The epididymal appendage, or the appendix epididymis, is a developmental remnant of the mesonephric duct that sprouts from the head of the epididymis. Due to its pedunculated anatomical configuration, the epididymal appendage is prone to torsion and can become a rare cause of an acute scrotum. Given its often challenging and atypical presentation, high clinical suspicion and Doppler ultrasonography are needed to guide diagnosis. We report a challenging case of epididymal appendage torsion that required prompt surgical exploration to accurately diagnose. Awareness of this condition and its radiological findings can play an important role in reaching an accurate diagnosis and avoiding surgical intervention. Torsion of the intrascrotal appendages is responsible for approximately 45%-60% of common urologic emergencies within the pediatric population. Of specific interest, the epididymal appendage, or the appendix epididymis, is a developmental remnant of the mesonephric/Wolfian duct that sprouts from the head of the epididymis with an autopsy incidence of 20%-24%. Although such a structure is generally of not much clinical significance, its pedunculated configuration makes it prone to torsion and a rare cause of an acute scrotum . While tAn otherwise healthy 14-year-old presented to the emergency room with right-sided scrotal pain. The pain developed gradually and was constant in frequency over the last 5-6 days. However, in the last 24 hours prior to presentation, the patient reported significant worsening of the pain associated with new onset of testicular swelling. No history of trauma, dysuria, or fever was reported. Upon physical examination, testes were descended bilaterally. The right testicle was mildly tender and indurated coupled with an exquisitely tender right epididymis. Prehn's sign was negative. The left testicle exhibited normal findings. No masses were palpated and a positive cremasteric reflex was observed bilaterally. Grey-scale sonographic examination of the scrotum was performed, revealing a small volume reactive hydrocele surrounding the right testicle , ice packs, and scrotal elevation. Nevertheless, surgical intervention through appendage excision can shorten the average duration of symptoms ,4.Torsion of the epididymal appendage is an uncommon cause of an acute scrotum in the pediatric population. Given its often challenging and atypical presentation, high clinical suspicion and Doppler ultrasonography are needed to guide diagnosis. Nevertheless, in clinically equivocal cases, prompt surgical exploration is necessary to reach a clear diagnosis.


Spindle cell sarcoma of the prostate is a rare variant of rhabdomyosarcoma (RMS), with the clinical experience limited to a handful of cases in the literature. We report a rare case of spindle cell rhabdomyosarcoma (SC-RMS) who presented to us with testicular torsion features. A 20-year-old male presented initially with lower urinary tract symptoms and features of epidiymo-orchitis, which was managed conservatively. He later presented with features suggestive of testicular torsion and underwent orchidopexy. The patient developed postoperative urinary retention. On per-rectal examination, there was gross prostatomegaly. He was evaluated with a trans-rectal biopsy and contrast-enhanced computed tomography (CECT). Subsequently, he was found to have metastatic prostatic SC-RMS, which is a rare disease. He was started on chemotherapy and radiotherapy. SC-RMS is a variant that has a comparatively favorable prognosis in children and an aggressive course in adults, as reported in the few cases so far. The treatment regimen is still evolving, and there is no consensus on the therapeutic approach. All these factors together result in the dismal outlook of patients diagnosed with this condition. Skeletal muscle soft tissue tumor includes rhabdomyoma and rhabdomyosarcoma (RMS). These are common in infants and children and reported very rarely in adults. The spindle cell variety is a rare variant of the embryonal RMS. Any part of the body can be affected by RMS. However, the most common primary sites are the head and neck region (35-40%), the genitourinary tract 25%), and the extremities (20%) . The dis5%, and tA 20-year-old male presented to surgical emergency with complaints of acute onset throbbing pain of the left hemiscrotum for one day. He had no associated fever. He also had difficulty defecating and a sense of rectal fullness that had gradually increased over one month. The patient had previously presented with acute urinary retention features three weeks before this episode, for which he was catheterized. He was then evaluated by the urology team, who found an enlarged prostate. The patient’s urinalysis showed plenty of red blood cells (RBCs), traces of protein with no pus cells on their further evaluation. An ultrasonogram (USG) done at that time showed an enlarged prostate with thickened left side cord structures and increased vascularity, which was suggestive of prostatitis and left epididymo-orchitis with funiculitis. He was then managed conservatively with oral antibiotics.The patient had mild lower abdominal pain, and on examination, there was tenderness over the left hemi-scrotum and lower abdomen. There was no local warmth or redness. The cord structures on the left side were tender and bulky. Right side testis and cord structures were normal on examination. On elevating the left testis, the pain was aggravated, suggesting a clinical diagnosis of testicular torsion. On per rectal examination, a grossly enlarged prostate, almost occluding the lumen, was noted. An USG examination of the scrotum was strongly suggestive of compromised vascularity to the left testis, and the patient was taken up for emergency scrotal exploration. It revealed a dusky left testis and twisted left cord. The cord was retorted, and orchidopexy was done bilaterally. Postoperatively there was an improvement in the testicular pain, and the patient was symptomatically better Figure .A contrast-enhanced computerized tomography (CECT) with an excretory phase (CT urography) was done to evaluate the grossly enlarged prostate gland. It showed that the prostate was replaced by a heterogeneous enhancing large irregular lesion, measuring approximately 8.5 x 9.9 x 10.1 cm Figure .Anteriorly, it infiltrated the posterior wall of the urinary bladder and projected into the lumen. It was encasing the prostatic urethra with the loss of fat planes. Laterally, it reached up to the lateral pelvic wall with loss of fat planes with bilateral obturator internus muscles. It showed loss of fat planes with the rectum, displacing it posteriorly Figure .Inferiorly it had lost fat planes with the levator ani. Heterogeneously enhancing bilateral internal iliac, right external iliac, and perirectal lymph nodes were noted. The features were suggestive of locally advanced prostatic malignancy. Since the patient’s renal parameters were within normal limits and the cause for bilateral hydroureteronephrosis (HUN) was downstream, he was managed with per urethral catheterization to relieve the obstruction at the level of the prostate. The patient then underwent a trans-rectal biopsy from the prostate. Histopathological examination (HPE) of the biopsy showed scores of fibromuscular tissue infiltrated by a tumor composed of sheets and fascicles of spindle cells displaying mild to moderately pleomorphic, ovoid to elongated hyperchromatic nuclei, inconspicuous nucleoli, and scant eosinophilic cytoplasm. On immunohistochemistry (IHC), the tumor cells were diffusely and strongly positive for desmin and Myo-D1 and were negative for cytokeratin (CK), smooth muscle actin (SMA), Schwannian markers (S 100 protein), synaptophysin, chromogranin, CD34, and prostate-specific antigen (PSA). The features were suggesting a diagnosis of RMS of the spindle cell type  scan was done. Increased metabolic activity was noted in the right external iliac, bilateral internal iliac, a few presacral, and left inguinal lymph nodes. The scan also revealed increased fluorodeoxyglucose (FDG) uptake in segment VI of the liver, T10, L1-L2 vertebrae, the sacrum, and the neck of the right femur. Hence a diagnosis of metastatic SC-RMS was made. During his hospital stay, he developed frank hematuria through the per-urethral catheter. USG of the abdomen revealed hematoma in the urinary bladder. He was managed conservatively with bladder irrigation, which settled the hematuria. Bladder tumors may be associated with hematuria and urinary obstruction, while prostatic primaries typically present as large pelvic masses causing urinary frequency or constipation from extrinsic compression of the bladder or intestinal tract. However, the hematuria, in this case, was due to the invasion of the bladder by the tumor. His performance status rapidly deteriorated, and he was confined to bed most of his waking hours. A multidisciplinary team (MDT) discussion was done, and he was started on chemotherapy with vincristine, actinomycin-D, and cyclophosphamide regimen (VAC regimen). He was given the first cycle of chemotherapy, which he tolerated well. He was discharged and received chemotherapy on a daycare basis. Following that, he received radiotherapy - 60Gy in 30 fractions. The patient subjectively noticed some improvement in pain and constipation; however, he continued to have rectal fullness. He also developed symptoms of peripheral neuropathy that was suspected to be due to vincristine. His performance status continued to be poor, and he is bedridden for most of the day.SC-RMS is a rather rare disease affecting infants and children. Among the various soft tissue sarcoma of childhood and adolescence, RMS is the commonest type with skeletal muscle differentiation . There aThe diagnosis of SC-RMS of the prostate can be challenging, as in our case, where it was initially diagnosed as a case of prostatitis, especially considering the younger age at which this tumor had presented. The patient was neither too young to consider RMS nor too old to consider prostatic carcinoma as a diagnosis. Also, he initially presented with a picture of epididymo-orchitis with prostatitis. This could have been, in fact, due to the infection resulting from the urinary stasis that had occurred due to the prostatic tumor. Also, that might have been overlooked, considering the age of the patient. However, on further evaluation, he was found to have a prostatic tumor, which was SC-RMS. There can also be a dilemma in diagnosing this condition in histology, as the histological picture can closely resemble other conditions. HPE of the SC-RMS consists of interspersed fascicles of elongated spindle cells. These cells may occasionally be arranged in whorls or in a herringbone pattern that is seen with leiomyosarcoma. And so it has been previously described as "leiomyomatous" embryonal RMS. Significant confusion occurs between the smooth muscle neoplasms and the SC-RMS due to their resemblance to histology. This is where the IHC can be of help in diagnosing the condition. The tumor's primary site, the nodes involved, and the metastatic sites are all the target sites for irradiation. The outlook with these therapeutic agents is encouraging in children with limited disease. However, in adults, the experience is limited, and outcomes are poor.  Because the clinical symptoms were very similar to testicular torsion, and the USG showed a definitive reduction of flow to the testis, the patient was explored. However, intra-operatively, there was duskiness of the left testis. SC-RMS is one of the types of sarcoma that can have nodal metastasis. On CECT, there were a few retroperitoneal nodes; however, there were no significant nodes that had any pressure effect or invasion of the testicular or renal vessels. The fact that the patient had relief from the acute testicular pain postoperatively also questions our theory. The renal vessel doppler was also done as a part of the hypertension workup and did not reveal any flow abnormality. So the above theory was discarded, and we finally concluded that it was, in fact, coincidental that our patient had testicular torsion with SC-RMS. The literature search did not reveal any similar case reports that showed an association between testicular torsion and SC-RMS. So we present this case report to document this occurrence of SC-RMS with testicular torsion so that a similar presentation in the future can help reveal the relation between the two entities, if any.As our patient was evaluated for the prostatic mass with CECT and biopsy, SC-RMS diagnosis came to light. We suspected that the symptom of testicular pain could be due to compression of the left renal vessels or testicular vessels by the retroperitoneal nodes.SC-RMS is a rare neoplasm that affects children and neonates. Few case reports have been reported in adults, in whom the disease is quite aggressive, with a poor prognosis. As described in this report, there can be a delay in diagnosing this malignancy in a young adult. We hereby report such a case of SC-RMS in a young adult who also had symptoms suggestive of testicular torsion, which could not be explained by the primary disease itself. We concluded it to be a coincidental disease process. Any more similar presentations in the future may throw light on the association between the two conditions, which we could not confirm at this stage.


Colloid cysts are the commonest masses of the third ventricle. Third ventricle neoplasms are uncommon. They include tumors arising from the choroid plexus , tumors arising from other than the choroid plexus , metastases, and lymphoma. Choroid plexus tumors usually occur in the lateral ventricle in children and fourth ventricle in adults, and often present with hydrocephalus. We herein describe the extremely rare occurrence of third ventricle choroid plexus papilloma in a 35-year-old man who presented to the emergency department with a long history of intermittent headaches, occasionally associated with photophobia. CT and MR imaging revealed a lobulated ovoid lesion in the third ventricle with minimal extension into the right lateral ventricle through the foramen of Monro, causing mild ventricular dilatation. Surgical resection was performed and histopathology revealed choroid plexus papilloma. The choroid plexus within the ventricles is responsible for producing cerebrospinal fluid (CSF). It consists of epithelial cells, capillaries, and connective tissue . ChoroidColloid cysts are the most common masses of the third ventricle, typically located at the anterior superior aspect of the third ventricle at the foramen of Monro. Less common masses of the third ventricle include neoplasms arising from the choroid plexus , neoplasms arising from other than the choroid plexus , metastases, lymphoma, vascular lesions, infectious lesions (e.g. tuberculosis) and congenital intraventricular cysts  . Tumors A 35-year-old male patient presented to the emergency department complaining of recurrent frontal headaches for one year. The headache was usually right-sided, associated with right periorbital pain and occasionally photophobia. He had no history of trauma, vomiting, or fever. On examination, he was afebrile, alert, and oriented, and had no weakness or numbness. An unenhanced CT scan of the head was performed, which revealed a lobulated ovoid well-defined hyperdense lesion at the anterior aspect of the third ventricle, extending into the foramen of Monro and slightly protruding into the anterior horn of right lateral ventricle Figure . It measMRI showed a lobulated mass with intense homogeneous post-contrast enhancement Figure . It was The patient underwent endoscopic resection of the intraventricular tumor. The tumor was firm and calcified and appeared to arise from the choroid plexus. Histopathology revealed a papillary lesion displaying delicate fibro-vascular cores covered by a single layer of fairly uniform cuboidal to low columnar epithelial cells with round to oval basally located monomorphic nuclei. No mitosis, necrosis, or anaplastic features were seen. Focal areas of calcification were noted within the papillae and stroma. Immunohistochemical studies showed tumor cells immuno-reactive with Vimentin, synaptophysin, S-100, EMA , GFAP , and CK7 ; and negative with CK20, p53, and TTF-1. Ki-67 proliferative index was approximately 2%. A histopathological diagnosis of CPP was made.Post-operative MRI performed six weeks after surgery showed a tiny residual enhancing tumor component, which was stable in size in a follow-up MRI performed one year later Figure . One yeaThe initial diagnosis of a colloid cyst in our case was mainly based on its location and features on CT. Colloid cysts are the commonest masses encountered in the third ventricle, usually located along the roof at the foramen of Monro, and are typically hyperdense on unenhanced CT. However, in view of the calcifications within the mass, alternative diagnoses should have been considered as calcifications are rare in colloid cysts . Other lThe intense homogeneous enhancement of the mass on MRI excluded the diagnosis of a colloid cyst which would be non-enhancing or have only a thin peripheral rim of enhancement. There was no vascular communication of the mass to suggest an aneurysm. The enhancement pattern coupled with the elevated Cho/NAA ratio of the mass on MRS was indicative of a neoplasm. Purely intraventricular neoplasms within the third ventricle can be broadly categorized into neoplasms arising from the choroid plexus  and neoplasms arising from other than the choroid plexus , metastases and lymphoma . Of thesMetastasis should always be considered in the differential of an avidly enhancing intraventricular mass lesion; however, this was less likely in our patient who had no known primary malignancy. Chordoid gliomas are rare neoplasms encountered in adults, they are usually hyperdense on unenhanced CT and show intense post-contrast enhancement; calcifications are rare . EpendymOn the basis of imaging features, the most likely possible differential diagnosis was either a meningioma or a choroid plexus tumor. Intraventricular meningiomas commonly occur in patients aged 30-60 years; they are usually well-defined iso to hyperdense globular masses, with calcification (in over 50%) and show intense enhancement; they are iso to hypointense on T1W1 and iso to hyperintense on T2WI; they demonstrate increased blood volume on perfusion imaging ,10. In tOur patient underwent endoscopic resection of his intraventricular tumor, and histopathology revealed a CPP. Choroid plexus tumors are primarily treated with surgical resection, which may be followed by adjuvant therapy (chemotherapy and/or radiotherapy) in cases of CPC ,13. GrosAlthough a well-circumscribed hyperdense mass in the third ventricle near the foramen of Monro on an unenhanced CT scan is most likely to be a colloid cyst, further assessment by contrast-enhanced CT and/or MRI should be performed to exclude alternative diagnoses. Third ventricle neoplasms are uncommon and preoperative differentiation can be challenging due to overlap in imaging features. However, awareness of the imaging features of different neoplasms on CT and MRI can help narrow the differential diagnosis.


Limbus vertebra (LV) represents a marginal interosseous herniation of the nucleus pulposus, usually in the midlumbar region. It is generally diagnosed as an incidental radiological finding during investigation of a case presenting low back pain or lumbar radiculopathy symptomatology. In this article, we report a case of a 37-year-old male patient complaining of acute low back pain. Imaging revealed a bone defect on the anterosuperior edge of L3 vertebra, finding that was attributed to LV. A comprehensive literature review was conducted regarding LV that should be included in the differential diagnosis of imaging findings of vertebral end defects. Limbus vertebra (LV) is a condition characterized by marginal interosseous herniation of nucleus pulposus causing non-specific symptoms such as back pain, local muscle spasm and radiculopathy. It is frequently confused with vertebral fracture, infection, Schmorl nodule or tumor since it does not present any specific symptoms . The chaA 37-year-old male patient presented to the emergency department complaining of sudden lower back pain after an abrupt rotation of the torso while playing football. He complained of sudden pain radiating from the lower back to the left lower limb without alleviation of the pain intensity during rest. No history of spine injury in the past was reported. During physical examination, no motor or sensory deficit was recorded. The Lasegue test, Achilles and patellar tendon reflexes were normal bilaterally. Lab tests were within the normal values.On plain radiographs Figure , a trianFurther testing was requested using CT Figure  and MRI The patient was admitted to the Department of Orthopaedic Surgery and treated conservatively. He was discharged the following day reporting obvious improvement of the symptomatology. LV displays a primary pathology of the intervertebral disc, occurring as a result of herniation of the nucleus pulposus into the adjacent vertebral body. When this process takes place during childhood and adolescence before ossification happens, the extruded disc material disrupts the endplate, warding off the ring apophysis from the vertebral body . This coWhile the mainstream of patients leads an asymptomatic life with LV being an accidental finding in the lateral radiographic series of the spine, occasionally it can manifest with non-specific symptoms and signs, such as acute or chronic low back pain, spasm of the paravertebral musculature and radiculopathy, with or without trauma history ,3,6. PosThe radiographic findings are typical in adults consisting of a small triangular or round bony fragment with sclerotic margins and osseous density. The adjacent vertebral body showcases a bony defect not corresponding completely to the later fragment with sclerotic and irregular borders. CT and MRI techniques can be used in cases where final diagnosis could not be established from plain radiographs and especially in difficult cases of PLV where lower lumbar vertebras are overlapped by pelvic structures .Many pathologic conditions such as vertebral fractures (teardrop fractures), focal calcification of posterior or anterior longitudinal ligament, osteophytic fragments, calcified intervertebral disc hernias, tumors, infection and Schmorl’s nodules can mimic LV and must be excluded before setting the final diagnosis ,13. The When LV is an incidental finding and the patient does not present any symptoms, no treatment is required. As far as symptomatic patients are concerned, conservative management is the mainstay of treatment, including management with muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics. Surgical management is rarely indicated and must be considered in cases of nerve compression causing radiculopathy resistant to conservative treatment. Total laminectomy is indicated for the excision of the LV fragment, while others support the removal of the mobile fragment alone ,12.Despite LV being described almost a century ago demonstrating clear radiographic findings, the condition remains widely unknown to the medical community making the definite diagnosis challenging. A physician should include the LV variant in the differential diagnosis of an anterosuperior triangular well-corticated fragment of a vertebra in the midlumbar region in order to achieve a more immediate diagnosis and avoid inessential diagnostic procedures.


Congenital intestinal atresia develops in 1 in 1500 to 20,000 births. Colonic atresia, which accounts for 1.8–15% of intestinal atresia cases, is accompanied by other gastrointestinal atresias such as small intestinal atresia, gastroschisis, imperforate anus, and intestinal malformation in 47–80%. Although a report shows that patients with multiple colonic atresias are 8.9% of those with colonic atresia.A male infant did not have the first bowel movement within 36 h of birth and had abdominal distention/vomiting. Radiography showed significant dilation of the intestinal tract. A contrast enema examination at 3 days of age showed a microcolon and disruption in the descending colon. We performed an emergency decompressive loop enterostomy in the distended segment. At the age of 7 months, imaging from the stoma showed disruption of the contrast medium in the intestinal tract at the right lower abdomen, and the continuity of the intestinal tract was not clarified. Intestinal malrotation was found during the second surgery, and the enterostomy was located in the ileum proximal to Bauhin’s valve. Continuity of the intestinal serosal surface was maintained. However, multiple membranous obstructions (three atresias and one stenosis) were observed in the distal segment of the bowel, which was penetrated by intraluminal advancement of a urethral catheter. Therefore, he was diagnosed with multiple colonic atresias. The intestinal tract was longitudinally incised, and membranectomy and mucosal/lateral suture were performed.It is important for neonates with intestinal atresia to evaluate and prepare for distal patency of the colon before radical anastomosis. In addition, anomalies associated with colon atresia should also be assessed. Congenital intestinal atresia develops in 1 in 1500 to 20,000 births , 4, is aThe course of pregnancy was normal. The infant was born at a gestational age of 38 weeks and 6 days by normal vaginal delivery, and birth weight was 2790 g at the previous hospital. The infant did not have the first bowel movement within 36 h of birth and had abdominal distention and vomiting. Plain abdominal radiography showed significant dilation of the intestinal tract and no gas in the pelvic cavity Fig. , which dBecause of his unsteady breathing condition, we performed emergency enterostomy at 3 days after birth. Laparotomy, with 3 cm transection in the upper right abdomen, observed serous ascites, but no adhesion was observed. After puncturing the dilated intestinal tract and depressurizing, we performed only emergency enterostomy with double orifices for the dilated intestinal tract. During the operation, we wanted to confirm distal patency and associated anomalies and make a definitive diagnosis, but we could not do it due to prominent intestinal dilatation and his unsteady breathing condition.A biopsy of the intestinal tract at the site of enterostomy showed ganglion cells in the Meissner’s and Auerbach’s plexus. And a biopsy of the rectal mucosa showed ganglion cells in the Meissner’s plexus. Therefore, Hirschsprung’s disease was ruled out. As associated anomalies, the infant had Ebstein’s anomaly (mild) and mild pyelectasis on the left side (I–II). His family history was noncontributory.He was admitted to our department to undergo radical operation at 7 months of age. The height was 65.1 cm and weight was 6.53 kg. Preoperative contrast enema from the anus showed a microcolon and disruption of the contrast medium in the descending colon. Imaging from the stoma showed a disruption of the contrast medium in the intestinal tract at the right lower abdomen, and the continuity of the intestinal tract on both sides was not clear  a membrane-like atresia in the Bauhin’s valve, (2) a membrane-like atresia in the 2-cm anal side of Bauhin’s valve, (3) a membrane-like atresia in the transverse colon, and 4) a stricture in the 2-cm anal side of the atresia (Fig.  a strictPathologically, the wall structure of the membrane-like atresias was maintained, and mucosal epithelial regenerative changes were observed Fig. . GanglioAt 9 months of age, he was admitted for the ileostomy closure. Simulated stool had been injected into the intestinal tract in the anal side of the stoma 7 days before surgery. A contrast enema examination confirmed the improvement in disuse atrophy of the intestinal tract and its passage. But at operation a stricture was observed in the region where the membrane-like atresia in the transverse colon was removed. We performed a balloon dilation and the ileostomy closure. The postoperative course was favorable, and the baby was discharged on day 11 after surgery. Currently, he has outpatient follow-up visits, and the control of defecation is favorable.Colonic atresia, a type of congenital intestinal atresia that develops in the colon, was first reported by Binninger et al. in 1873, and a lifesaving case was reported by Gaub et al. in 1922 . We had The causes of congenital intestinal atresia are explained by the theory of developmental anomaly due to failure of recanalization by Tandler et al.  and the Combined malformation is shown to occur in 47–80% of patients with colonic atresia , 6, and Since in colonic atresia, due to the presence of the Bauhin’s valve, which is different from intestinal atresia in other regions, closed loop obstruction occurs, the onset of abdominal distention and vomiting is delayed, and symptoms commonly occur after 24 h of birth. Therefore, necrosis and perforation easily occur, and early diagnosis is necessary. A report showed that, in patients who underwent surgery over 72 h after birth, the mortality is significantly higher than those who had surgery within 72 h after birth, and the cause of death is perforation due to dilation of the occluded colon in the rostral portion . For theIt is important for neonates with intestinal atresia to evaluate and prepare for distal patency of the colon before radical anastomosis. In addition, anomalies associated with colon atresia should also be assessed. In a case of potential multiple atresias, we consider that by performing multiple-stage surgery, radical operation, after a preoperative sufficient examination of the intestinal tract, is safe.


Tracheal intubation (TI) is a common procedure that rarely entails life‐threatening complications. A 1.5‐year‐old female spayed cat presented with acute signs of respiratory distress 5 weeks after undergoing TI. Radiographs revealed a marked, segmental, tracheal narrowing. A hard, 5‐cm‐long, white‐yellowish tissue was identified and removed from the trachea, with subsequent resolution of clinical signs and radiographic changes. Microscopically, the tissue consisted of fibrin and lytic neutrophils, interspaced with optically empty cavities and a few remains of talcum powder and hair shafts. Consequently, a diagnosis of obstructive fibrinous tracheal pseudomembrane (OFTP) was made. A rare complication of TI in humans, OFTP should also be suspected in cats with respiratory distress, a history of TI and radiographic evidence of tracheal narrowing. Based on cases from other species and the cat described herein, the condition can be easily resolved with OFTP removal. BALbronchoalveolar lavageETendotracheal tubeOFTPobstructive fibrinous tracheal pseudomembraneTItracheal intubation1A 1.5‐year‐old, female spayed, domestic shorthair cat presented to a referral center with a chief complaint of acute respiratory distress. Previous medical history included dermatophytosis and secondary bacterial pyoderma. Additionally, 5 weeks prior to presentation, the cat underwent general anesthesia, including tracheal intubation (TI), for the treatment of a suspected infected bite wound in her left hindlimb. Subsequently, the cat developed recurrent episodes of transient fever, which resolved and recurred over the course of 1 month, notwithstanding antibiotic treatment. The former included at first amoxicillin‐clavulonate  for 7 days, and then a combination of doxycycline  and clindamycin , which the cat received until first presentation to the referral center. Medications were forcefully administered per os because the cat refused their voluntary consumption in the food. Upon presentation, abnormal physical examination findings included inspiratory and expiratory distress, with intermittent open‐mouth breathing and wheezes. Additional findings included skin lesions, which consisted of alopecia with crusted papules, affecting the convex aspect of both ear pinnae. Two smaller lesions were noted on the head and the dorsal aspect of the neck. Furthermore, the cat was lame on both the right front limb and the left hindlimb. Otherwise, the cat was alert and responsive, with a body condition score of 4/9, respiratory rate of 32 bpm, pulse of 160 bpm, and a rectal body temperature of 38°C. Subsequently, neck and chest radiographs were performed, and revealed a marked narrowing of the cervical trachea, beginning approximately at the level of the 4th cervical vertebra and extending to the first rib, whereupon the narrowing abruptly ended Figure . The narKlebsiella pneumoniae strain, which was only sensitive to amikacin and gentamicin, but not to amoxicillin/amoxicillin‐clavulonate, cephalexin, cefpodoxime, enrofloxacin, chloramphenicol, or trimethoprim‐sulfamethoxazole. Microscopic examination of the abnormal tracheal tissue demonstrated a mixture of fibrin and lytic neutrophils. Scattered throughout were multiple round to oval optically empty cavities varying in size from approximately 20 to 300 μm in diameter. Rarely, these spaces contained strands of unidentified birefringent material or flocculent proteinaceous debris. A few remains of talcum powder and hair shafts were seen  was also isolated from the lesion in the right front limb, albeit of a different strain with a different antibiotic sensitivity profile when compared to the resistant strain obtained from the BAL fluid (this strain was susceptible to most antibiotic families tested).Cytological evaluation of the FNA sample from the right front limb was unremarkable, with no evidence of fungal or mycobacterial organisms , and no evidence of neoplasia. The same bacterial species  were administered at home, in addition to meloxicam . Respiratory clinical signs had not recurred during the following year. However, the cat experienced at least 2 recurrent fever episodes, for which further diagnosis was not pursued by the referring veterinarian. Furthermore, the outcome of the osseous lesions was similarly unclear since X‐ray studies had not been repeated.2Obstructive fibrinous tracheal pseudomembrane characteristically consists of a collection of fibrin, interspaced with leukocytes and desquamated necrotic epithelial cells. It is essentially a desiccated mucus plug that forms circumferentially in the trachea, without adhering to the adjacent tracheal wall.Obstructive fibrinous tracheal pseudomembrane can be suspected based on compatible history and clinical signs after extubation, corroborated by neck X‐rays and ascertained during tracheobronchoscopy. Nonetheless, this complication has only recently received attention in human medicine and is still believed to go unrecognized in many cases.The pathogenesis of OFTP remains poorly understood. Its formation likely stems from superficial damage to the tracheal wall since subepithelial stroma is often absent in histology, and deep macroscopic lesions are not appreciated during tracheobronchoscopy after its removal.Regardless of its cause, OFTP, if recognized early, is easily treatable and rarely recurs. Furthermore, spontaneous expectoration thereof has anecdotally been reported in humans.In conclusion, OFTP, hitherto unreported in cats, should be suspected in cases of respiratory distress, associated with a history of TI and radiographic evidence of tracheal narrowing. Based on cases from other species and the cat described herein, the condition can be easily resolved with removal of the obstructive tissue and rarely recurs.3Authors declare no conflict of interest.Authors declare no off‐label use of antimicrobials.Authors declare no IACUC or other approval was needed.Authors declare human ethics approval was not needed for this study.


The tumors showed calcification in 88.2% cases (15/17) on CT scans and hypointense on T1WI , mixed intense on T2WI , and inhomogeneous enhancement without dural tail sign after administration of gadolinium . Almost all the tumors were misdiagnosed as meningiomas preoperatively. In addition, almost all image available CDC lesions  located across the cranial sutures indicating that the tumor originated from ectopic chondrocytes from adjacent skull sutures. No tumors recurred after total resection in follow-up. CDCs are characterized with female predominance and may originate from ectopic chondrocytes from adjacent skull sutures. The lesion with inhomogeneous contrast enhancement without dural tail sign and avascular in cerebral angiography are key points to be differentiated from meningioma. The most effective treatment is total resection.Chondroma of the dural convexity (CDC) is a benign and extremely rare type of intracranial chondroma. In this study, we reported five CDCs in a single center and reviewed the available literature to determine the clinical characteristics and surgical outcomes and possible origins of the disease. The clinical data of five patients  who confirmed to be CDC between 2000 and 2019 in our single center was collected together with 22 cases from literatures. The clinical characteristics and surgical outcomes were reviewed and analyzed. Among all the available CDC cases, the mean age was 31 ± 13.7 years; the mean tumor volume was 42.3 ± 40.9 cm Chondromas are benign, slow-growing tumors that originate in cartilage . These tIn current study, by reviewing the medical records of 5 cases of CDCs from our single center and by fully reviewing the literature, we can attain a more comprehensive understanding of the common clinical characteristics, treatment strategies, and neurosurgical experience of CDCs. In addition, based on the fact that most lesions are close to the adjacent cranial suture, we can speculate on the possible origin of the chondroma.Data from 5 CDC patients  who were surgically treated and pathologically confirmed at Beijing Tiantan Hospital, Capital Medical University, from 2000 January to 2019 July were reviewed. We extracted information about the patient's gender, age at diagnosis, clinical neurologic dysfunction, surgical procedure, and pathology from the medical records. In addition, we evaluated the tumor location, volume, boundary, and enhancement by radiologic images . The outA tailored surgical approach based on tumor location was used to remove the tumors. The extent of tumor resection was evaluated based on pre- and post-MR and/or CT images. The extent of tumor resection was categorized as gross total resection (GTR) and non-GTR . Postoperative specimens were sent for pathologic examination .“Chondroma” and “dural convexity” were searched as key words in PubMed. Any location and histopathologically confirmed CDC case report was included, limited to English publications without data restrictions. In addition, all references provided in the identified publications and included relevant citations were further reviewed. This study included cases with sufficient clinical data reported in English for analysis.In our series, the mean age at diagnosis was 42.2 ± 13.5 years  . Besides3 ± 40.9 (range 1.8-144.0 cm3). Excluding the 9 cases not reported, 8 cases  had hyperdensity, 7 cases  had mixed density, and 3 cases  had hypodensity on CT. Half of lesions had cystic degenerations. Moreover, we found most lesion  calcified on the CT scans. In MRI, fifteen cases  were hypointensive on T1WI, and 10 cases  presented mixed intensitive on T2WI. After administration of gadolinium, 20 lesions  were enhanced inhomogeneously on T1WI with no dural tail sign  are located in the frontal area, and their mean tumor volumes are 42.3 cmail sign . Almost Studies by Maruyama and others have shown that suture mesenchymal stem cells play an important role in craniofacial bone development, repair, and regeneration . TherefoAll patients underwent craniotomy to remove the tumors, and surgical approaches are described in p < 0.01, t-test). In addition, none of the patients received any further adjuvant therapy, such as radiotherapy or chemical therapy. After mean and median follow-up durations of 96.8 and 112 months, respectively, no patients suffered from tumor recurrence, which is same as the all available patients' report.The neurological symptoms were improved in all patients when discharged. As for our series, the mean recent KPS was 98 ± 4.5, which is significantly higher than the preoperative KPS of 84 ± 5.5 . She had intermittent headaches and dizziness for more than 7 years. Neurological examination revealed negative signs. An MRI scan showed a slight hypointensity in the T1-weighted imaging. T2-weighted imaging showed a slight hyperintensity, and intratumor vessels were observed in the enhanced lesion. The enhanced scan showed inhomogeneous enhancement, and the right lateral ventricular occipital angle was deformed . And theBased on the MRI and CT images, we found that the lesion was located across the parieto-occipital suture, which was confirmed intraoperatively. During the operation, the lesions were clearly defined within the surrounding brain tissue. The tumor was separated along the arachnoid membrane between the tumor and brain tissue and completely removed. Upon histopathological examination, the tumor was diagnosed as a chondroma. Moreover, the immunohistochemistry examination of Case 1 showed positive results for vimentin protein, S-100, and Ki-67 (0-1%) and negative results for cytokeratin (CK), epithelial membrane antigen (EMA), Brachyury, and P53 in the tumor. There was no recurrence reported by the 1-year follow-up.Intracranial chondromas are very rare and benign neoplasms, accounting for less than 1% of all intracranial lesions. They can occur alone or as part of Ollier disease or Maffucci syndrome . IsolateIntracranial dural-based convex chondroma is rare. In our current study, only 5 cases were reported. Combined with the 22 cases in the published literature, we have comprehensively summarized CDCs, including clinical and radiological characteristics, histopathology, differential diagnosis, treatment strategies, and possible pathogenesis . SeveralGenerally, bone is formed by endochondral or intramembranous ossification. The base of the neurocranium forms through endochondral ossification , whereasVarious theories have been proposed for the occurrence of intracranial chondroma, and there are reasonable explanations. The speculative origin of dural convex chondroma reported in the literature can be divided into two categories. One is that ectopic chondrocytes enter the meninges during early development  or afterAlthough many theories about the origin of intracranial chondroma have been proposed, the pathogenesis of the disease is still controversial. It has been reported that systemic chondromatosis conditions may be related to intracranial chondromas . ChondroBecause the lesions grow slowly and do not invade brain tissue, CDCs usually have a long history of clinical symptoms , 45. TheThe neuroimaging features of CDC lesions are quite typical. CT scans show variable densities due to differences in the degree of calcification. Due to the increase in lesion size, some cases may also show hypertrophy or erosion and damage to adjacent bones , 21. In MRI showed no tissue edema around the tumor, which means that the lesions grew slowly and indicated the benign nature of the lesions . These lThe histological features of chondromas are lobules of hyalinized cartilage usually containing one cell per lacuna, and neoplastic chondrocytes remaining in the cavity are cytologically benign. Around the tumor, the cartilage undergoes endochondral ossification, and the center is often calcified. Lesions of myxoid degeneration can also be seen , 32, 48.Although the radiological and pathological characteristics are almost the same, the convexity dura-based chondroma can be distinguished from the skull base chondroma by the patients' clinical signs and symptoms.CDCs are difficult to differentiate from meningiomas . Almost Since CDCs are avascular lesions and do not invade or adhere to the surrounding tissue, the standard surgical strategy for these tumors is total resection , 27. FurIn this study, we found that chondromas of the dural convexity occur more frequently in females than in males. In addition, the lesion is close to the adjacent cranial suture, and we speculate that the occurrence of CDCs may be related to ectopic chondrocytes in the cranial suture. Due to easily misdiagnosed as meningioma, the lesion with inhomogeneous contrast enhancement without dural tail sign and avascular in cerebral angiography are key points to be differentiated. For chondroma of convex origin, it is expected that total surgical resection is more readily available and that the patient has no recurrence after surgery.


Giant cell tumors (GCT) of the bone are uncommon primary bone neoplasms that occur mainly in the epiphyses of long bones. Their incidence in craniofacial skeleton is rare, particularly in the maxilla. We report a case of a 12-year-old patient with a GCT of the left maxilla, who underwent a surgical excision of whole mass, and showed no recurrence one year after intervention. This lesion is uncommon in the craniofacial skeleton; the majority of them occur in the sphenoid, ethmoid and temporal bones. A review of the literature showed that GCT of the maxilla has been seldom encountered [The giant cell tumor (osteoclastoma) is a benign, locally invasive lesion of the bone . Giant cA 12-year-old girl was referred to Department of Oral Surgery, with a complaint of pain and swelling in the left of maxilla that appeared 3 months ago. The swelling was slowly progressive, associated with pain. However, the patient did not refer any motor or sensory deficit. There was no family history of similar swelling. Physical examination revealed a left maxillary swelling. There was no facial palsy. No cervical lymph node enlargement was seen. The oral examination showed a 4 cm x 5 cm, tender, compressible mass in the left maxilla, from the lateral incisor to the second premolar teeth. The tumor surface was smooth and red-purple . SeveralOrthopantomography and occlusal radiography showed a wide osteolytic area of the anterior left maxilla, extending from the first permanent molar to the central incisor . The canGCT is a true neoplastic process originating from the undifferentiated mesenchymal cells of the bone marrow . They arThe pathogenesis of GCT has added to diagnostic dilemma. Lichtenstein in 1950 postulated that GCT is a manifestation of altered haemodynamics. The pressure secondary to circulatory disturbance leading to congestion leading to bone resorption, with deposition of fibrous connective tissue, osteoid and new bone. A second hypothesis was given by Biesecker et al.  where thGCT shows many clinical and radiological features in common with other bony lesion of the jaw, including giant cell granuloma, aneurismal bone cyst, fibro-osseous lesions, cherubism, brown tumor of hyperparathyroidism and malignant neoplasm of the jawbone such as sarcoma . These lThe final diagnosis is established only on the basis of a biopsy. Histologically, GCTs are composed of multinucleated giant cells in a vascular stroma of epitheloid or spindle-shaped mononuclear cells, with peripheral osteoid formation ,18. The In conclusion, GCT arising from the maxilla is a rare disease whose diagnosis is difficult. Imaging and clinical features are often not sufficient to make the diagnosis. Therefore, the possibility of GCT should be included in the differential diagnosis of a bony lesion of craniofacial bones until a final diagnosis is made using a permanent pathologic specimen. Wide complete excision is required since incomplete excision results in a high incidence of recurrence.


Oncocytic adenolipoma is a rare tumor to occur in the salivary gland, which can present as a giant neck mass. Until now, <20 such cases are reported. We report this rare case for surgeons to consider it as one of the differential diagnoses. Oncocytic adenolipoma is a rare tumor to occur in the salivary gland, which can present as a giant neck mass. Until now, <20 such cases are reported. We report this rare case for surgeons to consider it as one of the differential diagnoses. Until now, <20 such cases are reported. We report another such rare case presented as a giant neck mass.Lipomatous tumors are one of the commonly seen tumors of subcutaneous soft tissue. However, those originating from the salivary gland are extremely rare.2A 46‐year‐old man, from remote and difficult to reach part of the country, came to our center with complaints of huge neck mass in the right side, almost occupying the whole of the right neck from levels 2, 3, 4, and 5. Informed consent was obtained from the patient for the case presentation. He gave a history of swelling, which was gradually progressive and painless for more than 18 years. As the patient had poor financial status and was from the remote part of the country, he presented very late after the onset of disease. Late presentation to the hospital is a common problem in developing countries. However recently, for the past 2 years, the size of the swelling had increased progressively than before. With the fear of cancer, the patient somehow managed to visit the hospital. There was no history of xerostomia, dysphagia, shortness of breath, facial deviation, change in sensation, fever, no intraoral discharge, loss of weight or change in appetite, and no known comorbidity.On examination, the mass was well defined, multilobulated with a size of approximately 15 × 11 cm at the right side of neck, superiorly up to the level of ear lobule, inferiorly 4 cm above the clavicle, medially up to midline and posterolaterally occupying half of posterior triangle  lobulated areas admixed with fatty tissue.Microscopic examination showed multiple lobules of tumor separated by thin fibrovascular septa with a fibrous capsule. The lobules composed of prominent oncocytes arranged in tubules, admixed with fatty tissue composed of mature adipocytes in varying proportions. Foci of squamous and sebaceous differentiation, chronic inflammatory cells, and stromal edema were evident as well. No features of malignancy noted Figure . The fin3Lipomatous tumors comprise 0.5% of salivary gland tumors, with the most common site being the parotid, followed by the submandibular gland.Thus, it can be of monophasic (only lipomatous component) or biphasic  histological type. Among the biphasic type, the epithelial component can be of oncocytic or nononcocytic.Most of the cases in the literature revealed that the oncocytic adenolipoma presented as a slowly growing, asymptomatic swelling most commonly from the parotid gland. The other areas where adenolipoma can be found include breast, thyroid, parathyroid, and skin.The pathogenesis of the lesion is still elusive. There are different speculations regarding it. One theory given by Nagao stated it as entrapment of glandular component during lipomatous proliferation. He suggested it being not of neoplastic origin but as a type of lipoma rather than hamartomatous origin.Clinically, the differential diagnosis of the present case with a huge lesion includes varieties of the neck mass, including all benign lesions of the salivary gland. Radiological investigation of CT scan helped us to narrow down the differential to the fat‐containing lesion as lipoma to lipoadenoma. Except for the huge size of the mass, radiologically the lesion was not suggestive of being malignant. However, FNA cytology was not found to be helpful for us. Histologically, oncocytic adenolipoma consists of circumscribed biphasic tumor surrounded by a thin fibrous capsule in which the adipose tissue intermingles with the oncocytic part. The epithelial component is formed only by the oncocytes with no ductal or acinar component, which is usually seen in sialolipoma.4Oncocytic adenolipoma is a unique, extremely rare salivary gland neoplasm that one needs to be aware of and should also be regarded as one of the differential diagnoses in the patient presenting with any giant neck mass. Given the rarity, we describe this case to generate awareness and add to the few reported cases in the literature.None declared.DS: involved in conceptualization and preparation of manuscripts. AN: critically reviewed the manuscript.


Solitary osseous plasmacytomas affecting the vertebrae, the zygomatic arch, and ribs occur in dogs. In this report, we describe clinical and imaging features of a solitary osseous plasmacytoma affecting the skull with deposition of amyloid forming a mass‐like lesion. To the authors' knowledge, no similar cases have been reported before. Solitary osseous plasmacytomas affecting the vertebrae, the zygomatic arch, and ribs occur in dogs. In this report, we describe clinical and imaging features of a solitary osseous plasmacytoma affecting the skull with deposition of amyloid forming a mass‐like lesion. To the authors' knowledge, no similar cases have been reported before. The referring veterinarian had prescribed phenobarbital  (2 mg/kg PO q12 h) after the last ES. The serum phenobarbital concentration 2 weeks after commencing the anti‐epileptic therapy was 26.8 mg/L . Physical examination revealed mild stiff gait on the thoracic limbs, compatible with the aforementioned osteoarthritis. Neurological examination was considered normal, except for mild discomfort upon rostral skull palpation. Based on the patient's age, structural epilepsy was suspected.A 9‐year 1‐month‐old spayed female Labrador Retriever dog weighing 33 kg presented for investigation of three generalized tonic‐clonic epileptic seizures that occurred 1 and 2 months prior to referral; the second and third seizures presented as clusters. Normal interictal periods were documented. The dog was receiving thyroxine supplementation  (15 µg/kg PO q24 h) and meloxicam treatment . Serum biochemistry revealed increased alkaline phosphatase  and alanine transaminase . These clinicopathological changes were most likely secondary to phenobarbital administration. Urinalysis detected no abnormalities. The urine protein: creatinine ratio was normal .Complete blood count revealed mild normocytic, normochromic, and nonregenerative anemia  and mild thrombocytosis  and Neospora caninum IgG (<100) serum titers were not suggestive of an active infection. Cryptococcus spp. antigen testing was negative. Thoracic and abdominal radiographs  revealed no osteolytic lesions or clinically significant abnormalities. Six weeks after presentation, incisional biopsy from the left parietal bone and underlying left intracranial mass were obtained via left rostro‐tentorial craniectomy. During the postoperative period, the dog suffered from a generalized tonic‐clonic epileptic seizure. Levetiracetam  (20 mg/kg PO q 8h) treatment was commenced. No postoperative neurological deficits were detected upon examination. Histopathological analysis of the skull sample revealed fragments of trabecular bone and large hematopoietic tissue. The latter was expanded by the infiltrative growth of a monomorphic population of discrete neoplastic cells associated with scant fibrovascular stroma. Cells had a scant to moderate light basophilic cytoplasm and centrally placed round vesicular nucleus with large eosinophilic nucleolus. Mitotic activity was 2‐3/high‐power field and cellular atypia was mild  of the head was performed with a 1.5 T MRI scanner . Several sequences  in multiple planes were acquired. An extensive lobulated and infiltrative mass was identified centered on the frontal and parietal bones, bilaterally. Large lobules were extending into both frontal sinuses filling most of their lumina Figure  asteriskA provisional diagnosis of solitary osseous plasmacytoma with subjacent amyloid deposition was established, and staging workup was therefore extended to exclude presence of distant tumor involvement. Radiographs of the four limbs showed no evidence of bone lesions. An ultrasound scan  revealed normal appearance of the medial retropharyngeal, parotid, and mandibular lymph nodes, mild splenomegaly, and changes compatible with a right caudal pole renal infarct. Cytology examination of the medial retropharyngeal lymph nodes, liver, spleen, and bone marrow was performed by means of ultrasound‐guided fine needle aspirates (FNA); and no evidence of plasma cell neoplasia was detected. Serum protein electrophoresis was also performed and revealed no abnormalities.Considering the imaging and the clinicopathological findings, a diagnosis of solitary osseous plasmacytoma with extensive calvarial involvement and subjacent intracranial amyloid formation was reached.2 PO q24 h) was instigated.Meloxicam treatment was discontinued, and therapy with prednisolone  (0.5 mg/kg PO q24 h) and melphalan   indicated that the extra‐axial mass in the left parietal lobe was approximately 2 mm longer compared to previous MRI and had a very mild mass effect. A computed tomography (CT) scan was performed at the same time for 3D conformal radiation planning using Prowess software (Panther TPS v 5.4). The gross tumor volume (GTV) included the left parietal mass extending into both frontal sinuses and a 1 cm margin was added for planned tumor volume (PTV). Planning achieved 95% dose delivered to PTV using four 10 MV wedged photon beams (one with split wedge and one with a field in field compensation beam). Bolus tissue equivalent of 0.8 cm was used on all beams to achieve dose distribution. Both eyes and brain were outlined as organs at risk. RT was delivered under general anesthesia with a linear accelerator (Siemens ONCOR Impression Plus) using a 20 × 2.4 Gy fractionation protocol . Positioning was achieved using a thermoplastic beam directional shell (Oncology Imaging Systems) and vacuum bag (Qfix) molded to the shape of the dog's head, clipped to a head frame on a flat‐topped treatment couch, and verified using an electronic portal imaging device and megavoltage radiation.Repeat MRI and CT scans of the head two months after completing the course of radiotherapy indicated a possible mild decrease in size of the left parietal mass and shrinkage of the right frontal sinus mass compared with previous scans although new areas of hyperostosis and sclerosis were noted in the parietal bone.Five months after completing the course of RT, a generalized tonic‐clonic epileptic seizure was reported and the dog was re‐presented for lethargy. Abdominal ultrasound revealed an enlarged and irregular‐demarcated right kidney with a heterogeneous hypoechoic mass occupying the entire caudal pole and extending to the cranial pole. There was extension of soft tissue material within the right renal vein and the caudal vena cava. CT scan of the thorax detected multiple small soft tissue nodules throughout the pulmonary fields. The cytological examination of the renal mass was not diagnostic. These imaging findings were compatible with primary right renal neoplasia with pulmonary metastasis. Renal cell carcinoma (RCC) was the main differential diagnosis; however, other histotypes could not be excluded. The owner refused further investigations, and treatment with oral toceranib phosphate was commenced  (3 mg/kg PO three times a week).Two months later, the dog acutely collapsed and died in the household. No postmortem examination was consented by the owners.2Solitary plasmacytomas are a myeloid‐related disorder that can form either in soft tissue as extramedullary plasmacytomas or in bone as solitary osseous plasmacytomas.In the 2016 revision of the World Health Organization (WHO) classification of lymphoid neoplasms, plasma cell myeloma, solitary plasmacytoma of bone, and extraosseous plasmacytoma were classified as mature B‐cell neoplasm.Clinical signs associated with solitary osseous plasmacytomas usually relate to the location of the anatomic involvement. These include pain and lameness if the appendicular skeleton is affected or neurologic signs if the vertebral column is involved.In a recent review of human solitary plasmacytomas, the authors proposed that a biopsy‐proven monoclonal plasma cell infiltration of a single lesion is required for the diagnosis of solitary osseous plasmacytoma. Furthermore, there must be absence of end organ damage including hypercalcemia, renal dysfunction, and anemia. A single site of involvement without any additional lesions on imaging must be demonstrated. In addition, a diagnostic bone marrow biopsy must display <10% of monoclonal plasma cells. Lastly, immunohistochemistry staining should be performed to ascertain the presence of a monoclonal plasma cell population.In veterinary medicine, the diagnosis of solitary osseous plasmacytoma and extramedullary plasmacytoma requires tissue histology or cytology. In the case of poorly differentiated plasmacytic tumors, immunohistochemical studies, directed at detecting immunoglobulin, light and heavy chains, MM‐1/interferon regulatory factor‐4 (MUM1/IRF4), and thioflavin T, may help to differentiate from other round cell tumors. It is paramount to thoroughly stage patients with plasmacytomas which are at higher risk for systemic spread if local or loco‐regional therapy without systemic therapy is considered, especially in cases of solitary osseous plasmacytoma and gastrointestinal extramedullary plasmacytoma due to their relatively high metastatic rate. This should include bone marrow aspiration, serum electrophoresis, abdominal ultrasound scan, and skeletal survey radiographs to ensure the disease is confined to a local site prior to therapy initiation.In the treatment of solitary osseous plasmacytomas, RT is the mainstay of therapy in humans and is commonly prescribed in pets due to the achievement of good local tumor control; however, most solitary osseous plasmacytomas in humans may progress to multiple myeloma (MM).Advanced imaging techniques (such as MRI and CT) have greatly improved the diagnosis of intracranial tumors.Based on the imaging diagnosis, ascertaining whether the osseous lesions were a consequence of the left parietal cortex mass or vice versa was difficult. Calvarial erosion, sclerosis, lysis, and hyperostosis associated with meningiomas, carcinomas, and glial cell tumors in companion animals and humans have been reported.The lack of histopathological confirmation of the frontal sinus masses remains an intrinsic limitation of this case, although their close proximity on MRI to the left frontal/parietal bone lesion (with confirmed diagnosis) makes other differential diagnoses unlikely.Another limitation is the lack of definitive diagnosis of the right renal growth and the multiple pulmonary nodules. Their ultrasonographic and radiological appearance was suggestive of RCC and pulmonary metastasis. Most metastasis in a study of canine RCC was pulmonary.3Bone mass‐like lesions affecting the skull should raise the suspicion of solitary osseous plasmacytoma. Nevertheless, amyloid deposition should be considered as a possible differential diagnosis in cases of extra‐axial growths affecting the brain, when presented in conjunction with overlying skull mass‐like growths. Histopathological confirmation and thoroughly staging remain mandatory to reach a definitive diagnosis. To the authors' knowledge, this is the first description of a solitary osseous plasmacytoma with associated amyloid deposition affecting the skull of a dog.None declared.EA: contributed to the evaluation and management of the patient, collected information, and was the writer of the manuscript. DSM: contributed to the evaluation and management of the patient and reviewed the manuscript. ER: assessed the histopathology and reviewed the manuscript. FS: provided the magnetic resonance, produced the figures and their descriptions, and reviewed the manuscript. JM: contributed to the evaluation and management of the patient and reviewed the manuscript. RF: contributed to the evaluation and management of the patient and reviewed the manuscript.


Enthesitis, inflammation at the attachment sites of tendons, ligaments, fascia, and joint capsules to bones plays a critical role in the pathogenesis of spondyloarthritis (SpA), including psoriatic arthritis (PsA). Magnetic resonance imaging (MRI) has aided in a better understanding of pathophysiology, early diagnosis, prognostication, therapeutic outcomes, and follow up of enthesitis. The concept of enthesitis as a focal insertional pathology has transformed over the past decade, with the help of MRI, to a more widespread entity involving both bone and surrounding soft tissues. The utility of MRI in the differential diagnosis of suspected enthesitis has recently been explored. With the emergence of the treat-to-target concept, and a domain-based approach in the management of SpA, objective and sensitive monitoring of response to targeted therapy becomes prudent. Properties like high sensitivity, ability to image intra-osseous pathology along with surrounding structures exemplify the utility of MRI technology. Considering the lack of a comprehensive, validated MRI score the Outcome Measures in Rheumatology (OMERACT) MRI in Arthritis Working Group, informed by a systematic literature review, developed the first international, consensus-based MRI-scoring system, combined with MRI definitions of pathologies for enthesitis in patients with spondyloarthritis (SpA) and PsA. An atlas with representative images of each grade of the scoring system was subsequently developed by the group to aid readers interested in using the heel enthesitis MRI scoring system (HEMRIS). The HEMRIS can find utility in clinical trials targeting enthesitis as the primary outcome. MRI also finds value for global assessment of the total burden of enthesitis. The concept of whole-body MRI (WBMRI), enabling visualization of entheses throughout the body using a single image is relatively new. The MRI whole-body score for inflammation in peripheral joints and entheses (MRI-WIPE) is a promising scoring system, which is undergoing further testing in clinical trials and longitudinal cohorts evaluating global measures of inflammation at entheses. This review discusses the role of MRI in diagnosis and monitoring of enthesitis in SpA and PsA, along with recent advances in the field, based on published literature. The entheses are insertion sites of tendon, ligament, fascia, or joint capsule into bone. Enthesopathy refers to involvement of entheses due to trauma, degeneration, or in pathological conditions including metabolic syndrome, endocrine disorders, and inflammatory arthritis . InflammThe prevalence of enthesitis in SpA, including PsA from various studies has been reported to be 13.6–35%, with Achilles tendon, plantar fascia, and lateral epicondyle insertion being the most common sites . ClinicaBy providing sensitive visualization of the extent of disease, MRI and ultrasound (US) in patients with PsA have shown utility in diagnosis, prognostication, and monitoring of treatment response.  The EuroThis review aims at elucidating the role of magnetic resonance imaging (MRI) in better understanding of enthesitis in SpA, including PsA, highlighting the recent advances in this field.Based on their structure and location two types of entheses have been described – fibrous and fibrocartilaginous, with the latter being affected more commonly in SpA , 14. MRIThe importance of enthesitis in explaining the relationship between the nail and distal interphalangeal joint disease in PsA was studied by Tan et al. using high-resolution MRI and histology, comparing patients with osteoarthritis (OA) and PsA. The MRI inflammation observed over the entire nail bed region was shown to be anatomically associated with an enthesitis organ apparatus, providing a novel explanation for distal interphalangeal joint (DIP) arthritis in PsA patients with nail involvement . Yet anoGiven the avascular nature of the entheses at bony attachment sites and low density of vessels in the surrounding ligaments and tendons, diagnosis of enthesitis with imaging can be demanding . MRI hasAn MRI and power doppler ultrasound (PDUS) study at the heel region compared SpA patients with current heel pain and those with no pain or past history of heel pain. MRI lesions considered to depict early injury included Achilles tendon (tendonitis) or aponeurosis hypersignal, peri-tendon or peri-aponeurosis hypersignal, retrocalcaneal bursitis, inferior or posterior BME, and thickening of the tendon, and those depicting chronic injury included enthesophytes and bone erosions. MRI pathologies of enthesitis were noted in 81% of SpA patients with current heel pain, compared to 56% of SpA patients without heel pain or with history of heel pain. Intra- or peri-aponeurosis MRI signal abnormalities were the most useful features, while only BME in calcaneum was specific to distinguish patients with SpA from controls . A similHigh resolution MRI with specialized “microscopy coils” have been used for detecting enthesitis at insertions of flexor and extensor tendons to the phalanges. Tan et al. investigated the microanatomic basis for localization of hand disease at the DIP joints in patients with PsA and OA using a high-resolution MRI. More severe changes at the DIP joint entheseal insertions, and marked extracapsular enhancement were noted in patients with PsA as compared to those with OA . AnotherMRI is the imaging method of choice for diagnosing axial enthesitis. The revised definition of MRI enthesitis in sacroiliac joints of patients with SpA excludes the inter-osseous soft tissues in the ligamentary portion of the SI joint . Pelvic Conventional MRI methods generally allow assessment of only one or few selected areas of the human body. Enthesitis in SpA, especially PsA can be widespread, and capturing the extent of disease can be challenging using conventional MRIs . Whole-bMonitoring of disease progression and treatment response is dependent on the responsiveness of the applied measure. MRI has found utility in following up patients with SpA and PsA on treatment. Marzo-Ortega et al., determining the efficacy of etanercept on axial and peripheral entheseal lesions in patients with SpA using MRIs noted improvement or regression in 86% of MRI detected entheseal lesions between baseline and 6 months . A similKarpitschka et al. demonstrated significant reduction in enthesitis using WBMRI with gadolinium enhancement at week 52 in patients with active AS being treated with etanercept. MRI enthesitis lesions showed reduction during therapy by 94% at week 52 . In an iExistence of a pre-clinical phase in PsA characterized by nonspecific arthralgias, stiffness and fatigue has been established in a prospective cohort study . UltrasoThese studies, although with significant limitations did provide insight into the possibility of MRI enthesitis being the initial subclinical pathology in SpA. In a recent study Simon et al., scanning psoriasis patients without clinical arthritis from a longitudinal cohort have established the role of structural enthesitis at the 2nd and 3rd metacarpophalangeal joints of the dominant hand in prediction of PsA . AnotherWith the advent of treat-to-target strategies in SpA and domain specific treatment approach in PsA, a subset of future clinical trials with novel molecules are expected to focus on enthesitis as their primary outcome –62. InclImprovement in overall enthesitis in the body, as assessed by WBMRI, have been studied in few clinical trials. A randomized clinical trial compared etanercept and sulphasalazine on active bony inflammation in patients with early axSpA using WBMRI. Reduction of peripheral enthesitis on MRI was a secondary endpoint. The authors demonstrated a 58% reduction in MRI enthesitis in patients on etanercept at week 48, as compared to no reduction in the comparator arm . AnotherFor MRI assessment of enthesitis in clinical trials, it is recommended to apply validated assessment methods, such as the OMERACT MRI scoring systems , 41. MorActive enthesitis and arthritis in patients with enthesitis related arthritis (ERA) at baseline has been reported to predict sacroiliitis at follow up . EnthesiNotwithstanding all these benefits, MRI has certain limitations which curtails its application in routine clinical settings. Practical impediments for clinical practice like cost, referrals to specialist facilities, and some contraindications, such as claustrophobia, pacemakers, or certain metal implants, cannot be overlooked. The avascular nature and limited water accumulation in structures that make up the entheses contribute to technical difficulties, with MR signals often being low . A majorLimitations with WBMRI include the examination time, low resolution of images and attainable spatial resolution compared to conventional MRI , 75. TheFor use in clinical trials, however, MRI has the major advantage of allowing fully standardized image acquisition across all study sites, storage of the entire examination for later review and centralized reading. This makes MRI the ideal method for objective assessment of entheseal inflammation in future clinical trials.Expected advancements countering the technical shortcomings of MRI in imaging entheses have recently been reported. Diffusion-weighted imaging (DWI), known to have a high signal to noise ratio has been analyzed as an encouraging alternative to STIR and T2 weighted fat suppressed sequences for sacroiliac joint assessment –78. LecoThe OMERACT MRI in arthritis Working Group, informed by a systematic review has developed consensus-based definitions and reader rules for enthesitis in patients with SpA and PsA. Through a series of multi-reader scoring exercises focusing on the heel region using an intuitive web-based image platform and data entry the group developed the OMERACT heel enthesitis in MRI scoring system (HEMRIS). HEMRIS exhibited good reliability and responsiveness among trained readers . This waBox 1A. Core set of basic MRI sequences and imaging planesShort tau inversion recovery (STIR)/T2-weighted fat suppressed (T2wFS) images or, alternatively, gadolinium-enhanced T1-weighted fat suppressed imagesT1-weighted images without contrast injection (not mandatory if only inflammation is being assessed)MRI studies that intend to assess inflammatory and structural changes at entheses should include at least the following sequences:Achilles tendon—Sagittal and preferably also axialPlantar fascia—Sagittal and preferably also coronalSuggested imaging planes for the heel region:B. Definitions and grades of inflammatory and structural pathologies at the Achilles tendon insertion and the plantar fascia insertion to the calcaneum Definition¥.Signal characteristics consistent with increased water content/inflammation within the tendon/fascia, close to its insertionGrades0: No intratendon/intrafascia hypersignal. *1: Minimal intratendon/intrafascia hypersignal spots * (≤ 25% of the tendon volume).2: Moderate intratendon/intrafascia hypersignal * (>25% and ≤ 50% of the tendon volume).3: Severe intratendon/intrafascia hypersignal * (>50% of the tendon volume).¥ For Achilles tendon: From the tendon insertion up to 2 cm proximal to the posterosuperior corner of calcaneum on all the available images. For Plantar fascia: From the fascia insertion up to 2 cm proximal to the anterior margin of the plantar tuberosity on all the available images.2. Peritendon/perifascia hypersignal (STIR/T2FS)DefinitionSignal characteristics consistent with increased water content/inflammation in the soft tissues surrounding the tendon or fascia, close to its insertion.Grades0: No hypersignal. *† (or mild) focal hypersignal. *1: Minimal† hypersignal. *2: Moderate† hypersignal. *3: Severe†By comparison with reference images * For Achilles tendon: From tendon insertion up to 2 cm proximal to the posterosuperior corner of calcaneum. For Plantar fascia: From fascia insertion up to 2 cm proximal to the anterior margin of the plantar tuberosity on all the available images.3. Achilles tendon/plantar fascia calcaneal bone marrow edemaDefinitionBone marrow edema (BME) should be assessed in the bone from the entheseal insertion to a depth of 1 cm on all available images.Grades:The scale is 0-3, based on the proportion of bone with edema, compared to the “assessed bone volume”, judged on all available images:0: no edema.1: 1–33% of the bone is edematous (i.e. BME occupying 1–33% of the assessed bone volume).2: 34–66% of the bone is edematous.3: 67–100% of the bone is edematous.If the lesion is judged borderline, i.e., 1 vs. 2 or 2 vs. 3, lesion intensity may be considered. For example, if a lesion is borderline between 1 (mild) and 2 (moderate), it may be scored 1 (mild) if not judged intense. Similarly, if a lesion is borderline between 2 (moderate), and 3 (severe), it may be scored 3 (severe) if judged intense.4. Retrocalcaneal bursitis (only relevant at Achilles tendon insertion)DefinitionSignal characteristics consistent with increased water content/inflammation in an above-normal sized bursa.Grades0: No hypersignal or maximal diameter of hyper-signal in the shorter of two perpendicular dimensions to be <0.25 cm.1: Maximal diameter of hypersignal in the shorter of two perpendicular dimensions to be ≥0.25 cm to <0.5 cm.2: Maximal diameter of hypersignal in the shorter of two perpendicular dimensions to be 0.5 cm to <1.0 cm.3: Maximal diameter of hypersignal in the shorter of two perpendicular dimensions to be ≥1.0 cm.5. Tendon/fascia thickeningDefinitionAbnormal thickening of the tendon/fascia close to its insertion. *Grades0: None.† *1: Mild.† *2: Moderate.† *3: Severe.†By comparison with reference images * For Achilles tendon: Maximally 2 cm proximal from the postero-superior corner of calcaneum. For plantar fascia: Maximally 2 cm proximal to the anterior margin of the plantar tuberosity.6. Achilles tendon/plantar fascia calcaneal enthesophyteDefinitionAbnormal bone formation at the insertion of tendon/fascia into the boneGrades0: None.†1: Small.†2: Medium-sized.†3: Large.†By comparison with reference images 7. Achilles tendon/plantar fascia calcaneal bone erosionDefinitionA sharply marginated bone lesion, with typical signal characteristics and a visible cortical break, located close to the tendon/fascia insertion.Grades0: None.1: Small.2: Medium-sized.3: Large.By comparison with reference images New and potentially better MRI sequences have been described in SpA, but they need validation in longitudinal studies and clinical trials, applying novel and established MRI enthesitis measures in the same studies, to document validity and additional value as outcome measures. Also, their utility in assessing axial and peripheral entheses, and differentiating inflammatory from degenerative and other causes of enthesitis needs to be appraised in larger number of patients. The UTE sequence in high resolution MRI may help in better understanding of pathogenesis of different forms of enthesitis. There seems to be a window of opportunity in patients with SpA and PsA wherein early diagnosis and prompt initiation of therapy will be key in curtailing long-term damage . The utiThe recently developed MRI enthesitis indices should be further tested in clinical trials. Refinements may further improve their utility. Development of detailed MRI scoring systems for other regions than the heel may be relevant, even though it seems likely that clinical trials aiming to document the effect of a new drug on enthesitis will choose either a detailed evaluation of the most common region, like the heel, or an overall measure of enthesitis in the entire body, by WBMRI. Image resolution in WBMRI needs further enhancement for better visualization of peripheral entheses. The OMERACT MRI in arthritis Working Group is currently endeavoring on a modular approach in WBMRI to assess the overall inflammation burden at individual sites, thus further validating the WIPE-MRI scoring system. Based on the definitions laid out by the Working Group scoring systems for other regions need to be developed.In the transition phase toward the development of PsA, a subclinical phase with soluble biomarkers and imaging findings but no clinical sign is well recognized . LongituEffect of treatment strategies to impede the development of PsA in psoriasis patients at risk may also be estimated. In the Interception in very early PsA (IVEPSA) study, MRI was used to assess inflammatory and structural changes in the joints at baseline and 24 weeks following secukinumab therapy . Most ofMRI has aided in understanding the pathogenesis, assessment of inflammatory and structural pathologies, monitoring, and prognostication of enthesitis in patients with SpA, including PsA. There is robust evidence for MRI as an adjunct to clinical examination in the assessment and follow up of enthesitis. Having a sound knowledge of its strengths and weaknesses, as compared to other imaging modalities, will facilitate optimal application of MRI in clinical trials, longitudinal studies and clinical practice.All the figures in this manuscript are unpublished, and original. These figures are based on the “MRI definitions of key entheseal pathologies” as described by the OMERACT MRI in arthritis Working Group in Table 1 of Mathew et al. .AM prepared the first draft of the manuscript, and MØ critically reviewed and modified the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Testicular microlithiasis (TM) is a condition in which punctate calcifications are present in the testicle. A case of a 29-year-old Saudi male who developed a cough, hemoptysis, and shortness of breath is presented in this report. A computed tomography (CT) scan of the chest revealed a large mediastinal mass. CT scans of the abdomen and pelvis were normal. Testicular ultrasonography (US) showed multiple, bilateral punctate echoes that are characteristic of TM. No primary testicular tumor was detected. Transthoracic needle biopsy of the mediastinal tumor was consistent with a mixed germ cell tumor. This is the seventh case of extragonadal germ cell tumor with TM. Testicular microlithiasis (TM) is an entity of unknown etiology that is characterized by the presence of intratubular calcifications . The prePatient information and clinical findingsIn March 2020, a 29-year-old male presented to the emergency department complaining of neck pain, cough, hemoptysis, and shortness of breath. He had no significant medical history and was not taking any medications. His family history was unremarkable. He was single and sexually inactive. Local testicular examination was unremarkable.Diagnostic assessment: A computed tomography (CT) of the chest demonstrated a large soft tissue mass in the anterior mediastinum Figure .Computed tomography (CT) results for the abdomen and pelvis were normal. Scrotal US showed bilateral diffuse testicular microcalcification (Grade IV microlithiasis) without a focal lesion Figure .The serum lactate dehydrogenase (LDH) level was 512 U/L , β-human chorionic gonadotrophin (β-HCG) level was 52.51 , and α-fetoprotein (AFP) was 2479.34 IU/ml . Other laboratory results, including hepatic and renal panels, were within normal limits. Transthoracic needle biopsy of the mediastinal tumor showed a mixed germ cell tumor. The diagnosis was enhanced by immunohistochemistry: focal positivity for placental alkaline phosphatase (PLAP), negative for neuron-specific enolase (NSE). Semen analysis showed complete asthenozoospermia, oligospermia, and hypospermia . Our diagnosis was primary mediastinal nonseminoma germ cell tumor (poor risk) with TM.Therapeutic interventionThe standard chemotherapy regimen for poor-risk disease is four cycles of bleomycin, etoposide and cisplatin (BEP). Alternatively, four cycles of etoposide, ifosfamide, and cisplatin (VIP) can be used to treat patients who may not tolerate bleomycin. Both regimens are category 1 recommendations  guidelines, version 1.2021). The patient was treated with four cycles of chemotherapy consisting of VIP.Follow up and outcomesAlthough tumor markers following chemotherapy returned to normal, CT revealed a residual mediastinal mass with the appearance of two new lung lesions Figure .The patient was then referred to a different oncology center for additional cycles of chemotherapy giving that consultation with a high-volume center should be considered for the management of such a patient.TM is an uncommon condition in which microcalcifications are present in the seminiferous tubules . These mTM can be associated with cryptorchidism, Klinefelter and Down syndromes, varicocele, testicular torsion, and male pseudohermaphroditism ,5. The cIn conclusion, the author has reported a rare case, which should elicit discussion on how to screen and treat such patients with extragonadal germ cell tumors and TM. Testicular US follow-up and CT scan of chest and abdomen with serum tumor markers might be considered in patients with incidental findings of TM.


Colorectal cancer (CRC) is the most common tumor type in both sexes combined in Western countries. Although screening programs, including the implementation of fecal occult blood test and colonoscopy, might reduce mortality by removing precursor lesions and making the diagnosis at an earlier stage. Unfortunately, ~25% to 40% will develop a tumor recurrence despite a curative operation. It is well-known that most recurrences occur within five years. There are a lot of solid guidelines for recurrence surveillance. We present a case of colon adenocarcinoma that underwent surgical resection of the descending colon with close recurrence surveillance follow-ups that showed normal carcinoembryonic antigen (CEA) for 12 years and then presented again with blood in stool and was found to have recurrent colon adenocarcinoma. About 140,000 people in the United States are diagnosed annually with colorectal cancer . The optA 70-year-old female with a past medical history of hypertension, hyperlipidemia, and moderately differentiated colon adenocarcinoma status post resection of the descending colon in 2006 and close follow-up with guideline-directed recurrence surveillance, including her last colonoscopy in February 2019 that was unremarkable, presented with complaints of weight loss and fatigue but no abdominal pain, nausea, vomiting, or change in bowel habits. Vital signs showed blood pressure 116/70 mmHg, respiratory rate 14 breath/minute, heart rate 74 beats/minute, and a temperature of 98.1 degrees Fahrenheit. The general physical examination was remarkable for pale conjunctivae. Abdominal examination revealed a soft abdomen with normal bowel sounds and no tenderness, guarding palpable masses, or organomegaly. Laboratory findings were remarkable for anemia, low ferritin, and elevated carcinoembryonic antigen (CEA)  scan of the chest, abdomen, and pelvis revealed omental masses with the largest measuring 2.36 x 2.61 cm . After the one-year colonoscopy, the interval to the next colonoscopy should be three years  and then five years. Subsequent colonoscopies should occur at five-year intervals -15. SurvCEA measurement and imaging studies were able to guide the diagnosis of colon cancer recurrence after 12 years of remission when colonoscopy didn't indicate that. Some patients might benefit from prolonged surveillance by extending CEA measurement and imaging studies. Further studies would be needed to identify those who might be considered a higher risk for late recurrence.


Fibromatoses or desmoid tumors are relatively rare tumors derived from the musculoaponeurotic system. This tumor has no specific clinical symptoms and it is sometimes misdiagnosed as other diseases such as gastrointestinal stromal tumors (GISTs).A 28-year-old man visited Peking Union Medical College for a tangible abdominal mass without abdominal pain or distention.Considering the imaging characteristics and clinical manifestation, this mass was primarily diagnosed as GIST before surgery. During the surgery, the occupancy was found under the ileocecal mesentery, with grayish white appearance, tough texture, and poor mobility, which was not consistent with the character of the GIST. After the surgery, pathological examination and individual immunohistochemistry results demonstrated that the lesion was compatible with the diagnosis of retroperitoneal fibromatosis with purulent inflammation of chronic lymphadenitis.Therefore, we decided to perform tumor mass resection, right colon resection, partial duodenum resection, and intestinal anastomosis on laparotomy, but the right ureter was retained. After excision of the tumor, the ends of the intestine segment were continuously sutured.The patient experienced no intraoperative or postoperative complications, and was discharged 3 days after surgery. Periodic follow-up physical examinations such as the abdominal ultrasound and computed tomography were performed each 3 months, and no evidence of recurrence was observed during the whole 12 months.To sum up, intra-abdominal fibromatosis is an extremely rare tumor that must be differentiated from other tumors of the digestive tract, and pathological and immunohistochemical examination is a critical part of the diagnosis. Early diagnosis of fibromatosis is essential for the outcome. Extensive resection of the mass minimizes the risk of relapse. Because these tumors are usually asymptomatic, there are no clear guidelines for treatment. The intestinal mesentery is usually the origin of intra-abdominal fibromas, but rare fibromas locate in abdominal ligands and the colon. Surgical resection with a wide margin is the preferred selection of treatment in most cases. For tumors that may relapse or are unable to be resected, medical therapy is recommended.Intra-abdominal fibromatosis is a rare tumor that accounts for approximately 0.03% of all neoplasms. This tumor is relatively benign as it may invade local tissue but hardly metastasize distantly.We herein report a case of duodenum-derived fibromatosis presenting as an abdominal mass, which was preoperatively considered to be a gastrointestinal stromal tumor with no particular symptom or trauma history.2A 28-year-old young male suffered from a tangible abdominal mass in the right middle abdomen and was referred to Peking Union Medical College Hospital. Physical examination revealed a palpable mass on the right side of umbilical cord with no tenderness.Abdominal enhancement computed tomography (CT) revealed Fig. A and B aOn laparotomy, 7.1 cm × 7.6 cm sized round tumor located under the ileocecal mesentery, with grayish white appearance, tough texture, and poor mobility was found. The base of the tumor was closely connected to the right ureter in the retroperitoneum and was adhered to the small intestine and ileocecal mesenteric region in the abdominal cavity, which was extremely difficult for separation and resection Fig. . Then tuGross pathology revealed that the tumor invaded the whole small intestinal and ascending colonic wall Fig. A and B. The patient underwent periodic follow-up physical examinations, in which the abdominal ultrasound and CT were performed each 3 months, and no evidence of recurrence was observed during the whole 12 months.3 Although there is no specific etiology, some risk factors are known to be associated with this tumor, including trauma, surgery, pregnancy, use of contraceptives, genetic mutation, family history of desmoid tumor, familial adenomatous polyposis, and Gardner syndrome. The involved scope of fibromatosis ranges from the gastrointestinal tract to the liver, and retroperitoneum. As for pathological features, spindle cells are common in desmoid tumor. For immunohistochemical features, vimentin and β-catenin are positive, whereas SMA  is immunonegative. But retroperitoneum-derived fibromatosis with immunopositive SMA and S100 that almost infiltrated the whole intestinal wall is rather rare.Fibromatoses or desmoid tumors are relatively rare tumors derived from the musculoaponeurotic structures. were determined by its size and surrounding anatomical structures. But in our case, although the large-sized mass involved the ureter and bowel, there were no intestinal obstruction or hydronephrosis in this patient, perhaps related to its retroperitoneum origin rather than from ureter and intestine.The main clinical manifestation of desmoid tumors, such as vomiting, abdominal distension, difficulty in defecation due to intestinal obstruction, and hydronephrosis coursed by ureteral involvement, Retroperitoneal fibrosis frequently presents as a mass involving small bowel mesentery, so it is extremely difficult to distinguish it from inflammatory lesions, mesenteritis, and several benign gastrointestinal tumors. The presurgical diagnosis of intra-abdominal fibromatosis depends mainly on imaging. On ultrasound, fibromatosis showed variable echogenicity with a smooth, clear border. On CT, this tumor usually presents as a slightly lower density with uneven enhancement. Therefore, the appearance of intra-abdominal fibromatosis on a CT scan is untypical. However, pathology is still the gold standard to provide a concrete diagnosis of intra-abdominal fibromatosis. Under microscopy, spindle cells arranged in bundles, surrounded by large amounts of collagen, could be seen. Immunohistological examination always indicates the positive expression of vimentin and SMA.As above, in about 30% of patients, fibromatoses are asymptomatic until it could be found in a regular clinical examination. For relapsed and unresectable tumor, anti-hormone therapy, nonsteroidal anti-inflammatory drugs, and other drugs can be used. The patient presented in this study has a high risk of recurrence because the tumor was much larger than 50 mm in diameter, so the strict follow-up of this patient should be ensured in the next 5 years.Treatments include surgical resection, radiation therapy, or a combination of both. Although in this case, the tumor has local invasive growth, its outer membrane makes it possible to determine the effect of intraoperative scar or the surrounding tissue and achieved R0 resection. However, it still has a strong tendency to local recurrence, so routine postoperative adjuvant radiotherapy is necessary.4It is usually incidental and challenging to diagnose fibromatosis especially in the case with no clinical symptoms. The retroperitoneum-originated fibromatosis invaded the ileocecal mesothelium and ureter was positive for S100 protein, which is very rare. This study provided some suggestions for diagnosis and treatment of anonymous abdominal mass, exploratory laparotomy is necessary in several cases, and pathological and immunohistochemical examination is the key to diagnosis. Early diagnosis of fibromatosis is essential for the outcome. Extensive resection of the mass can minimize the risk of relapse according to the existing literature.Postoperative pathological examination confirmed that it was a fibromatosis. The operative decision was correct and the effect was satisfactory. No complications occurred during postoperative follow-up.The authors would like to appreciate the patient who consented to disclose their medical records and answered our review calls.QQ conceived the idea of the study; XJ collected the information; ZW and XJ interpreted the results and wrote the paper.Conceptualization: Qiang Qu.Data curation: Wenzhe Zhou.Resources: Jianchun Xiao.Writing – original draft: Wenzhe Zhou.Writing – review & editing: Wenzhe Zhou and Jianchun Xiao.


Primary enteroliths as a result of pelvic radiotherapy are a rare cause of intestinal obstruction. Primary enteroliths as a result of pelvic radiotherapy are a rare cause of intestinal obstruction High clinical suspicion and radiological confirmation aid establishing the diagnosis.A 73‐year old Caucasian female patient presented to our acute surgical take with features of gastrointestinal obstruction, comprising of abdominal distension, vomiting, and sharp pain localized in the pelvic region. Her past medical history comprised of a course of radiotherapy for early cervical cancer, approximately 10 years prior, with the patient being cleared from subsequent oncology follow‐up due to complete response. The patient mentioned complete inability to tolerate oral intake and described previous similar episodes of intermittent intestinal obstruction over the previous year. Clinical examination revealed a moderately distended but soft abdomen, with tenderness in deep palpation in the whole of lower abdomen; no obvious external hernia was identified. Provisional diagnosis was that of intestinal obstruction either due to congenital adhesions or radiation enteritis causing intestinal stricture and hence an urgent abdominopelvic computed tomography (CT) scan with intravenous contrast was performed for further assessment. The performed CT scan revealed the presence of dilated small bowel loops and identified a transition point in the lower abdomen, with a concurrent intraluminal filling defect at the site of small bowel caliber change (Figure Our case is one of the very few in the literature describing acute gastrointestinal obstruction from a primary enterolith as a delayed complication of small bowel radiation‐induced enteritis.The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.CS and LA: contributed to the clinical data collection and prepared the case report; MAE and DG: contributed to the design of the case report presentation; AP and KZ: performed the final revision of the manuscript.Informed consent was obtained from the patient and is available upon request by the editorial office; no ethical committee approval was required for the publication of this case report.