Thyroid cancer is the most common endocrine cancer in the world, with a rising global incidence over the last three decades. Papillary thyroid cancer (PTC) is the most common type of thyroid neoplasia, accounting for 74%-80% of all cases. Skull metastasis from a differentiated thyroid malignancy is a rare occurrence, while a subsequent dural involvement is even more inimitable. As such, a clinician requires a high degree of clinical suspicion and resultant radiographic evidence in order to make the diagnosis. Here we present the case of a 54-year-old male patient who presented with a pathological fracture of his right humerus, a midline frontal bone swelling and an asymptomatic neck mass. Further workup revealed follicular variant papillary thyroid carcinoma (FV-PTC) with distant metastasis to the calvarium. The conventional therapy for metastatic PTC includes a total thyroidectomy, removal of resectable metastatic lesions and a supplementation with radioactive iodine (RAI) and/or external beam radiation at the sites of the metastases. This case and our literature review illustrate that skull metastases should be considered in the clinical course of PTC so that appropriate management can be started. Thyroid cancer is the most prevalent endocrinal malignancy in the world, with an incidence that continues to rise worldwide in the last three decades. Papillary thyroid cancer (PTC) is the most common variant of this malignancy and accounts for 74%-80% of all its presentations. PTC usually has a slow progression and is associated with a regional spread to the cervical lymph nodes. It carries a favorable outcome, except in the presence of a metastatic disease process . DistantCase presentationA 54-year-old male with multiple comorbidities including hypertension, hyperlipidemia, type II diabetes mellitus and stage II chronic kidney disease, presented to our facility with complaints of a gradually enlarging frontal bone mass for the last one month, as well as progressive right arm pain which exacerbated with movement, following a malunion fracture of his right humerus. He also had a painless neck swelling for the last two years which went unreported, owing to a lack of any associated symptoms such as dyspnea, dysphagia or hoarseness.Initial assessment suggested that he was in good physical health with a heart rate (HR) of 82/minute, respiratory rate (RR) of 18/minute with 97% oxygen saturation, a temperature of 98.4°F and blood pressure (BP) of 112/75 mm Hg. He was found to be well oriented with intact responses to an extensive cranial nerve exam. The swelling in the left frontal region of the head was easily discernable. It measured 6 cm x 7 cm, soft and warm to the touch with a normal overlying skin but a palpable erosion of the underlying bone. A concomitant examination of his neck divulged a large left thyroid mass which measured 8 cm x 6 cm. It was noted to be hard and fixed to the underlying soft tissue structures and led to a resultant right sided deviation of his trachea. His cervical lymph nodes were not palpable across all subgroups.He was further investigated with an X-ray of his right arm which revealed lytic lesions. A subsequent computed tomography (CT) scan of his right upper extremity Figure  showed tA CT scan of the neck Figure  showed aThe tumor had well-defined margins but was not associated with cervical lymphadenopathy. In order to establish a tissue diagnosis, the patient was subjected to a fine needle biopsy (FNA) and a CT guided biopsy of the mass, which revealed a metastatic papillary carcinoma of the thyroid gland. Immunohistochemistry further revealed it to be positive for Thyroid Transcription Factor 1 (TTF-1), Vimentin and Cytokeratin 7 (CK7) and negative for Napsin A, carcinoembryonic antigen (CEA), prostate-specific acid phosphatase (PSAP), prostate-specific antigen (PSA), Cytokeratin 20 (CK20) and CDX2 tumor markers. The patient was further analyzed for a metastatic disease via a bone scintigraphy Figure  which shThis mass was further investigated with a magnetic resonance imaging (MRI) scan of the head Figure  which reAs illustrated, the patient had a myriad of clinical issues which warranted prompt surgical intervention. He first underwent a total thyroidectomy. The histological evaluation suggested that the tumor was a follicular variant of a papillary carcinoma, measuring 10 cm x 6.5 cm x 6 cm with a lack of lymphovascular invasion. Three days following the thyroidectomy, the patient underwent a bi-frontal craniectomy which included the resection of the superior sagittal sinus and part of falx cerebri along with the tumor, which measured 5.8 cm x 6 cm x 4 cm. The histological evaluation revealed a metastatic papillary thyroid carcinoma involving the dura with extensive lymphovascular invasion. The tumor cells were morphologically similar to a follicular variant of a papillary thyroid carcinoma which is a very rare clinical find. The tumor cells were negative for CK20 and CDX2 and positive for CK7, TTF1, and PAX8 markers. These findings supported the morphological impression and the above diagnosis. Cranioplasty was performed one week after the craniectomy.His initial chief clinical complaint of a right humeral lesion was eventually addressed. The mass was excised and a reconstruction was performed with a humeral bone allograft and stabilized with a periarticular humerus plate. Following a recovery from this array of surgical interventions, the patient was started on radiotherapy. The patient is scheduled for an upcoming magnetic resonance imaging (MRI) scan and an I-131 whole body scan.DiscussionThyroid cancer is the most common endocrinal cancer in the world, with a rising global incidence over the last three decades . FortunaA frequent presentation of thyroid cancer is a neck mass which could be asymptomatic or present with troublesome features. The presence of symptoms such as dyspnea, dysphagia or hoarseness of the voice usually indicates that the tumor is aggressive and is involving the recurrent laryngeal nerve. Other symptoms such as a cough, dyspnea, and stridor suggest a tracheal impediment, secondary to the mass effect of a locally invasive tumor. Such findings accentuate the need for a thorough patient history and a comprehensive physical examination .Approximately 90% of the thyroid neoplasms are differentiated thyroid cancers (DTC). This term incorporates both papillary and follicular variants . Only a The histological description of a DTC plays a pivotal role in determining patient outcomes in terms of metastatic spread and their survival. Various studies have shown that histology is the single most important predictor of mortality in patients with distant metastasis, in comparison to other variables such as age, the degree of tumor infiltration, the extent of lymphovascular invasion and the size of the tumor . PTC is As already stated, a thyroid malignancy usually presents as a lone neck mass. It is rare for thyroid cancers to first come to attention with symptoms of a metastatic disease . Our patDiagnosing such a clinical entity is based on maintaining clinical suspicion and obtaining consequent radiological evidence. Imaging with a CT scan or MRI is essential for detecting the lesion, localizing the primary pathology as well as assessing the extension of the disease process. Lesions infiltrating into the bones may appear osteolytic on an X-ray and/or a CT scan. They usually have a very prominent vascular component which is analogous to the findings in our patient. These tumors may have a dense blood supply and an angiography may be necessary to assess the vascularity and guide resection . We follWe conducted a literature review of all the cases between 1986 and 2018 using PubMed. To date, 21 cases of PTC with skull metastasis have been reported (Table PTC with distant metastases markedly worsens the patient’s prognosis. It is rarely associated with a metastatic spread to the skull. Diagnosing such a rare clinical entity is a challenging task and is made possible via a high clinical suspicion and resultant radiographic evidence. Metastatic growth usually presents as an asymptomatic skull mass which is mostly located in the occipital region, but a few cases of frontal involvement have been reported. The conventional therapy for a metastatic PTC includes total thyroidectomy, the removal of resectable metastatic lesions, RAI and/or external beam radiation at the sites of metastases. Tyrosine kinase inhibitors have proven beneficial for refractory cases. This case and our literature review illustrate that skull metastases should be considered in the clinical course of PTC because early diagnosis leads to prompt treatment which can improve patient survival.


Trichobezoar is a rare cause of bowel obstruction. In general, Trichobezoars are composed of hair and usually found incidentally in patients undergoing upper gastrointestinal endoscopy or imaging. Patients diagnosed with Trichobezoar may have psychiatric disorders.Trichobezoars cause nonspecific symptoms like asymptomatic abdominal mass, vomiting, nausea, and anorexia. Diagnosis of Trichobezoar is made by endoscopic examination and radiological methods. Therapeutic options for trichobeazoar are chemical dissolution, endoscopic removal or surgery.Here we present a case of an 18-year-old girl who has a unique type of Trichobezoars caused by ingestion of hair and bristle clothes brush for 14 years. She presented to the surgical clinic complaining of vomiting, anorexia and epigastric mass. Abdominal computed tomography scanner showed nonattached intragastric mass which was consistent with trichobezoar. The patient was managed by surgical removal of the intragastric mass.Trichobezoar is caused by chronic ingestion of hair; it is commonly seen in young females who may have psychological disorders, such as trichophagia and trichotillomania. Common symptoms are abdominal pain, nausea, vomiting, and weight loss. Surgical intervention is performed for the majority of the patients. In hist22 weight, presented to the surgical clinic with a one-month history of recurrent vomiting and anorexia. On observation, the patient was pale, fatigued and thin built. For the last 3 years, her nutrition was limited to fluids only. Abdominal examination revealed a painless, mobile mass extending from the epigastric to the umbilical region and it was visible in rest. Abdominal palpation showed no muscular defense. Laboratory studies revealed: Anemia (hemoglobin was 9 g/dl) and electrolyte abnormalities . The patient had a history of anemia without any other gastrointestinal disease. The girl did not declare anything about hair ingestion, but her parents mentioned that she had a history of chewing hair. A CT scan with oral contrast was performed which showed a large non-attached intragastric mass  of 12.9Kg/mric mass . Based oric mass . After 63Bezoar is a rare cause of gastric outlet obstruction. It is as a mass of foreign material within the gastrointestinal tract. Bezoars include many types: trichobezoar [hair fibers], phytobezoar [plant material], lactobezoar [milk curds] and miscellaneous  . We pres4Trichobezoar is caused by chronic ingestion of hair; it is commonly seen in young females who may have psychological disorders, such as trichophagia and trichotillomania. Common symptoms are abdominal pain, nausea, vomiting, and weight loss. Surgical intervention is performed for the majority of the patients.The authors declare that they have no conflict of interest.There are no sources of funding.Not required for case reports at our hospital. Single case reports are exempt from ethical approval in our institution.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.Ahmad Al-Mouakeh: design of the study, data interpretation and analysis, revision.Mohammad Nour Shashaa: data collection, revision, corresponding author.Muhamad Zakaria Brimo Alsaman: design of the study, revising critically, wrote the manuscript.Aya Zazo: patient care, data analysis, wrote the manuscript.Mohamad shadi Alkarrash: data collection, data interpretation and analysis.Rama Zazo: design of the study, patient care, revision.Ammar Niazi: managed the patient and did the surgery, the Supervisor, patient care, revising critically.All authors read and approved the final manuscript.N/A.Dr. Ammar Niazi.Not commissioned, externally peer-reviewed.


We describe a case of complete intrathoracic stomach and intestinal herniation after pleurectomy/decortication due to diaphragm reconstruction without mesh. Is reconstruction with mesh always necessary? Can lung sparing obviate the tension on residual diaphragm? These are the questions not well described to which we try to give an answer. A chest CT scan showed complete intrathoracic stomach and intestinal herniation Figure A,B. AfteThe patient was discharged after ten postoperative days, without problems and with complete resolution of the herniation.3Malignant pleural mesothelioma is an aggressive neoplasm with no efficacy treatment until today. The best option is represented by trimodal approach: chemotherapy, surgical procedure , and radiation therapy; but also in these cases the life expectation is extremely poor, with median survivor of 24‐months in large series. After this surgical complication, the question if doing diaphragm reconstruction after left P/D remains controversial. During the last 8 years, we have performed about 70 cases of P/D and we have never recorded a diaphragmatic damage that required mesh positioning; this case report is the first in which the diaphragm breach was observed with bowel herniation. In literature, there is no clear evidence about diaphragm reconstruction during P/D and it depends by the surgeons and obviously on the volume of demolition of the muscle. After this case, we are not sure if P/D is a correct surgical technique without mesh positioning on the diaphragm, and if our complication depends only from the extension of muscle demolition. So the question arises spontaneously; is reconstruction of the diaphragm with meshes always necessary?4Then, is reconstruction really necessary?None declared.AT and EV: performed the operation, carried out the study, revised the manuscript. EB and MDS: helped in drafting the manuscript and revised the contents of the discussion of the manuscript. UC: carried out the concept and the design of the study and revised the manuscript.Not applicable.Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available on request.


Ectopic liver tissue (ELT) is a rare clinical entity that any surgeon faces in their career. Due to the association or propensity to develop hepatocellular carcinoma, this disease has gained clinical importance, and surgeons ought to be aware of the possible intervention and complications that can be associated with it. Incidence has been reported to be 0.24%-0.47%, with the gall bladder being the most common site. Anatomically, ELT in the gall bladder derives its blood supply either from the vascular pedicle arising with or without its own vein from the liver parenchyma or from branches of the cystic artery and, sometimes, through vascular structures embedded within the mesentery lying adjacent to the liver parenchyma. Surgically, it becomes important to delineate the blood supply because, often, the operating surgeon might encounter uncontrollable bleeding if the blood supply has been derived from the liver parenchyma itself. Complications that can be associated with ectopic liver are torsion, bleeding into the peritoneum, cirrhosis, and, sometimes, lead to malignant degeneration to hepatocellular carcinoma. It can be due to metabolic inactivity owing to less efficient vascular and biliary ductal systems, which sometimes might be confused for occult metastases from a primary hepatoma. Gall bladder-associated ELT is best managed by en bloc resection via laparoscopic cholecystectomy, which suffices if the biopsy comes out to be negative. However, as the risk of malignant degeneration still exists in about 3% of cases, some patients might need to undergo a second surgery for a negative resection margin and regional lymphadenectomy. Ectopic liver tissue (ELT) is a rare clinical entity due to an error of morphogenesis in which the growth of normal liver tissue occurs outside its normal anatomic location . Any surA 67-year-old lady presented with the complaint of pain in the right upper abdomen for three years, aggravated with fatty meals and relieved with medications. All laboratory parameters were within normal limits, with ultrasonography abdomen showing a distended gall bladder with calculi along with sludge Figure . Her symEctopic liver tissue (ELT) is one of the exceedingly rare conditions incidentally found both in the abdominal and thoracic cavity but clinically encounters limited to a few case reports . By 2007ELT can rarely be diagnosed before surgical procedures or autopsies. It can be ignored easily by radiological techniques, with only a small number of cases been diagnosed preoperatively because it is often asymptomatic. Usually, they are found incidentally during surgery or while on post-mortem examinations and the reported prevalence is 0.24%-0.5%, with the gall bladder being the most common site .Anatomically, ELT in the gall bladder derives its blood supply either from the vascular pedicle arising with or without its own vein from the liver parenchyma or from branches of the cystic artery and sometimes through vascular structures embedded within the mesentery lying adjacent to the liver parenchyma . SurgicaGall bladder-associated ELT is best managed by en bloc resection via laparoscopic cholecystectomy, which suffices if the biopsy comes out to be negative. However, as malignant degeneration chances still exist in about 3% of cases, some patients might need to undergo a second surgery for negative resection margin and regional lymphadenectomy ,8-9.To conclude, though gall bladder-associated ELT is a rare anomaly, surgeons might encounter it during their surgical career, and as various reports in the literature quoted the chances of malignancy, proper histopathological evaluation and patient follow-up is mandatory. This case report is the first of its kind from this region, and we believe this highlights the importance of ELT in the gall bladder and possible interventions and complications that might be encountered, which need to be ascertained by every treating physician worldwide.


Gastrointestinal stromal tumors (GIST) comprised 0,2% of all GI tumors. They are typically asymptomatic, but can manifest with nonspecific GI symptoms, GI bleeding, or intussusception. The authors report a case of a 55-year-old female patient with hematochezia and a palpable mass on the left lower quadrant. Ultrasound revealed possible intussusception. However, CT scan did not show any signs of lesions or intussusception. On reevaluation, the mass was no longer palpable. The patient had recurrent episodes of hematochezia with need of transfusional support. CT enterography revealed a 20-24 mm jejunoileal lesion. A laparotomy was undertaken with small bowel resection containing the lesion. Histological examination confirmed GIST. GIST presentation as transient intussusception and intermittent GI bleeding is rare. This case report emphasizes the rarity of jejunoileal GIST, its clinical details, diagnostic study, and treatment. Gastrointestinal stromal tumors (GIST) arise from mesenchymal stromal cells and comprise 0,2% of all gastrointestinal (GI) tract malignancies . These kA 55-year-old Caucasian female patient was admitted in the emergency department with hematochezia and lower abdominal pain. She had no significant prior medical history. On examination, the patient had normal vital signs and a palpable painful mass on the left lower quadrant of the abdomen. Laboratory data revealed a haemoglobin level of 11,8 g/dL. Abdominal ultrasound showed a mass on the left lower quadrant with possible intussusception .An abdominal computed tomography (CT) scan was then performed, with rectal and IV contrast, which had no signs of lesions or intussusception . On reevUpper endoscopy was performed which was normal, and lower endoscopy revealed hematic residues but no lesions detectable . ThroughHaemoglobin level dropped to 7,1 g/dL, with need of transfusional support. Repeated lower endoscopy did not show the haemorrhage source. CT enterography was ordered, which revealed a 20-24 mm jejunoileal lesion, compatible with GIST Figures 4.Hence, based on known findings, the diagnosis of intermittent GI bleed and transient intussusception due to small bowel GIST was established. A laparotomy was undertaken with small bowel resection containing the lesion . The patHistological examination confirmed jejunoileal GIST with 2,6 cm, without necrosis or vascular invasion, with a mitotic index of <5 per 50 high power field (HPF). Thus, it was a low risk GIST, according to the modified National Institute of Health (NIH) method. In multidisciplinary reunion, it was decided to keep the patient only on clinical surveillance.GIST are rare tumors that occur predominantly in males between 50 and 70 years old . JejunoiBleeding from the small bowel accounts for 2-10% of all GI bleedings, and the main causes are vascular abnormalities (70-80%) and tumors (5-10%) , 4. AbouOn the other hand, intussusception is a rare phenomenon in adults, which represents 5% of all cases of intussusception . The preThe rarity of GIST combined with nonspecific presentation frequently leads to delays in diagnosis . Based oSuccessful treatment of GIST requires assessment of the extent and progression of disease , establiIn this case report, the authors emphasize a rare form of presentation of small intestine GIST with transient intussusception and intermittent GI bleeding. Clinicians should consider this diagnosis whenever dealing with obscure GI bleeding and/or intussusception, to provide early diagnosis and adequate treatment.


Pneumatosis intestinalis (PI) is a radiographic finding which refers to the presence of gas within the wall of any part of the gastrointestinal tract. While in some cases it is an incidental finding which usually represent its benign nonischemic etiology, it may indicate a catastrophic intra-abdominal condition and distinctly characteristic of ischemic enterocolitis. Herein, we discuss the clinical signs and symptoms, the radiological features, the surgical management and outcome of an extremely rare concurrent triad of PI, gastric outlet obstruction, and the sigmoid volvulus based on a case of a patient who underwent surgery in our hospital, which, we think, can emphasize the mysterious concept of PI's mechanical etiology. Pneumatosis intestinalis (PI) is a radiographic sign characterized by the presence of gas within the submucosa or subserosa of any part of the gastrointestinal tract , 2. It cPI has been used in the literature confusingly under many names, including pneumatosis cystoides intestinalis (PCI), intramural gas, intestinal emphysema, bullous emphysema of the intestine, and lymphopneumatosis.Of these names, pneumatosis cystoides intestinalis has been used to represent the multifactorial rear disorder where the PI can be found morphologically as a multiple cyst in the gastrointestinal tract either incidentally with no visceral or mesenteric ischemic syndrome, or sometimes representing more serious intra-abdominal conditions.Hereby, we are trying to emphasize the mechanical etiology versus mechanical complication of PCI in a case of a patient who presented to our institution and underwent surgical management of a complicated PCI case.An 81-year-old man presented to our institution with a chief complaint of abdominal pain and distension. The patient reported one week of worsening, generalized abdominal pain with constipation that had progressed to obstipation. The patient also admitted to several episodes of nausea and vomiting over the last two days. Recently, the patient has undergone emergent sigmoidoscopy in another facility to decompress a twisted sigmoid colon, and it showed sigmoid colon with numerous polypoid-appearing lesions with grossly normal-appearing overlying mucosa . Past meOn presentation, the patient looked tired and dehydrated, and initial assessment revealed following vital parameters the following: blood pressure 110/50 mmHg, pulse 98/min, respiratory rate 20/min, saturation 94% on room air, and temperature 36.5°C. The patient complained of generalized abdominal tenderness but without peritoneal reaction. The abdomen was distended with generalized tenderness but without peritonitis signs or exaggerated bowel sounds. Rectal examination was normal and nasogastric tube revealed 1500 cc of stomach content fluid.μl, hemoglobin 9.6 g/dl, hematocrit 28.2%, and platelet count 167 k/μl.The patient's blood work was remarkable for the following results: WBC count was 12 k/The patient's abdominal CT scan showed massive distention of the stomach  with a cUpper endoscopy was performed for diagnosis and gastric decompression purposes. It showed a copious amount of fluids in the stomach with considerable gastric distention; however, it was very difficult to proceed with endoscopy, and surgical decompression was recommended. After initial resuscitation, the patient was then taken to the operating room. The stomach was severely distended with signs of fibrotic pyloric mass. The sigmoid colon was remarkably redundant. There were findings of chronic sigmoid volvulus with a twisted sigmoid mesentery. PI was apparent externally and covering the entire sigmoid colon; however, there were no signs of perforation. Another extensive PCI disease was found covering the ileum  but withThe final histopathology on the surgically resected specimens revealed benign fibrotic stenotic pylorus with extensive PI involving the sigmoid colon.PCI is a rare ambiguous disease that can affect individuals at any age  is advisable in a specific case; however, the efficacy is not well established and it is often challenging in clinical practice to distinguish those cases. On the other hand, surgery should be reserved for patients with PI who remain symptomatic despite medical therapy or who develop complications from PI such as bowel obstruction, perforation, peritonitis, and necrosisOxygen inhalation for 1-3 h/d for 2-5 d or hyperbaric oxygen therapy was suggested to lead to gas absorption within the cysts and has been used to treat PIHigh rate of surgical resection of benign etiology PI is associated with the lack of realization and misdiagnosis of PCI as many cases can recover with nonoperative management Hepatic portal venous gas (HPVG) can occur both with and without PI and is also associated with numerous similar conditions that range in severity and have similar mechanisms, including increased intraluminal pressure or mucosal alteration/injury and allow egress of air through the bowel wall into the mesenteric and portal venous system . The letThe link between the development of PI in the setting of a connective tissue disorder particularly systemic scleroderma has been clearly demonstrated, and studies have shown that even in the presence of pneumoperitoneum, urgent laparotomy is justified only in cases with highly suspected critical bowel ischemia, obstruction, perforation, abdominal abscess, or abdominal sepsis Mesenteric ischemia is the most common life-threatening cause of pneumatosis. Other potentially life-threatening causes of pneumatosis include toxic megacolon, bowel obstruction or strangulation, and trauma. Increased age, abdominal rigidity, and other signs of peritonitis, hypotension, increased serum lactate and creatinine, portomesenteric venous gas, and identification of arterial or venous mesenteric occlusion seem to be the main factors associated with increased morbidity and these should arise suspicion for potentially lethal PI etiologies Chemotherapy, underlying malignancy, organ transplantation, and graft-versus-host disease (GVHD) with subsequent long-term steroid treatment have also been reported as being associated with PI Since PI is usually a secondary finding, approaching and management pathway commonly follow the primary disease algorithms. Nonetheless, careful attention should be paid to the following specific considerations upon making decisions:Here, we described a concurrent triad of gastric outlet obstruction (GOO), chronic sigmoid volvulus (SV), and PCI. To our knowledge, no previous similar triad has been described before; on the other hand, separate concurrence has been reported in different studies.Historically, the first English article on a case of SV attributed to PI was reported by Wertkin et al. . The patIn 1979. Gillon et al.  have fouCase et al.  reportedIn 1989, Moote et al. , in an iThe pyloric-duodenal disease has been clearly described as the most gastrointestinal disease associated with PCI .Among these diseases, stenosis is frequently reported and most likely related to fibrotic pyloric ulcer disease , 4. RarePerforation is another concurrence disease and most likely related to perforated pyloric ulcer , 27; in In children, PCI is a well-known sign of neonatal necrotizing enterocolitis, but beyond the neonatal period, different single cases or small series of patients suffering from GOO due to duodenal web  have beeRemarkably, PCI has been mostly investigated through single case reports or small case series, only scant review articles have been performed. Since randomized controlled studies are not always available in such rare disease, the accurate approach would only be possible through the accumulation of more cases.Here, in this article, we presented the PCI as a possible rare complication of GOO, and we discussed the association between PCI and SV where we do believe that the PCI anatomical features (redundant sigmoid colon with a narrow mesentery) and associated constipation may predispose to sigmoid volvulus. However, we cannot exclude the theory that considers the SV itself as a primary mechanical factor predisposing patient to PCI.It is very important to distinguish patients who have associated conditions that require surgical intervention  from those with benign causes of PI where conservative management is favorable. However, surgical intervention is still required to deal with the complications of the primary disease or the PCI itself.


Aspergillus fumigatus. Ultimately, the vitreous biopsy, cultures, and a biopsy from the left frontal lobe brain abscess all confirmed this diagnosis as well. Transvitreal retinochoroidal biopsy can play a role in the diagnosis of a case of posterior uveitis and can be particularly effective in diagnosing a fungal endophthalmitis.Diagnosing culture-proven endophthalmitis is complicated by the insufficient yield of intraocular samples and the variety of etiologies which mimic true endophthalmitis. In cases of impending vision loss where vitreous biopsy cannot provide a definitive diagnosis, transvitreal retinochoroidal biopsy can be an effective next step. Our case is a 48-year-old male with B-cell acute lymphoblastic leukemia that presented with counting fingers vision, redness, and tearing of the left eye. Exam showed cell and flare with hypopyon as well as dense vitritis. The patient underwent diagnostic pars plana vitrectomy and vitreous culture was negative at the time. Flow cytometry demonstrated no malignant cells. However, the patient's vision and mental status continued to clinically decline despite being started on intravitreal and systemic antibiotic and antifungal therapy. Neuroimaging revealed rim-enhancing brain lesions. Transvitreal retinochoroidal biopsy was performed in an elevated area of the retina. The biopsy helped rule out malignancy and showed acute-angle, septate, branching hyphae characteristic of Sampling of vitreous fluid is still considered as the gold standard to diagnose endophthalmitis even though vitreous samples have limited diagnostic yield . The EndThe transvitreal retinochoroidal biopsy, first described by JR Griffin in 1975, is a type of surgical excisional biopsy that was originally utilized for diagnosing tumors of the posterior segment . AnotherA 48-year-old male with B-cell acute lymphoblastic leukemia in partial remission receiving inpatient chemotherapy experienced left eye progressive vision loss, tearing, and redness for three days. On ophthalmological consultation, the left eye had a visual acuity of counting fingers at 1 foot with an afferent pupillary defect. Examination revealed 4+ cell and flare in the anterior chamber with 2mm hypopyon and dense vitreous haze in the posterior pole. Given the concern for endogenous endophthalmitis in an immunocompromised patient, a diagnostic pars plana vitrectomy was performed and a vitreous biopsy was obtained. Intravitreal antibiotics and antifungals were injected through the trocars. Intraoperatively, a pink nonpigmented 2 x 3 x 2mm (W x L x H) elevation was noted on the mid-peripheral superonasal retina. Given this lesion and the patient's declining mental status, imaging and cerebrospinal fluid sampling were performed. MRI brain illustrated rim-enhancing lesions with diffusion restriction in the right peritrigonal and left corona radiata  while or Aspergillus fumigatus were noted on retinochoroidal biopsy ,” inferior retinal detachment was noted on exam, and the vitreous biopsy had still not grown any organisms. Both culture-negative endophthalmitis and uveitis masquerade syndromes such as intraocular malignancy still remained real life-threatening possibilities. Given the systemic risk of a bacteremia or malignancy, the ophthalmology team decided to proceed with a transvitreal retinochoroidal biopsy . Septatel biopsy . The patumigatus . Patholo as well . Flow cyBiopsy of chorioretinal tissue has historically been reserved for intraocular tumors that could not be diagnosed based on clinical features or noninvasive diagnostic techniques . This wa Aspergillus as well.This case was appropriate for retinochoroidal biopsy for several reasons. The patient's deteriorating vision, inconclusive vitreous biopsy results at the time, poor response to antibiotics and antifungals, and poor overall health created a sense of urgency in establishing a diagnosis. Retinochoroidal biopsy was an effective modality because it could distinguish between the life-threatening diagnoses of culture-negative endophthalmitis and intraocular malignancy. Due to the acute nature of events, enucleation was not preferred. Had the patient had an intractable panophthalmitis with corneal opacity, scleral abscess, and ruptured globe, enucleation or evisceration may have been the only choice . UltimatBecause of the inflammatory infiltrate seen in the vitrectomy specimen and the patient's history of leukemia, it was equally important to rule out primary intraocular lymphoma. Patients with primary intraocular lymphoma typically show features such as medium to large cell size, increased cellularity, nuclear apoptosis, and necrosis on cytology . CD20 im Aspergillus infections are also frequently associated with hematological malignancies [ Aspergillus endophthalmitis such as immunocompromise, neutropenia, lymphocytopenia, and malignancy [ Aspergillus is virulent enough to afflict immunocompetent hosts and literature shows that the response rate to antifungal therapies such as voriconazole may be as low as 35% [CNS aspergillosis is a diagnosis that requires clinical suspicion, evidence on neuroimaging, and ultimately a histopathological specimen from the brain. Blood vessel invasion and thrombosis in the brain result in abscess formation such as that seen in our patient. Invasion of the retinal and choroidal vessels can create the type of retinal elevation that was observed in our patient superonasally . Aspergignancies . Our patlignancy . Aspergiw as 35% –20. Aspergillus endophthalmitis that led to total vision loss in a matter of days. His disease process was resistant to empiric intravitreal antifungal treatment. In this case, transvitreal retinochoroidal biopsy was critical in confirming infection and helping isolate the specific pathogen involved.In conclusion, our patient presented with an aggressive, virulent


Ameloblastic fibroma (AF) is a rare, slow-growing benign neoplasm, comprised of tissues of odontogenic origin. It constitutes 2% of odontogenic tumours, occurring at any age, but has a predilection to present in the first two decades of life. AF principally affects the posterior mandible. It is characterized by epithelial islands and cords immersed in ectomesenchyme that mimics the dental papilla and enamel organ but without actual hard tissue formation. Herein, we describe the case of a 6-year-old Caucasian male who presented to the Oral and Maxillofacial Department at Alder Hey Children's Hospital, Liverpool, UK, with a painless expansile mass in the left mandible which was diagnosed as a benign ameloblastic fibroma and subsequently enucleated and reconstructed with a parietal calvarial bone graft. A brief literature review and the issues surrounding diagnosis are discussed. Ameloblastic fibroma (AF) is a tumour, classified under the World Health Organization as “odontogenic epithelium with odontogenic ectomesenchyme, with or without hard tissue formation” . They teWe present a rare case of AF affecting the left body of mandible in a 6-year-old boy, which was surgically enucleated and reconstructed with a parietal calvarial bone graft (CBG).A 6-year-old boy was referred to the Oral and Maxillofacial Department at Alder Hey Children's Hospital, Liverpool, UK, with a painless left mandibular swelling. The mass had been present for two weeks and was gradually increasing in size. There was no complaint of difficulty in mastication, and there was no history of paraesthesia or discharge. The patient was systemically well and a full blood count was within normal limits. He had no relevant medical, drug, or familial history.Clinical examination did not reveal any facial asymmetry or cervical lymphadenopathy. Intraorally, there was a localized swelling with expansion of the mandibular buccal plate extending from the left mandibular canine to the left first permanent molar . On palpRadiographically, an orthopantomogram (OPG) showed a multilocular, radiolucent lesion with scalloped margins affecting the left hemimandible . It exteAn incisional biopsy and removal of all carious primary teeth under general anaesthesia was performed. The lesion was submitted for histopathological examination. Histological sections Figures  showed aThe case was discussed at a craniofacial multidisciplinary team meeting. The proposed treatment involved enucleation of the tumour and reconstruction of the defect with a full-thickness parietal calvarial bone graft. The lesion was exposed via a transoral mucoperiosteal flap which extended from the lower left central incisor to the lower left wisdom tooth. While the lesion was successfully enucleated , it was The parietal bone graft was harvested via a full-thickness parietal scalp incision. The outer and inner tables were harvested as a single block, then separated on a “back-table,” with the inner table replaced over the dura and secured via titanium miniplates. The outer cortex and underlying cancellous bone were then cut into several small pieces (cortic-cancellous) facilitating placement into the mandibular defect.The surgical specimen was then sent for formal histopathological examination. Gross pathological analysis showed an irregular mass of white rubbery tissue measuring 30 × 25 × 15 mm . The cutThe postoperative period was uneventful, and the patient was discharged two days following surgery. He is currently under regular clinical and radiographic follow-up. An OPG taken 10 months post-surgery shows good bone formation with no signs of tumour recurrence .An electronic literature search was conducted using the PubMed, Embase, and CINAHL applications. The general search criteria were (Ameloblastic)∗, (Fibroma)∗, (Ameloblastic Fibroma)∗, and (Odontogenic Tumor)∗. In the second phase of the review, terms related to the initial keywords used above were enabled to allow for a broader search criteria of the topic. This allowed for wider search terms across all databases to include all articles which may be relevant. The literature review yielded 604 papers; duplicates were then removed to provide 334 papers.Evidence of greatest hierarchical value was a systematic review on AF by Chrcanovic et al., 2017; the most common publications that are related to AF and ameloblastic fibrosarcoma (AFS) were case reports and literature reviews descriptive in nature.The first publication of AF was by Kruse in 1891 . It is cIt is reported that AF has a propensity to affect males more than females in a ratio of 1.4 : 1 , althougThe most likely presentation is that of a unilateral painless swelling , 5. AssoThe radiographic features are variable, ranging from a well-circumscribed small lucent unilocular lesion to a more expansile multiloculated appearance seen in larger tumours . The borHistologically, AF is a biphasic tumour made up of odontogenic ectomesenchyme resembling tooth-related structures such as dental papilla and epithelial strands and nests similar to the dental lamina and enamel organ, but without dental hard tissues . The strHistological differential diagnosis of AF includes its malignant counterpart AFS and ACS and other mixed odontogenic tumours. AF along with AFD and AFO histologically resemble various stages of odontogenesis. AF lacks significant dental hard tissue formation such as dentin or enamel. If there is dentin or enamel present, the lesion is classified as AFD or AFO, respectively . AFS is In general terms, AF is primarily diagnosed morphologically, with immunohistochemistry having a limited diagnostic role. Ki-67, p53, and proliferating cell nuclear antigen (PCNA) are useful biomarkers of malignant transformation of AF into AFS in borderline cases, as AFS shows higher positivity of these markers , 18.Immunohistochemistry has been applied to understand histogenesis. AF express CK7, CK13, and CK14, similar to the immunophenotype of the dental lamina . A recenThe management of AF can be a challenge, and there is no clear consensus regarding the optimal approach. In our opinion, a “case-specific” approach is appropriate. The aims of treatment are to remove the tumour and decrease the chances of recurrence while preserving adjacent vital structures. Management is dictated by patient age, extent and spread of the lesion, and histopathological findings.In young patients, an AF could represent the primitive stages of a developing complex odontoma , 21. CurPhilipsen et al.  proposedThis is especially pertinent in a young patient where the emphasis is to preserve masticatory function and maintain dentofacial growth.A more radical approach of marginal or segmental resection is suggested by some authors because of the possibility of malignant transformation of an ameloblastic fibroma , 24. It In a large review of 123 cases of AF by Chen et al. , univariThere is conflicting data in the literature on the recurrence rate of AF. Furthermore, not all reported cases have long-term follow-up, and so it is difficult to determine the prognosis of AF. Dallera et al.  reportedLong-term follow-up is recommended . It is oIn our opinion, reconstructive options should be case and defect-specific and depend on a number of factors including site and extent of defect, patient age, and associated medical comorbities. Autogenous bone grafts are considered to be the gold standard for maxillofacial reconstruction . In thisCalvarial bone grafts are considered to be a safe and effective source of bone due to their low donor and recipient site complications . This isThe CBG is considered a viable alternative to the anterior iliac crest graft . HoweverIn extensive cases partial mandibular resection may be indicated involving reconstruction with rigid fixation or a composite vascularised free-flap.This case demonstrates that ameloblastic fibroma can be managed with enucleation and immediate reconstruction with autogenous parietal bone. Patients with AF, however, must be followed up for a long period because of AF's ability to transform into its malignant counterpart, ameloblastic fibrosarcoma. Heretofore, there has been no clinical or radiographic evidence for recurrence 2 years postoperatively, and the patient has made a successful return to function.


Small cell carcinoma (SCC) occurs mostly in the lung, and small cell lung cancer accounts for 13% of newly diagnosed lung cancers. Only 2.5% of SCC occurs in extrapulmonary sites, and SCC of pleural origin is especially very uncommon.An 85-year-old man presenting with progressive dyspnea for more than 7 days.Computed tomography scan of the chest showed massive pleural effusion and diffuse nodular thickening of the pleura on the right chest. Sonography-guided needle biopsy of the pleural mass was performed and histologic and immunohistochemical findings revealed SCC. Since no parenchymal lung lesion was observed, the patient was finally diagnosed with SCC of the pleura (SCCP).Due to the patient's old age and poor performance status, chemotherapy was not performed and only drainage of pleural effusion was conducted for symptom relief.Dyspnea improved after pleural effusion drainage. The patient was discharged and transferred to a local medical center for hospice care.Although primary SCCP is extremely rare, SCCP should also be considered as well as mesothelioma in case of presence of a pleural-based mass with massive pleural effusion. Extrapulmonary SCC (EPSCC) was first reported in 1930 and there have been many reports of cases since then. Since EPSCC is rare, its natural clinical course and optimal therapy has not been determined and it is still underdiagnosed and confused with metastatic small cell lung cancer (SCLC). The SCC of the pleura (SCCP) is especially rare and only a few cases have been reported so far.–9 Here, we report a recent case of SCCP.Small cell carcinoma (SCC) occurs mostly in the lung and small cell lung cancer accounts for 13% of newly diagnosed lung cancers.2An 85-year-old man with a 60 pack-year history of cigarette smoking was referred to our hospital due to progressive dyspnea for 7 days. He was a farmer with an unknown history of asbestos exposure. He had a medical history of type 2 diabetes mellitus and old treated tuberculosis. On physical examination, decreased breath sound in the right lung was observed. His blood cell counts and biochemistries were as follows; hemoglobin 13.8 g/dL, white cell count 6280/μL, platelet count 404,000/μL, total protein 4.18 g/dL, albumin 2.66 g/dL. Serological tumor markers were within normal limits . However, the level of CEA in pleural effusion was found to be elevated to 12.75 ng/mL (reference range 0–10 ng/mL).The chest X-ray image revealed pleural effusion at the right side with pleural-based nodular opacity Fig. . ComputeHistological sample obtained by sonography-guided needle biopsy of pleural mass revealed malignant cells, suggestive of SCC Fig. . Final dAs this study is a clinical case report, no ethical committee approval was required, which is in compliance with the institutional and national policies concerning research approvals. The family of patient was informed that clinical details and images concerning the case would be submitted for publication, and they provided consent.3 EPSCC was first reported in 1930 and is now considered as a clinicopathologic entity distinct from small cell lung cancer. Previous studies reported that EPSCC originated from various organs, and the common primary sites were the gastrointestinal tract, cervix, urinary bladder, head, and the neck in the cases reported.,10–12 However, SCCP is extremely rare, and only 5 cases have been reported so far, according to our knowledge.–9SCC usually occurs in the lung, but it can also occur in various other organs. Mesothelioma frequently shows pleural effusion in CT scanning at presentation, but in SCLC, pleural effusion is an infrequent clinical finding. One study reported that only 3% (8/256) of patients with SCLC had clinically significant pleural effusion. Our case was initially considered as mesothelioma because the CT scan showed massive pleural effusion and pleural-based mass without parenchymal lung lesion. However, it was distinguished from mesothelioma by microscopic features and the expression in IHC staining which was positive for chromogranin, synaptophysin, and CD56 (which is in favor of SCC) but negative for anti-mesothelial cell antibody. Though the expression of TTF-1 in our case was positive, it is controversial to some degree. Noguchi et al mentioned that TTF-1 is not presented in EPSCC, while another study reported that it is presented in 42% of EPSCC. To diagnose EPSCC, evidence of intrapulmonary lesion which can be the primary tumor should not be found. In the present case, there was no evidence of any intrapulmonary malignancy in Chest CT scan and 18-FDG-PET/CT.Mesothelioma is an important differential diagnosis in which pleural tumor without parenchymal lung lesion is found.,18 The prognosis of EPSSC depends on the extent of the disease and the organ of origin. In 2 previous case series, the median survival times of patients with extensive disease (ED) were 7 months and 12 months, respectively.,12 Multimodal treatment, including surgery or radiotherapy followed by chemotherapy, is the recommended treatment in patients with limited disease (LD),,11,12,19 while in patients with ED, platinum-based chemotherapy is usually performed. Although 2 case series had reported partial and complete responses to platinum-based chemotherapy, the prognosis and response rate of SCC of the pleura is unknown due to its extremely low prevalence. We also considered cisplatin-based chemotherapy, which could not be performed because of the poor performance status of the patient.The clinical course of EPSCC is aggressive and often recurs after treatment.An interesting finding in our case is the presence of massive pleural effusion, unlike the previous cases. In case of pleural-based mass with massive pleural effusion, SCC of the pleura and mesothelioma should be considered.In conclusion, though primary SCCP is extremely rare, SCCP should also be considered as well as mesothelioma in case of presence of a pleural-based mass with massive pleural effusion. As there are no randomized trials for treating SCCP, an individualized treatment plan is important, and observational strategy might be an appropriate option in patients with poor performance status.Conceptualization: Jong Geol Jang, June Hong Ahn.Resources: Min Hye Jang, June Hong Ahn.Writing – original draft: Jong Geol Jang.Writing – review & editing: June Hong Ahn.


We performed surgery for the intradural-extramedullary mass, and the pathological findings of the resected specimen were a benign histology consistent with World Health Organization (WHO) grade I SFT/HPC. She had no evidence of tumor recurrence three years after the surgery for intradural-extramedullary SFT/HPC. 18F-FDG-PET/CT before surgery may be useful for predicting the postoperative behavior of spinal SFT/HPCs.Intradural-extramedullary solitary fibrous tumor/hemangiopericytoma (SFT/HPC) is a rare entity. SFT/HPCs can recur after surgery, even if a benign histology of the tumor is observed. We herein report a 68-year-old woman with intradural-extramedullary SFT/HPC. On magnetic resonance imaging (MRI), the intradural-extramedullary mass was isointense on T1-weighted images and hypointense on T2-weighted images with heterogeneous gadolinium enhancement. Whole-body fluorodeoxyglucose-positron emission tomography/computed tomography ( Solitary fibrous tumors are rare mesenchymal tumors, first described in 1931 by Klemperer and Coleman as a primary neoplasm arising from the pleura . Althoug18F-FDG-PET/CT) before surgery.We herein report a case of intradural-extramedullary SFT/HPC at the level of the thoracic spine, which had a negative result on fluorodeoxyglucose-positron emission tomography/computed tomography  revealed an intradural-extramedullary mass with isointense changes on T1-weighted images and hypointense changes on T2-weighted images as well as heterogeneous gadolinium enhancement .18F-FDG-PET/CT was performed to differentiate between benign primary spinal cord tumor and spinal cord metastasis associated with lung or kidney cancer, and there was no accumulation on 18F-FDG-PET/CT (Whole-body G-PET/CT .18F-FDG-PET/CT findings indicating no spinal cord metastasis, we performed surgery for the intradural-extramedullary spinal cord tumor at the level of T9. First, we performed laminectomies of T8 and T9 and a biopsy of a white-yellowish hard tumor located in the intradural-extramedullary site for intraoperative pathological consultation (She developed back pain and numbness in the lower limbs two months after the kidney surgery. A neurological examination revealed hyperreflexia in the muscle stretch reflex in the lower limbs despite normal muscle strength and no bladder dysfunction. Based on the ultation , which sFinally, we achieved gross total resection of the tumor using a microscope despite the fact that the resection was done in a piecemeal fashion because of the adhesion between the spinal cord and the spinal cord tumor. A histological examination of the resected specimen revealed that the tumor showed a patternless architecture with alternating hypocellular and hypercellular areas and deposition of hyalinized collagen fiber. The tumor was composed of spindle cells with ovoid to spindle-shaped nuclei. Mitosis and necrosis were generally scarce. On an immunohistochemical examination, CD34, bcl-2, and STAT6 were positive, while S-100 protein, neurofilament protein, and EMA were negative . Those pAlthough she still complained of slight back pain three years after the surgery, she had no neurological deficits in the lower limbs. MRI of the thoracic spine showed no evidence of tumor recurrence , and enhSpinal SFT/HPC is a rare entity, and only about 90 cases have been reported to date. The majority of spinal SFT/HPC cases have occurred in adults with a slight male predominance. Spinal SFT/HPCs most often occur in the thoracic region followed by the cervical and lumbar regions, and most cases occur at intradural-extramedullary sites –6. AlthoRegarding the radiological diagnosis of spinal SFT/HPCs, it is often difficult to differentiate intradural-extramedullary SFT/HPCs from other intradural-extramedullary spinal cord tumors preoperatively because of a lack of specific radiological findings for SFT/HPCs , 5.At MRI, SFT/HPCs are usually isointense on both T1- and T2-weighted images and enhanced with contrast because they are vascular tumors . The MRI18F-FDG-PET/CT findings of spinal SFT/HPCs, although there have been several reports regarding the 18F-FDG-PET/CT findings of benign and malignant SFT/HPCs in the pleura, liver, extremities, and kidney [18F-FDG-PET/CT, although there was a case report of a false-negative malignant SFT/HPC in an extremity [18F-FDG-PET/CT, suggesting that this imaging modality may be useful for the preoperative prediction of the postoperative behavior of spinal SFT/HPCs.To our knowledge, this is the first report to describe the d kidney –15. Thosxtremity . In the 18F-FDG-PET/CT. The patient had no evidence of tumor recurrence three years after the surgery.We performed surgery for intradural-extramedullary SFT/HPC with a preoperative negative result on


A traumatic neuroma is a well-known complication after acute trauma to a peripheral nerve; the nerve tries to re-establish continuity by an orderly growth of axons from the peripheral to distal stump through the proliferation of Schwann cells. However, this process is not always perfect, and aberrant repair gives rise to a neuroma. We present a 50-year-old female who underwent an initial colonoscopy for change in bowel habits and was found to have a 7 mm submucosal lesion in the proximal rectum. Endoscopic ultrasound was done which showed a hypoechoic lesion in the submucosal plane without muscularis propria invasion. The patient underwent successful cap-assisted endoscopic mucosal resection of the lesion without complication. Pathology of the specimen revealed a traumatic rectal neuroma with immunostaining positive for S100. However, this patient did not have any known risk factors such as previous surgery including polypectomy or hemorrhoidectomy or any previous rectal manipulation. Interestingly, this is the second case of traumatic rectal neuroma reported in the English-language literature. A traumatic neuroma develops from a non-neoplastic proliferation of the proximal end of a severed, partially transected, or injured nerve as a result of trauma or surgery. Most commonly, the lesion demonstrates pain whenever palpated or manipulated. The most common location for a traumatic neuroma is the lower extremity after an amputation, followed by the head and the neck area, especially the oral cavity after a tooth extraction . We are en bloc endoscopic mucosal resection with a cap and snare was achieved  following nerve injury could reduce neuroma formation and neuropathic pain without damaging the cell bodies . TherefoThe usual presentation of a traumatic neuroma is of pain; however, our patient presented asymptomatically. This can possibly be attributed to the lack of somatic innervation within the rectal submucosa as opposed to neuromas located in an extremity. In the only other case report of a traumatic rectal neuroma, the authors hypothesized the lesion likely arose as a result of trauma to the submucosal Meissner's plexus fibers or Auerbach's plexus fibers after a previous polypectomy . Interes


Brown tumors represent a rare clinical manifestation reported in approximately 3% of patients with primary hyperparathyroidism and correspond to radiologically osteolytic lesions with well-defined borders in different parts of the skeleton.We report the case of a 53-year-old white man who presented to our hospital with osteolytic lesions of his distal ulna and radius, causing pain and swelling of 2-month duration. A subsequent biopsy revealed histological features consistent with giant cell tumor and a complete resection of his distal ulna was followed, along with curettage and cementoplasty of the distal radial metaphysis. Two weeks later, he was re-admitted with diffuse musculoskeletal soreness, anorexia, constipation, nausea, and localized abdominal pain and multiple osteolytic lesions on plain radiographs. A histopathological examination of the ulna and radius specimens showed similar findings and, given the multifocality, brown tumors related to primary or secondary hyperparathyroidism was included in the differential diagnosis. A laboratory examination showed high total serum calcium (14.5 mg/dl) and low serum phosphorus and 25-hydroxyvitamin D levels. Primary hyperparathyroidism was suspected and confirmed by the elevated parathyroid hormone levels of 1453 pg/mL. At radiological work-up, using computed tomography, ultrasonography, and parathyroid subtraction technetium-99m sestamibi scintigraphy, a 4.5 × 2.5 × 3.2 cm mass emanating from the right lobe of his thyroid gland was detected, displaying extensive uptake in the right lower parathyroid gland. After appropriate medical support including hyperhydration and high doses of diuretics and diphosphonates, his laboratory profile normalized and he underwent total thyroidectomy with removal of the parathyroid glands. Our patient is now recovering 12 months after surgery, with normal values of serum parathyroid hormone and calcium levels. The lytic bone lesions have almost disappeared and no other additional orthopedic intervention was necessary.The present case report emphasizes the need of inclusion of brown tumors in the differential diagnosis of multifocal osteolytic bone lesions, in order to avoid harmful surgical interventions. Laboratory testing of serum phosphate, calcium levels, and parathyroid hormone levels should always be included in the routine survey of patients with multifocal osteolytic lesions. Brown tumor (BT) represents a pathologic expression of “osteitis fibrosa cystica” encountered in patients with uncontrolled hyperparathyroidism. This tumor-like lesion represents the terminal stage of the bone remodeling process in prolonged hyperparathyroidism and has an overall incidence of 2–3% , 2. BTs We present a case of a 53-year-old white man, initially misdiagnosed with GCTs of the distal ulna and radius, who subsequently underwent unnecessary distal ulna resection; he presented later with multiple BTs attributed to primary hyperparathyroidism (PHPT) from parathyroid gland carcinoma. This report emphasizes the importance of considering PHPT in the differential diagnosis of patients with multiple lytic bone lesions, thus avoiding unnecessary and harmful interventions.A 53-year-old white man presented to our Department with a 2-month history of a painful and moderately swollen left wrist. His past medical history was unremarkable. Standard anteroposterior and lateral X-rays of his left wrist revealed two osteolytic lesions involving the distal ulna and the lunate fossa of the distal radius without any joint involvement Fig. , b. SubsTwo weeks postoperatively, he was re-admitted to our orthopedic department with diffuse musculoskeletal soreness, anorexia, constipation, nausea, and localized abdominal pain. He also reported weight loss of approximately 5 kg. On palpation he had tenderness in the thoracic wall, the second and fifth metacarpals of his right hand, the left tibia, the pelvic ring, and the left shoulder girdle and humerus. Plain radiographs revealed multiple osteolytic lesions in his ribs, right hand, left tibia, and scapula Fig. –e.Fig. 2A histopathological examination of both the resected ulna Fig. –c and th99mTc) sestamibi (MIBI) scintigraphy showed extensive uptake in his right lower parathyroid gland , low serum phosphorus , and low 25-hydroxyvitamin D . PHPT was suspected and confirmed by the elevated PTH levels of 1453 pg/mL . Serum potassium and sodium concentrations and thyroid hormone levels were in reference range as well as the main cancer indicators: cancer antigen (CA) 15-3, carcinoembryonic antigen (CEA), CA 125, and prostate-specific antigen (PSA). Serum protein electrophoresis was also normal. His human chorionic gonadotropin (hCG) was elevated . An isotope bone scan showed multiple sites of uptake over his ribs bilaterally, the lower pole of both scapulae, multiple foci in his pelvis, the metacarpal bones of his right hand, and his right tibia. At subsequent radiological work-up, both computed tomography (CT) and ultrasonography of his neck revealed a 4.5 × 2.5 × 3.2 cm mass emanating from the right lobe of his thyroid gland. Parathyroid subtraction technetium-99m , reported in approximately 3% of patients with PHPT and 2% of those with secondary hyperparathyroidism –18. On rNowadays, PHPT is mostly an asymptomatic mild disease, which is usually diagnosed by routine biochemical screening and not by the presence of typical clinical signs suggesting the disease . Bone isThere are several reports in the literature of BTs mimicking bone metastases . Despite the multiplicity of the lesions detected during his second admission, our patient had only mild skeletal pain and did not use narcotics for pain relief. On the other hand, the increased uptake on a whole-body bone scan and the negative serum protein electrophoresis rendered multiple myeloma less likely. His significantly elevated serum calcium and PTH levels were the clues that pointed our attention toward metabolic bone disease. Although hypercalcemia with high PTH levels and radiological evidence of a parathyroid gland tumor indicated BTs as a highly possible scenario, the correlation of clinical, laboratory, and histopathological findings established the diagnosis definitively. The increased secretion of PTH from the parathyroid carcinoma triggered high osteoclast activity, leading to the multiple osteolytic bone lesions seen in our patient.et al. [et al. [et al. [Of interest, there are several studies describing PHPT and BTs mistaken for GCTs –24. Pezzet al.  describe [et al.  describeet al. [et al. [There have also been reports describing the concomitant presence of a GCT with BTs of hyperparathyroidism , 25. In et al.  presenteTo the best of our knowledge, the present case is a rare example of multiple BTs associated with parathyroid carcinoma and PHPT. Only a few similar cases have been reported in the literature –28. ParaThe key treatment of BTs is surgical removal of the hyperfunctioning parathyroid gland. After addressing the parathyroid cause, BTs are expected to regress or to completely resolve. In our case, after normalization of serum PTH level, the bony lesions resolved and required no further orthopedic consultation. Surgical resection of BTs is generally not recommended, but orthopedic interventions should be considered in cases of pathological fractures or extensive cortical involvement. The risk of pathologic fracture should be estimated according to Mirels’ criteria . In the In conclusion, this case report emphasizes the need of including BTs of PHPT in the differential diagnosis of multifocal osteolytic bone lesions, in order to avoid unnecessary and harmful surgical interventions. A high index of suspicion is required for diagnosing BT at early stages; although osteolytic metastases and multiple myeloma should be considered first, laboratory testing of serum phosphate, calcium levels, and PTH levels should be included in the routine survey of patients with multifocal osteolytic lesions. Our mistake in accepting the diagnosis of multifocal GCT based on the suggestive findings of the biopsy report only led to an unnecessary surgery and put our patient’s life at great risk from hypercalcemia. A multidisciplinary approach with close communication between orthopedic surgeons, pathologists, and radiologists is crucial to arrive at the correct diagnosis.


Mature cystic teratomas are the most common ovarian germ cell tumour and account for 10–20% of all ovarian neoplasms. Malignant transformation of mature cystic teratomas is rare and has an incidence rate of less than 1%. The most common malignancy are squamous cell carcinomas. Here we present the case of an intestinal adenocarcinoma which is an exceedingly rare malignant entity arising within a mature cystic teratoma. Clinical presentation, imaging and histopathological diagnosis are discussed and previously presented cases in the literature reviewed. Mature cystic teratoma (MCT) of the ovary accounts for 10–20% of all ovarian neoplasms and is the most common ovarian germ cell tumour. Malignant transformation is rare and reported to occur in approximately 0.17–0.8% of cases .A 58-year-old woman living in a remote region was referred to the local general gynaecological service for investigation of an episode of light postmenopausal bleeding. A pelvic ultrasound demonstrated a right sided complex adnexal mass measuring 101 × 70 × 89 mm and a borderline endometrial thickness of 5.1 mm. The mass had a well circumscribed outer capsule with no evidence of increased internal vascularity and there was not ascites. A CT of the abdomen and pelvis demonstrated the complex mass containing internal calcification, fluid, fat and soft tissue . There wThe patient's medical history was unremarkable and included one normal vaginal delivery. She had gone through menopause at age 48 and had not used any HRT. In her family history, she only had her sister with an early-stage endometrial adenocarcinoma.The patient was referred to a tertiary gynaecological oncology service and after discussion at a multi-disciplinary team meeting with radiology review, the tentative diagnosis of mature teratoma with low risk for malignancy was made.A hysteroscopy, dilatation and curettage of the uterus were performed and showed atrophic endometrium. The patient then underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Intraoperatively, she was found to have a mobile 10 cm left ovarian mass with no surface excrescences. The lesion was removed intact. The right adnexa, uterus and peritoneum were normal. Peritoneal washings were obtained. The operation was uncomplicated, and the patient was discharged from hospital on day 3 after the procedure.Macroscopically, the left ovarian cyst measured 100 × 80 × 70 mm in diameter and had a maximum wall thickness of 2 mm. It contained yellow cheesy material, teeth and hair. The uterus, cervix and right ovary were unremarkable and histologically normal.Histology of the ovarian cyst showed mature cystic teratoma, predominantly comprised of skin and adnexal elements with large areas of foreign-body type granulomatous response to hair. One section of the cyst was lined by dysplastic columnar type epithelium in continuity with squamous epithelium. Within this area, there were atypical irregular glands infiltrating the underlying stroma. The atypical glands were lined by pleomorphic cells with hyperchromatic enlarged nuclei and luminal dirty necrosis Figures .Immunohistochemical staining showed the tumour cells were strongly positive for CK20, CDX2, focally positive for CK7 and negative for CD30, PAX-8, Vimentin, ER, PR, and CD10 Figures . MUC-2 sThe case was re-discussed at the multidisciplinary gynaecological oncology meeting and the disease staged as FIGO Stage 1A ovarian intestinal adenocarcinoma arising within a mature cystic teratoma. She was recommended to have adjuvant platinum-based chemotherapy to decrease risk of recurrence. However, after medical oncology review, the patient elected for observation only. She is alive and well after 12 months of follow up.MCTs or dermoid cysts are the most common ovarian germ cell tumour. They arise from totipotent cells in the ovary which develop into fully differentiated ectodermal, mesodermal, and endodermal tissue. Parthenogenetic activation of oocytes  is the most widely accepted theory for the origin of MCTs, primarily because of presence of 46, XX karyotype in almost all mature teratomas [th reported case in the literature (Intestinal adenocarcinomas arising within cystic teratomas are exceedingly rare and this is only the 12terature . IntestiThe mechanisms of malignant transformation in ovarian MCTs are uncertain. MCTs are thought to result from replication errors during meiosis and they may represent primary oocytes that have escaped from meiotic arrest. However, it is unclear how subsequent malignant transformation occurs. A systematic genomic evaluation of ovarian SCC arising in MCT showed similarities to other non-HPV SCC, but with distinct features, including bi-allelic TP53 mutations . FurtherIt has been suggested that prolonged exposure of MCTs to carcinogens in the pelvic cavity might promote malignant transformation, as MCTs are usually detected 15–20 years earlier than malignant transformations . If thisPredictive factors for malignant transformation of MCTs include old age, large tumour size, raised CA125, postmenopausal status and presence of solid components . HoweverDiagnosis is ultimately made after surgical resection and histopathological analysis. Immunohistochemistry with CDX2, CK20 and CK7 helps to differentiate between colorectal adenocarcinomas and extra-intestinal gastrointestinal adenocarcinomas . HoweverThe mainstay of treatment is surgical resection and complete staging. In most cases the malignancy is confined to the ovary and care should be taken to prevent rupture of MCTs with potential tumour spillage. Optimal surgical cytoreduction may be beneficial for metastatic disease . Cases wPoor prognostic factors for malignant transformation of MCTs include tumour dissemination, cyst wall invasion, ascites, spontaneous or accidental rupture, adhesion, and some tumour types other than squamous carcinomas .Prognosis of MCTs with malignant transformation has traditionally been reported to be poor as a large number of women die within the first year after diagnosis. However, the majority of these women had MCTs with squamous cell carcinomas at various stages. Intestinal adenocarcinomas in MCTs may have better prognosis and 9 of the 10 reported cases in the literature were diagnosed at FIGO Stage 1. Eight of those cases did not receive adjuvant therapy. Recurrence rates of intestinal adenocarcinomas in MCTs are unknown, but long-term survival and probable cure was reported for women with Stage 1A disease . HoweverIntestinal-type adenocarcinoma arising in MCTs are very rare malignancies and preoperative diagnosis is difficult. Histopathological diagnosis is aided by the use of the immunohistochemical markers, CK 7, CK20 and MUC2. Most cases are diagnosed at Stage 1 and tend to have a better prognosis than other forms of malignant transformation.


Diagnosis of gastrointestinal stromal tumors (GISTs) in the distal small intestine is difficult by endoscopic ultrasound. This is the first reported case of an ileal GIST, which is diagnosed by transabdominal sonography and strain elastography.A 75 y/o woman presented with tarry stool and dizziness. No definite bleeder could be identified by esophagogastroduodenoscopy and colonoscopy. The transabdominal sonography revealed a large heterogeneous tumor involving the muscular layer of the ileum. Strain elastography showed the strain ratio was 6.51. Strain histogram was skewed to the blue side, and mean color value was 230.5, signifying a stiff tumor. GIST was highly suspected. The patient underwent laparoscope-assisted tumor excision and the histological examination confirmed a malignant GIST. The patient was discharged without postoperative event.Transabdominal strain elastography could play a role to discriminate small bowel GISTs and other submucosal tumors, especially in the location with difficulty in endoscopic ultrasound. Gastrointestinal stromal tumors (GISTs), although rare, are the most common submucosal tumors (SMTs) of the gastrointestinal (GI) tract . GISTs mClinical characteristics of GISTs vary according to different anatomic sites. SB GISTs may present with abdominal pain, a palpable mass, intestinal obstruction, or bleeding although some are insidious . EndoscoElastography has been widely used for diagnosis of breast cancer, thyroid nodules and liver fibrosis . There aEvidence regarding the applications of elastography for GISTs are mainly with endoscopic devices. Tsuji et al reported that EUS-elastography could be used to differentiate gastric GISTs with other SMTs because of its stiffness . Few datOur case is the first reported ileal GIST, which was diagnosed with transabdominal ultrasonography and SE preoperatively. The characteristics of elastography are reported with a review of the literature. This study was approved by the Institutional Review Board of the National Taiwan University Hospital and an informed consent was obtained from the patient.A 75 y/o woman visited the emergency department because of tarry stool and dizziness for one day. Progressively exertional dyspnea was noted 2 weeks before the visit. Her medical history included coronary artery disease.At arrival, her physical examinations revealed pale conjunctivae, and soft abdomen without tenderness. Laboratory data showed normocytic anemia with hemoglobin 7.6 g/dL, and positive stool occult blood. Others were unremarkable. Esophagogastroduodenoscopy and colonoscopy were done, but no definite bleeder could be identified. Small bowel bleeding was suspected.Transabdominal sonography revealed a 7.8 cm × 4.2 cm heterogeneous solid tumor involving the muscular layer of ileum, suspected a GIST Fig. a. ElastoThe patient underwent laparoscope-assisted tumor excision. The tumor presented as a pedunculated mass extending from the ileal wall Fig. c. GrosslEUS-FNA has been demonstrated to have high diagnostic yield for GISTs at upper GI tract . HoweverElastography is a sonographic technique that depicts elasticity of tissues . SE and Recently, SE or SWE has been suggested as an adjunct tool for assessing GI diseases –17. HoweInhomogeneous surrounding tissue, and reference ROIs located in different depths are the challenges for strain ratio measurements , especiaA focal lesion with increased stiffness at elastography is usually suggestive of malignancy in breast, and thyroid diseases , 19. StrIn conclusion, our case well demonstrates the use of transabdominal SE for an ileal GIST. Transabdominal SE could play a role to discriminate GISTs from other SMTs, especially in the location that performing EUS-FNA is difficult.


Although relatively rare, an obturator hernia is a significant cause of intestinal obstruction. It usually occurs in emaciated elderly females. Computed tomography is the imaging modality of choice to diagnose obturator hernias.In this report we present a case of an elderly female who presented to the emergency department with features suggesting bowel obstruction. The patient was admitted to the hospital and was initially managed conservatively. Two days later the patient underwent an exploratory laparotomy and was diagnosed with a left sided Richter type obturator hernia. The hernia was successfully reduced and the necrotic bowel was resected with end to end anastomosis.An obturator hernia is a rare type of abdominal hernias which often occurs in very thin old females. Patients with obturator hernias usually present with symptoms of acute or intermittent small bowel obstruction. Mild symptoms without abdominal pain may be due to incomplete obstruction or Richter type hernia. Computed tomography is considered the gold standard diagnostic modality for obturator hernias. An early surgical intervention is the treatment of choice.The clinical diagnosis of an obturator hernia is often difficult due to its nonspecific symptoms and infrequent signs. Yet early diagnosis is mandatory because its delay contributes to bowel necrosis and to the poor prognosis in these patients. Surgery remains the only effective management of this condition. •Obturator hernias are a rare cause of intestinal obstruction.•An obturator hernia usually occurs in very thin elderly females.•Obturator hernias present with symptoms of intestinal obstruction.•Computed tomography is the imaging modality of choice to diagnose obturator hernias.•The only management of this condition is surgery through either laparotomy or laparoscopy. It accounts for 0.5–1.4% . The dia1.1An 83 year old female presented to the emergency department complaining of vomiting and constipation that started a few days ago. She did not report abdominal pain or distention. The patient was otherwise healthy and has not undergone any previous abdominal or pelvic surgeries. On arrival the patient was malnourished, well oriented, and afebrile. Her blood pressure was 100/80 mm hg and her pulse was 80 beats per minute. On physical examination the abdomen was soft, not tender, and not distended, and no hernias were palpable. The rectum was found to be empty on rectal examination. Laboratory findings showed a hemoglobin level of (17.6 gr/dL), mild leukocytosis (11400/μL) with a left shift (81%), and a platelets level of (279000/μL). Urea (285 mg/dL) and creatinine (3.9 mg/dL) levels were elevated. The patient also had low serum sodium (131 mEq/L) and a normal potassium level (3.5 mEq/L). The initial plain abdominal radiography showed air fluid levels with air present in the rectum suggesting small intestinal obstruction . Abdomin2An obturator hernia is a rare type of abdominal hernias, accounting for 0.5–1.4% of all hernias  and was 3Although the obturator hernia is a rare surgical case, it must be always kept in mind as a cause of small bowel obstruction, especially in thin elderly females. Early Diagnosis and intervention are essential to avoid complications like bowel necrosis. The only management of this condition is surgery through either laparotomy or laparoscopy.Informed consent was obtained from the patient for publication of this case report and accompanying images.Not commissioned, externally peer reviewed.Not applicable.Authors did not receive any Funding.Kusay Ayoub and Nihad Mahli: revised the case.M.Fateh Dabbagh: Case report writing and design.Bashar Banjah: Subject Research.Bassel Banjah: edited final draft.No conflicts to declare.Not applicable.This is a case report.Kusay Ayoub, Nihad Mahli.


Teratomas are rare germ cell tumors usually found in the gonads. Extra-gonadal teratomas are especially rare, mostly occurring in the thorax. Only a few cases of intrathoracic teratomas have been reported in medical literature and most reported were located in the mediastinum. An additional intrathoracic location for teratoma occurrence is in the pulmonary system, most commonly in the upper lobe of the left lung. In this report, we describe a case of a 35-year-old woman diagnosed with an intrapulmonary mature teratoma found in the right upper lobe. A 35-year-old Saudi female presented with a chief complaint of a three-week history of dry cough. Chest X-ray revealed a right-sided para-pericardial mass in the anterior mediastinum and a significant decrease in the size of the right middle lobe opacity. Subsequently, a chest computed tomography (CT) was performed and revealed a cystic mass in the right lung, which required removal by surgical intervention. The surgery was performed via a thoracoscopic approach and the tumor was excised with no complications. Intrapulmonary teratomas (IPT) usually present with vague and non-specific symptoms such as cough, hemoptysis, and chest pain. It is a rare condition without diagnostic features detected preoperatively, save for trichoptysis which is reported in approximately 13% of the cases. We report a rare appearance of mature IPT in the right upper lung zone which is an unusual location. Teratomas are rare germ cell tumors composed of one or multiple tissues, such as hair, sebaceous glands, teeth and other tissues derived from germ cells. They are mostly benign and occur most frequently in gonadal organs, namely the ovaries and testicles. However, they can also be found in extra-gonadal areas, especially the thorax -2.Intrathoracic teratomas are usually seen in the mediastinum. However, in some extremely rare cases, intrathoracic teratomas occur within the parenchyma of the lungs . Since iA 35-year-old Saudi female presented to her local hospital complaining of a three-week history of dry cough. Her past medical history was unremarkable. Chest imaging revealed a mass in the anterior mediastinum. The patient was referred to King Faisal Specialist Hospital (KFSH) for further workup.Repeated chest X-ray revealed a right-sided para-pericardial mass in the anterior mediastinum and a significant decrease in the size of the right middle lobe opacity Figure . No otheA chest computed tomography (CT) was ordered for the patient, which revealed a cystic mass for which surgical resection was indicated Figure .The patient was admitted and through a right thoracoscopic approach, the cyst was excised. Intraoperatively, there was significant adhesion of the right lung to the anterior chest wall surrounding the cyst. Dissection was made using diathermy hook and blunt dissection until the lung became almost completely free mainly in the anterior and mediastinal aspect of the pleura. A thick cyst at the anterior segment of the right upper lobe was identified. The cyst was then excised completely by wedge resection and small oozing around the hilum was encountered but controlled by clips. A small incision was made in the anterior chest wall and within was found cheese-like material. A chest tube was inserted in the apex and the anesthetist was asked to inflate the lung, which was done well. The wound was closed in layers, the patient was awoken, and she was sent to the recovery room in good condition. Her postoperative period was uneventful. The retrieved specimen consisted of 64.4 g of lung tissue measuring 14.5 x 6.0 x 3.0 cm. There was a mass opened on the pleural surface measuring 6.0 x 5.0 x 2.5 cm containing soft yellow material. The diagnosis of mature teratoma was then established. The chest tube was removed on the postoperative day two. The patient was discharged on postoperative day three in a good shape. The patient was given a follow-up appointment to the thoracic surgery clinic.In general, germ cell tumors in the thorax are either secondary tumors, metastasized from the gonads, or developed de novo at the thorax. The most common extra gonadal germ cell tumors in adults are located in the mediastinum -6. IPTs Most teratomas are benign and grow slowly. Although teratomas may be present in any age group, IPTs usually affect patients in their first and second decades of life. IPTs can be present in males and females equally, unlike malignant mediastinal germ cell tumors, which affect males more than females -8. SymptMalignant teratomas have a poor prognosis -3. One mThe recommended management of benign teratomas is complete surgical excision. Failure to surgically remove the tumor can lead to serious complications including excessive hemoptysis, tumor enlargement, adult respiratory distress syndrome and eventual demise -2,5,8.IPTs usually present with vague and non-specific symptoms such as cough, hemoptysis, and chest pain. It is a rare condition without diagnostic features detected preoperatively, save for trichoptysis which is reported in approximately 13% of the cases.


Primary gastrointestinal lymphoma is a rare neoplasm that accounts for less than 5% of all gastrointestinal malignancies. We present a case of a 37-year-old woman positive for human immunodeficiency virus who presented with abdominal pain and vomiting for three months. She underwent endoscopic biopsy and was found to have high-grade diffuse large B-cell lymphoma in the jejunum. This report discusses her treatments and includes a brief literature review highlighting the rarity of this entity, the etiological agents implicated in its pathogenesis, and the lack of specific guidelines for treatment. Most cases of gastrointestinal lymphoma are due to widespread nodal disease. Primary gastrointestinal tract lymphoma is a rare entity, accounting for 1%-4% of all gastrointestinal malignancies, and its occurrence primarily in the small intestine is even more uncommon [The overall incidence of diffuse large B-cell lymphoma (DLBCL) in the Midwestern region of the United States from 1992 to 2001 was approximately seven cases per 100,000 persons per year .Endoscopic evaluation is garnering wider acceptance for use in the diagnosis of gastrointestinal lymphoma. Surgery was the preferred treatment for primary gastrointestinal lymphoma, but newer research supports chemotherapy as the first-line treatment, especially in a highly aggressive lymphoma such as DLBCL. Our case represents a unique presentation of DLBCL as abdominal pain in a 37-year-old woman with human immunodeficiency virus (HIV).A 37-year-old woman with a history significant for HIV/acquired immunodeficiency syndrome (AIDS) , and epilepsy (treated via anti-epileptic meeldications) presented with abdominal pain ongoing for three months associated with nausea and vomiting. The pain was diffuse, radiating to her back, and it limited her oral intake. She reported night sweats and chills but did not recall exposure to any people with signs of illness. Clinical laboratory tests were performed, and abdominal computed tomography (CT) scan was ordered.3 . The CT scan of her abdomen and pelvis showed diffuse irregular small bowel wall thickening and submucosal edema along with retroperitoneal and diffuse mesenteric lymphadenopathy. Based on her history and the radiology findings, the patient received an endoscopy. The endoscopy revealed lymphoid nodules in the gastric body.Her most recent CD4 count was 37 cells/mmAlso, we noted multiple hard, friable nodules ranging in size from 5 mm to 2 cm starting at the second portion of the duodenum and extending into the visualized jejunum Figures -2; multiThe biopsy from the colon revealed colonic mucosa with mild stromal edema and focal lymphoid aggregate. The terminal ileum biopsy revealed small intestinal mucosa with preserved villous architecture. The small intestine, jejunum biopsy was significant for high-grade B-cell lymphoma showing small intestinal mucosa with submucosal large malignant lymphocytes with a moderately abundant cytoplasm Figure .Immunohistochemistry results showed that cells were positive for CD20 Figure  and CD3.The Ki-67 stain was positive showing large atypical cells Figure .Helicobacter pylori and some evidence of mild chronic inflammation. A bone marrow biopsy, clot, and aspirate showed small lymphoid aggregate and hemosiderosis with no evidence of lymphoma.Stomach, antrum, and body biopsies showed negative immunostain for In the context of the patient’s AIDS, our differential diagnoses were medication-induced pancreatitis, chronic pancreatitis, cholecystitis, and peptic ulcer disease. Regarding endobronchial findings, the differential would consist of familial adenomatous polyposis and its variants such as Turcot’s and Gardner syndromes, as well as mucosa-associated lymphoid tissue (MALT) lymphoma. The patient was started on chemotherapy with dose-adjusted rituximab with etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (DaRR-EPOCH).The patient was readmitted to our facility with recurrent seizures. Records from the outside hospital indicated she was recently diagnosed with toxoplasmosis after a magnetic resonance imaging (MRI) scan showed multiple new irregular predominantly peripheral enhancing lesions. She was receiving treatment. However, her care team recommended she undergo further testing which she refused. She signed out against medical advice.Gastrointestinal lymphoma is a rare entity and, in most cases, is secondary to extranodal involvement of Non-Hodgkin’s lymphoma . PrimaryH. pylori infection risk factor.A 10-year retrospective analysis conducted in the United States reported a 1.7:1 male-to-female predominance for intestinal DLBCL . A JapanPathogenesis of primary gastrointestinal DLBCL is very complex, involving genetic changes with aberrant gene and protein expression. It involves complex interactions of host immune cells with foreign antigens leading to activation of signaling pathways, which results in the proliferation of lymphoma cells.DLBCL originates from germinal center B-cells or post-germinal B-cells, most of which express the B-cell lymphoma 6 (BCL6) gene which has also been implicated in the pathogenesis of DLBCL . BCL6 neHuman immunodeficiency virus, causing a depletion of CD4+ T lymphocytes leading to AIDS, is a known risk factor for lymphoma . Non-HodThere are various subtypes of DLBCL based on histopathological findings. Typical features include complete disruption of normal architecture by atypical lymphoid cells. Tumor cells resemble normal lymphoblasts with large prominent nucleoli with abundant cytoplasm . DLBCL eWith the involvement of the small intestine, symptoms are nonspecific. The most common symptoms are abdominal pain, nausea, vomiting, weight loss, gastrointestinal bleeding, and, in rare cases, intussusceptions and perforations , 3. DiagSome radiological features  are suggestive of lymphoma. However, a diagnosis cannot be wholly established on these radiological features .Once a diagnosis is made, Ann Arbor staging with Musshoff modification is used to stage gastrointestinal lymphoma. Various modalities are used for staging purposes, including CT, MRI, positron emission tomography scanning, endoscopic ultrasound or molecular markers. Bone marrow biopsy is performed in the event of lymphoma cell involvement and for monitoring the response to treatment.No guidelines exist for the treatment of DLBCL of the small intestine. We suggest a possible preferential management based on our review of the data with chemotherapy as the first-line therapy, given the overall response to chemotherapy is better in gastrointestinal B-cell lymphoma when compared with T-cell subtype. For gastrointestinal lymphoma, surgery followed by adjuvant chemotherapy was the preferred treatment modality based on systemic reviews. However, this preference has been a point of recent debate -18. In aHistorically, in patients with HIV, chemotherapy combined with antiretroviral therapy remains the first step in the management of aggressive lymphomas . RadiothThe international prognosis index (IPI) is used for prognosis in DLBCL. Poor prognostic factors include a patient age of >60 years, high serum levels of lactic acid dehydrogenase, Eastern Cooperative Oncology Group performance status ≥2, clinical staging of II or IV, and more than one extranodal disease . PrognosIn the evaluation of a patient with HIV reporting abdominal pain and vomiting, we should consider primary gastrointestinal lymphoma as part of the differential diagnosis. Chemotherapy combined with antiretroviral therapy is the cornerstone for management of high-grade DLBCL in patients with HIV.


Choanal atresia is a rare complication of radiation for nasopharyngeal carcinoma, which has to be early detected. Its treatment is based on endoscopic endonasale surgery. We report a rare case of choanal stenosis observed in a 54-year-old patient, Ho presented 4 years after the end of radiotherapy for nasopharyngeal carcinoma, a progressive bilateral nasal obstruction, anosmia, and rhinorrhea without bleeding. The diagnostic of fibrous stenosis was confirmed by endonasal endoscopic examination coupled to CT scan of nasopharynx. The recanalization via endoscopic endonasal surgery with tube calibration gave a great functional result with the improvement of nasal symptoms. Even after 6 months of follow-up, there were no signs of restenosis. Choanal atresia is a common congenital malformity in newborns; it is characterized by a blocked choanae, the opening between the nose and the nasopharynx. Acquired choanal stenosis is rarely seen and those complicating radiotherapy is even rarer in the literature. Through this observation we describe the clinical presentation, the diagnostic means and the therapeutic value of endoscopic recanalization surgery.A 54 years old Moroccan man presented to our otolaryngology (ENT) department with a 5 months history of worsening bilateral nasal obstruction, anosmia and rhinorrhea from both nostrils without epistaxis, associated with progressive bilateral hearing loss. His past medical history included undifferentiated carcinoma of the nasopharynx (UNCT) diagnosed on 2001, American Joint Committee for Cancer TNM staging of T1N0M0. He received a course of radiotherapy (65 Grays). The patient had no other significant past medical history. On examination, patient was breathing with mouth open. A cold spatula test showed absence of air flow on left nostril and minimal air flow on the right side. Rigid endoscopic nasal examination revealed a complete choanal stenosis in the left side and incomplete in the right side. There were no signs of tumor recurrence . OtoscopNasopharyngeal cancer is a public health problem in South-east Asia and in the Maghreb countries , its incPost radiation choanal stenosis is an exceptional complication. Its treatment is based on endonasal video surgery associated with a calibration. Endoscopic surveillance is mandatory, in addition to imaging, in irradiated nasopharyngeal cancers, to ensure proper monitoring and early detection of this complication.


The differential diagnosis between pneumothorax and giant bullae is thought to be straightforward but sometimes poses a challenge.We present a case of a 54-year-old Caucasian man with a giant emphysematous bulla who underwent surgical resection. He had no smoking history and had previous pneumonia episodes. The surgery was free of complications, without air leaks, and he showed good ventilation of the lung.The main complications of bullae are pneumothorax, infection and hemorrhage. Pneumothorax is a serious complication in patients with compromised lung function. Therefore, it is very important to carefully distinguish bullae from pneumothorax to avoid iatrogenic pneumothorax in patients with bullous disease.We emphasize how to differentiate between giant bullae and pneumothorax utilizing history, physical examination, and radiological studies, including computed tomography (CT) scan. This case report demonstrates the clinical and radiological presentation of giant bullae and highlights the difficulty making a diagnosis and treating appropriately. In particular, we emphasized how to differentiate between giant bullae and pneumothorax through history, physical examination, and radiological assessments, especially computed tomography (CT) scan. This work has been reported in line with the SCARE criteria .21) that was 65% of the value predicted 6 months previously and FEV1 of 1.19 L that was 50% of that predicted 6 months previously. Arterial blood gas showed a pH of 7.41, partial pressure of CO2 (PCO2) of 43 mmHg, and partial pressure of oxygen (PO2) of 69 mmHg. The left hemithorax was hyperresonant to percussion, and decreased breath sounds were apparent upon auscultation. The chest radiography showed progressive enlargement of the bulla in the left lung of over 10 years  . On gene10 years A. A CT s10 years B.Fig. 1ASurgical criteria for resecting bullae are generally based on symptoms, particularly poor pulmonary function, inducing dyspnea. Moreover, the grade of dyspnea was previously classified : grade IThe patient underwent surgical resection of the bulla firstly by VATS approach, converted after 30 min into a left thoracotomy for dense pleural adhesions A and B. 3A “bulla” is defined as an emphysematous space in the lung with a diameter of more than 1 cm in the distended state . Giant bWe describe in this report a valuable sign to distinguish pneumothorax from adjacent giant bullae: the double-wall sign. This sign occurs when one sees air outlining both sides of the bulla wall parallel to the chest wall A and B. No funding.For single case report NO ethical approval needs. Patient signed a consent for publishing the case report.Patient signed a consent for the publication of this case report.BA and CR wrote the case report. AS and UM revised the case report.Ethical Board approval is not required for case reports in our Center.Prof. Uliano Morandi is the Guarantor of this case report.Not commissioned, externally peer-reviewed.The authors have no financial and personal relationships to disclose.