Non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP) was introduced as a separate entity by the World Health Organization in 2017 with strict inclusion and exclusion criteria.  Most NIFTP cases have been reported in adults and few cases have been diagnosed in children. Here, we present a classic case of NIFTP affecting a 10-year old female child. We also review previous reports of NIFTP in children regarding size, focality, nodal metastasis, recurrence, type of operation and follow-up data. The present report adds a new case of NIFTP in the paediatric age group characterized by multifocality, absence of nodal invasion and indolent course until last follow-up, recommending less aggressive management. The subjectivity in diagnosis of this variant and the indolent behaviour of encapsulated or non-invasive forms, led to revision and follow-up of a large number of these cases by international multidisciplinary collaborative group4. Consequently, the encapsulated variant of PTC was reclassified as non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP), which had strict inclusion and exclusion criteria for this diagnosis. The term NIFTP was then introduced as a separate entity by the World Health Organization in 2017, with a category of follicular tumour of uncertain malignant potential and well-differentiated tumour of uncertain malignant potential5. The majority of NIFTP reports have been in adults. Here, we present a classic case of NIFTP affecting a 10-year old female child.Generally, the diagnosis of papillary thyroid carcinoma (PTC) has increased over the past several decadesA female patient of 10 years presented to our department with an enlarged thyroid that had been observed by her mother. No previous relevant family history was recorded.Ultrasound revealed two suspicious nodules on the right side of the thyroid lobe. No pathological lymph node enlargement was reported. Ultrasound guided fine needle aspiration cytology was performed and the results showed sheets of follicular epithelial cells, some were elongated with occasional nuclear grooves and inclusions . This waThe patient was submitted for total thyroidectomy within one month from her first presentation. On resection, the right thyroid lobe measured 5.5 × 3.5 × 3 cm with two well-defined, firm, grayish white nodules. One nodule measured 2 × 1.5 cm and the other measured 1.5 × 1.5 cm . The lefHistological examination of the two nodules resected from the right thyroid lobe revealed well-circumscribed capsulated nodules formed of microfollicles, lined by follicular epithelial cells with wide-spread nuclear features of papillary thyroid carcinoma . There w10. Preoperative diagnosis of our case was based on ultrasound data and the cytology was not obviously malignant. The cytologic smears of NIFTP were usually hypercellular showing follicular epithelial cells arranged in microfollicles without papillae formation and they showed subtle features of papillary thyroid carcinoma but with infrequent or absent nuclear inclusions. NIFTP cytology was commonly interpreted as follicular lesion of undetermined significance in 30% (categories III and IV according to Bethesda system), follicular neoplasm in 21%, suspicious for malignancy in 24%, malignant in 8%, bnign in 10% and non-diagnostic in 3%12. Although the above findings would suggest lobectomy, our patient was submitted for total thyroidectomy and as has been done in previously reported cases10.Most NIFTP cases have been previously reported in adults and data concerning this diagnosis in children is scarce; only 21 cases in children have been reported in the English literature within the last two years 6–10. PV600EBRAF mutations, which is a common event in papillary thyroid carcinoma13. Immunohistochemistry forV600EBRAF mutations is available on paraffin blocks. Nuclear pseudinclusions are important diagnostic criteria for PTC, which could be highlighted by CK19 immunostaining in comparison to routine hematoxylin and eosin14. The latter authors demonstrated absence of CK19 positive nuclear pseudoinclusions in the investigated 7 cases of NIFTP.On a molecular level, NIFTP shares follicular neoplasm in RAS mutations but it lacks15 and in children9. The size of NIFTP lesion is usually small, rarely exceeding 2 cm in diameter (The current report demonstrated a classic case of NIFTP affecting a young female child, agreeing with previous reports that there are more cases in women than men . Althougiameter . 16 but the indolent behaviour reported for NIFTP necessitates less aggressive management in children, as well as adults. Therefore, completion lobectomy is not recommended for postoperative cases diagnosed as NIFTP8. NIFTP in children has a similar outcome as cases reported in adults, suggesting that paediatric NIFTP behaves indolently, as evidenced by the absence of local recurrence and nodal metastasis6.More aggressive therapy is recommended for PTC in childhood and adolescenceThe present report adds a new case of NIFTP in the paediatric age group characterized by multifocality, absence of nodal invasion and indolent course - until last follow-up, recommending less aggressive management of this disease.Written informed consent was obtained from the patient's father for the publication of this case report and any associated images.All data underlying the results are available as part of the article and no additional source data are required. The case is well written and with full explanation of the diagnostic category. The introduction included the accurate classification of the entity and why the nomenclature changed.The figures and tables are well presented. The references are up to date. No further comments and I agree for this case report to be indexed without changes.Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?YesIs the case presented with sufficient detail to be useful for other practitioners?YesIs sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?YesIs the background of the case’s history and progression described in sufficient detail?YesReviewer Expertise:Molecular Pathology, Digital Pathology and experimental pathologyI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. The case is well clinically presented with full clinical data.The procedure as FNAC is also presented well with clear figure.Histopathology is shortly presented with clear good figure.The discussion should be in more details.Is there any role for immunohistochemistry?This is a case report about a case of NIFTP in thyroid.Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?YesIs the case presented with sufficient detail to be useful for other practitioners?YesIs sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?PartlyIs the background of the case’s history and progression described in sufficient detail?YesReviewer Expertise:histopathologyI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.


Squamous Papilloma is a rare benign tumor of the esophagus. Esophageal squamous papilloma is thought to arise from a chronic inflammatory reaction due to mechanical or chemical irritant. ESP is usually considered to have a benign clinical course; however, some reports highlight the potential development of a malignancy. The development of extensive esophageal squamous papillomas also known as squamous papillomatosis of the esophagus is even less frequent.We present the case of an esophageal papillomatosis that developed into an invasive esophageal squamous cell carcinoma that was only diagnosed in the surgical specimen after minimally invasive Ivor-Lewis esophagectomy and in this case report, we discuss its etiology, diagnosis and treatment.Extensive papillomatosis with continuous symptoms, especially persistent dysphagia, should always prompt a thorough analysis into a possible underlying malignancy. They arWe describe the case of an esophageal papillomatosis complicated by the development of an invasive esophageal squamous cell carcinoma, that was only diagnosed in the surgical specimen after minimally invasive Ivor-Lewis esophagectomy, despite multiple nondiagnostic biopsies.This case has been reported in line with the SCARE criteria .2A 67-year-old Caucasian man visited his primary care physician with complaints of hematemesis and continuous dysphagia. He had history of cigarette smoking and social alcohol consumption. Previous medical history included hypertension and hyperlipidemia. An initial EGD showed multiple verrucous lesions extending from 30 cm to 39 cm from his incisors. Pathological examination of the multiple biopsies showed squamous papillomatosis.The patient was referred for evaluation at our hospital and a new EGD showed the same extensive verrucous lesions with three large growths on the distal esophagus causing significant stenosis. He repeated the biopsies and maintained the previous histological diagnosis. A thoracoabdominal CT-Scan revealed large esophageal lesions apparently superficial with thickening of the esophageal wall. Endoscopic Ultrasound showed that these changes were almost all limited to the mucosa and submucosa except in one area where they appeared to penetrate deeper.th PO day.At this time, the patient’s dysphagia got worse and there was substantial suspicion of potential malignancy. After a multidisciplinary discussion, he was proposed for surgery. He underwent a minimally invasive Ivor-Lewis Esophagectomy  with a mechanical termino-lateral esophago-gastric upper thoracic anastomosis (at approximately 24/25 cm from the incisors) Figs. , 2. The in situ (verrucous type) of the distal esophagus with areas of high dysplasia and extensive diffuse squamous papillomatosis. There were no signs of lymphatic or perineural invasion and margins were clear. The eighteen lymph nodes excised were all negative for malignancy. The TNM stage (8th edition) was Tis N0. One year later, at the follow-up consultation, there were no signs of recurrence.The examination of esophagectomy specimen  showed a3Esophageal squamous papillomas (ESPs) are epithelial tumors thought to be benign. These tumors are rare, occurring in about 0.01% of individuals at autopsy and 0.07% in an endoscopic series ,5,6. StuThe pathogenesis of the esophageal papillomas is thought to arise from chronic inflammatory reaction due to a mechanical or chemical irritant such as gastroesophageal reflux disorder (GERD), alcohol, smoking, caustic injury, food impaction or human papillomatosis (HPV) infection or a combination of these factors ,5,6. PanESPs are usually asymptomatic, and most lesions are found incidentally, but may present in a multitude of clinical manifestations such as symptomatic dysphagia, anemia and hematemesis . About tWhile most ESPs seem to be benign, there is still some controversy about its malignant potential. Furthermore, in other areas of the body, papillomas are known to be precursors to squamous cell carcinoma, and as such there are concerns that ESP are premalignant lesions ,5. The lThe finding of extensive esophageal papillomatosis with evolving and continuous dysphagia or hematemesis should prompt a very thorough investigation regarding underlying associated malignancy.4An esophageal squamous cell carcinoma arising from squamous papillomatosis is a rare condition and may be difficult to diagnose.Extensive papillomatosis with continuous symptoms  should always prompt a thorough investigation into a possible underlying malignancy and in some cases, only surgery will allow for a correct diagnosis and treatment. Overall, more information is needed on the long-term follow-up, as to better recognize their potential for malignant transformation and allow for better surveillance after removal or surgery.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.No sponsors or funding.This case report is exempt from ethnical approval in my institution.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Emília Fraga – Concept and design, data curation and collection, writing the paperJoão Almeida – Concept, Supervision and Writing - reviewCristina Camacho – Data collection and othersJoão Simões – Data collection and othersAntónio Bernardes – Supervision and reviewThe article is a case report.The article is a case report.Not commissioned, externally peer-reviewed.All authors have no conflicts of interest.


Liver abscesses are divided into two main subgroups: pyogenic and nonpyogenic abscesses. Early diagnosis is important for appropriate treatment and to reduce the morbidity and mortality rates in liver abscesses. We report a case of multiple pyogenic liver abscesses mimicking liver metastases on multidetector computed tomography (MDCT). The case is unique as it shows a rare presentation of pyogenic liver abscess that cannot be distinguished from metastatic liver disease. Microbiologic and pathologic correlations with follow-up may be necessary for these patients. The case is presented with an emphasis on the MDCT findings. Early diagnosis of a hepatic abscess is important to reduce its morbidity and mortality . In spit3/µL , elevated C-reactive protein at 315.8 mg/L , and elevation of liver enzymes. Results of the other laboratory tests, including pancreatic enzymes, electrolytes, and urinalyses, were within normal limits. Blood cultures were obtained from the patient.A 57-year-old woman was admitted to our emergency department with complaints of right upper quadrant abdominal pain and nausea. On admission, her body temperature was 38.6ºC; her pulse rate and blood pressure were within normal limits. On physical examination, mild tenderness was found over the right upper quadrant. There was mild hepatomegaly on palpation, and her scleras were icteric. There was no rebound tenderness. Bowel sounds were normal, and there was no splenomegaly. Laboratory studies revealed leukocytosis  and scattered everywhere within the liver parenchyma. The lesions were thought to be metastatic disease, so the patient had an abdominal MDCT examination performed to characterize the lesions further and to discover the primary focus. Abdominal MDCT with oral and intravenous contrast was performed. Precontrast 5-mm-thick sections were taken after oral contrast administration. The examination was repeated after 150 mL of noniodinated IV-contrast agent administration on the portal and late venous phases. Thoracic MDCT examination also was performed during the arterial phase.Abdominal precontrast MDCT demonstrated multiple hypodense lesions scattered throughout the liver parenchyma Figure . The larLiver abscesses are divided into two main subgroups: pyogenic and nonpyogenic abscesses. Eight to 20 cases per 100000 patients admitted to hospitals have pyogenic liver abscesses ,5. TheseThe most common pathogens causing liver abscesses are Escherichia coli and Klebsiella pneumoniae. Staphylococcus aureus can rarely be isolated, in 20% of the cases or fewer, and it is especially found in childhood ,5. PeptoThe classic triad of the hepatic abscess is right upper quadrant pain, fever, and jaundice, and it is seen only in 10% of patients ,4,8. OthOn plain chest radiographs, nearly half of all patients may show elevated right diaphragm, atelectasis of the lung bases, and right pleural effusion ,8. UltraCT is the most accurate imaging technique for detecting hepatic abscess. On contrast-enhanced hepatic MDCT, abscesses are seen as hypodense masses with an enhanced peripheral rim or capsule. The target appearance of the rim sign is the characteristic sign of the liver abscess . PyogeniJeffrey and coworkers compared CT findings of 36 patients that had pyogenic liver abscesses with CT findings of 50 patients with hepatic metastases . They idAntimicrobial therapy combined with percutaneous drainage is the major treatment modality and have 69%-90% cure rates ,8. TreatMDCT with contrast is the radiologic method of choice for detecting liver abscesses. Hepatic abscesses have well-defined CT findings, as discussed above. They may mimic metastatic or necrotic liver tumors with peripheral and lesion enhancement, as seen in abscesses in our case. In patients with delayed diagnosis, hepatic abscess may be fatal. Early diagnosis is crucial to decrease mortality and morbidity rates. In some patients like ours, it may be difficult with MDCT findings to distinguish the abscesses from metastatic lesions. Therefore, microbiologic and pathologic correlation with follow-up may be necessary for these patients.


Case Description. Two patients, a 79-year-old man and a 43-year-old woman, are presented. The primary diagnoses were AC with ossification of the ligamentum flavum and epidural hematoma, respectively, in previous hospitals. They were finally diagnosed by the characteristic MRI and CT myelogram finding called the “scalpel sign.” Histological findings showed epithelial cells and fibrous tissue derived from arachnoid tissues and microcalcifications. After surgery, the scalpel sign has vanished, and aggravation of their symptoms was prevented.  An arachnoid web (AW) is a relatively rare disease and shows clinical symptoms and radiological findings similar to those of an arachnoid cyst (AC) or spinal cord herniation (SCH). Since the operative procedures for an AW are generally different from those intrathecal disorders, correct preoperative differential diagnosis is important. The purposes of this study were to report the usefulness of magnetic resonance imaging (MRI) and computed tomography (CT) myelography for diagnosing AW and to show the histological findings and clinical results.  An AW is refractory, but early detection by MRI and CT myelography and early treatment improve outcomes after surgery. An arachnoid web (AW) is relatively rare and shows clinical symptoms and radiological findings similar to an arachnoid cyst or spinal cord herniation. Spinal arachnoid cysts are cerebrospinal fluid (CSF) pockets contained by the arachnoid mater, and intradural onset occasionally causes spinal cord compression. An AW has been reported as a variant of arachnoid cyst . The webA 79-year-old man presented with frequent falls and an unsteady gait. He had a three-year history of recurrent falls, and a primary diagnosis of arachnoid cyst and ossification of the ligamentum flavum was made at another orthopedic clinic. His past history included asthma, gastric ulcer, spontaneous pneumothorax, prostatic cancer, dementia, hypertension, hyperlipidemia, paroxysmal atrial fibrillation, and herpes zoster. His symptoms worsened gradually, and he was referred to our hospital. On neurological examination, he could not stand on his left foot. Manual muscle testing showed no muscle weakness. There was no numbness or sensory disturbance of the upper and lower extremities and trunk. Deep tendon reflexes, the patellar tendon and Achilles tendon reflexes, showed hyporeflexia.Spinal cord deviation at the T4 level was seen on MRI. T2-weighted sagittal MRI demonstrated a sharp dorsal indentation of the spinal cord Figures . CT myelAfter laminectomy and durotomy at T2, T3, and T4, a conglutinated arachnoid membrane covering the spinal cord and indentation of the spinal cord were observed. Intraoperatively, unidirectional pulsation was recognized from the head side to the caudal side. The arachnoid membrane was then resected . HistoloAfter the operation, the patient was gradually able to walk more smoothly and stably and fall less frequently than before. Seven weeks later, he was discharged from the hospital ambulatory. His postoperative MRI showed that the scalpel sign had disappeared, and the spinal cord was shifted posteriorly Figures .A 43-year-old woman presented with a 1-month history of back pain. A primary diagnosis of thoracic epidural hematoma was made at another general hospital. Her history included untreated diabetes. Her back pain gradually worsened, and she was referred to our hospital. On neurological examination, manual muscle testing showed no muscle weakness. There was no numbness or sensory disturbance of the upper and lower extremities and trunk. Deep tendon reflexes, the patellar tendon and Achilles tendon reflexes, showed hyporeflexia.Spinal cord deviation at the T5 level was seen on MRI. T2-weighted sagittal MRI demonstrated a sharp dorsal indentation of the spinal cord Figures , and CT After laminectomy and durotomy at T4, T5, and T6, a conglutinated arachnoid membrane covering the spinal cord and indentation of the spinal cord were observed. Intraoperatively, unidirectional pulsation was recognized from the head side to the caudal side. The arachnoid membrane was then resected Figures . HistoloAfter surgery, there was no aggravation of her symptoms, but there was no improvement. The scalpel sign on MRI seen before surgery has vanished Figures .AW is a rare disease with only 61 reports so far in the literature . Since sImaging findings are important in diagnosing AW. Several characteristic imaging findings such as the scalpel sign, syringomyelia, and dorsal indentation  have been reported on MRI and CT myelography –10. The The findings of syringomyelia are also characteristic imaging findings of AW –10. SpinPrevious reports have suggested that an AW is a subtype of arachnoid cyst or a change in the arachnoid after infection or trauma , but no No dramatic improvements were observed after AW resection in the present cases, but surgery is necessary to prevent the progression of symptoms. As for the treatment of AW, all cases reported in the literature were treated surgically. The surgical treatment is removal of the AW after dural incision, with no fixation or decompression .Several articles have reported that AW patients' symptoms improved after surgery. Nisson et al. reported that, after surgery, 91% of patients showed neurological improvement . On the In the present cases, it is probable that postoperative symptoms did not improve significantly because of the long waiting period between the onset of symptoms and surgery and the uncontrolled diabetes, which could cause numbness. Identification of postoperative prognostic factors requires further study.In case 1, the symptoms recovered slightly after the operation. However, the patient fell over after discharge and suffered a vertebral fracture. In case 2, her symptoms did not improve, and she continues to take medications, mainly analgesics. The neurologist in our hospital suggested that the remaining pain could be the result of atypical diabetic neuropathy. Lozeron et al. showed that atypical diabetic neuropathy disease has several patterns and sometimes affects the thoracolumbar region. In fact, the patient's glycemic control has been poor, so the endocrinologist still continues a strict regimen of treatment .Chang et al. measured the flow rate of CSF using MRI in a cardiac-gated phase-contrast cine-mode to clarify the one-way valve-like function of an AW . In the An AW can be diagnosed by characteristic MRI findings in the early stage. Though symptom improvement is difficult to achieve even with surgery for AW, surgery is useful to prevent aggravation of symptoms, and earlier surgery could improve treatment outcomes.


Band migration is a late complication of Laparoscopic Adjustable Gastric Banding insertion, although rare it could be life threatening presenting as peritonitis secondary to gastro-intestinal tract injuries. A case of an unexpected extension of severe gastro-intestinal tract injuries secondary to intra-gastric migration and distal band dislocation is reported.A 53 years old male, with a history of laparoscopic gastric banding 15 years before and known erosion of the band into the gastric lumen was admitted for abdominal pain and raised serum amylase. Imaging revealed dislocation of the band down to the jejunum.Endoscopy and exploratory surgery showed severe decubitus pressure on the gastric antrum up to the duodenum as well as on the pancreas due to rod-like effect of the gastric band catheter and multiple sites of perforation on distal duodenum and small bowel proximal to the band, which migrated within the lumen until 90 cm distal to the Treitz ligament. Extended distal gastrectomy and resection of distal duodenum and small bowel extended to the proximal affected small bowel were necessary. Digestive tract was restored by a gastro-jejunostomy and duodeno-jejunostomy in a Roux-En-Y configuration with duodenal stump closure on tube duodenostomy. A post-operative leakage from the duodenal stump was treated conservatively and the patient was discharged on post-operative day 21.Erosion and migration of the band within the digestive lumen is one of the less frequent late complications occurring after LAGB, furthermore, the amount of extensive damage reported in this case presentation has yet to be reported in literature.Migration of the band should be considered in the differential diagnosis of abdominal complain in patients with adjustable gastric banding. Such a complication could be severe, and lesions may have unexpected extension requiring complex surgical approach. Nausea, vomiting and chills accompanied the pain. His past medical history includes hypertension and type 2 obesity for which, LAGB operation was performed 15 years prior. He was known to have non-functioning gastric banding for 8 years due to intra-gastric erosion of the band with failed trial of upper endoscopic removal. In addition, the patient had undergone laparoscopic cholecystectomy 5 months prior to admission due to symptomatic cholelithiasis (episode of mild biliary pancreatitis treated conservatively). The patient is a non-smoker with no known allergies.On physical examination upon his admission, his vital signs were within normal limits. His BMI was 37.7. Abdominal examination demonstrated a soft abdomen, with left upper abdominal slight tenderness. Digital rectal exam was normal. No signs of port infection were observed. Complete blood count showed increased white blood cells of 21,000, of which 80% were neutrophils with 7% bands. His liver and kidney function tests were within normal limits. Serum and urinary Amylase levels were highly elevated at more than 3 folds the normal range . Due to these findings, the patient was admitted with clinical and laboratory diagnosis of Acute Pancreatitis, for conservative management.13 hours following admission, the patient complained of abdominal pain exacerbation despite adequate pain control regime, along with a documented fever of 38.8 c. Repeated abdominal exam revealed localized left mid abdominal peritonitis, without palpable masses. Revision of a plain abdominal X-ray done several months prior (former admittance due to biliary pancreatitis) demonstrated gastric band localized in the left lower quadrant of the abdomen, and therefore, distal migration was suspected . A CompuDue to these findings, the patient underwent diagnostic laparoscopy, performed by the head of the department, with intra-operative upper endoscopy. On intra-operative upper endoscopy, necrosis of the medial wall of the gastric antrum, through to the second part of the duodenum due to chronic severe decubitus pressure changes was demonstrated. These changes were the result of a rod-like effect of the band catheter, being fixed at the proximal (port) and distal (band) sides . A subsePost-operative period was complicated by a duodenal stump leak, treated successfully by conservative means including Nothing Per Os (NPO), Total parenteral nutrition (TPN), intravenous somatostatin analogues and antibiotics. The patient was discharged home on post-operative day 21. On 3 weeks follow up at the outpatient clinic, the patient was doing well without any complaints and the duodenostomy was removed.The pathology report showed stomach wall with ulceration and peritonitis and small bowel with foci of ulceration and necrosis of intestinal wall, ulcers were similar in size and shape suggesting mechanical cause.3Erosion and migration of the band within the digestive lumen is one of the less frequent late complications occurring after LAGB, The rate of band erosion incidence has been reported to have a median value of 3.9% with extreme value of 0.8%–28% on a review based on 17 selected studies According to the duration of follow up, a systematic review on erosion after LAGB In the present case, initial clinical presentation oriented toward pancreatitis due to pain and blood amylase levels of more than 3 times the normal limit, a known biliary lithiasis and previous episode of pancreatitis both supported this hypothesis. Worsening of the clinical status under expectant management which necessitated a CT scan allowed the change of the initial diagnosis. An initial presentation as pancreatitis or biliary disorder has been reported in 2 case reports. In the case reported by Shah et al. According to the literature data, life-threatening presentations of band erosion complications are very rare. As it occurred in the present case, 2 cases presenting with acute symptoms and peritonitis were reported in 2 case series As reported in the present case, distal dislocation into the gastro-intestinal tract may complicate the erosion of the band within the stomach. Dislocation without major gastro-intestinal injuries has been reported in 3 case reports The jejunum is not the only distal dislocation reported in the literature. Corvini et al. Moreover, injuries secondary to the dislocation may be source of further complications requiring different surgical approaches. In 2 cases of injured gastro-intestinal tract, the reported lesion was local necrosis of the jejunum at the site where the band was dislocated According to the study of Beitner et al. 4Although very rare, migration and distal dislocation of the band may occur as a late complication up to 18 years following LAGB, and according to the current data, additional similar cases may be expected in the future. Due to the clinical presentation, band migration and distal dislocation with gastro-intestinal injuries should always be considered in the differential diagnosis of abdominal complain in patients with gastric banding. Such complication could cause a severe clinical deterioration, an unexpected extension of gastro-intestinal injuries could furthermore require complex surgical approaches.The work has been reported in line with the SCARE 2018 criteria The authors disclose any financial and other personal relationships with other people or organisations that could inappropriately influence their work.No funding source. This is a self-financed manuscript.As this is a case report, no ethical approval was necessary. Patient informed consent was given.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Safi Khuri contributed to the writing of the manuscript as well as for the design. Subhi Mansour contributed as well for the design. Giuseppe Borzellino contributed to literature research and editing the manuscript. Yoram Kluger was the mentor and contributed to critical revision of the manuscript.N/A.Dr. Safi Khuri is the guarantor.Not commissioned, externally peer-reviewed.


Headache is the dominant factor for quality of life related disability in idiopathic intracranial hypertension (IIH) and typically has migraine-like characteristics. There are currently no evidence-based therapeutics for headache in IIH, and consequently this is an important unmet clinical need.We report a series of seven patients in whom headaches were the presenting feature of IIH and the headaches had migraine-like characteristics, as is typical in many IIH patients. Papilloedema settled (ocular remission) but headaches continued. These headaches responded markedly to erenumab, a monoclonal antibody targeted against the calcitonin gene related peptide (CGRP) receptor. Of note, there was a recurrence of raised ICP, as evidenced by a return of the papilloedema, however the headaches did not recur whilst treated with erenumab.Those with prior IIH who have their headaches successfully treated with CGRP therapy, should remain under close ocular surveillance (particularly when weight gain is evident) as papilloedema can re-occur in the absence of headache. These cases may suggest that CGRP could be a mechanistic driver for headache in patients with active IIH. Idiopathic intracranial hypertension (IIH) is a chronic debilitating disease characterised by raised intracranial pressure (ICP) that typically occurs in young, obese women . There iWe report seven patients who presented with headaches in the setting of raised ICP and who met the diagnostic criteria for IIH , whose IFollowing IIH diagnosis all patients were treated according to the IIH consensus guidelines with weight management advice and acetazolamide therapy where appropriate , 7. The The pathway for erenumab delivery entailed a full headache and neuro-ophthalmology assessment prior to erenumab initiation, including optical coherence tomography (OCT) imaging and dilated slit lamp fundus assessment, which confirmed complete resolution of papilloedema Table . Patient2 and her LP opening pressure was 34 cm CSF with no alternative cause of raised ICP on brain imaging (MRI Head and MR Venogram). A diagnosis of IIH was made [A 42 year old woman first presented with severe increased headaches with visual obscurations, double vision, tinnitus and was noted to have papilloedema. The headaches had migraine-like characteristics. She had a past history of occasional episodic migraines, asthma and fibromyalgia and a family history of migraines. Her body mass index (BMI) was 33 kg/mwas made  and she 2 (reported weight gain of 30 kg over the preceding 5 years). After normal neuro-imaging, CT Head and CT Venogram , she had an LP opening pressure of 34 cm CSF. A diagnosis of IIH was confirmed [A 34 year old woman initially presented with increased debilitating headaches, blurred vision, visual obscurations, tinnitus and was noted to have papilloedema by the optometrist. The headaches had migraine-like characteristics. She had a past history of episodic migraine but no family history of migraines. Her BMI was at 49 kg/monfirmed  and she 2 and no alternative cause of raised ICP on brain imaging (MRI Head and MR Venogram). LP recorded an opening pressure of 36cmCSF and a diagnosis of IIH was made [A 46 year old woman presented with substantially increased headache symptoms, with migraine-like characteristics, and was noted to have papilloedema. She had a past history of episodic migraine for 20 years, depression but no known family history of migraine. Her BMI was 39 kg/m2. The headaches had a migraine-like phenotype. She had a history of occasional tension type headaches, bipolar disorder and no family history of migraines. With no alternative cause of raised ICP on brain imaging (MRI Head and MR Venogram) an LP was performed revealing an opening pressure of 40 cm CSF and a diagnosis of IIH was made [A 24 year old woman first presented with worsening headaches and visual disturbances and was noted to have papilloedema with a BMI of 38 kg/mwas made . She had2, initially presented with debilitating headaches, tinnitus and visual disturbances. The optometrist noted papilloedema. Headaches had a migraine-like phenotype. She had a past medical history of low mood, familial structural renal tract abnormalities and no family history or prior history of migraines. Following normal neuro-imaging, CT Head and CT venogram , an LP was performed with an opening pressure recorded at 37 cm CSF. A diagnosis of IIH was given [2 with concurrent resolution of her papilloedema. Her chronic migraine-like headaches persisted over 12 months despite therapeutic trials of amitriptyline, topiramate, dosulepin and candesartan with inadequate efficacy or intolerable side effects. She was commenced on erenumab with a marked improvement in headaches (Table 2) and her papilloedema recurred. However, her headaches did not increase as they previously have when she initially presented with IIH  and an LP was performed with an opening pressure of 35 cm CSF and the diagnosis of IIH was made [A 25 year old woman originally presented with marked worsening of headaches and tinnitus, papilloedema was noted. Her BMI was 35 kg/mwas made . She was2) presented with disabling increasing headaches and papilloedema was noted. The headaches had a migraine-like phenotype. She did not have any significant past medical history and no family history of migraines. Neuro-imaging (MRI Head and MR Venogram) did not reveal an alternative cause of raised ICP and an LP recorded an opening pressure of 54 cm CSF (followed by post-LP headache exacerbation for 1 week). A diagnosis of IIH was made [A 25 year old woman (BMI of 31 kg/mwas made . She wasWe have reported seven patients with IIH who had disabling long term headaches with migraine-like characteristics (mean (SD) IIH duration 2.4 1.4) years) persisting despite complete resolution of papilloedema. Monthly headache burden was significantly reduced following initiation of a CGRP monoclonal antibody therapy (Table .4 years)Erenumab significantly reduced the mean frequency of MmsHD at the 3-monthly time-points up to 12 months compared to the 30-day pre-treatment period, with corresponding significant reductions in the total MHD and HIT-6 score, despite the recurrence of active IIH and relapse of papilloedema  . But in These cases may provide the first insight that CGRP may be a key mechanistic driver for IIH headaches when raised ICP is present, manifesting as papilloedema. Headache therapies are a patient priority and an unmet need in IIH with no previous trials of headache preventative therapies in IIH . CGRP maCGRP monoclonal antibodies successfully treat resistant chronic migraine-like headaches in those with IIH in whom their papilloedema had resolved.CGRP may have a mechanistic role in driving raised ICP headaches in active IIH.The therapeutic potential of CGRP monoclonal antibodies for IIH headache warrants further evaluation in a clinical trial.


After the patient began apatinib administration and underwent 125I seed implantation twice, the tumor size shrank successfully. After a follow-up of 13 months since the initial diagnosis of anaplastic thyroid cancer, the patient survived with a stable disease pathology. In conclusion, this study supports 125I seed implantation and apatinib as effective therapeutic alternatives for inoperable anaplastic thyroid cancer patients.Anaplastic thyroid cancer is known to be the most lethal malignancy among endocrine tumors for its extremely limited survival rate after diagnosis. As a result of this poor survival prognosis, multimodal therapy is currently under investigation to address this global concern. In this reported case, the  Based on clinical definition, anaplastic thyroid cancer (ATC) is an undifferentiated thyroid cancer demonstrating epithelial differentiation with immunohistochemical or ultrastructural detectable features . In all 125I seed implantation and molecule-targeted drugs, proven to be effective in other tumors  . IVa repr tumors –10. ApatHerein, we report a case of an ATC patient who received a novel multimodal treatment after two surgeries, with a favorable survival of 13 months.A 49-year-old woman who had a mass in her right thyroid for 3 months was referred to our department. The patient had recently undergone a right lateral thyroidectomy in another hospital. After histopathological testing, papillary thyroid carcinoma was confirmed. However, the mass in the right anterior neck increased rapidly in size within 1 month again. The mass was hard and unmovable. Cervical enhanced Magnetic Resonance Imaging (MRI) displayed a solid tumor with internal heterogeneity, 5.4 × 6.0 cm in size, compressing the trachea leftwards, as well as multiple right cervical lymph nodes enlargements around the carotid sheath . PositroBased on the clinical features above, we identified thyroid cancer reappearing. Moreover, the tumor type was also shown to be deteriorated. The tumor adhered tightly to the trachea and left common carotid and invaded the right sternocleidomastoid muscle. Thus, palliative surgery was performed, resecting the majority of the tumor, based on the aforementioned guidelines . The his125I seed implantation is the most used method of brachytherapy. For less side effect and cost, 125I seed implantation (a number of 40 particles) was performed under the guidance of the interventional radiologist.Twenty days after administration of apatinib, the patient came back to our outpatient department. Both cervical enhanced computer tomography (CT) and MRI showed a mass of 6.3 × 5.4 cm in the right anterior neck, extending to superior mediastinum . As a ma125I seed implantation appeared to be effective, thus the 125I seed implantation (a number of 40 particles) was additionally performed again.One month later, cervical enhanced CT  showed a125I seed except for a non-healing surgical incision. In order to improve the incision's appearance and life quality, dermepenthesis was advised for the patient. Pedicled pectoralis major muscle without flap was grafted to the defective neck and skin was collected from the thigh, which were designed to preserve the appearance of the breast. Two weeks after surgery, the pedicled muscle survived and the incision was gradually healing. Presently, it has been 13 months since the novel multimodal therapies, and the tumor size has no obvious enlargement.After 6 months, the disease was stable, and there was no severe adverse reaction against apatinib or 125I seed implantation plus the apatinib therapies after surgery.Given the international concern of thyroid cancer and its increased morbidity for all pathological types including ATC , better It has been reported that about 50% of ATC patients have distant metastases at presentation ; howeverIn view of rapid recurrence, radical resection even including laryngectomy or esophagectomy has little to no benefit to survival outcomes in ATC IVb and IVc , 17 patiThere has been controversy regarding chemotherapy for ATC with no sufficiently supportive evidence. It has been reported that chemotherapy combined with EBRT after radical surgery showed prolonged survival in IVc patients, and combined paclitaxel and pemetrexed was the only regimen associated with improved overall survival , whereas125I seed implantation to some extent. Radioactive particles that are directly implanted into the tumor induce radiation damage continuously, while sharply decreasing radioactive dosage causes adjacent tissue to sustain little harm. 125I seed implantation therapy has been a standard schedule for early prostate cancer recommended by NCCN guidelines  for the publication of any potentially identifiable images or data included in this article.BW and YF conceived the idea of this essay and were responsible for the treatment. YN, XD, JK, and BG participated in the treatment and collected the case history. YN wrote the case report. ZD revised the manuscript.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.


Parathyroid cysts (PCs) are uncommon entities in clinical practice. The lack of pathognomonic clinical presentation and radiological features of PCs makes preoperative diagnosis unlikely, therefore, most cases are diagnosed intraoperatively or postoperatively at the pathological analysis of the surgical specimen. Treatment of nonfunctional PCs remains controversial and includes fine-needle aspiration, injection of sclerosant, or surgical excision. However, surgical resection still the optimal treatment for functional and larger nonfunctional PCs. We report a case of a 60-year-old female presenting with asymptomatic left-sided cervical swelling diagnosed postoperatively as a nonfunctional PC. Parathyroid cysts (PCs) are rare entities, representing 0.5%-1% of parathyroid lesions . The cliA 60-year-old woman presented with a four-month history of left-sided cervical swelling. No dyspnea, swallowing disturbance, or dysphonia was recorded. Physical examination revealed a soft, painless, and mobile mass on the left side of the neck. Ultrasonography of the neck showed a cystic mass measuring 6 cm in the left thyroid lobe.Thyroid function tests and serum calcium were in the normal range. A cervical CT scan identified a left-sided cystic mass measuring 26 x 45 x 53 mm under the thyroid, and a diagnosis of the fourth branchial cleft cyst was suspected Figure , B.Despite the investigations, the diagnosis remained unclear, with the risk of increasing swelling size. The patient underwent exploratory cervicotomy with excision of the cyst. Intraoperatively, the left thyroid gland appeared normal on inspection and palpation. A thin-walled cyst of approximately 5-6 cm was found. This was located between the left thyroid lobe and the trachea but seemed to be separate from both structures Figures , 3.Histological examination of the specimen showed a 5.5 cm cyst bordered by a heavily abraded squamous epithelium, with the presence of atrophic parathyroid parenchyma. This concluded the diagnosis of a PC.The patient made an uneventful recovery and was discharged from the hospital on postoperative day two. She remained asymptomatic, with no recurrence at a six-month follow-up.Described for the first time by Sandström in 1880 . PCs areThe preoperative diagnosis of PCs is challenging due to their heterogeneous clinical presentations and nonspecific radiological findings. Cervical ultrasonography is considered the first-line imaging modality as part of the diagnostic workup; although it cannot distinguish between a PC and other cervical masses, ultrasonography may reveal the cystic nature and dimensions of the mass ,11.CT and MRI are used to determine the exact location of the lesion and the relationship with surrounding tissues and adjacent vascular structures. The definitive diagnosis is established by aspiration of cystic liquid, biochemical testing of the sample, and identifying parathormone (PTH) . In mostTreatment of PCs includes simple aspiration, percutaneous sclerosing agent injections, and surgical resection . UltrasoPCs are relatively rare lesions that should be considered in the differential diagnosis of cervical masses. Preoperative diagnosis of PCs is challenging; however, fine-needle aspiration and ﬂuid PTH measurement offer a valuable diagnostic tool. Most cases are diagnosed intraoperatively or postoperatively via the pathological analysis of the surgical specimen. Surgical resection is still the optimal treatment for these cysts.


To describe a case of choroidal melanocytoma mimicking a melanoma. Patient. A 48-year-old Moroccan woman presented with progressive, painless decreased vision in her left eye for 2 months.  Retrospective case report. Discussion. Melanocytoma is a rare benign pigmented tumor. It is classically described as a tumor of the optic nerve head, but there are some exceptional case reports of uveal tract locations . In such cases, it can be difficult to clinically differentiate a melanocytoma from a malignant melanoma. Her visual acuity was light perception in the left eye and 20/20 in the right one. Fundus examination and fluorescein angiography of the left eye showed a total retinal detachment with a large superior brownish mass. The clinical examination, B-scan ultrasonography, and magnetic resonance imaging all suggested a malignant melanoma. Consequently, the eye was enucleated. The histopathology later revealed a benign melanocytoma of the choroid.  Melanocytoma is a rare pigmented primary benign tumor that is usually located in the optic disc and the anterior portion of the optic nerve  where thA 48-year-old Moroccan woman presented with progressive, painless decreased vision in the left eye for 2 months. Her visual acuity was light perception in the left eye and 20/20 in the right one. Biomicroscopy of the left eye showed no conjunctival hyperemia, a clear cornea, and no inflammation in the anterior chamber. Intraocular pressure was normal. Fundus examination and fluorescein angiography of the left eye showed a retinal detachment (RD) with a large superior brownish mass . The rigB-scan ultrasonography of the left eye revealed a large choroidal dome-shaped mass, surrounded by subretinal fluid, with neither acoustic hollowing nor calcification . MRI of The histopathological study of the enucleated eye showed a brownish-black pigmented tumor arising from the choroid, composed of fusiform cells with brownish cytoplasm, elongated nuclei, and small nucleoli. No signs of necrosis or malignancy were found . ImmunohMelanocytoma is a distinctive variant of melanocytic nevus. It is a rare benign pigmented tumor. It is classically described as a tumor of the optic nerve head, but there are some exceptional case reports of uveal tract locations –4. In suAs opposed to the optic disc melanocytoma, the extrapapillary uveal melanocytoma is generally more challenging to diagnose clinically, since it is similar to other uveal nevi and small uveal malignant melanoma, even more so in case of a choroidal location.Exudative retinal detachment is the most common abnormality associated with malignant uveal melanoma and is present in up to 75% of eyes bearing this tumor. However, this finding is nonspecific and could be present in both benign and malignant tumors. In a series of 115 eyes with optic disc melanocytoma, Shields et al. found subretinal fluid adjacent to the tumor in 14% of patients [In general, it is believed that significant growth of a melanocytic uveal lesion is indicative of a malignant transformation . In our In fluorescein angiography, a large choroidal melanocytoma can be extremely difficult to differentiate from a melanoma considering that they both show hyperfluorescence . On B-scThough rare, choroidal melanocytomas should be considered as a differential diagnosis of uveal tract tumors. A conservative approach can have a sight-saving effect and allow a better quality of life for the patient. However, in some cases, like ours, the clinical appearance with retinal detachment, the size of the tumor, and ultrasound and radiological features did not suggest a melanocytoma. Therefore, enucleation could not have been avoided.


Ossifying fibromyxoid tumor (OFMT) is a rare fibro-osseous neoplasm. We present a case highlighting the occurrence of an intracranial OFMT masquerading as meningioma on imaging in a 46-year-old gentleman. Brain imaging revealed an extra-axial calcified lesion along the left cerebellar convexity appearing hypointense on T1- and T2-weighted MRI sequences with no post-contrast enhancement, suggestive of a meningioma. An intraventricular colloid cyst was also noted. The lesion, which was presumed to be meningioma, and the colloid cyst were resected in two subsequent operative settings. Histopathological examination of the calcified lesion confirmed the findings of an OFMT. This report aims to inform the physician about intracranial OFMT mimicking meningioma on imaging. In addition, since multiple brain tumors are not very common, the surgeon should always have a suspicion should there be any heterogeneous and peculiar radiological and histopathological characteristics. Ossifying fibromyxoid tumor (OFMT) was first described by Enzinger et al. in 1989 .A 46-year-old gentleman presented to the neurosurgery outpatient clinic with complaints of headache and vomiting of one-year duration. There was no family history of any age-related sporadic or familial neoplastic illness. A thorough neurological and physical examination was performed, and no evidence of neurocutaneous disorders such as café au lait spots, Lisch nodule, or adenoma sebaceum was found. No intraocular lesions were noted. The patient was fully oriented with no neurological deficit.Magnetic resonance imaging (MRI) of the brain revealed an extra-axial calcified lesion along the left cerebellar convexity appearing hypointense on T1-weighted (TIW) and T2-weighted (T2W) sequences, with no post-contrast enhancement and showing blooming on SWI (susceptibility-weighted imaging), suggestive of a meningioma  revealed complete excision with a thin extra-axial bleed (~6 mm), with a colloid cyst in the third ventricle Figure . On histThe patient was readmitted after eight weeks for the excision of the colloid cyst, which was performed through a right frontoparietal craniotomy through an anterior transcallosal approach. Grossly, the lesion was whitish, dome-shaped, partially obliterating the foramen of Monro, containing viscous fluid. Simple columnar epithelium lining fibrous wall with low cellularity on histopathology confirmed the lesion as a colloid cyst. The post-operative course was uneventful.The patient has been following with us for the last two years and is doing fine, with no post-operative neurological deficit.Enzinger et al. in a study on 59 cases described OFMT for the first time as a rare deep soft tissue tumor of uncertain differentiation predominantly occurring in the adult male population . Majority of the cases involved the lower extremities -17.The brain imaging in our case revealed an extra-axial calcified lesion along the left cerebellar convexity with features suggestive of a calcified meningioma. HPE revealed thickened dura mater and fibro-collagenous tissue showing foci of dystrophic calcification with low cellularity and mitotic rate < 2/50 high powered fields (HPF), suggestive of a “typical OFMT”. The HPE findings were consistent with the Folpe and Weiss classification of OFMT, which described “typical OFMT” as those showing low nuclear grade and low cellularity and mitotic rate < 2/50 HPF [OFMT is a much rarer entity as compared to meningiomas, which account for 14%-19% of the primary intracranial neoplasms . We woulAlthough most malignant OFMT may be recognized histologically, a small number of otherwise typical OFMT may behave in a clinically malignant fashion, supporting their reclassification as tumors of intermediate malignancy . RecogniTo the best of our knowledge, this case is also the first documentation depicting the synchronous occurrence of an OFMT with an intraventricular colloid cyst. Different hypotheses exist, which explain the coexistence of multiple primary intracranial tumors of different histogenesis in different compartments of the brain in patients without neurocutaneous disorders or cranial radiotherapy. Gelabert et al. reported the simultaneous occurrence of a frontal lobe astrocytoma and a colloid cyst of the third ventricle, both derived from displaced primitive neuroectodermal cells, suggesting the role of a single oncogenic factor in producing different tumors in the same individual . AnotherThere is no defined treatment strategy regarding which lesion should be treated first in patients with simultaneous brain tumors. We operated the OFMT first followed by the excision of the colloid cyst. It can be said that it is the surgeon’s preference in corroboration with the patient profile as to which lesion should be dealt with first.OFMTs are believed to commonly arise from the skull base locations or paranasal sinuses. This case reports the presence intracranial OFMT arising from the left cerebellar convexity. We believe this case would help in informing the physicians regarding the management of extra-axial calcified lesions where an OFMT could masquerade as a calcified meningioma, as reported in this case. This is also the first case to report synchronous occurrence of intracranial fibromyxoid tumor with a colloid cyst. Since synchronous brain tumors are not very common, the surgeon should always have a suspicion should there be any heterogeneous and peculiar radiological and histopathological characteristics.


Early diagnosis of small intestinal gastrointestinal stromal tumours (GISTs) is difficult. These tumours often present with peritonitis and intraperitoneal bleeding due to rupture. We experienced a case of a tumor that grows to 12 cm asymptomatic.A 46-year-old man presented with sudden abdominal pain. Computed tomography revealed free air in the abdominal cavity, a 12-cm sized dilatation in the small intestine, and pooled residues. He was diagnosed with perforation of the gastrointestinal tract, and emergency surgery was performed. Inside the abdominal cavity, approximately 500 mL of bloody ascites was observed. A diverticulum-like mass measuring approximately 12-cm long was observed on the jejunum approximately 30 cm from the Treitz ligament. There was a large hematoma inside the mass, and perforation was recognised at the neck of the diverticulum. Partial resection of the jejunum and intraperitoneal drainage were performed. Immunohistochemistry revealed that the tumour was positive for KIT and CD34, and GIST was diagnosed. The patient was discharged on postoperative day 10 without significant complications. The patient did not relapse while taking imatinib as an adjuvant chemotherapy.Gastrointestinal stromal tumours are the most common mesenchymal tumours of the gastrointestinal tract and may undergo increased diverticulum-like growth, as seen in this case. Local resection and proper chemotherapy increase long-term survival, suppress tumour growth, and reduce the risk of relapse.Diagnosing GIST can be difficult due to the absence of clinical symptoms. It is necessary to ensure local resection and careful long-term follow-up. ApproxiThis work has been reported in line with the SCARE criteria .2A 46-year-old man who was suffering from severe abdominal pain was brought to our hospital by ambulance. Examination revealed abdominal tenderness and guarding in the upper abdomen. Computed tomography (CT) showed free air in the abdominal cavity, a 12-cm cystic dilatation in the small intestine, and pooled residues inside the abdomen . BecauseThe excised specimen revealed that the mass-like diverticulum was 7.0 × 6.5 cm in size and contained blood. It showed that the mass had developed on the antimesenteric side of the jejunum, and it connected with the lumen of the jejunum b. Haemat3Diagnosis of small intestine GISTs is difficult, and it is often incidentally made during surgery, endoscopy, radiology, or at the time of autopsy ,10. Comm4This case reports a relatively rare case of an asymptomatic patient with a 12-cm diverticulum-like GIST in the jejunum that ruptured spontaneously. Preoperative diagnosis of small intestinal GISTs is often difficult because of the absence of clinical symptoms. Consequently, GISTs should always be considered in the differential diagnosis of peritonitis in patients with an intra-abdominal mass. If GIST rupture is suspected, it is important to perform radical resection, continue appropriate treatment after surgery, and closely follow the patient and observe for relapse.The authors have no conflicts of interest.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Ethical approval was not required and patient identifying knowledge was not presented in the report.Written informed consent has been obtained from the patient for the publication of this case report and any accompanying images.RA and HN participated in treatment of the patient, collected case details, literature search and draft the manuscript. TU and TN participated in treatment planning of the patient. TI participated in treatment planning of the patient and helped to draft the manuscript. All authors read and approved the final manuscript.Not applicable.Hideki Nakahara.Not commissioned, externally peer-reviewed.


Carcinosarcomas are rare malignant neoplasms formed by embryonic tissues (ectoderm and mesoderm) and present remarkably aggressive character with unfavourable prognosis. These lesions are rarely diagnosed in the sinonasal cavity and only a few cases are reported in the literature. This manuscript aimed to report a rare case of a large and aggressive sinonasal carcinosarcoma that involved the facial middle third and to discuss the proposed treatment.A 54-year-old female patient sought treatment for a large swelling on the left side of the face. A CT-scan revealed an expansive hypodense image in the facial middle third. An incisional biopsy was performed under local anaesthesia and the material was sent for histopathological analysis.Due to the extremely aggressive character of carcinosarcomas, the optimal management of carcinosarcomas remains uncertain and a challenge for clinicians. In this case report, the prognosis of such a large tumour became unfavourable since the patient sought late for treatment. Therefore, suspicion and early detection are crucial for improving the prognosis and quality of life of the patients with such neoplasia.Besides being rare and extremely aggressive, sinonasal carcinosarcomas present worse patient survival when compared to other carcinosarcomas in the head and neck region. Thus, this report may contribute to a better understanding of this tumour behaviour. These rCarcinosarcomas may arise from any squamous epithelium of the body, such as salivary glands, respiratory tract, upper aerodigestive tract or even female reproductive organs; however, its occurrence in the sinonasal region is extremely rare and only a few cases have been reported ,8. This 2A 54-year-old brown-skinned female presented to the Bucco-maxillofacial Surgery and Traumatology Department with a large swelling on the left side of the face. The patient reported progressive symptoms over the last 3 years such as dystopia, dysphagia, trismus, respiratory obstruction and dysphonia.The extraoral clinical examination of the maxilla revealed a hardened and symptomatic tumour located between the zygomatic arch and the labial commissure, dystopia and depletion of the nasolabial fold with the displacement of the right nostril A and B, A multislice CT-scan revealed an expansive hypodense image in the facial middle third that involved hard palate, left zygoma, ethmoid and sphenoid, invasion and destruction of the nasal cavity, total obstruction of the nasopharynx and partial destruction of the orbit. The lesion was poorly circumscribed, which is suggestive of a malignant neoplasm with extensive bone destruction and involvement of structures near the base of the skull such as the ethmoid and sphenoid bones C and D.An incisional biopsy was performed under local anaesthesia. The anatomopathological analysis revealed fragments of neoplastic tissue, a proliferation of cuboid cells with nuclear and cytoplasmic pleomorphism, atypical mitoses and block, island and lobe arrangements. The tumour was also observed in the respiratory epithelial tissue with the presence of keratin beads, in situ focal carcinoma, necrotic areas and scarce stroma, bleeding and myiasis .Fig. 2A–Moreover, the immunohistochemistry technique was used for diagnostic accuracy and revealed diffuse expression of vimentin and chromogranin, and focal marking of AE1/AE3, cytokeratin 14, EMA, and CD99. The neoplastic cells were negative for S-100, calponin, smooth muscle actin, HHF-35, desmin, cytokeratin 7 and HMB-45; while almost 80% were positive for Ki-67 . All cliThe patient was submitted to partial maxillectomy with subpalpebral surgical access (Weber-Ferguson approach), albeit parts of the lesion were not removed due to large posterior extension. After the removal of a 11 × 6 × 4 cm single piece and curettage of the cavity, the orbital floor was reconstructed with titanium mesh .Fig. 4SuAfter 30 days surgical recovery, the patient presented remission of diplopia due to dystopia correction, the reestablishment of normal nasal breathing, no episodes of epistaxis, reduction of dysphagia, persistent dysphonia due to extensive loss of the hard palate and presence of a buccal fistula as a result of the partial maxillectomy .Fig. 5CoAt the Oncology Department, the patient was submitted to 30 sessions of radiotherapy treatment (3.700MBq/100mCl) and followed intravenous chemotherapy with cisplatin at 8-h intervals during 3 months. Although clinical follow-ups were performed to control the extremely aggressive malignancy, the patient unfortunately died in 2019.3A case of carcinosarcoma was diagnosed in a 54-year-old female after approximately 3 years of evolution. It was observed a large swelling in the face, extensive bone destruction near the base of the skull. The diagnosis was determined with the aid of the School of Dentistry of the Federal University of Par. The treatment protocol was a combination of surgery, radiotherapy and chemotherapy. Carcinosarcoma may arise from any squamous epithelium of the body, such as the respiratory tract, upper aerodigestive tract and genitals. In the head and neck area, this tumour most frequently occurs in salivary glands, larynx and pharynx ,10,11. AThe evolutionary stage of the lesion is extremely important, since early-diagnosed cases may result in a more favourable prognosis and lower mortality rates, while late-diagnosed cases are associated with more complex treatments and dismal prognosis. Thus, particularly for tumorus with great proliferative and invasive magnitudes, the initial clinical stage directly influences the treatment type. The patient here reported sought treatment after 3 years, which represents a significant period that resulted in a large lesion with the invasion of important anatomical sites and an unfavourable prognosis. It must be emphasised the importance of early detection of lesions that present a more aggressive behaviour such as sinonasal carcinosarcoma.An epidemiological study conducted between 1973 and 2010 reported 135 cases of carcinosarcomas: 15 in sinonasal cavities, 34 in salivary glands and 81 in other regions of head and neck ,7. AmongAlthough no specific symptoms are associated with sinonasal carcinosarcomas , all casBoth treatment and prognosis of sinonasal carcinosarcomas are still not well established in the literature due to its rarity, tumourigenesis and uncertain clinical behaviour. Regarding histogenesis, carcinosarcomas present tumoural heterogeneity resulted from the presence of epithelial and mesenchymal components that constitute this mixed malignancy ,2,4,20. The pathogenesis of carcinosarcoma might be understood through studies on molecular genetics and immunohistochemical data of the disease stages. It is hypothesised that both monoclonal inactivation of the mechanism of tumour suppression on chromosome 17 and the block of p53 wild-type allele are the causes of this neoplasm. Ki-67 labelling is a common marker of the neoplasm stages, in addition to representing degrees of prognosis .The reported immunohistochemical analysis revealed a diffuse expression of vimentin and chromogranin, which may be related to the degree of differentiation of epithelial and mesenchymal components. AE1/AE3 characterises the lesion as a carcinoma, excludes the possibility of a third component of neuroendocrine origin and, together with cytokeratin 14, EMA and CD99, makes it possible to identify the epithelial portion of the specimen and its degree of differentiation. The absence of S-100 and HMB-45 labelling precludes the diagnostic of melanoma, while the negativity for calponin, smooth muscle actin, HHF-35 and desmin demonstrates no other components of muscular origin. Cytokeratin 7 may be absent in some tumours such as sinonasal carcinosarcomas. The proliferative potential of both epithelium and mesenchyme is evident due to the high pattern of Ki-67 labelling. Thus, it is possible to characterise a specimen as sinonasal carcinosarcoma and differentiate it from other malignancies, such as oesophageal carcinoma and teratosarcoma ,20,21.Cases treated with surgery and adjuvant radiotherapy are reported with better prognoses. Radiation is conducted after surgery to prevent local recurrence; however, it is not possible to accurately estimate the survival of patients with carcinosarcoma, especially in the maxillary sinuses. Chemotherapy is suggested as a possible treatment, albeit its use is demographically variable ,4. In thIn a case reported in the literature, the patient was initially treated with radiotherapy and chemotherapy due to the size of the lesion and then submitted to surgical treatment . In the 4Besides being rare and extremely aggressive, sinonasal carcinosarcomas present worse patient survival when compared to other carcinosarcomas in the head and neck region. Thus, this report may contribute to a better understanding of this tumour behaviour.All authors declare no conflict of interest related to this manuscript.This manuscript received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.We declare that our institution does not require ethical approval of clinical case reports.The patient's consent form was obtained.JJVP and JTCJ contributed in conceptualization. ATLM, BTCS contributed in study concept and design. ATLM, ELSC contributed in writing the paper. SMAJ contributed in diagnosis histopathological. FSNF, JTCJ and BTCS contributed in surgical management and case record. VAMM performed and interpreted the immunohistochemistry method, which is essential for the diagnosis of the case presented.None.The guarantor of this work, Joao de Jesus Viana Pinheiro, accept full responsibility for the study and the conduct of the study, had access to the data, and controlled the decision to publish.Not commissioned, externally peer-reviewedWe declare that the images in this paper do not reveal information about the patient or the authors.


Background: Follicular lymphomas are a common type of non-Hodgkin’s lymphomas (NHL). Presentation varies widely from being asymptomatic to painless peripheral lymphadenopathy to classic B symptoms. We present an unusual case of follicular lymphoma where the patient initially presented with signs and symptoms of acute pancreatitis. The aim of this study is to recognize the challenges faced while diagnosing retroperitoneal NHL and the need for timely management of this disease.Case report: A 66-year-old Hispanic female with a medical history of treatment compliant asthma and hypertension presented to the ER with complaints of abdominal pain in the right upper quadrant with serum lipase >3000 U/L and elevated liver function tests (LFTs), aspartate aminotransferase (AST) 139 U/L, alanine aminotransferase (ALT) 65 U/L, alkaline phosphatase (ALP) 122 U/L. Abdominal ultrasound identified gall bladder wall thickening and dilation of biliary ducts. CT scan showed soft tissue mass in the retroperitoneum, measuring 9.3x4.8cm which wrapped around the aorta and pushed it off the spine. After two days of conservative management, her pain resolved and lipase levels normalized, she was discharged and scheduled for outpatient endoscopic ultrasound (EUS) with biopsy of the retroperitoneal mass. The next day, the patient presented to the ER with similar pain, and labs again showed elevated lipase, EUS, and fine needle biopsy of mass showed CD-10 positive B-cell lymphoma. The patient was discharged after the resolution of pain. A positron emission tomography (PET) scan four weeks after the initial CT scan showed an increase in tumor size without any metastatic lesions. While awaiting core biopsy, the patient presented to the ER for the third time with worsening abdominal pain, lipase >3000 IU/L, and ultrasound showing cholelithiasis with cholecystitis. The patient underwent laparoscopic cholecystectomy. Core needle biopsy of paraspinal lymph nodes showed grade 1-2 follicular lymphoma. Finally, the patient underwent six cycles of chemotherapy with Bendamustine and Rituximab and after the fourth cycle, a repeat CT scan showed resolution of adenopathy with minimal residual soft tissue attenuation in retroperitoneum.Discussion: NHL rarely occurs in retroperitoneum and its diagnosis is challenging. Our patient presented with the primary and unique occurrence of follicular lymphoma in the retroperitoneum. She presented with symptoms of an acute abdomen with elevated lipase and LFTs. She underwent multiple hospitalization and cholecystectomy before the correct diagnosis was made and until she was treated for follicular lymphoma.Conclusion: This study emphasizes the importance of being vigilant when a patient presents with unusual presentations of a disease in order to diagnose and treat the condition early to decrease the risk of complications and to mitigate the risk of poor outcomes.  Presentation and histology of non-Hodgkin lymphoma (NHL) vary widely which makes the diagnosis challenging. Their timely diagnosis is necessary as effective therapy is available for many subtypes. Follicular lymphomas are the second most common histological subtypes of NHL after the diffuse large B cell lymphomas (DLBCL). There has been a significant rise in the incidence of NHL over the past few decades including the subtypes of DLBCL and follicular lymphomas, irrespective of the HIV ,2. AccorWe report a case of primary retroperitoneal non-Hodgkin follicular lymphoma which presented as acute pancreatitis and the challenges faced while diagnosing retroperitoneal NHL.A 66-year-old Hispanic female with a medical history of asthma and hypertension presented to the Emergency Department with complaints of abdominal pain of score 7/10 and associated nausea. The pain was sharp, constant, in the right upper quadrant, and radiated to the back. She reported no fever, night sweats, vomiting, diarrhea, or constipation. The patient had experienced similar intermittent pain with the intake of fatty foods over the past one month. She was an ex-smoker and had quit smoking 14 years ago. She denied any alcohol intake. She underwent no previous surgeries other than tubal ligation.Physical examination revealed a thin woman who was moaning and groaning in pain, with normal skin color and no generalized lymphadenopathy. Vital signs were normal. There was tenderness to deep palpation in the right upper quadrant on the abdominal examination, and there was no palpable abdominal mass. The rest of the examination was unremarkable.Laboratory workup yielded a lipase level >3000 U/L and elevated liver function tests (LFTs) with aspartate aminotransferase (AST) 139 U/L, alanine aminotransferase (ALT) 65 U/L, alkaline phosphatase (ALP) 122 U/L. Abdominal ultrasound identified gallbladder wall thickening with pericholecystic fluid. A diagnosis of cholecystitis and pancreatitis was being considered. The CT scan showed a large amount of soft tissue mass in the retroperitoneum measuring 9.3 x 4.8 cm. The mass wrapped around the aorta and pushed it off the spine Figure . It forcAfter conservative treatment, the patient’s pain resolved, and lipase levels normalized, and she was discharged to follow up for outpatient endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) with biopsy of the retroperitoneal mass. One day later, the patient presented to the ER with similar abdominal pain, and laboratory workup during admission showed elevated lipase levels and normal LFTs. After resolving the lipase level's pain and normalization, the patient later underwent EUS, which confirmed the previous CT scan findings. The fine-needle biopsy of the mass showed a CD-10 positive, CD-5 negative B-cell lymphoproliferative disorder on flow cytometry. The positron emission tomography (PET) scan performed four weeks after the initial CT scan showed the tumor's size slightly larger than the previous one, with a transverse diameter of 10.1 x 5.9 cm and a cephalocaudal length of 9.5 cm without any metastatic lesions Figure .While awaiting the core biopsy and chemotherapy workup, the patient presented to the ER for worsening abdominal pain for the third time. With lipase levels >3000 U/L and ultrasound showing cholelithiasis with cholecystitis, the patient underwent laparoscopic cholecystectomy. To confirm and classify B cell lymphoma type, a core needle biopsy of the paraspinal lymph node was done. It was consistent with grade 1-2 follicular lymphoma.The patient underwent six cycles of bendamustine and rituximab treatment without any side effects. After four cycles of chemotherapy, a CT scan was performed to determine the response to therapy. CT scan showed resolution of lymphadenopathy with minimal residual soft tissue attenuation in the retroperitoneum.Malignant lymphomas are divided into two broad categories - Hodgkin’s lymphomas and non-Hodgkin's lymphomas (NHL). NHL is the most common type of lymphoma and comprises about 90% of the cases . At presRetroperitoneal masses are diagnostically challenging due to their location and wide range of differential diagnoses including solid versus cystic and neoplastic versus benign lesions. Lymphomas comprise 33% of all primary retroperitoneal mass . PresentTreatment for follicular lymphoma includes radiation therapy, chemotherapy, and stem cell transplant especially in younger patients with relapsing disease. Multiagent chemotherapy options are rituximab, cyclophosphamide, vincristine, prednisone (R-CVP); rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone (R-CHOP); CHOP immediately followed by tositumomab/iodine-131 radioimmunotherapy (CHOP-RIT) bendamustine plus rituximab , rituximFollicular lymphoma has a very good overall prognosis of a relative five-year survival rate if diagnosed and treated early in the course of the disease. We emphasize on diagnosing and treating these patients on time to reduce morbidity and mortality associated with it.


Gastrointestinal neuroendocrine tumors (GINETs)  are rare tumors with reported incidence of up to 6.98 per 100,000 which has increased significantly due to the increased detection on imaging and endoscopy. They are most commonly located in the small bowel, particularly the terminal ileum. Patients with small bowel NETs may present with abdominal pain, diarrhea, or carcinoid syndrome. However, the disease is mostly asymptomatic, and patients are usually diagnosed incidentally during routine colonoscopy. Although the ileum is the most common site for GINETs, terminal ileal (TI) intubation is not always completed during routine colonoscopy. With terminal ileum intubation being successful in at least 70% of colonoscopies and the rate of neuroendocrine tumor detection 0.1–1% of those intubations, one critical question remains unanswered: should terminal ileal intubation be considered a part of the definition of a complete colonoscopy? Herein, we present nine cases of NETs found incidentally on routine colon cancer screening colonoscopy in asymptomatic patients. This case series adds to the sparse literature and highlights the importance of TI intubation technique in early detection of small bowel NETs which could potentially affect the outcome. Gastrointestinal neuroendocrine tumors (GINETs)  are rare tumors. The incidence has increased significantly due to the increased detection on imaging and endoscopy. They are most commonly located in the small bowel, particularly the terminal ileum. The disease is mostly asymptomatic, and patients are usually diagnosed incidentally during routine colonoscopy. Although the ileum is the most common site for GINETs, terminal ileal (TI) intubation is not always completed during routine colonoscopy. Herein, we present nine cases of NETs found incidentally on routine average risk screening colonoscopy to highlight the importance of TI intubation technique in early detection of small bowel NETs which could potentially affect the outcome.A 66-year-old male patient underwent surveillance colonoscopy for CRC due to personal history of colon polyps. A 20 mm submucosal lesion was found on terminal ileal intubation with histopathology revealing carcinoid tumor. His initial lab workup revealed a 5-hydroxyindoleacetic acid (5-HIAA) level of 3 mg\gCR and a chromogranin A of 7 ng\ml. A CT scan abdomen\pelvis was performed and showed a non-obstructing mass in the terminal ileum, with no evidence of metastasis. He underwent mini-laparotomy with right hemicolectomy, and histopathology confirmed the diagnosis of well-differentiated neuroendocrine tumor infiltrating muscularis propria with metastatic tumor in 4 out of 10 resected lymph nodes (T2N1M0). A follow-up lab workup revealed 5-HIAA level of 3 mg\gCR and chromogranin A of 40 ng\ml. He had repeated colonoscopy after 2 years with normal neo-ileum.A 57-year-old female patient underwent average risk screening colonoscopy. An 11 mm submucosal lesion was found on terminal ileal intubation with histopathology revealing carcinoid tumor. Her initial lab workup revealed a 5-HIAA level of 4 mg\gCR and a chromogranin A of 101 ng\ml. A CT scan abdomen\pelvis was performed and showed a mesenteric nodule measuring 9 mm adjacent to the terminal ileum, with no evidence of metastasis. She underwent laparoscopic right hemicolectomy, and histopathology confirmed the diagnosis of low-grade neuroendocrine tumor involving the muscularis propria with metastatic tumor in 7 out of 19 resected lymph nodes (T2N1M0). A follow-up lab workup revealed 5-HIAA level of 2.4 mg\gCR and chromogranin A of 99 ng\ml. She had repeated colonoscopy after 1 and 3 years with normal neo-ileum.A 57-year-old male patient underwent average risk screening colonoscopy. A 15 mm lesion was found on terminal ileal intubation with histopathology revealing carcinoid tumor. His initial lab workup 5-HIAA and chromogranin were unavailable. A CT scan chest\abdomen\pelvis was performed and showed a faint enhancement of the terminal ileum with no evidence of metastasis. He underwent a laparoscopic ileocolectomy, and histopathology confirmed the diagnosis of malignant carcinoid tumor with metastasis to 2 out of 15 resected lymph nodes (T4N1M0). A follow-up lab workup revealed a 5-HIAA of 2 mg/gCR and chromogranin A of 62 ng/ml. He had repeated colonoscopy after 1 and 4 years with normal neo-ileum.A 69-year-old female patient underwent average risk screening colonoscopy. A 20 mm lesion was found on terminal ileal intubation with histopathology revealing carcinoid tumor. Her initial lab workup regarding 5-HIAA was unavailable and the chromogranin A was 48 ng/ml. A CT scan abdomen\pelvis was performed and showed 10 mm lobulated excrescence involving terminal ileum and a nonspecific 1.8 × 0.9 cm central mesenteric lymph node. She underwent laparoscopic right hemicolectomy, and histopathology confirmed the diagnosis of well-differentiated NET with metastasis to 3 out of 27 resected lymph nodes (T1N1M0). A follow-up lab workup revealed a 5-HIAA and chromogranin A of 3 mg/gCR and 70 ng/ml, respectively. She had repeated colonoscopy after 2 years with normal neo-ileum.A 55-year-old female underwent surveillance colonoscopy for CRC due to personal history of colon polyps. A 10 mm polyp was found on terminal ileal intubation with histopathology revealing carcinoid tumor. Her initial lab workup revealed a 5-HIAA of 3 mg/gCR and chromogranin A of 1152 ng/ml. A CT scan chest\abdomen\pelvis and NM octreotide  scan were performed and showed no definitive lesions suspicious for metastasis. She underwent a right laparoscopic hemicolectomy, and histopathology confirmed the diagnosis of carcinoid invading the submucosa with metastasis to 6 out of 29 resected lymph nodes (T1N1M0). A follow-up lab workup revealed a chromogranin A of 1160 ng/ml, while 5-HIAA level was unavailable. She had repeated colonoscopy after 2 years with normal neo-ileum, and an octreotide scan 3 years later with no evidence of metastasis.A 64-year-old male underwent average risk screening colonoscopy. A 10 mm lesion was found on terminal ileal intubation with histopathology revealing carcinoid tumor. His initial lab workup including 5-HIAA and chromogranin was unavailable. A CT scan chest\abdomen\pelvis was performed and showed no evidence of metastasis. The patient underwent a laparoscopic right hemicolectomy, and histopathology confirmed the diagnosis of well-differentiated NET invading the submucosa with metastasis to 2 out of 13 resected lymph nodes (T1N1M0). The patient has not presented for follow-up labs or colonoscopy to date.A 60-year-old female underwent average risk screening colonoscopy. A 17 mm lesion was found on terminal ileal intubation with histopathology revealing carcinoid tumor. Her initial lab workup revealed a 5-HIAA of 2 mg/gCR and chromogranin A of 559 ng/ml. A CT scan chest\abdomen\pelvis was performed and showed no evidence of metastasis. She underwent robotic ileocolectomy, and histopathology confirmed the diagnosis of insular carcinoid tumor with no evidence of atypia (T2N0M0). A follow-up lab workup revealed a 5-HIAA and chromogranin A of 4 mg/gCR and 149 ng/ml, respectively. She had repeated colonoscopy after 1 year with normal neo-ileum.A 58-year-old female underwent average risk screening colonoscopy. A 6 mm lesion was found on terminal ileal intubation with histopathology revealing carcinoid tumor. Her initial lab workup regarding 5-HIAA was unavailable and chromogranin A was 48 ng/ml. A CT scan abdomen\pelvis was performed and showed a 1.1 cm soft tissue lesion in the terminal ileum with no evidence of metastasis. A NM octreotide  scan also showed no evidence of metastasis. She underwent an open right-sided hemicolectomy, and histopathology confirmed the diagnosis of well-differentiated carcinoid tumor infiltrating through the subserosal adipose tissue (T3N0M0). A follow-up lab workup revealed a chromogranin A of 56 ng/ml, while 5-HIAA level was unavailable. She had repeated colonoscopy after 1 year with normal neo-ileumA 69-year-old male underwent surveillance colonoscopy for CRC due to personal history of piecemeal polypectomy. A 15 mm polyp was found on terminal ileal intubation with histopathology revealing carcinoid tumor. His initial lab workup revealed a 5-HIAA of 6 mg/gCR and chromogranin A of 531 ng/ml. A chest CT scan and CT enterography were performed and showed small bowel tumor in the right lower quadrant with peritoneal and omental metastases. He underwent a laparoscopic right hemicolectomy, and histopathology confirmed the diagnosis of transmurally invasive and well-differentiated carcinoid tumor with angiolymphatic and perineural invasion. The tumor revealed metastasis to the mesentery, omentum, and 2 out of 12 resected regional lymph nodes (T4N1M1). The patient has not presented for follow-up laboratory and colonoscopy to date as it has been less than 1 year since initial colonoscopy.See Gastrointestinal neuroendocrine tumors (GINETs)  arise from the enterochromaffin cells and are most commonly located in the small bowel, particularly the terminal ileum. NETs are the most common type of small bowel tumors . OverallPatients with small bowel NETs may present with abdominal pain, diarrhea, nausea, and vomiting especially when they have carcinoid syndrome . HoweverAlthough the ileum is the most common site for GINETs, terminal ileal (TI) intubation is not always performed during routine colonoscopy unless ileal pathology such as inflammatory bowel disease (IBD) is suspected. This could be due to time limitations, lack of skills, and presumed unnecessity. On another note, an increase in incidence of rectal NETs has been noticed since the implementation of screening colonoscopy per review of SEER database . The ratPatients with locoregional disease are treated with resection of the involved segment and small bowel mesentery even in asymptomatic patients , 14. TecIn advanced disease, the role of surgery is less clear and reserved for patients without carcinoid syndrome and those who are deemed good candidates for surgical resection. Chemoembolization and systemic therapy are options if surgery is not appropriate. Ten-year survival for patients with small bowel NETs depends on the stage of the disease upon diagnosis. It drops from 95% in stage I to around 40% in stage IV . The sigOur case series is consistent with previous reports by Yarze et al.  and Ten In conclusion, our case series supports previously published data on terminal ileal NETs incidentally found on screening colonoscopy. Given the minimal increase in procedural time and risk as well as high success rate, the addition of TI intubation to standard screening colonoscopy can be of great added value in the detection of small bowel NETs.


Cameron lesion is an uncommon cause of overt upper gastrointestinal bleed (GI bleed). Though hiatal hernia is a well-known entity, Cameron lesions that may occur in them are usually missed during upper endoscopy. Patient with Cameron lesions usually presents as chronic iron deficiency anemia, rarely as acute GI bleed. Multiple other risk factors such as non-steroidal anti-inflammatory drug use, alcohol consumption, gastro-esophageal reflux disease (GERD) may be present concomitantly which makes initial differential diagnosis of Cameron lesions more difficult as seen in our case. Gastrointestinal bleed (GI bleed) accounts for 350/100,000 hospitalizations annually in the US. Of these, 50% are due to upper GI hemorrhage. The common causes of upper GI bleed in descending order of occurrence are peptic ulcer (38%), esophageal or gastric varices (16%), esophagitis (13%), UGI tract tumor (7%), angioectasia (6%), Mallory Weiss tear (4%), erosions (2%) and Dieulafoy’s lesion (2%). The cause is unknown in 8% of the cases [A Cameron lesion is a rare cause of overt upper GI bleed . It occuWe present one such case of a patient with multiple Cameron lesions with confounding risk factors for other common causes of a GI bleed.A 64-year-old male presented to the emergency room with multiple episodes of hematemesis. These episodes had been preceded by heavy binge drinking. He denied any abdominal pain, melena or hematochezia. No previous similar episodes in the past. His past medical history was significant for hypertension, dyslipidaemia, gastroesophageal reflux and ischemic stroke in the past with no residual deficit. Social history was significant for alcohol use of 4-6 shot of vodka daily for past 15 years. He denied illicit drug use or cigarette smoking. There was no significant surgical history. His medications included daily low dose of Aspirin.On his arrival to ER, blood pressure was 120/70 mmHg, heart rate of 118 beats per minute, respiratory rate of 30 breaths per minute and SaO2 88% at room air. On physical examination, he appeared pale, not in acute distress, with clear and bilaterally equal breath sounds and normal heart sounds. His abdomen was soft and not tender, without any organomegaly. Digital rectal exam revealed dark brown stool.Hemoglobin at presentation was 5.9 g/dl. Renal function, platelet and white blood cell counts were normal. Prothrombin time, international normalized ratio (INR) and activated partial thromboplastin time values were 13.6, 1.16 and 25.3 seconds, respectively. Total protein and albumin were slightly decreased . Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were normal. Ultrasound abdomen showed hepatomegaly of 22.1 cm with diffuse increased echogenicity of the hepatic parenchyma, no splenomegaly. Given history of alcohol use disorder, variceal bleeding was high on the differential. He had no previous esophagogastroduodenoscopy (EGD) performed in past.He was started proton pump inhibitor (PPI) and octreotide. He received two packed red blood transfusion without complications. The patient underwent EGD Figure . It reveCameron lesions were first described in 1986 by Dr Alan Cameron from Mayo Clinic as ‘linear gastric erosions’. They are found in the proximal stomach at the end of a large hiatal hernia near the diaphragmatic pinch . AccordiOverall prevalence of Cameron lesions in all EGD’s is less than 1% . In a stAmong obscure GI bleeders the prevalence is around 3.8% . In obscThe classic description of the lesion as given by Cameron is as follows: ‘The erosions were frequently multiple and were usually seen on the crest of an inflamed appearing fold. They were typically white, narrow and elongated with the longitudinal axis corresponding to the longitudinal direction of the gastric mucosal folds’ . The desCamus et al. in their case series found that 88% cases have multiple Cameron ulcers, with a median number of three ulcers and a median size of 10 mm ,10. In hCameron lesions have a range of manifestations from asymptomatic presentation of an occult GI bleed causing iron deficiency anemia to life-threatening overt GI bleed . Rate ofOur patient was a chronic active alcohol user and presented after hours of binge drinking. Additionally, the patient was also on long-term low dose aspirin for a past stroke. Consequently, prior to endoscopy, bleeding from varices, or a peptic ulcer was high on the differential. None of these lesions were seen. The finding of the hiatal hernia prompted the proceduralist toward the possibility of the Cameron lesion. Certain risk factors have been identified in the formation of this lesion. Gray et al., via multivariable logistic regression, showed that in their study, nonsteroidal anti-inflammatory drugs (NSAID) use and a large hiatal hernia were the two statistically significant risk factors for Cameron lesions . The othMechanical trauma has been proposed by numerous authors as being the most likely cause of the formation of the Cameron lesion ,5,11. WiCameron lesions have been treated medically, surgically and rarely endoscopically. Medical management consists of iron supplementation and PPI. Surgical treatment consists of fundoplication . In geneCameron lesions are a rare cause of upper GI bleed. The presentation may be acute and overt, instead of chronic and occult as commonly thought. In our case, the patient had an underlying alcohol use disorder which made us focus on possibility of more common diagnosis like variceal bleed and peptic ulcer bleed. Cameron ulcer bleed was not on our differential list. These are also easily missed during upper GI endoscopy due to lack of circumferential involvement and variable degrees of severity (from erosions to ulcerations). This case helps in increasing awareness regarding Cameron ulcers as a possibility of overt upper GI bleed in patient with multiple risk factors like alcohol use disorder and NSAID use.


Pigmented epithelioid melanocytoma (PEM) is an uncommon and recently described entity with unknown biologic behavior. It is a melanocytic tumor showing overlapping features of both an atypical epithelioid blue nevus and a low-grade “animal-type melanoma.”PEM occurs over a broad age range, with a predilection for children and young adults, and clinically appears as a macular, popular, or nodular lesion. Dermoscopically, PEM appears as a polymorphic lesion, characterized by homogeneous blue pigmentation and a combination of black, brown, and white colors. Histopathologically, it is characterized by a dermal proliferation of heavily pigmented, both dendritic and spindle/epithelioid melanocytes, admixed with slightly larger, plumper, and less pigmented epithelioid cells . InvolveWe describe a case of vulvar mucosal PEM, that occurred on the right small lip of a 50-year-old woman. Clinically it appeared as an intensely pigmented, brown-black papule about 1 cm in size. On dermoscopy, we observed many irregular, black blotches surrounded by a whitish blue veil. No atypical vascular feature was detected. Due to its globular structure and black-bluish color and considering the age of the patient and rapid onset, the lesion resembled a Spitz nevus or an atypical Spitz tumor . HoweverThe histological examination showed an acanthotic epidermis with a slightly warty profile overlying a large dermal nodular lesion with blurred borders consisting of hyperpigmented epithelioid and spindle dendritic melanocytes arranged in perivascular and periadnexal bundles, mixed with epithelioid nevoid cells and numerous melanophages. No significant atypia, mitosis, or necrosis was appreciated. Immunohistochemical staining was performed. While HMB-45 and Melan-A were positive, p16 was expressed on the entire lesion, and KI-67 showed low activity (1%) .Pigmented lesions of mucosal sites usually can be difficult to interpret. PEM is a rare entity, and we report on a case of a female genital mucosal variant. Uehara et al published a case of PEM on the glans . PEM cou