Accessory splenic torsion is a rare condition that occurs when the accessory spleen twist on its pedicle, leading to a loss of blood supply and subsequent tissue damage. It is a rare cause of acute abdomen with few cases reported in the literature. We report a case of accessory spleen torsion in a 16-year-old male with abdominal pain. The patient, whose lesion was interpreted as a hematoma on imaging at an external center, was admitted to our center with increased, intermittent abdominal pain. The patient's complaints and physical examination were similar to peptic ulcer perforation. Abdominal ultrasonography and abdominal CT performed for differential diagnosis showed a 45x50 mm heterogeneous, hypodense, well-defined lesion located in the splenic hilus, posterior to the stomach, and adjacent to the pancreatic tail. In our center, the lesion was considered to be lesser sac omental torsion and was operated on. A 720-degree torsed accessory spleen was found at surgery and resected. Accessory splenic torsion is not primarily a condition that comes to mind in children with abdominal pain. However, in case of delay in diagnosis and treatment, many complications can be seen. The fact that ultrasonography or computed tomography cannot clearly define accessory splenic torsion also complicates this diagnosis. In such cases, performing diagnostic laparotomy/laparoscopy reveals the definitive diagnosis and is very important in preventing complications. The accessory spleen is a congenital anomaly of the spleen, and its prevalence has been reported to be 10-30% of the population . AccessoA 16-year-old male patient was presented to the emergency room with intermittent abdominal pain for the last month, without any history of trauma. Over the course of a month, he initially had tolerable pain, but his symptoms gradually increased over the last three days. He described cramping pain in the epigastric region that increased after eating. There was no change in pain during respiratory movements. He had nausea but no vomiting. His vitals were stable, and his fever was around 36.5-37 °C. Physical examination revealed tenderness from the epigastric region extending to the left upper quadrant of the abdomen. He had no defense. His sclera was icteric, but his skin color was normal. The patient’s complaints and physical examination were primarily suggestive of a peptic ulcer perforation. No significant findings were found in other laboratory tests, except for total bilirubin level 3.21 mg/dL (the reference range 0-1 mg/dL), indirect bilirubin level 2.96 mg/dL , and C-reactive protein 127 mg/L (the reference range 0-5 mg/L) tests. Abdominal ultrasonography revealed a 45x46 mm mass containing cystic and heterogenous hyperechogenic areas with septations. The lesion was located in the splenic hilus adjacent to the tail of the pancreas, and there was no vascular coding on Doppler examination. An abdominal CT performed with intravenous contrast material for differential diagnosis showed a 45x50 mm heterogeneous, hypodense, well-defined lesion located in the splenic hilus, posterior to the stomach, and adjacent to the pancreatic tail (Figure Lesser sac omental torsion was considered in the differential diagnosis. Since there was no history of trauma and the hemoglobin was normal, the diagnosis of a hematoma was ruled out. After 12 hours of clinical follow-up, abdominal pain and epigastric tenderness persisted, so a laparoscopy was performed for diagnosis and treatment. Laparoscopic observation revealed serous fluid in the gastrocolic region and rectovesical space. When the gastrocolic ligament was opened to access the mass, the posterior wall of the stomach and adjacent mesenteric tissues were highly inflamed. The laparoscopic procedure was terminated, and the abdomen was explored through a median incision above the umbilicus. No fistula or perforation was found in the posterior wall of the stomach. With blunt dissections, the accessory spleen, approximately 40x50 mm in size and twisted 720-degrees clockwise, was found adjacent to the pancreatic tail (Figure The detorsion and subsequent excision of the accessory spleen were done Figure . The paiThe accessory spleen can be diagnosed at any stage of life, from early childhood to old age. Surgical intervention is not required in asymptomatic patients, but accessory spleens, which are encountered incidentally in any abdominal surgery and may cause future complications, should be excised. Complaints of abdominal pain in children are often atypical for their age group, and physical examination is difficult due to patient non-compliance. Especially in patients with abdominal pain, restlessness, vomiting, and fever; ultrasonography may be the first choice if there is a suspicious finding on physical examination regarding the acute abdomen. Although there are many causes of acute abdomen pain, accessory splenic torsion, which is a rare cause, is often difficult to diagnose and can lead to infarction, acute inflammation, spontaneous rupture, hemorrhagic shock, intestinal obstruction, and peritonitis if the diagnosis is missed . HematomAccessory splenic torsion is rare and difficult to diagnose, especially in children. The failure to detect significant pedicle torsion on ultrasonography and CT may have led to the missed diagnosis of these cases. Since accessory spleens are most commonly seen in the anterior or medial splenic and pancreatic tail regions, accessory splenic torsion should be considered in children with abdominal pain if a mass is found accompanied by abdominal tenderness. If difficulty is encountered in diagnosis, a diagnostic laparoscopy/laparotomy should be performed. Otherwise, a torsioned accessory spleen may cause an infarction, hemorrhage, abscess, sepsis, mechanical compression of adjacent organs, and many other complications.


Schistosomiasis is a parasitic infection caused by Schistosoma species, commonly found in tropical and subtropical regions. It affects millions of people worldwide and can lead to different clinical presentations like abdominal pain, weight loss, anemia, and chronic colonic schistosomiasis. In rare cases, chronic infection can result in the development of polyps, which can mimic colon carcinoma, posing a diagnostic challenge. Here, we present a rare case of a huge Schistosomiasis-associated cecal polyp in a patient initially suspected to have colon cancer. The patient's clinical history and the histopathological analysis confirmed the diagnosis, emphasizing the importance of considering parasitic infections in the differential diagnosis of gastrointestinal polyps in Schistosomiasis-endemic areas. This case report highlights the need for increased awareness among healthcare professionals of the potential for Schistosomiasis-associated polyps and the importance of multidisciplinary management in such cases.  Schistosoma mansoni in the Middle East, is a parasitic infection characterized by the migration of larvae against the portal circulation and subsequent deposition of eggs in the walls and mesenteries of the large intestine and rectum. Some of these eggs dig their way through the intestinal wall leading to minute ulcers that cause bleeding. However, the eggs that remain trapped in the intestinal wall evoke a granulomatous immune response. Over time, the accumulation of these granulomas can lead to the formation of polyps which may protrude into the intestinal lumen and can, in rare cases, be mistaken for malignant polyps.Schistosomiasis, a tropical parasitic infection caused by blood flukes of the Schistosoma genus, is the world's third-most prevalent devastating tropical disease. The disease is endemic in 74 countries across the Middle East, Africa, South America, Asia, and the Caribbean, infecting approximately 250 million people and rendering about 700 million people at risk of infection . To dateSchistosomiasis infection has rarely been reported to cause huge cecal polyps, and a massive polyp presented as the sole manifestation of intestinal bilharziasis is even less frequently encountered. This presentation can be easily confused for a malignant polyp because of the overlap in clinical manifestations and endoscopic appearance of both diseases ,4.Here we report a case of a huge bilharzial polyp originating from the ileocecal junction which caused a partial obstruction of the cecal lumen as a manifestation of bilharzial colitis.We present a case of a 52-year-old male Egyptian farmer who presented to our clinic with a primary complaint of right lower quadrant abdominal pain, constipation, and vomiting. The pain was colicky in nature, gradual in onset, progressively worsening over one and a half months, and associated with weight loss. It did not increase or decrease with food intake. He did not have a significant past medical history. He lived in a village and was frequently exposed to unhealthy water. He was from low socio-economic status and had no family history of bilharzial disease or cancer. Social history was considered irrelevant. Physical examination showed that his vials were stable, with general physical examination positive for pallor in the conjunctiva and palms. Abdominal examination showed a lax abdomen with some tenderness in the right lower quadrant. No mass was palpated. The digital rectal exam (DRE) was normal. His laboratory findings were significant for anemia, and the eosinophils were on the upper normal limit Table .CT scan of the abdomen and pelvis with oral and IV contrast showed a well-defined, homogenously enhanced soft tissue mass at the ileocecal junction measuring about 5×5×4 cm which was protruding into the cecum and thereby markedly attenuating the lumen. In addition, moderately dilated distal ileal loops with smudging of surrounding fat planes were noted Figure .He was then referred for an elective colonoscopy, revealing a large cauliflower polypoid mass protruding from the ileocecal valve and markedly obscuring the lumen. The size of the polyp was measured to be 5 × 5 cm Figure . Multiple biopsies were taken for histopathology, which showed multiple viable bilharzial ova with related granuloma in the submucosa Figure .Since the polyp was huge and the patient was at risk of developing complications such as bowel obstruction, he was referred to the surgical team. The patient underwent a right hemicolectomy with ileotransverse anastomosis. The microscopic examination of the specimen showed bilharzial granulomas formed of numerous viable bilharzial ova surrounded by epithelioid cells, giant cells, and excess eosinophils. No atypia or malignancy was noted, confirming the diagnosis of bilharzial colitis.S. hematobium, S. mansoni, and S. japonicum are more prevalent, with the disease burden estimated to be between 24-29 million disability-adjusted life years [S. mansoni and S. japonicum [Schistosomiasis is the third-most devastating tropical disease across the globe caused by a blood fluke of the genus Schistosoma (S). To date, seven species have been described to cause infections in humans, of which aponicum . These oaponicum .Bilharzial polyp formation starts with a submucosal granuloma elevating the mucosa above it, and the polyp grows in size with the accumulation of more granulomas. As the polyp grows, the mucosa surrounding and overlying it proliferates, and the stalk begins to form. A layer of functional mucosa covering a core of connective tissue with a blood supply makes up the stalk. The body of the polyp is made up of the same epithelium as the small bilharzial granuloma and comprises many goblet cells that secrete a large amount of mucus. Because of its fragility and high vascularity, it bleeds easily when touching or passing stools .Schistosoma mansoni in patients with gastrointestinal symptoms in Egypt. They found that 72.6% of the study population with high schistosomiasis titers had positive contact with canal water. Additionally, the male gender was also found to be a risk factor [Bilharzial polyps can be encountered anywhere in the colon, with a preference for the recto-sigmoid region ,9. The pk factor . Our patPatients with bilharzial polyps can present with vague and non-specific symptoms such as abdominal pain, nausea, vomiting, bleeding per rectum, diarrhea, or constipation which can occur in a multitude of gastrointestinal (GI) pathologies ,6. Issa The diagnosis of intestinal schistosomiasis can be made by egg detection from stool samples or endoscopy biopsy. Urine and serum serological antibody detection can be beneficial to rule out infection in epidemic regions but its sensitivity and specificity can sometimes be problematic in non-epidemic regions . As the  hematobium, S. mansoni, and S. intercalatum and 60mg/kg in two or three doses for S. japonicum and S. mekongi. Medical treatment alone is effective against the earlier stage of intestinal bilharziasis. Endoscopic removal is considered the gold standard for small polyps, but in cases of large polyps, surgical intervention may be required. Due to the rarity of this condition, there is no specific guidance for the management of partial colonic obstruction [The treatment of suspected bilharzial polyps involves praziquantel, with recommended doses of 40mg/kg in one or two doses for S.truction  In our cWe recommend that physicians should not be dissuaded from considering a diagnosis of bilharzial polyp merely because of the size of the polyp, as it can manifest solely as a giant polyp. We believe the physicians practicing in Schistosoma-prevalent areas should have a low threshold of suspicion for bilharzial polyps. Notably, bilharzial polyps can be formed anywhere in the large intestine, including the ileocecal junction. We believe that bilharzial polyp should be on the differential in the workup of a colorectal polyp or carcinoma patient. Risk factors, like traveling to any endemic area should be explored, as even a single contact with the contaminated water may lead to a huge bilharzial polyp mimicking colorectal cancer (CRC).Schistosomiasis is a significant health concern in endemic regions across the globe. A single massive polyp in the cecum may be the sole manifestation of intestinal schistosomiasis and be considered in the workup of any cecal or colonic polyp. Sometimes the polyp can be huge enough to cause partial intestinal obstruction. Physicians working in Schistosoma-endemic areas should have a low threshold of suspicion for bilharzial polyp and order diagnostic tests to rule it out to avoid unnecessary surgeries. Praziquantel is an effective modality of treatment for all Schistosoma species.


Apical periodontitis (AP) is defined as an inflammatory and destructive reaction of periapical tissues and a consequence of bacterial invasion to the dental pulp and root canal system. To avoid possible complications and undesirable repercussions of the surgical treatment of large AP, more conservative non-surgical approaches are endorsed. In the presented hopeless cases, a newly introduced modified combination of triple antibiotics, that is Penicillin G, metronidazole, and ciprofloxacin (PMC), was used as a long-term intracanal medication in the non-surgical endodontic retreatments of large AP. In the course of 10-month to 3-year follow-up, the large periapical lesions completely disappeared, and thorough bone healing was evident. Additionally, complete functionality of the involved teeth as well as other favourable treatment outcomes of the addressed cases showed that the long-term use of PMC, as a modified combination of antibiotics, in non-surgical endodontic retreatments may successfully resolve large AP. However, further investigations and well-designed controlled clinical trials are recommended. Apical periodontitis (AP) is described as the inflammation and destruction of periapical tissues and a response to damages to the dental pulp and root canal space, for example, infections of the radicular area, injuries following endodontic treatments, and consequences of root canal filling materials . AP is aOne of the main objectives of endodontic treatment is the removal of etiological factors; therefore, to treat AP, its etiological factors should be surgically and non-surgically removed. Indications for surgical endodontics are on decrease due to their complications and adverse effects; however, they still comprise 3–10% of endodontic treatments . To achiIt has been shown that if canals are carefully cleaned and disinfected but not obturated, endodontic success could be expected , 10. ConThe objective of the current study of three hopeless cases was to report the healing of large periapical lesions through the long-term application of a new combination of triple antibiotics, Penicillin G (PG), metronidazole, and ciprofloxacin (PMC), for the disinfection of the root canal system.A 33-year-old male patient was referred for the evaluation and possible treatment of previously endodontically treated tooth #18 with a large periapical lesion detected during clinical and radiographic examinations. The patient expressed severe pain in the mandibular left region and complained about a swelling in the area.Initially, medical and dental histories of the patient were taken. In clinical examination, tooth #18 was found to be highly sensitive to percussion, and a mobility of grade II next to swelling around the tooth was seen. Probing on the distal root showed a deep periodontal pocket, reaching the periapical area of the root. Furthermore, a mesio-angular wisdom tooth (#17) had caused food impaction and caries on the distal surface of the tooth. Periapical radiographic evaluation of the tooth #18 revealed inadequate root canal filling with a large periapical lesion and severe bone resorption around the involved tooth. The mesial/distal roots and bone in the distal aspect of the tooth seemed to have resorbed . The tooIn the first appointment, under regional local anaesthesia and rubber dam in place, necessary coronal restoration of tooth #18 was removed, an appropriate access cavity was prepared, and canal orifices were cautiously investigated, probed, and located. Using chloroform, previous root canal obturation materials were completely removed, and canals were carefully irrigated with 5.25% sodium hypochlorite . Then, the root canal system was chemomechanically cleaned, shaped, and gently/copiously flooded with normal saline. Next, the new combination of triple antibiotics  was prepared and inserted into the root canals. Then, the tooth was temporarily dressed with Zonalin™ , and the patient was dismissed for regular clinical observations . A week A 35-year-old female patient with severe pain on mastication and buccal swelling on tooth #19 was referred for further consultation and/or possible endodontic treatment.Medical and dental histories of the patient were primarily taken, and then, clinical examination was conducted. In intraoral clinical examination, despite typical periodontal probing and normal tooth mobility, swelling on the buccal side of tooth #19 and severe pain on percussion test were seen. Initial radiographic evaluation of tooth #19 showed inadequate root canal treatment with large periapical radiolucency and massive bone resorption around the mesial root. In addition, further careful radiographic observation revealed two broken instruments in mesiobuccal and mesiolingual root canals, close to radiographic apices. Moreover, inadequate root canal obturation was seen in the mesial and distal canals, with a small radiographic lesion surrounding the distal root . The tooIn the first appointment, after tooth isolation with rubber dam, anesthesia, removal of the tooth previous restorative materials, and localization of canal orifices, the obturation materials were totally removed from the canals, following the same treatment protocol in Case 1. Subsequently, the radicular canals were cleaned, shaped, and completely prepared with copious amounts of normal saline. In the mesial canals, and due to the blockage made by broken instruments left from the previous treatment, canals were carefully prepared and entirely irrigated to the place of broken instruments. Then, PMC was prepared (same formulation as Case 1) and applied into the canals for the disinfection and removal of microorganisms. Next, the tooth was permanently restored with dental amalgam , and the patient was dismissed for regular postoperative sessions . After aA 30-year-old female patient with a compromised previous endodontic treatment of tooth #30 was referred for further consultation and necessary endodontic treatment. The patient complained about localized swelling, severe pain, and extreme discomfort during mastication on tooth #30.Patient's medical and dental histories were primarily obtained, and clinical examination was then conducted. In the intraoral clinical examination, tooth #30 showed no abnormal mobility; however, a localized large swelling was seen on the buccal side of tooth #30 with severe pain reported on percussion. Radiographic evaluation revealed an inappropriate previous endodontic treatment in the mesial canals as well as a large periapical radiolucency surrounding the mesial-root periapical region with bone resorption evident in the area; nevertheless, the endodontic treatment conducted in the distal root, post insertion, and the crown restoration seemed to be satisfactory . The posIn the first treatment session, after the administration of local anaesthesia and rubber-dam isolation of tooth #30, a conservative access cavity was prepared through the coronal restoration. Then, the obturation materials were cautiously removed from the pulp chamber (the same protocol as Case 1), and mesial canals were thoroughly cleaned and shaped. Next, PMC was prepared (same formulation as Case 1) and transferred to the mesial canals, and tooth #30 was temporised with Zonalin™ Kemdent; . After 2Enterococcus faecalis  [E. faecalis seems to be the most dominant microorganism in endodontic failures [In the present case series study, PMC was used as the intracanal medicament. TAP, despite its advantages, has shown disadvantages, principally due to the presence of minocycline . PG has aecalis) , whereasaecalis) . E. faecfailures . Therefofailures  to be trfailures , 21.The postoperative radiographs of the reported cases showed regression of large periapical lesions, disappearance of mobility (Case 1), and thorough healing of bone. It seemed that PMC could (a) function well against intracanal and periapical microorganisms, (b) result in the removal of bacteria and disinfection of the region, and (c) end in the regeneration of bone tissue and eventually healing of the large periapical lesion surrounding the roots in the course of treatment. Therefore, throughout the ministration, the intracanal dressing managed to combat the intracanal pathogenic microbiota, remove the causative microorganisms, as well as preparing an environment/proper grounds for subsequent healing of the lesions. These findings were similar to the outcomes of an investigation conducted by Kusgoz et al. , where tIn the current study, the ministered teeth were completely functional after the treatment sessions although the root canals were not initially obturated, and no signs of swelling/pain were reported by the patient. The large periapical lesions were gradually replaced by newly formed bone, and peri-radicular healing seemed complete. The outcome of our cases was consistent with the treatment protocols introduced by Asgary and Fazlyab  and ShahThe current case reports presented a follow-up period of 36, 28, and 10 months for cases 1, 2, and 3, respectively. The length of follow-up could differ in various studies; Pieper and Piva  conducteBesides, it appeared that eventual complete obturation of the root canals managed to favour the repair in the periapical and peri-radicular tissues. This result followed a similar concept presented by Holland et al. , who shoUsing PMC, as a newly/recently introduced intracanal medication, to disinfect root canal system with proper cleaning and shaping of radicular canals, seems to successfully manage large periapical lesions and result in desirable endodontic outcome(s). It caused hopeless teeth to re-function normally despite initial poor prognoses. Moreover, the mentioned minimally invasive method was cost-effective and required a relatively simple clinical approach. Nevertheless, additional evaluation of the consequences and further well-designed clinical trials are recommended.


Struma ovarii (SO) is a monodermal teratoma containing at least 50% thyroid tissue. Classically, SO is a hormonally inactive benign neoplasm that occurs in premenopausal women, and has unspecific clinical and imaging features. Its treatment is surgical and its diagnosis is established histopathologically. We report the case of a euthyroid 16-year-old girl presenting with abdominal girth increase. An abdomino-pelvic ultrasound showed a giant multicystic mass with transonic content and multiple septa, and magnetic resonance imaging suggested the diagnosis of right ovarian mucinous cystadenoma. Blood tests showed inflammatory syndrome, iron deficiency anemia, mild hepatocytolysis, and elevated serum CA 125 levels. High-grade fever occurred on the third day of hospitalization, but none of the preoperative tests could identify its origin. Cystectomy was performed, and the histopathological examination revealed benign SO with a few small cysts with purulent content. The patient developed hypothyroidism postoperatively. In conclusion, this case report reunites most of the uncommon features of SO and confirms the superiorityof histopathology in its definitive diagnosis, as well as the suitability of ovarian sparing techniques, as the best treatment option for cystic ovarian pathology in pediatric patients, even in cases of large tumoral size and elevated serum CA 125 levels. Struma ovarii (SO) is a monodermal teratoma containing at least 50% thyroid tissue . Data frThe clinical features of SO are non-specific, the main symptoms being abdominal pain and abdominal girth increase . In veryRegardless of the imaging technique used, SO’s aspect is indistinct and often overlaps with other ovarian lesions, or even with ovarian malignancy . The mulSO treatment is surgical, but there are no consistent data on its management protocol. Regarding the extent of removal, it is worth mentioning that the final decision depends on whether the appearance of the tumor is benign or malignant, as well as on the patient’s age, her potential for future fertility, and even her own decision . The defWe present the case of an euthyroid 16-year-old female patient with a giant benign SO, high-grade fever, and elevated serum CA 125 levels, who underwent cystectomy and developed hypothyroidism postoperatively. Written informed consent for publication of this case report and the accompanying images was obtained from the patient’s mother. A 16-year-old girl from an urban area was presented to the emergency room of our hospital. A week before, she had started a symptomatic treatment with ibuprofen for low-grade fever and slight cough, without medical advice. Since the fever persisted, she went to a general physician, who noticed an increase in the abdominal girth due to a giant palpable abdominal mass and recommended an urgent visit to the hospital. She was admitted to the department of pediatric surgery, and we found that the progressive abdominal enlargement had started about a year prior, and was associated with intermittent mild pain. The patient had no medical history, had her menarche at 12 years old, and had normal menstrual cycles. Upon admission, she was asymptomatic with normal body temperature, and the clinical examination revealed a giant, tense, and relatively mobile tumor with a regular surface, and umbilical hernia. Additionally, in the right thoracic area, a brown-black lesion was observed . The abdomino-pelvic US showed a thin-walled, multilocular cystic mass occupying almost the entire abdomen and pelvis, with transonic content and multiple septa, some of them thick. None of the ovaries were visualized, and there was no free peritoneal fluid. Because the cyst origin could not be specified, we requested an abdomino-pelvic MRI, which showed a 115/224/350 mm cystic tumor originating in the right ovary that waswell-defined by a regular wall, multiloculated, had liquid content with some areas of high signal intensity in T1, and presented moderate mural and septal enhancement after gadolinium injection; the suggested diagnosis was ovarian cystadenoma .3/µL (150–450 × 103/µL), C-reactive protein: 26.45 mg/dL (0–0.5 mg/dL), D-dimers: 1.21 mg/L (0–0.55 mg/L), alkaline phosphatase: 213 U/L (50–130 U/L), ferritin: 480 ng/mL (13–68 ng/mL), iron: 28 µg/dL (37–170 µg/dL), aspartate aminotransferase: 70 U/L (14–36 U/L), alanine aminotransferase: 77 U/L (4–44 U/L), and gamma-glutamil-transpeptidase: 353 U/L (11–28 U/L). At the time of the study, we requested a pediatric endocrinological consultation for all adnexal lesions, and in this case, the hormonal tests were normal, including those for thyroid function. The carcinoembryonic antigen (CEA), α fetoprotein (AFP), β human chorionic gonadotropin (HCG), LDH, and CA 19-9 values were within the normal limits, but CA 125 was increased to 124.7 U/mL (<30.2 U/mL).The patient’s blood tests presented some abnormal values: hemoglobin: 10.12 g/dL (12–15 g/dL), hematocrit: 29.4% (35–45%), thrombocytes: 656.4 × 10Given the inflammatory syndrome, the iron deficiency anemia, and the mild hepatocytolysis, the preanesthetic examination was followed by additional investigations and preoperatory treatment with Ceftriaxone. Uroculture, as well as the nasal and pharyngeal exudate, did not detect any pathogenic microorganisms, and the pulmonary radiography was normal. On the third day of hospitalization, the patient presented high-grade fever (up to 39.5 °C) that was unresponsive to an intravenous antibiotic and antipyretic treatment, and was unaccompanied by other symptoms. We excluded the usual causes of fever, such as otorhinolaryngeal, respiratory, digestive, urinary, or cutaneous conditions, and the hemoculture and the ARN SARS-CoV-2 test were negative. We thought of an intracystic hemorrhage or infection, but the cyst content was unchanged on the abdominal US. A pediatric oncological examination raised the suspicion of a paraneoplastic syndrome and sepsis, and prompted intravenous treatment with meropenem, gentamicin, and metronidazole. After 2 days, the patient’s body temperature became normal. Consequently, with a presumptive preoperatory diagnosis of serous or mucinous cystadenoma, we performed a 3 cm subumbilical median incision. The cyst was underlying the abdominal wall, and drainage was performed under direct visualization. Because the sudden decompression of a giant cyst may lead to some changes in respiration and circulation due to an increase in venous return, we initiated slow drainage by using a puncture needle for the first 1000 mL, followed by a high-pressure suction cannula, without any spillage. In total, 4500 mL of clear, colorless liquid was extracted. A 40 mm cyst remained undrained, due to the fact that it did not communicate with the rest of the tumor . We perfThe histopathological examination of the multilocular cystic mass was consistent with benign SO, as its walls were composed of mature thyroid tissue without architectural or cytological atypia, with variable-sized follicles containing eosinophilic colloid . The strSince the patient had normal blood tests for thyroid function before surgery, the histopathological findings required us to perform an endocrinological re-evaluation. This time, the biochemical features showed subclinical hypothyroidism  with a normal thyroid on the US, and daily hormone replacement therapy with levothyroxine was recommended.Although thyroid cells may be found in about 20% of dermoid cysts, SO is a monodermal mature ovarian teratoma that is histopathologically defined by finding thyroid follicular tissue in more than 50% of the tumor . Like alConsidered to occur mainly in women aged between 30 and 50 years , SO is cUp to 40% of patients are asymptomatic, and the tumor is discovered incidentally during imaging examination. When present, the most common complaints are abdominal pain and distension , usuallyRegarding thyroid hormone secretion, SO can be inactive or active; recent studies have shownthat SO is the only serum thyroglobulin-secretingtumor . When acThe most common pattern on a US is a multilocular cystic mass with a lobulated surface, multiple cysts (dilated thyroid follicles), thickened septa, and various amounts of solid components (thyroid tissue). The cyst fluid is always anechoic or of low-level echogenicity. Because the thyroid tissue is highly vascular, upon color Doppler examination, most SO cases appear moderately vascularized and display variable flow, ranging from none to abundant. A typical feature of struma ovarii is “struma pearls”, which consist of one or more round, solid areas that are well-circumscribed by a smooth margin, and well vascularized upon Doppler examination. On the other hand, most often, these images are considered papillary projections, raising the suspicion of malignancy ,24,25. OMRI is a more accurate method of identifying the nature of cystic content. The typical appearance of SO on T1-weighted images (T1WIs) shows a multilocular cystic lesion with loculi that have variable signal intensities and punctuate foci of high signal intensity, located inside or adjacent to the thickened septa or the cyst walls. T1WIs show strong enhancement of the solid components after gadolinium injection. In T2-weighted sequences, most loculi have high signal intensity. There is no enhancement of these loculi on fat-saturated postcontrast T1WI sequences ,26.Except for cases in which the patient has hyperthyroidism and a normal thyroid, it may be inappropriate to speak of a differential diagnosis for SO, since this extremely rare condition is not usually the first preoperative diagnostic choice, and is often misdiagnosed as mucinous or serous cystadenoma , a functThe histopathologic examination of anovarian mass establishes a definitive diagnosis by revealing mature thyroid follicles of various sizes, lined by cuboidal epithelial cells and containing colloid ,12. If nDespite being described for the first time in 1895 by Von Klden, and in 1899 by Gottschalk , there sThe postoperative follow-up for benign SO consist mainly of an ultrasound and thyroid function investigations . Some auOur patient was admitted with a giant cystic multiloculated abdominal tumor appearing on an ultrasound, and because we had no information on its origin, the initial differential diagnosis included abdominal lymphangioma and ovarian cystadenoma. We also took into consideration a paraovarian or follicular cyst. The MRI showed the ovarian origin of the mass. Corroborating the clinical and imaging features, we were sure it was a mucinous rather than a serous cystadenoma: a benign tumor, that can grow to gigantic sizes, is multiseptated, and has high-signal-intensity locules on T1WI . Since tThis case report reunites most of the uncommon features of SO, a very uncommon ovarian tumor: the young age of the patient, the giant size of the SO, the association of the SO with elevated serum CA 125 levels without ascites, the absence of “struma pearls”, the postoperative hypothyroidism triggered by a hormonally active type of tumor, and the cyst infection, as a complication. In addition, it confirms histopathology’s superiority in establishing a definitive SO diagnosis, and the suitability of the ovarian sparing techniques as the best treatment option for cystic ovarian pathology in pediatric patients, even in cases of large tumoral size and elevated serum CA 125 levels.


Spinal subependymomas (SE) are rare, often indolent benign tumors presenting most frequently as intramedullary tumors in the cervical spine or cervicothoracic junction. When symptomatic, patients often present with years of sensory changes, weakness, paresthesias, or bowel and bladder dysfunction. Preoperatively, SE are difficult to distinguish radiographically from ependymomas or astrocytomas; however, it is important to make the distinction intraoperatively as complete resection can be curative. Here the authors present a rare case of recurrent, symptomatic cervical subependymoma which underwent gross-total resection and discussion of management strategies and outcomes of all SE at their institution. Here we present the surgical resection of a recurrent intramedullary subependymoma of the cervical spinal cord.This is the case of a 34-year-old male with a history of morbid obesity and a known cervical subependymoma for which he underwent a previous C2–7 laminectomy, tumor resection, and C2–T4 fusion in 2016. Postoperatively, he has significant left arm paresis, with partial regain of function following rehabilitation, but was subsequently lost to follow-up for several years.1 Within the limitations of instrumentation artifact, postoperative imaging in the bottom panel showed no evidence of abnormal contrast enhancement within the cord or the thecal sac and excellent decompression of the spinal cord.His initial preoperative imaging showed an extensive intramedullary lesion from C2 to 7 with minimal heterogenous T1 contrast enhancement seen in the top left and minimal T2 signal in the top middle.He returned in 2023 with 1 year of progressive left arm weakness and gait instability. By the time he presented, he had near-complete absence of motor and sensory function in the left arm.Repeat cervical MRI with contrast showed expansile intramedullary lesion from C3 to 7 with the largest bulk centered at C5–6. There is also T2 hyperintensity in the edge of the dorsal lateral left hemicord up to the C2 level and down to the T1 level compatible with myelomalacia.CT confirmed solid bony fusion and decision was made to remove hardware during the case to improve visualization and enhance the accuracy of tumor assessment on follow-up imaging.Patient was placed in prone position with the head secured in pinions. Previous midline cervical incision was identified and reopened in typical fashion. Neuromonitoring with SSEPs  and MEPs  was utilized during the case.Given the difficulty visualizing the tumor on MRI, ultrasound was used to identify the boundaries of the tumor.Despite scarring, the midline of the spinal cord was located based on cervical surface topography. Moving through the posterior median septum resulted in minimal spinal cord damage as a clear plane was found between the gracilis fasciculi.The tumor was identified and separated from the spinal cord by spreading plate forceps.This demonstrates one plate being used for gentle retraction on the cord and the other applying pressure predominantly to the tumor mass, lessening the trauma to the cord.Here we show removal of the final pieces of tumor that were adherent to the cord. Ultimately, a gross-total resection was achieved and the areas of adherence gently cauterized.Ultrasound was used to confirm gross-total resection.A primary watertight dural closure was completed.In the immediate postoperative period, the patient had new weakness in his right arm and hand as well as bilateral legs that correlated with intraoperative neuromonitoring changes.He was admitted to the Neuro ICU for MAP augmentation. His course was complicated by elevated CK (creatinine kinase) secondary to rhabdomyolysis. This was successfully treated without kidney injury. He was transferred to the general care floor on postoperative day 4.Baseline postoperative cervical MRI showed interval removal of C2–T4 instrumentation and gross-total resection of intramedullary lesion within the cervical cord. Similar T2 hyperintensity and left hemicord atrophy remained. There is an immediate postoperative fluid collection that is expected to resolve over time.The patient was discharged to inpatient rehab on postoperative day 9. At the time of discharge, his motor exam was improving, and he was regaining function of his right hand.2Final pathology showed clinically recurrent ependymal neoplasm with predominantly subependymoma morphology. It had low proliferative activity without significant anaplastic histological features, such as TERT promoter mutation or any chromosomal copy number alterations.A total of 4 patients were identified in our electronic medical record system with biopsy-confirmed intramedullary spinal subependymoma, and 1 patient with presumed subependymoma. Of the biopsy-confirmed patients, the average age of the patient was 40 years old with equal male to female ratio. Two patients had cervical thoracic lesions and two with isolated thoracic lesions. The patients had an average of 1.4 years of symptom progression prior to presentation, with sensory changes being the most common presenting symptom. Patients 1–4 underwent surgical management that included laminectomies and tumor resection of the respective levels. Given patient 5 was asymptomatic from the lesion, they were observed for a period of several years without progression.Gross-total resection was achieved in 3 of 4 patients. All patients experienced new postoperative deficits with at least partial recovery. Late tumor recurrence occurred in all cases with an average time to progression of 6.8 years.5 However, intraoperative ultrasound proved to be a useful technique to define the boundaries of the tumor. If feasible, gross-total resection can have a favorable outcome, though late recurrence is known to occur.In conclusion, spinal subependymomas are rare tumors that are difficult to visualize and distinguish on imaging.The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this publication.Assistant surgeon: Perez, Rotter, Everson. Editing and drafting the video and abstract: Clarke, Perez, Astudillo Potes, Rotter, Everson. Critically revising the work: Clarke, Perez, Everson, Raghunathan. Reviewed submitted version of the work: Clarke, Perez, Astudillo Potes, Everson, Raghunathan. Approved the final version of the work on behalf of all authors: Clarke. Supervision: Clarke, Perez, Raghunathan.Informed consent was waived due to minimal risk to research subjects.


A 71-year-old male presented to the clinic with two multiloculated cystic masses located over the distal bicep of his left upper extremity, causing discomfort when flexing the extremity. Referral and point-of-care ultrasound at an outside location suggested cystic masses that were consistent with that of a ganglion cyst. Physical exam and clinical presentation were also consistent with this diagnosis. Due to the patient’s symptomatic presentation, surgical intervention was proposed, and the patient consented. Intraoperatively, it was discovered that the patient’s mass was unexpectedly due to an arteriovenous malformation, revealing the importance of careful workup for cystic masses presenting in unusual locations. Ganglion cysts are common, mucin-filled cysts that typically occur on the hands, especially the dorsal aspect of the wrist. Oftentimes, they are asymptomatic but may cause discomfort due to enlargement or movement that can cause irritation over the area . There hThis is a case of a 71-year-old male who presented to our clinic for evaluation of a left antecubital fossa mass. The patient had previously been seen by internal medicine at another location in which a point-of-care ultrasound had been performed, revealing a fluid-filled mass. No Doppler ultrasound findings had been sent to us. He stated that the mass had been developing over multiple years until a point at which he experienced discomfort at the site of the mass when flexing his elbow greater than 90 degrees and decided to receive an evaluation. The patient had no known or significant prior surgical or medical history. Physical examination of the left upper extremity revealed an approximately 2 x 1.5 cm palpable multiloculated cystic mass over the medial aspect of the distal bicep just proximal to the elbow flexion crease  revealing feeding vessels that can emanate from major arteries and veins. Patients with AVMs pose a high risk of life-threatening hemorrhage and are treated with pre-emptive surgical ligation . Upper eIn the realm of orthopedics, ganglion cysts are a common and uncomplicated problem that usually does not require extensive diagnostic imaging or workup. In atypical situations such as this one, where a cyst-like mass was found on the distal biceps, further workup should be performed to rule out other abnormalities. While point-of-care ultrasound was performed, revealing a cystic mass, it is advantageous to perform further workup with Doppler ultrasound or MRI, as this case reveals how an arteriovenous malformation can masquerade as a ganglion cyst.Even though no complications arose from surgery, utilization of the aforementioned imaging options may have prevented the decision to pursue a relatively invasive approach and monitor the blood vessels instead. From the vantage point of vascular surgery, the progression of AVM symptomatology can be tracked via Schobinger’s four-stage scale to help inform further ameliorative or surgical options Table  8]..8].One case illustrated in the literature described a woman who presented with a bilobed palpable lesion over her left antecubital fossa. This was eventually diagnosed as a brachial artery aneurysm by means of a contrasted-enhanced MRI, proximal to a previous AVM arising from the dorsal interosseous and ulnar arteries that had been treated before by embolization. In this case, her presentation of an AVM and aneurysm of the peripheral vasculature was quite rare. However, the palpable mass was due to her aneurysm rather than the AVM itself .Although ganglion cysts and arteriovenous malformations are common disease processes, cystic masses that are present in the antecubital fossa are a rare and unique occurrence. If there is a concern for a cystic mass in an unusual anatomic location, there should be further preoperative workup and advanced imaging for this presentation. Ultrasounds should be performed with Doppler studies of cystic masses to rule out vascular cases. Further imaging with MRI may also be performed to better visualize structures and properly diagnose issues. In this case, while a prior ultrasound read demonstrated a fluid-filled mass, extra precaution should be taken in order to better visualize and properly identify the pathology.


Chondrosarcoma represents approximately 0.1% of all neoplasms of the head and neck and is considered a rare disease with a relatively good prognosis. The 5-year overall survival (OS) rate is estimated at 70–80%, being considered a disease with a low growth rate. Approximately 13% of all cases of chondrosarcoma are located in the region of the head and neck. We present the case of a 30-year-old patient without a medical history who reported dysphagia, swallowing difficulty, neck mass sensation and dysphonia that started insidiously after an upper respiratory tract infection. Subsequently, the patient was diagnosed with a low-grade glosso-epiglottic region chondrosarcoma and was multimodally treated with surgery followed by chemotherapy and radiotherapy. The radiation treatment was delivered with a Rokus M40 former Soviet Union cobalt machine without any image guidance capabilities. The inability to obtain resection margin information justified an aggressive adjuvant treatment with chemotherapy and radiotherapy. The early loss from the oncological record without recurrence of the disease could be associated in this case with the consequence of a major complication, of which we could assume an aspiration pneumonia secondary to a dysphagia associated with an aggressive multidisciplinary treatment. Large tumor size and positive resection margins (R1 resection) are risk factors that support an intensive adjuvant approach in order to reduce the risk of recurrence, but the low grade of tumor associated with a lower risk of recurrence as well as the adverse events (AE) of adjuvant radiotherapy and chemotherapy justify a more reserved therapeutic approach. Taking into account the longer life expectancy of these patients, it is recommended to use a more conformal irradiation technique in order to reduce doses to radiosensitive structures as well as to omit elective neck irradiation, taking into account the lower risk of lymph node involvement. The lack of guidelines, which include very rare tumors including low grade chondrosarcoma of the head and neck, makes a unified approach difficult, but the data presented in case reports could contribute to choosing the regimen that offers the best therapeutic ratio. Chondrosarcoma represents approximately 0.1% of all neoplasms of the head and neck and is considered a rare disease with a relatively good prognosis. The 5-year overall survival (OS) rate is estimated at 70–80%, being considered a disease with a low growth rate. A total of 1–3% of all cases of chondrosarcoma are located in the region of the head and neck. Chondrosarcoma has the highest incidence between the third and fourth decade of life, and cartilaginous neoplasms may have histological patterns that range from benign chondroid tumors to undifferentiated tumors [WHO classifies chondrosarcomas in three degrees: cell density, differentiation and nucleus size are the factors considered in the classification; however, a simpler classification divides this type of tumor into two classes (low and high grade). Low-grade tumors usually have a favorable prognosis and are well differentiated, being associated with a low number of pleomorphisms and cellular atypia ,3.Low-grade tumors are usually well-differentiated with moderate cellularity and very few cellular pleomorphisms or atypia. All chondrosarcomas, regardless of grade, have histological features of hypercellularity, pleomorphism, mitotic activity, mixed intercellular matrix and cellular atypia. Surgical treatment is considered the backbone of the multidisciplinary approach, but the recurrence rate is relatively high for grade II and III tumors compared to low-grade tumors (80% vs. 17%) even after optimal surgical treatment. Although chondrosarcoma is considered a radio-resistant tumor, high-dose adjuvant irradiation is recommended in cases with positive surgical margins ,4,5.The purpose of this study is to present the case of a low-grade chondrosarcoma in a young patient with risk factors for recurrence (lack of data about an adequate resection margin and large tumor size) but also to emphasize the need to balance the adjuvant benefit of radiotherapy and chemotherapy with limiting adverse effects and the risk of dysphagia and aspiration in this category of tumors missed and orphaned by therapeutic guidelines.We present a 30-year-old patient without a significant medical history who was addressed to an ENT department in July 2012 with dysphagia, swallowing difficulty, neck mass sensation and dysphonia, the onset being insidious apparently following an episode of upper respiratory tract infection (URTI). The ENT examination revealed a mure-shaped polylobed tumor formation that displaced the suprahyoid epiglottis by mass effect and oriented it with the concavity towards the left hypopharyngeal wall, deformed it and left an equilateral triangular slit with a wall of approximately 5 cm. Hypo-pharyngoscopy and direct laryngoscopy identified a valecular cyst, which was subsequently removed, the evolution being favorable. The surgery was performed endoscopically with endotracheal intubation and general anesthesia.In January 2013, the patient returned with inspiratory dyspnea, patient-reported dysphagia, stomatolalia and fever with progressive evolution. The ENT clinical examination highlighted a dyspneic patient with more pronounced inspiratory stridor, a multiform tumor process on the right valecula, which dislocated the suprahyoid epiglota on which it oriented with concavity towards the left hypopharyngeal lateral wall, deformed it and left an equilateral triangular slit with a side of approximately 5 cm. The chest X-ray did not show pathological pleuro-pulmonary aspects. The computer tomography (CT) exam revealed a polycystic-looking tumor formation with multiple septa inside and calcifications with 3–4 mm diameter that interest the right valecula, an aspect that suggested a possible chondrome. Under local anesthesia, tracheotomy was performed followed by tumor excision after hyoidectomy with a transvalecular approach. Epiglotopexy, laryngo-pharyngography, nasal-gastric feeding tube and Portex tracheal cannula were performed simultaneously. Postoperative evolution was marked by the development of a base of the tongue hematoma, surgical evacuation being performed. Favorable postoperative evolution was mentioned .The surgical pieces revealed a polylobate and polycyclic structure with a relatively smooth capsule and firm consistency through the transparency of the capsule brindle-like aspect red–violet areas, alternating with light areas. The tumor diameters were 105/65/85 mm. The section had a brindle-like, hard appearance of the whitish areas, and was the size of a rice grain, non-confluent, and separated by areas with a purple, fleshy, firm tint. The histopathological examination of the surgical pieces highlighted a nodular mycho-chondroid proliferation delimited by collagen fibrosis with reduced xanthomatous inflammation and chondrocytes. The cartilaginous tissue consisted of chondrocytes with irregular hyperchromic nuclei, rarely being binucleate, reduced mitotic activity and areas of bone metaplasia. In the periphery of the myxochondroid areas, striated muscle tissue was noticeable. The appearance of the histopathological examination suggested a hamartoma tumor (choristoma) that required a second opinion to differentiate from a low-grade chondrosarcoma . AdditioIn March 2013, the patient was addressed to the ENT department with swelling, hyperemia and pain at the lower pole of the cervical flap, patient-reported dysphagia and dehiscence of the wound on 1.5 cm with permanent bleeding. The ENT examination highlighted extensive valecular swelling in the suprahyoid epiglottis, the diagnosis being suppurative cervical cellulitis and acute epiglottitis. Subsequently, the patient was addressed to another ENT department, and a lingual tonsillectomy was performed. The histopathological examination revealed a fragment of the mucous membrane lined with squamous epithelium without atypical lymphoid tissue.Five cycles of Epirubucine + Cisplatin were performed between April and July 2013; the patient then received external beam radiation using a Rokus M40 former Soviet Union cobalt machine without any image guidance capabilities in a total dose of 50 Gy/25 fractions/5 weeks/5 days per week between August and September. Without the tumor board concept being implemented at that time, radiotherapy was decided by the radiation oncologist as there was no information available about the resection margins. The patient was evaluated periodically in the oncology and ENT departments, presenting a performance index ECOG 2 (Eastern Cooperative Oncology Group) and dysphagia for solids and liquids with no significant loco-regional recurrence until March 2014, when he was lost from evidence.Representing approximately 11% of all primary malignant bone tumors and the second most common sarcoma subtype after osteosarcoma, chondrosarcoma of the head and neck region is rare. The base of the skull, the sinonasal tract, the jaw and the larynx are the anatomical locations reported to be associated with the occurrence of chondrosarcoma. Differential diagnosis with chondroblastic osteosarcoma and chondroid chordoma is considered difficult. With the 5-year overall survival (OS) rate estimated at 80%, surgery as a single method or followed by adjuvant radiotherapy is considered the optimal approach. For cases not eligible for surgery or that are associated with cosmetically mutilating effects, radiotherapy has been reported to be effective .Horta et al. report a case of chondrosarcoma of the hyoid bone, a very rare subtype, with 20 cases being identified at that time in the literature. Worth noting in this case is the value of the computer tomography examination, which highlights the chondroid-like calcification originating from the hyoid bone, although previous cytology suggested pleomorphic adenoma. Prior to this case report, analyzing 19 cases of chondrosarcoma of the hyoid bone, Zhang et al. also mention the role of CT imaging and magnetic resonance imaging (MRI) in the diagnostic stage and of surgery followed by radiotherapy as the backbone treatment ,8. RetroVučković et al. mention a case in which the patient was operated on 14 years after the diagnosis of chondrosarcoma, diagnosed at that time with a chondroma. The authors draw attention to the differential diagnosis of chondrosarcoma, a subtype of tumor characterized by mesenchymal transformation originating in hyaline cartilage but also to the possibility of transforming a chondroma into a low-grade chondrosarcoma. In all cases of head and neck submucosal tumors, chondrosarcoma should be considered as a differential diagnosis. After the left partial vertical laryngectomy treatment, no local recurrence or distant metastasis was reported in a 12-month follow-up. In a case of a right maxillary sinus tumor, grade III chondrosarcoma with skin and bone infiltration of the maxillary sinus and orbital floor was identified. Despite an aggressive adjuvant treatment, a higher tumor grade associated with extreme chromosomal instability was also associated with local recurrence. Sprekelsen et al. mention the tumor grade as being associated with the risk of recurrence and with the profile of therapeutic failure. In the case of low-grade tumors, local growth is predominant, and for high-grade head and neck chondrosarcoma, distant metastasis becomes the predominant pattern of failure, even after years from the initial treatment ,11.Clear cell chondrosarcoma, which usually involves the end of long bones, was reported in nine cases in the head and neck, including four cases of tumors of the larynx, the nasal septum of the jaw and the skull. Clear cell chondrosarcoma was associated with septal bulging, and the maxillary tumor did not involve the mucosa. In the case of laryngeal tumors, a tendency of recurrence was observed. Being a rare and slow-growing tumor, a long follow-up and a diagnosis based on immunohistochemical tests are necessary. An unusual onset through 12 days of vomiting was reported in the case of a low-grade right cricoid chondrosarcoma with intraluminal and extraluminal extension. Eighteen months after the resection of the trachea with end-to-end anastomosis, the patient was alive with no signs of recurrence. And in this case, a resection with margins free of tumor was considered sufficient with radiotherapy recommended to prevent local recurrence in the case of incomplete resection . Rivero 2) and Ifosfamide-based chemotherapy are generally preferred for high-grade tumors. In the case of low-grade chondrosarcoma, the rate of distant metastases is relatively low (1.9%), but the analyzed group included only low-grade chondrosarcoma of the larynx [Tejani et al. consider that tumor size and resection quality are the main risk factors associated with an unfavorable prognosis in head and neck sarcomas. A size of 5 cm is considered the cutoff value for the prognosis . Althouge larynx ,17. Hoare larynx .Analyzing chondromas and chondrosarcomas of the base of the skull, Kremenevski et al. identify the incidence of chondrosarcomas as less than 0.15% of all intracranial tumors. The authors consider that chondrosarcoma has a better prognosis than chondroma, probably due to a more aggressive multimodal treatment. The overall survival (OS) for chondrosarcomas is 80% and 50% at 5 years and 10 years, respectively. Even if the authors note the benefit of adjuvant treatment with radiotherapy, chemotherapy is considered limited in value with maximum surgery being considered the basis of treatment. Although chondrosarcoma of the skull base is recognized by the high risk of recurrence, the multidisciplinary approach focuses on balancing the benefits/adverse effects to maintain the quality of life (QoL) .A study that included 40 cases of chondrosarcomas of the head and neck treated surgically retrospectively evaluated the relationship between certain clinical and imaging characteristics and prognosis but also quantified the relationship between isocitrate dehydrogenase 1 and 2  mutations and the evolution of the disease. The tumor infiltrated resection margin was associated with an unfavorable prognosis, but the IDH mutation did not influence the treatment results . Lower rA systematic review analyzing laryngeal chondrosarcoma cases identified 381 eligible cases. The most frequently involved anatomical structure was identified as the cricoid cartilage, and dyspnea, hoarseness and the sensation of mass in the throat were the most frequently reported symptoms. The surgical technique and the degree of histological differentiation were factors correlated with the prognosis . In anotAlmost 20 years ago, Eisbruch analyzed the anatomical strictures involved in late dysphagia/aspiration (DARS) in the case of HNC patients treated with chemotherapy based on Gemcitabine and high doses of concurrent radiotherapy for curative purposes, Coreland evaluation of swallowing and structural changes, videofluoroscopy, direct endoscopy and CT with radiotherapy plans obtained with the 3D-conformal technique (3D-CRT), intensity modulated radiotherapy (IMRT) and IMRT optimized for dysphagia reduction. A Cisplatin-based chemotherapy regimen was also proposed to evaluate the specificity of the changes associated with the treatment compared to a certain chemotherapy regimen. Prolongation of pharyngeal transit time, posterior tongue base weakness, lack of coordination between swallowing phases and limited laryngeal elevation, reduction in laryngeal closure and epigotic inversion were identified in the case of both regimens and were associated with a high aspiration rate. The study identifies the laryngeal constrictors, the glottic and supragotic larynx, as risk organs associated with dysphagia after radio-chemotherapy treatment. The authors demonstrated a moderate benefit of the IMRT technique in limiting the risk of late dysphagia, but by optimizing the IMRT plans related to dysphagia and reducing the radiation doses received by these structures, an additional benefit can be brought in limiting toxicities. Petkar et al. exploit this concept in a phase III randomized trial and evaluate whether sparing pharyngeal constrictor muscle and supraglottic larynx translates into the limitation of late dysphagia. The DARS trial (CRUK/14/014) assessed dysphagia according to the MD Anderson Dysphagia Inventory (MDADI) scale 12 months after treatment. The trial divides the cases of T1-4, N0-3 and M0 pharyngeal cancers into two equal groups that are treated with chemo-radiotherapy, using the IMRT technique for the delivery of radiotherapy and the IMRT technique optimized to limit dysphagia ,27,28.Dysphagia is one of the most serious tardive complications associated with an aggressive multimodal treatment including radiation therapy and chemotherapy, being a predictor for the risk of aspiration. Oropharynx and hypo-pharynx cancers but also the stage and size of the tumor are predictive factors of the risk of aspiration. Elderly patients and concurrent chemo-radiotherapy are also associated with an increased risk of late dysphagia and aspiration. Madan and collaborators report aspiration pneumonia as the cause for a 60% death rate in a group of 85 patients with head and neck cancers followed for a period of 12 years. The radio-biological model proposed by Christianen et al. identify the radiation dose received by the pharyngeal constrictor muscles and the supraglottic larynx as predictors for late severe dysphagia. The authors mention the impossibility of using a single dose-volume correlation to predict dysphagia. In the case of liquids, if the mean dose received by the supraglottic larynx is predictive, in the case of dysphagia for soft foods, both the radiation dose received by the superior pharyngeal constrictor muscle, the supraglottic larynx, and the age with a cutoff value of 65 years are associated with late toxicity. In this context, the use of a modern radiotherapy technique that reduces the doses received by these anatomical structures can significantly reduce the risk of late dysphagia and, as a consequence, reduce the risk for aspiration pneumonia ,30,31,32Although it is one of the most serious side-effects of HNC treatment, even associated with the risk of mortality, aspiration pneumonia associated with chemoradiotherapy and bioradiotherapy with Cetuximab is little investigated. Analyzing retrospectively the data obtained from 374 patients, of which 95 cases (25.4%) had associated aspiration pneumonia, the authors identified a correlation between aspiration pneumonia with treatment response and overall survival. Hospital treatment, hypoalbuminemia before treatment, N classification and oral hygiene were factors associated with the risk of aspiration pneumonia. Neck dissection and accelerated fractionation regimens are also considered risk factors for aspiration ,35.After an analysis of data from 3513 patients with HNC, aspiration pneumonia was identified in the history in 801 cases 5 months after the initiation of treatment. Hypopharyngeal tumors, male sex, advanced age, comorbidities and lack of surgical treatment before radio-chemotherapy were identified as risk factors for aspiration pneumonia in multivariate analysis. The hospitalization rate for patients with aspiration pneumonia is considered to be 84%, of which 45% are admitted to intensive care units. With a thirty-day mortality of 32.5% and a general risk of death of 45%, aspiration pneumonia must be considered as a possible late complication after radio-chemotherapy, especially in elderly patients. Xu et al. mention that 5 years after the end of the treatment, a quarter of this category of patients will be affected by aspiration pneumonia. Tumor stage is identified as a risk factor by Liu et al.; patients with ≥2 risk factors have a risk of 2.5 times more to aspire after the completion of radiotherapy treatment ,37.The early loss from the oncological follow-up programs of patients with a low degree of aggression tumor without evidence of a recurrence or metastasis can be the consequence of a major complication of which we can assume an aspiration pneumonia secondary to a dysphagia associated with an aggressive multidisciplinary treatment. Large tumor size and positive resection margins (R1 resection) are risk factors that support an intensive adjuvant approach to reduce the risk of recurrence, but the low degree of tumor, associating a lower risk of recurrence, as well as the adverse effects of adjuvant radiotherapy and chemotherapy are arguments that argue for an intensification of therapy. Given the long life expectancy of these patients, it is recommended to use an irradiation technique to reduce doses to radiosensitive structures as well as to omit elective neck irradiation, taking into account the reduced risk of lymph node involvement. The lack of guidelines that include very rare tumors, including low-grade chondrosarcoma of the head and neck, make a unified approach difficult, but the data presented in case reports could contribute to choosing the regimen that offers the best therapeutic ratio.


The Kasabach–Merritt syndrome (KMS) is characterized by the occurrence of hemangioendothelioma (giant hemangioma with thrombosis leading to thrombocytopenia), which can be associated with disseminated intravasal coagulation. Specific aim: Based on (i) selective references from the current scientific literature and derived recommendations as well as (ii) own experiences obtained in the diagnostic and perioperative management of a representative case from daily practice in abdominal surgery, the specific case undergoing elective cholecystectomy (CCE) in KMS is to be described by means of scientific case report.: – Medical history: 72-years old female patient with a known KMS of the left arm and upper thorax, recurrent thrombophlebitis of the left arm and thoracic veins, previous upper GI bleeding , intraabdominal adhesions, hypothyreosis, initial liver cirrhosis. – Symptomatology: Characteristic for cholecystolithiasis (CCL). – Diagnostic: Abdominal ultrasound shows CCL, fibroscan does not confirm suspicious cirrhosis. Laboratory parameters showed: Activation of intravasal coagulation with elevated prothrombin fragments, D-dimers and reduced antiplasmin concentration. Accelerated fibrinolysis capacity; currently, no secondary thrombocytopenia or factor-13 decrease. In addition, fibrinogen concentration within normal range, no hint onto the manifestation of an aquired von-Willebrand’s syndrome. – Diagnosis: Chronic fibrosing cholecystitis in CCL after former acute cholecystitis (3 months ago) with indication for surgical intervention. – Therapy: Laparoscopic CCE including careful exploration of upper abdominal cavity for KMS manifestation (with no revision of bile duct) and peritoneal adhesiolysis  under perioperative prophylaxis with antibiotics and temporary cessation of platelet medication for 7 d preoperatively, “bridging” with low molecular weight heparin ; 1 h preoperatively, 15–20 mg/kg body weight Cyclocapron i.v. . – Intraoperatively: Congestion of veins but not at the immediate surgical field . – Outcome: Uneventful, in particular, no (bleeding) complications.If surgical approach is indicated, the intervention should be thoroughly planned  with regard to hemangioma site and extension as well as distance to the surgical field and possible surgical alternative options  to prevent – at the best possible rate – bleeding complications intra-/postoperatively and, thus, to provide adequate patient safety. The Kasabach–Merritt syndrome  describes the occurrence of hemangioendotheliomas (giant hemangiomas) with an ongoing thrombosis within the lesion, which leads to the consumption of coagulation factors and platelets with a disseminated intravascular coagulation (DIC) [(i)selective references from the topic-related medical scientific literature and their recommendations as well as(ii)own clinical management experiences from daily practice in surgery, to describe the frequent elective cholecystectomy (CCE) in symptomatic cholecystolithiasis with the coincidence of a rare clinical picture of KMS.The aim of this scientific case report was based on–dental extraction,–open appendectomy in 1962 (and)–Caesarean section in 1968 (in which 60 red blood cell packs had been necessarily transfused) previously.A 72-years old female patient was transferred with a status after previous episode of conservatively treated acute cholecystitis in cholecystolithiasis to our outpatient clinic for elective cholecystectomy. Medical history was significant for KMS of the left arm and the left upper thoracic wall with recurrent thrombophlebitis of the left arm and thoracic veins. In addition, there were numerous bleeding complications after–status after upper GI bleeding in Mallory-Weiss syndrome in 2006,–chronic anemia in vitamine-B12 lack,–type-A gastritis,–hypothyreosis,–arterial hypertonus,–initial stage of liver cirrhosis,–chronic renal insufficiency – stage II (as well as)–allergy against macrolide and penicillin antibiotics.Furthermore, medical history comprisedThe medication prescribed by the family practitioner comprised L-thyroxin, an ACE inhibitor, hydrochlorothiazide and clopidogrel (platelet aggregation inhibitor) to avoid exaggerated platelet aggregation. The patient was provided with a compression sock for the left arm.Due to the symptomatic cholecystolithiasis after an episode of an acute cholecystitis, indication for an elective laparoscopic cholecystectomy was derived.At the regional hospital, angio-MRI –4 of tHemostaseological consultation recommended pausing platelet inhibition over 7 d by means of “bridging” with low molecular heparin and inhibition of hyperfibrinolysis with drugs (tranexamic acid) until the 3rd postoperative day or depending on symptomatology and hemostaseologic monitoring. For perioperative antibiotic prophylaxis, Imipenem was used.The camera trocar was placed in the perumbilical region according to the left-sided manifestation of the vascular malformation known from the angio-MRI –4. UndHistopathological investigation  revealedPatient’s further clinical course was uneventful – she could be discharged with subjective well-being, no wound problems and excluded excessive activation of coagulation as well as stable hemogram on the 3rd postoperative day.KMS is characterized by a combination of (giant) hemangiomas of the skin or/and inner organs with the potential for a DIC. In this context, genetic cause is assumed, however, the exact cause is not known. Predominatly, women are affected with a prevalence of 0.7/100,000  mortali.Symptomatology is predominated by the giant hemangiomas preferentially distributed at the extremities, in particular, by a bleeding tendency due to platelet consumption in disseminated intravascular coagulation and possibly reaching to a threatening multi-organ failure.Diagnosis-finding is not possible by direct detection (exact cause unknown) but the symptom combination is considered unique . Usually, the disease does not progress, spontaneous healing is considered to be controversial.–laser-based surgical removal/excision,–embolization :–* risk of local necroses,–* tumour lesions (hemangiomas) do have supplying vessels;–external compression,–α-Interferons and corticosteroids:–* mitigate particularly the high propensity of recurrency;–Propanolol – mostly not sufficient as the only medication (or)–substitution of platelets only in bleeding tendency due to thrombocytopenia.The therapeutic spectrum comprises:The therapeutic success is assessed by recovery of hemostasis and elimination of tumor cells. In this context, the early definitive surgical therapeutic success of KMS results in a higher healing rate and lower rate of drug-induced adverse effects.Histopathological finding revealed a locally aggressive, severely varying cell growth involving several tissue layers . Both entities are positive for.–D2-40,–LYVE1 (and)–Prox-1 but negative for GLUT-1.Skin hemangiomas are associated with a mortality of 10 %, retroperitoneal tumor lesions of this entity – depending on the reference – up to 60 %. It has to be taken into account that this hemangioma site can be overlooked in physical examen in case of only mild complaints, by which mean mortality of 30 % can increase.Considering differential diagnosis, there are hemangiomas, which can occur in 3–5 % of infants and which can be classified as embryonal “tumor lesion” with endothelial proliferation in secondary formation of vascular lumens. Eighty % of the hemangiomas reduce in size until the 5th year of life. Histopathologically, blood-filled wide vessels with flat endothelial lining are characteristic, smaller hemangiomas are also treatable with propanolol.The presented case demonstrates representatively remarkable aspects of surgical decision-making with regard to an operation:In case of an indicated surgical intervention, the approach needs to be thoroughly planned  with regard to the hemangioma extension and the fact that the lesions can possibly affect the potential surgical field as well as to verify alternative options of the approach  – finally to avoid intra-/postoperative bleeding complications as good as possible and, thus, to maintain a high patient safety.As limitation, only experience of a single case related to the diagnostic and therapeutic, in particular, perioperative management could be obtained.Surgical diseases with coincidental KMS require close collaboration with a hemostaseologist and adequate preoperative diagnostic of coagulation status as well as appropriate perioperative management.Surgical intervention as well as to avoid severe bleeding under perioperative thrombosis prophylaxis and inhibition of hyperfibrinolysis with drugs (Tranexamsäure) prevent activation of the coagulation system and consumption of coagulation factors. Even a platelet transfusion is to be prevented due to, thus, a possible activation of coagulation system.In particular, elective setting allows to clarify the hemangioma extension and whether it is tangent to the potential surgical field  to derive reasonable modifications of the approach .–coincidental heart insufficiency due to high shunt volumes,–presence of a “Cirrhose cardiaque” (and)–infectious diseases due to massive transfusions–should be taken into account in planning elective surgical care.In addition,Supplementary MaterialClick here for additional data file.


Pheochromocytoma is a catecholamine-producing tumor characterized by hypertension, headache, tachycardia, excessive diaphoresis and angina. The thunderclap headache is so named because the pain strikes suddenly and severely. Although the symptoms of bladder pheochromocytoma are rather evident, the diagnosis of this rare neuroendocrine tumor can be missed. This study reports the case of a woman diagnosed with bladder pheochromocytoma who experienced thunderclap headache triggered by micturition and angina as an initial manifestation. This case study suggests that thunderclap headache and angina occurring concurrently with sudden blood pressure elevation during or immediately after micturition are important diagnostic clues for bladder pheochromocytoma. Pheochromocytoma, which is a catecholamine-producing tumor that causes secondary hypertension, arises from any location in which the chromaffin cells of the sympathetic nervous system are present.,In most cases, history-taking is the most important tool for preoperatively diagnosing pheochromocytomas that primarily originate from the bladder. An elevated 24-h urinary excretion level of epinephrine and norepinephrine with their metabolites is the confirmatory diagnostic tool.We report the case of a patient diagnosed with bladder pheochromocytoma who had recurrent TCH after micturition and angina.A 61-year-old woman was admitted at this time with recurrent headaches after micturition and angina. She had experienced syncope during micturition 15 years prior to admission, and she had undergone coronary angiography and ballooning for chest pain, with angina diagnosed three years later (12 years prior to admission). Two years later, in 2002, the patient was found to have a bladder tumor. Imaging was the only form of follow-up performed for the tumor, which remained the same size until 2007. For seven years prior to admission, she experienced recurrent TCH with hypertension immediately after micturition or during micturition, and treatment with antihypertensive medication had not resulted in improvement. There was no known family history of pheochromocytoma.The findings from physical examination at the present admission, including funduscopic findings, were unremarkable. Her blood pressure was 120/90 mmHg upon admission but became elevated to 230/110 mmHg after micturition. An electrocardiogram revealed a 2-mm elevation on lead V2-3 and T-wave inversion on V2-6 (data not shown). Coronary angiography did not reveal any significant stenosis but a 30% tubular eccentric narrowing feature was found in the proximal left anterior descending artery, which implied minimal coronary artery disease. An echocardiogram showed that the ejection fraction of the left ventricle was 72% with intact wall motion. We suspected bladder pheochromocytoma on the basis of her history and symptoms, such as headache related to micturition and angina.Her 24-h urinary biochemical analysis showed the following findings: vanillylmandelic acid (VMA), 5.93 mg/day ; metanephrine, 473 µg/day ; normetanephrine, 1508 µg/day ; epinephrine 10.4 µg/day ; and norepinephrine 171.3 µg/day . The blood sampling analysis showed the following results: dopamine, 0.042 ng/ml ; epinephrine, 0.153 ng/ml ; norepinephrine, 0.5 ng/ml ; renin activity, 0.32 ng/ml/h ; aldosterone, 61.5 pg/ml ; adrenocorticotropic hormone (ACTH), 46.3 pg/ml ; cortisol, 11.30 ug/dl ; fasting glucose, 103 mg/dl ; white blood cell (WBC) count, 6,200; hemoglobin (Hb) 12.2 ; and platelets 189,000 . A contrast-enhanced computed tomography (CT) scan of her abdomen and pelvis revealed a well-enhanced, solid mass of dimensions 3 × 3.2 cm, on the left lateral wall of the bladder . When thAfter preoperative treatment with an α-blocker (doxazosin) for two weeks, the patient underwent partial cystectomy under general anesthesia. Immunohistochemical analyses revealed that the tumor cells were positive for CD56, chromogranin and synaptophysin. No remnant tumor was detected on follow-up cystoscopy after surgery, and the patient’s symptoms subsided. She no longer experienced TCH triggered by micturition and angina.Histological examination confirmed the diagnosis of bladder pheochromocytoma with morphological features that indicated benign behavior. Macroscopically, the surgical specimen measured 3 × 3.2 cm in size and the lesion appeared yellow/brown in color and measured 3 cm at the cut surface . Microsc,,,,,,,,,,,,,,,,,,,,Paragangliomas are rare neuroendocrine neoplasms that develop from the germinal cells of the neural crest and usually involve the adrenal glands. Bladder pheochromocytoma is a particularly unusual form of paraganglioma that represents less than 1% of all pheochromocytomas.The clinical features of bladder pheochromocytoma are various and include hematuria and hypertensive crisis together with headache, angina, palpitation, hot flashes and sweating. These crises are typically induced by micturition or overdistension of the bladder, which leads to systemic release of catecholamines. However, not all bladder pheochromocytomas result in this syndrome and some show no hormonal activity. Signs of hormonal activity are seen in 83% of bladder pheochromocytomas in the literature.TCH is a hyper-acute, severe headache that reaches maximum intensity at onset. The term TCH was first used to describe the headache caused by unruptured intracerebral aneurysms, and patients frequently describe this type of headache as the worst headache of their lives.This sudden, severe headache peaks within 60 s and usually fades over several hours.The diagnosis of pheochromocytoma is supported by measurements of catecholamines and their metabolites metanephrine and normetanephrine, in plasma and 24-h urine samples.We used contrast-enhanced CT scans and iodine-MIBG scanning to diagnose and determine the location of the tumor. To date, no definitive biochemical or histological markers have been defined for distinguishing benign from malignant tumors. The only definitive proof of malignancy is the presence of metastasis to other organs.The PASS system, which is usually used to study adrenal gland pheochromocytomas,This case showed a PASS score of < 2/20, thus indicating benign tumor behavior. Microscopically, bladder pheochromocytomas produce submucosal or intramucosal masses; furthermore, they are covered by intact epithelium and are characterized by the presence of nests  or cords of cells delimited by fibrovascular connective tissue. The majority of the cells are medium-to-large and polyhedral, and have eosinophilic cytoplasm and ovoid nuclei. The unclear chromatin is dispersed and one or more nucleoli are generally present. Large bizarre nuclei may be seen.Bladder pheochromocytoma is an extremely rare disease.In our case, a detailed history that included headache-provoking factors and detection of the transient hypertension and angina induced by micturition provided early diagnostic clues for this rare disease. Through recognizing the relationship between headache and micturition, we were alerted to the possibility of bladder pheochromocytoma in this case. Common presenting features of bladder pheochromocytoma include symptoms of painless hematuria, diaphoresis, hypertension, angina, headache, palpitation and fainting after micturition, caused by catecholamine release.In this case, blood pressure elevation was apparent following micturition and activities with the capability of increasing the pressure inside the abdomen, which would thus push down on the bladder. Imaging studies are useful for planning definitive treatment because they can determine both the tumor location and whether multiple sites of involvement or metastases exist.In our case, the diagnosis was established by finding increased levels of catecholamine metabolites in the urine and CT imaging after clinical suspicion. The optimal treatment for pheochromocytoma is prompt surgical excision, because these patients are at significant risk of lethal complications such as hypertensive crisis.Extra-adrenal pheochromocytomas are more likely to recur and metastasize than their adrenal counterparts, thus making long-term follow-up with annual determinations of catecholamine production essential because it is not histologically feasible to differentiate benign from malignant pheochromocytomas.Long-term follow-up with regular biological and clinical examinations is also necessary in order to detect recurrence or metastasis. Although no standard criteria for malignancy exist from a histological perspective, appearance of a metastasis is a sign of malignancy.Of the 170 cases of bladder pheochromocytoma that have been reported so far, only 17 well-documented cases were malignant.In summary, this case serves as a reminder of the importance of thorough history-taking and clinical examination in making diagnoses. Nephrologists, endocrinologists, cardiologists and urologists should work together to minimize the risk of misdiagnosis. This case study suggests that TCH and angina occurring concurrently with sudden blood pressure elevation during or immediately after micturition are important diagnostic clues for bladder pheochromocytoma.


Breast metastases from neuroendocrine neoplasms (NENs) are considered infrequent. We report a case of a patient with ileocecal neuroendocrine tumor (NET) metastases to both breasts, for whom the initial clinical presentation was chronic diarrhea. Breast metastasis was initially suspected by a 68-Gallium DOTANOC positron emission tomography (PET)/CT and was confirmed by histopathology. We also performed a literature review in which we identified 116 cases of NENs metastatic to the breast reported so far. Most cases occurred in older women, were caused by NETs, and had the gastrointestinal tract as the primary site. Neuroendocrine neoplasms (NENs) are tumors derived from the diffuse neuroendocrine system, which is why they can originate from most organs ,2. HowevAround 20% and 38% of patients will have metastases at diagnosis and on follow-up, respectively ,5. This A 50-year-old female presented with chronic diarrhea, up to four times a day, Bristol 5-6, with abdominal pain. She had a family history of Hodgkin’s lymphoma, colon, and thyroid cancer, with no other relevant history. Her physical examination was unremarkable but occult blood in stool was detected by guaiac test. She underwent a colonoscopy, which identified a giant sessile polyp on the cecum. Polyp biopsy revealed a well-differentiated NET with a 4% Ki67 index and zero mitoses per 10 high-power fields (HPF). It was positive for chromogranin and synaptophysin, while it was negative for PAX8. Staging was made with a chest and abdomen CT which showed a neoplastic thickening of the cecum walls and an ovarian mass. An octreotide scan  was also performed, which showed overexpression of somatostatin receptors at the ileocecal valve. Further workup revealed increased levels of chromogranin A (CgA) and 5-hydroxy indoleacetic acid (5-HIAA), 477 ng/ml and 96.5 mg/24h, respectively, with no other remarkable findings.A right hemicolectomy, bilateral salpingo-oophorectomy, and peritoneal biopsies were performed, during which invasion of serosa in the ascending colon was identified as well as malignant-appearing lesions in the small bowel, mesentery, and both ovaries. Histopathology revealed a 3 X 3 cm tumor with full-thickness invasion of the colonic wall, as well as nodules in the peritoneum, mesentery, ileum, and ovaries. It was consistent with a well-differentiated grade 2 NET, with two mitoses per 10 HPF and a 4% Ki67 index. Immunohistochemistry showed positivity for chromogranin, synaptophysin, CD56, cytokeratin AE1, AE3, and CDx2, and negativity for TTF1  was performed one month after surgery and it identified somatostatin receptor expressing metastases in the liver, the recto-uterine ligament, and in a left breast nodule. A breast MRI revealed multiple, bilateral, well-circumscribed, oval-shaped nodules with homogeneous enhancement, which were classified as Breast Imaging Reporting & Data System (BI-RADS®) 4 Figure . PercutaFor two years, the patient remained asymptomatic, except for occasional episodes of low-intensity abdominal pain. In addition, she did not develop new findings on physical examination or on routine blood chemistry. Follow-up MRI confirmed a reduction in the size and number of breast nodules, while follow-up CT did not reveal new findings on the chest, abdomen, or pelvis. However, a somatostatin receptor expressing new mass adjacent to the colon anastomosis and uterine bed was detected on a follow-up 68Ga-PET/CT. Therefore, a locoregional relapse was considered and the octreotide LAR dose was increased to 40 mg. The patient has been receiving this treatment for 18 months, without symptoms, carcinoid syndrome, and without increased levels of CgA and 5-HIAA. New images are consistent with stable disease.The most common site of NETs metastases is the liver, followed by lymph nodes, bone, lungs and peritoneum ,13,16. OWe performed a comprehensive literature review in which we identified 116 reported cases of NENs metastatic to the breast, nearly all from case reports or case series  or the lung 27%)  that could lead to a wrong diagnosis ,21,24,25Imaging allowed us to suspect breast metastases. Most guidelines advocate the use of contrast enhanced CT or MRI of abdomen, pelvis and chest to rule out metastasis in NENs ,40. Of cOptimal treatment for breast metastases from NENs is not clear given the paucity of clinical data ,34, so tWe reported a patient with an ileocecal NET metastatic to both breasts, initially suspected from 68Ga-PET/CT findings. A comprehensive (non-systematic) review of all cases of breast metastases from NENs indicates that most cases correspond to NETs and originate in the digestive tract. Also, there appears to be no preferred laterality for breast metastases. A correct diagnosis is of paramount importance for proper treatment. To this end, functional imaging, and histology (supported by immunohistochemistry) are of great value. Finally, it must be emphasized that the real incidence of these cases is probably greater than previously considered.


Lumbar hernias are quite rare, even more so when primary or of spontaneous nature. These defects in the lumbar region demand a comprehensive knowledge of the anatomy of the lateral abdominal wall and paraspinal muscles. Given the proximity of bone structures, they can pose a surgical challenge when trying to achieve an ideal dissection and appropriate mesh overlap. The authors report the case of a primary Petit’s hernia that underwent an open anterior surgical approach with the use of a preperitoneal mesh. In addition to the described surgical technique, the article also aims to detail the diagnosis and anatomic classification of this rare pathology. Lumbar hernias are defects that occur through the lumbar region bordered by the 12th rib superiorly, the iliac crest inferiorly, the paraspinal muscles medially, and the external oblique muscle laterally [Primary lumbar hernias can occur through the superior lumbar triangle (Grynfeltt-Lesshaf) bordered by the 12th rib, the quadratus lumborum, and the interior oblique muscle. On the other hand, if they occur through the inferior lumbar triangle bordered by the iliac crest, the latissimus dorsi, and the external oblique muscle, then they should be referred to as Petit’s hernia .With only a few hundred cases reported, lumbar hernias are extremely rare defects . TherefoAn 83-year-old female patient, with a past medical history of hypertension and atrial fibrillation, presented to the emergency department. The chief complaint was constant and non-radiating pain in the right lumbar area for the past two days associated with a bulge. The patient denied any trauma, previous surgery, or changes in bowel movements.On physical examination, the patient was found to have a palpable and reducible mass on the right lateral abdominal wall. An ultrasound was performed for further evaluation. It revealed the presence of a right lumbar hernia with a sac containing adipose tissue and ascitic fluid. Neither signs of incarceration nor dilated intestinal loops were identified. The patient was discharged and elective surgery was scheduled.In order to better characterize the size and location of the hernia, thus allowing to formulate a proper surgical plan beforehand, a computed tomography (CT) of the abdomen and pelvis was performed. It showed a right inferior lumbar hernia with a neck size of 3.5 cm and a hernia sac measuring 8.1 cm by 4.9 cm (Figure After an explanation of the planned procedure, the patient gave consent and was put under general anaesthesia. She was then placed in a left lateral decubitus position Figure . A surgiOnce all the adhesions had been removed, the surgeons were able to reduce the hernia contents while keeping the integrity of the hernia sac. Only then, did they manage to dissect the preperitoneal space, allowing for a mesh overlap of at least 5 cm in all directions. A double-layer polypropylene macroporous mesh, 10 cm by 10 cm, was placed in the preperitoneal plane and anchored with slowly absorbable sutures. Even though the peritoneum was inspected for any defects, the surgeons chose to use a double-layer mesh as the peritoneum was thin at this level and they wanted to ensure there was a low risk of bowel adhesions. The muscle plane was then closed by reapproximating the abdominal wall under physiologic tension, restoring the normal anatomy and its function Figure . The patThe most common clinical presentation of a lumbar hernia is pain associated with bulging . AlthougCT scan of the abdomen and pelvis should be preoperatively performed. Not only is it a great imaging modality to confirm the diagnosis, it also allows the assessment of the anatomical relationships and surgical technique planning . AlternaWhen symptomatic, lumbar hernias should be surgically repaired . The useDespite lumbar hernias being so rare, all surgeons must have an in-depth understanding of their management approach, as they may present in an acute setting requiring an emergent repair. If possible, a preoperative CT is recommended since it can assist in the formulation of a surgical approach.A tailored approach should be chosen, according to the lumbar hernia’s features and the surgeon’s expertise. Patient referral to specialized abdominal wall centres should be considered.