Intradermal nevi are common benign pigmented skin tumors. Their occurrence within the external auditory canal is uncommon. The clinical and pathologic features of an intradermal nevus arising within the external auditory canal are presented, and the literature reviewed. Intradermal melanocytic nevi are very common pigmented skin tumors, but they have rare occurrence inside the external auditory canal (EAC). There are few cases described in the literature.The purpose of the present study was to report a case of intradermal melanocytic nevus of external auditory canal, discuss clinical and histopathological findings and conduct literature review.SRC, 73 years old, Caucasian, Brazilian, presented left ear tumoration for approximately 20 days .Photo 1IOtoscopy showed dark colored mass occupying the medium third extending up to the opening of the external auditory canal (EAC). It was a completely asymptomatic mass, without otorrhea, pain or hearing loss, with softened aspect, which could be easily seen in the EAC. The lesion was completely removed under local anesthesia and the surgical specimen was sent for clinical pathology. The skin on the base was cauterized to control bleeding and the remaining portion of skin from EAC was normal. Tympanic membrane was intact and absolutely normal. Surgical site was completely tumor-free 30 days after the surgery.Clinical pathology analysis 5.Dome-like lesion: smooth, forming globous type elevation = intradermalClinically, five macroscopic types of melanocytic nevi may be recognizedAs to histopathologyIn the EAC, intradermal nevi may present aural obstruction and conductive hearing loss, leading to accumulation of water in the external acoustic canal, acute external otitis episodes or simply found as routine otoscopic finding, as in our case.When the nevus is symptomatic, it may be removed with excision biopsy and local anesthesia, via transcanal approach. The differential diagnosisIntradermal melanocytic nevi of the EAC are considerably rare. Despite their rare occurrence, the Japanese literature has some information about it. They should be excised and the material submitted to histopathological analysis.


Intramural duodenal hematoma is a rare entity, often secondary to traumatic origin, but more rarely spontaneous due to blood flow disorders, especially in the context of anticoagulant therapy.We report the case of a 66-year-old woman under anticoagulant treatment for atrial fibrillation, who was diagnosed with acute pancreatitis secondary to a spontaneous duodenal hematoma. The evolution was favorable under medical treatment.Intramural duodenal hematoma is frequently associated with abdominal pain and hematemesis, more rarely, it can be responsible for an acute pancreatitis, which is considerate as an unusual complication. We report here a case of duodenal hematoma revealed by acute pancreatitis along with a review of the literature since 2011.Monitoring of patients on oral anticoagulants helps prevent the occurrence of IDH and avoid its complications, which can be fatal. •Spontaneous Intramural duodenal hematoma is a rare entity, especially in the context of anticoagulant therapy•More rarely, it can be responsible for an unusual complication ' acute pancreatitis'•Monitoring of patients on oral anticoagulants helps prevent the occurrence of IDH and avoid its complications, which can be fatal It is usually a complication of blunt abdominal trauma, endoscopic biopsy, or peptic ulcer disease; more rarely, it is spontaneous and secondary to blood clotting disorders, especially in the context of anticoagulant therapy 2A 66-year-old female with a past medical history of hypertension and atrial fibrillation. She is under anticoagulant therapy, Vitamin K antagonists (VKAs), (Acenocoumarol 4 mg) was admitted to the hospital after experiencing four days of epigastric pain, jaundice and vomiting without any evidence of trauma. The physical examination revealed pale teguments and mucous membranes. Palpation of the epigastric region revealed tenderness. An electrocardiogram was performed to eliminate a myocardial Infarction. Then a pancreatic assessment was requested for the epigastralgia. We suspected also an alteration of the hemostasis balance because of the patient's antecedents. The blood tests showed, anemia with a hemoglobin level of 5.9 g/dl. The prothrombin level was at 12 % and the INR was 3.4 (target INR was between 2 and 3). The ionogram was normal. The lipase blood level was elevated to 500 U/L. The diagnosis of acute pancreatitis was retained. A CT scan (Without and with enhancement) was performed for the classification of acute pancreatitis , Fig. 3,3IDH was first described in 1838 by Mac Lauchlan. More than 70% of duodenal hematomas are of traumatic origin The diagnosis of spontaneous HID complicated by acute pancreatitis is based on a suggestive clinical context and biology which often shows anemia, alteration of the hemostasis balance with elevation of the lipase level 4Spontaneous intramural duodenal hematoma is a rare complication of overdosed anticoagulant therapy. It can lead to several complications including acute pancreatitis, gastrointestinal hemorrhage, or cholestasis. We reported a case of a patient with a non-traumatic IDH complicated by acute pancreatitis. We retained this diagnosis on a suggestive clinical context (patient under anticoagulant treatment), on biology  and CT imaging. Abdominopelvic CT scan plays an essential role in the diagnosis. Treatment is essentially medical. Monitoring of patients on oral anticoagulants helps prevent the occurrence of IDH and avoid its complications, which can be fatal.None.I declare on my honor that the ethical approval has been exempted by my establishment.informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Written Wissal SKHIRI writing original draftMarwa MOUSSAOUI investigationJamal SAAD resources, collecting the dataMohamed MAATOUK patient follow upAsma CHAOUCH VisualizationInes MAZHOUD validation, supervisionNot commissioned, externally peer-reviewed.None of the authors have any conflict of interest.


During Integrated Multiparametric Neurophysiological Monitoring (IMNA), a newborn with suspected hypoxia at birth and microhaemorrhagic and ischaemic lesions presented some clonic-tonic episodes with specific EEG patterns characterized by rolandic and temporal spikes and the appearance of a unilateral enhanced Somatosensory Evoked Potential (SEP) (10.45 µv). Since the literature does not seem to describe cases of giant SEP in newborns, in this case report, we will discuss the hypotheses underlying this potential. It could be assumed that the ischaemic and haemorrhagic lesions presented by the newborn may have developed as a result of neurotransmitter balance failure. This may be the origin of the EEG picture, which, consequently, could have triggered a potential with high amplitude. The role of somatosensory evoked potential (SEP) combined with EEG in the neonatal setting has already validated its importance in the evaluation of brain damage resulting from haemorrhagic and ischemic insult ,2,3,4. TThe literature describes the normative values of latency and amplitude of this component in adults  and chilThe mean amplitude of the cortical response in adults from the median nerve is 0.5–8.7 µV .Regarding the definition of giant SEP, it indicates a cortical potential of significantly increased amplitude. The so-called “giant” somatosensory evoked potentials were first detected by Dawson in 1947 . In the The first report describing giant SEPs in patients with myoclonus dates to 1946; Dawson found unusually large SEPs in the precentral area in patients with progressive myoclonic epilepsy . Since tThe literature provides us with cases of giant SEPs in adults in sepsis, cerebral hypoxia, myoclonus of various origins, progressive supranuclear palsy ,18, and In addition to adults, there are numerous cases of pathologies in children that were characterized by the appearance of this potential. Between 1989 and 1993, 282 children with different neurological diseases were registered as part of the diagnostic studies. In 31 children, the cortical component was greater than in the control group. Four children showed a giant SEP with a value of >40 µV, fifteen showed amplitudes between 20 and 39.9 µV (“high SEP”), and twelve had amplitudes between 14 and 19.9 µV (borderline SEP). There were multiple neurological pathologies of hypoxia at birth or stroke that showed “elevated” SEP [Cases of giant SEPs do not seem to be described in the literature in the neonatal setting. In particular, we do not know the specific biological mechanisms that are at the basis of the onset of this potential.In this case report, we will examine the case of a full-term newborn with suspected hypoxia at birth, who appears to have an episode of enhanced SEP in conjunction with a seizure.Since there are no data in the literature that attribute the adjective “giant” to potential with the amplitudes we have recorded, with the same recording setting and age group, we will limit ourselves to defining our potential as “enhanced”, since it is of considerable amplitude versus the mean of the amplitudes obtained by our research group in normative work conducted on newborns .We report the case of a 40-week, 4-day gestational age and 40-week, 5-day postmenstrual age full-term newborn. At birth, the newborn showed an Apgar index of (I) 6 and (V) 9, a funicular pH of 7.03, and a slightly hypotonic appearance.As the first instrumental examination, an encephalic ultrasound study showed an interhemispheric fissure inclination to the left, and the left lateral ventricle showed the presence of germinal matrix cysts.Neurological monitoring with aEEG lasting 4 h was performed 30 min after birth, with a normal trace.Integrated multiparametric neurophysiological monitoring (IMNA)  was clinSubsequently, with the end of the seizure and following the administration of phenobarbital (1 bolus of 20 mg/kg), the critical anomalies of the EEG traces disappeared. At the same time, the cortical SEPs of the left hemisphere were also normalized in terms of amplitude (3.75 µV) .An encephalic ultrasound study was repeated after the convulsive episode, which no longer highlighted the inclination of the interhemispheric fissure to the left as the previous one; the symmetry of the cerebral hemispheres was confirmed. The left lateral ventricle with the previously described germinative matrix cyst was more visible.Other monitoring was then performed: The newborn did not show other similar clinical episodes.A cranioencephalic MRI study at 7 days of age showed hyperintense spots in left fronto-parietal T1, likely a sign of microhaemorrhages.In addition, a large area of altered signal appeared at the left parieto-posterior site, extended to the splenium of the corpus callosum, with the restriction of diffusion, compatible with the ischaemic area.A slight nuance is added in T2, anterior to the left rolandic sulcus and at a deep frontal level. Furthermore, there was bilateral parieto-occipital posterior extracerebral blood collection at the tentorial and retrocerebellar level, which also extended to the vertebral canal.As a further instrumental examination, the venous and arterial MRI angiography study did not show changes in calibre. The spectroscopic examination performed with the PRESS TE 288 ms technique at the level of the left parietal lesion seemed to be compatible with a picture of subacute ischaemia.A second cranioencephalic MRI angiography performed as a follow-up at 14 days of life still showed a large area of altered left parietal-posterior signal that affects the corpus callosum to a lesser extent and did not show diffusion restriction, therefore compatible with a picture of chronic ischemia. An initial poromalacic evolution was noted. On the other hand, the posterior extracerebral, bilateral parieto-occipital blood collection at the tentorial and retrocerebellar level was reduced, with the extension of the posterior wall of the vertebral canal.Venous and arterial MRI angiography showed greater congestion of the main vessels, therefore superior sagittal sinus and transverse sinuses.The last study performed at 30 days of life showed a clear reduction in the blood component, now limited to a minimal presence in the slopes. Outcomes of an ischaemic event were noted at the left posterior parietal level, with enlargement of the subarachnoid spaces. A slight reduction in white matter was also shown. Furthermore, the corpus callosum was limited. Venous and arterial MRI angiographies were normal.The newborn was evaluated with simultaneous recording of VEEG and SEPs. According to the small size of the baby’s head, 10 paediatric disposable surface electrodes (including ground and reference electrodes) for EEG recordings were used, in agreement with the International 10–20 System.To ensure maximum symmetry during electrode positioning, SEPs responses were recorded from cortical and cervical levels using the same electrode as VEEG and the reference electrode at Fz . This double derivation for SEPs cortical responses allows us to identify the cortical component even in cases of dipole variation .Considering that the potential with high amplitude appeared during the recording, we ruled out that it might be due to an asymmetrical positioning of the active electrodes. In this case, the potential would have been asymmetrical from the beginning of the recording. We have decided not to define the potential object of our case report as giant since several authors have tried to establish a reference value higher than what the adjective “giant” could be attributed to. However, the literature, to date, does not allow us to find a common parameter setting in reference to the age range of our patient, to concretize the definition of giant SEP. We, therefore, decide to define it as “enhanced”, to mark the considerable increase in amplitude, in the absence of literature confirming a specific terminology in neonates. As previously illustrated, the literature to date does not report any cases of giant SEP in newborns, rather only in children. In this case, there are no clinical pictures reported for newborns, as there are for children, that could justify the appearance of giant SEP, such as sepsis, myoclonus, or infantile myoclonic epilepsy . The comIn fact, pharmacokinetics shows that phenobarbital acts by enhancing the inhibitory action of GABA and reducing the excitatory effects of glutamate . From this, by inverse reasoning, this cortical disinhibition can be understood as a temporary loss of GABAergic inhibitions originating at cortical interneurons . This isThe pathophysiology of enhanced/giant cortical SEPs is still uncertain, as well as the nature of the post-excitatory phenomena that likely create them. Neuronal populations that are generators of normal SEPs likely also induce giant N20-P25 and P25-N33 potentials .This is in agreement with what was reported by Valeriani et al. , who evaFurthermore, the rearrangement of the circuits leading to hyperexcitability can sometimes activate “inactive” cortical zones in the derivation of the normal SEP components, thus contributing to the “giant” components . HoweverThis difficulty in finding a common origin or common pathophysiology of these potentials leads us to the likely hypothesis that there is not only a single dipole and a single progression of the event.Reconstructing the reasoning from the fact that, at the end of the seizure and with the subsequent phenobarbital administration, the newborn showed the disappearance of the EEG and clinical pattern, as well as the correlated enhanced cortical potential, it could be advantageous to consider the ischaemic and haemorrhagic lesion as a factor that may have made the neurotransmitter balance unstable, an equilibrium that a neonatal brain has not yet fully achieved.The concept necessary to evaluate is the balance of GABA and glutamate in the newborn.A receptors in foetuses and infants causes excitatory phenomena. The transition from excitatory to inhibitory development in GABA reportedly occurs in the weeks following childbirth, characterized by a decline in NKCC1 expression and an increase in the Cl− - extruding K+ -Cl− co-transporter, KCC2 [GABA is the main inhibitory neurotransmitter in the brains of older infants, children, and adults, but the activation of chlorine permeable GABAer, KCC2 .Glutamate is expressed early in brain development and plays an essential role in activity-dependent plasticity and synaptic refinement ,35,36,37Both glutamate receptor (NMDA) activation and antagonism are implicated in increasing excitotoxicity and apoptotic neuronal damage, respectively ,35.Therefore, perinatal distress or hypoxia can alter these development-regulated transitions and/or can trigger potentially excitotoxic events following perinatal hypoxia/ischaemia that is not detected by conventional neuroimaging .A study conducted by Kilb et al. in 2012 assessed the maturation of GABA from birth to adolescence. During the antenatal period and in the early postnatal phases, GABAergic responses are depolarizing, hence excitatory, and transform into inhibitory responses during the first postnatal weeks .GABAergic depolarization favours dendritic differentiation and the generation of excitatory synapses ,41, whilA-mediated transmission is still depolarizing. However, the precise mechanism by which GABAergic transmission promotes the onset of GDP is unknown [From the aforementioned study conducted by Sipila et al. in 2005, spontaneous periodic activity emerges as a feature of neuronal network development and is involved in neuronal circuits maturation. In the immature hippocampus, these are defined as “giant depolarizing potentials” (GDPs) during the neuronal development phase, when GABA unknown .As previously mentioned in the literature, there are no cases of giant SEPs in newborns, and there does not seem to be any evidence of the specific triggering causes.Considering, therefore, that the glutamate levels increase during perinatal hypoxia; it is not certain that GABA has already developed its inhibitory function during the first days of newborn birth ; and, lastly, the complete regression of the symptoms (due to ischaemic and microhaemorrhagic lesions) with the end of seizures and the subsequent phenobarbital administration, it can be hypothesized that, in this case, the appearance of an EEG and clinical picture such as the one developed by the newborn and, in parallel, an enhanced SEP, may be the result of these factors. In support of this hypothesis is also the fact that there may be other contributing causes at the basis of this potential, the pathophysiology of which is still not completely known.


Pulmonary blastoma is an extremely rare and highly aggressive tumor. Only a few hundred cases of pulmonary blastoma have been reported. In other cases, a definitive diagnosis is often made through surgical resection. The use of preoperative histopathological sampling in diagnosing was of limited value because of the variety of pulmonary blastoma histology. And there was no literature that the first biopsy was attempted with medical thoracoscopy for diagnosis.A 65-year-old man presented to our hospital with pleural effusion and lung mass.The patient was initially diagnosed with dedifferentiated chondrosarcoma by medical thoracoscopic biopsy but the final diagnosis was pulmonary blastoma through bilobectomy.Medical thoracoscopy, and video-assisted thoracoscopic surgery (bilobectomy) followed by adjuvant chemotherapy.After surgical resection of the tumor, adjuvant chemotherapy has been performed 5 cycles at 3 weeks intervals, and there was no evidence of recurrence on follow-up computed tomography performed 4 months after surgery.Medical thoracoscopy is useful for the diagnosis of indeterminate pleural effusion; however, caution is needed when confirming rare malignancies, such as pulmonary blastoma. Although surgical resection is the treatment of choice, appropriate adjuvant chemotherapy to improve the prognosis may be necessary if there is pleural metastasis. Only a few hundred cases were reported in the literature.,3 The pathogenesis of these tumors remains uncertain, but owing to their resemblance to fetal lung tissue, it has been proposed that they originate from pluripotent PB.,5 PB usually presents as a mass on chest radiography, as in the present case. The use of preoperative histopathological sampling in diagnosing PB by methods such as needle aspiration was of limited value because the histology of PB varies and is misleading with features resembling adenocarcinoma or another sarcoma of the lung. So in other cases, a definitive diagnosis of PB is often made through surgical resection. But there was no literature that the first biopsy was attempted with medical thoracoscopy (MT) for diagnosis of a PB case. Herein, we report the case of PB treated by bilobectomy which was first diagnosed as dedifferentiated chondrosarcoma using MT.Pulmonary blastoma (PB) is an extremely rare and highly aggressive tumor, constituting approximately 0.5% of all lung tumors.Chest radiography in a 65-year-old man with mild dyspnea and right-sided chest discomfort revealed a mass in the right lower lung field. His medical history was uneventful except for previous dyslipidemia. He had a 15-pack-year smoking history but had denied smoking since 2000. He denied alcohol consumption, tuberculosis exposure, occupational exposure to asbestosis or teratogenic materials, or a family history of malignancy.Chest radiography revealed mass opacities in the right lower lung fields Fig. A. Chest We performed diagnostic and therapeutic thoracentesis and planned an enhanced chest CT tracing. Pleural effusion analysis showed lymphocyte-dominant exudate, and the results were as follows: protein > 5000 mg/dL, LDH 553 U/L, pH 7.555, glucose 231 mg/dL, polymorphonuclear cell: 12%, mononuclear cell: 88%, ADA 19 IU/L, negative for AFB, negative for MTB PCR, and no microorganism was isolated from the culture specimen. Cytological tests also reported non-diagnostic, benign cellular changes without malignant cells. Follow-up chest radiography (Fig. The patient was admitted to the emergency room and underwent percutaneous catheter drainage of the right lung. MT was performed as the diagnostic method. In MT, the pleural space was separated, and severe adhesion of the pleura was observed Fig. A. As manThe histology of the white mass revealed malignant mesenchymal tumor cells Fig. A. ImmunoAn exploratory thoracotomy was performed. A pleural frozen biopsy was performed at 5 sites through surgery, and a large mass originating from the right lower lung adjacent to a minor fissure was observed, which could not be fully dissected; thus, bilobectomy was performed Fig. B. The meThree weeks after discharge, he visited an oncologist and started adjuvant chemotherapy with etoposide, ifosfamide, and cisplatin. To date, chemotherapy was performed 5 cycles at 3 weeks intervals, and there was no evidence of recurrence on follow-up CT performed 4 months after surgery. Preoperative biopsy could be attempted but caution is needed when confirming rare malignancies with various histological types including PB. Surgical resection is the treatment of choice for PB. However, the prognosis of PB is considered poor. The 5-year survival rate for PB is documented at 16% to 25%, and 10-year at 8%. And the 5-year overall survival for patients with localized stage was more than 75%, while for patients with regional or distant stage was less than 40%. Therefore, surgical resection that does not leave residual mass is important for treatment. But local recurrence occurs in 43% after surgical resection, and regional and distant metastases are frequently reported.,10PB is an extremely rare and highly aggressive tumor, constituting approximately 0.5% of all lung tumors. In this case, adjuvant chemotherapy with etoposide, ifosfamide, and cisplatin has been performed because post-operative final pathologic stage was pT4N0M1 with R2 resection.Chemotherapy and radiotherapy also have been used for the patients with advanced stage. But no standard treatment guidelines have been established for inoperable cases. Chemotherapy regimens selected include various combinations of agents like cisplatin, etoposide, ifosfamide, mitomycin C, and pemetrexed.We present the diagnosis process of the case of PB, a rare pulmonary malignancy. And the patient treated with surgical resection and adjuvant chemotherapy. This case is interesting in that the first biopsy attempt was done through a MT and the lesson was learned to be caution is needed when confirming rare malignancies, such as PB. Although efforts have been made for complete resection with wide surgical margin excision, appropriate chemotherapy to improve the prognosis may be necessary if there is pleural metastasis as in this case.Conceptualization: Tae Hun Kim, Jae Hyun Jeon, Jin-Haeng Chung, Young-Jae Cho.Data curation: Tae Hun Kim, Jin-Haeng Chung.Investigation: Tae Hun Kim, Jae Hyun Jeon, Young-Jae Cho.Supervision: Jae Hyun Jeon, Jin-Haeng Chung, Young-Jae Cho.Writing – original draft: Tae Hun Kim.Writing – review & editing: Tae Hun Kim, Jae Hyun Jeon, Jin-Haeng Chung, Young-Jae Cho.


Myoepithelioma-like hyalinizing epithelioid tumors are rare neoplasms that share morphological characteristics of myoepitheliomas but lack traditional immunophenotypic findings. Though little is known about these tumors at present, a handful of recent studies have confirmed that they harbor a novel fusion gene known as “OGT-FOXO.” Though closely resembling myoeptheliomas, Myoepithelioma-like hyalinizing epithelioid tumors are considered a distinct tumor entity, and few studies have explored their clinical characteristics or their potential for malignancy. Furthermore, literature describing imaging findings of these tumors is virtually non-existent. Understanding the radiological and pathological differences between Myoepithelioma-like hyalinizing epithelioid tumors and myoepitheliomas is helpful in developing a comprehensive differential for soft tissue neoplasms of the foot. We describe a case of MHET of the foot and correlate MRI findings with pathology in addition to describing surgical technique and implications to care. Myoepithelial tumors are uncommon, soft-tissue neoplasms which are commonly found in the soft tissue of the extremities and limb girdles. They affect men and women equally, with mean age of incidence occurring at 40 years Diagnosis of most tumors requires tissue biopsy, assessment of morphology, immunohistochemistry (IHC), and genetic analysis once a mass is identified via physical exam and/or imaging The Forkhead box O-class subfamily includes transcription factors FOXO1, FOXO3, FOXO4, and FOXO6. FOXO proteins are tumor suppressor genes that regulate cellular differentiation, apoptosis, and cell proliferation. O-GlcNAc transferase (OGT) gene is an enzyme involved in protein glycosylation, regulating gene transcription, protein stabilization, and degradation. It is believed that the OGT-FOXO fusion causes glycosylation of FOXO, increased OGT activity, and possibly tumor growth through this mechanism A 58-year-old male initially presented to his podiatry clinic with foot pain 9 months after noticing a mass on the dorsum of his left foot .Fig. 1PhThe patient reported that the mass quickly grew over the few months prior and was now associated with pain. Associated symptoms included numbness, tinxgling, and difficulty wearing shoes. The severity of pain worsened over time, and the patient eventually required a cane to ambulate. During his visit, an X-ray was performed, which demonstrated a soft tissue mass along the dorsal aspect of the medial mid foot .Fig. 2RaAn MRI was ordered for further characterization. However, the patient had not followed up and subsequently presented to the ED 6 months after the initial presentation. At that time, the tumor had been present for about 1.5 years with significant interval growth, decrease in digital range of motion (ROM), interfering with the patient's activities of daily living. The MRI demonstrated an enhancing mass measuring 2.6 × 6.0 × 6.9 cm along the dorsum of the midfoot surrounding the extensor hallucis longus (EHL) and extensor hallucis brevis (EDB) tendons .Fig. 3 studies were negative for EWSR1 and NR4A3 which excluded the diagnosis of extraskeletal myxoid chondrosarcoma. Although the tumor appeared benign on histologic examination, it had an unknown malignant potential. The patient was presented options for amputation versus mass resection. The patient elected to undergo operative excision of the mass .Fig. 5GrSurgical intervention was staged in 2 parts and consisted of core decompression biopsy by the Division of Foot and Ankle Surgery and definitive excision by the Orthopedic Oncology Service.Percutaneous skin incision was made over the largest lobe of the tumor at the dorsal medial foot. Blunt dissection through subcutaneous tissue and sharp incision through the tumor capsule was performed. Superficial and deep biopsies of the tumor were obtained and sent in formalin for pathologic analysis.A 9-cm longitudinal skin incision was made over the mid-dorsal aspect of the mass. The mass's capsule was incised in line with skin incision and bluntly released from surrounding soft tissues. The dorsal pedal neurovascular bundle was identified inferior and lateral to the mass, and subsequently protected. A cobb elevator was used to resect the mass which abutted underlying bone. The EHL and EDB tendons had been fully encapsulated by the mass and were sacrificed during mass excision. The mass was removed en toto and sent to pathology for final analysis. The mass measured approximately 6.0 × 7.0 × 3.0 cm . This waThis MHET diagnosis has only been described 4 times previously in the literature and descriptive imaging findings were never reported Our case of MHET demonstrated intermediate T1 signal and high T2 signal with cystic components, imaging findings that were consistent with those described above, which posed challenge in developing a differential diagnosis. With no distinctive imaging findings to differentiate MHETs from myoepitheliomas, tissue biopsy was necessary for diagnosis. Biopsy results of our patient revealed no cytologic atypia, mitotic figures, or necrosis, indicating benign tumor characteristics. Identifying the novel OGT-FOX03 fusion gene and absence of typical pathognomonic immunophenotypic supporting features of myoepitheliomas allowed for diagnostic confidence.Pathology of previously reported myoepithelioma-like hyalinizing epithelioid tumors describe well demarcated tumors with hyalinizing to myxoid stroma and epithelial tumor cells. A matrix component consisted of eosinophilic collagen. Epithelioid tumor cells with uniform, rounded nuclei were arranged in cords or nests The pathology relating to these myoepithelioma-like hyalinizing epithelioid tumors demonstrates a benign nature of the tumor. In a study of 401 soft tissue tumors, Kaposi's sarcoma and synovial sarcoma were the most common malignancies of the foot Surgical intervention was staged with a needle biopsy followed by definitive excision. The initial surgical biopsy helped determine the treatment plan and prognosis for limb preservation. At most recent follow up, the patient was overall doing well with some reported paresthesia to dorsal foot and difficulty with active ROM of digits 1-3 secondary to EHL/EDL tendon sacrifice. Due to the rarity of this tumor, the most immediate concern is local recurrence. The consensus recommendation between orthopedic oncology, medical oncology, and pathology was for a repeat MRI and clinical exam in 6 months.MHETs are an extremely rare distinct tumor entity from myoepithelial tumors which harbor a novel OGT-FOX03 fusion gene. There are no distinctive MRI findings that can differentiate them from myoepithomas in the soft tissue. Tissue biopsy is required for definitive diagnosis of these tumors. Future studies with patient follow up of documented cases are required to better elucidate their malignant potential and establish standardized treatment guidelines.All authors contributed to project conception, manuscript preparation, and manuscript editing.A written consent was obtained from the patient for publication of this case and any accompanying images.


Point-of-care ultrasound (POCUS) in the head and neck region plays a particularly significant role in the diagnosis and treatment of upper airway stenosis, swelling, and painful diseases in the neck, and in the evaluation of swallowing function. Therefore, it should be performed in various medical settings beyond the boundaries of the clinical department such as general medicine, emergency medicine, anesthesiology, orthopedics, and pediatrics. The target diseases are salivary gland disease, lymph node disease, pharyngeal disease, laryngeal disease, esophageal disease, thyroid disease, and dysphagia and dyspnea due to various causes. Head and neck POCUS is an extremely useful diagnostic method for both patients and doctors, and its use is expected to become more widespread in the future. Point-of-care ultrasound (POCUS) is an examination procedure for doctors to make an ultrasound diagnosis as part of the initial examination and determine a medical treatment plan in primary care. Head and neck anatomy is complicated as various organs with various functions are confined to a small region, and a variety of diseases and conditions can arise in this region. In the head and neck region, lesions may occur near the body surface and can be easily visualized by ultrasound. Thus, POCUS is effective in obtaining accurate information rapidly at the early stage of treatment.POCUS in the head and neck region plays a particularly significant role in the diagnosis and treatment of upper airway stenosis, swelling, and painful diseases of the neck. Therefore, it should be incorporated into daily medical care beyond the boundaries of the field, including general medicine, emergency medicine, anesthesiology, orthopedics, and pediatrics, as well as medical care by specialized departments of the head and neck. However, a comprehensive POCUS education system and training curriculum have not yet been established –4.The anatomy of the head and neck is complicated and difficult to understand. Therefore, it is necessary to have sufficient knowledge to correctly identify what is visualized on ultrasound. In addition, since there are individual differences in the thickness and length of the neck, it must be taken into consideration that the depth and size of organs seen on ultrasound images varies from patient to patient.Patients with a severely swollen neck, having difficulty breathing, or severe pain may have restrictions on their posture and position. When the examination is performed with the patient in an inadequate position, it may not be possible to determine which part of the neck is currently visible. As a solution in such cases, it is recommended to first find the pulsating common carotid artery in the cervical transverse view that is easily recognizable in the neck. After detecting the common carotid artery, the thyroid gland and trachea and other structures can be identified by confirming the positional relationship.A linear probe with a frequency of around 10 MHz and a field of view of around 40 mm is suitable for head and neck POCUS. A lightweight and thin-shaped probe makes it easy to grip and adjust the angle, and it is easy to apply to various surfaces of the neck. Head and neck POCUS may sometimes need to be performed in a difficult position in various environments, so it is best to use a system that is easy to operate. Since POCUS must be performed in various environments and even in inconvenient situations, small machines with good operability  are more suitable than large high-end models with multiple functions –8.Naturally extending the patient's neck in the supine position makes it easier for the probe to fit the skin of the neck and makes it easier to scan the entire neck. The supine position with the patient's chin slightly raised and both knees bent is specifically recommended because it can relax the anterior neck, chest, and abdomen, and it does not interfere with natural breathing movements. Shoulder pillows are not needed as they overextend the patient's neck and cause tension in the neck muscles. Of course, if the patient has painful symptoms, it is important to devise a comfortable posture according to the patient's condition. If the patient has difficulty in the supine position due to severe pain or severe dyspnea, the examination may be performed in the sitting or lateral decubitus position. In these cases, it is necessary to consider that there are some limitations in the observable region and that various organs are in a different positional relationship in the sitting position or the lateral decubitus position than in the supine position. In the sitting position, the mandible lowers due to the weight of the skull, which makes it exceedingly difficult to examine the submandibular region and the upper neck area. Also, the organs in the lower neck are pulled into the mediastinum. Furthermore, it should be noted that in the sitting position, the blood vessels of the venous system collapse, which makes it difficult to identify the blood vessels and their blood flow. In addition, when performing an examination in a sitting or lateral decubitus position, the doctor is also forced into an unnatural posture, which makes a lengthy examination difficult. The posture of the doctor performing the examination should also be as comfortable as possible.When performing an ultrasound examination of the neck, a linear probe is usually used to continuously scan the left and right sides and the midline of the neck. The cervical organs are covered with fascia and are bounded by layers of each fascia, and various organs such as blood vessels, muscles, and pharynx and larynx run vertically to connect the head with the thorax and shoulders. Therefore, the probe is moved up and down while looking at the transverse-sectional image of the neck, and the location of the lesion is confirmed while following the continuity of the blood vessels and fascia. In addition, since the submandibular gland and the parotid gland exist at the end of the neck, it is necessary to consider the anatomical features when scanning. These series of procedures are called ‘‘systematic cervical ultrasonography’’ as a procedure for observing the entire neck briefly Fig. . This isIn an emergency such as upper airway obstruction with severe dyspnea, there may only be time for an airway examination, but no matter how urgent, you should try to observe the entire neck as much as possible.One of the most urgent conditions in the head and neck is upper airway obstruction. Diseases that cause upper airway stenosis include acute upper respiratory tract inflammation, laryngeal tumors, pharyngeal tumors, bilateral vocal cord midline fixation due to bilateral vocal cord paralysis, and foreign bodies in the larynx and trachea. Head and neck POCUS is often useful in diagnosing upper airway obstruction when specialized laryngeal fiberscope examination is not available. Not only abnormal findings of the pharynx, larynx , and trachea but also submucosal lesions and abnormalities can be easily detected –11. POCUWhen patients complain of dyspnea, diseases that occur in the lower respiratory tract such as the bronchi and lungs are usually considered, but upper airway POCUS should also be performed as primary care for dyspnea. Swelling of the laryngeal mucosa; tumors of the larynx, trachea, and its surroundings; thyroid lesions; deformity of the thyroid and cricoid cartilage; and vocal cord paralysis should be checked as pathological conditions. If an abnormality in the upper airway is suspected based on head and neck POCUS, professional treatment by an otolaryngology head and neck surgeon should be arranged immediately. Among the diseases that cause upper airway obstruction, in the case of acute epiglottitis and laryngeal cancer, there is a risk of airway edema and bleeding due to inadvertent intratracheal infusion, which promotes airway obstruction and leads to choking.In POCUS of the larynx, movement of the vocal cords, properties of the vocal cords and surrounding tissues, and findings of the epiglottis are observed Fig. . The thyThe epiglottis is observed in a transverse section view between the thyroid cartilage and the hyoid bone or from the upper edge of the hyoid bone between the base of the tongue and the larynx. In a normal epiglottis, the flat epiglottis cartilage appears as a hyperechoic line, but in patients with acute epiglottitis, the epiglottis becomes edematous with inflammation following infection-induced pharyngitis and the mucosa surrounding the epiglottis swells and thickens. appearing as a hypoechoic sphere obstructing the airway on POCUS Fig. .Fig. 3AcLaryngeal cancer also causes airway obstruction. In the type that progresses submucosally, laryngeal cancer invades the thyroid cartilage slowly without symptoms such as hoarseness or pain, and airway stenosis may gradually progress unnoticed. It is also important to know that laryngeal cancer is a common cancer among smokers and is often misdiagnosed as asthma or chronic obstructive pulmonary disease. Since dyspnea and wheezing during inspiration are findings peculiar to upper airway obstruction, POCUS of the larynx should be performed to check for neoplastic lesions and thyroid cartilage invasion. Laryngeal cancer that has invaded the thyroid cartilage can be very easily seen with ultrasound.The main causes of vocal cord paralysis are surgical injury and malignant tumor infiltration to the recurrent laryngeal nerve. When the vocal cords on both sides are fixed in the median position, upper airway obstruction occurs, and dyspnea appears. To diagnose vocal cord paralysis with POCUS, it is necessary to carefully observe and compare the movements of the vocal cords and arytenoid cartilage on both sides.Since stenosis and obstruction from the subglottic region to the trachea cannot be seen on laryngeal fiberscope examination, POCUS should be used to confirm the presence or absence of airway stenosis. In this region, the thyroid cartilage, the cricoid cartilage, and the tracheal cartilage are continuously observed in a transverse section view to diagnose the presence or absence of lesions in the cartilage lumen. This is a useful technique for diagnosing subglottic neoplastic lesions, foreign bodies, cricoid cartilage, and tracheal cartilage fractures and deformities.Head and neck POCUS plays a significant role in the primary care of patients who complain of cervical swelling, neck mass, and neck pain.Since it is difficult to communicate symptoms in the neck, patients often cannot correctly convey symptoms such as tumors, swelling, and pain, or the site with symptoms, and the chief complaint is often vague and ambiguous. The main complaints that are often expressed are hoarseness, difficulty speaking, difficulty breathing, shortness of breath, feeling pain, swollen neck, lump in the neck, pain in the neck, pain in the throat, pain on swallowing, discomfort in the throat, difficulty swallowing, and easy aspiration. Sometimes, the site where the patient complains of symptoms and the site where the lesion occurs may be different. Observing the entire neck with POCUS, keeping in mind all potential diseases and their characteristics, is a shortcut to a correct diagnosis.Visual inspection and palpation are usually performed on the neck, but palpation may be difficult depending on the condition of the patient's skin and muscles and the depth of the lesion. In such cases, POCUS can play a significant role, but if there are open wounds, subcutaneous emphysema, and/or hematoma at the examination site, it may be difficult to diagnose even with POCUS. In such cases, the need for examination by another modality such as CT must be properly decided.Diseases that cause cervical swelling and pain include inflammation and tumors of the cervical lymph nodes, submandibular glands, parotid glands, thyroid gland, pharynx, larynx, and cervical esophagus. It should be noted that patients with thyroid disorders, especially subacute thyroiditis, often complain of a sore throat and pain on swallowing rather than pain in the thyroid area. In addition, blood vessels such as the common carotid artery and internal jugular vein, muscles and nerves also cause neck swelling and pain.Salivary gland diseases such as sialolithiasis, acute and chronic inflammation, benign and malignant salivary gland tumors, and salivary gland autoimmune diseases cause neck swelling and neck pain. Since malignant tumors account for about 30% of salivary gland tumors, and it is also known that they change from benign to malignant, appropriate management is required . If a saLymph nodes are widely distributed in the neck and swell due to various causes such as reactive lymphadenopathy due to inflammation and infection, metastasis of cancer, and malignant lymphoma . In headThe thyroid gland, which is located in the anterior neck in front of the trachea and larynx, can be easily observed by applying a probe to the anterior neck. Benign lesions that are not the target of aggressive treatment are often visible, so proper judgment is required. By performing POCUS, diagnosis of diffuse thyroid disease such as chronic thyroiditis (Hashimoto's disease) and Basedow's disease (Graves’ disease), benign thyroid tumors, thyroid cancer, parathyroid disease, cricoid retropharyngeal cancer, and cervical esophageal cancer is possible Fig. .Fig. 4AdIt is also possible to evaluate swallowing function with POCUS Fig. . By obseFrom the preceding phase to the oral phase, observe the oral cavity from the submandibular area with POCUS. Visual information during the preceding phase stimulates salivation. During the masticatory phase, a large amount of saliva is observed to be released from the submandibular gland, and the movement of the tongue mixes food and saliva. During the oral phase, the base of the tongue rises and feeds the food mass into the pharynx. During the pharyngeal phase, a mass of food is sent from the pharynx to the esophagus. Observations from the submandibular area show elevation of the base of the tongue and contraction of the lateral wall of the pharynx. Observations of the submental cervical transverse section view show large movements of the base of the tongue and the collapse of the epiglottis. In addition, the anterior cervical longitudinal section view shows the elevation of the hyoid bone and thyroid cartilage toward the head. In the esophageal phase, you can see that the food mass sent from the pharyngeal phase vigorously passes through the cervical esophagus. By using ultrasound, it is possible to perform the examination with the contents of the meal that the patient usually eats in the environment where the patient usually lives, even if it is not a special examination room.In patients with dyspnea, head and neck POCUS should be used to diagnose the condition of upper airway obstruction and its causes. When performing POCUS in patients with neck swelling or neck pain, the entire neck should be examined as one organ. It is important to diagnose the presence or absence of lesions and the location of lesions, and to perform qualitative diagnosis based on comprehensive knowledge of head and neck anatomy and diseases. With the miniaturization and weight reduction of ultrasonic diagnostic equipment, the range of utilization of POCUS will be further expanded, such as swallowing function evaluation and its rehabilitation and home medical care. Head and neck POCUS is an extremely useful diagnostic technique for both patients and doctors, and its use is expected to become more widespread in the future.


TP53, PTPRB, PLCG1, KDR as well as FLT4 amplification have been observed in AS. There is a potential therapeutic value of inhibition of the VEGF pathway against angiosarcoma. Our case first described a patient with two sites of cutaneous angiosarcomas (cASs) that responded differently to anlotinib. And genetic analysis revealed that those two sites had different FLT4 variants, suggesting that FLT4 amplification could be the cause of anlotinib non-response.Angiosarcoma (AS) is a rare, clinically aggressive tumor with limited treatment options and a poor prognosis. Mutations involving the angiogenesis-related genes Angiosarcomas (ASs) are rare, aggressive tumors of vascular or lymphatic endothelial cell origin that account for about 2%–3% of all adult soft tissue sarcomas. They can arise from anywhere on the body, with cutaneous angiosarcomas  involving the head and neck, particularly the scalp, followed by the breast, extremity, trunk, liver, and other sites , 2. ASs When compared to Western countries, approximately 50%–60% of cutaneous angiosarcomas (cASs) originate in the head and neck, with Asians involving up to 90% of the scalp and face . cASs arSurgical resection with wide excisional margins is the main therapy for R0 resection cASs, but due to insufficient surgical excision and the infiltrative growth pattern, local recurrences or metastases are common, particularly in head and neck locations, with 5-year overall survival of 10%–15% , 12. SevMYC, KLT4, FLT4, and recurrent mutations in TP53, PLCG1 (R707), and PTPRB, as well as genetic alterations in the mitogen-activated protein kinase (MAPK) pathway, have been reported in ASs . The sequencing results showed that the primary lesions only had the EK2/IRS1 Table 1.FLT4 F131S mutation to regorafenib was not ruled out because of its extracellular location and complicated genomic profiles  1, VEGFR3, VEGFR2/KDR, platelet-derived growth factor receptor a (PDGFR-a), c-Kit, and fibroblast growth factor receptor (FGFR) 1–3 and inhibits tumor angiogenesis and tumor cell proliferation. It has been approved as a third-line treatment for patients with advanced non-small-cell lung cancer (NSCLC)  that targets vascular endothelial growth factor receptor ( (NSCLC) . Based o (NSCLC) . A phase (NSCLC) . More tr (NSCLC) . So far, (NSCLC)  and card (NSCLC)  or combi (NSCLC) . In the FLT4 gene encodes VEGFR3 and is involved in lymphatic differentiation. It has been reported that inappropriate genetic abnormalities of VEGFR signaling are critical in the genesis of angiosarcomas . The FLT1 gene encodes VEGFR1 and is a member of the VEGFR family. The point mutation c.542G>A was found in FLT1’s Ig-like domain 2, which is a high-affinity ligand-binding region  and endometrial cancer (37%) being the most common  for the publication of any potentially identifiable images or data included in this article.YiG treated and observed the patient. YuG, JM, and YiG collected the clinical information, diagnostic information, therapeutic information, and images of the patients. JL performed the histopathological and immunohistochemical examinations. YiG, YuG, JM, and JL prepared the manuscript and the literature search. YJ, XY, and TS performed data analysis and interpretation. YiG and JM reviewed and edited the manuscript. All authors contributed to the article and approved the submitted version.Authors YJ, XY, and TS are employed by Jiangsu Simcere Diagnostics Co., Ltd.The remaining 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.


Dermatofibrosarcoma protuberance represents less than 0.1% of all tumors, treatment of which requires wide local excision (≥5cm) but recurrence is not rare. Here we present a 32-year male presented with a swelling of 15 × 6cm over the left lumbar region for which he underwent excision three years ago, the histopathological examination of the swelling, showed a malignant mesenchymal tumor and Immunohistochemistry features were suggestive of Dermatofibrosarcoma protuberance. After three years of interval, he again presented with complaints of swelling in the previously operated site for nine months and underwent excision of the mass with Split Thickness Skin Graft. Although the tumor was confined to the skin and subcutaneous tissue in the present case, the patient didn't undergo any adjuvant radiotherapy to avoid a possible relapse that would infiltrate deeper structures for the first time. Being a recurrent tumor, long-term follow-up is strongly recommended. Originally present as a skin-colored plaque with possible dark red or blue discoloration which is painless. DFSP is a rare soft tissue neoplasm with low grade malignancy.2Dermatofibrosarcoma protuberance (DFSP) was first described by Darier and Ferrand in 1924, but the definition of "DFSP'' was established by Hoffman in 1925.2 We present a 32-year male presented with a swelling over the left lumbar region for which he underwent excision.The annual incidence is reported to be 0.8-4.5 cases per million in the USA. The most common location being the trunk (42-72%) followed by proximal extremities (20-30%), and head and neck (10-16%).A 32-year-old man presented with a mass located at the left loin, increasing in size associated with pricking pain for nine months . The patAt this presentation on physical examination, two firms, painless, masses of 8 × 3cm and 6 × 3cm was noted on the left loin with approximately 20cm horizontal scar mark on the overlying skin with no sign of inflammation. There were no palpable cervical or axillary lymph nodes. There was neither personal nor familial history of any skin or soft tissue malignancy.On soft tissue ultrasound, a well-defined hypoechoic lesion of 55.4 × 40.1 × 39.2mm was noted within the subcutaneous plane of the left lumbar region, suspected to be a recurrence. Magnetic resonance imaging (MRI) of the left lower abdominal wall demonstrated two oval lesions of 8 × 4.7 × 5cm and 3.5 × 3 × 1.5cm in the subcutaneous fat plane at the left loin region .An fine needle aspiration cytology of the tumor was done before planning for surgery which revealed the finding consistent with a tumor of the mesenchymal origin. All these findings were consistent with the recurrence of the previous lesion and the patient was prepared for surgery. Pre-anesthetic consultations were done and proper consent was taken from the patient. The patient underwent local excision of the tumor with a 3cm peripheral margin and the tissue defect that was created post-operatively was closed with a split-thickness skin graft taken from the left gluteal region. Mass of 8 × 5cm was excised and sent for HPE . Special6 Lipoma, myofibroblastoma, fibromatosis, keloids, and hypertrophic scars are some of its differential diagnoses. The tumor is primarily located at the dermis with some variants that permeates to the subcutaneous plane.7 Less than 5% of the tumors present with metastatic disease, the most common site for metastasis is the lungs and the lymph nodes.8The most frequently seen clinical scenario in dermatofibrosarcoma is its typical protuberant appearance. It can masquerade amorphea-like lesions with an appearance of an atrophic plaque at times.10 MRI is used widely to identify the extent of the disease and then plan for surgical resection but MRI also fails to distinguish the disease from other soft tissue conditions.Histopathological examination often supplemented with immunohistochemistry is the standard for diagnosing the condition. On ultrasound of the lesion hypoechoic or mixed hyperechoic appearance is seen with regular or irregular margin and a pseudopodialike projection such feature is also seen in conditions like lipoma, so diagnosis cannot be made based on the ultrasound findings.12 Incidence of less than 5% of recurrence was noted in series where a 5cm margin was taken.11Wide local excision is the standard of care in these conditions. A margin of 3 to 5cm is the usual recommendation.The skin, subcutaneous tissue, and the underlying fascia are respected en-mass while exercising such a lesion. In conditions where the bone has involved the periosteum or even a part of the underlying bone needs to be excised to acquire a negative margin. On excision of a large tumor with adequate margin, the closure of the defect is often a challenge. The functional deformity is an issue when a large defect needs to be made while excising such tumors with adequate margin, cosmetic distortion is also a problem that needs to be addressed at times, depending on the location of the tumor. The Mohs micrographic surgery is advocated these days as an initial modality of treatment provided the disease is limited to a small area.13 The failure to take radiation after surgery due to poor patient compliance could be a possible cause of recurrence in our case.Radiotherapy for local control is used as an adjuvant treatment, in cases when the tumor is adequately excised and the margins are clear. However, it can also be used as the sole modality of care when the tumor is inoperable. Tumors with a positive margin post-resection are also treated with radiotherapy. A cure rate of up to 85% has been noted with the use of radiotherapy.14Reports have shown the development of new lesions appearing even 5 years after treatment, which demands the need for twice-yearly clinical evaluation and monitoring of patients for an extended postoperative period.The origin of DFSP being dermis and tending to infiltrate underlying structures is the most common cutaneous sarcoma. It may infiltrate deeper structures like muscles, tendons, fascia and bone. In the present case, the tumor was confined to the skin and subcutaneous tissue, and our patient didn't undergo any adjuvant radiotherapy to avoid a possible relapse that would infiltrate deeper structures for the first time. Being a recurrent tumor, long-term follow-up is strongly recommended.


Leiomyoma is a benign smooth muscle tumor, more commonly found in the uterus (95%), skin (3%), nutritional and gastrointestinal tracts (1.5%)The goal was to describe a case with clinical manifestations and histopathology findings of angioleiomyoma of the nasal septum, a rare benign neoplasia which represents less than 1% of all the leiomyomas in the human bodyM.F.L.S., 62 years, female, Africandescendant, she came to our ENT service complaining of a tumor in her left nasal cavity with six years of evolution. In the three initial years it had a progressive growth, associated with low volume epistaxis episodes. After such period, she developed nasal obstruction on the left side and facial pain. Upon physical exam and fibroscopy we noticed a brown, smooth, pedicled lesion on the left-side septum, well outlined, measuring approximately 4 × 2cm, completely occluding the left nasal cavity and pushing the nasal septum. CT scan of the paranasal sinuses showed a well-outlined soft tissue mass, pushing the septum and the lateral wall. Biopsy reported leiomyoma. Later on, the tumor was endoscopically resected, with a 1cm margin, considered adequate according to anatomical and pathological criteria. Microscopy showed polypoid fragments, coated by a single layer of cylindrical hair cells, typical pseudostratified, showing in the stroma, typical leiomyoma bundles around the thick walls of vessels. Figure 1SThis is a slow growth tumor. The most common symptoms are: nasal obstruction, epistaxis, facial pain and headaches. He most frequent treatment for nasal septum angioleiomyoma is endoscopic resection with macroscopic margin, and this was the treatment option for this case - excision with macroscopic and microscopic free margins. Vascular leiomyomas are bundles of smooth muscle cells, relatively organized, and permeated by thick wall vesselsThe nasal septum vascular leiomyoma is an extremely rare tumor, of uncertain origin


Additionally, focal to multifocal areas with signal void in both dogs and caudal transforaminal herniation of the cerebellum in one dog was observed. Post mortem histopathological examination revealed lympho-histiocytic encephalitis and central nervous system (CNS) vasculitis in all dogs. No infectious agents were detectable by histopathology (hematoxylin and eosin stain), periodic acid-Schiff reaction (PAS), Ziehl-Neelsen stain and immunohistochemistry for Canine adenovirus-1, Parvovirus, Listeria monocytogenes, Parainfluenzavirus, Toxoplasma gondii, Herpes-suis virus, Pan-Morbillivirus, Tick born encephalitis virus, Severe acute respiratory syndrome coronavirus (SARS-CoV) 2. Furthermore, two dogs were tested negative for rabies virus. To the best of the authors' knowledge, this is the first report of a lympho-histiocytic encephalitis with CNS vasculitis with no identifiable infectious agent. It is suggested to consider this as an additional subtype of MUO with severe clinical signs.Meningoencephalitis of unknown origin (MUO) is an umbrella term for a variety of subtypes of meningoencephalitis of dogs and cats with no identifiable infectious agent. In dogs, granulomatous meningoencephalitis (GME), necrotizing meningoencephalitis (NME), and necrotizing leukoencephalitis (NLE) are the most commonly reported subtypes. However, sporadically there are reports about other subtypes such as greyhound encephalitis or eosinophilic meningoencephalitis. The following case series presents three dogs with peracute to acute progressive signs of encephalopathy. The magnetic resonance imaging (MRI) of two dogs ( Meningoencephalitis of unknown origin (MUO) is an umbrella term for a variety of subtypes of meningoencephalitis of dogs where no infectious agent can be identified –6. GranuVasculitis is defined as an inflammation of blood vessels with inflammatory cells infiltrating the damaged vascular wall as well as the perivascular space . Aside fThe present case series describes the macroscopic and histopathological findings of dogs that suffered from a so far undescribed meningoencephalitis with vasculitis restricted to the CNS. A causative infectious agent was not detectable.All examinations were performed with written informed owner's consent according to ethical guidelines of the University of Veterinary Medicine Hannover, Germany, between 2017 and 2021.Blood examinations were performed immediately after blood sampling and included blood cell count , biochemistry , and electrolytes .Radiography  of the thorax in three planes was performed in case 1.®, MSD Tiergesundheit, Unterschleißheim, Germany)], anesthesia was inducted with propofol (dose to effect 1-3 mg/kg i.v.) followed by orotracheal intubation and connection to a semiclosed circle absorber system . Anesthesia was maintained with isoflurane in an oxygen/air mixture  in one dog (case 3). MRI was obtained in transversal, sagittal, and dorsal view in T2weighted (w) and T1w sequences pre and post contrast administration . No contrast medium was applied in case 1. Fluid-attenuated inversion recovery (FLAIR) and gradient echo (GE) images were obtained in transversal plane. Cerebrospinal fluid (CSF) was sampled suboccipitally from the cisterna magna post mortem only in case 1 and was immediately examined for cell content via Fuchs-Rosenthal-chamber and microscopical cell differentiation. Case 1 and 3 were euthanized by i.v. administration of pentobarbital . A post mortem examination of all dogs was performed at the Department of Pathology, University of Veterinary Medicine Hannover, Germany. Following necropsy, specimens of various organs including brain, spinal cord, peripheral nerves, tonsil, lung, spleen, liver, heart, eye, thyroid gland, diaphragm, skeletal musculature, pituitary gland, adrenal glands, kidneys, urinary bladder, tongue, trachea, stomach, and small and large intestine were collected for further histological, histochemical, and immunohistochemical investigation. Samples were fixed in 10% neutrally buffered formalin for at least 24 h, paraffin wax-embedded, and cut into approximately 2 μm thick sections. Sections were stained with hematoxylin and eosin (HE) and central nervous system (CNS) regions with lesions were evaluated semi-quantitatively by using mild (single inflammatory cells in the perivascular space), moderate (1–3 layers of perivascular inflammatory cells), and severe (>3 layers of inflammatory cells in the perivascular space). Selected sections of CNS with inflammatory changes were further assessed by immunohistochemistry (IHC) and additional special stains including a periodic acid-Schiff reaction (PAS) and Ziehl-Neelsen stain. IHC for the detection of potential causative infectious agents was performed as described previously  of the brain was obtained under general anesthesia in one dog, and 20 min after euthanasia in another. MRI was not available in the third dog. After premedication with diazepam [0.5 mg/kg intravenously (i.v.)] and levomethadone with fenpipramide . FurtheTo the best of the author's knowledge, this is the first case series describing clinical signs, diagnostic imaging and histopathological findings of an acute, progressive, fatal non-suppurative meningoencephalitis with vasculitis restricted to the CNS. It is proposed to consider the described changes of the three dogs as a new subtype of MUO with CNS vasculitis as the histopathological distinguishing feature.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Ethical review and approval was not required for the animal study because retrospective case report. Written informed consent was obtained from the owners for the participation of their animals in this study.IZ performed and interpreted results of necropsy and histopathology and drafted manuscript. JR performed and interpreted findings of diagnostic imaging and finalized manuscript. FS performed and supervised anesthesia, took care for patients, and finalized manuscript. WB interpreted results of necropsy and histopathology and finalized manuscript. AT interpreted findings of clinical and diagnostic imaging examination and finalized manuscript. JN performed and interpreted findings of clinical and diagnostic imaging examinations, drafted, and finalized manuscript. All authors agree on authorship and publication of the manuscript. All authors contributed to the article and approved the submitted version.This Open Access publication was funded by the Deutsche Forschungsgemeinschaft  - 491094227 Open Access Publication Costs and the University of Veterinary Medicine Hannover, Foundation.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.


Paratesticular rhabdomyosarcoma is a rare and aggressive mesenchymal tumor, accounting for only 7% of all rhabdomyosarcomas. It is mainly encountered in children and adolescents. The standard treatment consists of radical orchidectomy with negative surgical margins. However, chemotherapy is recommended to control retroperitoneal micrometastasis. The place of surgery for progressive retroperitoneal lymph node metastases remains controversial. We present a case of paratesticular rhabdomyosarcoma with progressive retroperitoneal lymph node metastases treated with surgery.2. A left orchidectomy was performed. The final pathology report revealed an 8 cm paratesticular rhabdomyosarcoma of the embryonic type that displaced the testicle without invading it. Without going beyond it, it infiltrated the epididymis, the rete testis, and the albuginea. The surgical margin at the level of the spermatic cord was free. The patient had adjuvant chemotherapy . The patient had a challenging paraaortic lymph node dissection since the mass enlaced the left ureter and renal vessels. On histological examination, the paraaortic lymph nodes were metastatic.We report a case of a 17-year-old North African male with no particular medical history who presented with a left scrotal mass that had been evolving for several months. Beta-human chorionic gonadotropin, alpha-fetoprotein, and lactate dehydrogenase were normal. Scrotal ultrasonography revealed the presence of a 6 cm heterogeneous hypoechogenic tissular mass with cystic areas adherent to the left scrotal wall, which was thickened in some places and vascularized by color Doppler. It exerted a mass effect on the homolateral testicle, which was of average volume. The thoracic–abdominal–pelvic computed tomography scan showed the presence of suspicious paraaortic lymph nodes. The most voluminous one measured 16 × 23 mmRhabdomyosarcoma is an aggressive malignancy with high metastatic potential. Therefore, only an accurate diagnosis and early treatment can ensure better survival. Surgery in expert hands seems to be a good option for progressive retroperitoneal nodes. However, further studies are needed to determine the place of surgery in this setting. Paratesticular rhabdomyosarcoma (RMS) is a rare and aggressive tumor , accountThe primary differential diagnoses are scrotal emergencies that must be excluded , 5.Owing to the rarity of the disease, the management strategy is based on the management of non-seminomatous testicular tumors . It is aWe aim to report a surgically challenging metastatic paratesticular RMS case and shed more light on this rare disease.We report the case of a 17-year-old North African male with no particular medical or family history, studying at high school, who presented with a left scrotal mass that had been evolving for several months. The patient was not given any special medication prior to diagnosis. The patient has no history of smoking or alcohol consumption.On physical examination, there was an 8 cm painless left scrotal tumor. The light transmittance test was negative. The patient did not show any sign of testosterone deficiency, that is, testosterone levels were not measured. No regional lymph node areas were clinically palpable. The neurological examination was normal and no significant clinical findings were detected on other physical examinations.The tumor markers  were within normal ranges.The ultrasound (US) revealed the presence of a 6 cm heterogeneous hypoechogenic tissular mass with cystic areas adherent to the left scrotal wall, which was thickened in some places and vascularized by color Doppler. It exerted a mass effect on the homolateral testicle, which was of average volume with a loss of contours in areas more marked at the level of the inferior pole. The thoracic–abdominal–pelvic computed tomography (CT) scan showed some suspicious lateral–aortic enlarged lymph nodes. The largest of these was 16 × 23 mm.One week later, the patient had a left inguinal orchidectomy after first and high ligature of the spermatic cord with full resection margins.The final pathology report concluded with an 8 cm paratesticular rhabdomyosarcoma of embryonic type that displaced the testicle without invading it. Without going beyond it, it infiltrated the epididymis, the rete testis, and the albuginea. The surgical margin at the level of the spermatic cord was free.The patient was staged as stage III and was planned for adjuvant polychemotherapy implemented in nine cycles, combining these molecules: ifosfamide, vincristine, and actinomycin D. Chemotherapy was started 1 month later. He only received six cycles and refused further chemotherapy.A CT scan after six chemotherapy cycles showed a residual paraaortic 5 cm mass, with no other sign of metastatic disease.The patient had a positron emission tomography (PET) CT that showed a 4 cm hypermetabolic mass at the level of the renal pelvis; no other hypermetabolic location was present.After discussion with the patient and his guardian, the multidisciplinary meeting decided to perform a paraaortic lymph node dissection. The patient expressed an apparent refusal of any systemic treatment and wanted to have the disease surgically removed. Radiation therapy was also discussed, but it was ruled out due to the absence of an immediately available appointment.The surgery was performed 4 months after the second CT scan and 2 months after the PET CT. On admission, the examination was strictly normal. The patient was afebrile and had normal vital signs; pulse rate was 84 beats per minute and blood pressure was within normal measures of 120/60 mmHg. The patient did not receive any particular treatment, except for prophylactic anticoagulation one injection of enoxaparine 0, 6 UI per day.All the laboratory findings were normal Table .Table 1RWe started with laparoscopy, which found a 2 cm relapse at the level of the section of the left spermatic cord. The extraperitoneal approach was initially considered, but the mass was deemed unresectable with laparoscopy. We converted to midline laparotomy and first resected the spermatic cord relapse.The residual mass was 8 × 4 cm and enlaced the left ureter and the left renal vessels at the level of the renal pelvis Fig. . CarefulThe surgery was performed by a skilled professor and lasted 180 min. There was no significant blood loss. At the end of the surgery, there was no macroscopic disease left.The histological examination found a cellular tumor composed of sheets of small, stellate, spindled, or round cells Fig. . The tumThe multidisciplinary meeting decided to complete two cycles of chemotherapy and perform paraaortic external beam radiation. After 7 months of surveillance, the patient completed chemotherapy and radiation. He was last seen at our department 1 year after surgery and was still disease free. The planned follow-up for this patient will be as follows: physical examination every 3 months in the first 2 years with a thoracic–abdominal–pelvic CT scan every 6 months; carried out at the initial hospital.We reported the case of 17-year-old male patient with paratesticular rhabdomyosarcoma with progressive paraaortic lymphnodes, treated with debulking paraaortic surgery. Despite being difficult, the surgery was performed by an expert surgeon. Careful dissection also helped save the patent’s kidney. One year after surgery, the patient was last seen with no sign of relapse.Rhabdomyosarcoma (RMS) is the most common soft tissue sarcoma in children. It accounts for 5–10% of all malignant tumors. It arises from primordial mesenchymal cells with different levels of skeletal muscle differentiation .Paratesticular localization represents only 7% of all RMS . It may The age distribution is bimodal, with peaks in childhood (1–5 years) and adolescence 16–18 years) [–18 yearsThe symptoms of paratesticular RMS are non-specific . It ofteScrotal emergencies  are the primary differential diagnoses and must be excluded , 6.B-HCG and alpha-fetoprotein (AFP) tumor markers are usually not elevated in the case of paratesticular RMS .Testicular ultrasonography is the first line preferred imaging technique , 6, and Para testicular RMS can spread through the blood or the lymphatic system. The most common metastatic sites are the lung, liver, and bone. The paraaortic lymph nodes are reportedly involved in 26–43% of cases .A thoracic–abdominal–pelvic CT scan is necessary as part of the extension assessment.It is essential to get cross-sectional imaging of the retroperitoneum at the start of the process to look for patients with enlarged retroperitoneal lymph nodes (RPLN) . The mosThe rhabdomyoblast is the characteristic cell for diagnosis. When rhabdomyoblasts are absent, immunohistochemical studies with a panel of antibodies containing myosin and desmin are used .Loss of heterozygosity on chromosome 11’s short arm is a cytogenetic characteristic of this malignancy .The management strategy is well codified and depends on the tumor stage and the prognostic group .En bloc resection should be done for tumors invading scrotal skin. Testicle-preserving approaches should be avoided [For tumors in the paratesticular or spermatic cord area, a radical orchidectomy should be done through an inguinal approach. Tumor resection should not be done through the scrotum.  avoided .All patients, regardless of age, underwent an RPLN assessment if diagnosed with paratesticular rhabdomyosarcoma .et al. [P = 0.003).However, RPLN did not improve 5-year OS among children  or adults . Rhee et al. [Regardless of imaging results, all patients over 10 years of age should have an ipsilateral infrarenal nerve-sparing surgical RPLN assessment. Patients who are under 10 years of age and have not had any radiographic nodal enlargement should not have a surgical RPLN assessment . Occult et al. , in theie et al. , in the In the treatment of rhabdomyosarcoma, several chemotherapy regimens have been employed. The most widely used combinations are ifosfamide, vincristine, etoposide (IVE), ifosfamide, vincristine, dactinomycin (IVA) or vincristine, dactinomycin, cyclophosphamide (VAC) . RadiothParatesticular rhabdomyosarcoma is a rare and aggressive condition. Localized forms have a good prognosis, whereas metastatic forms show inferior results. Only an accurate diagnosis and early treatment will offer higher chances of survival. Despite being challenging, surgery seemed a good alternative for progressive retroperitoneal lymph nodes in this case.


Paraneoplastic tumefactive demyelination (TD) is a rare disorder of the central nervous system that can be challenging to diagnose. Here, we describe a 32-year-old Japanese man with a TD associated with testicular seminoma. He presented with symptoms of right-sided motor and sensory impairment 2 days after vaccination for coronavirus disease 2019 (COVID-19). Brain magnetic resonance imaging (MRI) showed a high-intensity lesion in the left internal capsule. He had a 3-year history of enlargement of the left testicle. Blood examination showed tumor marker elevation and the presence of anti-amphiphysin antibodies. Whole-body computed tomography (CT) revealed mass lesions in the left testicle and enlargement of the retroperitoneal lymph nodes. Radical orchiectomy was performed. As the pathology showed testicular seminoma, chemotherapy was administered. After surgery, his neurological symptoms deteriorated. MRI revealed that the brain lesion had enlarged and progressed to a tumefactive lesion without gadolinium enhancement. The cerebrospinal fluid (CSF) examination was normal without pleocytosis or protein elevation. Steroid pulse therapy was added; however, his symptoms did not improve. A brain stereotactic biopsy was performed and the sample showed demyelinating lesions without malignant cells. As the initial corticosteroid therapy was ineffective, gamma globulin therapy was administered in parallel with chemotherapy, and the clinical symptoms and imaging findings were partially ameliorated. TD seldom appears as a paraneoplastic neurological syndrome. In addition, there are few reports of COVID-19 vaccination-associated demyelinating disease. Clinicians should recognize paraneoplastic TD, and the further accumulation of similar cases is needed. Tumefactive demyelination (TD) is uncommon and its diagnosis is often difficult. Most instances of TD occur in the context of multiple sclerosis (MS), mainly associated with fingolimod and natalizumab . TD reseA previously healthy 32-year-old Japanese man was admitted to our hospital due to right hemiparesis. He was aware that his left testicle had started to enlarge 3 years earlier, but he had not sought medical attention. He received a second vaccination for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (Spikevax® Moderna) in his left deltoid muscle. Two days after vaccination, he developed right hemiparesis and was admitted to our hospital.On physical examination, he was alert and his body temperature was normal 36.4°C). He showed no headache or neck stiffness. He had no aphagia, apraxia, or agnosia. He showed right hemiparesis with a manual muscle test (MMT) score of 4/5, right hemihypesthesia, and right-sided hyperreflexia. His left testicle was enlarged to 15 cm in diameter. Blood examination showed elevated lactate dehydrogenase  and human chorionic gonadotropin  levels, but alpha-fetoprotein was within the normal limit . He was negative for anti-nuclear, -neutrophil cytoplasmic, and -SS-A antibodies. Among anti-paraneoplastic antibodies, he was positive for anti-amphiphysin antibodies by an immunoblotting method. He was negative for anti-CV2, -PNMA2, -Ri, -Yo, -Hu, -recoverin, -SOX-1, -titin, -zic4, -GAD65, and -Tr antibodies. We have not measured kelch-like protein 11 antibodies 6.4°C. He. Brain MAt first, the brain lesion was suspected to be an infarct associated with a malignant tumor. The testicular mass was suspected to be a malignancy based on the retroperitoneal lesions and the serological tumor marker findings. Radical orchiectomy was performed, and after surgery, aspirin was administered as prophylaxis for brain infarction. The testicular tumor was pathologically diagnosed as a seminoma. At 3 days after orchiectomy, the right-side paralysis worsened to an MMT score of 1/5, and right hemianopsia appeared. Follow-up MRI revealed enlargement of the brain lesion with invasion into the left optic tract. The brain lesion presented with slight edema and a mass effect showing a high-intensity lesion on fluid-attenuated inversion recovery and diffusion-weighted imaging. Gadolinium enhancement was still absent . MR specAs treatment for the seminoma, we started chemotherapy . We added corticosteroid therapy  for the brain lesion, but there was no neurological or MRI improvement. We performed a stereotactic brain biopsy from the left thalamus because the brain lesion showed tumor-like enlargement even after corticosteroid therapy. The sampled specimen consisted of gliotic brain tissue with marked myelin loss and infiltration of inflammatory cells, including numerous macrophages, however, neither malignant tissue nor infarct lesion, was observed . The CD6As disease onset occurred 2 days after COVID-19 vaccination, the post-vaccination demyelinating syndrome was also suspected. In addition to chemotherapy, we added second and third corticosteroid pulse and intravenous immunoglobulin therapy. After four courses of bleomycin, etoposide, and platinum chemotherapy, enlargement of the retroperitoneal lymph nodes was reduced, and serum seminoma markers (lactate dehydrogenase and human chorionic gonadotropin) were decreased to within the normal range. After immunoglobulin therapy, the neurological symptoms showed partial improvement, and the right hemiparesis recovered to an MMT score of 3/5. Plasma exchange was not performed because it was anticipated to attenuate the effect of chemotherapy. The hemiparesis and hemianopia remained, and he was referred to a rehabilitation hospital with MRI amelioration .Here, we report a case of a tumefactive demyelinating brain lesion accompanied by testicular seminoma. There are six previous case reports of TD associated with seminoma –9, of whTumefactive demyelination (TD) mainly occurs in connection with MS and is commonly associated with disease-modifying drugs, such as fingolimod and natalizumab . When a There are six previous case reports of TD with seminoma . In all As for the prognosis of TD, two previous cases showed favorable outcomes, while four showed poor outcomes. The treatment options are generally corticosteroid therapy and treatment of seminoma. Some cases, like our patient, did not respond to the initial steroid treatment and the lesions grew in size. Plasma exchange was used in one case. We treated our case with immunotherapy along with chemotherapy. Simultaneous plasma exchange with chemotherapy is considered to reduce the effectiveness of chemotherapy ; therefovia decreasing T cells, B cells, or NK cells. Another demyelination mechanism is provoked auto-immune reactions, resulting from excessive self-response and antigen-driven immune responses  for the publication of any potentially identifiable images or data included in this article.WS and TU participated in patient management, clinical data analysis, and writing of the article. YN participated in patient management and revision of the article. YY, MS, and TH participated in clinical data analysis and revision of the article. 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.


In humans, aural polyps comprise fibrovascular tissue covered by the respiratory epithelium. Aural polyps with ciliated epithelium are common in cats but are rarely reported in dogs. In a previous case, a mass filled the tympanic cavity alone, and it was surgically removed.To report a case of a canine aural polyp with ciliated epithelium extending from the dorsal tympanic cavity to the external auditory canal with detailed otological features and to demonstrate the usefulness of the transcanal endoscopic procedure (TEP) with a diode laser as a less‐invasive therapy.A 12‐year‐old castrated male Cavalier King Charles Spaniel presented with a 6‐month history of unilateral chronic otorrhoea. Video‐otoscope examination revealed a protruding, reddish and soft‐to‐rubbery round mass in the right horizontal ear canal. Computed tomography and magnetic resonance imaging further revealed a smooth mass extending from the dorsal portion of the tympanic cavity into the horizontal part of the external auditory canal. However, it showed no lesions in the dorsal tympanic cavity.The mass was removed using aural forceps by a traction‐torsion manoeuvre. The suspected base of the mass on the caudal side of the upper tympanic cavity was confirmed by a rigid scope, and it was completely vaporised with a diode laser. Histopathology revealed foci of columnar ciliated epithelium embedded in the connective tissue encapsulated by stratified squamous epithelium. No recurrence was observed at 3 years and 8 months.We describe a rare case of an aural polyp with ciliated epithelium extending from the upper‐middle ear to the external auditory canal in a dog. The TEP using a diode laser may be a useful minimally invasive treatment option for managing external auditory canal polyps. This is the first case report describing an aural polyp with cilliated epithelium extending into the auditory canal in a dog with successful outcome using diode laser. Aural p22.1A 12‐year‐old castrated male Cavalier King Charles Spaniel (CKCS) was referred to Dermatology at the Veterinary Specialists Emergency Centre with a 6‐month history of unilateral chronic otorrhoea in the right ear. This case had been treated with antimicrobials, including minocycline and metronidazole; however, there was no improvement. The dog was clinically healthy and had no neurological signs. A video‐otoscope  examination revealed a protruding, reddish and soft‐to‐rubbery round mass in the right external auditory canal with yellowish purulent ear discharge   revealed a smooth mass extending from the dorsal portion of the tympanic cavity into the horizontal external auditory canal, with a homogeneously enhanced distal portion and heterogeneously enhanced and partially mineralised proximal portion. The horizontal external auditory canal had been focally filled with the mass and fluid  for traction‐torsion via the TEP under general anaesthesia. The external auditory capacity showed no apparent pathologic changes after removing the polyp. The suspected base of the mass around the epitympanic recess on the caudal site of the upper tympanic cavity was confirmed by a rigid scope  and completely vaporised using a diode laser . In this operation, the ear was flushed using a soft feeding tube with neutral electrolysed water. Histopathological evaluation revealed a polypoidal mass with a thick fibrovascular stalk Figure . The les3We report a case of a dog with an aural polyp extending from the upper‐middle ear to the external auditory canal treated with traction and transendoscopic laser ablation. Blutke et al.  reportedThe polyp in the present case had partial central calcification. Similar clinical and histological findings have been reported in human aural polyps Sogebi, . A few fIn the case reported by Blutke et al. , the aur4A dog had an aural polyp with ciliated epithelium extending from the upper‐middle ear to the external auditory canal, which was confirmed by both diagnostic imaging and histopathology. It was successfully removed using transendoscopic traction plus laser ablation of the base without a traditional surgical approach. No recurrence was observed at 3 years and 8 months. TEP using a diode laser seems to be valuable as a less‐invasive approach.No conflicts of interest have been declared.Tomoya Hoshino: conceptualisation; data curation; resources; validation; visualisation; writing – original draft. Shoko Fukuda: validation; visualisation; writing – original draft. Masahiko Nagata: conceptualisation; data curation; resources; supervision; validation; writing – review & editing.The authors confirm that the ethical policies of the journal, as noted on the journal's author guidelines page, have been adhered to. No ethical approval was required as this is a retrospective case report with no original research data.This study has been presented in Asia Meeting of Animal Medicine Specialties in 2019.https://publons.com/publon/10.1002/vms3.845.The peer review history for this article is available at


A neurofibroma is a benign peripheral nerve sheath tumor. Its appearance in the nose and paranasal sinuses is extremely rare. We present the case of a 61-year-old female with a large sinonasal neurofibroma. The patient was referred to our department due to the findings of a large invasive lesion originating from the left sinus with extension to the adjacent structures on computed tomography. A thorough examination revealed a mass within the left nasal cavity and exophthalmos. The initial symptoms of the disease probably appeared three years ago when she reported that she developed facial swelling following dental work. In the following period and due to reported blurred vision, she consulted with several medical specialists without receiving a diagnosis, while later she visited an otorhinolaryngologist, complaining of ear fullness, and local treatment was prescribed. Due to persistent symptoms, the patient was finally referred for computed tomography. Upon arrival at our department, she underwent a biopsy, which revealed the existence of a neurofibroma. The patient underwent endoscopic resection of the tumor and remains under close follow-up with no signs of recurrence. Sinonasal neurofibroma is a rare condition that presents with non-specific symptoms and may take years to reach a diagnosis. Open or endoscopic surgical resection seems to offer satisfactory results; however, similar cases reported in the literature are scarce. Neurofibroma is a benign peripheral nerve sheath tumor (PNST) composed of mixed Schwann cells, perineural-like cells, and intraneural fibroblasts . It can A 61-year-old female presented to our department due to worrisome findings in her computed tomography (CT) scan, including a large mass involving the left nasal cavity and ipsilateral sinuses and spreading to the left orbit and cranial fossa with bony destruction Figures , 1b. CliThe patient worked as a house cleaner and had no pertinent medical history. The initial symptoms may have appeared three years ago when, following a molar extraction, she noticed ipsilateral facial swelling, including her eyelids. She visited several physicians, including an otorhinolaryngologist, a neurologist, an ophthalmologist, and a dentist, none of whom presented her with a diagnosis. Meanwhile, she noticed her vision blurring. Almost two years later, she visited an otorhinolaryngologist due to complaints of ear fullness and was treated with antibiotics and nasal decongestants. Finally, a few months later, she was referred for a CT by a general practitioner and later presented to our department.A biopsy via a transnasal endoscopic approach was scheduled. Histopathological and immunohistochemical examination demonstrated findings indicative of neurofibroma Figures , 4a, 4b.Neoplasms of Schwann cell origin occur only rarely in the nasal cavity and paranasal sinuses . These cA series of such cases revealed that there was no gender predilection among patients. The mean age was 46.2 years (ranging from 26 to 75 years), with a mean duration of symptoms of 42.9 months. The symptoms were non-specific and included a mass lesion along with obstruction, pain, and epistaxis. The tumor size ranged from 0.4 to 4.1 cm, which was significantly smaller than our case. The lesions were unilateral, most commonly affecting the nasal cavity, followed by the maxillary sinus, or more than one site [On pathologic examination, neurofibromas are identified below an intact mucosa with no encapsulation. The lesional cells are arranged in irregular interlacing fascicles, bundles, or single spindled cells, separated by variable proportions of coarse collagen bundles, which give the characteristic "shredded carrot" appearance. A myxoid to loose connective tissue stroma is seen in most cases ,13.Immunohistochemical findings include positivity for S100 protein and glial fibrillary acidic protein (GFAP), Sry-related HMg-Box gene 10 (SOX10), neurofilament protein (NFP), and calretinin, which highlight the axons, and CD34, which often highlights nerve twigs and pseudomeissnerian corpuscles. In the setting of NF1, features indicative of a malignant change in neurofibroma are increased cellularity, diffuse atypia, and mitotic activity .The nasal cavity may host a variety of rare neoplasms . MisdiagSurgical excision of sinonasal tumors significantly affects the patient's quality of life . SinonasNeurofibroma of the sinonasal tract is an extremely rare lesion, with only a few cases reported in the current literature. The non-specific nature of its symptoms, as well as the low clinical suspicion due to its rarity, often lead to a delayed or erroneous diagnosis. Both endoscopic and open approaches seem to offer satisfying results. However, as more cases are discovered and reported, physicians will become more aware of this rare clinical entity, and treatment options will be better investigated and understood.


Pelvic exenteration refers to a multivisceral resection of all pelvic organs, including the rectum, bladder, and reproductive organs . ApproxiThe patient is a 37-year-old woman who 5 years previously had undergone a Miles operation for pT1N0M0 stage I rectal adenocarcinoma and, 2 years later was diagnosed with a subcapsular tumor in segment VI of the liver and a pelvic mass involving the right pelvic wall. After three surgeries for metastatic tumors, a hemorrhagic neoplasm in the vulvovaginal region was found on physical examination. Biopsy confirmed locally recurrent rectal adenocarcinoma. The right ureter was involved and a mild hydronephrosis was present. Therefore, we performed a laparoscopic combined transperitoneal pelvic exenteration and bilateral cutaneous ureterostomy in March 2021. The pelvic floor defect was repaired with a biological graft and adjacent soft tissue.Operation time was 480 min. Blood loss was 600 ml. Complete tumor clearance was achieved without any complications. After multidisciplinary team discussion, adjuvant radiotherapy was suggested as complementary treatment considering the lesion was close to the pubic symphysis and pelvic sidewall. Two months after the surgery, a follow-up computed tomography scan revealed no sign of recurrence or residual lesion. The patient’s quality of life has greatly improved.Laparoscopic combined transperitoneal pelvic exenteration is technically feasible for a laterally recurrent pelvic tumor and urethral-vaginal fistula after Miles operation and concurrent chemoradiotherapy.Supplementary file1 (MP4 272129 KB)Below is the link to the electronic supplementary material.