Malignant pleural mesothelioma represents a rare etiology of lung cancer metastasis to the brain. Neurologically symptomatic presentations are extremely rare as these metastatic lesions are detected in the late stages of the disease. Despite many highly heterogenous treatment techniques reported in the literature, overall survival is poor. A 72-year-old male with a history of mesothelioma presented with recurrent episodes of altered mental status, confusion and expressive aphasia. Imaging indicated a large hemorrhagic, enhancing lesion in the anterior left frontal lobe resulting in midline shift of 6 mm. He underwent a left frontal craniotomy for resection, after which he had complete resolution of symptoms. The resected mass was metastatic high-grade malignant mesothelioma. On a 1-month follow-up, new lesions in the bilateral frontal lobes were discovered, and despite undergoing adjuvant stereotactic radiosurgery, the right one grew significantly, causing notable mass effect. The patient successfully underwent a right craniotomy for resection. Malignant mesothelioma represents a growth of mesothelial cells strongly associated with asbestos exposures . It can Malignant pleural mesothelioma represents a rare etiology of lung cancer metastasis to the brain with an estimated prevalence of 2–3.8% , 5. BraiA 72-year-old male with a history of prostate adenocarcinoma for which he underwent prostatectomy a year prior and mesothelioma that was discovered during a pulmonary thromboendarterectomy 6 months prior presented to the emergency department with recurrent episodes of altered mental status, confusion and expressive aphasia of 2 days duration. According to his partner, the patient would freeze up in the middle of sentences and be unable to finish them. On physical exam, he was oriented only to person and place. Pupils were equal round and reactive. Cranial nerves were intact. He followed commands with full strength in all extremities. His sensation was intact bilaterally. He did not have any pronator drift or pathologic reflexes. A complete blood count and comprehensive metabolic panel were both within normal limits. Computed tomography (CT) and magnetic resonance imaging (MRI) scans of the head were performed which indicated a large parenchymal hemorrhagic, enhancing lesion in the anterior left frontal lobe with surrounding white matter edema resulting in a midline shift of 6 mm . A seconThe patient presented in this report had a lifelong career in the construction industry with known extensive exposure to asbestos at work sites, known to be a primary risk factor for malignant pleural mesothelioma . There aThe prevalence of central nervous system metastasis from malignant mesothelioma is estimated to be ~2.7% . SymptomWe present a unique case in which a patient’s mesothelioma metastasized to the brain with resulting neurological deficits. As our patient was being treated with mycophenolate mofetil, had high supplemental oxygen demand and was suffering from pneumonitis, it was not feasible to treat with systemic chemotherapy. Despite being successfully treated with total gross resection, the patient had to undergo another craniotomy for resection of a new right frontal lobe lesion that was causing notable mass effect. Through this case, we aim to highlight that despite the employment of multimodal treatment approaches, including surgical excision of symptomatic lesions, further metastatic lesions can occur that complicate treatment plans.No authors have any conflicts financial or otherwise to declare.


Bowel obstruction is a surgical emergency that leads to a high rate of admissions. Twenty percent of patients with acute abdominal pain will be diagnosed with bowel obstruction; eighty percent of them are of small origin. It is classified based on etiology to either mechanical or functional. Mechanical obstruction is a physical barrier that obstructs the passage of bowel content; it could be caused by adhesion, tumors, volvulus, hernias, strictures, and gallstone ileus. Functional obstruction is usually due to impaired peristalsis or metabolic disorders.In this article, we report a case of an 80-year-old gentleman with no previous surgical history who was found to have a bowel obstruction. Diagnostic imaging and colonoscopy showed that his clinical presentation was due to gallstone ileus with cholecysto-enteric fistula and sigmoid mass. He underwent exploratory laparotomy with small bowel resection and sigmoidectomy with primary anastomosis and diverting ileostomy. The final pathology showed early moderately differentiated polyp adenocarcinoma T1N0 and was kept on surveillance.The novelty of this case is the presentation of two different abdominal pathologies, which lead to large and small bowel obstruction. Thus, the management decision was challenging, and a thorough workup is advisable in such cases. Bowel obstruction is a surgical emergency that leads to a high rate of admissions. Twenty percent of patients with acute abdominal pain will be diagnosed with bowel obstruction; eighty percent of them are of small origin . It is cGallstone ileus is a complication of gallstone disease with a rate of 0.3 to 0.5 percent, which is common in elderly patients between 70 to 80 years of age. It represents one to four percent of overall causes of bowel obstruction . It was An 80-year-old male with a past medical history of diabetes mellitus, and no prior history of surgeries, presented to the emergency department with a chief complaint of intermittent diffuse abdominal pain. The pain started suddenly, was colicky in nature, and lasted for three days. It was associated with constipation and vomiting. The patient recalled that a year earlier, he complained of abdominal pain, for which he sought medical attention and was diagnosed with cholelithiasis at another hospital.Upon assessment, the patient was alert, oriented, showing signs of dehydration while maintaining his vitals with normal blood pressure and heart rate. His abdominal exam showed generalized distension with diffuse mild tenderness; there were no signs of peritonitis. Laboratory workup, including complete blood count, urea and electrolyte, liver, and coagulation profile, were unremarkable except for evidence of dehydration.Initially, the patient underwent abdominal radiography, which showed dilated small bowel loops without pneumoperitoneum Figure .Since the patient was clinically stable, he underwent an abdomen pelvis computed tomography (CT), which showed intermediate grade small bowel obstruction due to gallstone ileus with cholecysto-enteric fistula and the presence of pneumobilia Figure .In addition, the CT showed sigmoid mass circumferentially obstructing the lumen Figure . The patResuscitative measures were taken: the patient was kept nil per oral, started on intravenous fluid, and a nasogastric tube was inserted. Since the patient was clinically stable, his abdomen exam was reassuring, and the oral contrast passed beyond the points of obstruction, he was further worked up. An urgent colonoscopy was performed, which showed fungating mass about 50 cm away from the anal verge, which was biopsied.The scope passed to the terminal ilium with difficulty, and no other lesions were noted. Findings and the surgical options were discussed with the patient and family. He then underwent exploratory laparotomy with small bowel resection and sigmoidectomy with primary anastomosis and diverting ileostomy.Intraoperatively, the gallbladder was not visualized as it was decided that a cholecystectomy be performed electively after the emergent procedure. The small bowel was mildly dilated, and around 120 cm from the ligament of Treitz, three stones were noted within the small bowel loops. These segments were adherent to each other with an area suspicious of fistula-like formation in between. This finding could explain the partial rather than complete obstruction he had. This segment was resected; both ends were utilized later for the creation of ileostomy and mucus fistula Figure .Then the attention was diverted to the sigmoid. A mass was noted proximal to the tattooed margin, which involved the whole lumen of the sigmoid. Oncological resection was obtained, and primary anastomosis was done. Given the nutritional status and frailty of the patient, a decision was made not to surgically manage the cholecysto-enteric fistula at the same time and to create a protective ileostomy.Final pathology showed early moderately differentiated adenocarcinoma T1N0M0 Figure . The casLarge bowel obstruction accounts for 80% of total colorectal cancer-related emergencies. In 70% of the cases, the obstruction is distal to the splenic flexure. Despite its high prevalence, diagnosing and managing such cases remains challenging for surgeons. Different surgical options have been described in the literature to approach the obstruction. The management is customized according to the patient's clinical and functional status, tumor staging, and the presence of a specialized surgical team .In our case, the patient presented with typical symptoms of bowel obstruction. Based on the patient's medical history, he was diagnosed with cholelithiasis years before his presentation to ER. In such cases, suspicion of gallstone ileus should always be of concern. Gallstone ileus is a rare pathological outcome of cholelithiasis; it is more common among elderly patients. However, gallstone ileus was reported by a group of colleagues in a 30-year-old gentleman . UsuallyDuring the preoperative workup of the patient, the CT images confirmed the diagnosis and showed another pathology, which was the colonic polyp. Initially, it was thought that the presence of the polyp was an incidental finding, however with the role of colonoscopy, we managed to confirm that it was a partially obstructing mass. The usual treatment of gallstone ileus causing obstruction is the surgical removal through an enterolithotomy with possible segmental resection of the affected bowel. Primary anastomosis or ileostomy creation is then decided based on complication and viability of the tissue. In 2020, Nicholas et al. reported an unusual resolution of obstruction due to gallstone ileus by passing the stones with the bowel motion; however, conservative management was not proposed in the literature as the standard of care . The litIt is extremely rare to encounter multiple pathologies causing bowel obstruction on different bowel segments. Upon reviewing the literature, no cases reported similar presentations, which made the management decision more challenging. Involving a multidisciplinary team in the treatment plan was a crucial step in the management. Bowel obstruction is a well-established abdomen disease with known etiologies. However, in special cases with elderly patients and multiple co-morbidities, a thorough assessment and a complete workup are indicated before a definitive intervention.


The artery of Percheron (AOP) is a rare variant of thalamic vasculature and is a single dominant thalamoperforating artery supplying bilateral paramedian thalamic territories. Occlusion of the AOP results in a characteristic pattern of bilateral paramedian thalamic infarcts and is estimated to represent between 0.1%-0.3% of all ischemic strokes and 4% to 35% of all thalamic strokes. Four distinct ischemic patterns of AOP infarcts have been identified: bilateral paramedian thalamic region with midbrain (43%), bilateral paramedian thalamic without midbrain (38%), bilateral paramedian thalamic with anterior thalamus and midbrain involvement (14%), and bilateral paramedian thalamic with anterior thalamus without midbrain involvement (5%).Despite our knowledge of the characteristic radiologic features of an AOP stroke, the true incidence of AOP strokes is challenging to estimate due to non-specific clinical symptoms and subtle findings on computed tomography (CT) and/or magnetic resonance imaging (MRI). Here, we present a case series of three patients seen within a 3-month span at one community hospital seen by one single neurologist with confirmed AOP stroke by radiologic imaging. The frequency of these cases suggests that the incidence of AOP infarctions may be higher than previously estimated and instead are underreported due to broad differential on clinical and imaging presentation. With an estimated incidence of 4-12% of the population, the artery of Percheron (AOP) is a rare variant of neurovascular supply to the thalami and midbrain [Case 1The patient was a 63-year-old woman with a past medical history of hypertension, chronic obstructive pulmonary disease, obesity, diabetes mellitus, and hyperlipidemia who presented with AMS. Three days prior to admission, she was observed by her granddaughter as being lethargic and drowsy. Labs were significant for leukocytosis, and urinalysis tested positive for white blood cells, nitrates, leukocyte esterase, and blood. Thus, this initial work-up suggested AMS secondary to urinary tract infection, and the patient was treated empirically with ceftriaxone and vancomycin.However, the next day neurology was consulted due to persistent AMS and recommended MRI, which revealed acute infarction of the medial thalamus and a positive “V sign”, hyperintensity along the midbrain adjacent to the interpeduncular fossa Figures -1b. On dCase 2E. coli and the patient was started on ceftriaxone. Her working diagnosis was metabolic encephalopathy secondary to urosepsis.The patient was a 90-year-old Caucasian female with a past medical history of hypertension, advanced Alzheimer’s disease, type 2 diabetes, recurrent urinary tract infections with extended-spectrum beta-lactamase (ESBL), and major depressive disorder, who presented with AMS from an extended nursing facility. On presentation, the patient had a Glasgow Coma Scale score of 8, and vital signs were notable for hypothermia with a temperature of 91.6 °F, which increased to 93.4 °F with external rewarming. Electrocardiogram revealed sinus bradycardia with no signs of arrhythmia. CT Head without contrast was obtained and revealed the absence of acute intracranial hemorrhage or infarcts, but did show several leukodystrophic plaques compatible with chronic microvascular changes. Urinalysis and urine culture was obtained and were positive for pan-sensitive However, after three days of therapy, the patient’s mental status did not improve, so the neurology team was then consulted. MRI revealed large acute infarcts in the medial aspect of bilateral thalami along with acute infarcts found in the left midbrain and right paramidline midbrain Figures -1d. AfteCase 3The patient was a 77-year-old man with a past medical history of cerebral toxoplasmosis and HIV who presented after a fall at home and AMS. The patient also complained of right-sided chest wall and abdominal pain that was reproducible upon palpation. CT Head and angiogram revealed a left middle cerebral artery aneurysm but with no evidence of acute hemorrhage. Urinalysis was positive for leukocyte esterase but was negative for nitrates and blood. Rapid urine drug screen was positive for opiates, and naloxone was administered with minimally positive effect. Encephalopathy in the setting of positive opioid use and central nervous system infection were the two top differential diagnoses given the patient’s previous medical history.On the second night of admission, the patient's blood pressure increased to 207/89 and was controlled with clonidine and lisinopril. On the third day of admission, EEG demonstrated mild diffuse encephalopathy with no clear abnormalities. MRI was performed and revealed bilateral thalamic infarcts and right paramedian midbrain Figures -1f. As aThe incidence of AOP strokes has been estimated to be 0.1-0.3% of all ischemic strokes and as high as 2% of all ischemic strokes . A previClassic symptoms include mental status changes and vertical gaze paresis, which overlap with other neurological disorders such as Wernicke-Korsakoff syndrome and toxic-metabolic encephalopathy . Two outIn the previous cohort of 12 patients in the previous University of Michigan study, all but one had residual deficits on discharge . The oneBecause of our small retrospective sample size, we cannot precisely identify the factors that resulted in delays in diagnosis and intervention with tPA. Thus, earlier suspicion for AOP infarct in our patients may have resulted in prompt intervention and better outcomes. Our case series reminds physicians the incidence of AOP strokes may be higher than previously estimated and to include this rare variant on the differential for mental status changes that are refractory to treatment.


This study sought to describe the case of an 86‐year‐old man who presented to our hospital complaining of abdominal pain, abdominal distention, and loss of appetite for 4 days prior. This case suggests that an amount of accumulated air clearly highlights the intestinal wall, like a “double‐wall sign,” even when the patient is standing. An 86‐year‐old man who had prostate cancer, bladder cancer, type 2 diabetes mellitus, and a history of duodenal ulcer presented at our hospital with abdominal pain, abdominal distention, and loss of appetite for 4 days prior. Physical examination revealed mild tenderness, with no rebound tenderness, on the right upper abdomen, and attenuation of bowel sounds. Abnormalities were not detected during the initial plain erect abdominal radiograph Figure . TherefoPlain abdominal radiographs are helpful for diagnosing intestinal perforation if free air is observed. A double‐wall sign, also known as the Rigler sign, indicates the presence of air along the luminal and peritoneal cavities outlining both sides of the intestinal wall in the supine position. It is one of the most useful findings for detecting pneumoperitoneum with plain radiographs.The authors have stated explicitly that there are no conflicts of interest in connection with this article.Patient consent has been obtained.


Sinonasal renal cell-like adenocarcinoma (SNRCLA) is a newly defined, rare malignant tumor of the nasal cavity. The clinical course and response to treatment remain uncertain. The purpose of this study is to report a new case of SNRCLA and review the literature to determine clinical characteristics, treatment options, and outcomes. A 26-year-old male presented with headache, epistaxis, and nasal obstruction. Physical examination revealed a tumor involving bilateral ethmoid sinuses and MRI revealed extension through the cribriform plate. Surgical excision with endonasal and a bifrontal craniotomy was performed followed by adjuvant radiotherapy (RT). After RT, the patient had persistent disease requiring salvage surgery.There are few previously reported cases of SNRCLA. A literature review yielded 14 previously reported cases with convincing diagnostic evidence of SNRCLA. Common presenting symptoms were epistaxis and nasal obstruction. Surgical excision was the primary treatment in fourteen cases, nine received RT, and none received chemotherapy. However, three cases had persistent or recurrent disease. Surgical excision is the mainstay of treatment for SNRCLA and adjuvant RT has been used in some patients with varying outcomes. The tumor is low grade with no reported cases of metastases or death. The best practice for treatment is yet to be determined. Malignancies of the sinonasal tract are rare, accounting for only 3% of head and neck carcinomas and 0.5% of all malignancies . SinonasAlthough several studies report the pathologic characteristics of SNRCLA, the clinical course and response to treatment is not well described in the current literature. We report a new case of SNRCLA and review previously reported cases to determine its clinical characteristics and outcomes.A 26-year-old male presented to our institution with three to four months of epistaxis, bilateral nasal obstruction, hyposmia, and headaches. Physical examination revealed a large bilateral intranasal mass emanating from the superior nasal vault and extending into bilateral ethmoid sinuses. Magnetic resonance imaging (MRI) with gadolinium contrast revealed a 5.1 cm × 3.3 cm × 3.4 cm enhancing soft tissue mass centered in the ethmoid sinuses with invasion through the ethmoid plate abutting bilateral frontal lobes (Figure After completion of RT, PET imaging at seven months post-op showed persistent disease that had a partial response to RT. Salvage surgery was pursued via combined open and endonasal excision where negative margins were eventually obtained. After salvage surgery, his treatment course was complicated by nasal wound healing complications. He required multiple reconstructive procedures including a skin graft and paramedian forehead flap reconstruction. He is currently without evidence of disease at 16 months after diagnosis.SNRCLA is a rare tumor of the sinonasal tract that does not classify as any of the previously described sinonasal primary tumors . SNRCLA A literature review yielded 14 previously reported cases of SNRCLA, making ours the fifteenth case Table  2,3,6-1-16-12. CSNRCLA is a rare entity, with previous studies focusing on the pathologic characteristics instead of the clinical behavior of the disease. Our literature review supports that SNRCLA is a low-grade malignancy, with a low recurrence rate and no reported cases of metastases. Primary treatment with surgical excision is the mainstay of treatment; however, location along the skull base can lead to difficult surgical management. The role of RT has yet to be determined and further studies are needed to determine best treatment management.


Hematogenous osteomyelitis is commonly reported in long tubular bones in the pediatric population. Acute osteomyelitis involving the patella is extremely uncommon in children, and its diagnosis is frequently delayed due to its rarity and variable clinical manifestations. Chronic granulomatous disease (CGD) is a rare genetic immunodeficiency disorder characterized by severe recurrent bacterial and fungal infections. The most commonly affected sites of infection are the lungs, lymph nodes, skin, liver, and gastrointestinal tract. Acute hematogenous osteomyelitis of the patella associated with CGD has never been reported. Our report describes the first case of acute hematogenous patellar osteomyelitis in a pediatric patient with CGD. Her clinical manifestations were similar to other possible differentials such as septic arthritis; however, use of advanced imaging confirmed the diagnosis, and the patient was successfully managed surgically. Since hematogenous osteomyelitis in children is uncommon, a high index of suspicion and advanced imaging may help with its diagnosis, and in cases where antibiotic treatment proves to be insufficient, prompt surgical management is imperative. Hematogenous osteomyelitis is commonly reported in long tubular bones and occasionally in cuboidal, vertebral, and pelvic bones in the pediatric population ,2. HowevAspergillus spp. is reportedly the most common organism associated with osteomyelitis in CGD, and skeletal infection in CGD is frequently associated with pulmonary aspergillosis, although the exact mechanism is unknown [CGD is a rare genetic condition of congenital immunodeficiency in which an underlying defect of nicotinamide adenine dinucleotide phosphate oxidase complex fails to generate reactive oxygen species in activated phagocytes such as neutrophils, monocytes and macrophages. Patients with CGD are unable to eradicate certain catalase-positive microorganisms including bacteria and fungi, resulting in recurrent infection . The mos unknown .Herein, we report the first case of acute patellar osteomyelitis in a 9-year-old girl with CGD, who was successfully managed surgically. To our knowledge, the current case is the first report on primary patellar osteomyelitis without an adjacent infection focus in a child with CGD. Her clinical presentation and intraoperative findings are explained and discussed in detail, in addition to a review of patellar osteomyelitis in the pediatric population.A 9-year-old girl with CGD was referred to our department from the department of pediatrics with a chief complaint of difficulty in ambulation due to left knee pain persisting for two days without antecedent trauma. She had been hospitalized for recurrent cervical lymphadenitis and multiple liver abscesses and had been on intravenous teicoplanin and cefotaxime. Physical examination revealed painful limitation of motion of the left knee aggravated by full extension, swelling, heating sensation, and tenderness with no penetrating skin injuries. Initial laboratory findings are shown in A Simple radiograph of the left knee showed no definite bony abnormalities other than moderate soft tissue swelling . SubsequWith the initial impression of infectious prepatellar bursitis, patellar osteomyelitis, and septic arthritis of the left knee, arthroscopic debridement and open incision and drainage were recommended; however, her parents strongly refused and opted for conservative management due to the patient’s immunocompromised status. Four weeks after the onset of knee pain, skin breakage with concurrent serous discharge appeared in the prepatellar area . ConsequOne year and six months after the onset of symptoms, the parents and patient finally consented to surgical intervention for left patellar osteomyelitis due to persistent pain, infection, and functional deficit. On admission to the department of orthopedic surgery, initial laboratory findings are shown in Following diagnosis of chronic osteomyelitis and abscess in the left patella, open lavage and debridement of abscess and sequestrum at the patella were planned by an anterior approach without arthrotomy. Intraoperatively, active pus and hypertrophied synovium were noted upon skin incision, and swab culture was performed. Necrotic bone debris and sequestrum at the patella were thoroughly curetted and debrided with massive irrigation through medial and lateral bone defects on the anterior cortex of the patella along with tissue culture and bone biopsy . The intTwo weeks after the discharge, follow-up laboratory investigations conducted at the outpatient clinic revealed WBC, CRP, and ESR within normal ranges, and the clinical examination was unremarkable without pain . At the In this study, we reported an extremely rare case of osteomyelitis with patellar involvement in a 9-year-old patient with CGD, a congenital immunodeficiency disorder. Surgical treatment of chronic patellar osteomyelitis was significantly delayed by the parents’ refusal due to the patient’s underlying immunocompromised status, invasive bacterial infection involving multiple organs, and recurrent liver abscess. To our knowledge, no incidence of patellar osteomyelitis has been reported in pediatric patients with CGD.Aside from its uncommon incidence rate of 2.9 per 100,000 children, the age of peak incidence of osteomyelitis is reportedly between 5 and 15 years ,8. The pAccurate diagnosis of patellar osteomyelitis is challenging and often delayed due to its rarity and variable clinical manifestations. Initially suspected diagnoses usually include septic arthritis, cellulitis, bursitis, and synovitis . ChildreCurrently, treatment guidelines or recommendations for patellar osteomyelitis are not well established. Most cases of hematogenous osteomyelitis in pediatric patients are managed using antibiotics, but the presence of abscess or sequestrum requires surgical debridement . Our revStaphylococcus aureus. In addition, unlike other forms of hematogenous osteomyelitis, 22 of the 28 (78.6%) patients underwent surgical management for hematogenous patellar osteomyelitis. Its rarity and difficulty in diagnosis, delay in commencement of antibiotics, or subsequent fistula or abscess formation may have contributed to the relatively higher rate of surgical management [In the literature, although few cases were confirmed despite the absence of bacterial growth, the most commonly cultured pathogenic organism was nagement . Surgicanagement . In addiIn conclusion, we report an extremely rare case of hematogenous osteomyelitis with patellar involvement in a 9-year-old girl with a congenital immunodeficiency disorder. Despite frequent reports on rarity, delay, and difficulty in diagnosis of patellar osteomyelitis, a high index of suspicion, close clinical monitoring, and application of advanced imaging modalities such as gadolinium-enhanced MRI are highly recommended. Although antibiotic treatment is generally sufficient for the management of osteomyelitis in pediatric patients, prompt surgical treatment is reserved for those with delay in diagnosis and persistence in spite of antibiotics treatment in pediatric patellar osteomyelitis.


Endometriosis is an estrogen-dependent chronic disease affecting about 10% of reproductive-age women with symptoms like pelvic pain and infertility. Pathologically, it is defined by the presence of endometrial tissue outside the uterine cavity responsible for a chronic inflammatory process. For decades the diagnosis of endometriosis was based on surgical exploration and biopsy of pelvic lesions. However, laparoscopy is not a risk-free procedure with possible false negative diagnosis due to an underestimate of retroperitoneal structures such as ureters and nerves. For these reasons nowadays, the diagnosis of endometriosis is based on a noninvasive approach where clinical history, response to therapy and imaging play a fundamental role. Trans-vaginal ultrasound and magnetic resonance imaging are suitable for recognizing most of endometriotic lesions; nevertheless, their accuracy is strictly determined by operators’ experience and imaging technique. This review paper aims to make radiologists aware of the diagnostic possibilities of pelvic MRI and familial with the MR acquisition protocols and image interpretation for women with endometriosis. Diagnostic laparoscopy is considered the gold standard for endometriosis, but it is invasive with possible false negative results.Nowadays there is a paradigm shift from surgical to non-invasivediagnosis based on symptoms, response to therapy and imaging.MRI is highly accurate for the diagnosis of Deep Infiltrating Endometriosis.The diagnostic results of MRI depend on an accurate imaging technique and on the comprehension of specific MR-findings.Endometriosis, particularly deep pelvic infiltrating endometriosis (DIE), is a clinical issue affecting premenopausal women who may experience severe pelvic pain and infertility . These sLaparoscopic exploration is considered the diagnostic golden standard, because it allows for direct visualization of lesions; however, it is not a risk-free surgery and may underestimate retroperitoneal structures, such as nerves and ureters, with possible false negative procedures , 7. BecaEndometriosis is a complex and heterogeneous disease that may manifest with three clinical patterns with increasing severity. Superficial peritoneal lesions are characterized by superficial implants of the pelvic peritoneum; ovarian endometriomas (OMA) are hemorrhagic cysts arising from ectopic endometrial tissue growing within the ovaries and less frequently outside the ovaries , 14; andMRI is a widely used technique for the diagnosis of DIE; however, an international consensus on the best imaging protocol is lacking. Recent guidelines published by the European Society of Urogenital Radiology describe consensus suggestions from a conference among nine imaging centers in Europe and one in Japan ; howeverMRI for endometriosis should be performed with a 1.5 T or 3 T scanner and high-resolution phased array coils (with 8–16 channels), whereas low-magnetic field or open-MRI lacks sufficient image quality to image DIE. High-resolution, thin section (3 mm) TSE-T2w sequences in the sagittal, axial and coronal planes are crucial to evaluate DIE, whereas TSE T1w (with and without fat saturation) should always be obtained to depict adnexal hemorrhagic lesions such as OMA. Oblique planes may be highly useful to visualize specific anatomical structures such as utero-sacral ligaments  images appear to be useless in the diagnosis of DIE. However, for specific indications, the injection of Gd-based contrast agent may be advisable. CE-images are mandatory in cases of complex adnexal hemorrhagic cysts showing mural thickening or other potentially malignant features in T2w images. Similarly, the use of contrast agents may aid in differentiating endometriomas from luteal ovarian cysts or tubo-ovarian abscesses , 37. In No consensus exists in the literature regarding the usefulness of vaginal and rectal opacification for the diagnosis of DIE; some authors find them extremely useful and have proposed the use double contrast barium enema or cross-sectional colonography with either CT or MRI –42, wherThe imaging evaluation of endometriosis should be guided by the statistical frequency of involvement of the pelvic anatomy  and be cAnterior compartment is the space limited anteriorly by the pubic symphysis and posteriorly by the uterus and contains the urinary bladder, the vesico-uterine fold and the round ligaments. The middle compartment contains the uterus and the ovaries, while the posterior compartment can be divided into the recto-uterine, recto-cervical spaces and the recto-vaginal septum and contains the serosal surface of the uterus, the pouch of Douglas, the torus uterinus, the USL well as the rectum and the sigmoid colon.Endometriosis is a multifocal disease that may involve multiple pelvic structures with possible extra-pelvic extension. OMA, superficial peritoneal lesions, and DIE have been reported in surgical series studies to affect the ovaries in 65–80%, 45–50%, and 63–70% of women, respectively , 47, 48.OMA may manifest as solitary or multiple thick-walled cysts showing homogeneous high signal intensity in T1w and fat-saturated T1w images regardless of the intensity in T2w images. According to the age at bleeding onset, OMA may be either hyperintense or hypointense in T2w images or may show a typical stratified appearance (shading sign), as a result of cyclic bleeding with blood products accumulating over the course of months Fig.  37]. In. In37]. DIE can manifest as pelvic nodules or plaque-like lesions and adhesions , 52. NodDiagnosis of bowel involvement is based on the presence of a nodular or plaque-like endometriotic bowel wall thickening and loss of the fat tissue plane between the intestinal loop and the uterus or other adjacent organs. The most frequent sites of bowel endometriosis are the rectum and the sigmoid colon, while the involvement of the cecum or the ileum can be found in about 5% cases Table . The diaEndometriotic nodules of the anterior or lateral pelvic compartment are less frequently observed and usually involve the urinary system, particularly the vesical dome for nodules of the vesico-uterine fold Fig.  and the In many cases, MRI may depict pelvic changes consistent with the presence of adhesions, which indirectly suggest DIE. In general, adhesions are suspected when fatty interfaces between adjacent structures are not clearly visible in any orthogonal planes. The most reliable finding to diagnose endometriotic adhesions is tethering and angulation of normal pelvic structures and bowel loops Fig. . AdhesioAnterior pelvic adhesions usually occur between the uterus and the bladder for plaque-like or linear implants in the vesico-uterine pouch, which may be visible as small spots with high signal intensity in the sagittal T1w fat-saturated images Fig.  but can Neural endometriosis is a rare condition characterized by perimenstrual radicular pain with no evidence of any alteration of the lumbar spine. The most affected nerves are the sacral plexus (57% of cases) and the sciatic nerve (39% of cases) , 55. MRIAdenomyosis in 30% of cases is associated with DIE; the presence of ill-defined nodules with hyperintense foci within uterine wall in T1w and T2w images or a thickening of the junctional zone > 12 mm, is the most common findings of this specific condition Fig. ; howeverBecause of its extreme clinical heterogeneity, pelvic endometriosis remains challenging to diagnose. Current evidence demonstrates that the disease should be diagnosed non-invasively by combining the information from patient history, clinical examination, imaging and response to medical treatment . Because


Infertility is a common medical issue with different etiologies. It can be related to female factors, male factors, or factors related to both partners. We report the case of a 35-year-old male patient who presented with primary infertility for 10 years. He was otherwise healthy with unremarkable past medical history. Physical examination revealed normal external genitalia with both testes were normal in size. Basic semen analysis revealed decreased sperm volume and sperm count. Abdominal ultrasound examination revealed an absent right kidney. Subsequently, the patient under a computed tomography scan that confirmed the right renal agenesis and demonstrated a well-defined right seminal vesicle cyst. Such findings were consistent with the diagnosis of Zinner syndrome. He underwent aspiration of the cyst that resulted in improvement in the sperm parameter of basic semen analysis. The case demonstrated a rare etiology of male infertility that was successfully managed conservatively. Despite its rarity, physicians should consider the developmental anomalies of the genitourinary system when encountering patients with infertility. Infertility is a prevalent health condition affecting up to 10% of the population and has significant psychological, economic, and medical implications . InfertiWe report the case of a 35-year-old male patient who presented to the infertility clinic with primary infertility for 10 years. He has a regular sexual activity every three days with no difficulties related to libido or potency. He had no urinary complaints. He has no history of smoking or alcohol drinking. The family history was unremarkable for infertility. The past medical history was non-contributory.His spouse is a 30-year-old woman with no health issues. She has regular menstrual cycles with no history of dysmenorrhea or menorrhagia. She had not undergone any operations in the past and had no history of sexually transmitted diseases. They reported that the problem of infertility was having a significant psychological impact on their lives.Physical examination of the patient showed normal abdominal and genital examination with both testes were in size. Physical examination of the spouse revealed a soft abdomen with no masses or tenderness. Bimanual pelvic examination was normal.Basic semen analysis was performed for the patient, which revealed a normal semen color and viscosity, a semen volume of 2 ml, and a sperm count of 10 million. Basic laboratory investigations, including hematological and biochemical tests, were within normal limits. Otherwise, his spouse had a normal hormonal profile with an unremarkable ultrasonic examination of the pelvis. Additionally, her hysterosalpingography examination showed a normal uterus and patent fallopian tubes.Subsequently, the patient underwent a bedside ultrasound which revealed an absence of the right kidney. Computed tomography examination confirmed the finding of right renal agenesis and a well-circumscribed cyst in the pelvis Figure , 2. SuchAccordingly, the patient was planned to have a transurethral aspiration of the seminal vesicle cyst combined with minocycline sclerotherapy. Analysis of the aspirated fluid revealed spermatozoa. A few months later, the patient repeated the basic semen analysis and showed improvement in the sperm parameters. We reported a case of Zinner syndrome, which is a rare congenital genitourinary anomaly that was first described in 1914 . It is cThe common embryologic origin of the genital and renal systems explains the association of seminal vesicle cyst and the ipsilateral renal agenesis in this syndrome. It is thought to be related to an in-utero insult resulting in maldevelopment of the distal Wolffian duct. Hence, some authors describe this syndrome as the male counterpart of the Mayer-Rokitansky-Kuster-Hauser syndrome .The diagnosis of Zinner syndrome can accurately be reached by imaging. Magnetic resonance imaging is the modality of choice to evaluate the anatomy of the genital tract. However, since it was not available in our institution, a computed tomography scan was performed.The management of Zinner syndrome depends on the clinical manifestation. Regular surveillance is sufficient for asymptomatic patients. Aspiration of the seminal vesicle cyst can be curative as in the present case. Surgical treatment and assisted reproductive techniques, such as in-vitro fertilization can be offered if the conservative management was not successful . LaparosThe case demonstrated a rare etiology of male infertility that was successfully managed conservatively. Despite its rarity, physicians should consider the developmental anomalies of the genitourinary system when encountering patients with infertility. Imaging modalities have the ability to make an accurate diagnosis of such anomalies.


Choroidal melanoma, although rare, is the most common primary intraocular malignancy among adults, with an incidence ranging from 6 to 7.5 cases per million per year globally. This tumor originates from the uveal tract’s melanocytes in the eye. Melanomas usually arise from the sixth decade of age with increasing incidence with progressive age.A 60-year-old male presented with a right-sided sudden painless decrease in vision due to a grade 4 vitreous hemorrhage. B-scan ultrasonography and CT scan of the orbits revealed a mushroom-shaped choroidal mass highly suggestive of choroidal melanoma, which was managed surgically with pars plana endoresection, endodiathermy, and endolaser.Endoresection can be an effective method for the management of solitary non-metastasized choroidal tumors, especially those that have become symptomatic. Pre and post-surgical imaging are necessary, along with careful follow-up to detect any recurrence. Uveal melanoma, although rare, is the most commonly diagnosed primary intraocular malignancy in adults with a mean age-adjusted incidence of 5.1 cases per million per year in the United States from 1973 to 2008)  to 2008 . The medBlurred vision is the most common presenting symptom of primary uveal melanoma , which wThese tumors have a high propensity to metastasize, as 50% of patients develop metastatic disease despite primary therapy and active surveillance ,6,7. LivThe primary treatment for localized uveal melanoma can be classified into globe preserving therapy or enucleation, the latter being most appropriate for tumors that have caused permanent vision loss, those with extensive extraocular growth, or those with very large diameters . AlthougEndoresection via the pars plana route , with or without brachytherapy, has been described previously by several authors as an alternative to enucleation for posteriorly located uveal melanomas, with excellent local control and eye salvage rate, and was not associated with a higher risk of metastasis, death, or local recurrence than other reported techniques used to treat similar melanomas ,16.A 60-year-old gentleman who was previously diagnosed with type 2 diabetes mellitus, hypertension, and a cerebrovascular accident, which he suffered two years prior to presentation, which left him with residual right-sided upper and lower limbs weakness, for which he is undergoing physiotherapy with continuous improvement, presented with a history of right eye sudden painless drop in the vision of one-day duration. He denied any history of trauma to the eye or head and gave no history of previous eye symptoms or surgeries. Apart from the right-sided upper and lower limb weakness, his general and systemic examination was unremarkable.His ophthalmic examination showed visual acuity of hand movement in the right eye and 6/6 in the left eye, with normal intraocular pressure in both eyes (18 mmHg in the right and 12 mmHg in the left). Slit-lamp biomicroscopy showed grossly normal anterior segments of both eyes with immature cataracts. Fundus examination of the right eye by binocular indirect ophthalmoscopy showed no view of the retina due to a grade 4 vitreous hemorrhage, while fundus examination of the left eye was unremarkable.B-scan ultrasonography of the right eye showed a large mushroom-shaped mass invading the choroid and retina, and protruding into the vitreous cavity in the inferior aspect of the posterior pole Figure  with a sMagnetic resonance imaging (MRI) of the orbits was also done and showed a small mass suggestive of a choroidal melanoma along the posterior aspect of the right globe extending into the vitreous and measuring 8 x 6 mm. The lesion appears of high signal intensity on T1-weighted images and low intensity on T2-weighted images and shows mild contrast enhancement in the post-contrast images. The vitreous body shows an abnormal V-shaped appearance with abnormal high signal intensity on T2-weighted images mostly suggestive of vitreous hemorrhage with posterior vitreous detachment Figures -5.Additional testing included positron emission tomography (PET) scan, chest X-ray, and laboratory studies, which included complete blood count (CBC), serum electrolytes, and liver function test (LFT), which were all within normal limits, excluding the possibility of metastasis to the lungs and liver, and confirming that the choroidal mass is a localized primary ocular mass.After discussing the treatment options with the patient, and due to the unavailability of plaque brachytherapy and the concurrent presence of a vitreous hemorrhage, which would already mandate a pars-plana vitrectomy, a decision was made to book the patient for an early surgical transretinal endoresection via the pars plana route.Under local anesthesia (peribulbar block), routine phacoemulsification complicated by a posterior capsular rent was first done with the implantation of a sulcus intraocular lens. Then, a standard 23-gauge three-port pars plana vitrectomy was performed to clear the vitreous hemorrhage, after which a mushroom-shaped mass measuring approximately 6 disc diameter in size Figure . This waBoth solid biopsy specimens and diluted vitreous samples from the aspirated fluid were sent to the lab for histopathological examination. However, the pathologist report showed that there was not enough sample for adequate histopathological grading, with mainly melanocytes in the slide.At one week post-operation, the best-corrected visual acuity of the right eye had improved to 6/36 with remaining anterior uveitis and fundus examination showed a flat retina with white laser marks around the retinotomy. At one month post-operative, the visual acuity had further improved to 6/9 with a flat retina and silicone oil tamponade in situ. Optical coherence tomography (OCT) of the macula Figure  at one mPost-operative MRI, which was done at one week post-operative to ensure complete resection, showed no evidence of residual tumor, and complete resolution of the exudative retinal detachment was seen pre-operatively, with a visible silicone oil bubble in the globe Figure .The patient was also referred to the oncology department to continue monitoring tumor control in liaison with the ophthalmology department with regular follow-up appointments, and he will be posted for silicone oil removal after six to nine months.In this case report, we are sharing our experience of managing a solitary non-metastasized choroidal melanoma by pars plana endoresection, endodiathermy, and endolaser photocoagulation, which is, to the best of our knowledge, the first case of choroidal melanoma managed by pars plana endoresection to be reported in the Kingdom of Bahrain.Globe preserving treatment modalities for localized choroidal melanoma such as brachytherapy have started to replace enucleation over the last decade ,11. HowePatients’ expectations and lifestyles are also very important factors to consider in the treatment plan of such cases. Our patient was extremely alarmed by the visual loss that he suffered after developing vitreous hemorrhage, and despite retirement, he was still an active person establishing his private business and leading a socially active life. He clearly needed to maintain as good a vision as possible, as long as possible for him to maintain his quality of life. All these factors were thoroughly discussed with the patient when the treatment options were explained.The most anticipated complications of tumor endoresection are cataract development and retinal detachment. Patients should be made aware of these complications and should understand the importance of continued follow-up. We managed to address the cataract at the time of surgery, because our patient had already had an early cataract in the affected eye, and phacoemulsification with intraocular lens implantation was done at the beginning of the surgery. Regular follow-ups with complete ophthalmic examinations will continue to be conducted to detect any recurrence of the subretinal fluid and/or retinal detachment.Local disease control of choroidal melanoma is reportedly excellent regardless of the treatment modality chosen. However, up to 50% of patients ultimately develop metastatic disease despite treatment , which iEndoresection can be an effective method for the management of solitary non-metastasized choroidal tumors, especially those that have become symptomatic. We presented this case to demonstrate how delicate endoresection via the pars plana route, combined with endodiathermy and endolaser, can be performed to successfully remove the tumor while preserving the patient’s central vision and the globe. This approach, though technically challenging, has proved to be useful when dealing with posteriorly located tumors that are easily accessible through the pars plana, and when the tumor is away from the fovea and optic nerve head. Compared to older modalities such as enucleation and radiotherapy, it has the advantage of preserving the globe and vision, which definitely has a huge impact on the patients' quality of life. However, lifelong follow-up is necessary to detect any signs of local recurrences timely.


Echinococcus granulosus sensu lato (E. granulosus s.l.), can be primary or secondary. However, primary disseminated intraabdominal hydatidosis is a rare form of the disease, accounting for about 2% of all intraabdominal cysts.Hydatidosis, a zoonotic disease caused by the larvae of We report herein a case of primary disseminated intraabdominal hydatidosis with multiple organ involvement in a 51-year-old Iranian man presenting to a healthcare facility with abdominal pain. During the physical examination, two abdominal masses were palpated. Ultrasound and computed tomography revealed six cystic lesions in the patient’s liver, subhepatic region, pelvic, and omentum. Afterward, he underwent surgery, during which the cystic lesions were completely removed. The patient received albendazole (400 mg/kg/day) postoperatively and was recommended to continue the treatment for 4 months.Although primary disseminated intraabdominal hydatidosis is rare, this problem is of great importance due to the fertility of cysts and the high risk of recurrence. Therefore, it is recommended to follow such patients with imaging modalities and enzyme-linked immunosorbent assay for native antigen B (AgB). In addition, patients should undergo albendazole therapy postoperatively for 4 months. Echinococcus granulosus sensu lato (E. granulosus s.l.). Canids and ungulates are the definitive and intermediate hosts in the life cycle of E. granulosus, respectively. However, human is an accidental intermediate host [E. granulosus eggs [Hydatidosis (cystic echinococcosis) is a zoonotic disease caused by the larvae of ate host . The orgate host . Howeverate host . Also, hate host , with prsus eggs . Howeversus eggs . Severalsus eggs , 6. Thersus eggs . We repo3/µL, including 68% neutrophils and 32% lymphocytes. Also, the patient underwent enzyme-linked immunosorbent assay (ELISA) for native antigen B (AgB), which was positive. Abdominal ultrasound and CT scan revealed six cystic lesions in the patient's abdomen, including two in the right hepatic lobe, one in the left hepatic lobe, one in the subhepatic region, one in the pelvic, and one in the omentum  count of 10.4 × 10E. granulosus (Fig. Examination of a direct smear of fluid from the hydatid cysts revealed brood capsules and protoscoleces of sus Fig. . In addiE. granulosus s.l., E. ortleppi, E. equinus, and E. canadensis, has a cosmopolitan distribution, with an estimated annual incidence above 50 cases per 100,000 people in the human population of endemic areas [Hydatidosis, a zoonotic disease caused by larvae of ic areas . Moreoveic areas . Althougic areas . The cysic areas , while aic areas .The disease is usually diagnosed on the basis of serological and imaging techniques . The WorMost intraabdominal hydatid cysts are asymptomatic because they grow quite slowly . Some haAlthough disseminated intraabdominal hydatidosis is rare, its management is highly important. In the present case, microscopic examination showed that the excised cysts were fertile. Given the multiple organ involvement, the fertility of the cysts, and their possibility of rupture or leakage during surgery, the risk of secondary cyst development and disease recurrence is increased. Therefore, it is recommended to follow up the patient using imaging modalities and ELISA. Also, albendazole therapy should be started and continued for 4 months postoperatively.


Wallerian degeneration of the cerebral peduncle is a common MRI finding after cerebral injury. The degree of peduncular atrophy reflects the extent of damage in the corticospinal tract. The acute phase of Wallerian degeneration is visible with Diffusion-Weighted-Imaging. New investigation with Diffusion-Tensor-Imaging quantifies Wallerian degeneration in the subacute ischemic phase and is a good predictor for later functional recovery after stroke. Wallerian degeneration (WD) in the central nervous system produces a contiguous tract of gliosis, starting at a damaged region of cerebral cortex and running through the deeper brain structures according to the topography of the involved white-matter tracts. The process starts immediately after injury but evolves to complete after months-to-years. On Magnetic Resonance Imaging (MRI), chronic WD of the corticospinal tract can be observed as shrinkage of the ipsilateral cerebral peduncle . We hereFigure 1) and three years later .MRI of a 65-year-old woman with left hemiplegia caused by an embolism. MRI during acute stroke  are compared to MRI three years later .MRI of an 83-year-old man with aphasia and right hemiplegia caused by intracerebral hemorrhage. Compare computed tomography (CT) and MRI during the hemorrhage .MRI of a 61-year-old woman with glioblastoma multiforme in the left cerebrum. Figure 7 shown the CT and MRI at time of trauma, and Figure 8 shows the respective size and T2-WI signal intensity of the cerebral peduncles over time .MRI of a 53-year-old woman with brain trauma due to a fall. Eventually she developed spastic paresis, especially on the left side. Figure 9).MRI of a 42-year-old woman with a large arachnoid cyst .MRI of a 2-year-old girl with hypoplastic left cerebrum (The degree of poststroke and posthemorragic peduncular atrophy is correlated with size of cerebral injury 3. DeduceIn addition to the chronic atrophy of the cerebral peduncle on the long term, the acute signs of WD are also visible on MRI by Diffusion-Weighted-Imaging. It is important to recognize these diffusion-restricted areas as acute WD from damage higher in the ipsilateral corticospinal tract, and not to mistake these with secondary zones of infarction .More recent investigation with Diffusion-Tensor-Imaging brought more insight on the progress of WD by the measurements of fractional anisotropy: the process of WD in the subacute phase of ischemia proved to be a predictor for later functional recovery .Cerebral injury frequently leads to Wallerian degeneration of the cerebral peduncle. It reflects degree of cerebral damage and predicts functional recovery, making it worth mentioning in the radiologic report.


Case Presentation. A 23-year-old male was admitted to the surgical ward as a case of acute appendicitis with localized tenderness in the right iliac fossa, positive rebound tenderness, a positive Rovsing's sign, and ultrasound findings of suspected complicated appendicitis. Appendectomy was performed. Histopathological examination of the appendectomy specimen revealed a double-expressor non-Hodgkin diffuse large cell lymphoma with Burkitt's-like morphology. He was sent for chemotherapy treatment.  Appendiceal lymphoma is a very rare entity accounting for 0.015% of all gastrointestinal lymphoma cases. Acute appendicitis is the most common presentation of primary appendix neoplasms. Burkitt's lymphoma presenting as an acute appendicitis is a rare entity with around 21% of the cases presenting as a lower iliac fossa mass.  Only 34 cases of Burkitt's lymphoma have been reported to present as acute appendicitis. Histological examination following appendectomy for an apparent appendicitis is essential. Furthermore, complete blood count and a computed tomography scan aid the diagnosis of lymphoma. Double-expressor lymphoma has been shown to have poor outcomes. Therefore, prompt and aggressive treatment is vital. Neoplasms of the appendix are rare and account for only 0.5 to 1 percent of intestinal neoplasms . AppendiBurkitt's lymphoma (BL) is a highly aggressive B-cell non-Hodgkin lymphoma characterized by the translocation and deregulation of the Myc gene on chromosome 8. A case series of 116 patients with appendiceal lymphomas showed that BL was the second most prevalent pathology, diagnosed in 25.9% of patients ..5].A cohort study by Alexander H. Mimery revealed that most of the patients with appendiceal lymphoma were predominantly males accounting for 66.7% of the cases and the average age of onset was around 20 years. A palpable right iliac fossa mass was only identified in around 21% of the cases. However, an appendectomy was done in 65% of the cases (22 out of 34 cases), while 8 of the cases ended up in right hemi-colectomy.Burkitt's lymphoma, although rare, may present as an acute appendicitis. Complete blood count and a computed tomography scan aid the diagnosis of lymphoma. Moreover, immunohistochemistry testing helps in detecting double/triple-hit Burkitt's lymphoma which has worse prognosis.Only 34 cases of Burkitt's lymphoma have been reported to present as an acute appendicitis.


Left ventricular pseudoaneurysm due to early left ventricle rupture is a serious complication after cardiac surgery. Urgent surgery is recommended in most cases with a high mortality rate. Conservative treatment of a left ventricular pseudoaneurysm due to early left ventricle rupture is very rare.We present a 61-year-old woman with left ventricular pseudoaneurysm after mitral valve replacement due to early left ventricle rupture. This patient was treated in a conservative approach. This patient had an uneventful recovery. She was in good condition and remained asymptomatic 3.5 years after mitral valve surgery.This case suggests that medical treatment left ventricular pseudoaneurysm patients has a limited but acceptable role in selected and unusual circumstances.The online version contains supplementary material available at 10.1186/s13019-021-01436-8. Left ventricular pseudoaneurysm (LVPA) is a contained left ventricle (LV) rupture which is encircled by adherent pericardium or scar tissue. It is a potentially fatal condition with a high risk of rupture. As a rare and serious complication after cardiac surgery, LVPA mainly occurs after mitral valve surgery. Urgent surgical intervention is recommended as the first choice in most cases with a high mortality rate of 57.4% . We repo2. She was admitted for MVR due to severe combined mitral valve stenosis and insufficiency. Preoperative transthoracic echocardiography (TTE) revealed rheumatic chordal shortening and severe mitral leaflet thickening with a preserved LV function of 59%. Electrocardiogram showed persistent atrial fibrillation. At the time of surgery through a median sternotomy, the valve was assessed unsuitable for repair. The anterior mitral leaflet was totally removed. Most of the posterior mitral leaflet was preserved. An MVR was performed with a 27 mm Mosaic® bioprosthesis . The valve was implanted using everted interrupted pledgeted polyester sutures. After discontinuation of cardiopulmonary bypass and closure of the sternum, the drapes were removed. However, before the patient was transferred out of operating room, a total of 700 ml bleeding was observed from the pericardial drainage tube during a short period of 20 min. The sternum was immediately re-opened. Careful exploration revealed no major bleeding from either the mediastinum or the pericardial cavity. After 30 min of observation with no major bleeding, the sternum was closed. Post-operative bleeding in the subsequent 24 h from the pericardial drainage tube was 200 ml. She was extubated the second day after surgery. The postoperative course was uneventful.A 61-year-oldwoman with left hemiparalysis and seizure caused by previous cerebral infarction was referred with fatigue and progressive dyspnoea on exertion. She had severe cardiogenic dyscrasia with a body weight of 32 kg and body mass index of 12.8 kg/mHowever, we noted an aneurysm-like cavity (29 × 25 mm) proximal to mitral annulus on the posteroleteral wall of the LV on postoperative day 10 during routine postoperative TTE , which had inflow synchronizing a cardiac cycle, from left ventricle to pseudoaneurysm in systole and from pseudoaneurysm to left ventricle in diastole.Additional file 1: Based on these findings, surgery was recommended immediately. However, both the patient and her family rejected our proposal due to high surgical mortality and her worsened frailty. Hence, we started the optimal conservative management. She was started on warfarin to prolong the prothrombin time  to 2.0. Her blood pressure was monitored and controlled. She was discharged on postoperative day 15 with stable clinical condition under the administration of warfarin because of persistent atrial fibrillation. Six months after MVR, TTE showed no blood communication between the clot-filled pseudoaneurysm and the LV (Fig. Video 2. Follow-up transthoracic echocardiogram in apical four-chamber view showed no blood communication between the clot-filled pseudoaneurysm and the left ventricle.Additional file 2: Left ventricular pseudoaneurysm after mitral valve surgery is a type of rare and lethal condition derived from rupture of LV. It can take place after both mitral valve repair  and replLeft ventricular pseudoaneurysm develops only when LV rupture is barely contained by adherent pericardium or scar tissue. Left ventricular rupture was classified according to the timing of rupture . Early rAlthough prompt surgical repair have been recommended as the method of first choice to prevent LVPA rupture, surgical repair may be hesitant because of the high mortality rate. In consideration of her extremely low body mass index and advanced comorbidity in our case, immediate surgery of this LVPA was believed to have an exceedingly high mortality rate. However, the aneurysmal neck and dimension of the LVPA was fortunately small, which made a conservative management feasible and successful despite continuation of warfarin therapy. During the long-term follow-up, the patient showed stable clinical and hemodynamic conditions. This interesting case suggests that conservative treatment can be an alternative in appropriate patients.Although 30–40% of untreated pseudoaneurysms rupture in the first year , the treWe presented a rare case of conservatively managed LVPA after early LV rupture. This case suggests that medical treatment LVPA patients has a limited but acceptable role in selected and unusual circumstances.


Background: Paravertebral localization of primary undifferentiated pleomorphic sarcoma (UPS) with bone and vascular involvement is infrequent and challenging. Multi-step surgical procedure has been described as a feasible and effective option to achieve sustained local tumor control.Methods: We report on a 62-year old man with paravertebral UPS infiltrating the aortic wall and the 9th thoracic vertebra who underwent a multi-step surgical procedure aimed at achieving oncologic radicality through a coordinated effort between thoracic, vascular and spinal surgeons. After balancing the risks and benefits of perioperative therapies, upfront surgery was performed including aortic resection with bypass grafting followed by a triple en bloc vertebrectomy with tumor excision. Mid-term follow-up (22 months) is then provided.Results: The combined procedure achieved oncological radicality and no local recurrence in the mid-term. No major complications occurred.Conclusions: Multi-step and multi-specialty surgery is a feasible and effective strategy to treat primary UPS in unfavorable localization. A strategic cooperation between surgeons and a multidisciplinary tumor board is required to define an optimal, personalized treatment strategy in sarcoma patients. Previously known as malignant fibrous histiocytoma, UPS is a rare high-grade mesenchymal neoplasm that may arise ubiquitously . RadicalIn this single case report, we describe a challenging multi-step upfront surgery aimed at providing oncologic radicality in a patient with locally-advanced paravertebral UPS.A 62-year-old man presented with abdominal pain in suspected kidney stone disease. The patient underwent a multiphasic abdominal CT scan which confirmed urolithiasis and showed a 25 × 19 mm paravertebral soft tissue lesion anterior to 9th thoracic vertebrae (T9), encasing the descending thoracic aorta . Notably18F-FDG-PET/CT) showed intense radiopharmaceutical uptake and excluded distant metastases  confirmed an extensive T9 bone involvement and a focal infiltration of the aortic wall . 18-fluotastases . A CT-guen bloc vertebrectomy. A bovine pericardium patch was finally employed to wrap the excluded structures and prevent adhesions. The early postoperative course was uneventful.As a first stage, after a low-dose heparin infusion, left thoracotomy was performed with the patient in right 60° lateral decubitus. Using an aortic side-clamp to prevent visceral and spinal cord ischaemia, a silver coated dacron aortic graft was anastomosed in an end-to-side fashion to the proximal aorta and distal to the region involved by the tumor. Low-dose heparin was promptly converted after aortic repair without the need for extracorporeal circulation support. The infiltrated aortic segment (8 cm-length) was therefore stapled and transected . The excThirteen days later, T8-T9-T10 vertebrectomy was performed. After a midline posterior spine incision, with the assistance of an O-arm and a spine navigator, peduncular screws were placed in T6-T7 and T11-T12. 4.5-mm titanic screws, connected with retractors, were placed to allow the posterior detriment of the T8-T9 and T10 vertebral elements. Spinal reconstruction was performed by placing an expandable cage in PEEK material filled with autologous and synthetic bone. Titanium screws were then replaced with carbon fiber screws .Blood loss was about 2,300 ml. The patient was recovered in the ICU for initial ventilation support and after 48 h was admitted to the ward. No neurological deficits were identified. A dehiscence of the surgical wound, requiring vacuum-assisted closure and antibiotics, was documented. The patient was eventually transferred for rehabilitation after 29 days from the procedure. The resection consisted of three vertebral bodies  and a 5 cm-tract of aorta. The tumor was grossly sized 3.6 cm in maximum diameter and was located between the aorta and the vertebral body, which was fixed to the aortic wall. At cutting section, T9 was soft, mostly non-ossified and fleshy in appearance. The neoplasm showed no immunohistochemistry positivity to alpha-SMA (1A4), p63, CD34, desmin, NGFR, MDM2, myogenin, SOX10, S100 protein, cytokeratin AE1/AE3/PCK26 or EMA; H3K27me3 was expressed in about 10% of tumor cells. Isocitrate dehydrogenase (IDH) genes were not mutated, which excluded the possibility of dedifferentiated chondrosarcoma. The final diagnosis was of undifferentiated pleomorphic sarcoma (UPS), grade 3 FNCLCC (D3M2N2), infiltrating the aortic wall, the soft tissues and the vertebral body of T9. Free margins of resection (R0) were achieved . UnfortuAfter 22 months from initial surgery, neither local relapse nor neurological sequelae have been documented.en bloc vertebrectomy as a feasible treatment for primary spinal malignancies (We reported on an aggressive multi-step upfront surgery that provided mid-term disease-free survival in a locally-advanced paravertebral UPS. In this case, the peculiar location of the primary UPS represented an oncological challenge, as the involvement of the axial skeleton along with the thoracic aorta is extremely infrequent and is associated with poor outcome , 5. The gnancies . Since tgnancies , 8. To tgnancies . In the For such complex and demanding procedures, multi-stage surgery limits morbidity and mortality by reducing operating time, the risk of organ ischaemia, bleeding and infection. In this case, the surgical plan comprised two separate steps. This choice aimed to reduce the overall length of the surgical intervention and to reduce the risk of complications. The decision to postpone the second surgical step from 5–7 to 13 days after the initial procedure was discussed in a multidisciplinary fashion and was finally advocated to assess the success of the grafting procedure, to wait for an optimal patient recovery and to ease spinal reperfusion.Despite the technical success of the procedure, we acknowledge that a longer follow-up is critical to define the impact of such aggressive surgical resection on local and distant control.en bloc radical resection of unfavorable localization of primary STS. A strategic alliance between multi-speciality surgeons with extensive expertise in STS is mandatory to define an optimal and patient-oriented therapeutic strategy.In conclusion, multi-step combined upfront surgery is a feasible and effective strategy to achieve The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study. The patient gave written consent for publication.UC performed surgery designed, supervised, and reviewed the draft. NG, AM, and AB wrote the draft. PN, FC, and EC performed surgery. SR provided histology analysis. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Fibrous Dysplasia (FD) is a benign fibro-osseous lesion, characterized by replacement with fibrous connective tissue instead of normal bone. The best treatment option for the condition has not yet been established, although several therapeutic approaches have been reported. The present case report describes the clinical, imaging and therapeutic aspects of an atypical bilateral presentation of FD in the mandible.A 26-year-old afro-descendent woman, who had previously undergone surgery to remove FD in the right hemimandible, complained of asymptomatic swelling in the left hemimandible. Imaging analysis showed an ipsilateral extensive multilocular mandibular lesion, with thinning of the cortical bone. After diagnosis of FD, complete surgical removal was performed, associated with immediate local reconstruction with xenograft and covering membrane, with primary wound closure.Bilateral presentation of FD is uncommon, and its diagnosis by means of clinical data, imaging and histopathological analysis, is relevant in order to establish the correct therapy.Complete surgical removal associated with immediate local bone reconstruction, has shown satisfactory clinical results, when adequate follow-up is performed. •There are few reports based on the atypical bilateral presentation of FD.•The bilateral presentation of FD in young non-syndromic patients is rare.•There is a lack of consensus regarding the best treatment for FD.•The surgical approach is still the best choice for avoiding recurrences.•Bone grafting after the removal of FD lesions has shown clinical satisfactory results. Several lesions that have been described, and it is essential to identify clinical, imaging and histopathological features to establish an accurate diagnosis .Fibrous Dysplasia (FD) is one of the most frequent slow growing FOLs, responsible for approximately 2.5% of all bone lesions and 7% of all benign bone tumors. It is more prevalent in young patients within the first three decades of life, predominantly affecting afro-descendent women ,4. The lAlthough its etiology still remains uncertain, FD has been associated with functional mutations in the GNAS1 gene, and is also a factor in the McCune Albright Syndrome (SMA) triad, characterized by the presence of FD, coffee-colored skin stains and metabolic disorders .As regards the clinical features of FD, it could appear as asymptomatic swelling or an increase in the local volume, associated with facial asymmetry, painful symptoms, eye disorders and pathological fractures. On imaging analysis, the lesion appears as an expansive, non-destructive mass, with a well circumscribed cortical and appearance of ground glass, which involves only one anatomical (monostotic) or several (polyostotic) bones . The monOn clinical and imaging assessment, differential diagnosis should be established for FD, which include mainly odontogenic tumors (myxoma and ameloblastoma), juvenile ossifying fibroma, keratocyst, central lesion of giant cells and low-grade osteoblastic osteosarcoma ,4. In hiThe treatment of FD is generally based on surgical management. However, there is still no consensus on the best approach in order to avoid recurrences. Therefore, adequate surgical removal is the best approach commonly used, because it has been associated with lower rates of recurrence . In factThe present case report aimed to describe the clinical, imaging and therapeutic features of bilateral fibrous dysplasia in the mandible in a young patient. This study was reported in line with the SCARE 2020 criteria .2A 26-year-old afro-descendent woman, with the complaint of asymptomatic swelling in the left hemimandible, which was previously detected in the imaging examination. Without relevant data from her medical history, the patient informed our team that had been submitted to surgical resection for removal of an FD lesion on the opposite side (right hemimandible).During extraoral examination, slight facial asymmetry was observed on the left side, with local swelling in the submandibular region, without the presence of lymph node enlargement in the region. Moreover, on intra-oral examination, an increase in buccal and lingual bone plate volume was detected, extending from tooth 33 to tooth 37 on the ipsilateral side, without tooth mobility and pain after manual palpation and percussion.On orthopantomography (OP)  and ConeBased on clinical data and imaging features collected, the initial diagnosis of fibro-osseous lesion was established; however, differential diagnosis was considered such as ameloblastoma, keratocystic odontogenic tumor, and central lesion of giant cells.Excisional biopsy that consisted of exposing the lesion by performing a Newmann modified incision  for finaAfter three and six months of follow-up, complete intraoral healing –B and ab3FD is a rare benign FLO that can involve a single bone (monostotic) or several (poliostotic) bones, frequently appearing with unilateral distribution. However, bilateral presentation in the same bone is rare, observed in patients with SMA ,8. In thAlthough the nature of DF is benign, this condition can become malignant, however, in rare cases ,6,9. ThuHigh recurrence rates have been associated with inadequate surgical techniques . In a reAs yet, the treatment modality described for FD that would be best, has not yet been fully established . In asym4Bilateral presentation of FD is rare, however, it could be observed in young non-syndromic patients. The diagnosis of FD continues to be a challenge because of its clinical, imaging and histopathological similarities with other fibro-osseous lesions; in advanced cases with long-term evolution, malignant transformation could be considered. Treatment remains controversial, however, complete removal by resective surgery and immediate reconstructive procedures such as bone grafting and covering membranes placed over remnant bone have been shown to achieve satisfactory clinical results after adequate follow-up.All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This report was exempt for ethical approval because of the use of medical data records of the patient without exposure of her identity or photos that shows her facial identification or characteristics.This work was supported by the National Council for Scientific and Technological Development of Brazil (140071/2019-9). The author WEBP is student fellow and supported with a scholarship provided by the National Council for Scientific and Technological Development of Brazil (CNPq).All authors have contributed in the each step for writing this paper, participating in the whole process to retrieve medical information, review of the literature, and writing of each issue included.Wilber Edison Bernaola-Paredes and Henrique Rocha Mazorchi Veronese have written and selected the topics for structuring this case report. Moreover, he did and worked in the Introduction and Discussion issues. On the other hand, Kleber A. Vallejo-Rosero, Miriã de Andrade Celestino, Ivan Solani Martins and Arthur de Arruda Ferrari has done the literature review in order to support our discussion and introduction. Wilber E. Bernaola-Paredes and Ivan Solani Martins were the oral and maxillofacial surgeons who performed lesion removal.Wilber Edison Bernaola-ParedesKleber A. Vallejo-RoseroNot applicable.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Not commissioned, externally peer-reviewed.None declared.


The histological diagnosis of pleural epithelioid mesothelioma can be difficult in the case of rare variants or in the definition of neoplasm origin in patients with previous or concomitant tumours. Currently, several immunohistochemical reactions are available in the surgical pathologist’s armamentarium that allow us to obtain a more sensitive and specific diagnosis of malignant pleural mesothelioma. However, in some cases, the final interpretation remains inconclusive. Historically, ultrastructural examination has represented a useful tool for the definition of the mesothelial nature of neoplastic cells due to their peculiar morphological characteristics. The recent international guidelines for pathological diagnosis of pleural mesothelioma suggest the use of electron microscopy when the immunohistochemical reactions are equivocal or when further support of a diagnosis of mesothelioma is needed. This paper presents three cases of pleural epithelioid mesothelioma whose diagnoses were finally supported by ultrastructural examination. Pleural malignant mesothelioma is a rare and fatal neoplasm that, in most cases, affects elderly patients who have had occupational exposure to asbestos . The mosAnother now-discussed tool to detect the mesothelial origin of the neoplastic cell is represented by transmission electron microscopy (TEM) . The ultThe introduction of immunohistochemistry and molecular pathology has progressively restricted the use of TEM for diagnostic purposes, especially in the oncologic field. However, TEM still is a useful adjuvant tool in challenging diagnoses, as in cases such as that of epithelioid pleural mesothelioma that are described in this paper. In the discussion section, we provide a short review of the limited literature currently available and comment on some important messages.A 72-year-old, non-smoker male with occupational exposure to asbestos presented with cough and chest pain. History was negative for previous or concomitant malignancies. Computed tomography (CT) showed right pleural effusion with pleural thickening that was biopsied. At histology, it was observed a neoplastic proliferation morphologically compatible with mesothelioma with several foci of squamous differentiation a,b. ImmuAn unexposed, non-smoking, 41-year-old man was admitted to the emergency room due to an accidental fall and tibial fracture. Pre-surgical radiological tests showed a large posterior, pleural-based, and well-defined nodular lesion in the right hemithorax. The patient underwent a complete surgical resection of the tumour. The surgical inspection of the pleural cavity was negative for other nodules with no pleural thickening and no pleural effusion. The mass showed a solid central portion and peripheral cystic and necrotic-haemorrhagic areas a,b. The An unexposed, 69-year-old woman presented with a right pleural effusion. She had a history of right breast cancer treated with a quadrantectomy with adjuvant chemo-radiotherapy followed then by right mastectomy for locoregional recurrence. Medical thoracoscopy showed significant pleural effusion and multiple nodules. At histology, a diffuse epithelioid growth pattern with papillary structures was seen in the biopsy fragments a. ImmunoThe recent guidelines for pathological diagnosis of malignant mesothelioma  report tThe three cases described represent a diagnostic challenge in defining pleural neoplasia for several reasons. The first case shows a very unusual morphological feature, the presence of several foci of squamous metaplasia in the context of a clear mesothelial proliferation. The diagnosis of epithelioid mesothelioma was achieved as a result of extensive multidisciplinary integration. Indeed, the patient’s history was negative for previous or concomitant neoplasms, nor did the radiological examinations show any other masses in the lungs or other organs. Furthermore, the loss of nuclear expression of BAP1 is a very rare event in squamous cell carcinoma , corroboThe second case shows an extremely rare variant of mesothelioma, the localized subtype. This was previously reported by our group as Clinical Picture in a peer-reviewed journal . The LMMGiven the uniqueness of these cases, the ultrastructural analysis provided further support in confirming the mesothelial origin of the neoplastic cells. Instead, the third case is emblematic of the difficulties that can occur in determining the histotype of a pleural tumour on a small biopsy in a patient with other neoplasms. The clinical history and the absence of exposure to asbestos suggested a pleural recurrence of breast cancer even if other immunohistochemical features, such as GCDFP-15 and BAP1 negativity, were in favour of an alternative diagnosis. TEM confirmed the mesothelioma hypothesis, showing elongated microvilli typical of mesothelial cells. Although breast cancer cells may display microvillar protrusions, they are shorter and unbranched . FurtherIn summary, we presented this anecdotic case series to illustrate the contributory value of ultrastructural analysis in principal settings either when immunohistochemistry is inconclusive or when there is a very rare case. Electron microscopy combined with laboratory experience obtains optimal and reliable results from processing formalin-fixed material retrieved from paraffin-embedded blocks.


Focal nodular hyperplasia (FNH) is a rare benign tumor-like space-occupying lesion of the liver that is especially rare in children. Since there have been no reports of malignant progression of this disease and these lesions remain unchanged for a long period of time or even disappear in some cases, it remains controversial whether clinical treatment is needed. However, if the diagnosis is unclear, the patient has symptoms or the lesion becomes enlarged during follow-up, clinical treatment should be considered. Here, we report the first case of FNH near the gallbladder treated by ultrasound-guided percutaneous microwave ablation (MWA) in a 9-year-old girl. Focal nodular hyperplasia (FNH) is a clinically rare benign lesion of the liver that is especially uncommon in children, accounting for approximately 2–7% of pediatric liver tumors –5. ThereA 9-year-old girl was admitted to Dongguan Children's Hospital 6 months ago due to breast development. Since the patient had no other obvious symptoms, we did some laboratory tests to help diagnose. A gonadotropin releasing hormone (GnRH) stimulation test showed that the peak values of luteinizing hormone (LH) and follicle-stimulating hormone (FSH) were 8.03 and 14.97 IU/L, with an LH/FSH ratio of 0.53. Based on her premature breast development, test results and the absence of relevant personal or family history, she was diagnosed with precocious puberty and treatment with a monthly intramuscular injection of triptorelin (decapeptyl) was initiated. The patient also received imaging examinations to exclude underlying diseases. Unexpectedly, ultrasonography indicated a single, solid, focal liver lesion in S5. Enhanced computed tomography (CT) showed hyperenhancement of the lesion in the arterial phase, which was 17mm × 18mm in size, with a hypodense central stellate scar visible inside the region . The lesAn APLIO I700 ultrasound system with a PVT-674BT 10C3 abdominal probe , incisive CT , and definition flash CT  were used for diagnosis. A 100A1 microwave generator  and an ECO-100CI10 MWA antenna  were employed for MWA. SonoVue  was utilized as the contrast agent for ultrasound and was prepared as a suspension with 5 ml of 0.9% normal saline (N.S.). For transvenous use of the contrast agent, 1 ml of SonoVue was injected through a central venous catheter, followed by 5 ml of N.S. For intracavitary use, the ratio of N.S. and SonoVue was 100:1. A coaxial needle (15 G) and an automatic biopsy gun  were applied for biopsy and a central venous catheterization set  was used for abdominal cavity intubation.Artificial ascites-assisted ultrasound-guided MWA and biopsy were carried out under general endotracheal anesthesia. Under ultrasound guidance, we performed abdominal cavity intubation, and SonoVue in N.S. at 40°C was infused into the abdominal cavity. Under CEUS, we observed hyperechoic contrast agent distribution between the gallbladder and the hepatic margin close to the lesion, indicating that this fluid could provide a cooling effect during thermal ablation . We alsoUnder color Doppler ultrasound guidance, the microwave antenna was inserted directly to the site of the feeding artery , and aftPost-operative medications included cefixime granules as an anti-inflammatory agent and compound glycyrrhizin capsules to protect liver function. The abdominal drainage tube was removed on the second day after the operation, and the patient was discharged on the sixth day. Examination by magnetic resonance imaging (MRI) 1 month later showed that the tumor was completely ablated and that the gallbladder was not injured . Based oApproximately two-thirds of liver tumors in pediatric patients are malignant, whereas FNH accounts for only 2–7% . Thus, tThe difficulty of ablation lies in completely ablating lesions with an abundant blood supply. In this case, we chose MWA rather than RFA. First, we ablated the feeding artery, and successful ablation of the blood supply to the lesion was accurately evaluated by CEUS. After ablation of the feeding artery, we commenced ablation from the periphery to the interior of the lesion until complete ablation was achieved.As the lesion was 1 mm away from the gallbladder, there was an additional challenge in this case of preventing thermal injury to the gallbladder. The lesion was near the bottom of the gallbladder, which meant that the gallbladder wall might be free from the liver. With the assistance of artificial ascites as well as an expansion tube and guide wire, we were able to push the gallbladder wall away to avoid injury during ablation. Thermal injury may also be assessed by CEUS to determine whether cholecystectomy should be applied. Overall, artificial ascites was useful for isolating the liver and the nearby intestine to avoid intestinal injury.Color Doppler ultrasound and CEUS indicated abundant arterial blood supply to this lesion. Two strategies were used to avoid bleeding caused by biopsy and the possibility of implantation metastasis. First, biopsy was performed after ablation of the feeding vessels. Second, a coaxial needle was used. After the biopsy was completed, a microwave antenna was inserted through the coaxial needle shell to ablate the biopsy needle tract.Although thermal ablation has been widely used for treating solid tumors such as hepatocellular carcinoma, there is only one report of FNH treated with radiofrequency ablation in adults and the procedure was only partially effective because a small residual was noted 2 months later . In our In general, the findings from this case suggest that ultrasound-guided percutaneous MWA is a safe and effective treatment for FNH near the gallbladder in pediatric patients.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.Informed consent was obtained from the patient's parents prior to potential publication of this case report and any accompanying images.Material preparation, data collection, and analysis were performed by ZY, QZ, SL, and SJ. The first draft of the manuscript was written by XY, DM, and KL. All authors commented on previous versions of the manuscript, read, approved the final manuscript, and contributed to the study conception and design.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Extraovarian granulosa cell tumors (GCTs) develop from ectopic gonadal tissue situated along the embryonal route of the genital ridge. Primary retroperitoneal tumors are extremely rare, with an incidence of 02% -06% and 80-85% probability of malignancy. Only eight such case reports have been published previously. We herein, report a rare case of extraovarian retroperitoneal GCT in a 55-year-old woman who presented with intermittent left lumbar region pain of one-year duration. She had a history of hysterectomy and bilateral salpingo-oophorectomy 8 years ago for uterine leiomyoma. Laparotomy revealed a retroperitoneal mass measuring 8cm x 10cm x 20cm in size, solid cystic with areas of necrosis and hemorrhage. The gross features, classical histopathology, and positive immunostaining of the retroperitoneal mass with inhibin, calretinin, PR, WT1 and immunonegativity for EMA were characteristic of adult-type GCT. Excluding any previous history of primary ovarian GCT in this patient, a de-novo retroperitoneal diagnosis was established. Granulosa cell tumors (GCT) of the ovary are rare and represent 2% - 5% of all ovarian neoplasmsA 55-year-old woman with no comorbidities presented with intermittent pain in the left lumbar region of one year duration. There was no associated history of weight loss, fever, or urinary complaints. Per abdominal examination revealed an 8cm x10cm ill-defined non tender and non-mobile mass in left lumbar region extending superiorly into left hypochondrium and inferiorly into pelvis. The patient had undergone total abdominal hysterectomy with bilateral salpingo-oophorectomy 8-years ago for uterine leiomyoma at our center with no evidence of primary GCT of the ovaries on histopathological evaluation. The slides of previous surgery were retrieved from department achieves, and both ovaries showed normal histomorphology on review.Abdominal-pelvic computer tomography imaging showed a longitudinally oriented heterogeneously enhancing solid cystic retroperitoneal mass measuring 7.2cm x 10.3cm x 19.4cm epicentered near the left kidney A. The maMicroscopic findings showed neoplastic cells arranged in diffuse, pseudopapillary, macrofollicular, microfollicular, and gyriform patterns. The tumor cells were small, uniform with scant cytoplasm, and round to oval nuclei exhibiting nuclear grooves .Call-Exner bodies were present. Lymphovascular space invasion was identified. On performing immunohistochemistry (IHC), the tumor cells were immunopositive for inhibin A, calretThe patient’s intraoperative and postoperative courses were uneventful.Granulosa cell tumors (GCTs) are malignant sex cord— stromal tumors of the ovary. These can be of adult or juvenile type based on clinical and histopathological features. The adult type of GCTs is more common and usually present during the perimenopausal or the early menopausal period, the median age being 50–54 years.,,,-Primary retroperitoneal GCTs are very rare, with 02% -06% incidence with 80-85% probability of malignancy.,Macroscopically, GCTs vary in size with an average diameter of 10cm. They are solid-cystic and rarely may be solid or entirely cystic. The solid areas are soft tan to yellow, while the cysts typically contain clotted blood. Rupture is associated with areas of hemorrhage.In our present case, GCT was not suspected clinically or radiologically and the preoperative tumor markers were within normal biological range. The diagnosis was made by characteristic histopathological features and confirmed by immunopositivity for inhibin, calretinin, PR, WT1, and immunonegativity for EMA.Granulosa cell tumors can arise in locations other than the ovary and are considered to be derived from the mesenchyme of the genital ridge. Women who have undergone oophorectomy may develop GCT at extraovarian location, including retroperitoneum. Thus, GCT should be kept as a differential diagnosis of retroperitoneal masses in female patients. Immunohistochemistry helps in differentiating GCT from other neoplasms.