Calvarial metastases are a relatively rare entity, with an overall incidence of 3–4%. Among these cases, metastases arising from salivary gland cancers are even rarer; in fact, large studies regarding salivary gland tumors showed that brain metastases are observed in 0.8% of the cases. Generally, bone metastases have been described in proximity to primary tumors, while bloodstream-disseminated lesions are often located inside the brain parenchyma. During every surgical step, traction on lower-lying infiltrated tissues must be avoided in order to successfully remove the lesion. This case report presents the first ever case of a 67-year-old woman affected by submandibular gland undifferentiated adenocarcinoma metastasis with a full-thickness involvement of the calvarium, pachy- and leptomeninges. The overall incidence of calvarial metastases is as high as 15–25% . In the A 67-year-old woman came to our emergency department complaining of a sudden onset right hand numbness and slurred speech. She had a previous history of left submandibular gland excision and monolateral ispilateral left-radical neck dissection for an undifferentiated salivary adenocarcinoma . Additionally, she underwent a schedule of adjuvant treatments composed of local radiation therapy, focused on the small metastatic foci identified with the total-body CT scan: cervical nodes, oral cavity, subpleural, surrenal gland and acetabular and a conventional chemotherapy (CDDP). This was followed, later by a biological therapy regime , with a clinical result of a cumulative 4 years of progression-free survival. The general history demonstrated an anaphylactic allergy to several drugs including iodine and gadolinium contrast media. The physical examination disclosed a slight right-hand weakness and numbness, with impairmea nt of the fine movements of the hands. The cranial surface examination revealed a lump of hard consistency, fixed on the deep and superficial layers. The preoperative brain CT and MRI scan could not be performed with contrast mediums. It revealed the presence of an osteolytic rounded lesion with irregular margins, involving in full thickness from the subcutaneous tissues to the dura, while the involvement of the leptomeningeal layer was not surely outlined. The diameters were 27 × 25 × 15 mm. T2w sequence and FLAIR disclosed the presence of a rolandic finger-shaped edema, together with an hyperintense dishomogeneous pattern on the lesion . The artSalivary gland tumors are rare and divided into several histopathological groups, generally affecting the parotid gland in near the 70% of the cases , while, This case offers several points of reflection. First of all, the patient suffered from severe allergy to multiple drugs; in this condition, since she was allergic also to gadolinium contrast medium, we did not have an unquestionable imaging disclosing the infiltration of the leptomeninges and cortex, although the preoperative MRI was highly suspicious . In suchUndifferentiated carcinomas of salivary origins can manifest as solitary skull metastasis: either, with an obvious potential to infiltrate the surrounding tissue deep into the cortex and outwards into the subcutaneous tissue; or with an insidious potential to encase and hemodynamically hijack small venous and possibly arterial collectors. Careful dissection may avoid the sacrifice of such important structures.


Parasitic fibroids are a rare type of extrauterine benign tumors that may be spontaneous or iatrogenic in origin and often difficult to diagnose due to their various presentations. We report an unusual case of a parasitic leiomyoma in a 33-year-old nulliparous woman with remote pelvic history who presented to our institution with sudden-onset lower abdominal pain. We performed an exploratory laparotomy, which revealed a 6.3x4.6 cm mass in the space of the adnexa of the right parametrium. Histopathological examination revealed features compatible with a leiomyoma. It is clear that physicians need to assess clinical findings and imaging techniques in order to establish a correct diagnosis of parasitic myomas, even when a history of myomectomy or a laparoscopic morcellation is absent. Fibroids of the uterus are among the most common benign pelvic tumors that gynecologic oncologists encounter in their clinical practice. They may occur in 20% to 40% of women of reproductive age . These bUterine fibroids are classified into four types by the International Federation of Gynecology and Obstetrics: submucosal, intramural, transmural, and subserosal. Parasitic fibroids are rare extra-uterine benign tumors detected in the abdominal cavity with no relation to the myometrium, grouped as a subtype of subserosal fibroids . They ar A surgical history of laparoscopic morcellation has been associated with parasitic fibroids in recent literature . Spread The most common method of treatment of a parasitic myoma is surgical excision either by laparotomy or under laparoscopic guidance. If during the operation, the surgeons encounter multiple myomas, the differential diagnosis should also include leiomyomatosis peritonealis disseminata (DPL) , in whic Herein, we present an unusual case of a parasitic leiomyoma with sudden-onset lower abdominal pain caused by necrotic ischemia in a woman with remote pelvic history.A 33-year-old nulliparous (Greek/Mediterranean) woman with regular menstrual cycles was admitted to our emergency department complaining of a 12-hour history of sudden-onset severe right iliac fossa (RIF) pain. Νο episodes of vomiting or any other intercurrent symptoms from the gastrointestinal tract were displayed. Her surgical history included appendicectomy at 17 years of age while her medical history was notable for bleeding disorders due to Willebrand factor deficiency. She was not under contraception medication. On examination, the patient’s vital signs were normal . Vaginal examination did not show any abnormalities. Physical examination revealed lower abdominal rigidity and guarding, with an associated pain on the RIF and right vaginal vault, with negative psoas and Murphy signs. Transvaginal ultrasound scan demonstrated a 6.3 x 4.6 cm mass with decreased blood flow in the location of the adnexa of the right parametrium. Blood tests showed elevated white blood count . Her inflammatory markers were mildly elevated (-reactive protein [CRP]: 42 mg/L), while the metabolic panel was unremarkable . Beta hCG was negative.On the basis of these findings and a high suspicion of adnexal torsion, the patient was taken to the operating theatre and an emergency laparotomy was performed under general anesthesia. Upon entry into the peritoneal cavity, a pedunculated subserosal fibroid was visualized, with what appeared to be a narrow stem attached to the uterus. A small amount of blood-tinged fluid was noted within the pelvic cavity. Multiple adhesions located in the right peritoneum were reported. The adnexa were examined, and no abnormalities were identified. During symphysiolisis, it was revealed that the fibroid’s major blood supply was provided by a large vessel originated from the peritoneum and the fibroid was held in place close to the uterus due to the adhesions. After grasping the myoma, cross-section and ligation of its peritoneal stem was performed. Thus, the fibroid was removed Figure . After cPost-operatively, the patient was administered intravenous fluids and broad-spectrum antibiotics. Blood tests performed after the surgery showed a sharp decline of inflammatory markers (CRP: 13 mg/L) and minimal decrease of hemoglobin (9.7 g/dL). The patient’s postoperative course was uneventful, and she discharged home four days later.At her four-week follow-up visit, the patient was symptom-free. Ultrasound imaging revealed no signs of mass in the cul-de-sac or blood in the peritoneal cavity. Histopathological examination confirmed that the mass was leiomyoma characterized by hyaline necrosis and increased cellularity.Myomas are a frequent finding in women of reproductive age . TraditiThe newer hypothesis is that as a byproduct of laparoscopic morcellation of uterine myomas in the past, tissue spread in the abdominal cavity provided the seed for parasitic leiomyomas . IncidenAny anatomical structure of the peritoneal cavity may be the site for development of a parasitic myoma. They are usually found in the peritoneum of the pelvic or abdominal wall, omentum, pouch of Douglas, small intestine, or colon . The diagnosis of a parasitic myoma is challenging since it presents with no special symptoms, and imaging techniques fail to differentiate it from other possible causes . ThankfuParasitic fibroids are usually treated by surgical removal, either in open surgery or laparoscopically. Since their blood flow can originate from the greater omentum, small intestine, large intestine, or peritoneum ,11,12, iIn our case, the patient presented with nonspecific symptoms and signs, which impeded a correct diagnosis. According to her medical history, no relevant causes of development of parasitic myomas according to current literature were reported. Since triggering factors causing the development of parasitic fibroids remain unclear, all necessary intraoperative precautions minimizing their formation should be taken.Parasitic fibroids are rare commonly presenting with no specific symptoms, making diagnosis difficult. Spontaneous parasitic leiomyomas, along with their complications such as torsion and necrosis, should be placed high in the differential diagnosis in women presenting with sudden-onset lower abdominal pain, especially in those with remote pelvic history of myomectomy or laparoscopic morcellation.


Implantation metastasis following stereotactic biopsy in the brain had been reported as a rare complication. A 36-years-old female patient was treated with ventriculoperitoneal (VP) shunt and stereotactic biopsy of a pineal parenchymal tumor of intermediate differentiation (PPTID) with hydrocephalus. The patient underwent five cycles of radiotherapy on the pineal area. Seven years after the procedure, the patient developed left hemiparesis with the brain MRI findings showing an enhanced mass along the biopsy tract. Craniotomy tumor removal was carried out and the pathological assessment was consistent with those of the PPTID. Radiation on metastase area and craniospinal was subsequently performed. The patient was disease-free during the 2-year follow-up assessments. The potential occurrence of implantation metastasis following the stereotactic biopsy of PPTID should be considered in the treatment plan and follow-up assessments and evaluations. Expanding the radiation area to cover the entire biopsy tract may be favorable to lower the risk of implantation metastasis. Pineal parenchymal tumors (PPTs) are rare and comprising of less than 0.3% of intracranial tumors. PPTs have heterogenous morphological and histological characteristics. Pineal parenchymal tumor of intermediate differentiation (PPTID) was first described by Schild et al.  and receStereotactic biopsy for pineal region tumors should be selective, although is often considered relatively safe. This procedure has a high success rate of between 70 and 98% with a relatively low complication rate of between 0.5 and 4%. The complications include infection, hemorrhage, and neurological deficits –9.To the best of our knowledge, the present case is the first case of metastatic seeding of the stereotactic biopsy tract trajectory of PPTID which occurred within 7 years following the procedure.A 36-year-old female patient presented with weakness and numbness in the left side limb. She recalled that the symptoms started 3 months prior and worsened gradually. Physical examination showed motoric strength of one-fifth on the left side. The patient had a history of pineal region tumor and hydrocephalus which were diagnosed 7 years prior from another hospital . PatientA brain MRI with IV contrast was then performed showing an isointense lesion with cystic parts that were slightly enhanced with contrast administration right below the burr hole site located in the right frontoparietal region. The lesion appeared to be causing a mass effect with the shifting of the midline . CraniotAfter the implantation, metastatic tumor removal surgery was performed. The motoric strength of the patient improved gradually and the patient was discharged on day 7. The external beam radiation with a 1.8 Gy fraction dose for 30 cycles to the tumor bed with volumetric modulated arc therapy (VMAT) and the craniospinal radiation was done 1 month after the surgery without the combination chemotherapy due to the patient's refusal. The follow-up brain and spine MRI scans were subsequently performed at 6 and 12 months. Brain MRI results showed gliosis at the surgical site without any sign of the residual tumor. The follow-up MRI was planned to be carried out every year thereafter. The patient was still disease-free at the latest follow-up at the 2-year mark .In the present case, the patient was diagnosed with an implantation metastatic tumor of PPTID, 7 years after undergoing the stereotactic tumor biopsy for the initial diagnosis of PPTID. On presentation, the patient had a primary symptom of left-sided paralysis. The resulting brain imaging showed a cystic lesion on the right frontoparietal region just inferior to the prior burr hole. Surgery was then performed to remove the lesion and the following histological examination confirmed the similar features of PPTID.The interesting radiographic feature that was observed in the patient was cystic-like lesions. These cystic-like lesions are features that are rarely seen in the PPTID (and its resulting metastases) radiographs , 11. ChaThe gross total resection followed by radiotherapy and chemotherapy is the ideal treatment for PPTID . Due to The secondary lesions that occurred, in this case, developed right below the burr hole site along the stereotactic trajectory tract with no evidence of residual tumor at the pineal region on MR imaging. We suspect this was the cause of the implantation metastasis. To our knowledge, this is the first report of PPTID with implantation metastases along the trajectory tract following the biopsy procedure of the pineal region. There were only two previously reported cases of implantation metastases along the trajectory tract but were associated with pineal germinoma and pineoblastoma , 14. HawThe pineal parenchymal tumor of intermediate differentiation is a rare central nervous system tumor (<1%) that arises from the pineal parenchyma. The spectrum is between pineocytoma (grade I) and pineoblastoma (grade IV). Due to its rarity and heterogenous behavior, there is still no consensus regarding the optimum treatment. The systematic review by Mallick et al.  reportedAlthough it is rare, the potential occurrence of implantation metastasis following the stereotactic biopsy of PPTID should be considered in the treatment plans and follow-up. Considering the area and doses of radiation on PPTID, particularly on the biopsy track, may be advantageous, but additional research is required.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article. The board of the Siloam Dhirga Surya Hospital's Ethics Committee  evaluated and approved this work (No. 0625/SHMD/DIR/SB/V/2022).ST and AS: conception, design, and reviewed submitted version of manuscript. ST, Julijamnasi, MS, AS, and RI: acquisition of data. ST, Julijamnasi, MS, and AS: analysis and interpretation of data. ST and ML: drafting the article. JJ and IJ: critically revising the article. ST: approved the final version of the manuscript on behalf of all authors.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Tenosynovial giant cell tumours (TSGCTs) usually arise from the synovial membranes of tendon sheaths, bursa, and joints. They are rarely found in the spine. Lesions of the upper cervical spine (C1/2) are extremely rare, with only 13 previous cases reported in the literature. Of these, all previous anterior upper cervical cases (C1/2) have been deemed unresectable and have been managed with immunotherapy or radiological surveillance.We report two cases of TSGCST in the cervical spine: one with a lesion at C1/2 and another at C6/7.The location of our C1/2 lesion was unique, allowing for a new endoscopic endonasal tissue biopsy method and a new transoral surgical approach for successful gross total resection. Our C6/7 lesion had a more typical location and was removed via a C6/7 laminectomy. Tenosynovial giant cell tumours (TSGCTs) are benign but locally aggressive primary fibrohistiocytic tumours that usually arise from the synovial membranes of tendon sheaths, bursa and joints , 2. TheyA 48-year-old woman presented with a 3-year history of persistent right sided neck pain. This was associated with reduced neck and jaw range of motion and mild proximal bilateral upper limb weakness. Given her recent diagnosis of cervical cancer, she underwent a positron emission tomography (PET)/computed tomography (CT) scan to exclude metastases. PET scan showed moderate to intense fluorodeoxyglucose (FDG) uptake in the upper cervical spine between the clivus and the anterior arch of C1. See Fig. Diagnostic CT reported a 15 x 12 mm focal nodular soft tissue thickening between the superior margin of the anterior arch of C1 and the clivus, with extension posteriorly around the right lateral side of the odontoid peg. There was also some minor bony spurring along the superior margin of the anterior C1 articular facet but no bony destruction. See Fig. The differential diagnosis at this point included joint-based pathology such as crystal deposition disease, metastatic cervical cancer, and a primary soft tissue tumor.Repeated magnetic resonance imaging (MRI) showed a stable 16 x 10 mm uniformly enhancing mass on the superior surface of the anterior arch of C1, abutting the tip of the odontoid peg. There were no bony erosive changes to the odontoid peg, and it did not invade the prevertebral muscles at C1. The lesion was bound anteriorly by the anterior longitudinal ligament and posteriorly by the tectorial membrane. There was no compression of the spinal cord or central canal stenosis. The lesion was isointense on T1, hypotense on T2 and did not demonstrate any diffusion restriction. See Fig. Given its location, the lesion was biopsied surgically via a stereotactic endoscopic endonasal approach with otorhinolaryngologist support. After an inferiorly based flap was made in the nasopharynx, stereotaxis was used to identify the basion and the upper border of the C1 arch. The lesion was found in the space between the basion and the C1 arch and biopsied. It was hard, fibrous and had ill-defined margins.Histology of the biopsy demonstrated a low grade fibrohistiocytic tumour and favoured the diagnosis of tenosynovial giant cell tumour. The specimen was of fibrotendinous connective tissue, with proliferation of mononuclear epithelioid to spindled cells within the fibrotic stroma. There was mild nuclear pleomorphism of these mononuclear cells. Giant cells were also seen. Both cells were positive for CD 68.Given the histological diagnosis, the patient underwent a gross total resection of the lesion. See Fig. Post operatively, the patient reported instant relief of her neck pain and much improved neck and jaw range of movement. Patient also reported resolution of her proximal upper limb weakness, improved posture, and a more linear gait.Histology of the gross resection was in keeping with a localized tenosynovial giant cell tumour, with mononuclear cells positive for CD68 and factor XIIIa. The 25 × 25 × 6 mm circumscribed fibrohistiocytic lesion was surrounded by a fibrous pseudo-capsule and divided into lobules by fine septa. It was morphologically heterogenous, moderately cellular and contained abundant mononuclear cells, multi-multinucleated giant cells and foamy macrophages. There was focal haemosiderin deposition, rare inflammatory cells, and no crystal deposition. Tests for AE1/AE3, S100, p63, CD1a and BRAF V600E were all negative. See Fig. Follow-up of the patient at 6 months showed complete resolution of symptoms. MRI of the cervical spine immediately post op and at 6 months excluded any residual or recurrence.A 48-year-old woman presented with an 11-month history of severe right sided headaches and an associated ‘heavy head’ sensation. She also reported neck pain with radiation into her right upper limb as well as severe vertigo. She had no change in limb power or sensation. Her symptoms progressed over 11 months and were transiently exacerbated each month during her menstrual cycle.She underwent an MRI of her brain and cervical spine to investigate the cause of her headache. MRI demonstrated a 19 mm intermediate T1/2 signal area in the left posterior perivertebral tissues between the C6 and C7 lamina, with extension to the margin of the left facet joint. It slightly expanded the left C6-7 facet and scalloped the left lamina of C7 without bone signal abnormality. The lesion was thought to be an incidental bone lesion rather than the cause of her symptoms and a CT scan was suggested to assess bone detail. See Fig. Subsequent CT cervical spine excluded a bony lesion and advised of a soft tissue density focus (20x5x16mm). There was bony remodeling of the superior aspect of the left C7 articular column as well as an absence of cortical bone and the presence of a well-defined defect from the inferior aspect of the left C6 articular column. See Fig. Differential diagnoses at this point included a neuroma or schwannoma from a branch of the C7 dorsal root ganglion or a facet cyst with complex fluid content.As the etiology was unclear at this point, the patient was referred for a CT guided core biopsy for further investigation. Histology of the core biopsy advised of a fibrohistiocytic tumour with a likely diagnosis of tenosynovial giant cell tumour. There was hypercellular proliferation of histiocytic cells and lobules of foamy macrophages associated with a fibrotic stroma. Mononuclear cells, focal multinucleate giant cells, foamy macrophages and siderophages were present. Majority of these cells were positive for CD68, with some occasional cells also showing p63 positivity.Given the severity of the patient’s symptoms, she underwent a left sided C6/7 laminectomy and resection of the lesion. Intraoperatively, a discrete vascular lipomatous tumour with capsular delineation was found. It arose between the C6/7 lamina and followed the left C7 nerve into the foramen. The tumour was removed en bloc from the scalloped C7 lamina after undercutting of the C6 overlapping laminar. Small islands of tumour were also seen on dura and removed. The proximal facet joint was opened and debrided. Bone around the lamina margins was debrided by 3 mm. There were no complications. See Fig. Histology of the gross resection demonstrated a diffuse type tenosynovial giant cell tumour. The lesion was described as an expansile nodular tumour with focal infiltration of fat and skeletal muscle. The tumour was hypercellular and composed of mononuclear cells, larger epithelioid cells, scatted osteoclast-like giant cells and sheets of foam cells with stromal hemosiderin deposition. See Fig. Cytogenetic analysis showed recurrent nonrandom translocation between the short arm of chromosome 1 and the long arm of chromosome 2 [t ]. This fused CSF1 (1p13) to COL6A3, which was consistent with the diagnosis of TSGCT.The patient’s symptoms significantly improved post operatively and were resolved within 6 weeks. Post operative MRI at 4 months excluded any residual or recurrent tumour.The current literature regarding cervical TSGCTs, particularly those of the upper cervical spine, is limited. We discuss the unique location, new tissue biopsy method and surgical approach of our upper cervical lesion compared to our lower cervical lesion as well as the gold standard for investigation and management to improve understanding, diagnosis, and management of future cases.TSGCTs usually arise from the synovium of tendon sheaths, bursa, or joints . Large lOut of the 13 previously known cases of upper cervical spine (C1/2), only Koontz, Quigley  and FinnIn Finn, McCall , the lesThe investigation of cervical lesions begins with radiological imaging in the form of x-ray, CT, and MRI. X-rays can show erosive bone changes, destruction of the posterior elements of the vertebral body and occasionally a definable soft tissue mass. CT generally shows a hyperdense homogenously enhancing soft tissue mass with expansile osteolytic bone destruction and incomplete or thinning of cortical bone , 3, 12. Imaging often lacks specific features for diagnosis . There iIn general, gross total resection is recommended for TSGCTs due to their locally aggressive nature and the considerable risk for recurrence 20%) , 5–7. In0% , 5–7.Both of our cases presented with typical symptoms of neck and radicular pain. Initial investigation of both cases was like previously documented cases, with CT and MRI imaging.The uniqueness of our first case was the lesion’s anatomical location, our tissue biopsy method, and our surgical approach. Like the cases in Koontz, Quigley  and FinnThe initial biopsy of our lesion occurred by a stereotactic endoscopic endonasal approach (EEA), rather than a CT guided biopsy. EEA is a minimally invasive technique that was first introduced by Kassam, Snyderman  in 2005 For gross total resection of the lesion, we used a stereotactic transoral approach due to the lesion’s size (16 × 10 mm). The transoral approach is extensively described for pathologies of the anterior craniocervical junction . HoweverOur first case is juxtaposed with the more typical location of our second case (C6/7), where the lesion was in the left posterior perivertebral tissues between the C6 and C7 lamina. This more typical location allowed for a CT guided needle biopsy to be performed, followed by gross resection via a C6/7 laminectomy.TSGCTs are rare primary spinal tumours. They are often not considered as a differential diagnosis for soft tissues masses in the spine. Misdiagnosis is common and can have serious implications due to its locally aggressive nature and potential to cause joint instability and neurological deficits . The uniWe present two cases to hopefully improve knowledge of TSGCTs, to suggest more frequent inclusion of TSGCT as a differential diagnosis and to highlight our unique approach for biopsy and resection of anterior upper cervical lesions.CARE CHECKLIST


This paper presents a case report of a 10-year-old child patient reported with the chief complaint of a painless, hard swelling in the lower right back region of the jaw. The clinical and radiographic examination, including intraoral periapical radiograph (IOPA) and cone-beam CT (CBCT), was performed. Conservative treatment was planned based on the clinical and radiological diagnosis of the cyst. But the histological examination revealed unicystic ameloblastoma (UA). This clinical case of UA, which was misdiagnosed as a combination of a radicular cyst and a dentigerous cyst, is being presented to highlight the importance of histopathologic investigation of all tissue specimens retrieved after surgery, particularly when the clinical and radiological findings are insignificant. Odontogenic and non-odontogenic tumors of the maxillofacial skeleton can be malignant or benign. Ameloblastoma is considered to be the most common of all tumors of odontogenic origin . AmeloblA 10-year-old boy was reported to the Department of Pediatric and Preventive Dentistry with the chief complaint of a hard swelling that was painless and present for one month in the lower right back area of the jaw. There was no accompanying fever. On palpation, a well-defined firm external swelling was seen on the mandibular lower body, which was hard in consistency. The overlying skin of the swelling was of standard color, consistency, and temperature. The intraoral examination showed a hard, firm swelling extending from the first primary molar to the second primary molar along the buccal vestibule. The bone margins were blended imperceptibly into the surrounding bone  was deeply carious near the swelling area. Proximal caries were also seen with the second primary molar  scan was suggested to the patient. The complete extent of this lesion was seen on CT scans, which also demonstrated no extension into the soft tissue around it. The scan showed an expansile lesion with dimensions 17.2 mm × 14.8 mm × 14.0 mm, which caused the buccal and lingual cortical plates to expand Figure , 3B, 3C.The intraoral periapical (IOPA) radiograph revealed an extended radiolucent periapical lesion from the distal root of 83 to the mesial root of 85 Figure . Pulpal Fine needle aspiration cytology (FNAC) revealed fluid with a pale straw color. There was the possibility of a cyst, and marsupialization was planned. Treatment was scheduled under local anesthesia (LA) because the patient was cooperative.TreatmentThe clinical and radiographic examination showed a possibility of the following differential diagnosis: 1) radicular cysts, 2) dentigerous cysts, and 3) odontogenic keratocysts. The suggested treatment for a dentigerous or radicular cyst in a child is marsupialization, which preserves the permanent tooth and allows it to erupt. A conservative treatment was intended to save the premolar tooth bud. Before the extraction, the impression was taken for fabricating an acrylic splint Figure .After the administration of LA, the extraction of 84 was done, followed by marsupialization. The region was irrigated with a saline and betadine solution. A betadine-soaked pack was placed inside the cavity for three days Figure , 6B, 6C.The excised tissue samples were sent in two different bottles for histopathological analysis. The first bottle contained the extracted tooth (84), and the second bottle contained the soft tissue lining of the lesion Figure .Histopathological analysis of the lesional tissue reveals a connective tissue wall made of fibrocellular connective tissue, a cystic space lined by odontogenic epithelium with hyperchromatic nuclei, and suprabasal cells that resemble stellate reticulum-like cells Figure . The imaAfter three days, the patient was recalled, the betadine dressing was removed, and an acrylic splint was given Figure . This acAccess opening was done with 85, followed by metrogyl irrigation, as there were deep proximal caries and lesions, including a mesial root of 85, which was partially resorbed. Rather than extraction, tooth 85 was preserved to help guide the eruption of the permanent second premolar, i.e., 45. Three months later, it was found that the underlying permanent mandibular premolar 44 partially erupted into the position they usually occupy in the oral cavity, and healing was seen in the cystic lesion space. Therefore, the splint was removed. Slightly expanded buccal cortical bone was seen Figure . Pulpectunicystic ameloblastoma in 1977 [Robinson and Martinez first used the term  in 1977 . UA is a in 1977 ,8. Amelo in 1977 . The mar in 1977 . As UAs  in 1977 . Accordi in 1977 . Althoug in 1977 . A recur in 1977 . For UA  in 1977 ,14. In s in 1977 . On the Based on the clinical and radiological diagnoses of the cyst, in this case, conservative treatment options, such as marsupialization rather than enucleation, are being considered to preserve the tooth bud of the premolar and enable tooth eruption. However, to rule out potential ameloblastomatous alterations, we conclude that the surgical protocol must include the postoperative histopathologic assessment for all lesions, adequate monitoring of the patient, and addressing of any recurrences.


Although small bowel cancer is rare, cases of carcinoma arising from the abdominal wall have not been reported. We report a case of a tumor arising from a stoma scar site, following ileostomy closure that was performed 60 years earlier. The tumor was resected for both therapeutic and diagnostic purposes and was found to be a primary cancer of the small intestine. The small intestinal mucosa survived long-term at the stoma scar site and developed carcinoma. No similar reports of small bowel cancer arising from the mucosa at the stoma scar site  exist. After tumor resection, the patient received chemotherapy for lung metastases and has survived, thus far, for 2 years since the surgery. Small bowel cancer is one of the rarest primary tumors of the intestinal tract. Small bowel cancer occurs in the small intestine of the abdominal cavity and, in some cases, in the ileostomy of patients after colorectal resection for inflammatory bowel disease (IBD).The liver is the most common metastatic site for small bowel cancer, followed by the peritoneum and distant lymph nodes . ColorecWe encountered a case of small bowel cancer arising from the abdominal wall at an ileostomy scar site >60 years after ileostomy closure. We consider this an extremely rare case of small bowel cancer arising from the abdominal wall.A 73-year-old man presented to our hospital with the chief complaint of a mass in the abdominal wall. The mass was reddish-brown, firm, hemorrhagic and protruded from the stoma scar with multiple nodules . He undeContrast-enhanced computed tomography revealed a giant irregular mass (45 × 35 mm) in the abdominal wall . No othePositron emission tomography revealed abnormal accumulation of a mass in the left abdominal wall  and slight accumulation of a mass in the S10 (SUVmax 5.7) and S1/2 (SUVmax 5.5) regions , but no Since the tumor was causing pain, and the bleeding from the tumor interfered with the patient’s activities of daily living, we decided to resect the tumor. The tumor was resected under general anesthesia. A defect in the rectus abdominis muscle of the abdominal wall was repaired using mesh. The pathological findings of the resected tumor were similar to those of the previously described mass and to the lung biopsy specimens, and the tumor was confirmed to be an adenocarcinoma of intestinal origin. Since no primary tumor was present in the intestinal tract, the tumor was thought to have originated from the small intestinal tissue remaining in the ileostomy scar, which then metastasized to the lungs.The patient underwent postoperative chemotherapy and is still alive 2 years after surgery.The diagnosis of malignant tumors arising in the abdominal wall includes primary soft tissue tumors of the abdominal wall and abdominal wall metastasis of cancer from other organs.et al. [In the present case, the tumor on the patient’s abdominal wall was a lesion continuous from the deep to superficial layers of the abdominal wall. Based on immunostaining results, we diagnosed the patient with intestinal-type adenocarcinoma. Hiramatsu et al.  stated tet al. [et al. [Reports of carcinogenesis from ileostomies exist; however, in many cases, IBD is a background disease. Metzger et al.  suggeste [et al.  describeTo the best of our knowledge, no reports of small bowel carcinogenesis from ileostomy scars exist. In addition, it is unclear why the small intestinal mucosa could survive for such a long period at the ileostomy scar site. To investigate the reasons, we focused on the wound-healing process during stoma closure surgery. Skin wounds heal through processes such as inflammation, granulation tissue formation, angiogenesis, re-epithelialization and remodeling. These processes are regulated by interactions between different cell types  that migrate to the wound site. These interactions are also mediated by intrinsic factors (such as cytokines) that are secreted by these cells . We beliIn conclusion, this is the first case of small bowel cancer arising from the abdominal wall. Therefore, when a tumor growing on the abdominal wall in the ileostomy scar area is detected, the possibility of small bowel cancer should be kept in mind during examination.


Computer tomography colonography (CTC) is an increasingly utilized diagnostic modality in Australia. CTC aims to image the entire colon, and is often used in higher risk patient populations. Colonic perforation following CTC is a rare complication, with only 0.008% of patients undergoing CTC requiring surgical intervention. Most published cases of perforation following CTC are due to identifiable causes, often involving the left colon or rectum. We present a rare case of caecal perforation following CTC, requiring right hemicolectomy. This report highlights the need for high suspicion for CTC complications, despite their rarity, and the utility of diagnostic laparoscopy for diagnosis in atypical presentations. Computer tomography colonography (CTC) is an increasingly accessible diagnostic modality used often in a higher risk patient population. CTC is performed by inflating the colon with carbon dioxide after the insertion of a flexible rectal catheter. Similar to traditional colonoscopy, it is essential that patients have a bowel-prepped colon. After gas insufflation, CTC uses computer tomography to create a 3D image of the colon to aid in the detection of colonic polyps . CompareAn 85-year-old female was referred from a peripheral hospital with large volume pneumoperitoneum detected during CTC . CTC wasCTC is indicated for colonic screening, and is commonly performed due to incomplete or failed colonoscopy. In the event of neoplastic lesions which preclude caecal intubation with colonoscopy, CTC can be used for excluding synchronous lesions in the remaining colon . CTC is A multicentre analysis from Victoria, Australia examining 3458 patients who underwent CTC over a 5-year period demonstrated a perforation rate of 0.06% (two cases) [Perforation from CTC is a rare complication, seldom requiring surgical intervention, with low morbidity likely due to rapid diagnosis in patients with a bowel-prepped colon. This report highlights the need for high suspicion for CTC complications, despite their rarity, and the utility of diagnostic laparoscopy for diagnosis in atypical presentations.None declared.None.


Strokes involving specific areas regulating cognition and behavioral functions constitute strategic infarct vascular dementia. We present three patients with acute behavioral changes and cognitive impairment following a strategic infarct. Case 1 is of a 59-year-old male, a known patient of diabetes mellitus under treatment, who presented with acute onset of memory deficit along with difficulty in recognizing faces, and left hemispatial neglect. Case 2 is of a 62-year-old male, a smoker, who presented with acute onset of behavioral abnormalities, gait apraxia, and decreased word output. Case 3 is of a 64-year-old female, a known patient of type 2 diabetes mellitus and cerebrovascular accident with left hemiparesis, who presented with psychomotor withdrawal, depression, and cautious gait. One of the most prevalent forms of dementia in adults is vascular dementia, often caused by multiple small strokes, termed multi-infarct dementia. Strategic infarct dementia, on the other hand, is usually caused by a small, single cerebral infarct. The strategic brain regions specifically involved in post-stroke cognitive impairment requires detailed clinical examination along with radiological imaging for accurate localization. Thus the cognitive impact of ischemic strokes can be understood and predicted by clinicians with the help of maps of strategic brain regions associated with global and domain-specific cognitive functions. Strategic infarct (SI) stroke involves specific areas of the brain critical for cognition and behavior  following an ischemic vascular lesion . The mosPatients can present with varying degrees and types of impairment in the different cognitive domains depending on the severity, extent, and location of the lesion. The paramedian nuclei of the thalamus, when involved, can cause impairment in both anterograde and retrograde memory, along with inattention and amotivation . SimilarCase 1A 59-year-old right-handed male, working as a sales executive, presented with acute onset of memory deficit of one-month duration. The patient had a medical history of diabetes mellitus and was under treatment. He found it difficult to learn new things and had problems recollecting recent events. Some events he could recollect with cueing and some of them he couldn’t recollect even with cueing. Memory loss was more for recent events than past events.He would often get confused in the middle of a discussion, partly because of memory loss and partly because of word-finding difficulty. He would make mistakes in calculations as in handling money. He also had difficulty identifying familiar places, recognizing known faces, and finding the way back to his home. Left hemispatial neglect was also present. He also found it difficult to locate the sleeve of his shirt, and in buttoning his shirt. On medical evaluation, laboratory test results were within the normal range . T1W magnetic resonance imaging (MRI) of the brain showed an ischemic lesion affecting the right parieto-occipital region with hemorrhagic transformation  examination appeared withdrawn, with decreased word output, with no signs of focal deficits, and the fundus showed no papilledema. He was suspected to be a case of SI and computed tomography (CT) scan of the brain showed a focal ischemic lesion involving the left medial occipital area with bilateral periventricular lucency Figure . FollowiCase 3A 64-year-old right-handed female, with a history of type 2 diabetes mellitus and CVA with left hemiparesis, presented with psychomotor withdrawal for the past two months. The patient became less active, took an abnormally long time to answer questions, and spoke with a minimal number of words; speech appeared telegraphic. She was reported to take abnormally more time for day-to-day activities like brushing her teeth and taking bath. She also appeared less interested in her surroundings and withdrawn. It appeared that the warmth of interpersonal relationships was lost and she appeared less interested in the emotional well-being of others.At times she appeared sad and wouldn’t indulge in pleasurable activities. She appeared depressed and with a cautious gait. On examination, higher mental functions seemed affected; she appeared less communicative and depressed. The fundus was not properly visualized. There was no obvious limb weakness but she had a cautious gait. T2W MRI brain showed bilateral basal ganglia infarct, with the involvement of the caudate nucleus, lentiform nucleus, putamen (right), and globus pallidus Figure . She wasOne of the most prevalent forms of dementia in adults is vascular dementia, only second to Alzheimer’s disease, and often caused by multiple small strokes or MID . On the In Case 1, the patient had a lesion of the right parieto-occipital region and presented with left hemispatial neglect due to the involvement of the dorsal stream. He also had an inability to recognize familiar places, faces, and objects due to the involvement of the ventral stream. Parietal areas involved in processing motion and spatial relationships constitute the “dorsal stream,” which receives inputs from distributed networks responsible for visuospatial processing. Hemispatial neglect is manifested by patients having lesions in the right parietal region and the associated networks. Inferior temporal areas involved in processing visual features of a face or an object constitute the “ventral stream” and receive inputs from networks associated with higher-order visual processing .In Case 3, the patient presented with emotional blunting, psychomotor withdrawal, decreased word output, and telegraphic speech. She also seemed to be severely depressed. She had a lesion involving the basal ganglia and the thalamus. She might also have involvement of the medial frontal lobe, which presents as psychomotor withdrawal mimicking features of severe depression . The limIn Case 2, the patient presented with acute onset of behavioral abnormalities consisting of disorientation, confusion, and agitation. He also had gait apraxia and anterograde amnesia with confabulation. His CT scan revealed a lesion of the left medial occipital area. The symptoms with which the patient presented were indicative of a left posterior cerebral artery (PCA) infarct. The PCA supplies the occipital lobe, inferior part of the temporal lobe, thalamus, midbrain, and posterior limb of the internal capsule. The involvement of the thalamus, hippocampus, and parahippocampus explains his memory loss and confabulation. Patients with PCA stroke can have aggressive behavior as well. They may become anxious, frustrated, and aggressive when they are stimulated by the environment .The ascending reticular activating system arising from the rostral brainstem and projecting to both the thalami and the cerebral hemispheres is associated with arousal. A lesion involving the hemispheres or the rostral brainstem can cause an alteration in arousal and thus the patient can present with altered sensorium, ranging from drowsiness to a vegetative state and coma. The frontal lobe has a major role in attention, which can be assessed by the patient’s ability to avoid distractions and answer directed questions . The dorBroca area in the inferior frontal lobe, arcuate fasciculus, and the Wernicke area in the superior temporal gyrus receive auditory and visual inputs, constituting the language networks in the brain . In the Memory is broadly classified into declarative (episodic memory and recognition memory) and non-declarative  . The PapVarious studies have shown the association between the infarct location and the specific cognitive deficit it produces ,3. SeverOur case findings shed light on the strategic brain regions involved in SI that can cause deficits in specific cognitive domains as a result of focal hemorrhage involving the respective region of the brain. Clinicians can predict or understand why a global or domain-specific cognitive deficit occurs following an ischemic lesion of a strategic brain area. Detailed neurophysiological testing and larger sample size can help substantiate the findings of these cases and to develop a model of location-specific infarct and the corresponding cognitive impairment.


T2 weighted imaging showed low signal intensity of the solid tissue in all cases and low diffusion-weighted imaging signal of the solid tissue in high b-value diffusion-weighted imaging in three patients. Contrast enhancement was avid with extension from the periphery in all patients. Knowledge of these distinct radiological features of sclerosing stromal tumor is important, as in the Ovarian-Adnexal Reporting and Data System risk classification system this may be scored as Ovarian-Adnexal Reporting and Data System 5. Because of its non-aggressive clinical course, pre-operative imaging assists to avoid unnecessary extensive surgery and to preserve the patient’s fertility by only resecting the tumor and preserving the ovary. Sclerosing stromal tumor of the ovary presents pathognomonic features in MRI that allow a specific pre-operative diagnosis and selecting candidates for fertility-sparing surgery.Sclerosing stromal tumor of the ovary is a rare benign sex-cord stromal tumor that affects primarily young females. In a series of six patients  findings of six MRIs and one CT were analyzed. Unilateral tumors ranging from 6 to 8 cm were found in all patients. The tumors were well encapsulated and polylobulated. The morphology was mixed solid and cystic in three and solid in three patients. In CT, a hypervascular tumor with centripetal enhancement was seen. In MRI  It accounts for less than 5% of all ovarian sex-cord stromal tumors and was first described by Chalvarijan and Scully in 1973. Patients usually present with menstrual irregularities and/or abdominal pain. Ascites is only found in a minority of cases. It has distinct radiological features and a non-aggressive clinical course. No malignant forms have been reported in the literature so far and surgical resection is the treatment of choice.Sclerosing stromal tumor is a rare benign sex-cord stromal tumor of the ovary that affects primarily young females under the age of 30.Ultrasound findings are usually non-specific and may overlap with those of malignant ovarian tumors, therefore further imaging evaluation with CT or MRI is usually required. and only a few published articles focus on its imaging findings, particularly on CT and MRI correlation.Most published literature on sclerosing stromal tumors of the ovary focuses mainly on the histological and immunohistochemical features of this tumor entity,Furthermore, to our knowledge our series of six cases is among the largest series described in the literature.−1) and no signs of inflammation were present at admission. Tumor markers were also negative .A 21-year-old female nullipara patient was referred to our hospital in Salzburg by her gynecologist for an incidentally detected adnexal mass on a routine examination. The patient denied any abdominal pain or menstrual irregularities. Transvaginal ultrasound depicted an adnexal mass arising from the right ovary, with mixed solid and cystic components, measuring 5,5 × 4,6 cm. Free fluid was seen in the Douglas cul-de-sac. β-HCG was negative (<1 U l−1) . Follicle-stimulating hormone, Luteinizing hormone, prolactin, progesterone and estradiol E2 were within normal ranges.Hormone tests were also performed, and a slight increase in testosterone was detected  showed a heterogenous hypointense solid tumor with a hyperintense central region and a hypointense capsule. No intralesional hemorrhage or areas of restricted diffusion were found. After intravenous contrast injection, the lesion showed early and avid peripheral contrast enhancement with centripetal progression on the following sequences. Time–intensity curve demonstrated enhancement higher than myometrium  and had a unilateral tumor ranging between 6 and 8 cm in size .Three tumors originated from the left ovary and the others from the right ovary .T1- and T2 weighted sequences in multiple planes as well as T1 weighted sequences with fat-suppression after intravenous contrast injection. In three cases, diffusion-weighted imaging (DWI) was also performed.MRI protocol included In all cases, tumors were polylobulated, had a well-defined capsule and showed avid contrast enhancement. Three of these tumors were mixed solid-cystic and three tumors were purely solid. Only in one case , pathological amount of free fluid was seen in the Douglas cul-de-sacT2 weighted images and the avid enhancement of contrast  are uncommonly encountered in this age. Patients usually present with menstrual irregularities Thus, further imaging evaluation, preferably with MRI, is warranted to pre-operatively correctly diagnose this benign tumor entity that has pathognomonic imaging features.Due to their solid or solid-cystic morphology, ultrasonographic findings may mimic a malignant ovarian tumor.In the literature, only about 200 cases have been described so far. with only a few of them focusing on the imaging features of this tumor entity.To our knowledge, our series of six cases is one of the largest series described so far,T2WI hypointense solid parts, a thin capsule and early avid contrast enhancement extending from the periphery to the center , inhomogeneous e center . This ceb-values, due to its benign stromal nature. In other case-reports that included DWI, no areas of restriction were also found. According to the recently published O-RADS MRI risk classification system, Class 2 lesions (likely benign) also include solid tumors with unique features of low SI on T2WI and on DWI, frequently related to ovarian fibromas and thecomas. Sclerosing stromal tumors do not classify as O-RADS 2 lesions as they demonstrate inhomogeneous hypointense signal on T2WI. Furthermore, due to their contrast enhancement (higher than that of the myometrium) they have to be classified as O-RADS 5, which is associated with a high risk of malignancy . However, in addition to assigning a score predictive for malignancy, O-RADS acknowledges that the final diagnosis may be suggested in cases of classical imaging findings . We consider that sclerosing stromal tumors could be included in this list.Our series also includes the DWI findings in three cases, with low signal intensity (SI) on high Because this is a benign tumor with a non-aggressive clinical course, the primary aim of pre-operative imaging is to avoid unnecessary extensive surgery and to preserve the patient’s fertility by only resecting the tumor and preserving the ovary. .This tumor is usually unilateral, a heterogenous solid tumor with septa and cystic areas (“spoke-wheel pattern”), inhomogeneous Because of its benign nature, preoperative diagnosis with CT or MRI is pivotal to avoid extensive surgery and preserve patient’s fertility.


Acute appendicitis classically elicits right-sided abdominal pain. Abdominal pain in patients with situs inversus may create a diagnostic challenge. We share a case of a seven-year-old boy who presented to the emergency department with left lower quadrant abdominal pain and tenderness. A chest x-ray showed dextrocardia and an abdominal ultrasound confirmed left-sided appendicitis. Diagnostic laparoscopy and appendectomy were uneventful. Thorough peri-operative evaluation and planning are key to a successful outcome in this rare condition Appendicitis is a common surgical emergency, and one of the most common causes of acute abdominal pain. Reported incidence rate is 4-8% -3. The cThe rarity of left side acute appendicitis may lead to misdiagnosis. Left lower quadrant pain could be attributed to any of many differential diagnoses -4. Some A seven-year-old boy, known to have Kartagener syndrome, presented to the ED with complaints of left lower abdominal pain and vomiting for one day. He had no fever, change in bowel habits, or urinary symptoms. On physical examination, tenderness was evident in the left iliac fossa with positive rebound tenderness. Lab data was significant for leukocytosis of 23,000 with neutrophilia. A chest x-ray showed dextrocardia Figure .An abdominal ultrasound (USG) revealed the liver in the left side of the abdomen and the spleen on the opposite side. A blind-ended mildly thickened-walled, distended tubular structure was seen at the left iliac/lumbar region, measuring about 7 mm at its mid-portion transverse diameter Figure , elicitiDiagnostic laparoscopy and appendectomy were performed. Operating room setup and trocars placement were modified in a “mirror image” of the standard laparoscopic appendectomy. Pneumoperitoneum was induced using the Veress needle technique, followed by the insertion of a 5 mm port at the umbilicus Figure . The telSitus inversus is a rare congenital anomaly ,3,7,8. DLeft-sided acute appendicitis can pose a diagnostic challenge and thus requires a high index of suspension. The correct diagnosis could be reached based on history taking, physical examination, imaging studies , and diagnostic laparoscopy ,7. AlthoLaparoscopic appendectomy is a safe and efficient approach for treating acute appendicitis. This technique has several advantages over open laparotomy. It has been associated with quicker recovery, less post-operative hospital stay, less psychological stress, and fewer postoperative complications ,10. LapaAcute appendicitis in patients with situs inversus can be challenging. High index of suspicion and thorough clinical evaluation are paramount. Diagnostic laparoscopy and appendectomy are recommended. Adjustment of operating room setup and trocars placement may facilitate surgery. Clinicians should be aware of rare anatomic variations and their implications.


The atypical parathyroid adenoma is a histological diagnosis. It is a parathyroid tumor with atypical histological features different from an adenoma and not similar enough to be considered as a carcinoma. It has an uncertain malignant potential. We report the case of a 55‐year‐old woman, diagnosed with severe hypercalcemia during her follow‐up with the rheumatologist for osteoporosis. The laboratory testing led to the detection of a very important level of parathormone PTH 1325.62 pg/ml , confirming the diagnosis of primary hyperparathyroidism. Investigations of the potential causes led to the presence of a large left inferior parathyroid adenoma. The patient was operated and on the examination of the removed tissue, the histopathological examination concluded to an atypical parathyroid adenoma, and the post‐operatory PTH level dropped significantly to 152 pg/ml. The atypical parathyroid adenoma is a very rare tumor, and the diagnosis is still a challenge, the outcome of patients is not well known yet, there for the surveillance is important and must be regularly. Parathyroid scan Sestamibi. It is an endocrine disorder, most often due to the presence of a parathyroid adenoma (80%–85%), sometimes to parathyroid hyperplasia (10%–15%) and less frequently to atypical parathyroid adenoma (APA) and parathyroid carcinoma (1.2%–1.3% and 1% respectively).22.1We report the case of a 55‐year‐old woman descended from a first degree consanguineous marriage, with a primary ovarian insufficiency at the age of 38 years old  treated by her rheumatologist for osteoporosis with vitamin D supplementation and bisphosphonate treatment. She was referred to us after discovering a severe hypercalcemia (Ca 3.68 mmol/L [2.2–2.6 mmol/L]). She was immediately hospitalized in our department.2.2The patient was dehydrated but with no signs of confusion. The cardiac assessment was normal; the blood pressure was at 120/80 mmHg, the electrocardiogram did not show an abnormal cardiac rhythm .2.3The biology confirmed the high level of calcium at 3.43 mmol/L, associated to a low level of phosphorus at 0.53 mmol/L [0.74–1.50 mmol/L], a low level of 25‐hydroxyvitamin D at 12.5 ng/ml [30‐50 ng/ml], a normal albumin level at 43 g/L, and a very important level of parathormone PTH 1325.62 pg/ml [10‐55 pg/ml] , confirming the diagnosis of primary hyperparathyroidism. The renal assessment was also normal , except for an hypercalciuria at 6.44 mmol/L/24 h .The cervical ultrasound revealed a left hyperechoic, heterogeneous parathyroid mass, measuring 2.05 × 3.97 × 3.18 cm in diameter with a normal thyroid gland, and the Technetium 99 SESTAMIBI‐Scintigraphy showed a large left inferior parathyroid adenoma  which was at 420 UI/L [44–147 UI/L]  and the βHCG was in the upper limit of the normal range at 4.09 mUI/ml (<5 mUI/ml).2.4Before referring the patient to surgery, she received an intravenous bipohosphonate therapy (Zoledronic acid) to control the hypercalcemia, and vitamin supplementation to prevent the hungry bone syndrome, then she underwent a surgery under general anesthesia with kocher's incision. The surgeons found a voluminous lower left parathyroid nodule very adhering to the thyroid gland, muscles and esophagus. They did a parathyroidectomy with left monobloc loboisthmectomy.The extemporaneous examination was in favor of a parathyroid adenoma and healthy thyroid lobe.On the examination of the removed tissue, we received a loboisthmectomy piece measuring 3 × 2 × 0.5 cm and joined and occupied almost entirely by a parathyroid nodule of 5 × 3.2 × 2.5 cm with poorly defined and friable contours. Microscopic examination shows proliferation of small monomorphic cells, non‐atypical and non‐mitotic associated with a low contingent of eosinophilic cells. Cells are organized into tubular structures within a richly vascularized stroma. This proliferation is fragmented by wide bands of fibrosis associated with hemosiderin deposits. Focally, this proliferation is poorly limited adherent to the thyroid parenchyma and to the adipose tissue and the striated muscle. Absence of vascular embolism and tumor necrosis.These histological aspects are consistent with an atypical parathyroid adenoma of 5 × 3.2 × 2.5 cm.2.5After the surgery, there were no postoperative complications, and the level of calcium normalized to 2.25 mmol/L and the PTH level dropped significantly to 152 pg/ml. The patient consulted 2 months after, she was in good health and the biology showed a calcium level at 2.2 mmol/L, Phosphorus level at 1.19 mmol/L, ALP level at 220 UI/L, and PTH level at 100 pg/ml.3Parathyroid tumors are very rare and affect between 0.1% and 0.3% of the general population.It predominates in the female gender with a sex ratio 1.5:1. It usually occurs in the fourth decade (median age 44 years), one decade earlier than the benign parathyroid disease.The pathogenic mechanisms responsible for the APA are still unknown and only few studies tried to explain.The clinical profile is similar to that found in severe hypercalcemia. The symptoms include fatigue, asthenia, anxiety, neurocognitive decay, anorexia, constipation, nausea and vomiting, bone pain, nephrolithiasis, hypertension, and sometimes depression.Some signs are not habitual in benign hyperparathyroidism and there for should be taken seriously, such as dysphonia and dysphagia which are signs of local compression, also a palpable neck mass are not rare to find , usually they are more than 2.5 cm.More over the biology shows a severe hypercalcemia with a markedly elevated PTH level. Alkaline phosphatase (ALP) activity can be also superior to upper normal range, and the human chorionic gonadotropin (HCG) plasma level may also be elevated .As for the radiological exploration, neck ultrasound is the first line imaging, describing the mass; nature cystic or solid, measures and its anatomical contact with adjacent structures. Associated with Single‐photon emission computed tomography (SPECT/CT), they represent the recommended radiological examination for the localization the tumor pre‐operatively.As for the management of the tumor, surgery is the only treatment and it consists to a total resection of the lesion “en bloc resection.” Then, it is the role of the histopathological examination to confirm the diagnosis of the APA and to differentiate it from other differential diagnoses such as a benign typical parathyroid adenoma and the parathyroid carcinoma. According to the world health organization, the APA is defined as a parathyroid tumor that do not show locally advanced growth or metastases, but may show cell atypia, fibrotic tissue, trabecular growth, fibrotic capsular involvement, and increased mitotic rate.Sometimes, despite the histopathological examination of the tumor, the differentiation between an APA and a PC may remain difficult and only the surveillance can define the diagnosis. PC has shown a recurrence rate >50% that most occur 2–3 years after the surgery.4The atypical parathyroid adenoma is a very rare tumor that shares similarities with both typical adenoma and parathyroid carcinoma making the diagnosis challenging. Moreover, the outcome of patients is not well known yet; therefore, it must be considered as“a tumor of uncertain malignant potential” justifying a regularly careful and strict follow‐up.Chayma Besrour contributed to the bibliographic research and to the writing of the article. Imen Rojbi contributed to the layout of the references. Nadia Mchirgui participated in the care of the patient and the correction of the article. Karima Khiari and Ibtissem Ben Nacef participated in the correction of the article. All authors have read and approved the final version of the manuscript.None.The authors declare no competing interest.Written informed consent was obtained from the patient for the publication for this case report and the accompanying image.1GalaniA, MorandiR, DimkoM, et al. Atypical parathyroid adenoma: clinical and anatomical pathologic features. World J Surg Oncol. 2021;19:19. doi:10.1186/s12957-021-02123-7334726512CetaniF, MarcocciC, TorregrossaL, PardiE. Atypical parathyroid adenomas: challenging lesions in the differential diagnosis of endocrine tumors. Endocr Relat Cancer. 2019;26:R441‐R464. doi:10.1530/ERC-19-0135310857703SFEndocrino. Accessed March 1, 2021. http://www.sfendocrino.org/article/832/poly2016‐item‐266‐ndash‐ue‐8‐hypercalcemie4hCG (Human Chorionic Gonadotrophin)/Blood Sciences Test/Exeter Clinical Laboratory International. Accessed March 7, 2021. https://www.exeterlaboratory.com/test/hcg‐human‐chorionic‐gonadotrophin/5SaponaroF, CetaniF, RepaciA, et al. Clinical presentation and management of patients with primary hyperparathyroidism in Italy. J Endocrinol Invest. 2018;41:1339‐1348. doi:10.1007/s40618-018-0879-z296164196WilhelmSM, WangTS, RuanDT, et al. The American Association of Endocrine Surgeons Guidelines for definitive Management of Primary Hyperparathyroidism. JAMA Surg. 2016;151:959‐968. doi:10.1001/jamasurg.2016.2310275323687LavelyWC, GoetzeS, FriedmanKP, et al. Comparison of SPECT/CT, SPECT, and planar imaging with single‐ and dual‐phase (99m)Tc‐sestamibi parathyroid scintigraphy. J Nucl Med. 2007;48:1084‐1089. doi:10.2967/jnumed.107.040428175749838DeLellisRA, LloydRV, HeitzPU, EngC. Pathology and Genetics of Tumours of Endocrine Organs. IARC Press; 2004.9MarcocciC, CetaniF, RubinMR, SilverbergSJ, PincheraA, BilezikianJP. Parathyroid carcinoma. J Bone Miner Res. 2008;23:1869‐1880. doi:10.1359/jbmr.0810181901659510McCoyKL, SeethalaRR, ArmstrongMJ, et al. The clinical importance of parathyroid atypia: is long‐term surveillance necessary?Surgery. 2015;158:929‐935; discussion 935–936. doi:10.1016/j.surg.2015.06.02226210223


Adult survivors of childhood Wilms tumor are at an increased risk of secondary malignant neoplasms. The presence of a solitary kidney further complicates clinical management in this population. Herein, we present the case of a 37 year old female with a history of childhood Wilms tumor presenting with a secondary renal neoplasm. We highlight important clinical considerations for renal function preservation and present a finding of predisposition to kidney stone formation due to urinary stasis from distorted ureter architecture secondary to tumor mass effect. Adults with a history of childhood Wilms tumor (WT) and chemoradiation are at an increased risk of secondary malignant neoplasms –4. Termu2, and hemoglobin was 10.1g/dL. Laboratory workup was otherwise non-significant.A 37 year old female was referred to the urology clinic for evaluation of a renal mass in the setting of a left solitary kidney. Past medical history is significant for a right Wilms tumor (WT) status post nephrectomy at three years of age, followed by adjuvant chemotherapy and radiation for two years. The patient states the contralateral kidney was not included in her radiation. History regarding treatment and management of this patient’s childhood WT is otherwise limited by time and access to records. However, the patient was able to recall that routine monitoring revealed no signs of recurrence, radiotherapy associated complications (i.e.soft tissue dystrophy), or evidence of ureteral anomalies. Additional surgical history includes two remote cesarean sections. She initially presented with 2 weeks of abdominal pain and pressure, nausea, and constipation. Review of systems was negative for hematuria, vomiting, diarrhea, and constitutional symptoms such as fever, fatigue, night sweats, or weight loss. Physical exam revealed a palpable mass in the left upper abdomen but was otherwise soft and nontender. Creatinine (Cr) was 0.7mg/dL, eGFR=120mL/min/mA CT-abdomen revealed a 7.5 x 8.3 x 10.0cm heterogeneous solid mass of the left solitary kidney with compression on the renal hilum and resulting hydronephrosis Figure 12) without need for dialysis.Following tumor board consensus, a retroperitoneal percutaneous core needle biopsy of the mass was obtained. Biopsy pathology revealed an oncocytic neoplasm, indicating likely benign oncocytoma versus chromophobe renal cell carcinoma (RCC). Given unlikely improvement with neoadjuvant therapy, a complex open partial nephrectomy was planned. Nephrology was consulted to assist with perioperative management given the patient’s history of unilateral nephrectomy. Intraoperatively, after achieving adequate exposure, a bulldog clamp was placed across the renal artery and the kidney was surrounded by ice slush. Following ten minutes of cold ischemia, tumor enucleation began; however, the bulldog clamp did not appear to sufficiently control the patient’s renal arterial supply. It was decided to instead place a Satinsky clamp across the renal vein and artery, leading to a bloodless field. The enucleation was completed, and the collecting system was entered in several places which was oversewn with 4-0 vicryl sutures. Importantly, the kidney was surrounded by ice during the excision and reconstruction with a total clamp time of 120 minutes. Following clamp removal, a few venous bleeders were controlled with 5-0 monofilament suture. No significant arterial bleeding was visualized. Hemostatic materials were placed into the defect, and renorrhaphy was completed with sliding V-loc barbed sutures in standard fashion. Omentum from the transverse colon and stomach was harvested, pediculated off the left gastroepiploic artery, and tunneled into the left gutter to fill the defect. A 19Fr blake drain was placed in the left lower abdomen. A 16Fr foley catheter and ureteral stent were additionally placed. Prior to closure, retroperitoneal ultrasound revealed good renal blood flow. Total operation time was 270 minutes. Estimated blood loss was 500mL and no transfusion was required. On post-op day 3, the patient’s drain was removed and she was discharged home with a foley catheter and ureteral stent in place. The foley catheter was removed two-weeks post-discharge, and the stent was removed one-month postoperatively. Final pathology of the mass confirmed oncocytoma. Postoperative imaging revealed continued arching of the ureter in the absence of the mass Figure 2Short-term recovery was uncomplicated. Nine months after the surgery, she presented with nausea and left flank pain without fevers, chills, hematuria, or dysuria. Her Cr was increased to 1.4 mg/dL from 0.7 mg/dL. There was no leukocytosis and the urinalysis was benign. CT-abdomen revealed multiple left sided nonobstructing stones and a 5mm obstructing stone at the ureteropelvic junction (UPJ) with hydronephrosis Figure 3Renal masses in solitary kidneys are complex cases that require multidisciplinary care. As an absolute indication for nephron sparing interventions, the simultaneous optimization of renal function and oncologic control becomes crucial for maximizing patient outcomes , 6. In tWT, or nephroblastoma, is the most common renal malignancy in childhood . The patRenal masses in young adults (17-45 years old), have been demonstrated to be benign in up to 20% of cases , 12. How2 compared to 46.7mL/min/1.73m2 for patients not requiring such interventions  for the publication of any potentially identifiable images or data included in this article.BS and SJ conceived and designed the study. SJ, VM, and RN played a critical role in the patient’s care and decision making, as outlined in the case report. All authors contributed to the writing, editing, and revision of the manuscript. All authors approved of the submitted version.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


A papillary tumor of the pineal region (PTPR) is a rare tumor of neuroepithelial origin formed from specialized ependymocytes of the subcommissural organ located in the lining of the posterior commissure, not the pineal gland itself. Patients with this type of tumor generally present with nonspecific symptoms secondary to obstructive hydrocephalus such as headache and vision changes. The mean age of patient presentation is 31, with a slight predominance in females. This type of tumor has a high rate of recurrence (56%) following surgical resection. This case study describes the presentation of this uncommon tumor in a 61-year-old woman, including presentation, imaging, surgery, and pathology findings. A papillary tumor of the pineal region (PTPR) is a rare tumor of neuroepithelial origin formed from specialized ependymocytes of the subcommissural organ located in the lining of the posterior commissure, not the pineal gland itself . The meaThis case was previously presented as a poster presentation at the LSU Health Shreveport 2022 Radiology Research Symposium on September 2, 2022.Appropriate protocols were followed, and consent from the patient was obtained. This project was approved by the hospital's institutional review board. We present the case of a 61-year-old woman with confusion, difficulty walking, cognitive changes, and decreased daily activity. Imaging from a prior institution demonstrated a hyperdense, partially calcified mass in the pineal region extending into the posterior region of the third ventricle, associated with obstructive hydrocephalus. She underwent a frontal ventriculoperitoneal shunt placement and a subsequent suboccipital craniotomy for subtotal tumor resection. The pathology report described a hypercellular, focally calcified pineal tissue with some corpora arenacea noted. While the report noted no clear neoplasm, a pineocytoma could not be ruled out and clinical follow-up was recommended.The postoperative MRI of the brain demonstrated a small amount of hemorrhage and a 15 mm residual pineal region tumor. One year postop, our patient had a follow-up contrast-enhanced MRI brain. She had no new relevant symptoms other than headaches, which she described as ‘head pressure’ with accompanying dizziness and nausea several times per week. Physical exam demonstrated nystagmus when looking up. Imaging revealed enlargement of a heterogeneously enhancing, hypercellular mass (2.4 x 2.4 x 2.1 cm) in the pineal region with associated calcification and hemorrhage , well-circumscribed masses that sometimes have cystic features [Though this patient’s imaging studies followed the known presentation pattern of PTPRs, additional pathology studies were necessary to rule out various other types of more common central nervous system (CNS) tumors that occur in the pineal region. It is important to note that even within these further studies, there can be an overlap between PTPR and other types of lesions. For example, tumors such as pineal parenchymal tumors of intermediate differentiation and ependymomas can look extremely similar to PTPRs histologically . StudiesThe mass from this patient underwent additional testing to help make a final diagnosis. Morphologically, the mass demonstrated papillary and solid architecture with rounded epithelioid cells, eosinophilic cytoplasm, round nuclei, granular chromatin, and small nucleoli. The tumor cells formed around fibrovascular cords and form perivascular pseudorosettes Figure . IHC revThe chromosomal microarray of the resected tumor was arguably the most helpful study, as it demonstrated the loss of chromosomes 10 and X, and the gain of material on chromosomes 8, 9, and 12. Previous molecular studies have shown the loss of chromosome 10 in 75% of cases of PTPRs, making this feature characteristic of this type of tumor .The diagnosis of PTPRs has been increasing since its distinction by the WHO in 2007 as a malignant entity separate from other CNS tumors. While the incidence of these PTPRs may be increasing, the overall prevalence of these tumors remains low. Our case report demonstrates the clinical presentation of a patient with a papillary tumor of the pineal region, the accepted phenomenon of tumor recurrence following the removal of PTPR, and additional knowledge gained through pathology reports such as histological and genetic information. Armed with this understanding of increasing cases, it is important to appreciate that while imaging can help lead to differential diagnoses, additional steps are necessary when making a definitive diagnosis of PTPR.


P < 0.05), there was no statistical significance in the specificity and accuracy of MRI combined with ultrasound to diagnose PIA (P > 0.05). The comparison of graded diagnostic accuracy showed that in ultrasound alone < MRI alone < MRI combined with ultrasound, the differences were statistically significant (P < 0.05). Ultrasound combined with MRI in the diagnosis of placenta accreta is in good agreement with the clinical and surgical pathological results; MRI examination can be used as an important method for prenatal placenta accreta screening. MRI can classify placenta accreta to some extent.In order to study the clinical application value of placenta accreta (PIA) diagnosis and grading, the authors propose a method based on ultrasound combined with magnetic resonance imaging in the diagnosis and grading of prenatal placenta accreta patients. This method is adopted in materials and methods: a retrospective analysis of hospital patients with high suspicion of placenta accreta by clinical or ultrasonography between October 2019 and October 2021, the imaging and clinical data of 312 patients who underwent placental MRI examination. The MRI imaging data of all patients were jointly analyzed, and the main observation indicators are as follows: (1) dark zone in the placenta, (2) disruption of the border of the myometrium, (3) disruption of the myometrium, (4) abnormal blood vessels in the placenta, (5) enlargement of the lower part of the uterus, and (6) local bulge of the bladder/or invasion of the adjacent tissues of the uterus. The results show the following: in MRI combined with ultrasonography ( Placenta accreta (PIA) is due to uterine hypoplasia or injury, resultiThe clinical importance of PIA arises from increased maternal morbidity and mortality and massive postpartum and sometimes intrapartum or antepartum hemorrhage. When there is placenta accreta, it is difficult to separate the placenta from the uterus, sometimes requiring instrumental forceps, which can lead to massive bleeding before, during and after the operation, and the bleeding is difficult to control and can cause shock in severe cases; it can also be complicated by disseminated intravascular coagulation (DIC), uterine perforation, and subsequent severe intrauterine infection, which increases the probability of hysterectomy and even endangers the lives of mothers and babies. In recent years, the incidence of placenta accreta has increased significantly, reaching 1/533, which is 20 times higher than before. It has become an important cause of postpartum hemorrhage, perinatal emergency hysterectomy, and maternal death. According to a WHO survey on caesarean section rates in 2007-2008, among the nine Asian countries surveyed, China has the highest rate of caesarean section at 46.2%. With changes in social concepts and population policy adjustments, the age of childbearing has been delayed, and the number of “second children” has increased; many people with “second children” are advanced mothers, which may increase the incidence of placenta accreta and clinical issues that must be faced by an obstetrician . T2-weighted imaging (T2WI) was performed using a single excited fast spin echo sequence  and a short reversal time reversal recovery (STIR) sequence  , the scaPrenatal MRI was combined with US diagnostic grading results, determined by discussion and consultation between 1 radiologist and 1 US physician. If the diagnostic grades of the two physicians are the same, this grade is used as the combined diagnostic grade; if the US and MRI physicians have different diagnostic grades , the US First, the tissue was grossly observed, then HE stained smears and microscopic observation. Histopathologically, it is confirmed whether there is placenta accreta . If therUnder the condition of not knowing the results of pathological examination, the single-blind method was used to read the films, and the MRI images focused on analyzing the signal in the placenta, the relationship between the placenta and the myometrium, the localized swelling or thinning of the uterus, the swelling of the lower segment of the uterus, the relationship between the placenta and the cervix , and theStatistical method SPSS16.0 software was used for statistical analysis of the data, and the measurement data was represented by xts; Prenatal MRI, US diagnosis and MRI combined with US diagnosis were performed by chi-square test, respectively ; The KapThere was no statistical significance in the comparison of the sensitivity of the three examination schemes for diagnosing PIA, however, the specificity and accuracy of ultrasound alone in diagnosing PIA were significantly lower than those of MRI alone, MRI combined with ultrasound examination, and the differences were statistically significant (P <0.05), there was no statistical significance in the specificity and accuracy of MRI combined with ultrasound to diagnose PIA (P >0.05), as shown in P < 0.05), as shown in The comparison of the grading diagnostic accuracy showed that the difference was statistically significant between ultrasound alone < MRI alone < MRI combined with ultrasound . The degree of agreement between the combined diagnostic grading and postoperative pathological grading was strong .As can be seen from P > 0.05) [After comparing the gold standard data of surgical or pathological diagnosis, it was found that the index of magnetic resonance imaging in the diagnosis of placenta accreta was 74%, which was slightly higher than that of color Doppler diagnostic index of 60.5%; there was no significant difference in the diagnostic index between the two groups ( > 0.05) . The kapUltrasound features with high sensitivity and specificity are as follows: placental lacuna and partial or complete disappearance of the retroplacental space, with a sensitivity of 92.1% and 79.4% and a specificity of 73.9% and 65.2%, respectively. The features with high sensitivity and specificity in MRI were irregular enlargement and deformation of uterine volume; the sensitivity and specificity were 87.3% and 87.0%; the second was the thinning or disappearance of the dark zone in the placenta and the myometrium on T2-weighted images; the sensitivity and specificity were 79.4%, 79.4%, and 69.6%, 78.3%, respectively. See Placenta accreta refers to the invasion of placental villi into the myometrium due to primary decidual hypoplasia or traumatic endometrial defect, which can lead to severe postpartum hemorrhage, uterine perforation, and secondary infection and is a common emergency in obstetrics . PatholoUltrasound is an imaging method represented by noninvasive, simple, nonradiation, and low-cost characteristics and has become an indispensable examination link during pregnancy. Relevant studies suggest that after the occurrence of PIA, the placenta can show abnormal thickening echo signs under ultrasound, and the hypoechoic zone of the myometrium at the attachment site becomes thin or even disappears, and due to the formation of venous blood pool, there are often multiple anechoes of different sizes and shapes in the placenta. In the recessed area, for pregnant women with placenta previa, the increase in gestational age was not accompanied by an upward shift in the echogenicity of the lower edge of the placenta. In this study, there was little difference in the sensitivity of the three examination schemes for the diagnosis of PIA, and the specificity and accuracy of the ultrasound examination scheme were significantly lower than those of MRI alone and MRI combined with ultrasound examination, which indicated that MRI was more suitable for the diagnosis of PAI, although the PIA placental parenchyma is usually accompanied by focal lacunar blood flow under color Doppler ultrasound, and the basal facial venous plexus is rich in signal; the acoustic signal is easily disturbed by the abdominal fat layer , amniotiMRI is more expensive and takes longer to scan; it is far less widely used in prenatal examination than ultrasound, but because of its high resolution of soft tissue, large imaging range, and more flexible orientation, it has positive significance for the diagnosis of PIA and the evaluation of implantation depth. According to relevant literature reports, the T2WI sequence of MRI can fully demonstrate the thinning and interruption of the myometrium and the nodular hyperintensity sign in the hypointense myometrium, and the serrated degeneration of the interface is more common in adhesive PIA; the placenta can be peeled off with bare hands, which can cause the placental surface to be rough and associated with a lot of blood oozing. Implantable PIA can find that the myometrium and placental tissue are fused with each other, and a large resistance can be felt when peeling off with bare hands; if the peeling is unsuccessful or the bleeding is excessive, hysterectomy should be planned. Penetrating PIA shows that the uterus and bladder wall are not intact, and it is impossible to dissect the uterus by hand; it is necessary to be careful to avoid uterine rupture and properly formulate a hysterectomy operation plan. This study found that prenatal application of MRI combined with ultrasound can obtain a more prominent PIA grading diagnosis effect, suggesting that the combined diagnosis can carry out multifaceted analysis of the PIA implantation depth, and objective selection of consistent diagnostic information can more accurately reflect the actual situation. And the degree of disturbance is not strongly correlated with the depth of placenta accreta; the diagnostic efficiency of color Doppler ultrasound in grading PIA is insufficient; although MRI has higher resolution, with the increase of gestational age, the difference of T2WI signal between placental stroma and placental lobule becomes more and more prominent, resulting in uneven internal signal, which may increase some false negative cases; therefore, the combined application of multiple imaging methods is more necessary .Prenatal MRI combined with US examination can better detect patients with placenta accreta, can reflect the basic pathological features of placenta accreta, and can better show the site of placenta accreta, the depth of invasion, and the involvement of adjacent organs. Prenatal MRI combined with US examination may play an important role in the graded diagnosis of placenta accreta, the setting of treatment plans, and the evaluation of efficacy; at the same time, it can provide an accurate imaging basis for the formulation of clinical surgical plans. In conclusion, both prenatal magnetic resonance imaging examination and ultrasonography have high diagnostic value for placenta accreta, and magnetic resonance imaging examination has a slight advantage, which can play a supplementary role in the diagnosis of placenta accreta by ultrasonography.


We report a case of retropharyngeal liposarcoma in a 53-year-old female, who had complaints of neck swelling accompanied with dysphagia, orthopnea and dysphonia. Clinical examination revealed huge multinodular swelling in front of neck with bilateral extension, more prominent on left side and moving with deglutition. The diagnosis of retropharyngeal liposarcoma was established following CT scan, MRI and incisional biopsy. Surgical excision of mass along with near total thyroidectomy was performed. Postoperative hospital stay was uneventful. She remained well in follow-up period of 1 year as well. In conclusion, retropharyngeal liposarcoma is a rare tumor. A review of the literature explores the reasons behind the late presentation as well as the difficulties in diagnosis and treatment of this rare tumor. Liposarcoma is a common type of soft tissue sarcoma that accounts for about 20% of all adult sarcomas. The common place for liposarcoma to develop is in deep soft tissues of lower limbs and retroperitoneal parts, accounting for 24 and 45% of limb sarcomas and retroperitoneal soft tissue sarcomas, respectively , 2. AtypA 53-year-old female with no comorbids presented to outdoor surgical department of Holy Family Hospital, Rawalpindi, Pakistan with complaints of swelling in front of neck for past 1.5 years that was enlarging progressively, along with dysphagia for last 3 months with more predilection for solid, orthopnea for 2 months and dysphonia for 1 month. There was no history of any swelling in this or any other location in the past. There was no history of smoking or any exposure to radiation.Clinical examination revealed stridor along with huge multinodular swelling ~15 × 10 cm in front of neck with bilateral extension, more prominent on left side as shown in Upon radiological investigations , a provisional diagnosis of retropharyngeal differentiated liposarcoma was made. On USG, the thyroid enlargement along with solid mass measuring 37 × 47 mm of size in cervical region was observed. The thyroid enlargement was attributed as multinodular goiter. On CT scan, a mass measuring 9 × 15 × 11 cm with bulging into left cervical region with extension into carotid space causing stretching of carotid vessels was observed. On CT scan analysis, a single enlarged lymph node in Para tracheal region was also observed. The CT scan findings are given in FNAC was attempted twice but it reveals hemorrhage only and was inconclusive. Incisional biopsy was done, which revealed atypical spindle cell lipomatous tumor. After complete workup, she underwent excision of mass along with near total thyroidectomy and tracheostomy and excised mass was sent for histopathology, which confirmed it to be atypical lipomatous tumor (well-differentiated liposarcoma). Postoperative period was uneventful, and patient remained stable during ward stay and was later discharged with follow-up. She was followed up to 1 year, no recurrence seen. The excised mass along with respect thyroid gland is given in Liposarcoma is among the most common types of soft tissue sarcoma in adults, and usually occurs in the lower extremities, retroperitoneum, perinephric space, mesentery or shoulders. The incidence of liposarcoma in the head and neck region, at ~1.8–6.2%, is extremely low . Their met al. [The most common histological type is the well-differentiated one , accounting for 40–50% of all types, whereas the most infrequent type is pleomorphic liposarcoma . Accordiet al. , ~10% ofet al. . FISH anet al. . Althouget al. , 10.In most cases, the liposarcoma occurred in patients > 60 years of age. Apart from their genetic predisposition, well-known risk factors for soft-tissue sarcomas are iatrogenic factors such as a chronic lymphedema and previous radiation; however, liposarcomas seem to be only rarely associated with these . AlthougPatients with liposarcoma are usually asymptomatic, however; they can produce pressure symptoms, such as dysphagia, dyspnea and dysphonia. The retropharyngeal space lies between the buccopharyngeal fascia and the prevertebral fascia and extends from the skull base to the mediastinum . DiseaseThe diagnosis of a liposarcoma is typically delayed secondary to its indolent, asymptomatic course. Imaging modalities aid the clinician in diagnosing liposarcomas, and the most utilized are the MRI and CT scans . The amoAlthough surgery with negative margins is very well documented as the treatment of choice for all histopathological subtypes of head and neck liposarcomas, routine regional lymph node dissection is not generally recommended, as node metastases of head and neck liposarcomas are quite rare . PostopeNone declared.None.Data supporting the conclusions are included in the article.


The prevalence and incidence of neuroendocrine tumors (NETs) are increasing worldwide. Primary mesenteric NETs are extremely rare. Solid tumors that arise in the mesentery are typically metastatic. We present an extremely rare case of a primary grade 2 NET (NET G2) in the ileal mesentery.3 tumor was pale yellowish-white. Immunohistochemistry revealed diffuse staining for synaptophysin and chromogranin A, and focal staining for CD56. The Ki-67 index was 3%. The final pathological diagnosis was NET G2. The patient’s postoperative course was uneventful, and he developed no recurrence 1.5 years after surgery. Postoperative antitumor therapy was not performed for this patient because the histological diagnosis was NET G2, and it was determined that the tumor could be completely resected by surgery.A 54-year-old man was referred to our hospital for further examination of a previously diagnosed right mesenteric tumor. Mild tenderness was noted on the right side of the abdomen, but there were no palpable masses. Fluorodeoxyglucose-positron emission tomography (FDG-PET) revealed slight FDG uptake  in the right abdomen, and a benign or low-grade malignant tumor was suspected. We extracted the ileal mesenteric tumor with an ileal resection (90 cm). The cut surface of the 55 × 33 × 33 mmWe report an extremely rare case of primary ileal mesenteric NET. Mesenteric tumors that show slight FDG uptake on FDG-PET examination should be considered well-differentiated NET. Neuroendocrine neoplasm (NEN) is a rare disease with a gradually increasing prevalence . NENs arA 54-year-old man was referred to our hospital after his previous doctor thoroughly examined him for right-sided abdominal pain. His previous diagnosis based on computed tomography (CT) was a right mesenteric tumor. Mild tenderness was noted on the right side of the abdomen, but there were no palpable masses. His medical history included diabetes mellitus and hypertension. Blood chemistry tests showed mild elevation of liver enzymes levels and elevated blood glucose and hemoglobin A1c levels, which are associated with diabetes mellitus. The tumor marker carcinoembryonic antigen level was mildly elevated at 6.2 ng/mL. Contrast-enhanced abdominal CT revealed a mesenteric lobulated mass with an artery running through the center  with 111In-diethylenetriaminepentaacetic acid-octreotide . Which iSurgery is the mainstay treatment for localized gastrointestinal NETs, and may be curative in cases of R0 resection. To our knowledge, only 10 cases of primary small intestinal mesenteric NETs have been reported in the literature , 12–20 . Of the Herein, we report an extremely rare case of primary ileal mesenteric NET resection. The preoperative diagnosis of a small intestinal mesenteric tumor is difficult. However, if FDG-PET shows a small accumulation in the tumor, the possibility of a well-differentiated NET G2 should be considered.