Ureteral endometriosis is a very rare but serious form of infiltrating endometriosis since the risk of urinary tract obstruction and secondary loss of renal function exists. Although not always possible, the clinical and radiologic assessment may help in obtaining a preoperative diagnosis.We report the case of a 42-year-old woman with left ureteral endometriosis, revealed by left flank pain. Imaging revealed left obstructive uropathy with an endometriotic cyst of the left ovary and a spiculated lesion of the left parametrium. She underwent laparotomy, resection of the diseased ureter with primary re-anastomosis, resection of a left parametrial lesion and an endometriotic left ovarian cystectomy. The pathological assessment confirmed the diagnosis of ureteral endometriosis. Follow-up of the patient showed complete resolution with a stable, normal kidney function.In conclusion, ureteral endometriosis involvement is infrequent but should be included in the differential diagnosis in a premenopausal woman with ureteral obstruction of unknown cause. An early diagnosis and obstruction relief are critical to a successful outcome. Endometriosis is defined by the ectopic presence of functional endometrial glands and/or stroma outside the uterus . Many thThis later form is defined by the presence of endometrial implants penetrating at a level greater than 5mm, beneath the peritoneal surface. This form of endometriosis can involve the uterosacral ligaments, the rectovaginal space, and intraperitoneal organs such as the bowel and urinary tract . In termWe report the case of a 42-year-old woman with left ureteral endometriosis, revealed by left flank pain. Imaging revealed left obstructive uropathy with an endometriotic cyst of the left ovary and a spiculated lesion of the left parametrium. She underwent laparotomy, resection of the diseased ureter with primary re-anastomosis, resection of a left parametrial lesion and an endometriotic left ovarian cystectomy.A 42-year-old primi-parous patient presented with a one-month history of progressively worsening non-cyclical left flank pain. The patient had no significant past medical history. She reported no abnormal vaginal discharge or bleeding and no urinary symptoms. Clinical examination revealed left flank and pelvic tenderness. A left pelvic mass was also found during a vaginal examination. No other significant findings were present.The complete blood count was normal. The kidney function was normal. Urinary tract ultrasound revealed an important left moderate hydronephrosis reaching 15cm in greatest diameter with identification of a heterogenous lesion of the left ureter measuring less than 1cm, next to a ureterovesical junction (UVJ). Ultrasound could also identify the presence of a 5cm left ovarian cystic lesion, suggestive of an endometriotic cyst.Abdominal pelvic Magnetic resonance imaging (MRI) was performed on our patient, in T2 FAT SAT (Fat Saturation) and T1 FSE (Fat Spin Echo) sequences, revealing the presence of left ureteral stenosis in communication with a spiculated lesion of the left parametrium. MRI also identified the presence of a left hematosalpinx and confirmed the endometriotic nature of the left ovarian cyst , with the urinary bladder being the first one with ratios of 40:5:1:1 for Bladder/ureter/kidney and urethra respectively [On the pathological level, ureteral endometriosis can be intrinsic when endometrial tissue is in the lamina propria or tunica muscularis of the ureter or extrinsic when endometrial tissue is present in the peri-ureteral tissue . Until nA hereditary component should also be present since endometriosis is increased in first-degree relatives of women with this disease . The repThis diagnosis could be suggested preoperatively in only 40% of patients, as shown in one study . In our Imaging can play a great role in preoperative diagnosis. Renal ultrasound can identify urinary tract obstruction and may also, as in our case, identify the presence of a ureteral lesion . CT scanMRI has since its apparition replaced Intravenous pyelography (IVP) and retrograde pyelography and remains as the best diagnostic tool to assess the disease extension and plan an adequate surgical approach. Sillou et al. in 2015 demonstrated that MRI has a sensitivity as high as 91%, but with a much lower specificity of 59% .The management of cases of ureteral endometriosis is different from one patient to another. Medical treatment can be indicated in early-stage disease but presents an incomplete response and high rates of relapse after cessation of hormonal therapy . MedicalThe surgical treatment of intrinsic ureteral endometriosis is based on resection and reconstruction of the ureter, with two existing techniques: Ureteral-ureteral anastomosis, indicated in cases of limited disease with a potentially preservable ureter . This teSurgical techniques also include nephrectomy, indicated in cases of renal function loss, which should be confirmed by renal scintigraphy that enables estimation of the residual renal function, or in cases where diagnosis surgery seems to be necessary because of malignancy suspicion. As for our case, who presented with a synchronous left ovarian endometriotic cyts, up to 90% of women with ureteral endometriosis had endometriosis in other sites, as demonstrated in a study by Seraccholi et al. . On the Ureteral endometriosis is a rare and challenging diagnosis because of the nonspecific nature of reported symptoms. Radiology, especially MRI and cystoscopy are the gold standard diagnostic tools for a preoperative diagnosis. Surgery remains the best therapeutic option, with existence of medical hormonal therapy, but with less promising results. A greater awareness is needed for early diagnosis and management since they are both key to better outcomes.


An ectopic ureter is a ureter that does not correctly connect to the trigone of the bladder and drains outside of the bladder. Here, we presented five cases of ectopic ureter opening into the vagina, whose clinical symptoms and malformations were rarely described in previous case reports. All five patients were hospitalized with complaints of gynecologic disease. Three of the five cases did not present the typical symptoms of urinary incontinence. Three of these cases showed congenital malformations of the female genital tract. Four cases were diagnosed in adulthood. All patients were analyzed using various imaging examinations. This study suggests that the ectopic ureter should be considered in the differential diagnosis of a pelvic mass in a patient with urinary and reproductive system abnormalities. It is essential to comprehensively evaluate complex malformations of the genitourinary system with multiple imaging tests. An ectopic ureter is a ureter that terminates outside the trigone of the bladder . The oveIn the case of an ectopic ureter combined with an atrophic kidney, it is challenging to diagnose depending on a single imaging examination due to the small-sized and dysfunctional kidney. Various imaging tests, including magnetic resonance imaging (MRI), computed tomography (CT), and urography, are applied to demonstrate the malformations. However, the detection rate and diagnostic value of each imaging test are still uncertain ,5,7. GeoA 46-year-old woman was admitted to the department of gynecology, reporting dysmenorrhea for 33 years and heavy menstrual bleeding with dizziness for 2 years. She attained menarche at the age of 13 and had severe dysmenorrhea, which impacted her quality of life. The menstrual cycle was 27–33 days, with menses lasting 12 days. The menstrual volume in the last two years doubled. Since then, she also experienced dizziness and fatigue during her periods and was diagnosed with anemia. Between the ages of 15 and 22, she had persistent spotting or moisture within her underwear, but did not require menstrual pads.Her medical history revealed that in 1999 and 2002, she delivered two children through cesarean section and then underwent tubal ligation. She had a hysteroscopy and laparoscopy in 2005 to treat a uterine malformation and an ovarian endometrioma, respectively. She consistently took antihypertensive medications and had a 10-year history of hypertension. A gynecological examination showed that the uterus was slightly enlarged, and a small hole, approximately 0.5 cm in diameter, was seen at the nine o’clock direction of the cervix.A three-dimensional transvaginal ultrasound revealed adenomyosis and a septate uterus . Two cysThe patient had severe dysmenorrhea due to adenomyosis and heavy menstrual bleeding, which led to anemia and negatively impacted her quality of life. Therefore, the patient asked for a hysterectomy. Following a multidisciplinary team conference, it was decided to perform an abdominal hysterectomy on this patient. During the hysterectomy, a 3 cm long oblique vaginal septum was found between the right vaginal fornix and the right vaginal wall and removed. Consequently, the 0.5 cm opening next to the cervix found during the gynecological examination was proved to be a hole in this oblique vaginal septum. After this septum was removed, a 1 cm in diameter ectopic ureteral opening was found in the right vaginal wall adjacent to the right vaginal fornix. The yellow fluid was observed inside the ectopic ureter with the same characteristics as shown in A 14-year-old girl was admitted to the department of gynecology due to monthly cyclic pelvic pain. A pelvic examination showed an imperforate hymen. A rectoabdominal examination showed a cyst 10 cm in diameter palpated in the pelvis. Additionally, the bottom edge of the cyst was located 1 cm away from the vaginal opening. The needle aspiration fluid through the hymen revealed values of 5213.2 μmol/L for creatinine and 39.63 mmol/L for urea. An abdominal MRI revealed a left pelvic cystic mass, left hematosalpinx, and left kidney atrophy . The pelA 37-year-old woman was referred to our hospital for persistent vaginal discharge. After she underwent vaginal cyst excision 11 years ago, she began to experience persistent vaginal discharge, requiring two sanitary pads daily. A pelvic examination revealed a pinpoint-like hole in the right anterior wall of the vaginal fornix. It was observed that clear fluid was leaking from the hole, and a 3-centimetre in diameter cystic mass was palpated nearby. An MRU demonstrated that the duplicated renal pelvis was located at the upper pole of the right kidney. The left kidney and ureter were normal A. An MRUA 29-year-old woman was admitted to the hospital with complaints of urine incontinence since childhood and an ovarian cyst for three years. A urinary tract ultrasound demonstrated a right duplex kidney with an ectopic ureter and left kidney agenesis A. A CTU A woman of 33 years old was advised to undergo a hysteroscopy before receiving assisted reproductive technologies. She received a hysteroscopic uterine septum resection at age 27. Her right fallopian tube was removed due to two ectopic pregnancies. A pelvic examination showed an oblique septum extending 3 cm from the left fornix of the vagina to the hymen border. The pelvic ultrasound demonstrated an ectopic ureter or ureterovaginal fistula . An MRI A summary of the clinical characteristics of each case is shown in In this study, all five cases were admitted to hospital for gynecological-related complaints. The diagnosis of the ectopic ureter was easily missed due to its rare incidence. Urinary incontinence, manifested as persistent wetness of the underwear or urine leakage, was a common symptom of an ectopic ureter with vaginal insertion in women . Case 3 The diagnostic tests for ectopic ureter were diverse, including ultrasound, CT, MRI, and urography. The diagnostic sensitivity and specificity of each imaging test for ectopic ureter are currently uncertain. In previous case reports, ectopic ureter was diagnosed through an MRU , CTU 2,,2,11, orIn the case of a highly suspected ectopic ureter, it was helpful that transvaginal aspiration could be applied to measure the creatinine value of the fluid inside the pelvic cyst near the vaginal wall. In both Cases 1 and 2, the elevated creatinine value of the fluid within the cystic mass indicated the presence of urine within the cyst.Previous studies reported varying geographical rates of ectopic ureters in dual  and singThe surgical treatment strategy for ectopic ureter is based on the urinary system’s function ,14. In CThe developmental disorders of the urinary system throughout embryogenesis contribute to the ectopic ureter mechanisms . AlthougThis study reported rare cases diagnosed with ectopic ureter insertion in the vagina. The differential diagnosis of ectopic ureters ought to be considered when a pelvic mass of unknown origin is detected in patients with malformations of the urinary and reproductive systems. This study suggested that a combination of multiple imaging tests ought to be applied to diagnose ectopic ureter. A multidisciplinary team consisting of urologists, obstetricians, and radiologists is necessary to diagnose patients with complex malformations and symptoms. Clinical symptoms, including urinary incontinence, urinary tract infections, and ipsilateral renal function, play an essential role in the surgical strategy for treating ectopic ureter.


Hyperplasias are the most frequent exophytic lesions in the mouth, which develop mainly as a consequence of mucosal tissue irritation by several types of trauma. Injured tissues respond with proliferation of fibroblasts followed by collagen fibrinogenesisFibroepithelial hyperplasia (FH) is the most common non-malignant soft tissue tumor in the mouth; its prevalence is similar in both sexes and there is no racial preferenceThe treatment is surgical excision and elimination of local irritative factors. The purpose of this study was to describe a surgical technique for removing oral FH and preserving Stenon's duct.A male patient aged 36 years presented with an enlarged mass in the right jugal mucosa. The tumor had developed over about 13 years; it was painless at first, but the patient had started to feel pain when applying pressure over the nodule or during chewing.Examination of the mouth showed a hyperplasic pediculated fibrous pinkish smooth surfaced tumor measuring about 2.0 × 1.8 cm, located on the right jugal mucosa close to the exit site of Stenon's duct . BecauseThe treatment consisted of catheterizing the parotid duct with a Jelco number 20 catheter , followeHistology revealed dense fibrous connective tissue with fusiform fibroblasts dispersed within a mature collagen matrix. There were many congested vascular spaces and mild chronic inflammation. The tumor was lined with hyperplasic epithelial squamous tissue .The catheter was kept in place for seven days to activate salivary drainage; there were no postoperative complications or recurrences in the first year of follow-up.Lewkowicz at al.Parotid duct injury may result in sialoceles, cutaneous fistulae, or salivary duct cysts. The most common causes of duct injury are trauma by cutting, pointed, and blunt objects, as well as surgical traumaSeveral treatment approaches have been described in the literature; the choice depends on the duration of injury, the site of the gland, the mechanism of trauma, and the surgeon's experience. Ideally parotid duct injury should be treated as soon as possible; in some cases (significant loss of tissues or polytraumatized patients) a delayed procedure may be done intentionallyConservative approaches are repeated percutaneous needle aspiration, compressive dressings, and antisialagogue medication. A few authors also recommend parenteral nutrition to reduce autonomous salivary stimulation of the parotidA more aggressive approach is needed if these measures are unsuccessful. These maneuvers include placing tubes in the site to create a new salivary duct path, radiotherapy, partial or total parotidectomy, tympanic neurectomy, and othersIn the present case, after the duct was located and the tumor was removed, the anterior portion of the Jelco catheter was left in place during a week to facilitate salivary drainage and to avoid the sublingual caruncule closure and duct stenosis during the healing process.The treatment for FH is surgery, taking care to remove the entire tumor and to avoid irritative factors to prevent recurrenceFH is one of the most common tumors in the mouth; it deserves attention when treated, as an adequate surgical technique is essential to avoid recurrences. Adjacent anatomical structures should be preserved as much as possible to avoid injury and future complications.


Rhinolithiasis is a disease caused by deposition of organic and inorganic compounds in the nasal cavity, leading to unilateral nasal obstruction, fetid rhinorrhea, epistaxis, and it may cause complications. The authors present a case of rhinolithiasis with oronasal fistula and literature review. Rhinolithiasis is an uncommon disease that may present asymptomatically, characterized by presence of mineralized tumor in the nasal cavity, which may be large and deviate neighboring structuresThe presence of deviation and nasal septum perforation, destruction of nasal cavity lateral wall, involvement of maxillary sinus and production of oroantral or oronasal fistula are rare complications.We report one case of rhinolithiasis with presence of oronasal fistula and present literature review on the condition.Female 43-year-old patient, Caucasian, single, housewife, born in Jacaúna-CE, living in Sao Paulo-SP, complained of left nasal obstruction for 11 years. She was seen in the outpatient clinic of Otorhinolaryngology, Hospital Sao Paulo, Federal University of Sao Paulo – Escola Paulista de Medicina.She reported progressive nasal obstruction, only on the left nasal fossa, intermittent, that progressed to continuous obstruction, with anterior and posterior purulent discharge and cacosmia.Six months before she had had perforation of hard palate, with drainage of nasal secretion into the oral cavity and regurgitation of liquids into the left nasal cavity. She did not report pain, nasal bleeding, headache, fever, loss of weight or allergic symptoms.She reported that at the age of 2 years she introduced a bean seed into the left nostril, which was “removed the next day”, and she had remained without complaints up to the current presentation.Rhinoscopy showed presence of purulent secretion and irregular surface tumor, which was gray and recovered by granulation tissue, stone-hard upon touch with scalpel, immovable, obstructing the left nasal fossa and affecting the floor, nasal septum, inferior and middle conchae, with nasal septum deviation to the right. The examination revealed extremely fetid odor from the nose.Oroscopy presented perforation in the left anterior region of hard palate, measuring 3 × 2 mm in diameter, with irregular margins, and drainage of purulent secretion into the oral cavity .Figure 1Paranasal sinuses CT scan revealed bone density tumor occupying the left nasal fossa .Figure 2It was not possible to perform nasofibroscopy because the tumor did not allow the passage of the instrument through the left nasal fossa.Actinomices sp. It was necessary to fragment the rhinolith so that it could be removed, owing to its extremely irregular shape and extension , or endogenous, resulting from dry secretion, clots, cell lysis products, mucosa necrosis and tooth fragments, which operate as foreign bodyForeign bodies normally access the site anteriorly, but they may occasionally reach into the nasal cavity through the choana owing to cough or vomitingForeign bodies are normally introduced during childhood, occupying the nasal floor in most situationsSymptoms are normally progressive unilateral nasal obstruction, rhinorrhea , cacosmia and epistaxis. Other less common symptoms are headache, facial pain and epiphoraThere may be complications such as nasal septum perforation or deviation, oroantral and oronasal fistula, chronic sinusitis and destruction of lateral nasal wall.The physical examination showed gray and dark mass, with stone-hard consistency and irregular surface.Diagnosis is normally based on symptomatology, history of foreign body introduction into the nose, physical examination and complementary tests. Simple x-ray and paranasal sinuses CT scan support the diagnosis through the presence of calcified tumor in the nasal fossa, in addition to supporting the planning of surgical approachDiagnosis may be made through routine examination or revealed by imaging exam conducted by other reasons, such as for example a dental treatmentDifferential diagnosis should take into account benign tumors (osteomas), bone sequestration and malignant tumors Treatment consists of removal of rhinolith and the surgical approach chosen depends on location and size of the rhinolith and presence or not of complications, but most of them may be removed endonasally. External approaches may be necessary in cases of giant rhinoliths, and endoscopes are extremely helpful in both approachesTreatment of complications can be performed in the same or in another surgical actIn the case of oronasal fistulas, there is a tendency in the literature to leave the correction to second intervention, which should be performed by rotation of palate and nasal flap, promoting two-layer closingRhinolithiasis is an uncommon disease that may be left undiagnosed for many years and present complications. The diagnosis is normally made by clinical history and physical examination, and it should be considered in cases of unilateral nasal obstruction. Treatment consists of removing the rhinolith and correcting occasional complications.


In this study, the clinical and diagnostic findings of a well-encapsulated para-ureteral urinoma associated with urinary-tract stones in a critical feline patient are reported. Due to the worsening of the cat’s health, to better define the extent and genesis of the lesion, a positive contrast radiographic study was performed by means of an ultrasound-guided percutaneous injection of a contrast medium into the lesion, which highlighted a wide and homogeneous radiopaque area in the left retroperitoneal space. These findings were confirmed with a postmortem examination, corroborating the diagnostic suspicion of urinoma.Urinoma is an encapsulated collection of urine due to a disruption in the collection system of the urinary tract. This condition is rarely reported in veterinary medicine. The aim of this study is to describe the clinical and diagnostic findings of a well-encapsulated paraureteral urinoma associated with urinary tract stones in a critical feline patient. The ultrasound examination of the abdomen revealed a well-defined collection of anechoic fluid containing the left kidney in the retroperitoneal space, while the radiographic examination revealed a loss of soft tissue contrast in the lumbar region. Both techniques confirmed the presence of stones in the bladder. Following the ultrasound-guided drainage of the lesion, the nature of the fluid was also confirmed to be urine. Due to the worsening of the cat’s health, to better define the extent and genesis of the lesion, a positive contrast radiographic study was performed by means of an ultrasound-guided percutaneous injection of a contrast medium into the lesion, which highlighted a wide and homogeneous radiopaque area in the left retroperitoneal space. These findings were confirmed with a postmortem examination, corroborating the diagnostic suspicion of urinoma. The percutaneous contrast inoculation performed in this critically ill patient plays a role in the diagnostic process to reach a final diagnosis in cases in which the patient’s clinical condition does not allow for performing an excretory positive contrast study. Urinoma or uriniferous pseudocyst is an encapsulated collection of urine that leaks from the urinary tract due to an interruption in the urinary collection system at any level, from the calix to the urethra ,2,3. In A 5-year-old neutered domestic shorthaired male cat was presented with clinical signs of lethargy, anorexia, and anuria during the last 24 h. The cat had an indoor lifestyle and had a chronic clinical history of urolithiasis, with recurrent episodes of hematuria, pollakiuria, and dysuria/stranguria. The clinical examination revealed sensory depression, moderate dehydration (6–8%) attested by a moderate loss of skin turgor, dry and pale mucous membranes, weak rapid pulses, and enophthalmos. Increased capillary refill time (>2 s), decreased rectal temperature (37.5 °C), rapid breathing, and abdominal distension with pain on palpation were also observed. Written informed consent was obtained from the owner to perform the required clinical investigations. A peripheral venous blood sample was taken to perform a complete blood count and a biochemical examination . Mild neutrophilic leukocytosis with a left shift , thrombocytopenia , increased serum creatinine , urea , and hypoproteinemia were observed. Intravenous fluid therapy was performed by administering isotonic crystalloid solutions, and pain medication with methadone was started .A direct radiographic study of the abdomen with orthogonal projections was performed, using a radiographic system  and a digital radiography system . This examination showed a loss of soft tissue contrast in the lumbar region, and radiopaque stones in the urinary bladder .The abdominal ultrasound examination was performed using a device equipped with 5–8 MHz microconvex and 10–12 MHz linear probes . Hyperechoic areas in the bladder with a posterior shadow were observed, confirming the presence of previously diagnosed uroliths; the bladder wall appeared to be intact with normal stratification. A modest amount of free fluid was observed in the peritoneum A,B.Both kidneys appeared to be enlarged with a dilated pelvis (4.5 mm), preserved echo structure, and intact renal capsule. Both ureters appeared to be dilated (5.6 mm), although the entire length of the left ureter was well-visible in contrast to the contralateral .A large perirenal collection of anechoic fluid containing small areas of echogenic tissue attributable to intraperitoneal fat was observed in the left hemiabdomen. A capsule surrounding the lesion showed an inhomogeneous pattern with no evident stratigraphy .® Bracco Imaging S.r.l., Milan, Italy) was injected with a volume of 5 mL, equal to the amount of fluid previously drained from the lesion.To reach a diagnosis, it was not possible to perform intravenous excretory contrast urography due to the impaired renal function; so, ultrasound-guided drainage and a percutaneous contrast medium injection on the sedated subject were performed. The cat was placed in right lateral decubitus, the skin of the renal region between the hypochondrium and the left sublumbar area was shaved and aseptically prepared for surgery, and a longitudinal and transverse preliminary scan of the kidney was performed with a high-frequency linear probe (13 MHz). Using a 8.5–10 MHz microconvex probe, an ultrasound-guided insertion of a 22-gauge spinal needle into the lesion was performed through the abdominal wall caudally to the kidney at the level of the L4–L5 intervertebral space. Then, after removing the stylet, and connecting a three-way stopcock and an extension set, the ultrasound-guided percutaneous drainage of the collection was performed by connecting a 5 mL syringe and aspiring its contents by applying gentle negative pressure. A nonionic, low-osmolar iodinated contrast medium . Urethral rupture with an urinoma formation was suspected.® S.A.L.F., Cenate Sotto, Bergamo, Italy, 3 mL/kg/h) was performed, and a surgical procedure was planned. After 24 h, the cat’s medical condition dramatically dropped and it died. In agreement with the owner, a necropsy and histological examination were performed.The patient was hospitalized; intravenous fluid therapy with Ringer’s lactate solution (Ringer LattatoThe postmortem examination showed a modest peritoneal collection of dense, yellowish, odorless fluid. After displacing the intestinal loops, in the left retroperitoneal space, an 11 × 5 cm ovoid cystic formation was detected A. The foThe microscopic examination of the urinary sediment showed the presence of struvite crystals; the analysis of the mineral composition of uroliths confirmed that they consisted of struvite.A histological evaluation of the cyst wall showed a dense extensive streaming sheet of fibroblasts, neutrophils, and cell debris A–C.A histological examination of the ureter and renal pelvis confirmed the presence of an inflammatory reaction of the ureteral wall and a thickening of the renal pelvis. The section showed adipose tissue surrounding the intense fibroblastic reaction and a copious area of necrosis; moreover, intense inflammation mainly characterized by neutrophils, which often surrounds the debris of lithiasis deposits, was found .These pathological findings support the suspected diagnosis of uriniferous pseudocysts.Uriniferous pseudocysts are a rare disease in companion animals, with some reports available in feline medicine as post-traumatic lesion, and a study in which a spontaneous ureteral rupture due to renal calculi was suspected ,10,11,12In dogs and cats, radiography and ultrasonography are useful diagnostic tools for documenting ureteral rupture and urinoma formation, although excretory intravenous urethrography and computed tomography still remain the gold-standard methods. In fact, a contrast study is necessary to confirm the location of the leakage and to plan surgical therapy . NeverthIn this case report, an ureteral obstruction due to lithiasis with ureter rupture and the consequent formation of the pseudocyst was suspected. This hypothesis was supported by the absence of a referred traumatic history and by the necropsy examination, which confirmed the presence of bladder stones already highlighted by radiology, and urolithic debris deposits identified with the histological exam; it showed no other causes of perforation of the ureter. In addition to the obstruction of the ureter by the stones, hydronephrosis may be due to the blocking of urinary excretion, secondary to the high pressure inside the urinoma.The combination of imaging, and clinical and laboratory findings led us to the suspected diagnosis. The ultrasound-guided percutaneous contrast inoculation helped in radiographically outlining the well-encapsulated fluid collection and differentiating it from ascite, playing a role in the decision to propose the surgery in order to find the source of extravasation and to perform the fluid drainage, as recommended by previous studies ,10,12. TFeline uriniferous pseudocysts are rarely associated with urinary-tract stones, as evidenced by a lack of reported clinical cases. Clinical signs are often only suggestive of a nonspecific postrenal disorder; therefore, it is necessary to combine different diagnostic techniques to achieve the final diagnosis. The percutaneous contrast inoculation performed in this critically ill patient played a role in the diagnostic process to reach a final diagnosis, and can be extended to those cases in which the patient’s clinical condition does not allow for performing an excretory positive contrast study.Although it is a rare condition, feline paraureteral urinoma should be considered to be a potential complication in cats affected by urolithiasis.


The surgery of posterior clinoid meningioma (PCM) remains one of the most formidable challenges for neurosurgeons because of its location at great depth in the cranium and proximity to vital neurovascular structures. Herein, we aim to describe the technique and feasibility of a novel approach, the purely endoscopic far-lateral supracerebellar infratentorial approach (EF-SCITA), for resection of this extremely rare entity.A 67-year-old women presented with gradually deteriorating vision in right eye for 6 months. Imaging examinations revealed a right-sided PCM, and the EF-SCITA approach was attempted for tumor resection. Tentorium incision allowed a working corridor toward the PCM in the ambient cistern through the supracerebellar space. During surgery, the infratentorial part of the tumor was found to compress the CN III and posterior cerebral artery medially and encase the CN IV laterally. Following debulking of the infratentorial tumor, the supratentorial part could be exposed and then excised, which had dense adhesions to the ICA and the initial part of the basal vein in front. After total tumor removal, its dural attachment was detected at the right posterior clinoid process and then coagulated under direct vision. The patient on follow-up at 1 month had improvement in visual acuity in right eye, with no restriction of extra-ocular movements.EF-SCITA approach combines advantages of the posterolateral approach and endoscopic technique, allowing access to PCMs with seemingly low risks of postoperative morbidity. It would be a safe and effective alternative for resection of lesions in the retrosellar space. Posterior clinoid process (PCP) is an uncommon site for the origin of meningiomas, which have only been reported in 18 cases as yet . HoweverExtreme-lateral supracerebellar infratentorial (ELSI) approach remains one of the most versatile approaches in neurosurgery with respect to its ability to address various anatomical regions, especially the posterolateral midbrain and tentorial region . In the Herein, we report a case of EF-SCITA in total removal of PCM, with specific emphasis on technical surgical nuances. In the discussion, we summarize breakthroughs and insights on operative approaches for the treatment of PCM, and analyze the operation essentials, and strengths and weaknesses of each passage from the perspective of surgery. In this report, we also review the previous relevant publications within PubMed and abstracts from international conference literature concerning PCM according to the PRISMA guideline. The literature review found a total of 18 cases which was listed in A 67-year-old female presented with progressively worsening vision in her right eye for approximately 6 months. On ophthalmological examination, she had mild bilateral peripheral visual field defects, which was severer in right eye. The visual acuity was 0.4 in right eye and 0.8 in left eye. The extraocular muscles were intact and no other neurological deficit was found. Routine laboratory investigations, including endocrinological studies, were normal. No specific past, medical, family and psycho-social history was reported.Computed tomography (CT) scans revealed a hyperdense lesion on the right side of suprasellar region. The mass grew into the ambient cistern, lying medially close to the medial temporal lobe and displacing the midbrain posteriorly Video 1.Surgery was performed in left lateral position after placement of a continuous lumbar CSF drainage system. The head was placed in upper flexion and backward rotation to allow gravity retraction of the cerebellum. As described before, a C-shaped retroauricular incision was performed to obtain adequate exposure of the suboccipital region and the mastoid bone. Then, the entire transverse sinus, the transverse-sigmoid junction, and the proximal part of the sigmoid sinus were revealed through suboccipital craniotomy . The surAfter opening the tentorium cerebelli, the tumor could be identified in the ambient cistern. Anatomically, it was located in front of the midbrain and was divided by the tentorial incisura into the supratentorial and infratentorial parts. The tumor was found to encase and compress the CN IV towards the tentorial incisura  and parasellar meningiomas. The direction of ICA displacement may help in differentiating PCM from ACM, since the ICA is often shifted posteriorly in the case of ACM but anteriorly in the case of PCM .Like most PCMs, the tumor in this case grew upwardly and forwardly beyond the tentorial incisura and up-elevated the right optic chiasma, which could account for progressively visual loss in right eye. However, this case is unique in the tumor site presented unlike those reported in previous studies. Intraoperatively, the tumor was located between CN III and CN IV in the mediolateral direction. Correspondingly, the origin of PCM was found to occupy the junction of the PCP and petrous apex. Thus, the protection of CN IV should also be emphasized during surgery.The principles of PCM surgery are early devascularization of tumor and careful dissection of tumor from ICA perforators, cranial nerves, PS, and even hypothalamus . Severalvia fronto-temporal craniotomy with wide splitting of the Sylvian fissure , optic chiasm and PS from the posterolateral side . Thus, tCompared with the retrosigmoid view, the supracerebellar view supplies the corridor from the medial to cranial nerves and significantly reduces the manipulation of neurovascular complex . By explvia combined EF-SCITA and microsurgical middle fossa approach might be an ultimate piece of the surgeon’s armamentarium to improve outcomes in patient with complex DS lesions.Despite these merits, we are clearly aware that it is not without flaws. Firstly, endoscopy technique has difficulties when handling deep bleeding and necessitates a steep learning curve. Secondly, it is not entirely risk free because it may endanger the brainstem and cerebellum, and has inherent shortcomings of suboccipital craniotomy such as injury to the cerebrovenous system . Thirdly, unlike lateral and other posterolateral routes, tumor devascularization could only be achieved after tumor removal owing to the final exposure of PCP. Thus, bleeding control should be stressed especially in resection of massive or easily bleeding tumors. Last but not least, this case represented resection of a small PCM. Considering the surgical corridor, it would be an ideal approach for PCMs with lateral extension to the temporal lobe or posterolateral extension to the petroclival region, but may not be enough for complex PCMs with extreme suprasellar extensions. In this situation, microscopic FTOZ craniotomy may be needed either as an add-on or instead of the EF-SCITA. We believe multi-corridor hybrid surgery To the best of our knowledge, this is the first case report describing the EF-SCITA approach in the treatment of meningiomas situated over PCP. Overall, this posterolateral approach is technically simple and appears to be associated with less morbidity, which provides neurosurgeons with a viable alternative to traditional approaches to this kind of extremely rare lesions. However, the efficacy of this approach for larger PCMs awaits further verifications.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.SF, GL, YB and SH have been involved in the operation and management of the patient. SF and GL designed the report. YB and SH reviewed the literature, drafted the article and prepared the figures. XTL and XNL provided important academic inputs during surgery as well as during the revision of this manuscript. All authors contributed in editing of the manuscript and approved its final version. All authors contributed to the article and approved the submitted version.


Intestinal obstruction is one of the most common complications of Crohn’s disease (CD), jeopardizing the quality of life of patients. Numerous factors may contribute to intestinal obstruction in CD. Thus far, the primary reason has been identified as intestinal fibrosis caused by repeated chronic inflammation during the active phase of CD. Herein, we report two rare complicated CD cases and provide a reference for the clinical diagnosis and treatment of similar patients. Case one involves capsule endoscope retention in the small intestine of one CD patient concurrent with intestinal obstruction. Case two is a CD patient with intestinal obstruction caused by a mesangial hernia and ileal stenosis. Individualized and minimally invasive surgical intervention ultimately resulted in the successful management of these two patients. The two cases serve as an excellent guide for diagnosing and treating CD patients who present with similar symptoms. Crohn’s disease (CD) is a chronic inflammatory bowel disease that is complicated by genetic susceptibility and environmental triggers , 2. It iOn January 25, 2021, a 26-year-old man was diagnosed with incomplete intestinal obstruction in another hospital after experiencing vomiting, abdominal pain, and abdominal distension following a meal. The symptoms improved after fasting, gastrointestinal decompression, anti-infective treatment, and parenteral nutrition support but remained intractable. On March 11 of the same year, the patient experienced severe abdominal pain while undergoing capsule endoscopy in the same hospital, and the capsule endoscope was not excreted after the examination. Enhanced computed tomography (CT) scans of the abdomen revealed small intestinal obstruction, with multiple thickening and strengthening of the small intestinal wall. The obstruction point was located in the small intestine of the pelvic region. According to the images, the first consideration was a CD of the small intestine. As a result, the patient was admitted to the Diagnostic and Treatment Center for Refractory Abdominal Diseases for additional treatment. Physical examination revealed tenderness in the lower abdomen and no other positive signs. The plain abdominal film revealed that the jejunum in the upper left abdomen was dilated, and the intestinal cavity contained a gas-liquid plane. Moreover, metallic shadows could be seen in the overlapping area of the pelvic cavity . The pat2).” After admission, a transnasal ileus tube was inserted under interventional guidance. 1,200, 200, 100 and 10 ml of dark green liquid per day were drained from the tube 4 days before the operation. The patient felt no more abdominal pain after that intervention. Following strict evaluation, the patient underwent subtotal colectomy, ileocecal resection, laparoscopic intestinal adhesiolysis, plication of small intestine, and ileostomy on November 30, 2021.In 2009, a 36-year-old man with lower abdominal pain and palpable right lower abdominal mass was diagnosed with CD. Since then, he has been followed up regularly in our Gastroenterology Department and treated with medication to slow the progression of the disease. Four days prior to admission, the patient experienced severe abdominal pain and distension following a full meal, which was accompanied by four to five episodes of vomiting. As a result, the patient was admitted to our department for follow-up care. Further examination of the patient’s medical history revealed that the patient had not had any excretion or exhaust in the preceding 3 days and had previously defecated two to three times per day. Physical examination revealed tenderness in the middle and lower abdomen, with a palpable mass in the lower abdomen. CT scans of the abdomen showed intestinal tract lesions in the right middle and lower abdomen, causing a proximal small intestinal obstruction . EndoscoDuring the operation, laparoscopic exploration revealed that the proximal small intestine was significantly dilated. Furthermore, a mass wrapped by the omentum majus was seen in the ileocecal junction adhering to the lateral abdominal wall. When an ultrasonic scalpel separated the ileocecal mass, pus was seen flowing from the mass. We then switched to laparotomy because of the unclear anatomical structure and limited vision during the laparoscopic operation. During exploratory laparotomy, contractures were found in the ascending, transverse, descending colon, and mesangium. The proximal small intestine passed through the transverse mesocolon, causing the formation of an internal hernia . Then, aIn CD patients, intestinal obstruction resulting from capsule endoscopy is uncommon. However, according to Guevara-Morales and Castellanos-Juárez , the capIn case 2, the primary cause of intestinal obstruction is the formation of trans-mesenteric internal hernia. According to the literature, the incidence of internal hernia is about 0.2∼0.9%, accounting for 0.6∼5.8% of all intestinal obstruction cases . InternaMedical treatment is frequently ineffective in CD patients who developed intestinal obstruction, and in both cases, the obstruction was eventually resolved through surgical intervention. Endoscopic intervention or surgical resection is primarily used to treat intestinal stenosis in CD. Endoscopic balloon dilation (EBD) is indicated when the length of strictures is ≤ 5 cm, non-angulated, with a sizeable intestinal cavity large enough to allow balloon dilators in the absence of contraindications such as the presence of fistula, abscess, or malignancy , 14. In Notably, our department emphasizes minimally invasive surgery, putting the concept of enhanced recovery after surgery (ERAS) into practice. By minimizing pain, hospital stay, and adhesion formation, minimally invasive surgical options have significantly reduced postoperative morbidity . Our teaIn conclusion, there are numerous CD cases complicated by intestinal obstruction, and surgery is the mainstay modality to relieve the obstruction. As surgeons, we should thus choose individualized and minimally invasive options that will result in long-term benefits for CD patients.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by the Ethics Committee of Shanghai Tenth People’s Hospital. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individuals for the publication of any potentially identifiable images or data.KX: disease diagnosis and treatment, collection of cases, and draft manuscript. RG, XW, and YR: disease diagnosis and treatment, collection of cases, and revise manuscript. JW, TW, FW, YL, LY, and CC: disease diagnosis and treatment, and revise 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Abdominal wall neoplasms are usually benign and, in the majority of these cases, no further work-up or treatment is indicated. The percentage of malignant abdominal neoplasms, however, is not negligible. Radiologists play a pivotal role in identifying imaging features that should favor malignancy, including larger lesion size, edema, neurovascular involvement, and peripheral or inhomogeneous dynamic enhancement, thus indicating to the clinician the need for further work-up. Histopathology is the reference standard for the characterization of abdominal wall neoplasms. In patients undergoing surgery, radiological assessment is needed to guide the surgeon by providing a comprehensive anatomic guide of the tumor extension. We present a pictorial review of benign and malignant abdominal wall neoplasms that can be encountered on radiological examinations, with a main focus on CT and MRI features that help in narrowing the differential diagnosis. Abdominal wall neoplasms may be encountered incidentally on imaging or may present as palpable masses, leading the patient to the radiologist. Malignancies could be identified in about 40% of cases, based on a study by Bashir et al. . HoweverRadiologists play a pivotal role in recognizing imaging features that deserve close attention. Imaging features that should favor malignancy in soft-tissue tumors of the abdominal wall include larger lesion size, edema, neurovascular involvement, and peripheral or inhomogeneous dynamic enhancement ,3.Ultrasonography (US) is the first-line imaging technique for abdominal wall masses, and it is indicated in patients with palpable masses in the abdominal wall. US plays a main role both for diagnosis and as a guide for interventional procedures and biopsies. In many cases, however, abdominal wall neoplasms are identified incidentally on computed tomography (CT) and magnetic resonance (MR) .CT provides information on tumor extension and involvement of deeper abdominal wall structures, but it is burdened by ionizing radiation exposure. Contrast-enhanced MR is a second-line imaging technique that allows a better understanding of the composition and nature of a mass ,3. HistoBased on the European Society of Musculoskeletal Radiology (ESSR) guidelines on soft tissue tumors, masses above 5 cm should always undergo biopsy after imaging .Benign neoplasms are mainly derived from mesenchymal tissues, with 70% of them classified in six main diagnostic categories: lipomas, fibrous histiocytoma, nodular fasciitis, hemangioma, fibromatosis, and nerve sheath tumors ,5.Malignant lesions usually show a larger volume, heterogeneous structure (mainly on MR), and heterogeneous and early contrast enhancement . Around This pictorial review aims to provide an overview of the broad spectrum of all these benign and malignant neoplasms, with tips for the differential diagnosis. For each condition, key imaging aspects will be highlighted, in order to provide a complete visual diagnostic guide for the radiologist.Lipoma is the most frequent benign soft tissue tumor, with a prevalence ranging from 16% to 50% ,8,9. TheWhen inflammation, necrosis, or infarction occur, a heterogeneous appearance  with calLipomas are commonly painless, have no malignant potential, and do not require follow-up. However, subcutaneous lipomas could be surgically removed for symptomatic relief, pathologic confirmation, cosmetic reasons, or if there is an increase in size ,10. In tDesmoid tumors   are beniOn imaging, desmoid tumors resemble the surrounding muscles ,12,13. HLarger tumors may appear heterogeneous, as a result of bleeding or necrosis, and may contain calcifications ,12,13. OThe first sign of a desmoid tumor may be a firm, painless lump. When they develop in flexible, elastic tissues or deep spaces, the tumor can often push normal tissue out of its way as it grows, causing vague symptoms. In the past years, direct complete surgery was the standard primary treatment modality; however, in recent years a paradigm shift towards a conservative management has been introduced in order to prevent local recurrences, as they are usually more aggressive than the original tumor . MoreoveAbdominal wall hemangiomas are rare mesenchymal tumors (<1%), mainly occurring in children ,17. US wOn CT, hemangiomas appear as lesions without clearly infiltrating characteristics, usually with phleboliths, which are punctuate calcifications, suggestive for the diagnosis . In postOn MR, abdominal wall hemangiomas are isointense or only slightly hyperintense on T1-w images, and hyperintense on T2-w ones ,8,17, wiAlthough true hemangiomas have no malignant potential, all management strategies should include regular follow-ups.Conservative management is the first line of treatment for nearly all isolated intramuscular hemangiomas. When the degree of pain or functional impairment warrants more intervention, nonoperative measures may decrease symptoms, and, if nonresponsive, options include conservative management, topical or systemic corticosteroids, embolization, sclerotherapy, and surgical excision .Benign nerve sheath tumors (NSTs) are mainly comprised of neurinomas and schwannomas and are typically located along the course of major peripheral nerves ,7,8,13. Neurofibromas and schwannomas contain a solid and a myxoid part and will show low signal on T1-w images, with heterogeneous appearance on T2-w images. A “target sign” could also be appreciated on T2-w sequences ,4,8, conSarcomas are rare mesenchymal tumors, often large, with poorly defined margins, which can arise in the subcutaneous tissue or in the musculature of the abdominal wall ,3,23. ThSarcomas of the abdominal wall are usually non-vascularized solid masses, with necrotic or fluid areas , giving Among sarcomas we can distinguish:Liposarcoma: well-defined fat and myxoid areas will be seen inside a heterogeneously enhancing lesion, with a characteristic sharp demarcation among fatty and nonfatty elements. Calcifications are rare : either primary  ..36].Melanoma metastasis are also common, and have a tendency to bleed ,38,39,40AWMs can also be a consequence of laparoscopy, needle biopsies, and radiofrequency ablation  in multiA particular AWM appearance is “Sister Mary Joseph’s Nodule” (SMJN), a metastatic deposit located in the umbilicus. SMJN can be the first complaint of an unknown cancer and it is indicative of an aggressive disease ,44,45,46The spectrum of abdominal wall neoplasms is wide, ranging from benign tumors that can be conservatively managed to malignant ones, which require treatment.The role of the radiologist is fundamental in curtailing the differential diagnosis and correctly interpreting these processes, especially in the case of incidental findings.Some imaging clues may help to narrow the differential diagnosis, indicating the need for further diagnostic work-up in case of larger lesion size, edema, neurovascular involvement, or peripheral or inhomogeneous dynamic enhancement. Some benign tumors may have atypical features or may lead to complications, and this may lead to diagnostic challenges at imaging and indicate the need for a biopsy to rule out malignancy.


Extranodal lymphomas of the gastrointestinal (GI) tract are known entities, but primary lymphoma of the colon is extremely rare. Symptoms are non-specific, such as abdominal pain, bloody diarrhea, unintentional weight loss, night sweats, and changes in bowel habits. Some patients do not have any specific symptoms, which makes diagnosis extremely difficult. We present a 69-year-old asymptomatic male who was incidentally found to have an inflammatory mass in the descending colon on screening colonoscopy; the initial biopsy was inconclusive. However, due to high suspicion of any underlying malignancy, a repeat colonoscopy with biopsy was done, which revealed diffuse large B-cell lymphoma (DLBCL). Prompt and early diagnosis is extremely crucial for timely management. Management includes chemotherapy, radiotherapy, and surgery. Non-Hodgkin's lymphoma is a lymphoproliferative disorder originating from B lymphocytes or T lymphocytes or natural killer cells. Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin's lymphoma. Primary diffuse large B-cell lymphoma of the colon is extremely rare. It affects both men and women, with male predominance and the peak incidence seen in the sixth to seventh decades ,2. ThereA 69-year-old Caucasian male presented to a gastroenterology clinic for a routine screening colonoscopy. He had a two-year history of night sweats; otherwise, he did not have any symptoms. He denied unintentional weight loss, fatigue, and change in bowel habits; abdominal pain; nausea; and vomiting. The medical history was significant for hypertension, dyslipidemia, and coronary artery disease. Surgical history was significant for percutaneous coronary intervention for coronary artery disease and hernia repair. He had a 20-year history of smoking and no alcohol or drug use. No significant family history. On physical examination, vitals were stable. The lungs were clear on examination, the heart sounds were regular in rate and rhythm, there was no abdominal tenderness, bowel sounds were normal, and no frank blood was seen on rectal examination. The rest of the physical examination was unremarkable.Initial screening colonoscopy showed a 4 cm ulcerated, non-bleeding, non-obstructing mass in the descending colon Figure . A biopsHe underwent a laparoscopic colon resection. 20.1 cm of splenic flexure and proximal descending colon segment were resected; the serosa of the resected lesion was pink- tan and smooth; multiple possible lymph nodes were resected and sent for immunohistological examination. The histology of the resected colon revealed a 1.4 cm atypical lymphoid lesion involving mucosal, submucosal, and superficial midmuscularis propria; it is composed of intermediate to large lymphocytes with diffuse pattern involvement. Immunohistochemistry was positive for CD10, CD20, BCL6, and negative for CD30 and MUM1. The proliferative index Ki-67 is high, around 95%. Morphological and immunophenotypic findings are consistent with diffuse large B-cell lymphoma. Negative FISH for MYC and large cell size make Burkitt lymphoma unlikely. All the resected lymph nodes were negative for any metastatic disease. He was seen by a hematologist and was started on chemotherapy with six cycles of rituximab, cyclophosphamide, hydroxydaunorubicin, oncovin, and prednisone (R-CHOP). He was seen after two cycles of R-CHOP. He is tolerating chemotherapy well without any dose-limiting toxicities.DLBCL is one of the aggressive lymphomas that can be cured, even in advanced cases, with effective treatment regimens. It is the most common lymphoma in adults, accounting for 37% of B-cell lymphomas and 30-40% of non-Hodgkin's lymphomas . Among tCampylobacter jejuni and Helicobacter pylori. Other risk factors include viral infections like HIV, Epstein-Barr virus (EBV), hepatitis C virus (HCV), human T-cell leukemia virus-1 (HTLV-1), and human herpesvirus-8 (HHV-8); immunosuppressants and immunodeficiencies [Risk factors are mostly similar to nodal DLBCL with some differences, like associations with inflammatory bowel disease, celiac disease, and infections like ciencies . Pathogeciencies . Among tciencies .Diagnosing colonic lymphomas needs imaging modalities like contrast-enhanced CT of the abdomen along with double-contrast barium enema followed by colonoscopy and biopsy for confirmation, as imaging only provides information about size, depth of invasion, and nodal involvement. They also needed a wide range of hematological testing and further staging of lymphoma, along with prognostication of the type of DLBCL. Basic labs include complete blood count (CBC) with a differential that helps to find the bone marrow involvement; a peripheral smear, comprehensive metabolic panel (CMP), serum lactate dehydrogenase (LDH), and uric acid levels usually correspond to tumor burden and are also used as an early marker for relapse . TestingTreatment modalities include multi-agent chemotherapy, surgical resection, and radiotherapy, and these are used alone or in combination based on the staging of lymphoma, subtype, and other co-morbidities that vary between individuals. Even in colonic lymphomas, R-CHOP induction therapy is the gold standard regimen that includes rituximab in combination with cyclophosphamide, doxorubicin (hydroxydaunorubicin), vincristine (Oncovin), and prednisone . The rolOur patient was completely asymptomatic, and his lymphoma was identified on routine screening colonoscopy. This case helps us realize that DLBCL of the colon can be asymptomatic. Any concerning lesions on colonoscopy need proper histopathological examination. Without an appropriate and timely diagnosis, the prognosis is poor.DLBCL of the colon is an extremely rare entity. Patients can be asymptomatic or have non-specific symptoms that can delay diagnosis. Histopathological examination findings are key for diagnosis. Early diagnosis is really important for the timely management of these patients. Treatment includes chemotherapy and radiotherapy, and the role of surgery is still controversial.


Gestational trophoblastic neoplasias (GTN) are malignant neoplasms that occur in pregnant or recently pregnant women. Choriocarcinoma (CCA) is a highly aggressive and rare GTN, and cases outside the female genital tract are commonly seen as secondary manifestations of gynecologic disease. In this paper, we describe the case of a 40 years-old female patient with a primary pulmonary CCA who was surgically treated and for whom the confirmation of the primary origin of the tumor was possible using a DNA short tandem repeat genotyping. Distinction between gestational and non-gestational trophoblastic neoplasia is crucial as they require different therapeutic approach and have different prognoses. Gestational trophoblastic neoplasias (GTN) are malignant neoplasms that occur in pregnant or recently pregnant women. Gestational choriocarcinoma (CCA) is a highly aggressive, malignant GTN consisting of cytotrophoblastic and syncytiotrophoblastic cells, distinct from other forms of malignancy for containing genetic material from the male partner. CCA can arise from any type of normal or abnormal pregnancy, and although its diagnosis generally occurs within months of pregnancy, it can be exceptionally present during gestation . The tumCCA may have an exceedingly rare non-gestational origin in women. Extra-gonadal non-gestational CCA usually arises in midline structures such as the mediastinum, retroperitoneum, and central nervous system. Non-midline CCA is uncommon and mainly affects the lungs, gastrointestinal tract, or breast .Few Primary Pulmonary CCA (PPC) cases are reported in the literature. They are generally metastatic and with poor prognosis. Here we report the case of a localized PPC, initially assumed as gestational CCA, where a DNA test confirmed the tumor’s non-gestational origin and ultimately guided our choices for the patient’s treatment.A 40-years-old female patient presented in our clinic in May 2021 for evaluation. She reported active smoking (20 packs-year) and had a history of secondary hypothyroidism. She had one uneventful vaginal delivery at age 31 and, since then, has been under continuous oral contraceptive.In November 2020, she had a pregnancy diagnosis after a period of persistent nausea. One week later, she presented in the emergency room with spontaneous vaginal bleeding associated with pelvic pain. Physical examination was unremarkable. The analytic panel showed a β-hCG of 175U/mL , but pelvic ultrasonography (US) wasn’t compatible with pregnancy, suggestive of spontaneous abortion. In early December 2020, due to continuing complaints of pelvic pain and bleeding, she resorted to the ER again. Pelvic US suggested a right ectopic pregnancy and β-hCG was 200U/mL. A multidisciplinary decision was made for two courses of single-dose methotrexate (MTX) to be administered one month apart, with an initial reduction of β-hCG (nadir: 140U/mL) but subsequent elevation.Due to failure of MTX therapy, surgical treatment was carried out with laparoscopy, bilateral salpingectomy, dilation and curettage procedures that showed no ectopic pregnancy, pelvic tumor, or pregnancy in the uterus. Her endometrium was in the proliferative phase, and biopsies from both salpinges showed no evidence of malignancy or scarring.18F-FDG PET/CT scan showed a single hypermetabolic lesion (SUVmax 10.8) in the right upper lung lobe, measuring 24x32mm. A transthoracic needle biopsy of the lung lesion was consistent with CCA. No other lesions were identified after performing MRI of the brain, abdomen and pelvis, and thoracic CT scan.A whole-body According to the WHO/FIGO criteria  we assumConsidering the persistent elevation of the β-hCG despite the CTX, the absence of other foci of disease except for the lung and the fact that ectopic pregnancy has not been confirmed, a decision was made to treat the pulmonary lesion surgically.In June 2021, or 8 months after the first symptoms, the patient had a thoracoscopic right upper lobectomy with systematic mediastinal lymphadenectomy. The postoperative course was uneventful, with the return of β-hCG titers to normal levels within three weeks. Histologic findings were consistent with CCA; immunochemistry showed positivity for β-hCG, Inhibin A, GATA3, SALL4, and negativity for TTF-1. Pathologic staging was pT2a pN0 R0  Figure 1As a) there was no further evidence of more metastatic sites on the PET scan, b) the laparoscopy failed to reveal the initially supposed ectopic pregnancy in the absence of a molar pregnancy, and c) with the normalization of hCG hormone level after surgery according to the expected half-life of 24-36 hours, we considered the diagnosis of a non-metastatic PPC.Being so rare, to confirm a non-metastatic PPC, we decided to analyze the genetic material of the tumor. A previously published case series used DNA’s short tandem repeats (STR) to investigate the non-gestational origin of CCA . For shoNo adjuvant treatment was offered, and after thirteen months Figure 3PPC is a very rare condition with a challenging diagnosis and management. The optimal therapy for PPC, especially in the early stages, is yet to be defined. The addition of chemotherapy after surgery has been suggested to improve survival, based on the aggressive nature of this rare cancer, and supported by a small series of patients . NeverthDifferentiation between gestational choriocarcinoma and non-gestational choriocarcinoma can be very difficult since the clinical presentation and histology of these two diseases are identical. This differentiation is essential in order to establish the best therapeutic strategy.In the case presented, with the initial suspicion of a recent abortion and subsequently of an ectopic pregnancy (refuted by laparoscopic examination), we considered the hypothesis of a metastatic lung lesion from gestational CCA as a more probable diagnosis. In addition, we know that this disease has very good prognosis and a high cure rate with chemotherapy. In order to define treatment, we applied the FIGO staging and the WHO risk score , resultiThe critical step for subsequent clinical decisions, such as adjuvant treatment, was determining the relation of the tumor with a gestational event or its primary origin. Molecular analysis of tumor tissue to identify unique paternal genetic contribution from a prior gestational event provides a definitive diagnostic distinction between tumors of gestational and non-gestational origin. Short tandem repeats (STR) genotyping is currently the most applicable method of identity testing, including diagnosis of gestational trophoblastic disease .As reported above the tumor’s DNA fully matched to the patient’s, with no contribution from her partner’s DNA. This established the diagnosis of PPC. There are no clear prognostic features nor guidelines to assist in clinical decisions of PPC treatment. PPC tends to grow rapidly and has high propensity to metastasize to other organs such as bone, liver, brain, spleen and contralateral lung . Most reIn contrast to previously published cases, the clinical course of this patient’s tumor was indolent, with stable disease for about 8 months until surgery was performed. We discussed with the patient the possibility of adjuvant CTX but ended up adopting a follow-up strategy instead.Looking at the patient’s trajectory, the gynecological symptoms presented by the patient contributed to the delay in the diagnosis of PPC. When in doubt, we emphasize the possibility of performing STR genotyping to establish the diagnosis.Given the current availability of STR DNA analysis and the possible benefits for patients with cases like the one presented here, we suggest that an STR DNA analysis from the tumor, the patient and partner should be used to support the diagnosis of PPC , 11.The original contributions presented in the study are included in the article/Supplementary Material. Further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Champalimaud Foundation's local ethics committee. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.The authors want to thank Margarida Reis-Lima, MD, Elsa Garcia, MD, and the Synlab laboratories in Lisbon, Portugal, for their help and collaboration in this case.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Usually occurring entirely intrasellarly or extending suprasellarly (intra-suprasellar), Rathke’s cleft cysts (RCCs) can present with an intrasphenoidal location. Extrasellar positions are rare. To date, only seven patients with intrasphenoidal RCC have been reported in the literature. Despite the rarity of the condition and the lack of pathognomonic radiological features, preoperative diagnosis remains challenging. A trans-sphenoidal approach can be adopted to treat this type of cyst, which has great clinical relevance. Awareness of this different presentation of RCC before respective management may be of value in its approach. Intrasphenoidal RCC should be diagnosed preoperatively and the surgical approach should be changed accordingly by aspiration and partial removal before the histological examination. Rathke’s cleft cysts (RCCs) in the nasopharyngeal region are midline cystic lesions with rare incidence . No pathA woman in her 70s presented with progressive headaches for three months, with intensity on a Visual Analog Scale of 5 out of 10. These headaches were persistent throughout the day, located in the parietal-frontal region with no irradiation to other regions. In terms of aggravating factors, the patient complained of an increase in pain with cough and defecation. The patient took paracetamol 500mg, twice a day for one week, with no relief of the symptoms, and referred no alleviating factors. Patient had a history of Pott disease with paraplegia for 50 years and obesity with a BMI of 35. Blood pressure was 140/56mmHg with a heart rate of 72 bpm on average. She sought primary care who referred her to a Neurology specialist who, in turn, requested a CT scan. This CT scan showed a lesion in the sphenoidal region. There were no visual symptoms, body temperature deregulation, loss of libido, changes in urination habits. Cranial pair assessment was unremarkable. Neurologic exam was also unremarkable except for paraparesis of inferior limbs. The patient was promptly referred to the ENT department after hormonal study and ophthalmologic examination at the Neurology department. From the onset of symptoms to the diagnosis of this mass, four months passed. After a detection of the mass on MRI, two months were needed to reach a consensus to its surgical excision. Flexible fibroscopy and rigid rhinoscopy were performed at the ENT department. There were no other findings on physical examination. The patient's ophthalmologic examination and hormone study were normal - pituitary hormones, adrenal cortical hormones, thyroid hormones and hypothalamic releasing hormones values were at the range of the levels of reference. During the follow-up no change of size of the mass was seen. At the ENT evaluation, rigid rhinoscopy of 0, 30 and 70 degrees and flexible fibroscopy revealed hypertrophy of the inferior turbinates with no accessory visible masses. CT scan demonstrated a lesion of the sphenoidal region by low-attenuation cystic mass without calcification. MRI imaging showed a cystic sphenoidal extradural lesion, isointense on T1-weighted images (WI) with peripheral gadolinium enhancement and hyperintense on T2 WI . The postoperative course was uneventful and patient was discharged home after two days. Headaches disappeared after one week, and the patient didn’t develop neurologic symptoms or post-operative complications from the endoscopic surgery Figure .At present time and after nine-month follow-up, no recurrence has been verified. Until the day, a follow-up is being maintained under a close surveillance of the symptoms and a MRI yearly in the first five years, and every two years after that.RCCs have their origin in Rathke’s pouch. They appear mostly within the sella turcica, eventually extending to the suprasellar region -3. Its pMRI presents of utmost importance in the preoperative assessment for differential diagnosis of RCC with other cystic sellar lesions. Usually, RCCs are well-defined with a homogeneous appearance. More than 60% of the lesions are hyperintense on T1-MRI, because of the presence of mucous. On T2-weighted MRI, the lesions are mostly hyperintense, while 33% can be iso- to hypointense. Often, contrast reinforcement is missing, and a thin magnifying edge is found - usually credited to inflammation or squamous metaplasia of the cyst wall or to a circumferential rim of the displaced pituitary gland ,14,15. TGenerally speaking, recurrence rates after surgical approach of RCC can assume values up to one-third of cases - being correlated with factors such as the shape of enhancement of the cyst wall, existence of squamous metaplasia, signs of chronic inflammation or stratified epithelium, fierceness of cyst wall resection, and the use of fat graft in an eventual repair ,7. When Intrasphenoidal RCC is a midline cystic lesion and a rare entity. Biopsy of the lesion and respective histopathology is the cornerstone of diagnosis. Awareness of this different presentation of RCC before respective management may be of value in its approach. Intrasphenoidal RCC should be diagnosed preoperatively and the surgical approach should be changed accordingly by aspiration and partial removal before the histological examination.


A few intracranial lesions may present only with positional vertigo which are very easy to misdiagnose as benign paroxysmal positional vertigo (BPPV); the clinicians should pay more attention to this disease.To analyze the clinical characteristics of 6 patients with intracranial tumors who only presented with positional vertigo to avoid misdiagnosing the disease.Six patients with intracranial tumors who only presented with positional vertigo treated in our clinic between May 2015 to May 2019 were reviewed, and the clinical symptoms, features of nystagmus, imaging presentation, and final diagnosis of the patients were evaluated.All patients presented with positional vertigo and positional nystagmus induced by the changes in head position or posture, including one case with downbeating nystagmus in a positional test, two cases with left-beating nystagmus, one case with apogeotropic nystagmus in a roll test, one case with right-beating nystagmus, and one case with left-beating and upbeating nystagmus. Brain MRI showed the regions of the tumors were in the vermis of the cerebellum, the fourth ventricle, the lateral ventricle, and the cerebellar hemisphere. Positional vertigo is a transient vertigo attack caused by gravity-related changes in head position or posture (after reaching the new head position). It can be divided into peripheral and central types. Generally, peripheral vertigo is the most common symptom . Benign A 27 year old woman presented with more than 2 years history of episodic vertigo which often occurred when changing from lying position to sitting position, or from sitting position to lying position, and turning around quickly, accompanied by mild nausea. She denied any vomiting, headache, diplopia, choking cough in drinking water, dysarthria, ear symptoms such as tinnitus, ear tightness, and hearing loss, and she had clear consciousness when the episodic vertigo occurred, which often lasted for 1–2 min each time. She was initially diagnosed with BPPV in another hospital, but repositioning maneuvers for BPPV failed to relieve her symptoms. There was no progress in the disease in the past 2 years. She did not pay attention to it and did not conduct further examination. There was no spontaneous nystagmus in the examination in our hospital, and the visual eye movement, video head impulse testing, and Romberg test were normal. She had vertical downbeating nystagmus when changing from sitting position to supine position for more than 1 min in a positional test. In a roll test and Dix-Hallpike (DH) test, vertical downbeating nystagmus occurred at all positions and lasted for more than 1 min. Brain MRI showed the regions of the tumors were in the vermis of the cerebellum, which was considered as low-grade glioma, and there was no significant change in brain MRI at 8 months after diagnosis in the follow-up.A 29 year old woman presented with a 3-month history of positional vertigo, provoked by rolling in bed to the left and right, which was mild . She denA 54 year old man presented with more than 1 month history of positional vertigo which often occurred when changing from lying position to sitting position or from sitting position to lying position. He denied any nausea, vomiting, headache, amaurosis fugax, diplopia, dysarthria, fear of light and sound, ear symptoms such as tinnitus, ear tightness, and hearing loss. He was relieved for several seconds and had recurrent attacks. He was initially diagnosed with BPPV in another hospital, but repositioning maneuvers for BPPV failed to relieve his symptoms. There was no spontaneous nystagmus in the examination in our hospital, and the visual eye movement, video head impulse testing, and Romberg test were normal. He had left-beating nystagmus when changing from sitting position to supine position for more than 1 min in a positional test. In a roll test and DH test, left-beating nystagmus occurred at all positions and lasted for more than 1 min. Brain MRI showed the regions of the tumors were in the vermis of the cerebellum, and metastatic tumor could not be ruled out. The patient went to another hospital for treatment without further follow-up.A 65 year old man presented with a 17-year history of positional vertigo which was often provoked by rolling in bed to the left and right, sometimes accompanied by mild headache. He denied any obvious visual rotation, nausea, vomiting, amaurosis fugax, diplopia, dysarthria, fear of light and sound, ear symptoms such as tinnitus, ear tightness, and hearing loss. He was relieved for more than 10 s. He had no significant medical history. There was no spontaneous nystagmus in the examination in our hospital, and the visual eye movement, video head impulse testing, and Romberg test were normal. He had left-beating nystagmus in the left DH test and the left roll test and lasted for more than 1 min. Brain MRI showed the regions of the tumors were in the lateral ventricle which was like a circle and had long T1 and long T2 signals. The tumor was considered as choroid plexus after the neurosurgical consultation. There was no significant change in brain MRI at seven months after diagnosis in the follow-up.A 53 year old man presented with more than 2 years history of dizziness which often occurred accompanied by top-heavy and unstable walking . He presA 39 year old man presented with a 1-week history of episodic vertigo which was provoked by changing the head position, accompanied by mild headache and nausea . He deniClinically, patients with positional vertigo as the primary complaint are prevalent, most of them are BPPV; CPPV is only a minority. Intracranial tumors, often with hidden onset, can be seen in all ages. Whether the patients with an intracranial tumor only present positional vertigo depends on the region and extent of involvement of the lesion. If the lesion is small and the functional area is not involved, there may be no clinical symptoms; if the lesion is large and the other functional areas are affected, it may be accompanied by central nervous system symptoms and signs, such as double vision, facial numbness, limb numbness, dysphonia, dysphagia, etc., which is easier to identify clinically; if the lesion is relatively limited and only involves the vestibular conduction pathway, it only manifests as position-related vertigo, dizziness, and imbalance, which is easily misdiagnosed clinically. The six patients in this group showed sole positional vertigo with positional nystagmus without other central nervous system symptoms. Before the diagnosis, three patients were misdiagnosed for BPPV and were treated with repositioning maneuvers.CPPV caused by intracranial tumors mainly violates the vestibular conduction pathway. The lesions are mostly located in the dorsal lateral part of the fourth ventricle, the dorsal part of the cerebellum, the cerebellar nodules, and the cerebellar lingual lobe , 10. TheSince the clinical incidence of CPPV is low, Cranial CT or craniocerebral MRI is not a routine examination for patients with positional vertigo. If patients do not present with central nervous system symptoms, nystagmus in positional tests is often the first breakthrough. Central paroxysmal positional nystagmus (CPPN) associated with central lesions is often different from the nystagmus in BPPV and it has its independent characteristics. CPPN usually has no latency, can appear in multiple positions, has no noticeable change in strength, and has no attenuation in the fixation test. CPPN cannot be explained by the theory of canalith flow , 13, 14.CPPV needs to be differentiated from other diseases, first of which is BPPV. For most patients with BPPV, the characteristics of nystagmus are consistent with the canalith theory, and the treatment effect is good. Next is the relatively rare cupulolithiasis of the horizontal semicircular canal BPPV. Its nystagmus often has no incubation period, easy fatigue, and has a great duration , in addiAlthough CPPV is rare in the clinic, once it is a missed diagnosis, it may cause serious consequences. When patients complain of positional vertigo, nystagmus characteristics are inconsistent with BPPV, and CRP is invalid, etc. we should think of the possibility of CPPV, take a craniocerebral MRI examination promptly, determine if there are intracranial lesions, and get timely and appropriate treatments.When presenting with nystagmus features that are not consistent with BPPV, patients should receive a brain MRI examination to distinguish BPPV from intracranial diseases.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by the Ethics Committee of the Chinese PLA General Hospital (S2020-465-01). The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.QS and NY designed the experimental paradigm, summarized the results, and wrote the article. YC collected the clinical cases. HS, XM, CJ, HW, QZ, YQ, JL, LLZ, and LZZ examined the patients, like hearing examination, vestibular function examination, and imaging examination. All authors contributed to the article and approved the submitted version.This research was supported by Beijing Natural Science Foundation (7222185), National Foundation (2020YFC2004001), and NSFC (81470700).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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Paraduodenal hernias (PDHs) represent an unusual cause of acute abdominal pain in the Emergency Department (ED) and are associated with high morbidity attributable to a challenging clinical and radiological diagnosis, as signs and symptoms mimic other frequent causes of acute abdominal pain. We report a right paraduodenal hernia in a 37-year-old female patient who presented to the ED complaining of abdominal pain located in the right lower abdomen and hypogastrium, accompanied by nausea. During diagnostic work up, the abdominal computed tomography scan revealed the presence of small bowel malrotation with concomitant right paraduodenal hernia. These findings were confirmed intraoperatively. We performed a brief literature review about the clinical manifestations and treatment options of right paraduodenal hernias, which retrieved only 30 articles related to this condition. Prompt diagnosis, radiological or intraoperative, of paraduodenal hernias is crucial because nearly 50% will progress to small bowel obstruction. Therefore, it is essential for every clinician to account for them in the differential diagnosis of acute abdominal pain in the ED. An internal intestinal hernia is a rarely encountered condition, with an incidence of less than 1%, and develops when bowel loops penetrate through a peritoneal or mesenteric defect into the abdominal compartment . Fifty-tA 37-year-old female presented to the emergency department with complaints of acute hypogastric pain, accompanied by nausea, which persisted for 6 h prior to presentation. She had no history of abdominal surgery nor trauma or known morbidities, but reported occasional postprandial abdominal pain.The clinical examination revealed abdominal tenderness localized in the right lower abdomen and hypogastrium, positive McBurney’s sign, and rebound tenderness. Bowel sounds were normal and no abdominal distention was noted. Laboratory results were unremarkable except for elevated leucocyte count, which was 19,000/μL. Based on clinical presentation and physical examination, differential diagnoses included acute appendicitis, gynecological disorders, and inflammatory bowel disease.Initial imaging work-up included abdominal X-ray and ultrasonography with findings negative for gynecological causes of abdominal pain, but inconclusive of acute appendicitis.In this setting, a computed tomography (CT) scan of the abdomen and pelvis was performed. The protocol included thin (0.625 mm) slices before and after intravenous contrast administration, and images were then reformatted in the axial, coronal, and sagittal planes. Oral contrast to opacify the gastrointestinal lumen was not used as this case was considered an emergency. CT scanning demonstrated an abnormally low position of the transverse colon and right colic flexure with the concomitant presence of small bowel loops above and to the right a,b. The Another finding, which was considered to be incidental, was the formation of an acute angle between the aorta and superior mesenteric artery, which resulted in compression of the left renal vein a, an entThe patient was managed conservatively with intravenous fluids and antibiotics under close clinical and laboratory observation, as there were no signs of complete ileus or bowel ischemia. The patient’s clinical condition improved over time during conservative treatment, while nausea and abdominal pain decreased, probably because of spontaneous retraction of small bowel herniation. However, 72 h later, the patient deteriorated progressively with increasing abdominal pain and vomiting. Surgery was then decided. Under general anesthesia, a limited midline sub-umbilical incision was made, the white line was opened, and an entrance to the peritoneal cavity was made, and pneumoperitoneum was created (open Hasson technique). Due to the presence of dilated small bowel loops accompanied by hemorrhagic and dirty fluid in the peritoneal cavity, the laparoscopy was converted to an open laparotomy. The hernia sac was identified on the right side of Treitz’s ligament, containing small intestine loops a. AppareOne month after surgery, a follow-up CT scan was performed with an identical scanning protocol to the previous one . There wParaduodenal hernias (PDH) are the most frequently encountered types of internal hernias . They arClinical manifestations of right PDH include diverse non-specific symptoms, varying from acute to chronic abdominal pain accompanied by nausea and vomiting, and less commonly, fever. Patients may report a history of recurrent ileus since childhood, weight loss, or may be asymptomatic . In our Although intestinal obstruction occurs in only 1% of all cases of internal hernias, nearly 50% of all patients with PDH will develop acute bowel obstruction with a mortality rate of up to 50% ,18. ThusWe performed a literature search on PubMed database using the term “right paraduodenal hernia”. The articles retrieved were in English and no other search restrictions were applied. In the current literature, 32 cases of right paraduodenal hernias have been reported . The vasRight paraduodenal hernias are a rare abdominal condition with varying manifestations ranging from incidental findings to acute bowel obstruction with high mortality. A CT scan is an important diagnostic tool in acute and chronic abdominal symptoms associated with PHDs and should be obtained immediately. Early and correct diagnosis is essential, as only surgical treatment prevents intestinal complications.


Laryngeal hemangiomas in adults are uncommon. Laryngeal hemangiomas are more common in children, and if treatment is required, it is treated with propranolol. An eighteen-year-old female with rare glottic hemangioma extending to a supraglottic region presented with shortness of breath and hoarseness of voice. Although complete resection of the hemangioma was impossible due to its proximity to the vocal cord, it was treated with Microlaryngoscopy ablation with a CO2 laser. She has been followed up for over 10 years. The patient has had three recurrences, which have also been described. The cause of recurrence after treatment and the trigger for the increase in the size of the hemangioma is yet to be identified. The patient is now stable after her last Microlaryngoscopy and CO2 ablation. In conclusion, a near complete resection of hemangioma is required to prevent regrowing of hemangioma. Hemangioma is a benign tumor made up of blood vessels. The Greek suffix “oma” means a cellular proliferation of a tumor, and “hemangioma” is related to blood vessels. So, hemangioma refers to a tumor of the blood vessel. They are more commonly seen in pediatric groups and are usually benign. They first undergo a proliferative phase in which hemangiomas undergo rapid proliferation during the first few weeks/months of life, and they last for 12-18 months. After that, in the involution phase, the size decreases, and complete resolution can take up to 12 years. In the adult, they can occur at any age and do not follow the proliferation and involution phases. In Infants, laryngeal hemangiomas are almost exclusively capillary type. They commonly involve the subglottis, the narrowest portion of the pediatric airway [An otherwise healthy 18-year-old girl started complaining of difficulty breathing after exercise and a change in her voice for three months. Difficulty breathing has worsened over the past month, even with mild to moderate walking. She had no history of smoking, infection, past intubation, trauma, or voice overuse. Her physical examination, blood work, and chest X-ray came back negative. X-ray of the soft tissue neckshows a well-defined space-occupying lesion the in the vocal cord region. A polypoidal lesion was visualized with direct laryngoscopy. On Multi-slice Computed Tomography (MSCT) scan, a well-defined soft tissue polypoidal lesion from the true vocal cord involving posterior commissure on the left side and projecting into rima-glottidis was identified, narrowing the airway. The size of the lesion was 12.5*9*10 mm.Tracheostomy and micro laryngeal surgery with co-ablation were done under general anesthesia. A pathology report identified capillary-type vascular proliferation - hemangioma- in supraglottis. On postoperative day 5, her tracheostomy tube was removed, and she was discharged. But the following day, the patient was re-admitted with complaints of breathlessness and was taken for direct laryngoscopy with the removal of slough and re-insertion of the tracheostomy tube. The histopathology report showed a post-surgical reaction. A follow-up MRI two months later showed the lesion size to be 10*6*7 mm.2 laser was done. Biopsy results showed lymphoplasmacytic cell infiltrate with a thin-walled capillary. After three months, patients started feeling difficulty in breathing. MRI with angiography showed an increase in supraglottic laryngeal hemangioma to 13*14*16 mm. It showed a well-defined homogenously enhancing lobulated submucosal lesion at the level of posterior commissure in midline projecting in the laryngeal ventricle and supraglottic larynx and abutting inferior aspect of the left aryepiglottic fold as shown in Video After five years, patients started developing difficulty breathing during exertion. MRI showed an increase in the size of the hemangioma to 10*13*13 mm at the level of posterior commissure in midline projecting in the laryngeal ventricle and supraglottic larynx. Her symptoms kept worsening, and a repeat MRI showed an increase in the lesion size to 11*14*15 mm  to shrink the remnant of the hemangioma . AlthougArgon plasma coagulation can be used, which has high safety profile due to reduced depth of penetration . A paper2 laser excision and an ultrasonic scalpel. The causes and triggers for recurrence are still unknown. This case report suggests that complete or near complete resection is necessary to avoid regrowth. However, few articles have suggested use of intralesionalnal corticosteroids after excision may prevent a recurrence. More studies need to establish the guidelines for treating laryngeal hemangiomas in adults and how we can prevent their recurrence.In conclusion, adult laryngeal hemangiomas are very rare. An adult supraglottic hemangioma can be treated in one or more stages with CO