safe and accurate method for the initial investigation of soft tissue masses. The notion exists that needle biopsies should be performed in specialized sarcoma centers, which can place a financial burden on patients without a sarcoma center near their place of residence. There is no consensus in the current literature regarding the diagnostic accuracy and clinical utility of clinic-based percutaneous core needle biopsy performed by community orthopedic surgeons with fellowship training in musculoskeletal oncology.  Our primary goal was to determine if office-based core needle biopsy of soft tissue masses could safely yield accurate diagnoses when performed by a community orthopedic surgeon with fellowship training in musculoskeletal oncology.  We retrospectively reviewed the charts of 105 patients who underwent percutaneous core needle biopsy of soft tissue masses in a community clinic. All procedures were performed by one fellowship-trained musculoskeletal oncologist. Accuracy of the initial clinic-based needle biopsy was determined through comparison to the results of pathological analysis of the surgically excised masses. Final data analysis included 69 patients who underwent both clinic-based biopsy and subsequent surgical excision of their masses. p < 0.0001). Minor complications related to the clinic-based biopsy occurred in 5.80% of cases, with no documentation of major complications.  We found clinic-based biopsies to be 87.0% accurate for exact diagnosis and 94.2% accurate in determining whether the mass was benign or malignant ( Our results provide evidence that office-based percutaneous biopsy can be administered safely and yield accurate, clinically useful results when performed by a fellowship-trained musculoskeletal oncologist. Soft tissue sarcomas are exceedingly rare tumors with a mesenchymal origin . They moIt has been suggested by multiple authors that percutaneous soft tissue biopsies should be performed at sarcoma referral centers under the care of experienced musculoskeletal oncologists, citing decreased accuracy and potential alterations in the clinical course when biopsies are performed in the community , 23–25. This retrospective chart review was performed under Institutional Review Board (IRB) approval with waiver of informed consent. The initial list of patients was generated using ICD and CPT codes related to percutaneous needle biopsy. All data were collected from the electronic medical records (EMRs) of one community orthopedic clinic and one large academic medical center.n=105). Patients who did not ultimately undergo surgical excision of their lesions were excluded from further data collection and analysis.We reviewed the charts of all patients who underwent ambulatory percutaneous needle biopsy of a soft tissue mass  between © needles , taking multiple cores to maximize the amount of tissue biopsied, thus increasing the diagnostic ability [All procedures of office-based percutaneous needle biopsy and final surgical excision of soft tissue lesions were performed by a single board-certified and fellowship-trained musculoskeletal oncologist. Informed consent was obtained following a thorough discussion of risks, benefits, and expectations prior to the completion of any procedures. Needle biopsies were performed with Tru-Cut ability . Image g ability .n=69) included the following:Patient demographic information Lesion locationLesion diameterLesion depth relative to fascia Result of percutaneous biopsy Result of final surgical pathological analysis Documentation of biopsy-related complicationsDocumentation of the propriety of patients' ultimate treatmentData collection from the final study population  and the exact diagnosis. All pathology reports were reviewed by a third-party board-certified pathologist in order to determine the accuracy of ambulatory percutaneous biopsy when compared to the final pathological analysis of the surgically excised masses. In order to assess safety, we included documentation of any complications determined to be related to the ambulatory biopsy. Clinical utility of the clinic-based biopsy as a diagnostic test was assessed through determination of whether appropriate clinical treatment for each patient's final diagnosis would have been initiated with office-based CNB as the only diagnostic tool.α = 0.05). This statistical test is used to quantify the correlation between two nonparametric variables [All statistical analysis was performed using Stata . Accuracy was determined through the percent agreement between the exact diagnoses given by each biopsy method. Spearman's rank correlation coefficient (Spearman's rho) was used to quantify the level of agreement between the two biopsy techniques  and determine statistical significance of the primary outcome (ariables . Sensitip < 0.0001). Accuracy results are further stratified by gender, lesion location, lesion size, and depth of lesion in Demographic information of the 69 patients included in our final data analysis is described in A 45-year-old female with a left distal lateral arm mass. Initial CNB was read as “adipose and fibrous tissue with focal myxoid change.” Due to a high clinical suspicion and the fact that this mass could be excised with adequate margins without increased morbidity, a wide resection was performed. Final pathology reported the mass as a grade 1 myxoid liposarcoma.A 60-year-old male with a mass about the left proximal posterior calf, enveloping the distal popliteal neurovascular bundle. Initial biopsy at the margins of the lesion reported “spindle cell neoplasm.” Due to high clinical suspicion for malignancy, the nonspecific nature of the biopsy report, and involvement of critical neurovascular structures, the patient was given the option of open biopsy for further diagnosis. However, the patient declined this and opted for above knee amputation. The final pathology report diagnosed a “malignant solitary fibrous tumor.”A 55-year-old female with a mass about the right shoulder. Initial biopsy reported a “low-grade spindle cell lesion.” Due to high clinical suspicion and the nonspecific results of the biopsy, an open biopsy was performed at the time of planned excision. This frozen section was read as high-grade sarcoma, and thus a wide excision was performed. Final pathology was reported as a high-grade pleomorphic sarcoma.A 56-year-old male with a mass to the right anterior thigh. Initial biopsy reported skeletal muscle and mature adipose tissue. Following marginal excision, the final pathology report indicated the mass was a well-differentiated liposarcoma.In our study, 4 patients had malignant lesions that were reported benign by CNB, and thus these biopsies were counted as incorrect for both exact diagnosis and determining benign versus malignant. These patients were as follows:A 46-year-old female with a left shoulder mass. Initial CNB was read as “fragments of skeletal muscle and adipose tissue”; however, final pathology after marginal resection reported the mass as a desmoplastic fibroblastoma.A 45-year-old male with a mass about the left arm. Initial CNB reported “benign skeletal muscle.” After marginal resection, final pathology diagnosed a benign vascular malformation.A 55-year-old male with a mass to the posterior elbow. Initial biopsy reported benign skeletal and adipose tissue. This mass was marginally excised, and the final pathology report diagnosed a “benign vascular malformation with thrombosis and papillary endothelial hyperplasia.”A 50-year-old male with a mass to the right lateral thigh. Initial biopsy reported a benign lipomatous lesion. Due to clinical suspicion and the ease of wide resection without increased morbidity, wide resection was performed. The final pathology report diagnosed the mass as a “hibernoma with myxoid features.”A 84-year-old male with a mass to the right posterior thigh. Initial biopsy reported a “bland fibromyxoid spindle cell neoplasm.” Due to high clinical suspicion and the ease of wide resection without increased morbidity, wide resection was performed. The final pathology report diagnosed the mass as a perineuroma.Additional 5 biopsies did not report the exact diagnosis, but were correct with regards to benign versus malignant. These patients were as follows:Upon retrospective review of all of these cases, the use of office-based core needle biopsy, in combination with clinical suspicion and the optional use of an open biopsy, leads to the correct treatment in 100% of cases.We also assessed the clinical utility of our office-based biopsy in terms of a diagnostic test for malignancy. Overall sensitivity, specificity, PPV, and NPV were found to be 87.1%, 100.0%, 100.0%, and 90.5%, respectively. Using the results of the pathological analysis of the final surgical excision, we determined that all patients received correct treatment following the use of the office-based CNB.Percutaneous needle biopsy has been shown by numerous studies to be safe and effective for diagnosis of soft tissue tumors when compared to open biopsy , 29, 30.Currently, there is no consensus in the literature regarding the accuracy and clinical utility of office-based CNB of soft tissue masses. Skrzynski et al. examined the diagnostic accuracy and financial burden of musculoskeletal tumor biopsy, comparing clinic-based percutaneous needle techniques to open surgical biopsies. Their results showed substantially lowered cost associated with percutaneous biopsy and decreased but acceptable diagnostic accuracy when compared to open biopsy . Howeverp < 0.0001) accurate in determining the status  of the masses. There were few complications related to the clinic-based percutaneous biopsy. Of the 69 patients that were included in final data analysis, 2 patients experienced pain following the initial percutaneous biopsy, 1 patient developed a hematoma at the biopsy site, and 1 patient had bleeding from the wound site requiring sutures. This resulted in a biopsy complication rate of 5.8%, which is substantially lower than the 46% reported by Bedi et al. [In this study, we determined the accuracy of the outpatient percutaneous biopsy through comparison with the pathology report from the final surgical excision. We found that percutaneous biopsy was 87.0% accurate in determining the exact diagnosis of soft tissue masses and 94.2% (i et al.  This decUsing our data, we also investigated clinic-based CNB as a diagnostic tool for detecting malignancy. We determined the sensitivity, specificity, PPV, and NPV by comparing the results of the outpatient biopsy to the pathology of the final excision. The overall sensitivity was found to be 87.1% while the overall specificity was 100.0%. Overall PPV and NPV were 100.0% and 90.5%, respectively. The high level of specificity meant that we were likely to detect all benign masses as benign with our outpatient biopsy. However, our sensitivity and NPV indicate that some false negatives did exist and some malignant lesions were initially detected as benign. The specificity of our outpatient biopsy demonstrates that there were no false-positive results, and that all truly benign masses were identified as such. Our PPV shows that all masses identified as malignant by initial clinic-based CNB were identified as malignant by subsequent pathologic analysis of the excised masses. We determined these measures to be acceptable for using clinic-based biopsy as a diagnostic test, particularly when compared to results previously reported in the literature , 32. In Limitations of this study centered on its retrospective nature. Retrospective chart review studies do not allow for proper randomization of subjects or control of confounding variables. Additionally, there is no potential for standardization of procedures or data collection, but this was likely mitigated through the use of a single physician's patient population. Since this chart review covered multiple years of patient visits, multiple pathologists were involved in the reporting of biopsy results. Our study design likely minimized this impact through the use of a third-party experienced pathologist in interpreting the level of agreement between the two biopsy methods. We also recognized that this study only included those patients who underwent surgical excision of their soft tissue masses following the clinic-based biopsy. This could have led to our population including a disproportionate number of patients with malignant diagnoses. However, final surgical excision pathology was needed in our study design to be used as a gold standard with which we compared our results. The best approach to this research question would involve a double-blind, randomized clinical trial in which patients were placed into one of the two biopsy techniques. However, our study design allowed for comparison of two validated biopsy techniques in the same masses, essentially using the subjects as their own control.Many orthopedic surgeons believe that percutaneous biopsies of soft tissue masses should only be done in sarcoma referral centers, with concerns of decreased accuracy, potential complications, and alterations in the clinical course if biopsies are performed in the community , 23, 25.