Vertebral osteosarcoma is infrequently reported in cats. In this case report, we describe the diagnosis, treatment, and outcome of vertebral osteosarcoma in two cats. In both cases, preliminary diagnosis was based on diagnostic imaging findings. Treatment involved surgery with the aim of gross resection and post-surgical chemotherapy. Confirmation of the diagnosis was achieved by a histopathological examination of surgical biopsies. Short-term and medium- to long-term outcomes were excellent in both cases. This case report highlights the possibility of good outcomes after the surgical treatment of feline vertebral osteosarcoma supplemented with post-surgical chemotherapy.In this case report, we describe the diagnosis, treatment, and outcome of two feline cases of vertebral osteosarcoma. Case 1: A 6-year-old female neutered domestic longhaired cat was presented with progressive paraparesis, ataxia, and spinal hyperesthesia. MRI of the thoracolumbar spinal cord and vertebral column revealed a strongly contrast-enhancing mass lesion originating from the dorsal lamina and spinous process of T13. The lesion caused extradural compression of the spinal cord. Surgical debulking was performed, and the histopathological evaluation of surgical biopsies was consistent with vertebral osteosarcoma. The cat was paraplegic with intact nociception post-surgery. Subsequently, the cat recovered ambulation while remaining mildly ataxic and paraparetic at long-term follow-up. Post-operative chemotherapy was started with doxorubicin. CT scans at 2, 4, 9, 13, and 20 months post-surgery showed no signs of local recurrence or metastasis. Case 2: A 15.5-year-old male neutered domestic shorthaired cat was presented with progressive paraparesis, tail paresis, and spinal hyperesthesia. Radiographs and CT scan of the lumbar vertebral column showed a large mass originating from the dorsal lamina and spinous process of L6, suggestive of neoplasia, with severe compression of the spinal cord. Surgical debulking was performed, and the histopathological evaluation was consistent with vertebral osteosarcoma. Post-operative chemotherapy was started with doxorubicin. Seven months post-surgery, the patient was neurologically normal with no signs of metastatic disease. This case report highlights the possibility of good outcomes after the surgical treatment of feline vertebral osteosarcoma supplemented with post-surgical chemotherapy. Compared with its canine counterpart, feline osteosarcoma (FO) is infrequently diagnosed in veterinary medicine ,3,4,5,6.According to the findings of a large FO study by Heldmann et al., FVO accounts for a large percentage of skeletal FO; 40 out of 90 (44%) skeletal FO affected the axial skeleton in that study .Based on the literature, aggressive surgical treatment seems to be the most effective treatment for all types of FO, irrespective of additional treatment such as chemotherapy ,9,10,11.In this case report, we describe the diagnosis, treatment (including surgery and chemotherapy), and outcome of two cats with vertebral osteosarcoma.A 6-year-old female neutered domestic shorthair cat was presented for chronic progressive paraparesis and spinal hyperesthesia. The referring veterinarian had prescribed meloxicam (0.05 mg/kg q24h per os) and gabapentin (10 mg/kg q8h per os), but this treatment had not resulted in a significant improvement. Residual signs of back pain were reported by the owner, especially when that cat was picked up. No traumatic events were reported by the owner. Upon presentation to the referral hospital, a general physical examination revealed no abnormalities. Neurological examination revealed mild, ambulatory paraparesis and proprioceptive ataxia, with delayed hopping responses of the left pelvic limb. Severe hyperesthesia was noted upon palpation of the vertebral column in the area of the thoracolumbar junction. An asymmetric (left-sided) T3-L3 myelopathy was suspected. Hematology and biochemical blood tests revealed no significant abnormalities. An MRI study of the thoracolumbosacral spinal cord and surrounding structures, including the T2-sacral vertebrae, was performed under general anesthesia. The following sequences were included: sagittal plane T2-weighted (T2W), T1W, and short-tau inversion recovery (STIR); dorsal plane 3D fast gradient echo combined with water excitation technique (FFE3D combined with WET), T1W, and T2W with fat saturation; transverse plane T2*W, T1W, T2W, and T2W with fat saturation over the region of the T12-L2; and post-contrast (IV gadolinium 0.15 mmol/kg) T1W sagittal plane, T1W transverse plane, and 3D T1W magnetization prepared—rapid gradient echo (MPRAGE) sagittal plane .MRI revealed a 1.2 cm × 1 cm × 1.1 cm mass lesion centered on the dorsal lamina and left caudal articular process of T13, with disruption of the cortex. Relative to the spinal cord, the lesion was homogeneous and mildly hyperintense on T1W images, and heterogeneously hyperintense on T2W and STIR images . The masSurgical treatment was selected. General anesthesia was performed, and the cat was positioned in sternal recumbency. A dorsal midline skin incision was performed from T12 to L2. The fascia was incised just paramedial to the spinous processes on the left and right side. The spinous process of T13 was localized with fluoroscopy. The epaxial muscles were elevated from the spinous processes with a periosteal elevator and retracted laterally on both sides. Hemostasis was achieved using bipolar electrocautery. The zygapophyseal (facet) joint T13-L1 on the left was partially removed using a rongeur. The most ventral part was left in situ. The mass was directly visible between the dorsal laminae of T13-L1, and the lamina of T13 was thin. The tumor was debulked based on gross appearance. However, complete excision was deemed unlikely due to invasiveness into the surrounding bony margins of T13. Decompression was achieved and deemed satisfactory based on the visualization of the spinal cord in the expected position in the spinal canal. A thin autologous free fat graft was placed to cover the laminectomy defect. Monofilament absorbable suture materials were used to close the fascia, subcutis, and skin . Post-operative care consisted of urinary bladder catheterization, ketamine (5 ug/kg/h) for 24 h, meloxicam (0.05 mg/kg q24h for 2 weeks), amoxicillin/clavulanic acid (15 mg/kg q12h for 5 days), and gabapentin (10 mg/kg q8h for 3 weeks). Physiotherapy was initiated within 2 weeks post-surgery. A neurological examination was performed 24 h post-surgery and revealed paraplegia without nociception. During the next 12 weeks, nociception, urinary and fecal continence, ambulation, and coordination returned progressively. Complete neurological recovery was achieved 3 months post-surgery.The histopathological examination of surgical biopsies revealed a proliferation of polygonal to plump fusiform mesenchymal cells in clusters with the formation of osteoid in-between the cells . The celChemotherapy was initiated 2 weeks post-surgery. A total of six doses of doxorubicin  were administered every 3 weeks. Before each treatment, hematologic blood values were checked. Two months post-operatively, a CT scan was performed to monitor for local recurrence or signs of metastasis. No signs of local recurrence were found, but a small soft tissue nodule was noticed in both the left and right cranial lung lobes. Therefore, it was advised to repeat the CT scans during the course of treatment. Computed tomographic (CT) scans at 4, 9, 13, and 20 months post-surgery showed no signs of local recurrence or metastasis. The previously noted nodules were not present anymore. The cat was reported to be doing well 28 months post-surgery. No significant side effects were noticed during treatment.A 15.5-year-old male neutered domestic shorthaired cat was presented for chronic progressive lameness of the right pelvic limb over the last 4 months. During the last 2 weeks, the signs had progressed with the involvement of the left pelvic limb as well. The referring veterinarian had prescribed meloxicam (0.05 mg/kg q24h per os). However, a significant improvement was not achieved. During a follow-up neurological evaluation, proprioceptive deficits and spinal hyperesthesia were noted. Orthogonal radiographs of the lumbar vertebral column revealed a right-sided osteolytic mass lesion affecting the L6 vertebra . GabapenUpon presentation to the referral hospital for surgical treatment, a general physical examination revealed no abnormalities. Neurological examination revealed ambulatory paraparesis and hopping deficits of the right and left pelvic limb (right more than left). Hyperesthesia was noted upon palpation of the vertebral column in the area of L6. Hematology and biochemical blood tests revealed no significant abnormalities aside from a hematocrit of 25.7% (reference range 30.3–52.3%). Pre-operative CT revealed similar findings regarding the L6 mass lesion. Additional findings included an enlarged left adrenal gland, mild hepatomegaly, mild diffuse bronchial wall thickening, a mass lesion in the pituitary fossa measuring 5.3 mm dorsoventral height (suspected pituitary tumor), degenerative joint disease of multiple joints, and multifocal spondylosis deformans. The owners did not elect further diagnostic tests for these findings and elected to proceed with the surgical treatment for the L6 mass lesion.A dorsal midline skin incision was performed from L4 to S1. The fascia was bilaterally incised on the midline dorsal to L5-L7. The epaxial muscles were elevated from the spinous processes with a periosteal elevator and retracted laterally on both sides. Hemostasis was achieved using bipolar electrocautery. The tumor was visualized. It had a very hard consistency on the outer aspect. The dorsal and right lateral parts of the tumor wall were removed using rongeurs. Thereafter, the soft content of the mass was removed by curettage. The compressive, thin external bony layer was easily removed using a curette and a Kerrison rongeur. The L6 spinal nerve on the left side was accidentally severed in the process. Decompression was achieved and deemed satisfactory based on the visualization of the spinal cord and nerve roots in the expected position in the spinal canal. A thin autologous free fat graft was placed to cover the laminectomy defect. A molded piece of polymethylmethacrylate (PMMA) was placed dorsally to L5-sacrum to replace the removed dorsal lamina and cover the spinal canal. Monofilament absorbable suture materials were used to close the fascia, subcutis, and skin . Decompression was evaluated as satisfactory on post-operative CT images . Post-opThe histopathological examination of the surgical biopsies revealed a highly cellular proliferation of spindle-shaped mesenchymal cells in bundles and whorls, with scattered multinucleated giant cells . In betw9/L (grade 1 neutropenia). The fourth doxorubicin treatment was postponed for 10 days, when the values were rechecked and the neutropenia was normalized to 3.81 × 109/L. No other significant side effects were noticed during treatment. Seven months post-surgery, the patient was neurologically normal, with no signs of metastatic disease.The cat was referred for further treatment by the oncology department. Chemotherapy was initiated 3 weeks post-surgery. A total of four doses of doxorubicin  were administered every 3 weeks. Before each treatment, hematologic blood values were checked. Two months post-operatively, thoracic radiographs were acquired to monitor for signs of metastasis. No abnormalities were noticed. Additionally, radiographs of the surgical site revealed no complications related to the PMMA implant. After the third dose of doxorubicin, the patient had developed a mild neutropenia of 2.15 × 10This case report highlights the possibility of good outcomes after surgical treatment of FVO supplemented with post-surgical chemotherapy. Such positive outcomes have been documented in a few cases of FVO before ,8,9,10. Surgical treatment options of FVO include but are not limited to cytoreduction, extirpation, debulking, and vertebral replacement ,7,8,9,10The use and value of radiographs, CT (with or without myelography), and MRI for the diagnosis of FO and FVO has been reported ,11,12,13Imaging characteristics of FVOs are only reported in a few case reports and described as space-occupying osteolytic lesions that cause extradural spinal cord compression ,8,9,10. FVO seems to have quite well-defined margins ,8,9,10. MRI is considered the most accurate imaging modality to determine tumor margins in dogs with intramedullary osteosarcoma of the appendicular skeleton . In dogsSince osteosarcoma is much more prevalent in dogs than cats, a short discussion with the aim of comparing dogs to cats is provided here. Osteosarcoma often affects the appendicular skeleton in dogs ,18,19. TMacroscopic metastatic disease in appendicular osteosarcoma is seen in less than 15% of dogs at first presentation, but most are presumed to have undetectable micro-metastatic disease. For this reason, chemotherapy is strongly recommended and has been shown to increase survival time significantly. The median survival time (MST) after limb amputation is just 3-4 months, but with chemotherapy, post-operative MST increases to 307-366 days ,20,21.Metastatic disease in canine vertebral osteosarcoma seems to occur less commonly when compared to the appendicular osteosarcomas, but the MST is worse. An MST of just 42 days is reported in dogs with vertebral osteosarcoma after surgery, while the MST of surgery with chemotherapy was 82 days, and surgery with chemotherapy and radiotherapy was 261 days . The locAppendicular osteosarcoma occurs more rarely in cats compared to dogs, but the MST is much longer depending on the anatomic location and histological grade. A low percentage of about 5–10% of the FO is reported to metastasize ,13,23,24About 28–44% of FO in cats is of axial origin, including the skull, vertebrae, ribs, and pelvic bones ,25. In oBecause of the usually low metastatic rate in cats, chemotherapy is variably recommended . But theAlthough some case reports of feline osteosarcoma that employed surgery and adjunctive chemotherapy have shown long ST and recurrence-free periods, currently, there are no studies that evaluate the role of chemotherapy and radiation in the management of FVO ,8,26,27.The limitations of the current case report include the relatively limited length of follow-up for the second case , the lack of further characterization of tumor type and immunohistochemistry, and the lack of further diagnostic testing with regard to staging the patients. Nevertheless, this case report adds to the existing body of literature that describes the possibility of positive outcomes of the surgical treatment, supplemented with chemotherapy, of FVO.Based on previous case reports and the findings in the cases reported here, the surgical treatment of feline vertebral osteosarcoma, supplemented with post-surgical chemotherapy, can result in excellent medium- to long-term outcomes.


Spindle cell tumors in the paratesticular region are infrequent. Accurate diagnosis requires clinical assessment, pathological analysis, and immunohistochemical (IHC) analysis.The present study reports a 33-year-old male who presented with a painless mass in his right testis. The mass grew from the size of a marble to that of a tennis ball in two years. Physical examination and ultrasonography revealed a solid mass in the right paratesticular area. The patient underwent a right paratesticular tumor excision, without interfering the right testis. Histopathologic analysis showed spindle cell tumor appearance referring to inflammatory myofibroblastic tumor (IMT).IMT, also known as inflammatory pseudotumor, is a rare and benign neoplasm that can occur anywhere. Diagnosis is challenging, because it mimics other neoplasms. Immunohistochemical profiles were decisive in concluding a definitive diagnosis. Treatment, on the other hand, depends on tumor burden and connectivity to other region.Spindle cell tumors are very rare and can be treated with simple excision if no organ adhesion is detected. Therefore, right orchidectomy was not required in our case. •A paratesticular spindle cell tumor leading to inflammatory myofibroblastic tumor is very rare worldwide.•Pathological analysis alone is insufficient to gain a definitive diagnosis.•Not all paratesticular spindle cell tumors needed orchidectomy; it depends on each case.•Prognosis for this case is favorable, but do not underestimate it in the long term. Paratesticular tumors refer to neoplasms located in the epididymis, spermatic cord, and their surrounding structures within the scrotal region. Although these tumors are very rare, a diverse range of paratesticular cysts and tumors may manifest as inguinal masses within the scrotum 2A 33-year-old man came to the urology office presented with a painless mass in his right testis. Starting from a marble size mass to that of a tennis ball in the past two years. The patient had no history of tumors, familial tumors, or other systemic diseases, but had a smoking habit of consuming at least one box of cigarettes per day. Physical examination identified an oval round shaped mass without any adhesion to the testis . There w3Intrascrotal tumors could be testicular or paratesticular, PSCTs are rarer (7–10 %) and only 30 % of them are malignant. PSCTs are heterogeneous group of tumors, ranging from benign lesions to malignant tumors. The most common malignant tumors in the paratesticular area are sarcomas, and among adult sarcoma cases, rhabdomyosarcomas account for approximately 24 % and only 7–10 % of them involve the paratesticular region The diagnosis is very challenging due to the rarity of these tumors and the lack of specific clinical features as their clinical presentation and imaging features are non-specific and can mimic other neoplasms or inflammatory conditions. Ultrasonography, CT scan, and magnetic resonance imaging (MRI) can be used for diagnosis and staging Treatment of these rare cases depends on the histological subtype, size, and stage of the tumor. The mainstay of treatment is surgical resection with negative margins. Tumor-sparing surgery was performed in our case as there was no discernible tissue connection to the testis. A different approach would be considered if our intraoperative findings revealed malignancy. Radical orchiectomy would be considered for such cases, followed by pathological analysis, chemotherapy and other treatments if necessary. If a tumor is difficult to remove due to its location, alternative therapies such as chemotherapy or radiation therapy may be utilized as an alternative 4In conclusion, our case presents a rare and benign neoplasm that can occur in various organs. While the exact etiology is not fully understood, the proliferation of myofibroblasts and inflammatory cells is believed to play a role in its development. Diagnosis can be challenging, but pathological findings and IHC will be sufficient for definitive diagnosis. Surgical resection with close follow-up is the preferred treatment for all patients. Despite its generally favorable prognosis, some cases of could recur or metastasize, underscoring the importance of long-term monitoring for patients with this condition.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.Ethical approval was provided by the authors institution.There was no financial support associated with the publication of this article.Moammar Andar Roemare Siregar.Study concept and design: MARS, AA, SPData collection: MARS, AA, SPAnalysis and interpretation of case presentation: All AuthorsDrafting of the manuscript: MARS, NP, SPCritical revision of the manuscript: AA, HM, DHS, MARSStudy supervision: HM, DHS.The authors declare no competing interests that may affect the publication of this article.


The left lobe of the liver is connected to the left hemi-diaphragm by the left triangular ligament (LTL) which crosses the left upper quadrant (LUQ) of the abdomen. LTL lesions are rare and can cause diagnostic confusion. We encountered a hepatocellular carcinoma in the LTL of one patient and given that the LTL has been shown to contain liver tissue in cadaveric studies, we hypothesise that LTL lesions are likely hepatic in origin. The aim of this case series and systematic review was to develop a list of pathological processes encountered at the LTL, which could impact differential diagnoses of lesions within the LUQ.A case series of two patients are presented. MEDLINE, EMBASE, PubMed, and Google Scholar were searched for studies published until September 2022. All case reports of LTL lesions were eligible for inclusion. PROSPERO registration: CRD42022368250.Twelve out of 166 screened studies were included, with 14 cases in total. Seven described mass lesions of hepatic origin, of which three were initially misdiagnosed as gastric tumours leading to considerable diagnostic delay and additional procedures. Seven other cases described postoperative bile leaks from aberrant biliary ducts in the LTL.All mass lesions observed in the LTL were hepatic in origin, and all iatrogenic injuries described resulted in bile leaks.To reduce the burden of diagnostic delay and unnecessary procedures, we would suggest that these observations support the addition of hepatic lesions to the differential diagnosis of LUQ lesions. The falciform ligament is continuous superiorly with the coronary ligament, which is continuous with the left triangular ligament (LTL) at the lateral aspect of the left lobe of the liver . The LTL In a sample of Greek cadaveric livers, 13/80 (16%) had bile ducts in the LTL. Multiple histological studies also describe ‘irregular islands of hepatic tissue’ specifically within the LTL.At the long free edge of this ligament is the appendix fibrosa hepatis (AFH), which is atrophied liver tissue, which commonly contains bile ducts and remnants of hepatic tissue. In a sample of Japanese cadaveric livers, 23/27 had complete portal tracts with hepatocytes in the proximal third of the AFH.Given the embryological origins of the LTL and AFH, we hypothesised that lesions within both structures were likely to be hepatic in origin. Lesions within these structures are rare and to date there has not been a review of the literature of lesions found in the LTL or AFH. We present two cases of lesions within the LTL and have undertaken a systematic review of all the available case reports on the LTL. The primary objective of the systematic review was to develop a list of pathological processes encountered in the LTL and AFH. This would have implications for both diagnosis and management of lesions in the LUQ.An 82-year-old male underwent a CT of the chest, abdomen, and pelvis as part of the diagnostic workup for a spinal mass. CT imaging revealed an incidental 26 × 25 mm thin-walled cyst (average 6 Hounsfield Units) in the LUQ of the abdomen . The lesA 69-year-old male smoker was referred for a CT scan by his primarycare physician on a suspected cancer referral pathway for chronic cough and left lower zone atelectasis on chest X-ray. CT imaging revealed a 27 × 24 mm lesion adjacent to the stomach wall that was initially thought to be a gastrointestinal stromal tumour (GIST), given its location and exophytic appearance . During  The review protocol is registered on the international prospective register of systematic reviews (PROSPERO), CRD42022368250.This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).The search strategy was designed to be comprehensive to capture all the available literature published on the LTL and AFH. The full strategy is listed in Supplementary Material 1.Click here for additional data file.We searched MEDLINE, EMBASE and PubMed databases for studies published until first September 2022. Google Scholar was used to identify manuscripts not in these databases until first September 2022, with the search limited to terms appearing in the title only, as limiting to abstracts was not available. Bibliographies from identified studies were searched for additional relevant studies.All case reports or case series that described a pathological process at the LTL or AFH in humans were included. Publications were not limited by year of publication, language, or study type. Conference abstracts and pre-prints were included where identified.Duplicates were removed from all abstracts identified from the literature search. Two authors (SA and CC) independently screened all abstracts using the Rayyan platform and excluded ineligible studies against the eligibility criteria.If author thought either an abstract matched the eligibility criteria or it was unclear whether a study matched eligibility from the abstract alone, that study was included for full-text screening (including any disagreements). From the full texts, SA and CC screened and excluded ineligible studies. All disagreements were resolved with discussion, without the need for arbitration.Patient demographic data and descriptive details and context of LTL pathology were extracted from the included studies into a summary table by one author (SA) and were reviewed by two other authors independently .Case reports are inherently anecdotal therefore a risk of bias assessment was not considered appropriate. No further analysis or formal assessment of publication bias was performed.Database searches and citation searching yielded 166 unique records, of which 40 potentially eligible full texts were assessed; this process is summarised in a PRISMA flow diagram . We wereSupplementary Material 2.Click here for additional data file.PRISMA 2020 Checklist.Click here for additional data file.The above two cases described in this article were included with the 12 cases identified from the systematic review bringing the total cases to 14. There were seven cases of mass lesions in the LTL and seven cases of post-operative bile leaks originating from the LTL. From the available titles and abstracts of the four records not retrieved, one describes a hepatocellular carcinoma in the LTL and three describe post-operative bile leaks . No caseEvery pathology described at the LTL was hepatic in origin . Brief summaries of each case can be found in Included studies were published between the years 1959 and 2022, the age at presentation ranged from 36 to 82, and 3/7 (43%) were female. In 3/7 (43%) of cases, mass lesions were initially misdiagnosed on CT imaging as tumours of gastric origin. All leaks were resolved by ligating the LTL.Included studies were published between the years 1950 and 2022, the age at presentation ranged from 51 to 91, and 2/7 (29%) were female. In all cases, bile leaks were observed from aberrant bile ducts in the LTL. In the majority of cases, this was from a cut surface of the LTL , and in one case from a ruptured bile duct shortly following sphincterotomy.All cases except one described LTL pathology of hepatic origin. Half of them described mass lesions while the other half described postoperative bile leaks. Given our broad search strategy, this likely represents the majority of all the reported literature available on pathology in the LTL or the AFH, suggesting that pathology at this site is rare.Three (43%) mass lesions were initially misdiagnosed as tumours of gastric origin - the anatomical course of the LTL from the left lateral segment of the liver towards the left hemi-diaphragm, means that lesions here can indent the stomach. The burden of misdiagnosis caused diagnostic delay and additional unnecessary procedures in two out of three of these cases. One of these cases resulted in additional two endoscopies with endoscopic ultrasound, laparoscopy and ultimately a laparotomy to determine that the lesion originated from the LTL.Radiologists should consider whether lesions could be arising from the LTL when reviewing masses seen in the LUQ of the abdomen. It is easier to determine if LUQ mass lesions arise from the LTL when the LTL is visualised separate to the stomach Case 1, . In pracThe lesion appears predominantly ‘exophytic’ or external to, but in close contact with the stomach fundus.i.e., the LTL) is seen to run from the lesion to either the diaphragm or the left lobe of the liver as demonstrated in Case 2 .All three cases of diagnostic confusion arose from lesions which were initially considered to be gastric in origin due to their close relation to the stomach. It may not be possible to differentiate a gastric lesion from a LTL lesion on imaging features alone; however, an LTL lesion should be considered in the differential diagnosis of a seemingly gastric lesion if any of the following features are present: characterising LTL lesions may be challenging as we cannot assume the blood flow dynamics are the same as if the lesion were seen within the liver parenchyma. Of note, none of the patients with HCC in this review had background cirrhosis.Although one HCC case in this review demonstrated the characteristic enhancement pattern of early enhancement and washout,To our knowledge, this is the first systematic review of pathology encountered at the LTL and AFH. A limitation of the design of this study is that the overall level of evidence is low as case reports are inherently anecdotal, precluding any risk of bias assessment. Only 14 cases were identified, despite having a broad search strategy. No formal assessment of publication bias was possible. No case report described AFH pathology, although clinically the AFH is rarely distinguished from the LTL so some of the LTL lesions described may have originated from the AFH instead.Four case reports were not able to be retrieved. The titles and abstracts describe one HCC and three postoperative bile leaks which suggest that the conclusions would be unlikely to change had they been included.Our initial hypothesis was that LTL and AFH lesions are likely hepatic given that cadaveric studies have demonstrated remnant hepatic tissue in both structures. All lesions observed were considered to have originated from the LTL, which appears to support this hypothesis. Whilst the quality of evidence from each individual case report is low, to reduce the burden of diagnostic delay and unnecessary procedures, we would suggest that these observations support the addition of hepatic lesions to the differential diagnosis of LUQ lesions, particularly if it is difficult to exclude attachment to the LTL.


The labyrinthine bifurcation of the facial nerve is extremely rare. Diverse congenital temporal bone anomalies usually coexist, and a detailed preoperative evaluation is needed to detect them. We report a case of labyrinthine bifurcation of the facial nerve detected on the preoperative evaluation of a patient with congenital aural atresia. Congenital malformations of the facial nerve (FN) are uncommon . BifurcaA 3-year-old female, with family history of Nager dysostoses , presented to our centre with hypoacusis and facial dysostoses. Additionally, she presented a bilateral congenital aural atresia (CAA), micrognathia, microtia (grade I) and mandibular synodontia. However, she had passed the hearing screening at birth.We performed a conditioned play audiometry; it showed a bilateral conductive hearing loss with air- conduction thresholds at 60–70 dB. Genetic test for dysmorphias was negative. However, a new alteration was found (2q11.1q11.2).A temporal bone computed tomography (CT) identified a bilateral complete aural atresia Fig. a and a rSince the third year of life (since she visited our centre), non-surgical bone conduction hearing aids were adapted bilaterally. One year later, a passive transcutaneous bone anchored hearing device was implanted on the right ear. Currently, the patient is 9 years old and a left side canalplasty with ossiculoplasty is to be performed soon.The diverse FN anatomical variations and their relationship with middle and external ear anomalies are explained by a complex embryologic process, extended from the third week of gestation until the postnatal period . The facThe embryologic process explains the fact that bifurcation of the FN  is usually coexistent with external, middle, or inner ear dysplasia , 2, 6. IAn early auditory brainstem response is useful to evaluate the auditory pathway and CT is useful to evaluate the thickness and composition of the atresia and to detect related anomalies. The intratemporal FN can be depicted on MRI and CT while distally to the mastoid segment indirect landmarks are needed to understand the FN course . In our In bilateral CAA, hearing amplification during the early years (including bone- anchored hearing devices) is essential to allow the development of speech and language . Our expTo summarize, we report the first case of labyrinthine bifurcation of the FN since it was described. This anomaly, like other congenital FN anomalies, may be associated to external and middle ear malformations due to common embryologic pathways. Once an otologic malformation has been detected, the temporal bone should be carefully evaluated to detect additional anomalies as they might have therapeutic implications. We report a case of labyrinthine bifurcation of the FN to familiarize physicians with this rare temporal bone condition.


Primary mediastinal seminomas are exceedingly rare tumors, often localized to the anterior mediastinum. They may present with numerous complications, including superior vena cava syndrome, chylothorax, and pericardial effusions. Less commonly, they may present with paraneoplastic encephalitis. In this report we describe a case of a 19-year-old male with no significant past medical history who presented with bilateral hearing loss, progressive neuropathy, and ataxia. Subsequently the patient was found to have mediastinal mass with a high-titer anti-Hu antibody. To our knowledge, only one other case of mediastinal seminoma presenting with anti-Hu antibodies has been described in the literature. In this report, we describe a rare case of mediastinal seminoma, describe treatment options, and discuss additional known cases presenting with paraneoplastic encephalitis. First described in 1955 by Wolner et. al, primary mediastinal seminomas (PMS) are exceptionally rare germ cell tumors that account for 0.5-5% of mediastinal tumors . We presDespite presenting as a diagnostic challenge, PMS can present with distinct complications often related to mass effect. Known common complications of mediastinal tumors include superior vena cava (SVC) syndrome , chylothA 19-year-old male with no significant past medical history presented with a chief complaint of hearing loss. Initial otolaryngology work-up revealed severe bilateral sensorineural hearing loss, and he was fitted with hearing aids. Shortly thereafter he began to experience progressive dizziness, neuropathy, ataxia, hand tremor, and generalized seizures. He had no family history of testicular cancer. No past medical history of Klinefelter syndrome. Physical exam was significant for symptoms of cerebellar impairment, including wide-based gait with varying stride length, and prolonged finger-to-nose testing. Extensive work up was performed including serum neoplastic antibody panel: ANNA1 (Anti-Hu), ANNA2S (Anti-Ri), ANNA3S, P/Q-type Calcium Channel, CRMP-5-IgG, PCA2, PCA1,PCA-TR, Neuronal Voltage-Gated K+ Channel, AGNA-1, Amphiphysin, MOGFS Myelin Oligodendrocyte Glycoprotein (MOG-IgG1), NMO/AQP4 FACS, and Muscle-Specific Kinase (MuSK) were normal except Anti-Hu (titer: 1:3840); tumor markers: serum beta-hCG, and alpha fetoprotein were normal. LDH also was within normal limits at 196 . No lumbar puncture or CSF studies were performed, as antineoplastic antibodies were detected prior to procedure. Computed tomography (CT) head with contrast was unremarkable. Magnetic resonance imaging (MRI) head performed with and without IV contrast demonstrated midline cerebellar atrophy. No restricted diffusion noted on MRI. No mass lesions noted. Video electroencephalogram performed was normal without evidence of epileptiform activity. CT chest with contrast revealed a heterogeneous anterior mediastinal soft tissue nodule located within the thymus Figure 1Anti-Hu associated paraneoplastic rhombencephalitis is uncommonly associated with mediastinal germ cell tumors. Also known as antineuronal nuclear antibody (ANNA-1), presence of anti-Hu antibodies can result in varying neurologic disturbances, such as psychoses, seizures, hemiparesis, unexplained fevers, visual disturbance, and hearing loss. As the symptoms of paraneoplastic syndromes that occur secondary to PMS are nonspecific, diagnosis of these tumors can be difficult to ascertain. The mediastinum is also common location for thymomas, thyroid carcinomas, and T-cell lymphoma . ThyroidIn addition to our documented case of PMS with paraneoplastic rhombencephalitis, there are six additional reported cases as described in Patients in each of these cases underwent a variety of treatments, including chemotherapy, plasmapheresis, IVIG, and surgical removal. A recently published study performed by Zhai et al. compared outcomes of patients with PMS who underwent surgical treatment versus chemotherapy +/- radiation. This single-center retrospective study in 27 patients showed that there was no significant difference in 5-year overall survival, cancer-specific survival, and progression-free survival between patients with and without surgery . In contWhile outcomes of patients with PMS are well-described in the literature, outcomes of patients with PMS and concurrent paraneoplastic encephalitis are not articulated. The paucity of cases involving PMS with paraneoplastic encephalitis makes it difficult to assess which treatments are the most effective at benefitting the patient’s mortality and improving patients’ symptoms. In reference to the cases discussed here, neurologic recovery and patient outcomes differed on a case-by-case basis in PMS patients with paraneoplastic encephalitis. One case of a 22-year-old male with Anti-SS DNA 189 u/ml antibodies reported a nearly full recovery of cognitive functions with treatment . It appeIn a 2022 published report by Budhram et al, 27 patients with anti-Hu extralimbic encephalitis were identified and patient outcomes were described . None ofIn conclusion, PMS is a rare tumor, and presentation with paraneoplastic encephalitis is even more infrequent. A multidisciplinary approach should be considered in the setting of paraneoplastic symptoms. There is a need for more frequent documentation of unique cases in order to better establish treatment approaches that may improve patient outcomes.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.CW: drafting of the article and final approval of the manuscript. ZM: drafting of the article, acquisition of data, and final approval of the manuscript. DA: providing histopathology pictures and final approval of the manuscript. AC and RB: drafting of the article. All authors contributed to the article and approved the submitted version.


Subcutaneous granuloma annulare (SGA) is a rare, self-limiting granulomatous disease in children, commonly diagnosed by histopathology following biopsy or surgical excision. This study aimed to identify imaging clues for SGA that could expedite accurate diagnosis and avoid the need for biopsy in children.We retrospectively analyzed complete hospital records of all children diagnosed with SGA at our institution from January 2001 to December 2020. Detailed disease history, imaging findings, management, and outcome were evaluated.n = 26/41). Ultrasound examinations were performed on all patients, and 12 (43%) patients also received an MRI. Surgical intervention was conducted in 18 (64%) patients either by incisional biopsy (n = 6) or total excision of the lump (n = 12). In all patients who did not undergo surgery, SGA resolved spontaneously. A careful review of the MRIs led to the discovery of a characteristic imaging shape of SGA lesions: the epifascial cap with a typical broad circular base laying on the fascia, extending towards the subdermal/dermal tissue. This distinctive shape was evident in every patient in our cohort.We identified 28 patients (20 girls) at a median age of 3.75 (range 1–12.5 years). Ten patients presented with multiple lesions. Most lesions were located on the lower extremities (The “Epifascial Cap Sign” is a specific imaging sign for SGA, which to the best of our knowledge, helps distinguish this disease from other subcutaneous lesions. Recognition of this novel diagnostic sign combined with the historical and physical findings should enable clinicians to establish SGA diagnosis easily and diminish the need for further invasive diagnostic procedures. Granuloma annulare (GA) is a self-limiting granulomatous disease of unknown etiology with a clear histopathological appearance. The GA lesions consist of typical palisading granulomas, with a central necrotic zone surrounded by radially oriented histiocytes, lymphocytes, and fibroblasts , 2. GA cGGA is defined as the presence of more than ten widespread skin lesions . A diverIn most cases, diagnosing LGA and GGA as visible ring-shaped skin lesions is straightforward for a dermatologist. Unfortunately, this is rarely the case among pediatric patients with SGA lumps. Regardless of its harmless, self-resolving nature, SGA still is the most frequently biopsied, benign soft tissue mass in the lower extremity of children under the age of 5 , 10. TheWe have performed this institutional review to investigate the current practice of diagnosing children with SGA, intending to find a specific imaging sign of this disease that can quickly and effectively achieve a definite, accurate diagnosis without needing a biopsy.https://www.slicer.org/) version 4.7.0-2016-11-04 r25501 by manually segmenting the SGA lesions and superimposing them by volume renderings of the respective body regions in all relevant slices  of all children aged 0–18 years diagnosed with SGA from January 2001 to December 2020. Evaluation of the data according to the patient's disease history, management, and outcome is done. The information identified and analyzed for each patient included: sex, age at first presentation, the duration of symptoms and signs prior to the first presentation, the location of the lesion(s), the number of the lesions, associated pain, the clinical description of the lesion(s), the report of trauma prior to the appearance of the lesions, the time between the first presentation at our Department and treatment starting, the diagnostic imaging and lab work performed, the histopathologic report provided, the type of conservative or surgical treatment performed, the recurrence after treatment and the follow-up time from the first presentation. Three-dimensional reconstructions of MR images were performed with 3D Slicer . In 50% of the patients, the SGA lesions were located on the lower leg area, indicating the high clinical possibility of a typical location for an SGA lump. Ten patients presented with multiple lesions. The SGA lumps were described as solid, nontender, and without signs of inflammation. All children were otherwise healthy, and the SGA lumps were not associated with overlying cutaneous abnormalities.A strong female predilection of 2.5:1 is noted among our patients. The median age at the first presentation was 3.75 years (range 1–12.5 years). SGA lesions were mainly found on the lower extremities (The median time from the subcutaneous lump(s) appearance until the first presentation at the hospital reported by parents was 2 months (range 0.5–5 months). In 9 SGA patients (33%), parents reported that trauma preceded the appearance of the lump(s), and its persistence made them seek a doctor's opinion.Every SGA patient included in the study has received an ultrasound examination (US) at the time of the first presentation. An unclear subcutaneous soft tissue mass with poorly defined borders, hypo- and hyperechoic zones, and mild vascularization was regularly described. In 16 SGA patients (57%), x-rays were performed at the time of the first presentation to exclude osseous abnormalities. Because of the several possible pathologies and the difficulty in excluding a potential malignancy, 12 patients (43%) were referred for magnetic resonance imaging (MRI), all of which had to be performed under general anesthesia. Yet, MRI findings did not yield a definitive diagnosis in any of the cases. The lesions were regularly described as subcutaneously located with ill-defined borders. Imaging led to the consideration of several differential diagnoses, most commonly a subcutaneous low-flow vascular anomaly, fibromatosis, fasciitis, and post-traumatic fat necrosis. Only in one case was SGA considered among the potential differential diagnoses.n = 6) or complete excision (n = 12) was performed depending on the size of the lesion(s). Preoperative lab work included a complete blood count and basic metabolic panel, which resulted uneventfully in every case.Surgical intervention was performed in 18 patients (64%), including all who received an MRI. The median time between the first presentation of the child in the hospital and the surgical intervention was one month. Biopsy (All patients who did not undergo surgery (10/28) were diagnosed by an attending specialist who recognized SGA after clinical and imaging examinations. These children experienced a spontaneous resolution of the subcutaneous lesion(s) which lasted from 7 to 29 months. Two of these patients received local corticosteroid treatment for 2 weeks, which led to a mild reduction of the lump(s) size, whereafter the local treatment was discontinued. The pediatric surgeons who clinically suspected these lesions to be SGA lesions decided on the clinical follow-up of these patients.The median time of the follow-up was 19 months (range 14–48 months). Two patients who underwent complete surgical excision of the lump experienced a local recurrence occurring 4 and 5 months after surgery, respectively. Both recurrent cases resolved spontaneously 6 months later.All patients were reviewed in November 2021 in the frame of the long-term follow-up. One girl had developed juvenile chronic arthritis 5 years after the biopsy for SGA, and another girl was diagnosed with chronic inflammatory bowel disease 9 years after having a complete excision of SGA.A careful retrospective review of all imaging led to the recognition of a novel and specific imaging sign for SGA, which we are not aware to be present in other pathologies. The SGA lesions show a well-defined broad-based rounded fascial border and an ill-defined crescent, cap-shaped epifascial border . We haveIn the present study, we show for the first time that SGA lesions mirror a raised-rounded epifascial cap with a broad circular base and a continuous curved surface shape that extends towards the more superficial tissues. This shape of SGA is characteristic of this disease and, to the best of our knowledge, is not found in any other subcutaneous lesions.Most SGA cases occurred around the age of 4 years  with greTrauma has repeatedly been reported as one of the triggering events in the etiology of SGA . HoweverIn the absence of a trauma history, the clinical picture usually resembles a manifestation of a neoplastic disorder in the eyes of a physician unfamiliar with the SGA entity. As a matter of fact, despite the harmless nature of the SGA lumps, a large portion of our patients underwent either incisional or excisional biopsy of the painless lump due to an unclear diagnosis and fear of a possible malignant trait. Indeed, according to a review from Chung et al., SGA is the most frequently biopsied, benign soft tissue mass in children under 5 despite its very low clinical incidence in the United States .Few studies have described the MRI characteristics of the SGA lesions but failed to find a common pathognomonic imaging pattern, enabling clinicians to properly diagnose and differentiate SGA from other possible diseases based solely on imaging characteristics , 16, 23.The epifascial cap shape of the SGA lesions is also evident in US examinations, even though our retrospective analysis of the US images has limited value and reliability due to inter-examiner differences and the lack of standardized guidelines for image assessment of subcutaneous tissues. The US has three major obstacles which are difficult to standardize: the cooperation of a young patient, the subjectivity of the examiner, and the intensity of pressure applied to the lesions with the US probe, which often alters the shape of the subcutaneous lesions. On the US images of most of our SGA patients, we have detected the same cap-shaped presentation located on the muscle's fascia compatible with the sign as it is seen on the MRI images of these patients. US findings were otherwise described as solid nodules with ill-defined borders and noted central hypoechoic zone surrounded by a hyperechogenic periphery, agreeing with the sonographic characteristics of SGA reported in a few previously published studies , 24–26. In addition, we have reviewed all previously published cases of SGA that have provided MR or US imaging of the lumps and confirmed that every reported image in the literature so far consistently presents as an epifascial cap formation , 24–30. There are numerous subcutaneous pathologies in children, with both specific and unspecific imaging findings. In some diseases, subcutaneous lesions can be one of several clinical signs in the context of systemic diseases such as rheumatoid arthritis, sarcoidosis, tuberculosis, and others, with imaging findings that are not specific. Most of these lesions present as nodules, which can be singular or multiple, and vary in size. The nodules are mobile, show irregular shape and margins in imaging, and enhance after the application of a contrast agent in MRI, due to inflammation , 14, 15.The hypothesis of granuloma formation on an autoimmune basis and its association with diabetes mellitus, rheumatoid disease, and other systemic disorders have been investigated in several studies –36. A stThe epifascial cap is a typical imaging sign of SGA lesions which, to the best of our knowledge, distinguishes this disease from other subcutaneous lesions. Recognition of this sign in an otherwise healthy child presenting with a symptomless subcutaneous lump over bony prominences should enable clinicians to diagnose SGA accurately, schedule the patient for a follow-up visit and prevent the majority of children with this disease from undergoing further invasive diagnostic procedures.


Hepatocellular carcinoma (HCC) is the most common liver cancer and has a propensity to develop arteriovenous fistulas with the surrounding vasculature, making targeted intravascular treatment more difficult. HCC can oftentimes be accompanied by portal hypertension and liver cirrhosis, which can, in turn, cause recanalization of the umbilical vein. In rare circumstances, arteriovenous fistula formation and shunting into the recanalized and enlarged umbilical vein can occur. In the following presented case of HCC, an arteriovenous shunt between the anterior division of the right hepatic artery and a recanalized umbilical vein is demonstrated. Subsequent successful endovascular coil embolization of the fistula was performed to avoid shunting and non-target embolization of the radiation particles in the umbilical vein territory. Post-embolization angiogram with DynaCT and lack of Tc-99m macroaggregated albumin deposition in the umbilical vein distribution confirmed the resolution of the shunt. The patient then received targeted Y-90 transarterial radioembolization locoregional therapy in combination with systemic therapy. Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver and one of the most common causes of fatal cancers worldwide . There aThe Barcelona Clinic Liver Cancer (BCLC) staging system outlines several factors to be considered when determining HCC treatment and prognosis. These factors include AFP levels, albumin-bilirubin (ALBI) score, Model of End-stage Liver Disease (MELD) score, Child-Pugh score, Eastern Cooperative Oncology Group Performance Status (ECOG PS) rating, and individual patient characteristics . CurrentYttrium-90 (Y-90) radioembolization is a form of TARE that delivers radioactive microbeads laced with Y-90 directly to the HCC tumor through injection from the feeding artery. Y-90 is an unstable radioactive isotope that emits cytotoxic beta particles with a half-life of 64.2 hours and mean tissue penetration of 2.5 mm . The Y-9Before TARE can be performed, mapping is required for several treatment planning purposes: angiography of the hepatic vasculature, predicting the level of Y-90 pulmonary shunting to avoid ≥30 Gy to the lungs, and determining the appropriate therapeutic Y-90 dosage to avoid ≥40 Gy to the surrounding healthy liver parenchyma . A lung Although TACE is the more established treatment option, TARE is increasing in popularity for several reasons. In comparison to TACE, TARE appears to be just as efficacious, providing a similar overall survival rate at one-year post-procedure, yet a longer time to progression of HCC ,13. TAREThe following presented case describes a rapidly growing BCLC stage B multinodular HCC lesion with an extension of non-occlusive eccentric tumor thrombus into the hepatic veins and hepatic inferior vena cava (IVC) (about 5-7 mm) and with concerns for high lung shunt fraction. In addition and notably, on pre-procedure cross-sectional imaging and mapping angiography, significant shunting into a prominently dilated umbilical vein was noted.A 55-year-old male presented with intractable right upper quadrant abdominal pain, abnormal weight loss, decompensated grade IV liver cirrhosis, and intermittent hepatic encephalopathy. Notably, a prior history of two episodes of perihepatic peritoneal tumoral hemorrhage was treated with bland embolization at an outside hospital. He had a past medical history of chronic HCV infection, tobacco abuse (30 pack-years), and alcohol abuse. His AFP marker was elevated at 4,136 ng/mL , with his previous AFP level being 8.4 ng/mL 11 years prior. He was positive for both HCV and HAV antibodies, reflecting his chronic HCV viral infection and either a prior HAV infection or immunization. He was negative for antibody detection against HIV and HBV. Anemia and thrombocytopenia were present and likely related to long-standing liver cirrhosis.Subsequent CT imaging revealed two liver masses: a 10 × 7 × 8 cm exophytic hemorrhagic mass in segment 7 and a smaller 2.6 × 1.9 cm mass in segment 8, both of which were highly representative of HCC (LI-RADS category 5) with superior transcapsular subdiaphragmatic extension without peritoneal seeding. There was no active extravasation of contrast into the existing perihepatic hemorrhagic fluid accumulation and no evidence of distant metastasis. The mass was complicated by IVC and right hepatic vein invasion, as well as porta hepatis lymphadenopathy. There was also portal hypertension present, as evidenced by splenomegaly (16 cm), portosystemic collaterals, duodenal varices, a large recanalized umbilical vein, and a small volume ascites . The patient had an ECOG PS score of 0, an ALBI score of -2.5, a MELD-Na score of 15, a MELD score of 13, and a Child-Pugh score of B. These factors determined the HCC in question to be BCLC intermediate stage (B). The recommended treatment options for this BCLC stage included liver transplantation, TACE/TARE, or systemic therapy. The patient was not a candidate for liver transplantation, making TACE/TARE and systemic therapy the therapeutic options available. The case was discussed at the multidisciplinary gastrointestinal tumor board meeting, which determined local Y-90 radioembolization, as well as atezolizumab and bevacizumab combination systemic therapy to be the next course of action. The tumor board recommended the patient start atezolizumab immediately and then begin bevacizumab after the Y-90 treatment procedure had been completed.With moderate sedation, ultrasound-guided access to the right common femoral artery was obtained using a micropuncture kit. A vascular sheath was inserted into the access site and a Benson wire was then advanced into the abdominal aorta. A Mikaelson catheter was sheathed over the Benson wire and advanced to the level of the celiac artery. Contrast injection confirmed celiac artery catheterization with subsequent angiography. The Benson wire was replaced with a microsystem consisting of a microcatheter and a microwire. Angiography, DynaCT, and three-dimensional (3D) reconstruction performed at the level of the proper hepatic artery revealed a large hypervascular hepatic mass with significant arteriovenous fistulization. The microsystem was advanced to the anterior branch of the right hepatic artery, where angiography revealed an arteriovenous fistula (AVF) formation with shunting to the large recanalized umbilical artery Figure .Embolization of the unnamed medial-subsegmental branch of the segment 8 artery was performed using metallic coils Figure . AdditioThe mapping Tc-99m MAA single-photon emission computed tomography (SPECT) CT demonstrated significant uptake in the tumor-free hepatic segment 5, relative to the tumoral segment 8, discordant to the intraprocedural DynaCT findings. Hence, on the day of treatment, this segment was embolized with Gelfoam to spare the healthy liver from radiation and increase the blood flow and treatment particle delivery to the tumoral segment 8. Y-90 microembolic microspheres were injected intravascularly at the level of the right hepatic artery with subsequent SPECT CT demonstrating successful uptake of Y-90 microbeads localized to the area of interest Figure . The patThe umbilical vein is an embryologically significant vascular structure that provides oxygenated blood from the placenta to the fetal circulation in utero. After birth, the umbilical vein begins to involute to form the ligamentum teres hepatis (round ligament of the liver), a fibrous structure connecting the liver to the umbilicus . Under iAVF presence is not an uncommon finding in HCC, with one study noting a prevalence of 31.2%: 28.8% involved portal vein shunting, and 2.4% involved hepatic vein shunting, with no report of umbilical vein shunting . SimilarIn cases where there is HCC extension into the portal vein or hepatic vein, combinatorial treatment involving locoregional therapy and systemic therapy can provide increased response rates . As withPortal hypertension and liver cirrhosis in the presence of HCC resulting in a recanalized umbilical vein is not an entirely uncommon phenomenon. However, HCC AVF formation with a recanalized umbilical vein is a rare occurrence. For patients undergoing targeted liver-directed therapies, including TARE and TACE, an AVF associated with shunting vessels, including portal vein, hepatic vein, and umbilical vein, can have significant side effects if left patent during these locoregional therapies. Hence, endovascular embolization of these AVFs is quintessential for the safe and targeted delivery of Y-90 microembolic microspheres to the HCC with minimal adverse effects. In particular, AVF formation with associated recanalized umbilical vein shunting in the setting of HCC can be recognized as a phenomenon that warrants transarterial embolization to improve patient outcomes.


Tailgut cysts are congenital cysts arising in the retrorectal space. They are thought to be benign with variable malignancy risks. We report a case with previous surgical intervention decades prior that had undergone a tailgut cyst excision with surgical complications leading to carcinomatosis. An elderly female (70s) presented with tailbone/pelvic pain. She underwent cyst excision that was complicated by an intraoperative rupture. The cyst was pathologically proven to be a tailgut cyst with adenocarcinoma. She presented 13 months postoperatively to the emergency department with worsening abdominal pain. Imaging was concerning for diffuse omental nodules and narrowing of the proximal sigmoid colon. She was not deemed to be a surgical candidate and was transitioned to hospice care, where she passed away shortly afterward. This case report highlights the utility of complete excision of tailgut cysts and possible complications. Tailgut cysts (TGC) are congenital cysts arising in the retrorectal space from primitive tailgut remnants. They comprise only a small fraction of retrorectal tumors, and arise due to incomplete involution of the postcloacal gut. During embryogenesis, the embryo starts to fold inward during the 4th week. The lining can include a combination of epithelia, including transitional, glandular, and squamous.Tailgut cysts have a female predominance of 5 : 1 . ClinicaPreviously, they were thought to behave in a benign fashion, with rare cases having cancer . Lately,A 71-year-old well-nourished (BMI of 22.5) elderly patient presented to her physician for increasing pain in the tailbone/pelvic area for the past few months. She denied any complaints of bloody stool, changes in bowel movements, or urinary changes. She had not had a previous screening colonoscopy but has done yearly cologuard that has been negative. Given her clinical presentation, she underwent magnetic resonance imaging (MRI). The initial MRI demonstrated a large (10.6 × 12.8 × 14.1 cm) complex multiloculated cystic mass with solid components in the presacral space and extending into the perineum. T1 signaling demonstrated increased intensity, with findings likely secondary to intralesional hemorrhage or mucinous/proteinaceous components. Abdominal and pelvic computer tomography (CT) imaging performed at the same time as the MRI demonstrated a similarly large mass with multiloculated cysts. Within the septations, there were focal areas of calcification. On both imaging modalities, the mass is separate from the rectum and was suspicious for retrorectral cystic hamartoma, but the differential was broad. Given the mass effect and extension into the perineum, this most likely explains her presenting symptoms. Interestingly, the patient recalls a previous operation performed decades prior when she was approximately 9 years old to remove a cystic mass that was “gelatinous.” She did not recall any specific diagnosis or the specifics regarding the operation. Previous records were unretrievable due to the time elapsed between the two events, and previous healthcare providers were no longer reachable.Given her history of a childhood mass decades prior, it was assumed that the mass was indolent in nature and not malignant. Plans to perform a colonoscopy were arranged with the goal of surgical excision. During surgery, the patient was placed in a supine position with careful preparation of the abdomen. A deep midline incision was performed with cautery down to the fascia after which the perineum was opened. The bowel was retracted, and a Balfour retractor was placed. Attention was focused on the perineum, where manual dissection was performed to free most of the mass. However, the portion of the mass within the pelvis was tightly adhered to the pelvis, coccyx, sigmoid colon, and rectum. With retractors and careful dissection, the mass was finally separated from important structures. When trying to skeletonize and shell out the mass, there was limited space for the retractor due to the size and firmness of the mass. An incision on the top aspect of the mass was performed where 800 cc of brownish fluid was suctioned with some spillage into the abdominal cavity. After the mass was partially decompressed, the anterior aspect was grasped with an Allis clamp and retracted anteriorly. Attention was then turned to the sacrum to remove the mass. The sacral vein unfortunately bled, leading to technical complications that were ultimately resolved with suture ligature and pressure. Unfortunately, the mass was severely adhered to the coccyx, and ultimately a complete excision was not possible (80% was removed). The pelvis was then washed with multiple liters of saline to ensure hemostasis was maintained as well as pelvic and abdominal cleaning. A 19-French round Blake drain was placed in the pelvis. The midline fascial wound was then closed, and the skin was stapled. Overall, the estimated blood loss was 2,500 milliliters.Histologically, the specimen demonstrated fibrous tissue with cholesterol clefts, foamy histocytes, necrosis, and focal calcification . There wShe was then treated with FOLFOX followed by chemoradiation with continuous 5-fluorouracil for a 6-month duration of adjuvant treatment. 13 months postsurgery, she presented to the emergency department with worsening abdominal pain due to refractory constipation. A CT abdomen and pelvis were performed and demonstrated diffuse, ill-defined soft tissue density and areas of multiloculated fluid with omental nodules highly suspicious for carcinomatosis as well as narrowing of the proximal sigmoid colon. The surgical care team was consulted, and given her clinical presentation, she was not deemed a surgical candidate. After a discussion with the patient and the family, she was placed in hospice. However, she developed an ileus/obstruction with emesis refractory to nonoperative management. The decision was made to perform an exploration and create a diverting ostomy with the potential for a sigmoid colectomy depending on the location of the obstruction. Ultimately, an area of obstruction was found in the sigmoid colon, and resection was performed. Unfortunately, the patient succumbed to her disease and dies shortly after.A gross examination of the resection showed the mucosa was mottled with patchy areas of necrosis but no areas of induration, masses, or polyps. Cut surfaces of the colon show multiple scattered ill-defined areas of white-tan induration in the colon wall and pericolonic tissue.Histological examination demonstrated similar morphology to the initial specimen but more patchy areas with voluminous intracytoplasmic mucin Figures . The bulTumors occurring in the presacral space are extremely rare and estimated to affect less than a fraction of 1% . HoweverTailgut cysts tend to occur in women with a ratio of 5 : 1 compared to men and have a wide age range . Half ofThe original specimen was diagnosed as TGC with a carcinomatous portion arising within. There was weak CK20 and patchy staining for CDX2 which further add doubt to colorectal as the primary source. Additional immunohistochemical staining to rule out common sites of adenocarcinoma from the thyroid and Mullerian derived (PAX8), pancreatobiliary (CK7), breast (ER), and neuroendocrine tumors (synaptophysin and chromogranin) were all negative. When she presented the second time, there was discussion clinically that this might represent a colorectal primary. However, the gross findings did not suggest a colon primary as the mass was predominately submucosal with the apex abutting the colonic epithelium. Furthermore, the histology was similar to that of the primary specimen, and the immunostaining of the lesion is closer to that of the primary lesion while not having the stereotypical immunophenotype of a colonic adenocarcinoma (strong CK20 and CDX2 positivity).The unique features of this case are the appearance of potential mucosal colonization of the tumor and the patient's history of prior surgery in the same anatomical location. Although efforts were made to find the records of the surgeries in her childhood, they could not be located. We speculate that the excision during her childhood could have been an incompletely excised tailgut cyst, given her age at the time. Over the decades, it could have enlarged and developed the carcinoma. The rupture during surgery, not an uncommon occurrence of these lesions, likely led to carcinomatosis and the findings in the colon wall.We report a case of a tailgut cyst that was ruptured on initial excision and presented 13 months later with metastasis. Although tailgut cysts are rare, they should still be in the differential diagnosis of presacral lesions. Careful surgical excision is warranted to minimize the risk of recurrence and potential metastasis.


We present findings on cine magnetic resonance imaging (MRI) using steady-state free precession (SSFP) pulse sequences in a patient with pulmonary arteriovenous malformation (PAVM). The technique has the advantage of demonstrating the pulsation of lesions during the cardiac cycle on cine images. It may not replace but may complement other MRI sequences in the characterization of pulmonary lesions in selected cases. To our knowledge, no prior video of cine images of PAVM has been provided in the literature. Pulmonary arteriovenous malformation (PAVM) is an abnormal communication between pulmonary arteries and pulmonary veins, creating a right-to-left shunt. PAVMs are usually associated with hereditary hemorrhagic telangiectasia (HHT), inherited in an autosomal dominant pattern There is an estimated cerebral abscess risk of 5%-19% and a 9%-18% risk of ischemic stroke in those who manifest PAVM [Transthoracic contrast echocardiography (TTCE) is the preferred initial screening test. This test allows for potential shunt identification in suspected PAVM cases. TTCE has a high sensitivity and negative predictive value of 97% and 99%, respectively. Unfortunately, it has a high false positive rate and cannot localize lesions . ContrasA 53-year-old female with a history of acute ischemic stroke had an extensive workup, including transesophageal echocardiogram (TEE), which suggested a patent foramen ovale (PFO). However, there was no PFO demonstrated on intracardiac echocardiography (ICE) imaging during attempted closure. A bubble study performed during ICE showed a late crossing of bubbles suggesting a pulmonary shunt. CTPA demonstrated a simple PAVM in the right middle lobe Figures , 2A-2D.Incidentally, this PAVM appeared as a pulsating lesion on cine cardiac MRI images using steady-state free precession (SSFP) sequences Video .Classification of PAVMs is based on the number of feeding arteries. The simple type has one segmental feeding artery, whereas the complex type has two or more segmental feeding arteries . This clCT techniques, without and with contrast, are most commonly used in the initial evaluation and follow-up of patients with PAVM or risk of developing PAVM. Cumulative radiation dose may be substantial in patients with HHT secondary to repeated diagnostic and therapeutic interventions .SSFP cine MRI sequence may not replace currently used MRI sequences since this sequence type and protocol is typically used for a small field of view rather than the entire lungs. It may complement currently used MRI sequences by demonstrating pulsation of the lesions on cine images.The unique feature of the technique may help the characterization of pulmonary lesions since certain vascular and non-vascular abnormalities may mimic PAVM . Non-vasSSFP cine MRI demonstrates potential in aiding initial diagnosis and follow-up of PAVM in conjunction with other MRI sequences. Optimization of the technique and comparative studies are required to determine the value of this technique to complement established MRI sequences in selected cases.


ChatGPT (Chat Generative Pre-trained Transformer) is a chat robot program developed by OpenAI . It is a natural-language processing tool driven by artificial intelligence technology. It can complete tasks such as writing emails, video scripts, copywriting, translation, coding, and writing papers. At present, several studies have been conducted on the use of this tool for academic writing, so we report a rare case of suprasellar ectopic pituitary neuroendocrine tumor (PitNET) secreting growth hormones, in a female 53-year-old patient with facial changes and hypertrophy of her hands and feet for six years. When asking questions on unusual topics, ChatGPT can provide answers but not specific ones, and similar to most machine learning solutions, verifying the correctness of information is a problem.Question asked from ChatGPT: Summarize ectopic pituitary neuroendocrine tumor.“Suprasellar heterotopic pituitary neuroendocrine tumors refer to tumors formed by the heterotopic growth of pituitary neuroendocrine tumor cells in the sellar region other than the pituitary glands. This tumor is common in middle-aged women, and it often manifests as headache, visual impairment, and endocrine dysfunction. Diagnosis is usually made by combining history, physical examination, blood tests, and imaging. Treatment is primarily performed through surgical resection of the tumor, radiotherapy, and drug therapy, and the prognosis is mostly good.”The content in quotation marks is generated by ChatGPT. ChatGPT  is a state-of-the-art large language model (LLM) based on the GPT-4 architecture . Since iA 53-year-old woman presented with facial changes and hypertrophy of her hands and feet for six years. Physical examination upon admission showed hypertrophic nasal lip, widened nasal ala, prominent forehead and mandible, prominent zygoma, and hypertrophic extremities were observed. No evident abnormality was found in the rest of the physical examinations. After admission, hormone examination showed that the fasting random growth hormone level was 10.5 ng/ml, insulin-like growth factor 1 (IGF-1) was 484 ng/ml, free thyroxine (FT) 49.64 pmol/L, and the trough value of growth hormone was 10.5 ng/ml after oral glucose administration. Other hormone levels were normal. MRI examination of the pituitary gland revealed a quasi-circular, space-occupying lesion in the suprasellar region, with a slightly hypointense signal on T2WI and a slightly hyperintense signal on T1WI. After enhancement, the lesion showed mild to moderate uniform enhancement, the boundary with the pituitary and pituitary stalk was clear, and the optic chiasm was pressed superiorly Figures -1C. FourAn ectopic pituitary neuroendocrine tumor(PitNET) originates from the residual embryo tissue of pituitary tissues in the pharyngeal region and the residual tissue of Rathke’s capsule during embryonic development and migration (from the nasopharynx to the sella turcica) . The incCharacteristic imaging features of ectopic PitNETOn CT, it is often as dense as gray matter and moderately enhanced imaging, which can be used to evaluate bone erosion . MRI shoSimilar to typical pituitary neuroendocrine tumors, surgery is the treatment of choice for ectopic PitNET. However, given its special location, ectopic PitNET is difficult to operate, and completely removing part of the lesions is a challenging task. Patients who cannot receive total resection can be assisted with radiotherapy or medication after surgery. For example, bromocriptine (a dopamine antagonist) is commonly used to treat prolactin (PRL) adenomas. Ectopic PitNET is generally benign, with no recurrence or metastasis and a good prognosis . After tThe combination of AI and medicine is reflected in many medical fields . The impChatGPT is a technology for automatically generating text based on known text, which has high accuracy and the advantage of automation . The genChatGPT concluded that suprasellar ectopic PitNETs are a rare subtype of ectopic PitNET involving the suprasellar region. The clinical presentation, diagnosis, and treatment of suprasellar ectopic PitNETs are similar to those of ectopic PitNET located elsewhere in the brain, but the procedure is more complex and challenging. The development potential of ChatGPT in medical scientific research writing is considerable, which can provide faster and more accurate support for medical scientific research writing. However, the generated content must be reviewed and verified by experts.


Chest pain is a very common symptom in an emergency context. Its differential diagnosis is extensive and includes some conditions that require immediate recognition and intervention. It can also be a symptom associated with rarer diagnostic possibilities. Here, we report the case of a 53-year-old woman admitted to the emergency department due to chest pain and initially diagnosed with non-ST elevation acute myocardial infarction. A transthoracic echocardiogram revealed a large hyperechogenic round mass, suggestive of a left atrial cardiac myxoma. Coronary angiography showed no significant lesions. The patient underwent cardiac surgery with excision of the mass, whose histological diagnosis was atrial myxoma. The immediate postoperative period was uneventful, and the patient was discharged asymptomatic and without echocardiographic changes. Cardiac tumors are a rare finding, of which myxomas are the most common. Symptoms can typically result from embolism, obstruction, or constitutional symptoms. A myxoma presenting as acute chest pain and mimicking an acute coronary syndrome is an uncommon finding. This case reminds us of an extremely rare differential diagnosis of chest pain and awakens us to the usefulness and importance of using echocardiography as a diagnostic tool. Internists in emergency departments frequently encounter chest pain as a symptom. A thorough characterization and careful examination are imperative for a proper diagnosis ,2. Its dPrimary percutaneous angioplasty is recommended for certain cases of acute coronary syndrome, which should be performed as soon as possible. Hence, for this purpose, the approach to a patient with acute chest pain necessarily involves performing instantly an electrocardiogram, in order to identify the candidates for primary percutaneous angioplasty and direct them immediately to a cardiac catheterization laboratory ,4.The diagnosis of acute coronary syndromes without ST-segment elevation involves the measurement of markers of myocardial ischemia. In recent years, high-sensitivity troponin has been shown to be the most sensitive marker . HoweverA 53-year-old female patient with a past medical history of arterial hypertension, osteoarthritis, and active smoking (3.5 smoking pack years). The patient took bisoprolol 1.25 mg, perindopril 5 mg + indapamide 1.25 mg, and acemetacin 90 mg as a daily medication. She was admitted to the emergency department due to retrosternal oppressive chest pain radiating to the left upper limb, with a duration of three to four hours. The pain started at rest and had no relieving or aggravating factors, and the patient denied other accompanying symptoms. The patient's physical examination showed hemodynamic stability, with normal blood pressure and heart rate. During cardiac auscultation, regular rhythmic sounds were observed, as well as a mild diastolic murmur in the apex. Pulmonary auscultation and the remaining physical examination showed no abnormalities.An electrocardiogram was performed, which did not show significant ST-segment elevation or other changes consistent with acute ischemia Figure .The only analytical alteration was a slight elevation in high-sensitivity troponin, with an upward momentum. High-sensitivity troponin at admission was 8.59 ng/L, after three hours was 39.66 ng/L, and after six hours was 189.70 ng/L. A working diagnosis of non-ST segment elevation myocardial infraction was established.This hospital does not have a cardiac catheterization laboratory, which resulted in a delay of more than 24 hours in performing coronary angiography, and the patient received a loading dose of aspirin and ticagrelor. Analgesia was initiated, with a clear improvement in pain.Subsequently, a transthoracic echocardiogram was performed Figures , showingConsidering the echocardiogram findings suggestive of myxoma, antiplatelet therapy was suspended. Furthermore, the patient was transferred to the cardiology department of the local area, where she completed the preoperative evaluation, including coronary angiography, which showed coronary arteries without significant lesions. Subsequently, she was transferred for cardiac surgery and underwent excision of the intracardiac mass. Histological evaluation of the operative specimen identified stellate and spindle cells with eosinophilic cytoplasm, arranged in aggregates and cords, around vessels and isolated, in a background of myxoid stroma. No mitoses or necrosis was documented, and the histological diagnosis was atrial myxoma.The immediate postoperative period was uneventful, and the patient was discharged asymptomatic and without echocardiographic changes.Primary cardiac tumors are extremely rare clinical entities. Approximately 50% to 75% of these masses correspond to myxomas, which are defined as non-neoplastic cardiac masses, resulting from an uncontrolled proliferation of mesenchymal cells. In the majority of cases, they are located in the left atrium -9. From The clinical presentation of myxomas is variable and dependent on their size and location, which can include constitutional symptoms, resulting from embolization and/or obstruction. Typically, obstructive symptoms include shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, palpitations, and hemoptysis and may also involve hepatic congestion, ascites, or syncope. Some of these symptoms may worsen in certain body positions ,7,9.In this case, the patient exhibited an atypical and sudden clinical manifestation, accompanied by an elevation in high-sensitivity troponin, which mimicked an acute coronary syndrome.There are few reported cases of myxomas with this type of clinical presentation. In some of these cases, an elevation of myocardial necrosis markers was observed, resulting from embolization to the coronary arteries ,10,11. IHowever, taking into account the absence of segmental wall motion abnormalities, in the early echocardiogram performed on this patient, the chest pain could be consequent to the obstruction to the transmitral flow caused by the myxoma, identified on the echocardiogram, making this a rare case.Obtaining an echocardiogram is crucial for the early diagnosis of rare causes, such as atrial myxoma, in atypical presentations of acute coronary syndrome.In a specific case of myxomas, in addition to obtaining diagnostic confirmation and differentiating this type of mass from vegetations or thrombi, the echocardiogram allows for the identification of the location, size, site of attachment, and mobility. Echocardiography is an essential diagnostic tool for emergency physicians that cannot be overlooked. Its ability to characterize the mass aids in surgical preparation .Despite their benign clinical nature, myxomas can be associated with devastating complications. Considering that their presentation can be highly variable, depending on the location and characteristics of the mass, a high level of suspicion is important in the face of constitutional, embolic, and obstructive symptoms.The echocardiogram is a crucial diagnostic tool that expedites referral for cardiac surgery. Furthermore, it plays a pivotal role in preoperative characterization, especially in cases requiring urgent surgery, as presented in this clinical case.


Acute cholecystitis is the most common presentation of gallbladder (GB) disease. It has an incidence of around 200,000 cases a year in the United States (US) and affects approximately 20 million individuals in the US. In most cases, it presents with a history of symptomatic gallstones. Initial management includes intravenous hydration and antibiotics, bowel rest, and analgesia. Complicated cases are typically resolved with surgery (laparoscopic cholecystectomy). The pathogenesis of acute cholecystitis is most often explained by obstruction of the cystic duct. Research has shown that there are more contributing factors than just obstruction alone.We present a case of a 38-year-old Hispanic woman who came to our emergency department with a chief complaint of the anterior chest wall and epigastric pain. Physical examination was remarkable for epigastric tenderness and negative Murphy's sign. She had no fever. Cardiac troponins and electrocardiogram (EKG) were negative. Initial labs showed no sign of infection with white blood cell (WBC) count within the normal range, and only mildly elevated aspartate aminotransferase (AST), alanine transaminase (ALT), and total bilirubin. Follow-up abdominal computerized tomography (CT) scan without contrast and right upper quadrant (RUQ) abdominal ultrasound showed cholelithiasis without evidence of cholecystitis. An hepatobiliary iminodiacetic acid (HIDA) scan on day three of admission revealed an obstruction of the cystic duct. The patient was scheduled for laparoscopic cholecystectomy with an intraoperative cholangiogram. The surgery was uneventful; it was remarkable for a very distended, inflamed, and edematous GB, which had to be decompressed with a lap needle for removal.It is evident that acute cholecystitis may not always present with the classic diagnostic criteria, including laboratory results  and physical exam findings . However, a thorough work-up can be just as effective in diagnosis. Acute cholecystitis is the most common presentation of gallbladder (GB) disease. It has an incidence of around 200,000 cases annually in the United States and affects approximately 20 million individuals . In mostEscherichia coli, Enterococcus, Klebsiella, or Enterobacter. Cholecystitis histologic changes range from mild findings, such as edema and acute inflammation, to more severe changes, including gangrene and necrosis [The pathogenesis of acute cholecystitis is most often explained by obstruction of the cystic duct . Howevernecrosis ,3.Acute cholecystitis typically presents with right upper quadrant (RUQ) pain or epigastric pain that often radiates to the right shoulder or the back. The pain is usually associated with onset after ingesting fatty meals. It usually lasts a prolonged time (four to six hours) and stays steady at high intensity. Some associated symptoms include nausea, vomiting, fever, and anorexia ,3. PhysiThe presence of gallstones associated with RUQ pain and fever highly supports the diagnosis of cholecystitis. Abdominal ultrasound is a wildly used tool with a sensitivity and specificity of 84% and 99%, respectively. Sonographic findings show GB wall thickening along with pericholecystic fluid and edema . A sonographic Murphy’s sign can also aid in the diagnosis ,5.A hepatobiliary iminodiacetic acid (HIDA) scan is the next best step if the diagnosis remains inconclusive after ultrasonography. This shows a physiological picture of the GB. In an average healthy patient, visualization of contrast occurs within 30 to 60 minutes after administration. A delay in the visualization of the GB after 60 minutes or after delayed imaging (3 to 4 hours) supports a diagnosis of acute cholecystitis in the correct clinical setting [A computerized tomography (CT) scan of the abdomen, which has a high sensitivity (94%) but low specificity (59%) is not usually indicated for the diagnosis of acute cholecystitis, may be ordered to rule out other conditions before a final diagnosis is made. Findings include wall edema, high-attenuation bile, and pericholecystic stranding and fluids .A 48-year-old female with a past medical history of gastroesophageal disease (GERD) and obesity presented to the emergency room via private vehicle complaining of chest and abdominal pain. The pain started the day before after she had lunch and continued bothering her throughout the day. The pain was described as sharp and located on the anterior chest wall without significant radiation. It was associated with nausea and four episodes of non-bloody emesis. The patient denied alcohol, tobacco, and illicit drug usage, as well as the presence of other significant symptoms.On examination, the patient was alert, oriented, and in moderate distress, with vitals within normal range. Physical exam was remarkable for tenderness at the epigastric region with no guarding or rebound tenderness. Murphy's sign was negative. The patient had features of obesity. Lab work was significant for ALKP: 102, ALT: 52, AST: 52, and total bilirubin (TBILI): 2.6. Cardiac troponins and electrocardiogram (EKG) were negative. Abdominal CT  and physical exam findings . However, a thorough work-up can be just as effective in diagnosis. Early detection and treatment of acute cholecystitis are vital due to the possibility of complications if left undiagnosed. In our patient, a prompt and excellent work-up prevented the development of gangrenous cholecystitis, a potentially life-threatening complication. By having a high index of suspicion for cholecystitis with each complaint of abdominal pain, we can improve patient outcomes and prevent mortality.