Intussusception is a rare cause of late complication after gastric bypass. We report the case of a 53-year-old woman having a gastric bypass in 2011. The patient presented to the emergency department with abdominal pain and vomiting. The diagnosis of intussusception was made by CT scan. Laparoscopy found an invaginated intestinal segment at the level of the jejuno-jejunal anastomosis without necrosis. Adhesiolysis and revision of the anastomosis were performed. The post-operative course was favorable. The diagnosis of intussusception was made by CT scan. Bariatric surgery has become a common surgical technique for the treatment of morbid obesity worldwide, it is more effective compared to conservative treatment with greater weight loss and lower morbidity related to obesity. Among the many surgical techniques, the most common procedure in the world is the gastric bypass .Intussusception is rare in adults (only 5%), almost 90% of intussusception in adults are secondary to a pathologic lead points  .Like any surgery, gastric bypass can have complications that sometimes require revision. The most common long-term complication is bowel obstruction due to internal hernia or adhesions. Another less common complication is intussusception, which can occur many years after surgery .The diagnosis of intussusception is difficult because the symptoms and laboratory results are not specific. The classic triad of abdominal pain, bloody stools and a palpable mass is rarely seen. The symptoms may be acute, chronic, or intermittent .A 53-year-old woman presented to the emergency department with diffuse non-specific abdominal pain for the last three weeks associated with vomiting. The patient also reported asthenia and a weight loss. The patient underwent a gastric bypass in 2011.The physical examination revealed hypertympanic distended abdomen and hypochondrium mass at palpation. Blood test was unremarkable. The abdominal CT scan showed an intussusception at the level of the jejuno-jejunal anastomosis in the left hypochondrium. The CT also revealed an acute obstruction of the proximal jejunum with segmental dilatation and stasis. These findings were confirmed at laparoscopy performed 15 hours after the CT. Laparoscopic exploration revealed dilated small bowel loops around the jejuno-jejunal anastomosis and intussusceptions on a fibrous adhesion encircling the jejunum proximaly to the common channel. Intussusception reduction was achieved and the post-operative course was favorable Figures .Intussusception is a rare cause of obstruction after gastric bypass, its incidence is 0.1% to 1.2% with a median interval of 36-52 months after the procedure .Intussusception is defined as the pull of a segment of the gastrointestinal tract into an adjacent segment, the exact mechanism is unclear, but an increase of peristalsis and the caliber of the small bowel is cited in the literature. Intussusception occurs most frequently at the anastomotic site of the proximal jejunum .The classic triad of abdominal pain, bloody stools, and a palpable mass is rarely seen in these cases of intussusception, only 10% of patients have this triad. The majority of patients presented with nonspecific abdominal symptoms including diffuse acute, chronic, or intermittent abdominal pain, nausea, and vomiting .Ultrasound is the technique of choice for children. In adults, CT with contrast injection is the technique of choice and the most sensitive technique, he does the diagnosis, give the location , the cause , and look for complications.Three CT signs are described in intussusceptions in relation to the evolution of the pathology: the "target sign" and “sausage-shaped” mass, representing bowel-within-bowel with alternating layers of low (mesenteric fat) and high  attenuation forming concentric rings when imaged at right angles to the lumen, and a soft tissue sausage when imaged longitudinally. And at the end, a “kidney mass” formed by the mesenteric fat, dragged into the intussusception mimicking the renal hilum, and by the bowel edema mimicking the renal parenchyma.Abdominal ultrasound and X-ray have no place in the diagnosis in adults .As the symptoms are not very specific and are similar to other post-operative complications like internal hernia or bridles, the CT scan should be performed in emergency in all operated patients who have acute or chronic abdominal pain of unknown origin. Emergency laparoscopy should be performed for all patients who have signs of peritonitis or shock .Early laparoscopic surgical exploration is recommended to prevent progression to infarction and perforation, it reduces morbidity and mortality of patients. The surgical technique consists of revision alone in the absence of ischemia or resection with revision of the anastomosis if ischemia is present .The diagnosis of intussusception in adults is relatively rare and are secondary to a pathologic lead points, it can also be a rare long-term complication of gastric bypass with serious consequences like small bowel ischemia or perforation. The etiology is not very well understood but most of the authors suggest a disturbance in the motility of the digestive loops following surgery. Diagnosis is difficult because the symptoms and laboratory results are non-specific, the majority of patients presented with acute, chronic, or intermittent abdominal pain, nausea, and vomiting. Internal hernia should always be included in the differential diagnosis. Abdominal ultrasound and X-ray have no place in the diagnosis. The scanner is the technique of choice for diagnosis and to look for complications, it must be performed in all patients operated with abdominal pain. Early surgery with reduction of the intussusception, revision of anastomosis and bowel resection of non-viable bowel reduces morbidity and mortality.


Liposuction is one of the most performed procedures in aesthetic plastic surgery worldwide, and its spectrum of applications covers almost all body areas.Systemic or visceral complications following liposuction are rare, but unfortunately, they can be very serious.We discuss the case of a 69 y.o. woman who underwent abdominal contouring surgery consisting in flank pseudohernia correction, liposuction and short scar abdominoplasty, which was complicated by intestinal perforation.Bowel perforation was suspected on the 3rd day following surgery after a CT-scan and was treated with exploration through a median laparotomy, resection of the perforated bowel and subsequent ileo-ileal anastomosis. The 10 cm-long resected segment of the small intestine presented multiple 2 mm-large holes at the microscopic examination.We assume that patient position on the operating table and abdominal wall laxity during surgery as well as the timing of each specific procedure played an important role in the occurrence of bowel perforation.To our knowledge, this is the first case report of an accidental visceral perforation during a combined procedure of flank bulging correction and abdominal liposuction.Overall the increased risk of combined procedures in plastic surgery is linked to increased operative time. In the current case timing of surgery sequence more than operative time itself was relevant in increasing anterior abdominal wall pressure and thus setting the patient at a higher risk of bowel perforation. Awareness of this kind of complication is essential to promptly treat the patient and avoid dramatic consequences ,3.Talmor et al. describe a series of 7 cases of abdominal viscera perforation from 1983 to 1995 and showed a mortality rate of 50% . A FrencLumbar hernia is an uncommon defect of the posterior abdominal wall, that represents less than 1% of all abdominal wall hernias ,7. InsteTrue lumbar incisional hernias have to be distinguished from abdominal wall musculature atrophy caused by division of the lower thoracic nerves can complicate flank incisions.Patients who develop an uncomfortable and cosmetically displeasing flank bulge resulting from transversus abdominis and oblique muscles laxity often require correction of the defect. Because no wall defect exists, this is not to be considered a true hernia and surgical correction for cosmetic reasons is usually difficult and unsatisfactory . Wall muAim of this case report is to highlight a rare but potentially lethal complication, that can occur after a very frequent plastic and aesthetic surgical procedure.2A caucasian, 69 y.o., nonsmoker and not consuming alcohol woman referred to our outpatient office seeking for an abdominal profile reshaping procedure. The patient suffered from hypertension and gastroesophageal reflux, both drug-treated. Her BMI was 25,6 and the anesthesiologist assigned her ASA II score.The patient presented an 18-cm long linear scar on the left lateral side of her abdomen due to open kidney surgery performed 30 years before for renal stones removal and she did not complain any abdominal symptom at the time of the visit. Thus, trunk contour was characterized by both a bulge deformity of the left side and moderate subcutaneous adipose tissue excess with skin laxity of the inferior abdomen , Fig. 3.At the ultrasound investigation, the bulge revealed a portion of 0,7 cm of relaxed fascia underlying the existing scar with protrusion of fatty tissue through the gap, without any sign of intestinal loops involvement.The patient was scheduled for flank bulge repair, liposuction and short scar abdominoplasty, which did not include umbilical transposition or recti abdominis muscles plication.Surgery was performed by a senior consultant specialist of our clinic with the patient under general anesthesia and placed on her right lateral decubitus with a sandbag gel positioner under her right flank. Through a direct skin incision traced along the existing scar we exposed the left bulge: no true adipose tissue hernia was encountered, but only abdominal wall deformity with absence of proper muscle fascia.A double plication of the left external oblique muscle was performed, after drug-induced muscle relaxation. Turned the patient in supine decubitus we focused on the lower abdomen performing two stab incisions medially to anterior superior iliac spines to infiltrate 800cc of tumescent solution . Then liA short scar abdominoplasty completed the procedure, removing conventional skin and subcutaneous flap from the hypogastric area, any sign of muscle wall damage was noticed.Overall, surgery time took 95 min, antibiotic and antithrombotic prophylaxis therapies were administered.Day 1# post-op was characterized by vital parameters and laboratory values in normal range, pain 5 on a scale of 10, slight nausea and lack of appetite.In day 2# post-op a slight rise of body temperature (37.3 °C) occurred, associated with vomiting, skin pallor and gasping (sO2 90%), heart rate was 105. Physical evaluation of the abdomen evoked mild pain, without a positive Blumberg’s sign, neither skin alterations nor inferior limb edema was present. Intestinal transit of gas or solids was absent.Abdominal radiography revealed free intraperitoneal air in the right hypochondriac region associated with a minor expansion of the pulmonary basal region on the same side. CT-scan confirmed the presence of free air in the abdomen, ascending colon alterations and showed fluids in the perihepatic area and in the small pelvis.An emergency laparotomy was performed after investigation by exploratory laparoscopy and fecal peritonitis was intraoperatively diagnosed. A portion of ileal loop about 10 cm long injured by multiple perforations was found located at 50 cm from the ileocecal valve. The segment was resected, and an ileo-ileal anastomosis was performed.The histological examination of the 10 cm long resected loop showed multiple perforations of 2 mm diameter without inflammatory signs Figs.  and 5.FiThe postoperative 7 days showed to be regular, gradually the patient started eating until the resolution of postoperative paralytic ileus and a complete canalization was reached.The patient was discharged on the 14th day of hospitalization provided with a diet schedule, drug therapy, and advised to wear a girdle for 3 months. Follow up didn’t show any sign of further complication.This case report has been reported in line with the SCARE criteria .3Multiple surgical procedures are often used in body contouring to obtain a satisfying result. Combined procedures are worldwide accepted in plastic surgery, but data about the increased risk of complications is not unambiguous. Overall, the increased risk of combined procedures is due to the operative time taking more than 3 h .A questionnaire to board-certified members of ASAPS showed a significant increase of complications when liposuction was combined with other procedures . On the Practice Advisory on Liposuction of 2003 recommends limiting liposuction aspiration volumes in other to safely perform combination with additional plastic surgery procedures .In our case liposuction, short scar abdominoplasty and flank reshaping were all considered essential steps to effectively correct patient’s trunk deformities.Overall surgery time was 95 min and the total aspirated volume was 800cc of clear adipose tissue, according to the guidelines.In literature cases of incidental bowel perforation are described, even with minimum lesions.In the current case, multiple point-like wounds of 2 mm diameter were detected by pathologists.An accredited hypothesis is that liposuction cannula was responsible for these perforations even if the vacuum-assisted cannula had a blunt tip and larger diameter (4 mm). This finding can be explained by bowel wall developing a certain degree of collapse after perforation.Another interpretation could be that the smaller infiltration cannula (2 mm diameter), used before fat aspiration, has caused the perforations.The absence of inflammatory tissue reaction around the holes validated the hypothesis of an external trauma instead of a chronic-stress related damage.Along abdominal wall areas of different resistance to external trauma coexist, among them, the supraumbilical area is accredited to be the most susceptible one . For thaIn the current case, patient position was supine during aspiration, moreover, there was probably an increased endoabdominal pressure, caused by the flank pseudohernia correction previously performed. Flank correction before abdominal wall procedures were planned to reduce patient position changes and overall surgery time.The muscles wall plication needed drug-induced myorelaxation, the half-life of curare drug can vary depending on patient weight, age, liver cytochrome activity. One possible scenario is that at the time of liposuction the abdominal wall muscles were still deeply relaxed, and because of this more susceptible to penetrating trauma, even using a blunt tip cannula.In literature, a similar case of perforation of lumbar hernias is described, but in that case they were unknown and containing intestinal loops . Our patPrevious studies described also spontaneous free perforation of the small intestine, however the postoperative course was slower and less painful than in our case .After the body contouring, we didn’t discharge the patient hastily and we monitored her constantly in the postoperative time. Firstly, perforation symptoms were confused with gastroesophageal reflux syndrome, that was reported in patient’s medical history. The early diagnosis allowed the more conservative treatment with bowel anastomosis, avoiding temporary colostomy, and a further operationIf an abdominal perforation is suspected, a chest/abdominal x-ray and abdominal-pelvic CT-scan should be immediately requested. Treatment should be prompt, through laparoscopic or open laparotomy, as well as management of perforations according to their location, size and time of evolution .4Liposuction is a safe procedure if properly performed, but intraoperative changes of patient decubitus, increased endoabdominal pressure and trunk extension could determine a higher risk of iatrogenic damage. Combined procedures in trunk contouring surgery are widely accepted, but the sequence of the procedures could be itself crucial to determine adverse events.In case of symptomatic intestinal transit alteration after abdominal liposuction it is mandatory to rule out the possibility of a rare but life-threatening complication such as iatrogenic bowel perforation.Careful monitoring of postoperative clinical course and timely use of radiologic exams are of paramount importance to avoid dramatic consequences.To our knowledge, this is the first case report of an accidental visceral perforation during a combined procedure of flank bulging correction and abdominal liposuction.In University Hospital of Padua, Italy, Caterina Gardener, MD, is a Plastic Surgeon; laura Pandis, MD, is a Plastic Surgeon; Martina Grigatti, MD, is a Plastic Surgeon; Vincenzo Vindigni, PhD, is a Plastic Surgeon; Franco Bassetto is a Plastic Surgeon and Tito Brambullo, MD, is a Plastic Surgeon. The authors have disclosed no financial relationships related to this article.No conflict of interest.No source of funding.It is a retrospective case report and no ethical approval was required.Written informed consent was obtained from the patient for publication of this case report and accompanying images.Caterina Gardener: data collection, literature search, writing and editing of the article.Laura Pandis: literature search, interpretation and editing of the article.Martina Grigatti: literature search and data collection.Vincenzo Vindigni: supervision and contribuition to the submission process.Franco Bassetto: study concept and validation of the article.Tito Brambullo: conceptualization, supervision, review and editing of the article.All authors participated in the design of the case report, read and approved the final manuscript.Article submitted was a case report and therefore not applicable.Primary Surgeon – Prof. Franco Bassetto.Not commissioned, externally peer-reviewed.


Neuroblastoma (NB) is the most common solid tumor seen in children under two years old. It has both solid and cystic forms. It generally involves the adrenal gland unilaterally. Only 10% of the NBs are as seen bilateral. Both bilateral and cystic forms of NB are a very rare entity. Magnetic resonance imaging (MRI) is a suitable imaging modality for evaluating lesions radiologically to avoid ionizing radiation exposure in children. Herein, we present the MRI findings of a bilateral cystic NB case. Neuroblastoma (NB) is the most common extracranial tumor in infancy and childhood. It can arise anywhere in the sympathetic nervous system, including the adrenal glands . It is cA one-year-old girl was admitted to our hospital with abdominal distention of two days and abdominal discomfort of 10 days' duration. She was born at term by Caesarean section and her antenatal history was insignificant. Routine laboratory findings were within normal limits, except for elevated urine vanillyl mandelic acid (VMA) levels (157 mg/L).On physical examination, a right abdominal mass was palpated. Sonography of the abdomen revealed bilateral adrenal anechoic cystic lesions with thick irregular walls. To avoid the ionizing radiation of computed tomography (CT), intravenous (IV) contrast-enhanced magnetic resonance imaging (MRI) was performed for further evaluation of the masses.MRI findingsAn MRI was performed with a 1.5-T MAGNETOM Aera unit with a body coil . The contrast medium ) was infused through a 24-gauge venous catheter by using a power injector (Spectris) . Axial T1, coronal T1, coronal T2 true fast imaging with steady-state free precession (TRUFI), axial two-dimension time of flight (TOF), coronal three-dimension TOF, and precontrast and post-contrast fat-saturated axial and coronal T1-weighted images were taken with 3 mm section thickness.The MRI demonstrated a 6.5 x 5 x 5 cm right adrenal cystic mass and a 4 x 3.5 x 3 cm left adrenal cystic mass with hyperintense hemorrhagic changes on T1 and T2-weighted images. The right adrenal lesion was pushing the right kidney inferiorly. Both lesions had enhancing, thick, irregular walls. There were no solid components. The inferior vena cava was narrowed and compressed by the right adrenal mass. According to the MRI findings, the preliminary diagnosis was bilateral hemorrhagic CNB Figures .Ultrasound-guided fine-needle aspiration cytology (FNAC) was performed, and the diagnosis of NB with hemorrhagic changes was made pathologically. There was no evidence of lymph node or liver metastasis. The lesions were excised surgically. The patient was given chemotherapy after surgery and has been in remission for nine months.NB is the most common malignant solid tumor of childhood and infancy. Nearly 50% of patients are under two years of age. The majority of patients reported in the literature are newborns . The tumLaboratory findings are generally insignificant. Vanillylmandelic acid (VMA) and homovanillic acid (HVA) levels are generally normal in CNBs. Ultrasound is the first step imaging modality for diagnosis. IV contrast-enhanced CT or MRI is performed for further diagnosis. However, because NB is a childhood tumor, an MRI should be performed instead of a CT to avoid ionizing radiation. Radiologic diagnoses were done by using a CT in most of the past studies, but there are a few reports in the literature about MRI findings of this entity -7. MRI iOn MRI, the content of adrenal masses (solid or cystic), contrast enhancement pattern, presence of hemorrhage in the lesions, and metastasis of the masses can be easily detected.Cystic forms have a more benign clinical course than solid forms . Liver, A Tru-Cut® biopsy  can be impossible in CNB if it has thin walls. FNAC or incision biopsy can be performed for pathologic diagnosis. Treatment generally consists of surgical resection with or without chemotherapy protocol.NB is the most common solid tumor seen in children under two years old. It has both solid and cystic forms and generally involves the adrenal gland unilaterally. The finding of both a bilateral and cystic form of NB, as was documented in this case report, is a very rare entity. MRI is the most suitable imaging modality for evaluating lesions radiologically to avoid ionizing radiation exposure in children.


The abdominal cavity has long been used for absorption of cerebrospinal fluid (CSF) in patients with hydrocephalus. Although the procedure is quite common, there are complications that can potentially arise following ventriculoperitoneal (VP) shunt insertion. Here, we report a case of a 39-year-old female patient in which a large abdominal pseudocyst was developed as a complication of VP shunt placement. Ultrasonographical evaluation of the abdomen showed a well-defined cystic mass lesion later confirmed on CT abdomen. She subsequently underwent surgical excision of the pseudocyst with resolution of previous symptoms. Clinicians should be aware of this complication since early diagnosis improves outcome and reduce patient's suffering and distress. Ventriculoperitoneal (VP) shunt placement is a common neurosurgical procedure performed for the management of hydrocephalus. Although rare, there are potential complications that might arise from the procedure, including abdominal wall perforation, peritonitis, and ascites . AbdominA 39-year-old Caucasian female with a history of cerebral palsy with spastic quadriplegia and congenital hydrocephalus with VP shunt presented to our institution for rapidly developing abdominal distension, pain, and coffee-ground emesis. On examination, the patient was lethargic and in obvious discomfort. Her abdomen was markedly distended with rebound tenderness and decreased bowel sounds. Abdominal ultrasound revealed severe free fluid in the abdomen which was confirmed on CT of the abdomen. Upper endoscopy was negative for active bleeding, varices, or ulcers. Diagnostic paracentesis showed serum-ascites albumin gradient (SAAG) > 1.1, total protein (TP) < 2, and clear yellow fluid. There was no evidence of cirrhosis on imaging with patent hepatic vein, splenic vein, and inferior vena cava (IVC). She had an echocardiogram that did not show any cardiomyopathy or restrictive pericarditis. Fibrosure showed F0, no hepatic fibrosis. Repeat CT later on in that admission showed large amount of intra-abdominal partially loculated fluid suspicious of CSFoma , it seemed CSFoma was caused by loculations and septations around the peritoneal end of the VP catheter. She was taken to the operating room for attempted laparoscopic drainage of her intraperitoneal CSF cysts. That was followed by open conversion to repair a loop of bowel that was inadvertently dissected during the laparoscopic procedure. There were multiple adhesions seen during the procedure with several anastomoses created. At the same time, one nonfunctioning peritoneal shunt was removed, and a second was replaced in the right upper quadrant. She recovered very well from her surgery and there have been no additional complications following the procedure.VP shunt placement is a procedure performed to drain excessive CSF which otherwise can lead to serious complications, including increased intracranial pressure and hydrocephalus formation. Pseudocyst formation due to shunt placement is mostly seen in the abdomen as most ventricular drains are placed in the peritoneal cavity. Inadequate absorption, blockages, and abdominal adhesions are some of the common complications leading to accumulation of CSF at the end of the catheter with subsequent pseudocyst formation .Signs of VP shunt malfunction include headache, nausea, altered level of consciousness, and other findings commonly observed in those with elevated intracranial pressures. Abdominal complications related to VP shunt placement include pseudocysts, intraabdominal infections (e.g. abscess), and bowel perforation . PseudocThe exact pathogenesis of abdominal pseudocyst remains unknown; however, three different mechanisms have been proposed: chronic infection, foreign body reaction, and particle like protein in CSF . The timAbdominal pseudocyst remains a rare but important complication of VP shunt placement and is likely attributed to a low-grade inflammatory process. Clinicians other than neurosurgeons and pediatricians should be aware of this complication and keep it on the differential in those with history of VP shunt placement presenting with acute abdomen. Early recognition and intervention have been shown to improve clinical outcomes and limit unnecessary and costly diagnostic workup.


Angioleiomyoma is a benign tumor of the vascular system that is often not considered in the differential diagnosis of a painless subcutaneous nodule of the body. In this report, we present a rare case of angioleiomyoma of the phalanx in the left hand in a middle aged man. He underwent surgical excision of the mass with no complications. Given the nonspecific and indolent presentation, our case had a broad differential diagnosis including ganglion cyst and histopathological examination was warranted for definite diagnosis. At 9-month follow-up, the patient was asymptomatic with no signs of recurrence.  Angioleiomyoma, also known as “vascular leiomyoma,” is a benign tumor derived from the muscular tissue in tunica media layer of the vascular system. Although it can arise anywhere in the body, finger involvement is a very rare entity ,2. It tyA 68-year-old male presented with a two-year history of a cystic nodule on the radial aspect of the P1  phalanx of the left third finger. The cyst had been progressively increasing in size over the last two years and became painful a few months prior to the presentation. He had no other associated symptoms. His past medical history was significant for HIV , chronic atrial fibrillation on dabigatran, diabetes mellitus type 2, essential hypertension and hyperlipidemia. Physical exam showed a 12 mm x 11 mm, nontender, mobile subcutaneous cystic lesion at the dorsal aspect of the left distal phalanx of the third finger. Complete blood counts, renal function, basic electrolytes and liver function were unremarkable. Given the location and clinical characteristics of the lesion, ganglion cyst, arteriovenous malformation, hemangioma, lipoma and fibroma were initially considered in the differential diagnosis. The patient opted for excision of the nodule. On macroscopic examination, the tumor was a well-circumscribed tan-pink nodular mass measuring 0.7 x 0.7 x 0.5 cm. Microscopic examination showed a solid type tumor with well-circumscribed closely packed smooth muscle fascicles with moderately low cellularity surrounding vascular lumina (Figures There was no evidence of atypia, hemorrhage, necrosis, mitosis or calcifications. Immunohistochemical staining with CD34 and smooth muscle actin were positive (Figures Angioleiomyoma is a rare tumor consisting approximately 4.4% of all benign soft tissue masses . It origPain is the most common presenting complaint, occurring in 60% of cases ,3,4. TheAngioleiomyomas can be divided into three histologic subtypes: solid or capillary, venous and cavernous ,5. SolidAngioleiomyomas are rarely diagnosed before excision and histopathological study conducted due to its rarity and vast differential diagnosis, including glomus tumor, traumatic neuroma, angiolipoma and hemangioma ,6-8. DueAngioleiomyoma is an uncommon tumor. Due to rarity of the lesion and extensive differential diagnosis, it is commonly misdiagnosed before histopathological study. Therefore, it should be considered in the differential diagnosis in patients presenting with a painless subcutaneous nodule of the upper extremities.


Scrotal leiomyomas are benign tumors arising from the dartos layer of the scrotal wall. The exact cause of this tumor is not yet clear. Malignant transformation to leiomyosarcomas has been reported.A 52-year-old male who complained of a painless lump on the right side of the scrotum that lasted 12 years. Physical examination revealed a single, firm, and non-tender, mobile lump on the anterior aspect of the right scrotum. Both testes were normal and no inguinal lymph nodes could be palpated. Ultrasound scan of the scrotum showed a 40 mm × 20 mm hypoechoic, poorly vascular lesion in the scrotum. Under spinal anesthesia, the mass has been excised. Histopathological and immunohistochemical findings were consistent with the diagnosis of scrotal leiomyoma.Leiomyomas may originate from any location in the genitourinary system where there is smooth muscle. Scrotal smooth muscle tumors can be categorized into Leiomyomas, atypical or symplastic leiomyomas, which are not hypercellular and lack mitotic activity, and leiomyosarcomas. Ultrasound is the first-line imaging investigation in patients with suspected scrotal masses. Typical leiomyomas and atypical ones behave similarly. Therefore, they are managed only with surgical excision, while leiomyosarcomas need a wide 3−5 cm margin resection. Both recurrence and malignancy have been described. Close follow-up is required to detect recurrence.Scrotal leiomyoma is a rare benign mesenchymal tumor of the middle-aged men. The current report describes the clinical and histopathological characteristics to help reduce erroneous diagnoses of this rare tumor. The uterus is known to be the commonest site of the tumor but scrotal leiomyoma is essentially a rare benign pathology arising from the dartos muscle . Scrotal2A 52-year-old man presented with a painless mass in the right side of the scrotum for 12 years. There was no history of trauma, infection, inflammation, or any surgical procedures. He is diabetic, and for the last 5 years, he has been on daily 500 mg single dose metformin therapy.Physical examination revealed a single, well-formed, firm, non-tender, mobile lump of 5 cm × 4 cm × 3 cm on the anterior aspect of the right scrotum. The mass had no connection to the testis, epididymis or spermatic cord. The covering skin was normal with no ulceration. Both testes were normal and no inguinal lymph nodes could be palpated.Ultrasound scan of the scrotum showed a 40 mm × 20 mm hypoechoic, poorly vascular lesion in the scrotum associated with calcification.We enucleated the mass under spinal anesthesia and sent the sample for histopathology that showed a benign scrotal leiomyoma that had been completely excised. The cut section demonstrated a well-localized, non-capsulated tumor that was composed of fascicles of spindle cells arranged in intersecting bundles and separated by variably-collagenized stroma. No mitotic figures were seen .Fig. 1InImmunohistochemistry was performed with positive control and it revealed a positive reaction to both Desmin  with dif3Leiomyomas may originate from any location in the genitourinary system where there is smooth muscle . There hScrotal smooth muscle tumors can be categorized into three. Leiomyomas, atypical or symplastic leiomyomas, which are not hypercellular and lack mitotic activity, and leiomyosarcomas . PatholoMost cases reported have been asymptomatic. This leads the patients not to seek treatment until the lesion becomes large and cosmetically undesirable . The larClinical manifestations of a scrotal leiomyoma may mimic other conditions. Therefore, to correctly identify it, a list of differential diagnoses has to be considered including schwannoma, neurofibroma, dermatofibroma, adnexal tumors, and metastases .Ultrasound is the first-line imaging investigation in patients with suspected scrotal masses. MRI can be more sensitive and accurate but is usually not needed. A definitive diagnosis requires histological examination of a resected specimen . Based oDespite atypical leiomyomas have histological characteristics mimic malignancy, they have a benign course and behave like the typical one even if they have a larger size. Hence both are managed with surgical excision. However follow up is required to detect recurrence. If detected, a thorough investigation should be carried out to rule out any possibility of malignancy. Nevertheless, the use of radiation should be avoided as it may result in malignant transformation. In contrast leiomyosarcomas need a wide 3−5 cm margin resection that includes the subcutaneous tissue and fascia and negative margins ,16.4Scrotal leiomyoma is a rare benign mesenchymal tumor of the middle-aged men. The current report describes the clinical and histopathological characteristics to help reduce erroneous diagnoses of this rare tumor, as the method of treatment relies heavily on the correct diagnosis.There are no conflicts of interest.None to be stated.Approval has been given by Ethical committee of University Of SulaymanyiahWritten informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Operating surgeons: Saman Salih Fakhralddin and Muhamed Hussen BabarasulDesign and idea: Saman Salih Fakhralddin and Rawa BapirDrafting: Zheen Bahaddin Ibrahim and Muhamed Hussen BabarasulData acquisition: Muhamed Hussen Babarasul and Rawa BapirFinal revision: Rawa Bapir, Ismaeel Aghaways and Saman Salih FakhralddinNot applicableThe corresponding author is the guarantor of submission.Not commissioned, externally peer-reviewed


Orbital solitary fibrous tumors (SFTs) are rare neoplasms. Recurrent, hypervascular, malignant variations of orbital SFTs have recently been noted and can present a surgical challenge.We describe a case of a 53-year-old Chinese woman with a history of a resected orbital SFT. She presented with proptosis, limited eyeball movement, and visual loss in the right eye, suggestive of a recurrent SFT. Ocular examination with multimodal imaging revealed a large, nonpulsatile, noncompressible, hypervascular mass behind the eyeball. The patient underwent preoperative transarterial embolization of the main blood supply to the tumor in order to control intraoperative blood loss, followed by ocular enucleation to optimize exposure and enable complete resection of the tumor. Embolization of the right ophthalmic artery and the distal branch of the right internal maxillary artery caused an immediate, substantial reduction of vascular flow, which allowed us to enucleate the eyeball and resect the tumor with minimal blood loss and no complications.Our case is so far the first Chinese case of successful preoperative embolization of the main blood supply to a large, recurrent, hypervascular orbital SFT. This case also described a different surgical approach to achieve total removal of an orbital SFT without osteotomy. Solitary fibrous tumors (SFTs) are uncommon mesenchymal neoplasms that occur most frequently in the pleura and occasionally in the orbit . SFTs arA 53-year-old Chinese woman presented to the hospital with an 8-year history of progressive proptosis of the right orbit. It is associated with progressive reduced of vision, visual field deficits and excessive tearing. She denied diplopia, eye pain or headaches. Nine years prior to this presentation, she had undergone surgical resection of a right orbital tumor via anterior orbitotomy, and histopathology confirmed that it was an SFT. Nine months post operative, patient began to develop symptoms that reflected a slow increase of tumor size. Because the tumor was closely adherent to the optic nerve, it was thought that resection might injure the nerve, potentially damaging the patient’s sight. Considering her normal best corrected visual acuity, patient was advised to attend regular follow-ups. However 2 years later the patient was no longer heard from until 2018. On examination, there was a large non-pulsetile, non-compressible mass in the right orbit cause the proptosed eye displaced infero-temporal. Exopthamometer measurement showed 23 mm proptosis in the right eye and 15 mm in the left eye. The best corrected visual acuity in the right eye was 2/20 with restricted visual field. The cornea is clear, conjunctiva was injected and extra ocular movement was restricted in elevation and adduction. Fundus examination showed significant optic nerve edema. Examination in the left eye and general physical examination were normal.Upon reviewing of the MRI in 2009 before the initial resection, an ill-defined, well-encapsulated, mixed-intensity circular lesion measuring 2.4 cm × 2.1 cm with 3 septate cystic spaces was observed posterior to the right orbit between the optic nerve and the medial rectus, iso- or hypo-intense on T1, slightly hyper-intense on T2  extreme pain in the right eye; (2) immediate loss of light perception; (3) significant swelling of conjunctiva; and (4) a decrease in heart rate of 45–50 bpm compared with the previous heart rate of 65–80 bpm. Of the 4 phenomena observed after embolization, the drastic drop in heart rate was especially alarming. ‘Oculo-cardiac reflex’ was diagnosed, so 1 mg intravenous atropine was administered preoperatively, which stabilized the patient’s heart rate at 60–92 bpm, and surgical tumor resection was completed as scheduled.The eyeball was extracted firstly. The giant mass appeared slightly reddish internally, with a wide engorged vein on the central surface. It filled the orbit and displaced the retro-bulbar segment of the right optic nerve, shifting it infero-temporally. Atrophy of the orbit tissues was also noticed. The tumor capsule was found to adhere to the periosteum of the medial orbital wall. As a result, debulking was performed to isolate the neoplasm, followed by en bloc tumor resection. The total volume of blood loss was less than 50 mL, and there was no abnormal bleeding. After the tumor was resected, the patient’s heart rate stabilized at 60–80 bpm. An ocular prosthesis was made for aesthetic purposes. One week postoperatively, an MRI demonstrated that the orbit was filled with gelatin sponge that was slightly hyper-intense on T1 (Fig. Pathological review of the tumor following the initial surgery in 2009 showed that the tumor was composed of diffused spindle cells, with oval to fusiform nuclei and a pale eosinophilic cytoplasm. ‘Antler’-like vessels were noted in the background Fig. a. The imSFTs are rare spindle cell tumors first described in 1931 in pleural tissue . Since tSince recurrent or malignant SFTs can be highly vascular with multiple large feeder vessels, the attempts to biopsy and resection them might fail because of massive hemorrhage without taking preoperative measures , 7. PreoPrevious reports have used orbitotomy or craniectomy to expose the mass , 5, 6. IIn this case, embolizing the tumor’s main blood supply caused an immediate cascade of reactions, including intense eye pain, loss of vision, conjunctival edema, and a decrease in heart rate. The eye pain may have been the result of acute ischemia or vasospasm of the tumor, or the cytotoxicity of dimethyl sulfoxide adjuvant used in Onyx. Conjunctival edema secondary to circulatory disturbance and inflammatory reaction likely raised intraorbital pressure in the eyeball, which further aggravated the pain . HoweverIn conclusion, orbital SFTs can be hypervascular, especially in recurrent and invasive cases. Preoperative CTA can be performed to assess the blood supply to the lesion. Embolism can be an effective technique to minimize intraoperative hemorrhage. The size and location of the tumor, patient visual function, as well as patients’ intention should be considered when deciding the surgical approach. The surgical techniques described in this study could be a feasible approach for complete resection of orbital SFTs.


A hibernoma is an uncommon benign soft tissue tumor composed of brown adipose cells; the mediastinal location as presentation is scarce, with only six cases previously reported. The diagnosis of hibernoma is challenging and must be made based on the clinical, radiographic, and cytologic features. Here we present a 33-year-old woman without any relevant medical history presented for outpatient evaluation of a dry cough persisting for three months, and the X-rays revealed a dense well-defined mass with smooth borders in the left upper posterior mediastinum. Posterior mediastinal lesions represent a relatively small proportion of patient loads in thoracic surgery and account for a total of 25% of the cases, with neurogenic tumors among the most frequently seen in adults. Of these, the nerve sheath tumors  are the most seen. Other differential diagnoses of paravertebral masses are the paraspinal abscess, metastases, hematoma, descending aortic aneurysm, among others.The patient underwent surgical resection via left posterolateral thoracotomy, without complications. A hibernoma is an uncommon benign soft tissue tumor composed of brown adipose cells. Their brownish color is due to the presence of numerous mitochondria, with a high concentration of cytochrome pigments. Unlike white adipose tissue, which primarily serves as an energy store, brown adipose tissue serves primarily to create heat. Merkel first described this type of tumor in 1906 who called it a pseudolipoma and subsequently reported by Gery in 1914 as hibernoma due to its microscopic similarity to the brown fat of hibernating animals . HoweverA 33-year-old woman without any relevant medical history, only bilateral breast implants, presented for outpatient evaluation of a dry cough persisting for three months. The patient denied shortness of breath, chest pain, fever, chills, weight loss, or any other related symptoms. Gastroesophageal reflux, upper airways nasal syndrome, and tuberculosis were excluded. The patient does not smoke. She works as a nurse but denied unprotected contact with patients exhibiting respiratory symptoms.Physical examination revealed normal vital signs. Cardiovascular examination revealed a normal cardiac rhythm without murmurs, rubs, or gallops. The pulmonary examination does not reveal any abnormal breathing pattern, without dyspnea or use of accessory muscles; there are no peripheral signs of respiratory dysfunction: cyanosis or clubbing, no abnormalities in the shape of thorax or asymmetry of chest expansion. Lungs were clear to auscultation, with vesicular breathing, without pathological breath sounds. Tactile fremitus was normal; no percussion dull note was noted. Complete blood count (CBC) and serum chemistry results were unremarkable; serial sputum acid-fast mycobacteria stain and cultures were negative.The posteroanterior chest X-ray (CXR) Figure  revealedMagnetic resonance imaging was not considered necessary due to sufficient data on CT images, and the cleavage margin was observed, and it did not change the surgical conduct.Biopsy before surgery was not considered due to the risk of tumor implantation.The patient underwent a left posterolateral thoracotomy through the fifth intercostal space. The tumor was encapsulated and adhered to the third intercostal space, over the emergence of the nerve root, and compromised the posterior segment of the upper left lobe and the superior segment of the inferior lobe. An upper lung decortication with posterior parietal pleurectomy over the mediastinum was made to leave a margin of resection of the tumor lesion with segmentary lobectomy of the posterior upper lobe and the superior segment of the inferior lobe due to the compromise of the visceral pleura. An open thoracic approach was made considering their strategic position in the mediastinum and the size of the tumor >5 cm. Although it is worth clarifying that the posterior mediastinum location is not a contraindication for a video-assisted thoracoscopy (VATS), it is a widely accepted treatment modality, and the size >5 cm is a relative contraindication as there are reports of lesion resections up to 18 cm in diameter.On gross examination, the specimen was a lobulated mass with a smooth, tan to a brown external surface, 11 cm x 8 cm x 6 cm  and weighed 195 g. Histological sections were cut and stained with hematoxylin-eosin Figure ,B. MicroA hibernoma is an uncommon benign soft tissue tumor composed of brown adipose cells.These tumors represent 1.1% of all adipocytic tumors and at least 1.6% of the benign lipomatous tumors. Four morphologic variants have been identified: typical, myxoid, spindle cell, and lipoma-like . ImmunohDespite the use of multimodal imaging, the diagnosis of hibernoma is challenging. The diagnosis must be made based on the clinical, radiographic, and cytologic features.In the first instance, this is an isolated posterior mediastinal mass. On CXR, the differential diagnosis is broad. This mass could be a paraspinal mass caused by a peripheral nerve sheath tumor such as schwannoma, neurofibroma, paraspinal ganglioneuroma. Other differential diagnoses of paravertebral masses are the paraspinal abscess, metastases, hematoma, descending aortic aneurysm, focal mass or dilatation of esophagus, duplication cyst, and extra-medullar hematopoiesis.It is challenging to diagnose hibernoma through images alone. However, the radiologic features provide helpful information for differential diagnosis. Radiographs may show a consistent radiolucent mass, typically without areas of calcification or bone erosion . The sonDifferential diagnosis of a mass with a signal similar to fat or containing large intratumoral vessels on CT or MRI should include benign and malignant lesions such as lipoma, angiolipoma, hemangioma, liposarcoma, well-differentiated liposarcoma, or atypical lipomatous tumors , 16. A reliable diagnosis is difficult because hibernomas have a variable histologic appearance depending on the relative amount of multivacuolated, mitochondria-rich, and brown fat cells, which can alter the MRI signal characteristics . RecentlThe histopathology is necessary for a diagnostic certainty; in these cases, a core needle biopsy can be performed with few complications despite their vascularity.The treatment in most cases is complete surgical excision, which is generally curative and has a low potential of local recurrence; there is no conclusive evidence of a malignant form or metastatic disease, and their existence is debated with most reports dating back to the 1960s and 1970s. In the case reported by Lowry and Halmos, they argued malignancy by the mere fact of infiltration of the striated muscle by a typical hibernoma, which is inappropriate. While the three cases reported by Apatenko et al. histopathology reminds more a hibernoma but with larger and pleomorphic nuclei besides containing "strips reminiscent of liposarcoma or polymorphocellular sarcoma" and "immature fibroblastic tumor." The case reported by Teplitz et al. looked more like an anaplastic sarcoma  with brown adipose tissue traces. Other authors such as Enterline et al. postulate the term of highly atypical hibernoma. Nevertheless, this case in their analysis does not rule out that it is a poorly differentiated liposarcoma by the widespread nuclear atypia in brownish areas and the low nuclear to cytoplasmic ratio ,19-20.This patient after the tumor removal had a satisfactory postoperative evolution; the chronic cough resolved, and the patient had a steady follow-up course.Mediastinal hibernoma is a rare benign soft tissue tumor. The majority of cases occur in extremities with few cases with mediastinal localization. It should be suspected in cases of intra-thoracic fat density lesions in CT or MRI. The PET-CT can differentiate a hibernoma from a liposarcoma in case of doubts. The histopathology is necessary for a diagnostic certainty. It can be observed expectantly, or it can be excised when it becomes symptomatic, this being the definitive treatment with a low risk of recurrence.


Inflammatory pseudotumor-like follicular dendritic cell sarcoma (IPT-like FDCS) is a rare tumor. This study aimed to reveal the radiological characteristics of IPT-like FDCS by radiologic-pathologic correlation.We analyzed two cases of IPT-like FDCS in the liver, nine in the spleen, and two in both the liver and spleen concomitantly. IPT-like FDCS presented as well-defined iso- or hypodense masses on unenhanced computed tomography (CT) images in both the liver and spleen. Hyperintensities on T1-weighted images and hypointensities on T2-weighted images with hypointense rings were characteristic features in splenic cases. “Halo signs” were observed in two out of three liver tumors. Hepatic lesions showed significant enhancement, whereas splenic lesions showed only mild enhancement. Delayed annular enhancement was observed in both liver and spleen cases. On ultrasonographic examination, IPT-like FDCS presented as hypoechoic lesions with enhancement similar to that observed on CT. Hyaline fibrous pseudocapsules, which correlated with the hypointensities on T2-weighted images, were microscopically observed at the tumor edge. IPT-like FDCS was characterized by an abundance of small blood vessels and capillaries. Capillaries were also found in the fibrous capsule of some IPT-like FDCSs, which may explain the delayed annular enhancement.The manifestations of IPT-like FDCS in the liver and spleen showed differences that warrant them to be approached differently during diagnosis. Characteristic radiological findings of IPT-like FDCS included different enhancement patterns between liver and spleen tumors and rim-like hypointensities on T2-weighted images, as well as annular enhancement on CT and magnetic resonance images. These imaging features correlated with tumor pathology. Follicular dendritic cell sarcoma (FDCS) is an extremely rare type of tumor. While it usually arises from dendritic cells in lymph nodes, a wide variety of extranodal sites may also be involved. There have been no more than 100 reported cases of FDCS in the literature, mostly case reports, especially of extranodal forms . The impThis study was approved by the Institutional Review Board of Ningbo Medical Center Lihuili Hospital, and the study complied with the guidelines of the Healthcare Insurance Portability and Accountability Act. The requirement for written informed consent was waived because of the retrospective study design.All IPT-like FDCS cases from 2010 to 2019 were retrieved from multiple centers and were confirmed by the local pathological center. In total, 13 patients were included in this retrospective study. The following clinical and pathological data were collected: age, sex, anatomic tumor location, tumor size, clinical symptoms, surgical and pathological findings, treatment outcomes, and follow-up time. For all patients, preoperative images were reviewed.Contrast-enhanced MRI was performed in 11 cases, contrast-enhanced CT was performed in eight cases, and both contrast-enhanced MRI and CT were performed in six cases. Ultrasound was performed in four cases, of which one case was also examined by contrast-enhanced ultrasound imaging. Contrast-enhanced CT was performed using a 256-row CT  or 16-row multi-detector computed tomography . For multiphasic contrast-enhanced CT scanning, an 80–100-mL intravenous iopromide bolus  with 300 mg iodine/mL was injected at a flow rate of 4–6 mL/s, followed by an injection of 30–40 mL of saline solution. The scanning was delayed by 20, 60, 90, and 120 s for the arterial, portal vein, hepatic vein, and delayed phases, respectively. A 1.5-T MR scanner  or 3.0-T MR scanner  with corresponding 8-channel abdominal phased-array coils were used for MRIs. Conventional axial spin-echo sequence T1-weighted images, axial fast spin-echo sequence with fat suppression T2-weighted images, and single excitation of spin-echo diffusion-weighted images were acquired. For multiphasic contrast-enhanced MR scanning, a 15-mL intravenous bolus of gadopentetate  was injected into the elbow vein at a flow rate of 2.5 mL/s before axial and coronal T1 high-resolution isotropic volume excitation scanning. The contrast scan was delayed by 25, 80, 110, and 200 s for the arterial, portal, hepatic venous, and delayed phases, respectively. The Philips S2000 or Toshiba Aplio500  systems were used for ultrasound imaging. The frequency of the convex array probe was 3.5–5.0 MHz.All images were retrospectively reviewed by two senior radiologists  who were blinded to the patients’ clinical information until a consensus was reached. The radiological findings were analyzed considering the following criteria: location of lesion; number of lesions; shape; size ; tumor density/intensity on unenhanced CT and MRI images ; contrast enhancement pattern ; presence of a “halo sign” (a thin hyperintense ring surrounding the tumor on T2-weighted images); and presence of pseudocapsules .Ultrasound examinations were performed at two hospitals by senior ultrasound physicians with 16 years of experience each. The images were retrospectively analyzed by another senior ultrasound physician with 25 years of experience. The physicians agreed on the following signs: tumor location, size, shape, boundary, internal echo, relationship with adjacent organs, color Doppler blood flow, and enhancement intensity and mode of the tumor on contrast-enhanced ultrasound.In all 13 cases, the tumors were resected, and the tissue samples were examined using hematoxylin and eosin staining as well as immunohistochemical EnVision staining. The antibodies that were used are listed in Table Statistical analyses were performed using SPSS . A Student’s t-test was used to compare the patients’ age at onset and the maximum tumor diameters in the liver and spleen. The Chi-square test was used for qualitative variables, such as sex, the presence or absence of symptoms, density, signal intensity, enhancement pattern, the presence or absence of pseudocapsules, and “halo signs.” P values < 0.05 were considered statistically significant.9/L and 31.1 mg/L, respectively; whereas alpha-fetoprotein, carcinoembryonic antigen, carbohydrate antigen 125, and carbohydrate antigen 19–9 were within the normal ranges. Both hepatitis B virus surface antigen and the antibody were negative. All tumors were resected without radiological recurrence during the follow-up periods of 10–24 months.Our patient cohort included seven men and six women aged 36–88 years. Three patients presented with abdominal distension and epigastric pain, and two presented with low-level fever. The other eight asymptomatic cases were detected during health checkups. In these eight cases, physical examinations revealed no signs of tenderness or rebound tenderness. Only one case had an increased white blood cell count before surgery. The white blood cell count and C-reactive protein levels were high at 19.5 × 10The clinical manifestations of IPT-like FDCS and comparisons of the liver and spleen lesions were listed in Tables The imaging characteristics of IPT-like FDCS differed slightly between the liver and spleen Table . Most unAll liver tumors demonstrated slightly hypointense signals on T1-weighted images Fig. a and sliTwo-dimensional ultrasound imaging demonstrated round-like lesions inside the spleen, with clear boundaries in two cases Fig. e, uncleaThe pathological feature of IPT-like FDCS in both the liver and spleen was very similar. Macroscopically, masses were round or nodular with diameters ranging from 3.5 to 12.0 cm . Sections were solid and grayish-white with clear boundaries, and fibrous pseudocapsules could be seen Fig. g, h. TheImmunophenotypically, the tumor cells were strongly positive for CD21 Fig. j and CD3All 13 patients underwent surgical excision without adjuvant chemotherapy. The tumors were resected, and splenectomy and/or right or left hepatectomy and wedge resection of the liver were performed, accordingly. All cases were followed up postoperatively for periods ranging from 10 months to two years, and none exhibited local recurrence or distant metastasis.IPT-like FDCS is more common in adults. Compared with classical FDCS, IPT-like FDCS is more frequently observed in female patients; however, there was no statistically significant difference in sex in our study. Most patients had no clinical symptoms or those that were unspecific. In our study population, only two patients had prodromal symptoms of low-level fever, and three patients had symptoms of abdominal distension and pain, whereas eight patients had no obvious typical symptoms. This is consistent with previously reported findings . While IFDCS has a low degree of invasion but high local recurrence and metastasis rates, making it a moderately malignant tumor. IPT-like FDCS is more inert, and surgical resection is the first choice of treatment. In patients with tumor recurrence or those who cannot be treated by surgery, chemotherapy or radiotherapy can be administered . None ofTo date, most imaging findings reported have been from individual cases or small cohorts; large-scale data of imaging findings are scarce. To our knowledge, this study represents the largest radiologic-pathologic correlation study of IPT-like FDCS cases. Imaging findings of IPT-like FDCS in the liver and spleen revealed both similarities and differences. In both intrahepatic and intrasplenic tumors, the density was often homogeneous and hypodense on CT. We speculate that slow tumor growth, sparse tumor cells, and abundant blood supply may be the reasons behind this observation. Seven of eight cases showed slight hypodensities on CT; only three tumors (> 5 cm in diameter) had a central hypodense necrotic area. After contrast medium injection and enhancement of the solid components, the enhancement of IPT-like FDCS in the spleen was found to be weaker than that in the liver, which may be related to the obvious enhancement of the spleen itself. On MRI scans, IPT-like FDCS was more characteristic. Intrasplenic IPT-like FDCS showed relative hypointensities on T2-weighted images due to the hyperintense signals on T2-weighted images of the spleen itself. Our study confirmed that the pseudocapsule formed at the tumor boundaries in nine cases presented as hypointense signals on the T2-weighted image sequence, because it mainly comprised collagen fibers, which was consistent with other studies . Our stuAlthough the imaging manifestations of the tumors vary, IPT-like FDCS contrast enhancement can be divided into three types according to the enhancement characteristics, and this is closely related to the tumor’s histopathological features. (a) Centrifugal enhancement type: following contrast agent administration, the center of the tumor was substantially enhanced in the arterial phase, further enhanced in the portal and venous phases, the scope of the enhancement was enlarged, and the edge of the tumor was enhanced in the delayed phase. In our study, this type was only found in the liver Fig. . (b) MarIn summary, IPT-like FDCS is a rare tumor that is mainly observed in the liver and spleen. By correlating imaging and pathology findings, our comparative study of 13 IPT-like FDCS cases identified characteristic imaging features of this type of tumor in the liver and spleen. Although these tumors are usually indolent, surgical resection is still the fundamental treatment and requires postoperative follow-up.Our study has some limitations, with the relatively small sample size being the most important. IPT-like FDCS is an uncommon tumor; moreover, patients with IPT-like FDCS may never undergo diagnostic imaging because they are asymptomatic. Second, owing to the retrospective nature of this study, we did not obtain both multi-detector CT and MR images for the majority of patients. Additionally, different MRI scanners and techniques were used. However, these issues are unavoidable due to the rarity of this tumor type, and this limitation should not have significantly affected the radiological characteristics studied.We believe that complete CT and MRI examinations may be of great help in the diagnosis of IPT-like FDCS. Consideration should be given to a possible diagnosis of IPT-like FDCS when single or multiple masses are found with different patterns of enhancement on CT and MRI, a “halo sign,” the presence of a pseudocapsule appearance, and annular enhancement in the delayed phase are observed.


High-grade gliomas are the most common and aggressive malignant primary brain tumors. Current therapeutic schemes include a combination of surgical resection, radiotherapy and chemotherapy; even if major advances have been achieved in Progression Free Survival and Overall Survival for patients harboring high-grade gliomas, prognosis still remains poor; hence, new therapeutic options for malignant gliomas are currently researched. Sonodynamic Therapy (SDT) has proven to be a promising treatment combining the effects of low-intensity ultrasound waves with various sound-sensitive compounds, whose activation leads to increased immunogenicity of tumor cells, increased apoptotic rates and decreased angiogenetic potential. In addition, this therapeutic technique only exerts its cytotoxic effects on tumor cells, while both ultrasound waves and sensitizing compound are non-toxic per se. This review summarizes the present knowledge regarding mechanisms of action of SDT and currently available sonosensitizers and focuses on the preclinical and clinical studies that have investigated its efficacy on malignant gliomas. To date, preclinical studies implying various sonosensitizers and different treatment protocols all seem to confirm the anti-tumoral properties of SDT, while first clinical trials will soon start recruiting patients. Accordingly, it is crucial to conduct further investigations regarding the clinical applications of SDT as a therapeutic option in the management of intracranial gliomas. Intracranial gliomas are the most common primitive malignant neoplasms of the central nervous system, accounting for approximately 24.1% of all primary brain tumors .,56.55,56


Primary chondrosarcoma of the penis is rare. We present a case of primary chondrosarcoma of the penis in a young patient.A 35‐year‐old man presented with a painless mass at the base of his penis for the past 6 months. Incisional biopsy of the lesion revealed a chondrosarcoma. Pelvic magnetic resonance imaging and computed tomography of the thorax, abdomen, and pelvis ruled out a primary lesion in the bones and soft tissues. The patient rejected total penectomy and decided to start chemoradiotherapy followed by local tumor resection.Primary chondrosarcoma of the penis is rare. Interdisciplinary management plays an important role in planning the therapy for rare tumors. A combined chemoradiation therapy can be followed by penis‐preserving surgery to improve the quality of life in young patients with proximal penile tumors. CTcomputed tomographyESOextraskeletal osteosarcomaMRImagnetic resonance imagingR0negative resection marginSCCsquamous cell carcinomaPrimary chondrosarcoma of the penis is rare. We propose a penis‐preserving approach in the treatment of a primary chondrosarcoma of the penis. This may improve the chance of an acceptable quality of life for patients with this disease.Chondrosarcoma is a rare type of cancer that commonly begins in the bones but can sometimes occur in soft tissues in proximity to the bones. The incidence of chondrosarcoma is approximately 1 per 100 000 individuals worldwide.The most common primary malignant neoplasm of the penis is SCC.2). The chemotherapy was tolerated without any side effects being experienced. MRI of the pelvis after the third cycle of chemotherapy showed a regression of the primary tumor by ~1 cm  at the base of his penis. Sonographic examination revealed a hyperechoic structure with perfusion. MRI of the pelvis showed a hyperintense mass in the pelvic region without associated lymphadenopathy (Fig. This case of a chondrosarcoma is unique based on its primary location. To the best of our knowledge, this is the first report in the literature of a primary chondrosarcoma of the penis. The treatment decision for our patient was based on patient desire and tumor grade. Based on the European Society for Medical Oncology guidelines, surgery is considered as a standard therapy for all patients with localized soft tissue sarcoma with wide excision and negative margins. The guidelines also indicate that neoadjuvant radiotherapy, possibly in combination with chemotherapy to a total dose of 50 Gy in 1.8–2 Gy fractions, followed by surgery, may be considered.In a single case of chondrosarcoma of the jaw that metastasized to the penis,Only seven cases of primary ESO of the penis have been reported in the literature.The choice of treatment modalities available is based on anecdotal information, as no prospective trials have been conducted, and no treatment has been shown to be superior in prolonging patient survival.This is the first report of a primary chondrosarcoma of the penis. Extensive patient counseling must be considered before treatment initiation in these cases. Inductive chemotherapy may be used to minimize the extent of surgical resection, with the aim of genital preservation. As an alternative to surgical intervention, a combination of chemotherapy and radiotherapy may be applicable. Compared with penile amputation, penis‐preserving surgery may improve patients’ quality of life, at the cost of an increased risk of local recurrence.The authors declare no conflict of interest.


Canaliculops is a rare condition, and only 11 cases have been reported previously. We report 2 cases of canaliculops, which were successfully treated using the new recanalization technique under dacryoendoscopy followed by bicanalicular lacrimal intubation.A 78-year-old man and a 76-year-old woman had 3- and 1-year histories of medial-upper eyelid swelling  without any inflammatory signs, history of periocular trauma, herpes infection, use of specific drugs, or ophthalmic diseases of note.The cystic lesions were evaluated using ultrasound biometry or computed tomography to find the lumen of the horizontal canaliculus was exceedingly expanded, and to confirm the clinical diagnosis of canaliculops.As the 2 cases of canaliculops were caused by upper puncta and common canaliculus obstructions, canaliculops of the upper eyelid were recanalized under dacryoendoscopic guidance, followed by bicanalicular intubation. The tubes were kept in situ involving bi-weekly irrigation and instillation of antibiotic and anti-inflammatory eye drops, and were removed after 2 to 3 months of follow-up.Epiphora, and eyelid swelling were completely resolved immediately after the procedure, and the lesions did not recur on follow-up after more than 6 months.Eleven case series of canaliculops have been described previously, but this is the first report of this recanalization procedure offering a new, less invasive treatment option compared to complete or partial resection of the cystic lesion. Canaliculops causes epiphora and cystic eyelid swelling, for which complete or partial resection of the cystic lesion, marsupialization of the ectasia, and re-canalization without the use of imaging studies are diagnostic treatment options. However, these procedures have low reliability and high invasiveness.Canaliculops is a tense, bluish cystic lesion found in the medial canthus, characterized as a non-inflammatory ectasia of the lacrimal canaliculus filled with non-infectious serous fluid and mucus. This is a rare condition, and only 11 cases have been reported previously. Those cases showed a female predominance as well as primary lacrimal drainage obstruction, and the pathology can occur in upper or lower canaliculi, or even both as described in 1 case.Herein, we report 2 cases of successful recanalization of canaliculops under dacryoendoscopy followed by lacrimal intubation. This technique seems more reliable and less invasive, suggesting a new alternative to previously reported procedures.2This study was conducted in accordance with the tenets of the Declaration of Helsinki and its later amendments. Written informed consent for publication was obtained from both patients.This retrospective, observational case series included a 78-year-old man (involving the left eye) and a 76-year-old woman (involving the right eye). None of the patients had any history of periocular trauma, herpes infection, use of specific drugs, or ophthalmic diseases.Both patients showed a cystic mass in the medial upper eyelid. The upper punctum was obstructed, resulting in a high-tear meniscus. The lower punctum, lower lacrimal canaliculus, lacrimal sac, and nasolacrimal duct were patent, as confirmed by lacrimal irrigation. The mass in both patients was clinically diagnosed as canaliculops and was treated by recanalization under dacryoendoscopic guidance, followed by bicanalicular intubation. All surgeries were performed under local anesthesia in an office setting by 2 of the authors (MM and YT).We present the details of each case as below.2.1A 78-year-old man became aware of the left epiphora and swelling of the left upper eyelid 3 years before referral. At the initial presentation, a cystic mass was found at the medial end of the left upper eyelid without hyperemia or pain Fig. A. ImaginAfter local infiltration of anesthesia around the cyst using 1% lidocaine with 1:100,000 epinephrine, punctoplasty of the upper punctum was performed to insert the dacryoendoscope into the canaliculus. Although the lumen of the vertical canaliculus was slightly dilated, that of the horizontal canaliculus was exceedingly expanded Fig. A. The inPostoperative care involved bi-weekly irrigation and instillation of antibiotic and anti-inflammatory eye drops. The lacrimal tube was removed 2 months postoperatively. All symptoms resolved without recurrence for more than 1 year postoperatively.2.2A 76-year-old woman became aware of right upper eyelid swelling 1 year before referral. At the initial presentation, slit-lamp examination demonstrated a bluish cystic mass without any evidence of inflammation at the medial end of the left upper eyelid. Computed tomographic images showed a mass, but this mass did not seem to extend to the lacrimal sac fossa. Based on these findings, a diagnosis of canaliculops was made. The same surgical procedure as in case 1, recanalization and bicanalicular intubation under dacryoendoscopy, was performed, followed by the tube kept in situ for 3 months, to the successful outcome without recurrence at the 1-year follow-up period.3The current case series reports 2 cases of canaliculops that were successfully treated by recanalization and lacrimal intubation under dacryoendoscopy. However, these procedures are invasive and can pose a risk of re-obstruction of the lacrimal canaliculus. Conversely, recanalization of the lacrimal canaliculus under dacryoendoscopy does not require excision of the cyst wall. In addition, dacryoendoscopy enables reliable probing of the obstructed point at the common canaliculus and insertion of a tube under direct visualization, even in cases where the ectasia obscures the end of the cyst, which impedes accurate probing. Subsequent bicanalicular intubation is advantageous in terms of its stability and high success rate, particularly for common canalicular obstruction (90.1%–94.6%),,9 which could lead to successful long-term outcomes.Canaliculops represent ectasia of the canaliculus resulting from obstruction of both the punctum and common canaliculus, similar to dacryocystocele. Previous case reports have recommended complete or partial excision and marsupialization of the cyst wall for the treatment of canaliculops.,6 However, dacryoendoscopy can directly detect mucosal abnormality, ectasia of the lacrimal canaliculus, and obstruction of the common canaliculus, allowing sufficient clinical diagnosis of canaliculops without histopathological examination.On the other hand, pathological specimens cannot be harvested in our procedure. A lining of nonkeratinized multilayer original squamous epithelium in the cyst wall, superficial cytokeratin 7 staining, and patchy suprabasal cytokeratin 17 staining are significant pathological findings for the diagnosis of canaliculops. particularly the interior of the distended area. This is more useful for the differential diagnosis of tumors and foreign bodies, including dacryoliths, preoperatively.Tumors, foreign bodies, and other space-occupying lesions, such as dermoid cysts, mucoceles, and meningoencephalocele, are included as differential diagnoses for canaliculops. Computed tomography, as used in 1 of our patients, or magnetic resonance imaging can provide additional information on the lesion, particularly for large lesions. However, low-resolution images make differential clinical diagnosis difficult. UBM provides higher-resolution images of canaliculops,In conclusion, we have reported 2 rare cases of canaliculops treated successfully by recanalization using dacryoendoscopy. Based on previous reports on canaliculops with histopathological arguments, we suggest that less invasive recanalization utilizing lacrimal dacryoendoscopy can be a considerable intervention for canaliculop patients.Conceptualization: Masashi Mimura, Yasuhiro Takahashi.Data curation: Tomoko Kitada, Masashi Mimura, Yasuhiro Takahashi, Mai Takagi.Investigation: Tomoko Kitada, Masashi Mimura, Yasuhiro Takahashi, Mai Takagi.Methodology: Masashi Mimura, Yasuhiro Takahashi, Mai Takagi.Supervision: Hidehiro Oku, Tsunehiko Ikeda.Writing – original draft: Tomoko Kitada, Masashi Mimura.Writing – review & editing: Yasuhiro Takahashi, Hidehiro Oku, Tsunehiko Ikeda.


Meckel’s diverticulum is a common congenital anomaly found in ∼2% of the population, its classic location aiding in its diagnostic criteria, is the anti-mesenteric side of the distal ileum. However, reported cases of Meckel’s diverticula found on the mesenteric side, are present but rare. Here we report a case of a perforated mesenteric Meckel’s diverticulum with synchronised anti-mesenteric Meckel’s diverticulum, in a 70-year-old male, initially misdiagnosed as left strangulated inguinal hernia. The purpose behind this paper is to raise clinical suspicion regarding this rare pathology, so that timely diagnosis and management could be carried out. The anomaly’s clinical significance is that the persistent diverticulum can lead to complications such as intestinal obstruction, inflammation of the diverticulum, bleeding, ulceration or perforation, which may often be misdiagnosed. The anti-mesenteric side of the distal ileum, is the classic location of a Meckel’s diverticulum and aids in its diagnostic criteria. However, this diagnostic concept is challenged by few rare reported cases of Meckel’s diverticulum found on the mesenteric side of the ileum. Like previously reported cases, the pathology in our case was misdiagnosed at first; the pre-operative diagnosis made was strangulated inguinal hernia presenting with left groin swelling.This work has been reported in line with the SCARE criteria .270-year-old male patient, medically and surgically free, presented to the emergency department complaining of left groin swelling for 3 days’ duration. The patient’s swelling started gradually over a course of 3 days, associated with pain, nausea and vomiting, constipation and subjective fever. Patient denied previous history of trauma, chronic constipation and work-related heavy object lifting. Patient has no previous surgical history, no family history of similar presentation and no pharmacological history.9/L, haemoglobin concentration of 8.1 g/dL, creatinine level of 484 μmol/L and urea level of 24.8 mmol/L. Electrolytes and other routine analysis were all within normal values. Patient’s chest and abdominal x-rays were unremarkable.Physical examination: patient was conscious, alert and oriented; but hypotensive, tachycardic, tachypneic and in pain. Abdominal examination revealed a right sided inguinoscrotal swelling, around 20 × 15 cm, non-tender, reducible, with no skin changes. Also, there was another 5 × 7 cm left sided inguinal swelling but severely tender with bluish discoloration and hotness of the skin. Patient received initial fluid resuscitation, antibiotics and analgesia. Meanwhile, patient’s laboratory findings showed a white blood cell count of 27.55 × 10Patient was diagnosed with left strangulated inguinal hernia and was pushed directly to the operating room. Intraoperatively, a left inguinal approach was used. Around 20 cc of pure pus was drained, and the bowel looked healthy to the surgeon; so no resection was done and the hernia was repaired primary without mesh.Post-operatively, the patient was doing fine, tolerating oral feeding and passing stool. On post-operative day 4, the patient became febrile with a temperature of 39 and his leukocytic count increased up to 30. Therefore, abdominal CT was done, which reported unremarkable findings, except for some subcutaneous oedema which was excepted post-operatively. Yet the patient was still sick.On post-operative day 5, the wound was draining faecal matter. Patient underwent urgent exploratory laparotomy, where two Meckel’s diverticula at the terminal ileum were identified; one of them was perforated in the intra-abdominal wall, communicating with the left inguinal opening through the retro-pubic canal. Release of the bowel from the abdominal wall was done, resection of the part that contained the diverticulum was also done, with side to side anastomosis.As for the two Meckel’s diverticula; one was on the anti-mesenteric side, while the other was on the mesenteric side, which was perforated. Histopathology result of taken samples revealed perforated Meckel’s diverticulum associated with dense inflammation and ischemia .Images 1Post operatively, the patient was kept in high dependency unit, NPO and on antibiotics. On post-operative day 4, patient spiked fever again with a sudden onset of severe lower abdominal pain. The patient underwent CT abdomen and pelvis which showed complete disruption of the anastomotic site. Another laparotomy was carried out were the anastomotic site was taken down and double barrel ileostomy was created.The operator was a general surgery consultant with years of experience. In the following post-operative period, the patient unfortunately acquired a pulmonary embolism and passed away and no further follow up nor outcomes could be measured.3Meckel’s diverticulum, known as the most common malformation of the gastrointestinal tract, is a remnant of the prenatal vitelline duct that failed to regress between the fifth and seventh week of foetal life, first described by Johann Friedrick Meckel in 1809 [The diagnostic criteria for Meckel’s diverticulum include the rule of 2, characterised by: 2 in. long, 2 feet away from ileocecal valve, occurring in 2% of population, containing 2 types of heterotopic mucosa (gastric and pancreatic), 2 years of age is the most common age of presentation and 2:1 male to female ratio. Commonly, it arises from the anti-mesenteric side of the ileum, located ∼40 cm proximal to the ileocecal valve, containing all 5 layers of small intestine and has a separate mesentery for blood supply .Despite these criteria, the diagnostic concept that a Meckel’s diverticulum must arise from the anti-mesenteric side is challenged by its variant, the mesenteric type that is even rarer, with only few cases reported in the literature. First report was published by Chaffin in 1941, as an unusual variant of Meckel’s diverticulum located on the mesenteric side of the small bowel . Meckel’Haemorrhage, as reported in over 50% of cases, is the most common presentation of Meckel’s diverticulum in young children, while bowel obstruction is the most common in adults. Whereas perforation is considered the least faced complication, as reported in less than 0.5% of symptomatic Meckel’s diverticulum cases . PerforaUpon reviewing previous literature and case reports made on similar findings, it was found that they are very often misdiagnosed until the surgical intervention. However, no previous literature reported similar pre-operative diagnosis as our case, where the mesenteric Meckel’s diverticulum was perforated into the inguinal canal, resulting in a sealed perforation leading to the diagnosis of strangulated inguinal hernia. The following is a collection of mesenteric Meckel’s diverticulum cases reported in the surgical literature. The following table, extracted from a previously made table by a previous study , alongsiThe table summarises how often, although the total number of cases is few, mesenteric Meckel’s diverticulum cases are misdiagnosed as they present with a variation of non-specific symptoms. However, once intra-operatively encountered, cases of mesenteric Meckel’s diverticulum underwent similar approaches of treatment.Surgical resection is the treatment of choice for symptomatic Meckel’s diverticulum. Procedures made to achieve treatment most commonly include diverticulectomy, segmental bowel resection and anastomosis and wedge resection . Moreove4In summary, Meckel’s diverticulum can be in the mesenteric side despite its classic anti-mesenteric location as a variant, possibly proceeded by a misdiagnosis or a delay of diagnosis until surgery, despite pre-operative workup and examination. Therefore, high clinical suspicion of this pathology and its complications should be encouraged and kept in mind as a differential diagnosis for acute abdomen, as the learning point and purpose of this report, so that timely diagnosis and management of resection could be carried out.None of the authors have any conflict of interest to declare.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.The study is exempt from ethical approval.Signed consent couldn’t be taken from deceased patient nor family members, despite exhaustive attempts made to contact the family. However, the report has been sufficiently anonymised not to cause harm to the patient or their family.A signed document by the head of department to the above is available.Orjuana Khudari gathered patient’s data, designed the case report and drafted the manuscript. Basem AlShareef participated to the manuscript editing to its final version, supervised the report and revised it critically. All authors read and approved the final manuscript to be published.Not Applicable.Orjuana Khudari is the guarantor of submission and accepts full responsibility.Not commissioned, externally peer-reviewed.


Degenerated leiomyomas can rupture during pregnancy, and leakage of the fluid causes peritonitis in rare cases. If peritonitis associated with a degenerated leiomyoma is observed, the occurrence of rupture of the leiomyoma should be considered. Degenerated leiomyomas can rupture during pregnancy, and leakage of the fluid causes peritonitis in rare cases. If peritonitis associated with a degenerated leiomyoma is observed, the occurrence of rupture of the leiomyoma should be considered. The patient had no history of uterine or abdominal surgery. At a gestational age of 14 + 3 weeks, she had lower abdominal pain and was admitted to a primary health facility with a diagnosis of pain due to a degenerated leiomyoma, for which conservative therapy was started. Because of increased abdominal pain, she was transported to our hospital at a gestational age of 15 + 0 weeks. The patient characteristics at the time of hospital presentation were as follows: height, 158 cm; weight, 52 kg; blood pressure, 97/74 mm Hg; pulse rate, 98/min; and body temperature, 37.0°C. On admission, she complained of severe abdominal pain and vomited several times. In addition to the peritoneal irritation sign, a goose egg‐sized mass was palpated in the right upper abdomen, and severe tenderness was observed at the same site. Abdominal ultrasonography revealed an intramural leiomyoma measuring 7 cm in diameter at the uterine fundus. Blood tests showed the following results: white blood cells (WBC), 12300/mm3; CRP: 2.3 mg/dL). However, because of the poor improvement in abdominal pain and prolonged ileus, ruptured degenerated myoma was listed as a differential diagnosis, and emergency surgery was performed.Plain abdominal radiography revealed marked dilatation of the small intestine and ileus was diagnosed. Pelvic magnetic resonance imaging (MRI) revealed a leiomyoma with partial high‐signal intensity at the uterine fundus; it was considered a degenerated leiomyoma Figure . Based oThe intraoperative examination revealed an intramural leiomyoma measuring 7 cm in diameter at the uterine fundus. When the omentum and small intestine adhering to the surface of the leiomyoma were dissected, the leiomyoma, with its capsule ruptured, was exposed Figure . Accordi3This case highlighted the following two findings: First, leiomyomas can rupture during pregnancy. There have been cases reported of the rupture of a blood vessel overlying the leiomyoma during pregnancy4Degenerated leiomyoma can rupture during pregnancy. When this occurs, bleeding in the abdominal cavity due to the rupture of blood vessels often results in acute abdomen. In rare cases, however, the fluid from the degenerated leiomyoma leaks into the abdominal cavity, causing peritonitis, and therefore, surgery may be required. In pregnant women with degenerated leiomyomas, we should always keep in mind that leiomyoma rupture may occur.5MO: drafted the manuscript contributed and performed the surgery. MM: performed the surgery. SA: contributed to the first draft and finalization of the manuscript. EM: supervised the case report.None declared.Prior to submission, appropriate consent for publication of images and data has been obtained.


Yolk sac tumor (YST) is one of the malignant germ-cell tumors (MGCT) that usually occurs in the ovaries and testes of young patients. Its occurrence in the vagina is extremely rare. We present a rare case of extragonadal YST occurring in the vaginal region. A 12-year-old girl, presented with vaginal bleeding and pain in the perineal region. Physical exam identified a limited pelvic mass, 5 x 4cm in size. Abdominal ultrasound and magnetic resonance imaging (MRI) showed a heterogeneous mass in cervico-vaginal region. The patient was taken to the surgery, where an excisional biopsy was obtained. The diagnosis of YST is confirmed by histopathology and immunohistochemistry studies. However, the tumor marker  was normal. The patient was treated according to the French TGM-95 protocol. Surgery was done after chemotherapy, hysterectomy in front of the cervical invasion, with a good decline at 2 years of end of treatment. Malignant germ-cell tumors (MGCT) are rare in childhood and represent less than 5% of all pediatric cancers . Yolk saA 12-year-old girl with no previous medical history presented with vaginal bleeding and pain in the perineal region reporting the onset of the symptoms three months before. A physical examination identified a pelvic mass, 5 x 4cm in size, not painful. The pervaginal exam was difficult given the age of the girl and the absence of suitable equipment. Radiological studies (ultrasound and MRI) showed a heterogeneous mass measuring 5.1 x 6.2 x 6.5cm in cervico-vaginal region . There wThe patient was taken to the surgery, where an excisional biopsy was obtained. Microscopic examination showed neoplastic cells arranged in a reticular growth pattern with glomerular-like structures composed of a central blood vessel enveloped by atypical large pleomorphic cells with prominent nucleoli  and numerous intracellular and extracellular periodic acid-Schiff positive diastase . Immuno-Vaginal bleeding in young girls poses a challenge. The etiology of vaginal bleeding in young girls varies widely from idiopathic bleeding to sexual abuse and malignant tumors. Although genital tumors are very rare in childhood it is important that they are ruled out when a girl presents with unexplained vaginal bleeding. A genital examination, which can be used to diagnose most pediatric gynecological problems is recommended in all cases . MGCT arThe clinical presentation includes a history of bloody vaginal discharge, often accompanied by a polypoid mass protruding from the vagina which was not the case in our patient. Most common differential diagnosis is botyroides sarcoma differentiated by its characteristic grape like appearance and histopathology . The useMost of the cases of vaginal YST reported in the literature are limited to the vagina, only a few of them report involvement of the cervix , which wYST in the vagina is very rare and may not be recognized early. Final diagnosis is obtained by histological examination and AFP levels, which are also helpful during follow-up. Recommended treatment includes neo-adjuvant chemotherapy and conservative surgery because together they improve the prognosis and preserve both reproductive and sexual function.


The incidence of synovial sarcoma is 1.548 per 1,000,000. Synovial sarcoma localized to the palmar surface should, therefore, be considered extremely rare. This report documents a 34-year-old male with a right hand mass that had been present for a few years, continuing to grow in size. The mass was located at the palm and extended from the mid-third metacarpal to involve all digits except the thumb. The mass was determined to be monophasic synovial sarcoma on histopathologic exam. Fluorescence in situ hybridization for SYT gene rearrangement was positive in 72% of cells. Resection of the mass was followed by radiation and chemotherapy. The patient had a long-term follow-up of 3.5 years with no evidence of any local recurrence of the tumor. This report increases awareness of this extremely rare malignancy—an awareness that is crucial for early diagnosis and improved survival rates. It is more common at younger ages but it can occur at any age, so it should be suspected and included in the differential diagnosis, especially when evaluating slow growing, nonresolving hand lesions. The incidence of synovial sarcoma, in general, is 1.548 per 1,000,000 . In the Because of the rarity of synovial sarcoma of the hand, as well as a paucity of reports on such pathology, its identification warrants a detailed account. Therefore, this report documents a rare case of synovial sarcoma existing in the digits of a 34-year-old man.The written consent of the individual described in this study was obtained.A 34-year-old male with an unremarkable medical history presented with a chief compliant of what he believed to be a cyst on the palmar side of his right hand. The patient stated that the mass had been there for a few years. The area had grown in size and had been causing griping issues. He also complained of numbness at the finger tips which he attributed to the mass.Physical examination revealed a soft, nontender, nonpulsatile mass, and normal blood flow to the finger tips. Magnetic resonance imaging, performed with contrast, demonstrated a large lobulated enhancing lesion measuring 4.7 cm in its greatest dimension . The lesExcisional biopsy of the mass revealed a soft-tissue tumor with ovoid spindle cells surrounding hyalinized material without gross or histologic evidence of hemorrhage or necrosis. Occasional mitotic figures were identified . The lesComplete resection of the mass was done with R0 margins. The resected tissue was characterized by a well-circumscribed mass that involved deep soft tissue and skeletal muscle without involvement of underlying bone. The tumor showed hyalinization, fibrosis, and focal calcification. The specimen consisted of one pale pink unoriented ellipse of skin measuring 2 × 1.8 × .5 cm. The epidermal surface showed one brown nodular lesion measuring 1.8 × 1.5 × cm. Histopathologic exam showed skin with focal ulceration and associated granulation tissue overlying a cellular mesenchymal neoplasm composed of monomorphic spindle cells arranged in compact fascicles admixed with coarse collagen bundles, myxoid stroma, and scattered mast cells. Accordingly, the tumor was classified as a monophasic synovial sarcoma . BecauseSurgery was followed by adjuvant radiation treatment and three cycles of chemotherapy with Adriamycin and Ifosfamide. Reconstructive surgery was deemed unnecessary. The patient had regular follow-ups for three and a half years. At the last follow-up, the patient noted pain when trying to write or type for any extended period of time. Also, there were deficiencies in range of motion related to scar tissue from radiation. There was no evidence of any local recurrence of the tumor.Soft tissue sarcomas of the upper extremities are rare with perhaps only one or two undiagnosed soft tissue sarcomas encountered by hand surgeons throughout their entire career . The mosThere may be a long delay in diagnosis, or misdiagnosis, altogether, due to slow growth pattern, varied radiological features, change in size of the tumor, and joint pain which can mimic traumatic pain . TherefoA unique chromosomal translocation t X; 18), , as in our case, involving genes SS18 and either SSX1, SSX2, or SSX4, is involved in the oncogenesis of synovial sarcoma . Synovia, (p11; qAlthough radiologic features of these tumors are not pathognomonic, cross-sectional imaging features are vital for staging tumor extent and planning surgical resection . For locThe prognosis of primary, nonmetastasized disease is related to the age of the patient, with much better relative survival in children compared to older patients, and more genomic instability with increasing age ; whereasA reported case of a 63-year-old woman with a hand resected synovial sarcoma with no metastases followed by radiotherapy and chemotherapy with 12-year disease-free period, came back with local recurrence and died within one year of recurrence, whereas another reported case of a 22-year-old female with local recurrences occurring twice after resection within 10 years and without any metastases, indicating a potential influence of age at presentation upon survival [In conclusion, synovial sarcoma of the hand is a rare, yet highly malignant type of soft tissue sarcoma, for which survival has not improved significantly during the past three decades . This re