Given the wide range of differential diagnoses for adnexal masses, the key issue is the correct assessment of the initial location to rule out malignant or emergency cases. Here, we report a case of perforated sigmoid colon cancer initially diagnosed as a tubo‐ovarian abscess. Colon cancer is a malignancy that can be confused with various conditions such as abscesses and inflammations, due to the possibility of involvement in different areas of the abdomino‐pelvic cavity. It is important to consider when facing abdomino‐pelvic findings, as early diagnosis will lead to a less morbid, curative treatment.  The etiology and prevalence vary with age. A wide range of these masses are benign and asymptomatic and are found randomly on examination or through imaging. Accordingly, the true prevalence of these masses in the general population is unknown.Given the wide range of differential diagnoses and the lack of need to treat many benign cases, the key issue is the correct assessment and accurate diagnosis of the initial location of the mass to rule out malignant or emergency cases. This constitutes the primary challenge when dealing with these masses. Masses of gastrointestinal origin are among the most common non‐gynecological causes that should always be considered as a differential diagnosis.Here, we report a case of perforated sigmoid colon cancer in a 45‐year‐old female patient which was preoperatively diagnosed as a tubo‐ovarian abscess.2A 45‐year‐old female, P3L3/ND , was referred to the gynecology department with abdominal pain in the left lower quadrant (LLQ) region, fever, and chills.The patient had also referred to the emergency room a week earlier with a similar abdominal pain, without fever. At the time, an ultrasound imaging report had described a 4‐centimeter heterogeneous area in left ovary, and she was discharged with a prescription of cefixime based on the diagnosis of hydrosalpinx on ultrasound and the absence of fever.The pain intensified during the 2 days, and she also mentioned the reduction of appetite and chronic constipation over the last few months. There was no nausea and vomiting. She had no medical illness history, no surgical history, and no remarkable drug or family history.The patient was ill and febrile during the general examination. Blood pressure was 100/60 mmHg, heart rate was 110 beats/minute, and body temperature: 39°C. On physical examination, the patient's abdomen was soft and had no tenderness or rebound positivity, and the lungs were clear. On genital examination with a speculum, the appearance of the cervix was normal, mucopurulent secretions were seen in the cervix, and cervical motion tenderness was positive. The patient underwent an ultrasound investigation which demonstrated a normal uterus with endometrial thickness of 10 mm and a round hypoechoic cystic lesion containing hyperechoic areas with approximate dimensions of 61 × 82 mm on the left side of the pelvis. Significant inflammation and edema in the surrounding soft tissue with possibility of tubo‐ovarian abscess on the left side were reported, while the right ovary was normal.According to the examinations and the results of ultrasound imaging, there was a suspicion of pelvic abscess, and the patient was hospitalized with a diagnosis of PID and tubo‐ovarian abscess. She underwent antibiotic therapy with ampicillin 2 g QID, clindamycin 900 mg TDS, and gentamicin 80 mg TDS.As the patient's fever did not alleviate after 48 h of antibiotic administration, the antibiotic regimen was changed to Imipenem and the patient was a candidate for repeated ultrasound evaluation and Ultrasound Guided Abscess Drainage. The next ultrasound assessment revealed a heterogeneous cystic structure with internal echoes and gas foci in the left adnexa extending to the posterior cul‐de‐sac with dimensions of 100 × 41 mm, along with evidence of fat stranding and increased thickness of the adjacent intestine  is a common and deadly disease and one of the three leading causes of death in women, according to the statistics reported by the World Health Organization.Site of the tumor is a major contributor to the clinical presentation. Cancers of the right colon are often exophytic and commonly associated with anemia due to occult blood loss. Cancers of the left colon and sigmoid colon are often deeply invasive and annular. Obstruction, perforation, peritonitis, rectal bleeding, and alteration in bowel habits are common in these cases.Most colorectal cancer is associated with symptoms such as nausea, vomiting, and constipation, before resulting in perforation and peritonitis and it is uncommon for the colon to be perforated before the complete intestinal obstruction. As such, these symptoms, along with imaging results of adnexal masses, can lead to the suspicion and misdiagnosis of tubo‐ovarian abscess, which was reported in a similar case study by Sayan et al.The evaluation of colorectal cancers should include pan‐body computed tomography (CT) scan. Nevertheless, considering the fact that the evaluation of acute abdominal pain, especially in the Department of Gynecology and in patients with suspected gynecologic problems, begins with ultrasoundReports of misdiagnosis cases of gastrointestinal pathologies with adnexal masses have been published, indicating the great importance of using diagnostic tests and imaging along with principled physical examination. However, misdiagnosis of appendix pathologies is more relevant to adnexal diseases. In the cases reported by Cristian et al., Hajiran et al., and Kumar et al., the patients were presented with the symptoms of adnexal mass. However, after final diagnostic examinations, the presence of mucinous adenocarcinoma of the appendix in these patients was confirmed.Whereas transabdominal ultrasound is not routinely used in the diagnosis and staging of colon cancer, recent technology advances as well as the highly cost‐effective and noninvasive nature of this technique has prompted new interest, with much less excuse to call it a weak assessment tool. Although still investigational, transabdominal ultrasound could prove to be an important alternative to existing standard protocols.Mucinous adenocarcinoma accounts for 10%–20% of colorectal adenocarcinomas, which are common in women and young patients. Studies in patients with this type of colorectal cancer have demonstrated that despite the relatively poorer prognosis, systemic chemotherapy and surgery have had positive effects on the treatment process of patients. To achieve an appropriate therapeutic response, it is important that patients are identified and treated in a timely manner.4Given the variety of symptoms in patients with pelvic masses and the risks of misdiagnosis, along with the importance of a timely diagnosis of malignant or emergent situations, it is recommended that all diagnostic possibilities be considered to rule out irrelevant diseases before the patients with pelvic masses are treated.Authors AM, PL, and SHS contributed to conception, design, and drafting of the manuscript. Authors MK, MA, and MD contributed to data collection. MA contributed to providing microscopic data and imaging.The authors have no conflict of interest to declare.Written informed consent was obtained from the patient to report the case, and the manuscript was approved at the Ethics Committee of Mashhad University of Medical Sciences.Published with written consent of the patient.


Primary lymphoma of the liver, gallbladder, and extrahepatic bile ducts or secondary involvement of these organs by leukemia is exceedingly rare. Patients with primary lymphoma or leukemic involvement of the biliary tract and liver often present with symptoms and signs of biliary tract obstruction or inflammation.We present a case of a 24-year-old male with biliary tract symptoms who underwent laparoscopic cholecystectomy. His precholecystectomy complete blood count performed on the same morning showed 72% lymphocytes while peripheral blood smears showed approximately 15% blasts. Surgeon went ahead with the procedure. Imaging done prior to surgery showed thickened gallbladder, while the liver, biliary tract, and pancreas did not show any thickening or mass lesion. However, the liver was enlarged. Grossly, the gallbladder wall did not show any stones or discrete mass involving the wall. Instead, there was subtle thickening of the gallbladder wall due to diffuse infiltration by the leukemic infiltrate. This lymphoid population reacted with PAX-5 and TdT immunohistochemical antibodies in a diffuse manner confirming precursor B-cell origin. This patient was found to have B-lymphoblastic leukemia involving his bone marrow on further clinical and diagnostic workup. Patient responded well to chemotherapy and is currently on maintenance treatment. He is well 1.5 years after his diagnosis.This case highlights a unique and rare scenario where a previously undiagnosed and unsuspected hematologic malignancy initially presented with clinical features of a chronic inflammatory condition involving an abdominal organ owing to secondary involvement by the malignant infiltrate. Primary lymphoma of the liver, gallbladder, and extrahepatic bile ducts or secondary involvement of these organs by leukemia is exceedingly rare. Both lymphoid and myeloid leukemia have been reported to involve the gallbladder. Most patients with primary or secondary involvement of the gallbladder present with symptoms mimicking cholecystitis. Patients with lymphoma/leukemic involvement of biliary tract and liver often present with symptoms and signs of biliary tract obstruction such as cholestatic jaundice and liver failure. Clinical presentation, radiological findings, and pre-operative findings are not often helpful in distinguishing primary or secondary involvement of these organs by hematolymphoid malignancies and preoperative diagnosis is extremely difficult –5. A galHerein, we report a case of acute lymphoblastic leukemia (ALL) in a young male involving the gallbladder secondarily. We describe the clinical, radiological, gross, microscopic, and immunohistochemical (IHC) findings and present a detailed review of the published literature.9E/L. Peripheral smear showed approximately 15% blasts. Hemoglobin was 9.4 gm/dL, while platelet count was low 100 × 109E/L. The surgeon decided to proceed with the procedure as he had no suspicion that the gallbladder was infiltrated by a neoplastic lesion and believed that the blast cells seen on complete blood count were an independent finding from cholelithiasis and cholecystitis.A 24-year-old male presented with severe right upper quadrant abdominal pain for 3 months. There was no significant past medical history. He was vitally stable and general examination was unremarkable except for epigastric tenderness. His laboratory findings revealed abnormal liver function tests. Imaging studies were suggestive of cholelithiasis with an evolving cholecystitis. The liver was enlarged. An elective laparoscopic cholecystectomy was planned. His initial peripheral blood smears done on the day of the surgery showed 72% lymphocytes on differential leukocyte count, although total white cell count was 3.9 × 10Pre-cholecystectomy ultrasound of liver and gallbladder showed moderately distended and thickened gallbladder measuring 80 × 35 mm and containing tiny stones mixed with sludge. Wall thickness was 7 mm. The liver was enlarged and showed mild increase in parenchymal echogenicity suggesting mild fatty infiltration. No focal lesion was seen. No intra- or extrahepatic biliary dilation was present. The common bile duct (CBD) and portal vein were unremarkable. Magnetic resonance cholangiopancreatography (MRCP) showed slightly edematous, distended, and thick-walled gallbladder with sludge and stones. Ultrasound, MRI, and MRCP findings were suggestive of cholelithiasis with evolving cholecystitis. There was no evidence of any intra or extra hepatic biliary dilatation. The right and left hepatic ducts and cystic duct appeared unremarkable. Post-cholecystectomy ultrasound, MRI, and MRCP showed no focal lesion or distortion in liver, biliary tract, or spleen. However, the liver appeared enlarged. No evidence of bilateral pleural effusion or ascites was noted. He underwent laparoscopic cholecystectomy.On laparoscopic cholecystectomy, the gallbladder was distended and was adherent to the liver. The cystic duct was short and wide. Dissection was difficult due to adhesions and hepatomegaly. The liver appeared inflamed and friable; peri-hepatic fluid was present. Adhesiolysis was performed and dissection was continued over the liver bed. The gallbladder was dissected from the gallbladder fossa. Some bleeding was encountered due to traction on the liver.Grossly, the gallbladder measured 7 cm in length and 2 cm in diameter. The serosal surface was smooth. The fundal wall showed an average thickness of 5 mm, with very subtle thickening at some places  was rendered. Peripheral blood film was repeated and bone marrow biopsy was performed post-resection. Peripheral blood film showed normochromic, microcytic red blood cells. Hemoglobin was 7.8 gm/dl. Approximately 80% blast cells were seen. Platelets were low on film. Bone marrow aspirate revealed diffuse infiltration with blast cells which constituted approximately 85% of the total nucleated non-erythroid cell population. Similarly, section of bone trephine also showed hypercellularity (approximately 80 to 85%) and diffuse infiltration by blast cells. Immunophenotyping by flow cytometry performed on bone marrow showed reactivity of blast cell population to pan B-cell markers i.e., CD10, CD19, CD22, and CD79a along with HLA-DR and CD45. This population also showed positivity to CD9, CD58, CD34, and TdT. Overall findings were consistent with B-LL.ABL1 by FISH/PCR was subsequently performed and was negative. Conventional cytogenetics showed 46 XY chromosomes.9E/L, platelets 450 × 109E/L. He is well 2 years after the diagnosis.Our patient responded well to treatment. He received treatment with MRC UK ALL XII protocol. His minimal residual disease after induction phase I was less than 0.01%. He subsequently successfully completed all blocks of treatment till consolidation. During induction phase I, he developed steroid-induced hyperglycemia which reverted with insulin and oral hypoglycemics. Since then, he has not developed any other chemotherapy-related complications. He is currently on maintenance treatment with 6-mercaptopurine and methotrexate with prophylactic trimethoprim/sulphamethoxazole. His last complete blood count (CBC) showed hemoglobin 13.2 gm/dl, white blood cells (WBC) 5.1 × 10Secondary involvement of gallbladder by malignancies is extremely rare and malignant melanomas constitute the most common tumor type . In moreOver the years, several case reports have documented primary or secondary involvement of liver, gallbladder, and biliary tract by acute and chronic lymphoid –15 or acMost cases of leukemic infiltration of gallbladder present with clinicopathological features closely resembling acute and/or chronic cholecystitis , 16, 17.Constitutional symptoms in such patients include nausea, vomiting, right upper quadrant and epigastric abdominal pain and cramps, bloating, abdominal swelling, and mass due to enlargement of the liver, spleen and regional lymph nodes, and/or fluid accumulation in the abdominal cavity, persistent weakness and fatigue, weight loss, obstructive jaundice, and gall stones , 20, 22.In cases where cholecystectomy was performed with suspicion of cholelithiasis and acute or chronic cholecystitis reveals infiltration by lymphoma or leukemia, blood tests , bone marrow aspirate, fine needle aspiration cytology (FNAC) of abdominal fluid for malignant cells, and endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) for evaluation of lymph nodes in porta hepatic region should be carried out. In addition, abdominal ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT) scan should be performed to investigate systemic involvement .Leukemic infiltration only rarely produces a discrete focal mass. Even the gross appearance at cholecystectomy is often strongly suggestive of acute and/or chronic cholecystitis , 16, 17.Prognosis of B-LL has improved with new chemotherapy. There is a >95% complete remission rate in children compared to 60–85% in adults. Approximately 80% children are cured while cure rate in adults is <50% . T-LL isThe usual chemotherapy regimen for patients with LL includes vincristine, dexamethasone or prednisolone, and an anthracycline drug such as doxorubicin (Adriamycin) or daunorubicin. Some regimens may also include cyclophosphamide, L-asparaginase, and/or high doses of methotrexate or cytarabine (Ara-C) as part of the induction phase. In LL patients whose leukemia cells have the Philadelphia chromosome, a targeted drug such as imatinib (Gleevec) or dasatinib (Sprycel) is often included. For AML, combination of cytarabine with anthracycline (Daunorubicin) has been used for decades. However, several novel targeted therapies are now becoming available. These include hypomethylating agents, drugs inhibiting Hedgehog pathway and drugs modulating TP53 pathway, etc. In addition, allogenic hematopoietic stem cell transplant can be considered for post-remission therapy in patients with adverse risk of relapse. In CML, targeted therapy with imatinib, dasatinib, and nilotinib (Tasigna) is given. In a group of patients with CLL , a defined course of therapy with fludarabine, cyclophosphamide, and rituximab has been shown to be of great benefit and many patients achieve durable remissions , 34–43.Involvement of the gallbladder, biliary tract, or liver by leukemic infiltrate is very rare and documented cases mostly present with symptoms strongly mimicking acute and/or chronic inflammation of the involved organs. Gallbladder involvement usually presents with features suggestive of acute or chronic cholecystitis and diffuse thickening of the wall rather than a discrete mass. When there is no previous diagnosis of leukemia, it is not possible in most cases to make a pre-operative diagnosis and leukemia is only diagnosed on histopathological examination of the resected gallbladder.


We encountered a case of life-threatening pulmonary embolism (PE) after an extensive retroperitoneal tumor (RT) surgery. The patient complained of abdominal distension. Preoperatively, an ovarian tumor and colon adenoma were suspected. Upon laparotomy, tumor resection and partial rectal resection were performed; the tumor had originated from the retroperitoneum. On postoperative day 11, the patient suddenly went into fatal shock complicated by strong back pain and dyspnea after the continuous pressure drain was removed. Thrombolysis, anticoagulation, and percutaneous catheter-directed treatment were attempted for the massive PE; however, these induced copious intra-abdominal bleeding. A substantial blood transfusion was required, which increased her body mass by 40 kg. On day 22, an intra-abdominal embolism was resected, and hemodynamics stabilized. RTs have a potential risk of perioperative thromboembolism; therefore, we suggest that surgery should take place in an academic hospital with an experienced circulatory team. To preserve life after PE, early diagnosis and multidisciplinary treatment are indispensable. Pelvic retroperitoneal tumors (RTs) are relatively rare tumors that are sometimes unexpectedly found by gynecologists. Among pelvic tumors in women, especially ovarian neoplasm is known to be the main cause of deep venous thrombosis and pulmonary embolism (PE), and adequate perioperative thromboprophylaxis is required . MeanwhiHere, we report a case of a giant retroperitoneal borderline malignant tumor that caused a massive PE after surgery; the patient survived owing to multidisciplinary treatment. We detail the processes leading to a successful outcome and suggest it is worthwhile to review the etiology of PE in RTs.Full, informed consent was obtained from the patient. This study was conducted in accordance with the Declaration of Helsinki . The patient, a 64-year-old woman, was referred to our hospital with a history of abdominal distension and increased vaginal discharge beginning 18 months previously. A gigantic multicystic tumor was found in the pelvis, and ovarian cancer was suspected. Her body height was 158 cm, and her body weight was 48 kg. Examination of imaging revealed a 32 cm-sized (maximum diameter) giant multilocular cystic tumor involving a solid part in the abdominal cavity  was initiated for 24 hours. Enoxaparin sodium (2000 U × 2/day) was injected five days after surgery. The patient was treated according to deep vein thrombosis prophylaxis guidelines in Japan.The patient recovered uneventfully until an event occurred on day 11 post-surgery. After her abdominal drain was removed, she felt dizzy, and her blood pressure dropped to 75/52 mmHg. Five hours later, she suddenly went into fatal shock, complicated by strong back pain, dyspnea, and peripheral coldness; her blood pressure was also unmeasurable. She was immediately taken to the intensive care unit (ICU), and dopamine hydrochloride and heparin were administered. Shortly after entering the ICU, cardiopulmonary arrest (CPA) occurred, and cardiopulmonary resuscitation (CPR) took place. She was put on an artificial respirator and entered the catheter room for the introduction of veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Cardiac ultrasound showed right ventricular and right atrial dilatation, suggesting severe pulmonary hypertension (the estimated systolic pulmonary artery pressure was 58 mmHg). We suspected PE and performed pulmonary angiography, which revealed a massive thrombus floating in the bi-pulmonary artery.We started thrombolysis with t-PA (64 000 U) and anticoagulation with heparin. However, hemodynamic improvement was poor, and thrombectomy was considered. Surgical pulmonary embolectomy was too risky, so percutaneous catheter-directed treatment was performed on day 4, and her hemodynamics improved temporarily. However, the thrombolysis-induced copious intra-abdominal and subcutaneous bleeding persisted. As a result, cardiac output could not be maintained due to intra-abdominal bleeding putting pressure on the vessels and decreasing venous return. To maintain her hemodynamics, she required substantial daily blood transfusions and continuous hemodiafiltration (CHDF) management. The total blood transfusion amounted to RCC 152 U), FFP (154 U), and PLT (110 U). Her weight increased to 88 kg from 48 kg after the blood transfusion; a notable increase of 40 kg. We planned to perform a thrombectomy after discontinuing VA-ECMO with an understanding of the high risk of death. On day 12, intraperitoneal thrombectomy was performed immediately following the discontinuation of VA-ECMO during surgery. In the laparotomy, a large amount 3920 g) of intra-abdominal hematoma was removed (Figure  U, FFP (920 g of This case shows that an RT has the potential to cause a fatal perioperative PE. Immediate cardiopulmonary resuscitation and prompt intensive treatment were provided by our academic cardiovascular treatment team. Therefore, we suggest that cases at high risk of PE, including RTs, should be managed in a specialized cardiovascular facility, even if there are no thrombosis-related preoperative abnormalities.RTs that arise from mesenchymal connective tissues are relatively rare, while malignant RTs are more common . These tThe correlation between RTs and thromboses is not understood. In addition to abdominal symptoms, it has been reported that RTs may be detected by thrombosis ,6. PE-rePE has increased 2.25-fold in the past 10 years in Japan . Acute PIn this case, ovarian cancer was suspected in the preoperative diagnosis, and a laparotomy was performed. The huge tumor was unexpectedly derived from the retroperitoneum, but it could be removed completely without any problem. Age, tumor size, and borderline malignancy were risk factors for DVT and PE. The preoperative examination did not reveal thrombosis, and we took maximum preventive measures by considering the patient to have a high risk of venous thromboembolism. Possible reasons why the patient developed the potentially fatal PE include that her large pelvic RT directly pressed upon the retroperitoneal vessels, causing more complications than intraperitoneal tumors alone. Second, continuous negative pressure drains may have affected the development of severe thrombosis. An abdominal drain was required until the 11th day postoperatively because of the partial colectomy. It has previously been reported that a continuous suction drain after retroperitoneal lymphadenectomy for a gynecological tumor may increase DVT .The diagnosis of PE and multidisciplinary intensive treatment were initiated promptly; however, the postoperative period of the giant retroperitoneal tumor resection caused a large amount of intra-abdominal bleeding. The most difficult management for anticoagulant therapy is coexistence with the risk of bleeding. We, therefore, decided to perform a laparotomy to remove the intra-abdominal thrombi and succeeded in preserving her life.Although RTs are relatively rare tumors, gynecologists sometimes encounter them unexpectedly. Compared to an intraperitoneal tumor such as an ovarian tumor, a retroperitoneal tumor is associated with a higher risk of thrombosis; therefore, it is critical for clinicians to pay close attention to perioperative thrombosis. As RTs have the potential to become new risk factors for thromboembolism, it is recommended that they are treated by an experienced team of surgeons, including a cardiologist and an emergency specialist, thus employing a multidisciplinary approach.


Background Spigelian hernias are a rare type of lateral ventral abdominal hernia and their content can include any of the intra-abdominal organs. Many cases have described the presence of a variety of abdominal organs in Spigelian hernias, but only few cases report the presence of an incarcerated appendicitis. Imaging is an important step in the diagnosis to avoid the lack of knowledge in such cases. Surgical treatment can be through open or laparoscopic approach, with or without using a mesh according to the size of the defect.Case Report We report a case of an 82-year-old patient who presented with an acute appendicitis with peri-appendicular abscess strangulated in a right Spigelian hernia. The patient was successfully treated by a laparoscopic appendectomy, a surgical drainage of the abscess, and direct muscle approximation without using of mesh due to inflammation.Conclusion Spigelian hernias with acute appendicitis in their content are a very rare condition. Clinical diagnosis is usually difficult and challenging and computed tomography scan is the imaging modality of choice. The treatment is surgical. Abdominal wall hernias through Spigelian aponeurosis are a rare type of hernia.We describe the case of an 82-year-old patient, suffering from chronic kidney disease due to diabetes, who presented to his dialysis session complaining of exacerbated abdominal pain located at the right flank, associated with shivers. He mentioned an abdominal discomfort, which started 5 days before with increasing intensity until it became unbearable. He denied experiencing nausea, vomiting, constipation, or diarrhea.The patient, known to have chronic kidney disease, is on hemodialysis since 2019 through an arteriovenous fistula, three sessions per week. His past medical history is relevant for type 2 diabetes mellitus, long-standing hypertension, hyperlipidemia, hyperuricemia, heart failure (ejection fraction 35–40%), and atrial fibrillation. He has a 200 pack/year smoking history, which stopped in 2001. His medical history is also significant for recurrent hypoxic pneumonias, chronic obstructive pulmonary disease exacerbations, and recurrent pyelonephritis.His surgical history includes left nephrectomy, exploratory laparotomy for penetrating gunshot wound, bilateral cataracts, and corneal transplants.2.On physical examination, the patient is obese, conscious, and alert. Vital signs were within normal limits, with no fever. Body mass index is 31 kg/mBowel signs were present. Palpation of the abdomen revealed an indurated painful mass at the right flank. No redness or signs of cutaneous inflammation were seen on the abdomen. Otherwise, the abdomen was soft, with no rebound tenderness or guarding.9/L of white blood count and a protein C reactive level at 202 mg/L.A computed tomography (CT) scan of the abdomen with intravenous contrast showed an inflamed and thickened appendix, surrounded by fat stranding, with the formation of a loculated abscess of 60 × 40 mm at its tip, protruding through the muscle wall and strangulated in a right Spigelian hernia -3. LaAn empiric large-spectrum antibiotic was initiated (Piperacillin-Tazobactam) since the patient has a long history of hospitalization and recurrent infections (urinary and pulmonary). He was then transferred to the operating room. The operation was a laparoscopic appendectomy (ligation of the base and controlling the mesoappendix) and a surgical drainage of the peri-appendicular abscess located on the right flank and5. Escherichia colisensitive to the previously used antibiotic. There was no chance for downgrading the antibiotic. The patient had an uneventful hospital course and he was discharged on day 7. During this week, the patient received the same antibiotic for 48 hours and the gauze was changed daily. The pathology report showed an acute appendicitis with peri-appendicular abscess integrated within the mesoappendix and no signs of malignancy. Postoperative follow-up at 1 month revealed a recovered patient from this episode without any complaints.Culture of the abscess showed the growth ofSpigelian hernias are a rare type of abdominal wall hernia, with an incidence of only 1 to 2% of all hernias. They are more common in women, can be congenital or acquired, and predisposing factors, such as obesity and pregnancy, can play a role. In definition, a Spigelian hernia is a weakness in the aponeurosis located between the rectus muscle and the linea semilunaris.It is always challenging to diagnose a Spigelian hernia without complications. The hernia is difficult to assess on clinical examination, especially in obese patients. In the absence of incarceration or strangulation, the patient describes a chronic diffuse abdominal pain, increased by contraction of the abdominal wall musculature.When a high index of suspicion is found, sonography appears to be effective and accurate in the diagnosis.Chronic herniation caused adhesions and exteriorized the perforation from the abdominal cavity, preventing our patient from developing more severe medical conditions, such as peritonitis. Cox et alSurgical correction is the treatment for Spigelian hernias. A review of different surgical approaches in the cases discussed above appears inAcute appendicitis strangulated in a Spigelian hernia is a very rare condition that presents with a painful indurate flank mass. CT scan is essential for diagnosis, surgical treatment is required, and laparoscopic approach is safe. More studies are a must to approve the use of mesh in this condition of hernia repair.


Microwave ablation (MWA) has been proven to be an efficient and safe method for local tumor control of liver tumors. Reported complications are rare, but include liver abscess, hematoma, pleural effusion, and occasional thermal injury of the adjacent colon. Intestinal perforation usually requires immediate surgical treatment to prevent generalized peritonitis and sepsis.Herein, we describe a case of gastric perforation following percutaneous MWA for hepatocellular carcinoma as a bridging therapy prior to liver transplantation.Due to the clinical condition of the patient, conservative treatment was considered sufficient. Nine months after MWA, successful liver transplantation followed. Intraoperative findings revealed a scar in the gastric wall with tight adhesions to the liver, requiring adhesiolysis and subsequent suturing. Postoperative recovery was uneventful.At present, the patient is doing well. No further gastrointestinal events occurred.To our knowledge, this is the first report of such a complication occurring after MWA. Moreover, in this case, the gastric perforation could be treated conservatively. However, a large number of patients do not qualify for open surgery because of multifocal tumor appearance in the liver or marginal hepatic function. These patients may benefit from local tumor control using locoregional treatment modalities. Microwave ablation (MWA) belongs to various treatment modalities that have been introduced in recent years. In this technique, high-frequency electromagnetic energy is applied to the center of the tumor using a special applicator. In doing so, the tissue near the antenna can be heated to cytotoxic levels.Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related deaths worldwide. However, due to the application of heat at the cytotoxic level to the target tissue, distinct complications may evolve. Heat injury to the gastrointestinal walls after MWA has been described previously.MWA has been proven to be an efficient and safe method.Usually, transmural thermal injury of the gastrointestinal wall requires surgical treatment. However, with covered perforations and a lack of signs of peritonitis or systemic inflammation, conservative treatment can occasionally be considered as an exception.Herein, we describe a case of gastric perforation following MWA of a HCC nodule. Interestingly, this complication was treated conservatively in this case.2TM Probe and Microwave Generator; MedWaves Inc., San Diego, CA). At the end of the procedure, ultrasonography revealed complete ablation of the nodules. Radiographic imaging of the abdomen could exclude the presence of free abdominal air after MWA.A 62-year old patient with cirrhosis due to chronic hepatitis C infection presented with bifocal HCC recurrence. Open atypical resection of a HCC in segment VII was performed 4 years previously. The HCC nodules were now located in segments III and VIII. Due to the impaired general condition and poor liver function, MWA of the HCC-nodules was scheduled as bridging therapy prior to liver transplantation. Based on the accessibility of the tumor nodes and minimal invasiveness, a percutaneous approach was chosen. The intraoperative course was uneventful with a total procedure time of 48 minutes. MWA was performed under sonographic guidance for 4 minutes (segment III) and 5 minutes (segment VIII) using a 14 gauge probe  with no increased systemic leukocyte counts.Two weeks after MWA, computed tomography (CT) angiography was performed for further evaluation of liver transplantation. Herein, a defect of the gastric antrum wall in direct vicinity to the necrotic ablation area in segment III of the liver was discerned. The defect presented with a size of 1.2 cm and gas inclusions  and MWA have been favored in most centers. It has been shown that RFA provides significantly increased survival rates compared to ethanol instillation into tumors. Moreover, the complication rate was significantly lower. In comparison to RFA, MWA provides technical advantages, such as a larger zone of coagulation necrosis and higher temperatures within the tissue, leading to shorter treatment duration and fewer heat-sink effects. Owing to the high temperature and larger ablation areas in the case of MWA, safety concerns have appeared. In fact, in our case, it was assumed that the defect within the gastric wall was caused by thermal injury. However, it is important to note that it has been shown that complications of MWA do not differ from those of RFA, and it is not likely that gastric perforation might have been avoided by the application of a different thermoablative treatment modality .Ablative treatment of liver tumors represents the option of choice for local tumor control in patients who do not qualify for open resection. Laparoscopic ablation offers specific technical advantages, as the positive pressure of the pneumoperitoneum decreases portal venous blood flow and thus increases the ablation area.,11 Moreover, the percutaneous approach is associated with an increased risk of perforation of the gastrointestinal wall due to thermal injuries. This risk is especially present when treating lesions adjacent to the gastrointestinal lumen and in patients with a history of abdominal surgery, intestinal adhesions, or anatomical variations. However, in patients with HCC due to liver cirrhosis, an open surgical or laparoscopic approach may not be favored because of their poor clinical condition. Accordingly, bridging patients with HCC for orthotopic liver transplantation is performed percutaneously in most cases. In our patient, a percutaneous approach was chosen, although an open atypical liver resection of an HCC had previously been performed. Causes for this preference were poor hepatic function and planned liver transplantation as a definitive treatment for HCC.Thermoablation of liver tumors can be performed using open surgical, laparoscopic, or percutaneous approaches. Laparoscopic and open access have the advantage of increased tumor control compared with percutaneous ablation.,14 Reported complications include thermal injury of the skin, liver hematoma and abscess, pneumothorax and pleural effusion.,15 Moreover, thermal injury to the colon has been described previously. To the best of our knowledge, no gastric perforation following MWA of HCC has been described to date. In fact, practical experience with other thermo-ablative treatment modalities  shows that gastric perforation due to thermal injury is a rare entity compared to colonic perforation. This may, at least in part, be caused by the relative thickness of the gastric wall compared to that of the colon.MWA for HCC is associated with a low complication rate, ranging from 0% to 11%.Interestingly, the described intestinal perforations did not occur immediately after ablation but on days 3 to 5 after MWA. This time course might be due to the fact that MWA causes a coagulation necrosis of the tissue. Secondary perforation became apparent after decomposition of the necrotic tissue. Unfortunately, in our case, we could not determine the exact time point of perforation, as the patient presented with a regular postoperative clinical course, and the perforation was diagnosed on a CT-scan 2 weeks after MWA. However, retrospectively, the peak in the serum inflammatory values (C-reactive protein) could be noticed 5 days after ablation and may have been a correlate of gastric perforation.,18 In individual cases with localized peritonitis and a clinically stable condition, conservative treatment of the perforation might be successful. In the described case, the patient did not present with any clinical signs of gastric perforation. The perforation was incidentally diagnosed 2 weeks after ablation. By that time, regressing inflammation parameters had been observed, and the patient had presented with no signs of peritonitis. MWA was performed as bridging therapy for HCC before liver transplantation. In addition, the patient presented with poor liver function due to cirrhosis. To avoid a delay in planned transplantation arising from an explorative laparotomy and suturing of the gastric perforation, further conservative treatment was decided. Under close gastroscopic monitoring, healing of the gastric perforation was observed, and liver transplantation was successfully performed 9 months after MWA.Intestinal perforations usually require immediate surgical treatment. However, several cases have been described where gastric perforation at early diagnosis could be treated endoscopically and emergency surgery could be avoided.Conceptualization: Robert Martin Eisele.Data curation: Vincent Zimmer.Formal analysis: Jonas Roller.Funding acquisition: Robert Martin Eisele.Methodology: Matthias Glanemann, Robert Martin Eisele.Resources: Vincent Zimmer, Arno Buecker.Supervision: Matthias Glanemann.Validation: Robert Martin Eisele.Visualization: Arno Buecker.Writing – original draft: Jonas Roller.Writing – review & editing: Robert Martin Eisele.


Thermal ablation by microwave ablation (MWA) or radiofrequency ablation (RFA) is a frequently used technique for hepatic lesion treatment due to its low rate of complications. Surgery, transarterial chemoembolization (TACE), and yttrium-90 (Y-90) transarterial radioembolization (TARE) are other ways to treat hepatic lesions. Thoracobiliary fistula (TBF) is a rare side effect of thermal ablation. Other side effects include vascular injury, damage to the biliary system, and infection. We present the case of a 62-year-old male patient who has a history of lymphoma and was diagnosed with a hepaticellular carcinoma lesion on follow-up CT in segment VII, which appeared in close relation to the right diaphragm. The patient had been through several interventional procedures, including Y-90 therapy, TACE, and MWA with thermal impact, which resulted in a biloma forming and ramping up the progression of pleurobiliary fistula, which is confirmed by HIDA scan, this case highlights the significance of monitoring patients after thermal ablation, particularly in cases of large justa-diaphragmatic tumors, to detect any diaphragmatic or biliary tree injuries. When it comes to the treatment of hepatic lesions, surgical resection can be considered as the most effective approach. However, other treatment options, such as radiofrequency and microwave ablation (MWA), transarterial chemoembolization (TACE), and yttrium-90 (Y-90) trans-arterial radioembolization (TARE), have recently been shown equal effectiveness as surgical resection in small, medium, and large hepatocellular carcinoma (HCC). Although the thermal ablation is minimally invasive and relatively low risk, complications can occur We describe the case of a 62-year-old Saudi male patient with chronic hepatitis B virus infection on entecavir prophylaxis who was diagnosed with Stage IA peripheral T-cell lymphoma in December 2017. He completed 6 cycles of CHOP medications in April 2018 with no complications. During follow-up, his abdominal computerized tomography (CT) scan revealed a 5.5-cm hypodense lesion with a cirrhotic liver appearance . The lesAt the same time, his blood work showed an aspartate transaminase (AST) level of 21 U/L , an alanine transferase (ALT) level of 36 IU/L , a total bilirubin level of 0.53 mg/dL , alkaline phosphate 133 U/L , an albumin level of 3.56 gm/dl mL , an alpha-fetoprotein level of 5 ng/mL , CEA level of 3.46 ng/mL , and a carbohydrate antigen (CA) 19-9 level of 16.58 U/mL .In September 2020, he was treated for an HCC lesion with TARE using Y-90. A pretreatment injection of a Tc-99m MAA radiotracer showed that there was no significant shunting outside of the liver. Under the guidance of ultrasound, an injection of 1 GBq of Y-90 SIR-spheres by Sirtex (resin microspheres) from the right hepatic artery was performed, which supplied the VI/VII hepatic tumor. Normal immediate postprocedure single photon emission computed tomography (SPECT)/CT was performed., which was performed via the transarterial injection of 50 mg of doxorubicin hydrochloride loaded into 2 ml of DC beads (biocompatible).A follow-up abdominal CT performed after 2 months showed a sizable residual lesion in the medial aspect of the lesion. The outcome of TARE was not satisfactory; therefore, the patient underwent an extra session of transarterial chemoembolization (TACE)The patient continued regular postoperative follow-up examinations. Four months later, a new lesion was found and treated with one session of microwave ablation, which was performed under and CT-guided insertion under general anesthesia. The microwave antenna was moved into the lesion in segment VIII, and a 100-W generator set was used to deliver maximum power with the automatic impedance control method.Six months postmicrowave ablation, the patient attended the hospital with history shortness of breath, productive cough, and chest pain. On examination, vital signs were normal. A bronchoscopy was performed and was reported as normal uneventful procedure.Chest and abdomen CTs were acquired following administration of intravenous contrast. The thoracic CT scan demonstrated hepatic biloma at the ablation site with cranial extension into the right lower pleural space with right anterior basal mass-like consolidation  and 3. TIn order to establish the presumed diagnosis of TBF, a technetium-99m (Tc-99m) HIDA scan was performed. Initial dynamic images of the abdomen were performed immediately after intravenous injection of 185MBq of Tc99m-HIDA over 55 minutes, showing prompt hepatic uptake followed by excretion of the tracer into the bile duct and bowel within 25 minutes of radiotracer injection. A delay planer and SPECT/CT scan performed at 1 and 2 hours postradiotracer injection revealed tracer passage cranial to the right lower lung . This coUsing microwave ablation to treat both primary and secondary liver tumors in a timely manner has been proven an effective therapy, because of its quick ablation duration and steady intratumoral temperature, and the ability to treat large lesions Cholescintigraphy is a safe, easy, and inexpensive way to confirm that there is communication between the biliary tree and a bile-containing collection or fistulous tract. The SPECT/CT is a hybrid study that combines SPECT and CT scans. By putting these tests together, the technology gives a full and clear picture of the body's anatomy and physiology. The primary objective of this tomographic imaging system is to offer a better 3D image of the radioactive distribution within the patient, improving contrast and image quality.Our patient exhibited a progressive accumulation of radiotracer in delay images with normal early TC-99m HIDA images. These emphases the importance of delay images in suspected fistula cases. If tracer accumulates in the pleural cavity, the likelihood of biliopleural fistula is more than biliobonchial fistula, in which tracer accumulation takes place in the bronchial tree. The negative bronchoscopy results with no bile found in the lavage fluid were consistent with the biliopleural fistulous type ,6.Any event that damages the biliary tract, diaphragm, and/or bronchioles might lead to the formation of a TBF. A TBF can also be caused by a local infection, a blocked biliary tract, a tumor, an injury, surgery, or procedures like thermal ablation or TACE Peacock reported the first instance of TBF in 1850, which was caused by a local infection There have been roughly 16 articles published on TBF following thermal ablation therapy since 2002, according to a literature analysis . The ageCT scan is usually the initial imaging modality, and even though it may not depict the fistula tract directly, it can disclose indirect abnormalities such as pleural effusion, lung consolidation, subphrenic fluid collection, hepatic biloma, or abscess.In the presented case, pneumonia or lung neoplasm can be differential for the right lower lobe mass-like opacity. However, constellation of HIDA scan findings and improvement of lung consolidation following therapy confirmed the diagnosis ,11.This case showed a rare thermal ablation complication with extrahepatic thermal damage. Patients who have had thermal ablation treatment, especially those with large tumors that are close to the diaphragm, need to be watched closely to prevent problems with the biliary system or damage to the diaphragm.All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation  and with the Helsinki Declaration of 1964 and later versions.Informed consent was obtained from the patient for the publication of this case report.


Intussusception with a lipoma as a lead point and associated bowel obstruction is very uncommon in adults. The patient presents with abdominal pain and intermittent or sudden intestinal obstruction requiring surgical intervention. We report the case of a 68-year-old male who presented with complaints of severe abdominal pain, nausea, vomiting, and constipation. A CT scan revealed ileocecal intussusception with a lipoma as a lead point. Evidence of small bowel obstruction and ascites was also noted on imaging. The patient underwent an ileocecal resection followed by an ileocolic side-to-side anastomosis. Pathological examination of the specimen revealed two adjacent submucosal lipomas with focal mucosal ischemic hemorrhagic changes of the large distal lipoma. We present this case owing to its rarity and believe that it will serve to broaden the horizon of research regarding intussusceptions secondary to submucosal lipomas. Intussusception is defined as the telescoping of a proximal segment of the intestine into the distal segment. It was first described by Barbette of Amsterdam in 1674 ,3. Intus0C. Complete blood count (CBC), liver function tests (LFTs), and renal function tests (RFTs) were normal.A 68-year-old male presented to the emergency department complaining of severe abdominal pain, nausea, vomiting, and constipation. The patient had a past medical history of hypertension, emphysema, and chronic bronchitis. He was a chronic smoker (16 pack years) with no past allergies. Physical examination showed abdominal distention with generalized tenderness, particularly in the right iliac fossa. Rigidity or rebound tenderness was absent. On administration, his blood pressure was 110/60 mmHg, pulse rate of 90 bpm, respiratory rate of 16 breaths per minute, oxygen saturation of 89% at room air, and fever of 36.7An x-ray of the abdomen showed multiple air-fluid levels suggestive of bowel obstruction Figure . UltrasoEmergency laparotomy was performed and the diagnosis of ileocecal intussusception was confirmed. The caecum, appendix, and 70 mm of terminal ileum were resected. Two adjacent polyps within the terminal ileum serving as lead points were revealed during exploration of the resected mass. Both were yellow, lobular, and pedunculated, indicating a lipoma. The distal one was larger, at a distance of 5.3 cm from the ileocecal valve, and was protruding through the ileocecal valve into the cecum. The resected mass was sent for histopathological analysis. Side-to-side anastomosis of the ileum to the ascending colon was performed. The surgery was successful and the patient was hemodynamically stable and afebrile. The post-surgical histopathological examination showed a large distal polypoidal lipoma of terminal ileum lined by ulcerative bowel mucosa (6 cm in the greatest dimension) and an adjacent small proximal polypoidal lipoma of terminal ileum lined by ulcerative bowel mucosa (2 cm in the greatest dimension). Focal mucosal ischemic hemorrhagic changes of large distal lipoma were observed. The proximal and distal resection margins were unremarkable. A small paracolic lymph node was also revealed, which was unremarkable, incidental, pericolic, and benign.Intussusception is a relatively rare condition in adults as compared to children. Depending upon its location, it may be classified as enteroenteric, colocolic, ileocolic, or ileocecal . ContrarIn adults with intussusception, nonoperative reduction with barium or air is not the preferred therapy as it is in children due to an underlying pathological lead point or predisposing disease . As a reIleocecal intussusceptions secondary to lipoma as a lead point are quite rare in adults. They may lead to intestinal obstruction, which results in a medical emergency. This condition presents with abdominal pain and symptoms of bowel obstruction but cannot be diagnosed on clinical examination alone. Despite the fact that intussusception itself has a favorable prognosis, the key prognostic factor influencing the course of disease is the type of causing lesion. Imaging modalities such as ultrasonography and CT scan are used to establish the final diagnosis. Ultrasonography may be inconclusive due to the presence of bowel gases. Surgical intervention is generally required for treating this condition. Intussusception is confirmed on exploration during surgery. Lipoma is confirmed on post-surgical histopathological examination.


Head and neck is the second most common region for lymphomas. Extranodal lymphomas of the larynx are rare in the pediatric population. Non Hodgkin Lymphoma (NHL) of the larynx is common in the supraglottic region as its rich in lymphoid tissue. They may present with dysphagia, dysphonia, snoring and progressive respiratory distress. Early visualization of the larynx is essential in such cases for appropriate diagnosis to improve the survival rates. We present a case of 9 year old boy who presented with a change in voice, snoring and feeding difficulties for one year. Video laryngoscopy revealed globular mass arising from the epiglottis. He underwent excision biopsy and by immunohistochemistry was diagnosed to have diffuse large B cell lymphoma. He was treated with chemotherapy and the child is clinically well in the follow-up, 1 year after the completion of therapy. Although primary lymphomas of the larynx in children are rare, a high index of clinical suspicion is warranted to avoid diagnostic delays to initiate appropriate management to have better outcomes.  Primary extranodal lymphoma of the head and neck account for 2.5% of all lymphomas . LaryngeA 9 year old boy presented with complaints of difficulty in swallowing, change in voice and snoring for one year associated with a weight loss of 4 kgs during this period. The child did not have any complaints of breathing difficulty, fever or night sweats. On examination the oral cavity was normal. There was no cervical lymphadenopathy. Indirect Laryngoscopy showed a single globular mass seen occupying the base of the tongue and epiglottis. Bilateral vocal cords could not be visualized. Video laryngoscopy done showed a single globular mass with irregular surface arising from epiglottis extending till vallecula and base of tongue . Fibre Optic Laryngoscopy showed bilateral vocal cords were mobile, pyriform fossa free on both sides. Contrast-enhanced computed tomography (CECT) neck was done to look for the extent of the lesion which showed hyperdense lesion measuring 2.8 x3.7 x3.5cms involving epiglottis extending into vallecula obstructing the airway .The patient underwent coblation assisted complete excision of the growth by ENT surgeons. Histopathological examination showed fragment tissues lined by stratified squamous epithelium with underlying subepithelium showing sheets of a monomorphic population of lymphoid cells infiltrating into the mucosal and adjacent cartilaginous tissue .By immunohistochemistry, the cells were diffusely positive for CD20, CD45  which waHe was risk stratified as Group B disease and treated with chemotherapy as per LMP 96 protocol. He received COP , COPADM 1 and 2,  CYM1 & 2  and intrathecal methotrexate and cytarabine. PET CT and video laryngoscopy done after completing chemo- therapy showed no evidence of recurrent or residual tumor. He was on regular follow up with pediatric oncology and ENT. A repeat video laryngoscopy done on follow up after 1 year of diagnosis showed normal findings . Head and neck is the second most common site for primary extranodal non-Hodgkin lymphoma, followed by gastrointestinal tract . NHL of In laryngeal neoplasms, the most commonly involved site is the supraglottic region as its rich in follicular lymphoid tissue . A revieSymptoms of laryngeal lymphoma include dysphonia, dysphagia, hoarseness of voice, cervical lymphadenopathy, cough, dyspnoea and occasionally systemic features like fever and weight loss might be present  9)..9).Laryngeal lymphomas remain localized for a longer duration without progression of symptoms, and a low index of suspicion in children leads to diagnostic delays. The symptoms are generally attributed to prepubertal voice changes or respiratory infections. For a child with laryngeal mass, the differential diagnosis to be considered are cystic lesions, recurrent respiratory papillomatosis, and laryngeal malignancies. In the presence of a submucosal mass centered in the supraglottis in imaging studies, NHL should be considered if there is a superior extension to the oropharynx or nasopharynx . The biopsy of the lesion is essential to determine the pathology and guide treatment options. Chemotherapy is the treatment of choice. Diffuse Large B Cell Lymphoma is treated like Burkitt lymphoma. Surgery is recommended in cases of extensive airway compromise . Though Though laryngeal neoplasms are rare in children, symptoms like voice change, dysphagia, and dyspnoea need extensive evaluation with a direct laryngoscope to rule out laryngeal masses. As the treatment outcomes are better with chemotherapy, early diagnosis is essential in such cases.


A giant cell tumor is a common, benign but locally aggressive bone tumor faced by orthopedic surgeons. The proximal humerus is a rare site of occurrence for this tumor, and the challenges posed while approaching such a case are discussed in this report of a 29-year-old male who presented with pain, swelling, and restricted motion at the left shoulder. Plain radiographs and MRI were suggestive of an aggressive giant cell tumor of the proximal humerus, which was confirmed on histopathological examination. Due to the lesion's extensive soft-tissue involvement, en-bloc resection with reconstruction was planned, but due to the COVID-19 pandemic, surgery was delayed. During the same period, the patient had trivial trauma to the same shoulder, following which the size of the lesion began increasing. The patient was operated on with en-bloc resection and reconstruction with a custom megaprosthesis; following the surgery, there was a complete resolution of pain and improvement in the range of motion. En bloc resection and replacement with a customized megaprosthesis, though technically demanding, offer a safe and cost-effective modality for limb salvage surgery for large giant cell tumors, with good functional outcomes and decreased chances of recurrence. A giant cell tumor (GCT) is a frequently encountered bone tumor of benign and aggressive nature that occurs in patients aged 20-45 years, occurring slightly more frequently in females ,2. The pPatient informationA 29-year-old right-handed Indian male factory worker presented with a year-long history of dull aching pain and a gradually increasing swelling over the left shoulder. Apart from these, the patient had no other complaints and did not have any history of trauma at the time of the index visit. The patient had no addictions, and neither had any contributing familial or past history. The patient was evaluated with plain radiographs, and further investigations were planned, but given the various restrictions due to the COVID pandemic, investigations and management were deferred at the time. During the same four-month period, the patient had a history of trivial trauma due to a fall over the left shoulder from standing height, following which the patient had aggravation of pain and swelling and further restriction in movement.Clinical findingsThe patient had a swelling over the proximal aspect of the left arm; the swelling had a smooth contour and was immobile and firm in consistency. Restricted abduction up to 80° and flexion up to 70° on examination were noted at the index visit Figure . The skiOn a subsequent visit four months later following the trauma, there was an increase in the size of the swelling with increased pain and tenderness and further restriction of movements, with only up to 30° of abduction and 20° of flexion and no extension possible  were done to rule out metastatic disease. A core biopsy was performed for a histopathological diagnosis, and a giant cell tumor was confirmed Figure .InterventionGiven the extent of soft tissue involvement, en bloc resection followed by reconstruction was planned. Preoperative planning was carried out, and templating for customizing the megaprosthesis was done Figure .The deltopectoral approach was used, extending the incision from the coracoid process down to the midshaft region; major neurovascular structures were identified and protected to ensure non-contamination of the surrounding normal tissue; after exposure of the tumor, surrounding tissue was diligently packed to avoid spillover of tumor cells; and osteotomy was performed through normal bone with a distal bony margin of 1 cm. Tumor tissue was grayish-brown and soft in consistency. Resection was grossly guided until all abnormal tissue was removed and further carried out for a 1 cm margin in the normal tissue. Following the completion of curettage, a thorough saline wash was given. Thinning of the rotator cuff tendons was noted, likely attributable to disuse atrophy, which made identification of individual tendons difficult. Involved soft tissues were carefully resected, followed by a saline wash to curtail residue from resection. Reconstruction was performed by using the customized megaprosthesis with a cemented stem Figure , and rotFollow-upThe patient in this case was reviewed for up to three months. Review at one month showed an improvement in the range of movement up to 35° abduction and 30° flexion, and at three months, there was an improvement in the range of movement up to 40° abduction and 40° flexion without any distal extremity functional deficit. The patient had complete relief of pain, and no surgical site complications were evident. A three-monthly follow-up routine was advised to the patient to watch for any recurrence.Patients affected by GCT are young, with the most common presentation being complaints of pain and swelling. Pathological fracture is found in 10-15% of cases . A higheWhen available, it is preferable to do a PET scan in cases where salvage is planned. A biopsy helps confirm the histopathological diagnosis. Either a core biopsy or an open biopsy can be performed. In such sizeable lesions, the risk of insufficient sample collection is lessened, and with improvements in histopathology techniques, a core biopsy may be preferable, as it is safer, easier to perform, more cost-effective, and gives a good representative sample of the relevant tissue with minimal trauma and minimal biopsy track seeding.In this case, due to the unavailability of PET scan facilities, it was not performed, and a core biopsy confirmed the diagnosis. As the lesion was extensive on the index visit, the approach would have been along the same lines even if the pandemic had not delayed the treatment, with wide resection and endoprosthetic replacement. To ensure non-contamination of the surrounding normal tissue, after exposure of the tumor, the surrounding tissue must be diligently packed to avoid spillover of tumor cells, and following completion of curettage, a thorough saline wash must be given. Enbloc resection must be done with a 1-cm-wide margin of normal bone to ensure complete removal of abnormal tissue. Regular clinical and radiological follow-up every three months to look for any recurrence is advisable, and in case of relapse, repeat resection may be attempted. Thus, a safe, realistic route for treatment of proximal humerus GCT is with custom endoprosthetic replacement following tumor resection, which offers low rates of complication. An additional advantage is an immediate stability, which allows for aggressive recovery of movements at the shoulder joint, which in turn expedites limb function.


Necrotizing soft tissue infection (NSTI) is a rapidly progressive infection of the soft tissues that necessitates early identification and emergent aggressive surgical debridement due to its high mortality. NSTI most often results from the introduction of microbes through breaks in the skin. Unique sources, like appendiceal fistulae, can be etiologies of abdominal wall NSTIs. We present the case of a 46-year-old female with a past medical history of poorly controlled type II diabetes mellitus and ventral hernia who presented in septic shock with a necrotic wound in her abdominal wall. The wound was overlying a large ventral hernia and was consistent with NSTI. She was treated urgently with fluid resuscitation, antibiotic therapy, and surgical debridement of the wound. On repeat exploration, an appendiceal fistula was found protruding from the hernial sac. Open appendectomy and primary repair of the ventral hernia were performed. Principles of immediate intervention and repeat surgical debridement allowed control of the septic insult and definitive source control upon identification of an appendiceal fistula. A necrotizing soft tissue infection (NSTI) is an infection involving the skin, subcutaneous tissue, fascia, and/or muscle that is characterized by rapidly progressive tissue destruction, systemic toxicity, and high mortality -2. PreseNSTIs typically develop after the introduction of microbes through breaks in the skin. These infections most frequently affect the extremities, however, nearly any site of the body can be involved. NSTIs of the abdominal wall may be seen as a complication following abdominal surgeries, as in Meleney’s synergistic gangrene. Uncommonly, they may be due to enterocutaneous fistula formation after bowel surgery or in other intra-abdominal inflammatory processes. Appendiceal fistulae are the most uncommon type of enteric fistula -4. Speci9/L), hyponatremia (sodium 128 mmol/L), acute kidney injury (creatinine 159.12 μmol/L), and hyperglycemia (glucose 29.53 mmol/L). A computed tomography (CT) scan of the abdomen and pelvis revealed a large ventral hernia containing multiple loops of normal-appearing small bowel. There was a 13 cm wide abscess with associated prominent soft tissue gas extending to the hernial cavity and the right abdominal wall  for debridement. Necrotic tissues were sharply debrided back to healthy tissue. A portion of the hernial sac was opened revealing no purulent fluid within the hernia nor intra-abdominally. Bowel appeared adhered together but viable and without signs of perforation. Due to continued hemodynamic instability, the patient was left intubated with plans to return to OR once stable.Within several hours, there was increased erythema and warmth of the abdomen surrounding the wound, necessitating an emergent return to the OR. Re-exploration was performed with extensive debridement of necrotic tissues, including fascia. During this second debridement, the peritoneal cavity was explored through the prior opening of the hernial sac. The exposed bowel was noted to have significant adhesions but once again appeared viable. The abdomen was left open, and the wound was packed with wet-dry dressings. The patient returned to the intensive care unit (ICU) in critical condition. She remained on IV antibiotic therapy, and her clinical status started to show improvement.Once hemodynamically stable, she was taken back to the OR for the third time for re-exploration. Initial examination of the wound showed a small, prolapsed piece of mucosal tissue protruding through the remaining hernial sac. The hernial sac was fully opened, and the abdominal cavity was entered through the sac. Lysis of adhesions was performed to release the small bowel from the abdominal wall to allow for close inspection of the bowel. Following identification of the ileum and cecum, the appendix was identified and found to have a defect with exposed mucosa through the hernial sac. The exposed mucosa was identified as the prolapsed piece of tissue that was initially seen protruding from the hernia, consistent with an appendiceal fistula that contributed to her initial necrotizing soft tissue infection. An open appendectomy was performed. The examined bowel was found to be viable. After resection of the hernial sac, the transverse fascial defect measured eight cm long by 15 cm wide. In the setting of class III, i.e. contaminated wound, the defect was closed primarily. Minimal additional debridement of the soft tissues was performed. The abdominal wound was then packed with gauze and allowed to heal by secondary intention. After the third procedure, the patient recovered rapidly and was discharged home four days later.Streptococcus anginosus, few Klebsiella pneumoniae, and few Escherichia coli. Pathologic examination of the soft tissue samples confirmed necrotizing fasciitis. Pathological examination of the appendix revealed a benign appendix with acute peri-appendicitis and serositis but without transmural appendicitis. The presence of an appendiceal fistula in the tip of the appendix was confirmed.Cultures obtained from the abdominal wound during the initial procedure grew mixed aerobic and anaerobic flora consistent with intestinal flora. Specifically, aerobic culture grew many At the six-week follow-up appointment, the wound appeared to be healing well without signs of infection.Incarceration of the appendix within hernias is unusual but well-described in the literature, dating back to 1735 when Claudius Amyand described a case of an inguinal hernia with an incarcerated appendix . IncarceAppendiceal fistulae are an uncommon type of enteric fistulae. They are defined as the primary perforation of the appendix into an adjacent hollow viscus or skin . AppendiNSTI due to appendicitis with perforation is an infrequent but severe complication -8. NSTI The uniqueness of the present case lies in the fact that a large ventral hernia with multiple bowel loops and the appendix as its contents had formed a fistula with the anterior abdominal wall and necrotized the skin, which was not identified by imaging or by initial surgical exploration. There were signs of intra-abdominal inflammation with adhesions between loops of the bowel, but the bowel did not appear acutely distressed. Furthermore, there was no apparent inciting acute appendicitis or other inflammatory processes such as an abscess within the abdomen that led to fistulization.NSTIs are aggressive subcutaneous infections with high mortality. The cornerstone of treatment is early and aggressive surgical debridement -2,11. AfWe present a unique case of an appendico-cutaneous fistula within an incarcerated ventral hernia presenting as an NSTI of the abdominal wall. Although uncommon, it is important to consider intra-abdominal pathology as a source of NSTI in the abdominal wall. An appendiceal fistula is an unusual cause of an NSTI. However, successful treatment still depends on the principle of source control with early, aggressive surgical debridement and, in this case, removal of the fistula via appendectomy.


Secondary malignancies following radiotherapy are well documented, with an estimated incidence of 5%. These may manifest as carcinomas, gliomas, or sarcomas within the previous radiation field. Glioblastoma multiforme following radiotherapy for nasopharyngeal carcinoma is an uncommon occurrence and carries a poor prognosis, whereas papillary thyroid carcinoma following radiotherapy is well documented, though the exact incidence is not well documented. The occurrence of synchronous radiotherapy-induced malignancy over both sites has not been described in the literature before. We describe a middle-aged gentleman diagnosed with glioblastoma multiforme and papillary thyroid carcinoma 6 years after radiotherapy for nasopharyngeal carcinoma. Though our case is the first reported case of a synchronous tumour of its nature, it is likely that such cases are under-reported. Long-term vigilance for loco-regional radiotherapy-induced secondary malignancies is a must, and the presence of a second distinct secondary malignancy must be entertained. The first case of radiation-induced papillary thyroid carcinoma (PTC) was reported in 1950 by Duffy et al., and glioblastoma multiforme (GBM) was reported in 1978 by Kleriga et al.  There isA 42-year-old man was diagnosed with nasopharyngeal carcinoma (NPC) 6 years ago and underwent radiation therapy. Subsequent annual clinical surveillance did not reveal a recurrence of the tumour. His last annual computed tomography (CT) of his brain was 3 years prior, and there was no recurrence or new lesions. He presented 6 years later with an unsteady gait and facial numbness for 2 weeks, as well as slurring of his speech and vomiting. Examination revealed left facial palsy upper motor neuron-type House–Brackmann grade III with positive cerebellar signs on the left. The findings from examinations of the other systems were essentially normal. CT scan of the brain revealed an intra-axial lesion in the left cerebellum with an incidental finding of a right thyroid nodule Figure 1Unfortunately, his clinical condition worsened, and he progressed to develop gross left lower limb weakness and left bulbar palsy. A follow-up MRI 2 months later revealed enlarging left cerebellar/pons mass with central necrosis Figure 3He became stuporous with a Glasgow Coma score of 11/15 (E2 V3 M6) a week after the follow-up MRI, with normal vital signs. Upon discussion with and consent by his immediate kin, he underwent left retrosigmoid suboccipital craniotomy and debulking of the tumour. Intraoperatively, the tumour was granular with areas of necrosis and thrombosis from the left cerebellar peduncle extending into the superior aspect of the pons. His immediate post-op CT showed a small haematoma at the left cerebellopontine angle with no mass effect and hydrocephalus Figure 4The carcinogenic potential of ionizing radiation first came to be described approximately 7 years after Wilhelm Roentgen proved the presence of electromagnetic radiation of a specific wavelength termed “X-ray” in 1895. This mutation results from a broad spectrum of deoxyribonucleic acid (DNA) lesions including damage to nucleotide bases, cross-linking, and DNA single- and double-strand breaks (DSBs)  irradiated should be screened for the possibility of synchronous SRIM.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.All the authors have contributed by means of clinical management, proof reading as well as processing and contributing the histological and radiological diagnosis. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Solid pseudopapillary neoplasm (SPN) is a rare tumor with low malignant potential, which typically occurs in the pancreas. Extrapancreatic SPN is also extremely rare worldwide.We report a case of a 70-year-old woman hospitalized with abdominal pain and bloating. The patient did not have any underlying diseases, such as diabetes, coronary heart disease, or hypertension. More than 30 years ago, the patient underwent surgery for “ectopic pregnancy”. The patient had no family history of hereditary disease, nor did any immediate family members have a history of cancer. Laboratory tests showed that her hemoglobin and albumin levels were low and she had a high level of cancer antigen 125 (CA125). Enhanced computed tomography (CT) showed a large tumor in the abdomen and pelvis. The patient subsequently underwent surgery, and it was found that the tumor was attached to the terminal ileum. Pathological findings suggested that the tumor was an extrapancreatic SPN, with an ectopic pancreas found in the tumor tissue. The patient did not receive chemotherapy or radiotherapy after surgery. After 13 months of follow-up, the patient was admitted again with abdominal pain. CT showed tumor recurrence with extensive systemic metastases. The patient and her family refused reoperation and biopsy, and the patient was discharged after the abdominal pain and anemia resolved.We report a rare case of extrapancreatic SPN of ileal origin, which could be the first report worldwide. It had aggressive biological features, with recurrence and metastasis 13 months after surgery. For extrapancreatic SPN, the risk of recurrence should be assessed, and for tumors suspected of malignant behavior, a longer follow-up after discharge may be needed. Although SPN generally has a good prognosis after surgery, there is no consensus on whether postoperative chemotherapy and other treatments are needed for patients with high recurrence risk. Solid pseudopapillary neoplasm (SPN) of the pancreas is an uncommon pancreatic tumor, accounting for approximately 0.3%–2.7% of all pancreatic tumors . In 2010Extrapancreatic primary SPN is extremely rare, and only approximately 50 cases have been reported –43. ThisA 70-year-old woman was admitted to the hospital with sudden abdominal pain and bloating. The patient did not have any underlying diseases, such as diabetes, coronary heart disease, or hypertension. More than 30 years ago, the patient underwent surgery for “ectopic pregnancy”. The patient had no family history of hereditary disease, nor did any immediate family members have a history of cancer. Physical examination revealed mid-abdominal tenderness and a palpable 6 cm × 6 cm mass, with a firm texture and unclear boundary. Abdominal enhanced computed tomography (CT) showed a large mixed density mass in the lower abdominal cavity-pelvis, approximately 162.5 mm × 105 mm × 182 mm . The masThe patient had a definite diagnosis of a large tumor in the abdomen and pelvis. After communicating with the patient's family, we decided not to perform a preoperative biopsy and to surgically remove the tumor and perform a pathological biopsy. The patient underwent an exploratory laparotomy, and a large tumor in the abdomen and pelvis was revealed, approximately 20 cm × 20 cm in size. The tumor was attached to the terminal ileum, approximately 12 cm away from the ileocecal region, and could not be separated. We considered that the tumor probably originated in the small intestine . The terThe postoperative recovery of the patient was uneventful, and she was discharged after half a month. The tumor was histologically composed of cells arranged in the form of solid sheets and pseudopapillary areas . EctopicThe patient did not receive chemotherapy or radiotherapy after surgery. Thirteen months after surgery, the patient was admitted again with abdominal pain. Laboratory examination showed her hemoglobin was 88 g/L, and her CA125 was elevated to 47.4 However, CA19–9 and CEA were within normal limits. Enhanced CT of the chest and the whole abdomen showed that there was a mixed density mass in the right middle abdomen, approximately 59 mm × 57 mm × 92 mm (left and right × front and back × up and down), and the boundary was not clear . A cystiWe identified 50 cases with definite extrapancreatic SPN reported between 1990 and 2022 (including the case we reported). The characteristics of all cases are summarized in The clinical symptoms of extrapancreatic SPN are often nonspecific, and some cases were even discovered incidentally during routine examinations. The symptoms are described in detail for 37 of the 50 patients. The clinical manifestations included abdominal pain in 16 cases , abdominal distension in 9 cases , abdominal mass in 6 cases , vomiting in 4 cases , and asymptomatic in 6 cases . A few patients had weight loss, nausea, fever, and fatigue. The patients' symptoms can also be different depending on the primary site, and they usually have more than one symptom. For example, menorrhagia, pelvic pain, and postmenopausal bleeding can occur in patients with SPN on the ovary. Laboratory tests of some patients may show decreased hemoglobin and increased white blood cells, but they are not specific. In addition, although serum markers  can be increased, they are also not typical for diagnosing SPN . In our In recent years, reports on SPN have gradually accumulated in various countries. However, there is still no clear conclusion about the origin of SPN. Some researchers found ectopic pancreatic tissue in the SPN tissue or at the tumor margin, so it is speculated that the SPN originated from this ectopic pancreatic tissue , 41–43. Imaging examinations play an important role in the initial diagnosis of SPN, among which the most commonly used imaging modalities are ultrasound, CT, and magnetic resonance imaging (MRI) , 46. ThePathological examination and IHC are the most reliable methods for diagnosing SPN. The average size of surgical resection specimens among the 50 cases was approximately 10.2 ± 7.5 cm 0.5–30 cm). The growth pattern of SPN is more diverse, and it can manifest as solid, pseudopapillary, and cystic structures in different proportions. Microscopically, one or more layers of tumor cells are arranged around the fibrovascular axis to form pseudopapillary protrusions, which are typical pathological features . IHC sho0 cm. TheIn the literature we reviewed, a total of 49 patients with extrapancreatic SPN received surgery, and one patient received antibiotic and antifungal therapy due to severe infection. Among 50 cases of extrapancreatic SPN, five patients received chemotherapy, one received molecularly targeted therapy (the drug was imatinib), one received herbal medication, and one received HIPEC. However, the current number of cases is too small, and more clinical evidence is needed to evaluate the effect of adjuvant therapy on SPN. Ten patients with extrapancreatic SPN had tumor metastasis , 36 had no tumor metastasis , and 4 had no mention. Among the 50 patients with extrapancreatic SPN, 38 patients had follow-up information, and the follow-up time ranged from 3 to 144 months. There were 8 patients  with tumor recurrence, 30  without recurrence, and 12 who did not mention recurrence. There were 38 patients with clear outcomes, and 32 patients  survived well, including 30 patients with no evidence of disease (NED) and 2 patients alive with tumors. There were six deaths , of which five died of SPN recurrence, and one died of severe sepsis.Pancreatic SPN is a low-grade malignant tumor; only 15% will develop metastasis, and a long-term survival rate is observed in more than 95% of the cases. The metastasis rate of extrapancreatic SPN was 21.7%, and the survival rate of 38 patients with follow-up was 84.2%. Therefore, extrapancreatic SPN may have a favorable clinical course similar to that of SPN. Although the liver is the most common site of distant metastases, the mesentery, mentum, peritoneum, and lungs may also be involved. However, metastasis or invasion of adjacent organs is not a contraindication to surgery, and the patients could also have a longer survival time after reoperation . In addiExtrapancreatic SPN is a rare low-grade malignancy with a good overall prognosis. It mainly occurs in the ovary, testis/paratestis, retroperitoneum, mesocolon, and omentum. Abdominal pain, bloating, and a palpable mass are the most common symptoms. Laboratory tests and serum tumor markers are usually nonspecific. Immunohistochemical staining of biopsy or the surgical resection specimen is the main method for diagnosis and differential diagnosis. The most unique immunohistochemical marker is the abnormal nuclear staining of β-catenin. The best treatment for extrapancreatic SPN is still radical surgical resection. Even in the case of tumor metastasis, most patients can still be radically cured by surgical resection of the primary tumor and metastases because of the slow clinical progression after metastasis. For unresectable patients, there is limited evidence to support other treatments, such as chemotherapy.P < 0.012). Larger tumor size was significantly associated with the risk of metastasis and recurrence (P < 0.002)  . The tumWe report a rare case of extrapancreatic SPN of ileal origin, which could be the first report worldwide. It had aggressive biological features, with recurrence and metastasis 13 months after surgery. For extrapancreatic SPN, the risk of recurrence should be assessed, and for tumors suspected of malignant behavior, a longer follow-up after discharge may be necessary. Our case may extend our understanding of the biological behavior of extrapancreatic SPN and provide clinical experience with the diagnosis and treatment of extrapancreatic SPN to avoid a missed diagnosis and delayed treatment.


Schwannomas are the most common nerve sheath tumors in the paravertebral mediastinum. Although radiological imaging is helpful in diagnosing schwannomas, a definitive diagnosis is dependent on pathological features of a surgical specimen. For patients who require preoperative diagnosis, an incisional biopsy using minimally invasive surgery is preferred. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is less commonly used for suspected schwannomas.A 48-year-old woman presented to the clinic with complaints of productive cough for >1 month, expectorating yellow and mucoid sputum approximately 4 to 5 times per day. Chest computed tomography revealed a well-circumscribed, homogeneous, soft tissue mass lesion in right upper posterior mediastinum, measuring 55 mm × 44 mm. Vocal fremitus in the right upper lung was diminished, the percussion note was slightly dull, and breath sounds were slightly reduced on auscultation. The patient was a nondrinker and nonsmoker, with no other relevant medical history. There was no significant relevant family medical history.Complete blood count and blood biochemistry were within normal limits, except for an elevated erythrocyte sedimentation rate (32 mm/h). EBUS-TBNA was performed and histopathological findings were consistent with schwannoma.The patient underwent schwannoma excision by thoracoscopy. Pathological findings from the surgical specimen were consistent with the EBUS-TBNA results. Based on EBUS-TBNA and postsurgical pathology, the patient was diagnosed with a right upper mediastinal schwannoma (Antoni B).The patient experienced an uneventful postoperative recovery with no adjuvant therapy and was discharged on April 18, 2017. The patient has been followed up for 4 years and has not experienced any symptoms.Cell blocks obtained from EBUS-TBNA afford the possibility of cytological examination and immunocytochemical staining, which can confirm diagnosis of schwannoma. Schwannomas and neurofibromas are the most common nerve sheath tumors. Most schwannomas, however, are benign and usually grow slowly; as such, for a malignant peripheral nerve sheath tumor to arise from a schwannoma is extremely rare. Surgical excision is the preferred treatment for schwannomas,4 and the prognosis is favorable, with a typical 5-year survival rate of 97% after surgery.Neurogenic tumors are the most common neoplastic lesions of the paravertebral mediastinum, accounting for approximately 53.9%,4,6 Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has conventionally been used to diagnose mediastinal and hilar lesions and to stage malignancies, but is less commonly used for neurogenic tumors. In particular, the use of EBUS-TBNA to diagnose schwannomas has not been frequently reported.–12 Herein, we report a case involving a patient with schwannomas diagnosed using EBUS-TBNA and confirmed by pathological analysis of surgical specimens.The use of computed tomography (CT), magnetic resonance imaging (MRI), and/or positron emission tomography-CT (PET-CT) enables a precise preoperative diagnosis and the design of an appropriate surgical treatment strategy. Preoperative diagnosis facilitates disease management and prompts further clinical measures. For patients who require surgical treatment, a definitive diagnosis can guide the choice of surgical approach.A 48-year-old woman with a >1-month history of cough and expectorating sputum presented to the hospital. The patient complained of cough for >1 month, associated with expectoration of yellow mucoid sputum approximately 4 to 5 times per day, but without fever, chest pain, shortness of breath, or malaise. Chest CT performed on March 22, 2017, revealed a well-circumscribed, homogeneous, soft tissue mass lesion in right upper posterior mediastinum, measuring 55 mm × 44 mm, and mildly heterogeneous enhancement on contrast . A coagulation function test was in the normal range and tumor markers were negative. Sputum smear and culture, as well as sputum acid fast staining smear, were negative. Electrocardiography findings suggested sinus arrhythmia. Bronchoscopy revealed no abnormalities. EBUS revealed a well-circumscribed, round, homogeneous echogenic mass at the upper right paratracheal area, and TBNA was performed , followed by the visceral (13.5%) and paravertebral (5.4%) mediastinum, although some lesions have been found within 2 or 3 compartments. Neurogenic tumors are the most common neoplastic lesions of the paravertebral mediastinum, accounting for approximately 53.9% to 96.1% of lesions. Neurogenic tumors arise from tissues originating in the embryonic neural crest and can be further classified based on whether these grow from the nerve sheath, nerve cells, or paraganglia. Schwannomas and neurofibromas are the most common tumors originating from the nerve sheath. Most schwannomas are benign and grow slowly. A malignant peripheral nerve sheath tumor arising from a schwannoma is extremely rare. Patients are usually asymptomatic when the tumor is small. However, as the tumor increases in size, it may cause compression with adjacent vital organs, nerves, and blood vessels, which may manifest as chest and back pain, Horner syndrome, dysphagia, cough, shortness of breath, hoarseness, wheezing, superior vena cava syndrome, or muscle weakness.,16,17 In severe cases, massive hemoptysis may also occur.Mediastinal lesions are rarely encountered. The prevalence of mediastinal lesions ranges from 0.73% to 0.9%. Benign schwannoma on CT is characterized by a round or oval hypodense mass with an envelope and well-defined borders, with a uniform to markedly heterogeneous enhancement on contrast. Margins of the adjacent bone may be sclerosed due to chronic compression. Malignant cases exhibit infiltrative growth with indistinct borders, often with dense heterogeneity within the tumor due to necrosis, hemorrhage, and dystrophic calcification. Occasionally, the tumor degenerates to form a cyst and calcification may occur along the cyst wall. Some tumors grow across the intervertebral foramen, with one side of the tumor located in the mediastinum or thoracic cavity, and the other side in the spinal canal, growing in a dumbbell shape, connected by an enlarged intervertebral foramen, with resorption or destruction of adjacent bone. Schwannomas occurring in the spinal canal are generally well-defined and exhibit characteristic target and nerve access signs, in addition to positive signs of foraminal enlargement. For mediastinal neurogenic tumors that are a challenge to diagnose using CT, MRI can provide useful diagnostic information. In particular, it is a useful diagnostic modality for evaluating the extent of invasion into adjacent structures, characterizing tissue components, such as fat or hemorrhage, and is more effective in differentiating cystic from solid lesions. Schwannomas generally exhibit low or moderate signal on T1-weighted imaging and high signal on T2-weighted imaging, with the T1-weighted imaging and T2-weighted imaging fat suppression sequences being superior to the others and revealing internal tumor pathological changes and tissue features. On enhancement scan, the tumor is heterogeneously enhanced. Diffusion-weighted MRI has been used for the differential diagnosis of neurogenic tumor subtypes. Schwannomas exhibit significantly higher apparent diffusion coefficient values than that of neurofibromas and overlap with apparent diffusion coefficient values of malignant peripheral nerve sheath tumors. Use of 18F-Fluorodeoxyglucose PET-CT is recommended by the National Comprehensive Cancer Network guidelines, and is helpful in the evaluation of mediastinal tumors. However, the maximum standard uptake value of schwannomas range from 1.5 to 17.3 with a median of 3.7; therefore, definitive diagnosis of schwannoma may be difficult based on SUV profile on PET-CT because maximum standard uptake values appear to vary dramatically.Imaging studies are important tools in diagnosing and predicting the behavior of schwannomas. Chest X-ray has a limited diagnostic yield for mediastinal lesions. An international, multicenter study investigating the distribution of mediastinal lesions based on a radiological database reported that CT examination was the most commonly used method for the diagnosis of mediastinal lesions. Surgical excision is the preferred treatment for schwannomas.,4 Preoperative diagnosis facilitates disease management and prompts further clinical measures. For patients who require surgical treatment, a definitive diagnosis will provide guidance for the choice of surgical approach . In a study by Lacquet et al, 17 of 51 (33%) patients underwent preoperative biopsy. In general, for cystic lesions and well-encapsulated solid tumors that can be resected primarily, a preoperative tissue biopsy is not required because it will not impact the surgical plan in most cases. However, for mediastinal tumors with suspected malignancy, a biopsy is required to reach a definitive diagnosis to guide the surgical approach. The diagnosis of schwannoma is usually based on findings from examination of the surgical specimen. For patients who require preoperative diagnosis, an incisional biopsy obtained through minimally invasive surgery is preferred. However, some reports have described EBUS-TBNA, endoscopic ultrasound-guided fine-needle aspiration, and transthoracic biopsy for the diagnosis of schwannomas, and diagnosis based on these small specimens is consistent with that of surgical specimens.,16,23–25 When properly prepared, cell blocks obtained from EBUS-TBNA enable cytological examination and immunocytochemical staining, which can confirm the diagnosis of schwannomas. However, when spindle cells are encountered in small specimens , it is difficult to make a definitive diagnosis based on cytological features in some cases because a broad differential diagnosis is needed. Sometimes, small specimens do not reveal immature components of the tumor, which could lead to a false-negative result. In a study by Mlika et al, 2 cases of EBUS-TBNA and 3 cases of transthoracic biopsies failed to obtain an accurate diagnosis. However, EBUS-TBNA enabled us to rule out more frequently encountered mediastinal lesions, such as malignant lymph nodes, lymphoma, thymoma, and cysts.Although radiological imaging is helpful in diagnosing schwannomas, definitive diagnosis remains based on pathological features.Schwannoma is the most common benign neoplastic lesion of the paravertebral mediastinum. Cell blocks obtained from EBUS-TBNA enable cytological examination and immunocytochemical staining, which can confirm the diagnosis of schwannomas. EBUS-TBNA is a helpful method in diagnosing and establishing a treatment strategy for intrathoracic schwannoma.The authors are grateful to Dr E.K. Makoni, from the Parirenyatwa group of Hospitals in Zimbabwe, for her advice regarding language editing.(I) Conception and design: Wei Liu; (II) Administrative support: Weidong Zhang; (III) Provision of study materials or patients: Wei Liu, Zhiguang Liu, Yun Li; (IV) Collection and assembly of data: Wei Liu, Yun Li, Lingjia Chen; (V) Data analysis and interpretation: Wei Liu, Weidong Zhang; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors