Dermatofibrosarcoma protuberans (DFSP) is a rare soft tissue sarcoma. Neurofibromatosis type 1 (NF1) is a neurocutaneous syndrome that affects multiple organ systems. We present the case of a 47-year-old African American male with a two-year history of a slowly enlarging right lower back lesion. Upon workup, the 3 × 2 cm mass was biopsied confirming a diagnosis of DFSP. This was identified in concert with axillary freckling, café-au-lait spots, and pedunculated plaques evaluated with biopsy. The findings were consistent with neurofibromas, leading to a new diagnosis of NF1. The patient was definitively treated with wide local excision of the DFSP lesion without tumor recurrence over six years. DFSP has a favorable prognosis when treated with wide local excision and negative surgical margins. However, lesions may recur with inadequate margins. Although deferred in our patient, treatment with imatinib mesylate, a tyrosine kinase inhibitor, may be employed in the setting of advanced disease, metastasis, positive surgical margins, or irresectable locations. Imatinib has also been used to treat NF1. Hence, we posit that the concomitant presentation of these two disease entities in our patient highlights a potentially unique treatment with imatinib mesylate. To our knowledge, this is the second reported case of both entities in the same patient. Dermatofibrosarcoma protuberans (DFSP) is an uncommon, slow-growing, intermediate-grade tumor in the dermis and subcutaneous fat . It mostcollagen type 1 alpha 1 gene (COL1A1)on chromosome 17 and platelet-derived growth factor-beta polypeptide gene(PDGFB) that ultimately results in an overproduction of PDGF [NF1 gene, a tumor-suppressor gene that codes for neurofibromin type 1, is also located on chromosome 17 [Although the pathogenic mechanism of DFSP is not fully understood, the pathogenesis is thought to involve a chromosomal fusion secondary to translocation between chromosomes 17 and 22. Over 90% of patients diagnosed with DFSP harbor the t translocation that causes an upregulation of platelet-derived growth factor (PDGF) and subsequent tumor formation [osome 17 . Given oosome 17 . We theoosome 17 .A 47-year-old African American male with no significant medical history presented to his primary care provider for concerns of a two-year history of a slowly enlarging right lower back lesion with infrequent lower back spasms that were well-controlled with cyclobenzaprine and ibuprofen. The patient denied any systemic symptoms or other new or worsening dermatologic conditions. Physical examination was significant for a painless 3 × 2 cm mass located on the right lower back.Sonographic examination revealed a heterogenous and vascularized tumor that was originally thought to be a simple lipoma based on history and physical examination findings Figure . A magneWith the diagnosis of DFSP, the patient was referred to dermatology. At the dermatology clinic, the patient was noted to have at least six hyperpigmented patches consistent with café-au-lait spots scattered over the left frontal scalp, left chest, left flank, left lateral thigh, and left upper back. The physical examination further revealed left axillary freckling and multiple soft 1-2 cm pedunculated plaques consistent with neurofibromas located on the bilateral shoulders and left upper back. Biopsy of one of the lesions confirmed a neurofibroma without plexiform features. These findings confirmed a new diagnosis of NF1. The patient had no other systemic involvement and is now six years from DFSP resection and remains tumor-free.The traditional gold standard for the treatment of a DFSP lesion is wide local excision with clear margins. However, some recent studies suggest Mohs micrographic surgery is a better therapeutic option compared to wide local excision, with lower rates of local recurrence given the ability of DFSP lesions to be more widespread than clinically apparent . HoweverNF1 gene is a tumor-suppressor gene that codes for neurofibromin, and mutation may manifest in cutaneous tumors such as plexiform neurofibromas [Patients with plexiform neurofibromas in NF1 have also been successfully treated with imatinib mesylate ,5. The Nfibromas . Tumor ffibromas . Mouse sfibromas . Heightefibromas . Other cfibromas . Unlike fibromas .Similar to DFSP, plexiform neurofibromas are slow-growing tumors that do not respond well to chemotherapy . ImatiniThis case report illustrates a rare case of DFSP occurring in the context of a patient with NF1. While these two disease entities involve aberrations in chromosome 17 and respond in some capacity to treatment with imatinib mesylate as previously discussed, their pathogenesis is currently unrelated. Only one other case of DFSP in a patient with NF1 has been described in a four-year-old patient with a DFSP involving the left temple . American Society of Human Genetics Annual Meeting 2011; 11-15 Oct 2011). Despite a lack of literature demonstrating related pathogenesis, imatinib mesylate has been utilized in both disease entities and could be worthy of further consideration as therapy in patients with DFSP in combination with NF1 in the setting of promising therapeutic responses to each individually.


Sternal resection and anterior chest wall reconstruction techniques for malignant processes are not always standardized. We report an innovative method of sternal osteosynthesis in two patients, 65-year-old and 41-year-old women, with Ewing's sarcoma, and infiltrating thymoma, respectively. The first case manifested itself as a voluminous palpable mass while the second case was characterized for a paramediastinal mass widely extended to the anterior chest wall. Reconstruction with titanium mesh allowed the quick restoration of parietal stability, facilitating respiratory dynamic and recovery of patients. Ewing's Sarcoma (ES) is the second most frequent primary bone cancer in adolescents and is rarely found after the age of 30. It mainly affects the diaphyses of the long bones and, in only one-third of cases, the soft tissues. It probably originates from neural crest or mesenchymal stem cells and shows three variants of histology: classical ES (the most common), primitive neuroectodermal tumor (PNET) and atypical ES. Classical ES is genetically characterized by a translocation involving the EWSR1 gene locus22q12) and the ETS transcription factors with the formation of an aberrant chimeric protein (EWSR1-ETS) that promotes oncogenesis 2q12 and . In the Sixty-five year old female with palpable mass of the sternum. Lesion showed volumetric progression (doubling in volume in the last month was reported), causing anterior chest pain refractory to painkilling treatment.Computed tomography (CT) of the thorax revealed a lesion in the sternal body (5 × 4cm), involving the manubrium and the body of the sternum and the internal mammary vessels . ConsideAfter longitudinal skin incision in the midline of the chest and dissection of pectoralis major muscle in the midline sternal insertions, an intraoperative biopsy was performed which revealed a sarcoma. Ribs were resected at level of the chondro-sternal cartilages  and the sternum was removed with the chondro-sternal joints “en bloc.” The reconstruction of the anterior chest wall was carried out with a titanium mesh, modeled according to the characteristics of the thorax. The device was fixed by non-absorbable polyfilament stitches inserted between the mesh and the anterior arc of the ribs. The implant was strengthened through myoplasty with pectoral major superiorly and rectus abdominis inferiorly .No postoperative complication was noted. Patient was discharged 8 days after surgery and the definitive histological examination showed the classical Ewing's Sarcoma. The 40-day follow-up revealed the perfect mesh tightness with no signs of displacement  and paraThe patient is a 41 year old female, affected by myasthenia gravis, positive for anti-acetylcholine receptor (anti-AChR) antibodies and under medical treatment. She underwent thymectomy by median sternotomy in the 2 two thousand and10 associated with “en bloc” subtotal resection of pericardium, replaced with a polytetrafluoroethylene mesh. Histological examination showed a thymoma B2, with infiltration of the thymic capsule and the mediastinal adipose tissue. Patient underwent adjuvant radiotherapy on the thymic lodge, with a total dose of 50 Gy, and the oncologic follow-up was negative until 2016.Computed tomography (CT) of the thorax carried out in June 2017, due to cough and retrosternal weight, revealed a paramediastinal mass (6 × 4 × 2 cm), largely infiltrating sternal body, chondro-sternal joints, xiphoid process, and pericardial fat. Positron emission tomography/computed tomography PET/CT,  displayeThe patient was positioned supine. A vertical skin incision was performed. Ribs from the third to the seventh were bilaterally resected with a rib cutter. The sternal body was transversally divided with an oscillating saw. We revealed a neoplastic infiltration of the right upper pulmonary lobe. Therefore, a wedge resection by endostapler was performed in order to obtain “en bloc” tumor resection, including the sternal body with the chondro-sternal joints, lung and pericardial fat. The bony chest wall was stabilized using a 4 mm thick fenestrated titanium mesh , which was fixed to the ribs by prolene stitches and reinforced with a titanium bar in the central part of the prosthesis . PectoraThe patient was transferred to the intensive care unit under mechanical ventilation, and was extubated on postoperative day 1. No paradoxical movements were revealed, chest wall stability was assessed both in supine and seated position, and respiratory physiotherapy exercises were started. The postoperative course was free from respiratory complications. Histological examination confirmed a relapse of thymoma B2 (pT3Nx). A CT-scan 6 months after surgery confirmed that the titanium mesh was correctly in place. The patient complained of chest pain in the right hemithorax for some months, but no breathlessness.In case of anterior chest wall tumors involving bones, muscles and soft tissues, surgical resection with wide-free margins is the most relevant prognostic factor for disease-free survival, and often massive demolitions are required to obtain a radical resection . The steThe original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.Written informed consent was obtained from the patients for the publication of any potentially identifiable images or data included in this article.DD contributed to conception and design of the study. DD and DT wrote the first draft of the manuscript. AD, GZ, CD, and RC wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Type A thymomas comprise a homogenous population of neoplastic epithelial cells that are characterized by a spindle/oval shape without nuclear atypia. They may be accompanied by few non-neoplastic lymphocytes. Most type A thymomas are detected in the earlier Masaoka stages. Compared to other thymoma subtypes, they rarely metastasize or recur. There have been some reports of patients with type A thymomas with pulmonary metastasis; however, these thymomas were 20 mm or more in size. Herein, we report the case of a patient who underwent surgical resection for a small-sized type A thymoma (12 mm) with pulmonary metastasis.18F-fluorodeoxyglucose positron emission tomography/computed tomography revealed uptake in the anterior mediastinal tumor, but did not show a significant uptake in the pulmonary nodule. The patient underwent surgical resection on two separate occasions, and was diagnosed with an atypical type A thymoma and pulmonary metastasis. The TNM classification was p-T1aN0M1b stage IVb, and it was stage IVb according to the Masaoka staging system. No recurrence was observed during the follow-up.A 62-year-old patient presented with an abnormal shadow in the left lung on plain chest radiography during a medical checkup. Chest computed tomography revealed a 12-mm tumor in the anterior mediastinum and a 13-mm nodule in the left lower lobe. We report a case of the smallest type A thymoma with pulmonary metastasis. Pulmonary metastasis secondary to a type A thymoma should be considered even if the thymoma is small in size (< 20 mm). Type A thymomas comprise a homogenous population of neoplastic epithelial cells that are characterized by a spindle/oval shape without nuclear atypia. They may be accompanied by a few non-neoplastic lymphocytes. Type A thymomas are associated with a favorable clinical course. Compared to other thymoma subtypes, they rarely metastasize or recur , 2. Howe10. The anterior mediastinal tumor measured 12 mm in size, and there was no evidence of infiltration into the adjacent tissue  revealed uptake in the anterior mediastinal tumor (SUVmax = 1.5), it did not reveal significant uptake in the left lower-lobe nodule (SUVmax = 1.1)  revealed a nodule in the left lower lobe and a tumor with calcification in the anterior mediastinum. The well-defined hilar nodule of the left lung measured 13 mm and was located in Smax = 1.3) in the nodule. The nodule itself was considered a low-grade malignant tumor  and incomplete tumor resection , 9. In tPrevious reports have described pulmonary metastases of type A thymomas along with the thymoma sizes Table  3–8]. I–8. I3–8]This report presents a case of the smallest type A thymoma with pulmonary metastasis reported yet. Due to the smaller size of the thymoma, the pulmonary nodule was not identified as a metastatic lesion. In cases wherein the type A thymoma measures less than 20 mm, pulmonary metastasis should still be considered. Complete surgical resection is the most important prognostic factor in thymomas with local infiltration or metastasis . TherefoWe report the case of a patient who underwent surgical resection for an atypical type A thymoma and solitary pulmonary metastasis. In cases of a type A thymoma with a pulmonary nodule, pulmonary metastasis secondary to the thymoma should be considered even when the type A thymoma measures less than 20 mm, as in our case.


This paper describes a case of partial lack of the mesocolon in a 7-month-old colt. The foal was referred to the hospital with clinical signs of severe abdominal distension of a few hours duration. Because analgesics did not relieve pain, the foal remained uncomfortable, and distension of the abdomen increased; an exploratory laparotomy was performed under general anaesthesia in dorsal recumbency. The final diagnosis was confirmed intraoperatively. During exploration of the abdominal cavity, other problems like right dorsal displacement and torsion of the colon were recognized. Correction of all problems was completed, and the mesentery was sutured. Recovery from anaesthesia was uneventful. The foal was recovering well a few months after surgery, and the owner did not complain about the results of the treatment. Abdominal pain, described as colic, is a relatively common problem in equine practice . The mosCongenital disorders are reported in approximately 3.5% of newborn foals, of which only 3.1% are gastrointestinal anomalies. The most frequently described abnormality of this type is intestinal atresia ,8,9. BecIn the diagnosis of colic in foals, a rectal examination is not applicable due to their small body size. However, balloting, abdominal palpation, radiography of the abdomen and ultrasound examination may be helpful ,16. SomeThe mesenteric defects predispose the foal to increased intestinal mobility within the peritoneal cavity, which may lead to subsequent development of various types of colic ,14,15,17A 7-month-old purebred Arabian foal was referred to the clinic because of non-resolving colic symptoms. The first signs of abdominal discomfort appeared several hours earlier and were gradually progressing.The foal was restless in the stall, lying down and rolling. The abdominal distension was noted along with significant bloating in the right flank region. Clinical examination showed dry, pale-pink mucose membranes. Capillary refill time was prolonged to 4 s. The pulse rate was elevated to 90 beats per minute, and the respiratory rate reached 32 breaths per minute. Body temperature was within normal physiological limits (37.8 °C). Auscultation of the abdominal cavity revealed weakened peristaltic murmurs and increased amounts of gas in the right and left flank region.12/L, HGB 227 g/L, HCT 60.5%), and total protein was elevated (7.8 g/dL). Because of no improvement after analgesic treatment and the patient’s deteriorating condition, surgical intervention was chosen.Due to the size of the animal, a rectal examination was omitted. After the placement of a nasogastric tube, 8 L of reflux was evacuated. An ultrasound examination revealed a large amount of free fluid in the abdominal cavity. In the lower part of the left flank, bloated loops of small intestines were visualized, and in the right flank, the large intestine was observed to have a significantly thickened wall. External jugular vein catheter was placed, the blood sample was collected, and fluids  were administered. Blood count showed dehydration . After the foal was placed in dorsal recumbency, a median laparotomy was performed. A thirty-centimetre incision was performed in the white line through the umbilicus in both the caudal and cranial directions. Upon inspection of the abdominal cavity, the right dorsal displacement of the large colon with torsion was identified . The walAfter the restoration of the physiological position of the colon, the return of its motility and normal colouration were observed. The edges of the mesentery were refreshed and then sutured with PGA 2/0, using a simple continuous suture . The recmesenterium) has been classified as a separate organ of significant importance in gastroenterology [arteria mesenterica cranialis) runs [According to the latest reports, mesentery  runs . The venis) runs . The rotis) runs . Postnatis) runs . The patis) runs ,15. The is) runs .In human medicine, cases of internal hernias related to the mesenteric defect at its different segments have been described. The incidence of this anomaly among children is estimated at 0.2–0.9% . CongeniRegardless of the identified defect, due to the stabilizing and suspending function of this structure, all its anomalies predispose it to the development of colic related to secondary intestine displacement, torsion and volvulus; it is also not uncommon for the intestines to become strangulated within the gates of the internal hernia ,10,15,17Congenital anatomical anomalies should always be considered in the differential diagnosis of changes in foals and young horses. The presented case emphasizes the high importance of a quick decision on surgical treatment of diagnostic laparotomy in making a definitive diagnosis and increasing the chances of survival.


Introduction and Importance. Rosai-Dorfman disease (RDD) is a rare, benign type II histiocytosis characterized by the infiltration of S100+ histiocytes and emperipolesis. The disease may present in the lymph nodes , in extranodal sites, or in both nodal and extranodal sites. Among those patients who present exclusively in extranodal sites, only a minority of cases present in the soft tissue. Case Presentation. An 18-year-old female presented to orthopedic oncology clinic with a chief complaint of a mass located in her lower back. The patient underwent excision of the lumbosacral mass. Pathologic review demonstrated emperipolesis of lymphocytes and plasma cells within enlarged, eosinophilic histiocytes in a background of lymphoplasmacytic infiltration and collagenous stroma. Immunohistochemical staining demonstrated S100+ and CD163+ histiocytes, consistent with diagnosis of soft tissue RDD. Clinical Discussion. Histologically, RDD is generally characterized by emperipolesis—the presence of intact lymphocytes within the histiocyte cytoplasm—and a mixed infiltrate of S100+ histiocytes, mononuclear cells, plasma cells, and lymphocytes. Although soft tissue RDD may histologically resemble nodal RDD, soft tissue RDD also demonstrates some notable histologic differences including the lack of nodal architecture, the presence of increased fibrosis and collagen deposition, and generally fewer RDD cells. Conclusion. This case presentation demonstrates one few reports of isolated soft tissue RDD within the lumbosacral region without associated lymphadenopathy or skin changes and highlights the heterogeneity that still exists in the treatment paradigm of extranodal RDD. Rosai-Dorfman disease (RDD), also known as sinus histiocytosis with massive lymphadenopathy (SHML), is a rare, benign type II histiocytosis characterized by the infiltration of S100+ histiocytes and emperipolesis . The disWhile RDD most commonly presents in lymph nodes, RDD can also present in extranodal sites including the respiratory tract, skin, bone, genitourinary tract, central nervous system, bone marrow, visceral organs, and soft tissues , 2. AmonThe patient was informed that data concerning the case would be submitted for publication, and she provided consent.This case report has been reported in line with the Surgical Case Report (SCARE) 2020 criteria .An 18-year-old female presented to the orthopedic clinic with a chief complaint of a slow-growing mass located in her lower back for the past year. A firm, nontender large superficial soft tissue mass that was approximately 25 centimeters long and 12 centimeters wide overlying the lumbar spine was noted. The mass appeared to be mostly fixed to underlying structures. There were no skin or surface changes overlying her mass, and no lymphadenopathy was noted on physical examination. An MRI of the lumbar spine demonstrated a large, intermediate T1/T2-weighted lesion in the superficial subcutaneous tissue abutting the deep fascia of the lumbosacral spine . The patWith the pathology of the soft tissue biopsy, the differential diagnosis included a regressing RDD as well as a localized massive lymphedema. Although emperipolesis was not seen on the pathology specimen and cyclin D1 was only focally expressed, the leading diagnosis remained RDD. With these results, treatment options (including operative and nonoperative intervention) were discussed at length with the patient, who ultimately wished to proceed with surgical excision of her lumbosacral mass.The patient was brought into the operating room by the senior author (DML) and placed prone on the operating room table. A straight 20-centimeter midline incision was made over the mass. Dissection was carried to the lesion, which was noted to be fibrous in nature. The mass was subsequently meticulously shelled out with electrocautery and sent to pathology. The wound was closed in several layers—with a deep Jackson-Pratt (JP) drain left in the wound bed—with 0 Vicryl  for the deep fascial flaps, 2-0 Vicryl  for the subdermal layer, and a running 3-0 Monocryl  subcuticular closure. The wound was subsequently dressed with a PREVENA wound vac . A pressure bolster was placed on top and an abdominal binder used for reinforcement. The patient's postoperative course was uneventful, and she was not placed on any activity restrictions. The JP drain was removed on the second postoperative day, and the patient was subsequently discharged.The resected mass was unencapsulated but well defined with a tan-white, firm cut surface . A microAt the patient's two-week postoperative visit, she was doing well without any complaints. The patient had developed a large seroma at the operative site, but the incision had healed well. At the patient's six-week postoperative visit, she reported less pain and increased motion of her lumbosacral spine. The seroma was still present, but it remained soft and nontender. Nine months following her operation, an MRI of the lumbar spine  demonstrAlthough nodal RDD is most common form of the disease, 43% of RDD cases involve at least one extranodal site, with 23% of cases presenting exclusively in extranodal sites , 2. AmonThe diagnosis of RDD was determined based on the radiological, gross, histological, and immunohistochemical findings. Histologically, RDD is generally characterized by emperipolesis and a mixed infiltrate of S100+ histiocytes, mononuclear cells, plasma cells, and lymphocytes. These histiocytes, also called “RDD cells,” contain abundant clear to pale eosinophilic cytoplasm and small, central nuclei with eosinophilic nucleoli , 8, 9. HThe differential diagnosis for RDD includes Langerhans cell histiocytosis (LCH), soft tissue fibrohistiocytic lesions, histiocytic sarcomas, and myxoinflammatory fibroblastic sarcomas. LCH may occur in similar sites as RDD, but these lesions exhibit Langerhans cells with grooved nuclei, eosinophils, and Birbeck granules . AdditioAlthough a treatment strategy for patients with extranodal RDD has been described , at thisRDD is a rare, benign type II histiocytosis characterized by emperipolesis—the presence of intact lymphocytes within the histiocyte cytoplasm—and a mixed infiltrate of S100+ histiocytes, mononuclear cells, plasma cells, and lymphocytes. Although soft tissue RDD may histologically resemble nodal RDD, soft tissue RDD also demonstrates some notable histologic differences including the lack of nodal architecture, the presence of increased fibrosis and collagen deposition, and generally fewer RDD cells. This case presentation demonstrates one few reports of isolated soft tissue RDD within the lumbosacral region without associated lymphadenopathy or skin changes and highlights the heterogeneity that still exists in the treatment paradigm of extranodal RDD.


Kaposiform hemangioendothelioma (KHE) is a neoplasm originating mainly from vessels and has a mild proclivity for malignancy. This neoplasm mainly involves somatic soft tissue and retroperitoneum. Histological findings include a nodular arrangement of oval-to-spindle cells containing pale cytoplasm. Vascular spaces are in the form of slit-like channels in which red blood cells are evident. Here, we report the case of a two-year-old male who presented with Erb’s palsy and a mass lesion in the right humerus. Tissue biopsy features were compatible with KHE. Kaposiform hemangioendothelioma (KHE) is a rare, often deep-seated, vascular neoplasm, mainly found in infants and children. The tumor is characterized by lobular infiltrates of capillaries and spindled endothelial cells. KHE commonly affects the skin, deep soft tissues of extremities, head and neck, trunk, and retroperitoneum; less commonly, the mediastinum, spleen, bone, and testis are affected . KHE mayTreatment options vary and include surgical excision with wide margins and adjuvant chemotherapy in various combinations. Very few case reports of KHE involving long bones have been published worldwide. Here, we report the first case of primary bone KHE from Pakistan.A two-year-old male child presented in the outpatient department with an abnormal position of the right arm. A mass on the shoulder joint was palpated at that time, but no cutaneous changes were seen. The patient appeared to be in no discomfort or pain; however, his parents reported that he pulls the affected arm with his left arm often at night, which may be due to pain. On magnetic resonance imaging (MRI), there was cortical destruction and associated periosteal reaction Figures -1C. The Tissue biopsy showed bony tissue with a vascular lesion that comprised nodules of spindled endothelial cells forming elongated slit-like, lumina-containing erythrocytes. Curving around these epithelioid nodules were pericytes surrounding platelet-rich microthrombi. No necrosis or mitotic activity was seen Figures -2D.On immunohistochemistry, podoplanin (D2-40) and ETS-related gene (ERG) were positive in neoplastic cells and vascular channels, while CD-99 and human herpesvirus 8 (HHV-8) were negative Figures -3D.Based on the morphological features and immunohistochemistry findings, a final diagnosis of KHE was rendered. The patient was referred to the oncologist who started chemotherapy with vincristine.The term Kaposiform means Kaposi’s sarcoma-like which has spindle pattern cells. KHE is a neoplasm originating mainly from vessels and has a moderate malignant capacity. It can occur in any region such as the retroperitoneum, thoracic spine, appendicular skeleton, and, rarely, visceral organs. In our case, the lesion was present on the proximal end of the right humerus and was involving the bone itself. Although it could be seen on imaging, a definitive diagnosis was made on tissue microscopy and immunohistochemistry. The other differential diagnoses included spindle cell hemangioma, verrucous hemangioma, infantile hemangioma, and Kaposi sarcoma . Ewing sEven when KHE is not associated with any cutaneous lesion, it can be dangerous in terms of clinical outcome and disease progression . KHE is On MRI, a lesion was seen which was looking aggressively infiltrative and ill-defined and was involving the right humerus. This lesion was seen as a hyperintense mass arising from the metadiaphysis of the right humerus. The cortex of the bone was eroded, and an associated periosteal reaction was present. The lesion measured 3.2 × 3.1 × 7.1 cm . The MRI scan also showed numerous enlarged cervical lymph nodes on the right side. Light microscopy showed irregular nests of undifferentiated vascular channels invading the surrounding tissue. According to the literature, on electron microscopy, incomplete basement membrane and intercellular gaps can be seen . PositivSirolimus and vincristine are used in the chemotherapeutic management of KHE. The literature shows that sirolimus is very effective in the treatment of KHE . VincrisKHE is a very infrequently occurring neoplasm of vascular origin with moderate malignant potential that may or may not be present along with KMP. This lesion can be present in various areas of the body with or without cutaneous involvement. Hence, it should be kept in mind when differential diagnoses are made in the context of vascular tumors in children.


Enchondromas originating in the epiphyses of long bones are rare and epiphyseal osteoid osteomas are also uncommon. Diagnosis can become elusive when enchondromas or osteoid osteomas occur in atypical locations and present with nonspecific clinical and imaging characteristics.We report a case of epiphyseal enchondroma of the left proximal femur in a 15-year-old girl with a 2-month history of left lower extremity pain. Preoperative CT displayed thickened cortex in the anterior surface of the left proximal femur with specks of calcification and inhomogeneity of the adjacent bone marrow cavity. She was diagnosed with osteoid osteoma. Postoperative pathological examination of surgically excised specimens revealed a diagnosis of enchondromas.Our case highlights that enchondroma should be considered in lesions of the epiphysis. Major clinical manifestations included lumbago and radiating pain along the femoral nerve distribution with decreased sensation and paresthesia of the left lower extremity. She also had limitation of motion of the lower limb, which was relieved after rest. The patient visited a local hospital in July 2018 and received no definite diagnosis. She was given vitamins and calcium supplementation, but her pain was not alleviated. In August 2018, her pain worsened and swelling also appeared in the left thigh. She visited the Department of Neurology of our hospital on September 6, 2018. Electromyography revealed injury of the left femoral nerve; she received mecobalamin and vitamin B12, but pain failed to improve. The patient had no history of trauma. Her medical history was unremarkable.Physical examination at admission revealed firm, tender mild swelling of the left proximal thigh, with normal overlying skin. Adduction and flexion of the left hip were limited and elicited pain. There were no other remarkable abnormalities. Plain radiographs showed increased density of the greater trochanter of the left femur Fig. . CT dispThe patient underwent surgical exploration. Soft tissue swelling was observed adjacent to lesion in the proximal femur and massive granulation tissues were present in the medullary canal. The periosteum, and the granulation tissue and cartilage tissue were excised by curettage and pathological study revealed thickening of the periosteum and bone Fig. . Iliac cEnchondromas originating in the epiphyses of the femur are very rare. In the current report, we describe a case of epiphyseal enchondroma of the proximal femur in a 15-year-old girl that was erroneously diagnosed as osteoid osteoma. Both conditions rarely occur in the epiphysis of the femur and have clinical and radiological manifestations that make diagnosis elusive. Lack of thorough understanding of the two disease entities, especially in an atypical location, indefinite radiological findings and misleading clinical and radiological features of the current case led to our erroneous diagnosis of the disease.Osteoid osteoma is a common benign tumor among young boys and adolescents , 7, typiThe osteolytic lesions of enchondromas manifest as local bone destruction on radiographs, with a well demarcated border and specks of calcification . EnchondOsteosarcoma, clear cell chondrosarcoma, chondroblastoma, giant cell tumor are often emphasized as differential diagnoses of lesions in the epiphysis  as epiph


Radial tunnel syndrome (RTS) is a rare condition resulting from posterior interosseous nerve  compression, within the radial tunnel. Lateral epicondylitis as a possible aetiology for RTS has been previously described. Here we report a 64-year-old female, with history of scalp psoriasis, who presented with pain over the lateral aspect of the left elbow and proximal forearm for one year, and decreased sensation over the lateral aspect of distal left forearm including the hand for 20 days. Examination revealed enthesitis at left lateral epicondyle, which was confirmed on magnetic resonance imaging. Touch and pain sensations were reduced over the left thumb, index finger, lateral aspect of the hand and distal forearm, and forearm pain was exaggerated with restricted extension of the wrist and third finger. Rheumatoid factor, anti-nuclear and anti-neutrophil cytoplasmic antibody were negative, and nerve conduction study were normal. A diagnosis of RTS as a possible complication of psoriatic enthesitis was suggested, and patient showed good response to non-steroidal anti-inflammatory drugs. Descriptions about RTS in the literature are ambiguous. Possible etiological factors for RTS are trauma, tumours with mass effect, and elbow arthritis. arrow). Tenderness was elicited over the left lateral epicondyle and five centimetres distal to it. Forearm pain was exaggerated with restricted extension of the wrist and third finger. Touch and pain sensations were reduced over the left thumb, index finger, lateral aspect of the hand and distal forearm. Power at all the joints including interossei, lumbericals, thenar, and hypothenar muscles was normal.A 64-year-old female with history of scalp psoriasis for more than 30 years, presented with pain over the lateral aspect of the left elbow and proximal aspect of the left forearm for one year, and decreased sensation over the lateral aspect of distal left forearm including the hand for 20 days. Physical examination showed psoriatic lesions over the scalp ( arrow). A diagnosis of RTS as a possible complication of psoriatic enthesitis was made, and patient showed good response to non-steroidal anti-inflammatory drugs.On evaluation, erythrocyte sedimentation rate and C-reactive protein were normal. Rheumatoid factor, anti-nuclear and anti-neutrophil cytoplasmic antibody were negative. Radiographs of the left elbow, electromyography (EMG), and nerve conduction velocity (NCV) studies were normal. Magnetic resonance imaging (MRI) confirmed enthesitis at left lateral epicondyle , the fibrous edge of ECRB, the Frohse arcade , and the distal edge of supinator muscle.1Radial tunnel is a space in the proximal forearm, extending from the radiocapitellar joint to the distal margin of supinator muscle, bordered laterally by the brachioradialis, extensor carpi radialis brevis (ECRB) and longus muscles, and medially by the biceps and brachialis muscles.1 However, both these conditions can coexist,3 and lateral epicondylitis has also been considered as an etiological factor for RTS.2RTS presents with pain in the dorsolateral aspect of the proximal forearm. Sometimes sensory disturbances are also found along lateral aspect of the hand and distal forearm, without any motor weakness. RTS is diagnosed solely on the clinical signs after excluding other aetiologies. The closest differential diagnosis is lateral epicondylitis, where the site of tenderness is on the lateral epicondyle. Whereas, tenderness in RTS is elicited around five centimetres distal to the lateral epicondyle.4 Enthesitis is one of the entry components of the CASPAR (ClASsification for Psoriatic Arthritis) criteria.5 Lateral epicondylitis/enthesitis in the present case was an early manifestation of PsA disease spectrum, and RTS was possibly a complication of this process. However, the possibility of these two conditions coexisting cannot be excluded. Further observations are required to strengthen the association of RTS and lateral epicondylitis/psoriatic enthesitis.Enthesitis is inflammation of tendons and ligaments at their insertion into bone. It is the hallmark of psoriatic arthritis (PsA), with a prevalence of 35–50%.6Making a diagnosis of RTS remains a difficult task due to lack of confirmatory tests. Although MRI, EMG and NCV are usually normal in these patients, these helps in excluding other aetiologies of the elbow/proximal forearm pain. Initial step of management of RTS remains non-surgical methods which include anti-inflammatory medications, physical therapy, wrist immobilisation using a splint or cast, and modification of activities such as avoiding wrist flexion, forearm pronation and prolonged elbow extension. Surgical decompression is the next option if there is no response to these non-surgical treatment methods.The present case emphasises on the importance of determining the exact location of pain by detailed clinical examination in a patient with elbow and/or proximal forearm pain.Written informed consent was obtained from the patient.


The differentiation of solitary intra-axial hematomas from hemorrhagic neoplasms based on their magnetic resonance imaging (MRI) features is challenging. The treatment and prognosis for these two disease entities are vastly different and distinction between them is often based on MRI findings alone. The aim of this study was to describe the 1.5 tesla MRI features of canine intra-axial hematomas and correlate these findings with the evolution of hemorrhages described in human brains. Retrospective evaluation of patient details, clinical signs, and MRI findings of dogs with intra-axial hematomas that were histopathologically confirmed or determined via repeat MRI study and/or resolution of neurological signs. Ten dogs met the inclusion criteria. All 10 hematoma lesions were determined to be 2–7 days in age. On MRI, all 10 hemorrhagic lesions were comprised of two distinct regions; a relatively thin T1-weighted (T1W), T2-weighted (T2W) and gradient echo (GRE) hypointense (9/10) peripheral border region and a large central region that was heterogenous but predominantly T1W, T2W and GRE hyperintense (8/10). The peripheral border region was complete in its integrity in all 10 cases on T2W and GRE sequences. Contrast enhancement was present in (6/10) hematoma lesions and was always peripheral in nature with no evidence of central enhancement associated with any of the lesions. An intra-axial hematoma should be suspected in solitary hemorrhagic space occupying lesions that have a complete hypointense peripheral rim, elicit a peripheral contrast enhancement pattern, and display the expected temporal pattern of hematoma evolution. The smorrhage –6. Consent echo T* and/or The MRI appearance of intracranial hemorrhage can be complex and has different signal intensity patterns, which depend on several factors including: (a) intrinsic factors  ; (b) bioAngiostrongylus vasorum infection ; (b) the MRI study confirmed a solitary hemorrhagic space-occupying intra-axial lesion, and subsequently; (c) there was histopathological confirmation of a benign hematoma , or a follow-up MRI that indicated resolution or marked improvement of the previous lesion with only supportive treatment, and/or the patients clinical signs resolved with only supportive treatment. In cases where diagnosis of an intra-axial hematoma relied upon clinical resolution alone, a sufficient follow-up period was defined as 3 months after first presentation. Patients were excluded if the MRI study or medical data was incomplete, if they had received cytotoxic therapy , if they had a suspected or known history of trauma, if they underwent repeat MRI and this revealed a worsening of the severity of the intracranial lesion or the lesion remained unchanged, and if insufficient clinical follow-up was available.In this retrospective multicenter descriptive study, medical records of three different referral institutions were reviewed to identify dogs that had intra-axial hematomas on MRI. Ethical approval was granted by the Ethical Review Committee of the University of Nottingham School of Veterinary Medicine and Science. Patient inclusion criteria were set as: (a) a complete brain MRI study was performed  and clinical/neurological findings at re-examination.MRI protocols and sequences varied between institutions, but all MRI examinations were completed with dogs under general anesthesia, using high-field-strength magnets: 1.5 Tesla . Anesthetic protocols were varied and adapted to individual patients by the attending anesthetist. The MRI studies were reviewed by three observers independently [two ECVDI certified veterinary radiologists (AH and IC) and a ECVDI resident (JW)], followed by collective consensual evaluation. All available follow-up MRI studies were also evaluated. Reviewers were aware that all dogs had intra-axial hematomas. The following features were assessed on image evaluation:The location of the lesion, and the distribution of the lesion within either the gray or white matter.Lesion margination was characterized subjectively as well or poorly circumscribed.Lesion shape was defined as spherical, ellipsoidal, or irregular.* or SWI.The signal intensity of the lesion in each sequence was evaluated both at the lesions periphery and at its center and graded as hypointense, isointense, hyperintense, or mixed intensity, relative to cerebral gray matter on T1W, T2W, and T2If there were distinct regional differences in the signal intensity between the periphery of a lesion and its center, then the diameter of the peripheral region was measured at its widest point.The degree of contrast enhancement was subjectively categorized . Furthermore, the pattern of enhancement was also noted .Perilesional edema was graded as absent, mild (present in the area immediately adjacent to the lesion), moderate (extending beyond the area immediately adjacent to the lesion) or marked (involving the entire hemisphere). The amount of edema was determined by the extent of abnormal hyperintensity on T2W images, which was T1W iso to hypointense, non-contrast enhancing, and exceeded the boundary of the hematoma.Any mass effect  was subjectively graded as mild, moderate, or severe.Finally each reviewer estimated the age of each lesion  based on its signal intensity pattern and how this correlated to temporal hemorrhage evolution according to previously published data in dogs  Table 1Table 1.All MRI examinations were assessed using a PACS workstation DICOM viewer . All measurements were performed collectively during group evaluation.Ten dogs met the inclusion criteria. These included four Crossbreeds, two Staffordshire Bull Terriers, a Dachshund, a Border Collie, a Jack Russell Terrier, and a Yorkshire Terrier. Of these, five were neutered females and five were neutered males. The age of the dogs varied between 7 and 13 years (median age 9.8 years) and the weight varied between 5.4 and 25.6 kg (median weight 15.72 kg).The presenting neurological signs for each patient are summarized in A.vasorum. One patient was diagnosed with systemic hypertension on presentation (Case 9) via repetitive non-invasive indirect estimations of systolic blood pressure using a doppler devices. The hypertension was considered idiopathic in nature due to concurrent normal hematology, serum biochemistry, and urinalysis results. Aside from this patient, an underlying etiology responsible for the intracranial hemorrhage was not identified in the remaining cases. Records of blood pressure were not available in the remaining cases. Medical treatment prescribed to the patients included: prednisolone (5/10), fenbendazole (3/10), levetiracetam (4/10), and dexamethasone (2/10). All treatments were discontinued in all patients within 3 months of the initial presentation.Hematology and serum biochemistry results were available for all 10 patients. Hematologic abnormalities included mild neutrophilia (2/10), increased hemoglobin concentration (1/10) and mild anemia (1/10) and in all other cases the hematology results were normal. The only biochemical abnormalities identified were increased alanine aminotransferase (2/10), increased alkaline phosphatase (1/10), and hyperglycemia (1/10). All patients had clotting profiles within normal limits. All patients tested negative for Histopathological confirmation of the diagnosis of a benign intra-axial hematoma was achieved in (2/10) of the patients. A diagnosis of a benign hematoma was made in (4/10) patients based on the results of a follow-up MRI study, which was also accompanied by neurological improvement. In the remaining four patients diagnosis was met by clinical follow-up alone, all these dogs were reported to have shown marked neurological improvement within 1 month after first presentation. On subsequent re-evaluations after 3 months all dogs were considered neurologically normal.In all 10 dogs the hematoma lesion was located within the forebrain and in 9/10 the lesion was localized to the white matter. The most frequently involved forebrain substructure was the frontal lobe , followed by the parietal lobe , the thalamus , and then single cases of occipital and temporal lobe involvement . All 10 Contrast enhancement was evident in (6/10) hematomas and absent in 4/10) cases. When present the enhancement was always present at the periphery of the hematoma , 4. Enha/10 casesFluid-fluid level lesions were evident within the central portions of the hematomas in Case 3 and 4. In Case 3 this feature manifested as the dependent and ventral region being T2W hyperintense and T1W hypointense, and the dorsal region being T2W hypointense and T1W isointense . In CaseFour out of the ten dogs had repeat MRI studies; case 2, case 4, case 8 and case 10 at 207, 32, 46, and 83 days following their initial MRI study, respectively . On evaluation of these follow-up studies, it was observed that in all four cases the lesions had markedly reduced in volume, were hypointense in all sequences, and both perilesional edema and contrast enhancement were absent .*W hypointense peripheral border region that is also T1W hypointense but thinner, and a large predominantly T2W hyperintense central region. Additionally, intra-axial hematomas were shown to have mild to moderate peripheral contrast enhancement with no central enhancement. Furthermore, hematomas were frequently associated with mild to moderate mass effect and mild to moderate perilesional edema. These findings largely reflect the MRI characteristics of intra-axial hematomas observed in humans.This study demonstrates that in the period of 2–7 days post hemorrhage, intra-axial hematomas most commonly appear as ordered dichotomous lesions on MRI images consisting of a complete T2W and T2The fact that all hematoma lesions in this study demonstrated a uniform regional duality consisting of a complete thin peripheral region and a large central region is in direct agreement with human studies , 29. ThiWhen considering the predominant blood breakdown products within the hematoma lesion it is important to bear in mind the peripheral to central nature of hematoma maturation. The “oldest” or most advanced breakdown products will be present at the periphery of the lesion. When considering the likely constituents of the peripheral border in the hematoma lesions in our study, this factor was considered alongside the hypointense signal of this region in all sequences and the pattern of signal intensity within the central region that showed loss of the magnetic susceptibility effect (indicating the presence of extracellular methemoglobin). Consequently, the peripheral border had to be ferritin and hemosiderin and not a less advanced product like deoxyhemoglobin that would have also satisfied the signal intensity pattern seen.* weighted hypointense peripheral region noted in all 10 cases. This is in agreement with previous human literature which also found that the presence of a complete peripheral hypointense rim in a hemorrhagic lesion was associated with benign intra-axial hematomas  rather than the 7–14 day period (late subacute phase) following the hemorrhage . CompartTwo hematomas had regions where a fluid-fluid interface was evident. This feature in intracranial hemorrhage has been associated with coagulopathic disorders . HoweverThe underlying etiology for the development of the intracranial hematoma was not established in 9/10 cases. This is not uncommon with a previous study observing that 32 of 43 dogs (74%) with a solitary intracranial hematoma had no concurrent underlying medical condition and the underlying etiology could not be established . The undThe principal limitation of this study is the small number of cases where gold-standard histopathological confirmation of a hematoma was available. Nonetheless, resolution of the clinical and neurological signs, long-term clinical follow-up, and a repeat MRI study (where available) for the remaining cases provides a reasonable assertion that these lesions were attributable to simple hematomas rather than hemorrhagic malignancies. The subjective and qualitative nature of assessment of multiple factors on the MRI studies  may have also led to inaccuracies. However, the individual and collective group assessments of the MRI findings may have mitigated these to a degree. Additionally, the study was limited by the low numbers present in the sample population, but this reflects the uncommon occurrence and/or identification of solitary benign intra-axial hematomas in the clinical setting. Serial monitoring of the hematoma lesions with MRI over time would have been rewarding to document the characteristics of more chronic phases of hematoma evolution, but this was not viable in the clinical setting. Finally, it must always be kept in mind that the imaging characteristics of hemorrhage are linked to magnetic field strength with higher magnetic field strengths enhancing susceptibility effects and related signal loss. Consequently, this changes the appearance of hematomas at 1.5 T relative to lower magnetic field strengths because more profound hypointensity will be shown in the presence of deoxyhaemoglobin, hemosiderin, or other compartmentalized paramagnetic material .In conclusion, this study suggests that a benign intra-axial hematoma should be considered as a primary differential when a solitary intra-axial hemorrhagic lesion with a complete thin hypointense peripheral rim, a variable intensity central region, and a peripheral enhancement pattern is identified on MRI. Accurately differentiating between benign intra-axial hematomas and hemorrhagic tumors using MRI is challenging and can be stressful for all those involved in the clinical decision-making process, particularly given that euthanasia or an expensive treatment could be chosen if a malignancy is suspected. This is further compounded by the fact that a definitive diagnosis is seldom achieved for such lesions antemortem. In this scenario, depending on the patient's clinical status and severity of the neurological signs, the authors propose that it would be prudent to monitor the patient for further improvement or deterioration combined with follow-up advanced imaging, if feasible. Further studies could also be conducted evaluating the potential inverse MRI characteristics of solitary intra-axial hemorrhagic neoplasms in dogs.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The animal study was reviewed and approved by Ethical Review Committee of the University of Nottingham School of Veterinary Medicine and Science. Written informed consent was obtained from the owners for the participation of their animals in this study.IC conceived of the presented idea. JW, IC, and AH performed the image evaluation. JW wrote the manuscript. All authors contributed cases and discussed the results and contributed to the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Background: Squamous cell carcinoma (SCC) is one of the most common neoplasms affecting the oral cavity and the face. Its more differentiated forms may be associated with human papilloma virus (HPV) infection. Case report: In this paper, we report the case of an 86-year-old patient with a well-differentiated SCC of the lower lip associated with HPV treated with surgery with a non-complete histological resolution. Imiquimod 5% cream was applied on the surgical scar once a day for two weeks and then once a week. Two years after SCC removal, no relapse has occurred. Conclusions: Topical imiquimod may be a safe and effective treatment after surgery in SCC of the oral area to reduce the risk of relapses. Head and neck cancer is a term used to define malignant tumors developing on the lips, mouth, nose, and other head and neck areas . The majAn 86-year-old male came to our attention seeking medical treatment for a growing lesion of the lower lip. The patient previously treated the lesion with topical antibiotics and steroids, with no improvement in the condition. The lesion was exophytic and with a warty appearance . SuspectThe histopathological examination confirmed the diagnosis of SCC, describing a histologically well-differentiated lesion. HPV typization of the lesion showed positivity for HPV 16 after a conventional polymerase chain reaction assay. The margins of the lesions were not microscopically clear. Considering the patient’s old age and the unwillingness to undergo another surgical procedure, the patient, one month after surgery, was sent to the Dermatological Unit of Magna Graecia University, Catanzaro, for examination . The patImiquimod is a stimulator of the innate immune system that activates toll-like receptors. Cells activated by imiquimod via toll-like receptor-7 secrete cytokines as interferon-α, interleukin-6, and tumor necrosis factor. Imiquimod may activate various immune cells, such as natural killer cells, macrophages, and lymphocytes ,11. ThisDue to its high aggressiveness, SCC should always be surgically treated. In cases where surgery is not possible, or in case of comorbidities, other treatments, such as radiotherapy or chemotherapy, are usually proposed ,14. AlthWester et al. reported an 87-year-old female patient affected by an oral SCC twice treated with surgery and subsequent radiotherapy. The lesions reoccurred after treatment and, due to the old age of the patient, a treatment with imiquimod 5% cream was applied with a cotton swab once a day on the affected area for two weeks, and then once a week. Two months after starting therapy with imiquimod, a biopsy in the treated lesions showed no sign of SCC. Four years after the beginning of local applications with imiquimod, no recurrence of the tumor was present . We usedAlthough precancerous lesions of the area, such as actinic cheilitis, have been treated with various topical drugs, such as actixicam, ingenol mebutate, diclofenac, imiquimod, fluorouracil, and photodynamic therapy ,19,20, tWe believe that combining traditional surgery techniques with a topical treatment such as imiquimod or photodynamic therapy may help reduce the relapse of this condition, as the recurrence of SCC is a common problem.Limitations to this case include the fact that a biopsy of the region was not performed before or after the treatment with topical imiquimod and that incompletely removed SCC may not relapse independently of the applied topical therapy. However, we believe, due to the location of the condition, that imiquimod contributed to the absence of the condition’s relapse. In addition, testing for oncoproteins E6 and E7 was not performed, so the association of HPV 16 with the development of SCC, although probable, is not certain.This case suggests that the combination of surgery and subsequent application of topical 5% imiquimod may reduce the risk of relapses when surgery has not been radical, proposing an alternative treatment in elderly patients or in areas where surgical enlargement may be cosmetically unacceptable, has been refused, or is not possible. Testing SCC for HPV positivity may help select the better treatment available, as HPV-related SCC is usually less invasive . This ki


Dural chondrosarcoma is a very rare intracranial tumor, given that meninges do not normally contain cartilaginous tissue from which it can originate. We present a case of primary extraosseous dural chondrosarcoma.A 48-year-old woman presented to our tertiary center neurosurgery consultation with progressive headache, vomiting, vertigo, and gait instability of 5 months’ duration.An initial brain CT revealed a large parietal mass with gross calcifications and subtle hyperostosis of the inner table. Subsequent brain MRI showed a heterogeneous expansive lesion with a honey-comb enhancement.Discussion of intra- or extra-axial location was warranted, and finally, initial presurgical suspicion of meningioma arose although some atypical imaging features were detected. The differential diagnosis included solitary fibrous tumor–hemangiopericytoma and dural metastasis.Total resection of the lesion was performed, extra-axial origin was confirmed, and pathology resulted in a primary dural chondrosarcoma.The importance of this case presentation lies in the unusual nature of the final diagnosis, the brief literature review and differential diagnosis with emphasis on imaging pearls, as well as the useful reminder for physicians to consider less frequent diseases when key findings do not unambiguously lead to the usual suspects. Chondrosarcoma is a malignant tumor characterized by the formation of a cartilaginous matrix. It is usually located in the appendicular skeleton; however, in few cases it is found inside the skull and even more rare it has a meningeal origin where cartilaginous tissue is usually absent , 2. We pWe report the case of a 48-year-old woman who presented to neurosurgery consultation with a five-month history of progressive headache, vomiting, vertigo, and gait instability. Neurologic examination also revealed a subtle bradypsychia.Non-enhanced CT (Philips Incisive CT) showed a large right parietal mass with gross calcifications. Serious doubts about intra- or extra-axial origin of the lesion arose. Nevertheless, the detection of a subtle underlying hyperostotic spicule on the inner table revealed the extra-axial nature of the lesion Fig. a, b.Fig.Brain MRI (Philips Ingenia 1.5 T) confirmed an expansive-lobulated mass in the right parietal region with mild peripheral edema. It was hypointense on T1-weighted images (WI) and hyperintense with foci of low signal intensity on T2-WI. A partial CSF-cleft and heterogeneous gadolinium enhancement with an internal honey-comb pattern could also be assessed. It showed a strikingly low cerebral blood volume (CBV) on dynamic susceptibility contrast- perfusion-weighted imaging (DSC-PWI). There were no signs of diffusion restriction. With an extra-axial location in mind, spectroscopy did not uncover any helpful specific biomarkers such as presence of alanine for meningioma, high myo-inositol for solitary fibrous tumor-hemangiopericytoma (SFT-HPC), or high mobile lipids for metastasis . It predominates in adults after 40 years of age and is slightly more frequent in males , 8. It u0–27%. ItHistologically, three types of intracranial and dural chondrosarcoma have been reported: conventional (grade I-III), mesenchymal, and myxoid. Classic or conventional chondrosarcomas usually are avascular and have few or no mesenchymal components and no myxoid stroma. In contrast, the mesenchymal subtype is the most malignant, highly vascular, and often associated with metastasis , 10.Some authors have described the radiological features of dural chondrosarcoma. This lesion is usually a lobulated dural tumor with low enhancement, intratumoral calcifications, a very hyperintense signal on T2WI, and islands of low signal intensity due to well-differentiated cartilage. Other features include the absence of a dural tail and mild vasogenic edema. The presence of honeycomb enhancement and poor vascularity is characteristic of classic chondrosarcoma, and these are clearly depicted in our case .Radical surgical resection is the treatment of choice, and adjuvant radiotherapy is often considered, especially after incomplete resection , 9. TherA precise bibliographic review on intracranial dural chondrosarcomas above the skull base is hindered because they are often treated altogether with skull-base (different origin in synchondrosis cartilage) and most reports are from some decades ago with incomplete and non-comparable data with nowadays. Nonetheless, the scarce comparable literature collects similar characteristics to those of the current case and some assumptions can be extracted: 1. the disease frequently involves young and middle-aged patients with a possible slightly male predilection; 2. radiology hallmarks are chondroid calcifications, T2-hyperintensity, honey-comb enhancement and signs of poor vascularity; 3. surgical resection and adjuvant radiotherapy is the accepted treatment of choice; and 4. overall prognosis is good in general terms due to an often-indolent growth, rare metastases and the implementation of adequate treatments –10.The importance of this case presentation lays on the rarity of the presented diagnostic with its fully available clinical information. And also, on the always-useful reminder for physician to consider less frequent diseases when any of the imaging pearls do not convincingly lead to the usual suspects, because an accurate pre-surgical diagnostic may directly impact patients’ management.


Acute intestinal invagination is the pathology of infants and small children. Its occurrence in adults is rare, and it represents 1 to 5% of intestinal occlusions often leading to the discovery of an organic cause that may be tumor. We report the case of a 72-year-old patient admitted to the emergency room of Ibn Sina Rabat, Morocco, for intestinal occlusion. The abdominal CT scan showed a voluminous intestinal invagination on a very probable heterogeneous digestive mass. The treatment was an open right hemicolectomy. The histopathological examination of the surgical specimen concluded a colonic well-differentiated adenocarcinoma with a 30% mucinous component. By review of literature, we discuss diagnostic and therapeutic procedures in emergency. Intestinal invaginations are rare in adults, and they represent 1 to 5% of intestinal occlusions often leading to the discovery of an organic cause that may or may not be tumoral, unlike in children, where the majority of cases are primitive.It is defined by the incorporation of an intestinal segment into the one immediately downstream.Abdominal CT scan can diagnose easily the invagination, but the characterization on the underlying lesion is much more difficult, if not impossible.Treatment is always surgical. We report the case of an elderly woman being treated in the emergency room of the IBN SINA Rabat hospital.A 72-year-old female with no significant past medical history presented with diffuse abdominal pain, vomiting, and subocclusive syndrome for 10 days without any notion of rectorrhagia, in a context of deterioration of the general state and apyrexia.At the time of presentation to the emergency room, her temperature was 37 C, blood pressure was 110/60 mm Hg, pulse was 60 beats per minute, respiratory rate was 16 breaths per minute, and oxygen saturation was 99% while breathing ambient air.The abdominal examination showed a slightly distended abdomen with the perception of a mass on the left flank extended to the left iliac fossa without adhesion to the abdominal wall. In addition, there was no hepatomegaly or splenomegaly; digital rectal examination does not revealed a palpable masse and rectum was empty; the rest of the clinical examination was without particularities; the biological assessment was normal; an abdominal X-ray radiography was performed showing some air fluid levels, Ultrasound revealed a mass on the left flank , and abdWe performed an exploratory laparotomy that revealed colocolic intussusception caused by colonic tumor  and 5, aThe patient underwent a right hemicolectomy with terminolateral ileotransverse anastomosis in a single step . The posHistopathological examination of the surgical specimen revealed a well-differentiated adenocarcinoma infiltrating the colonic musculosa with mucinous component estimated at 30%, tumor-classified PT2N0Mx.Intestinal invaginations are relatively rare in adults; they represent 2 to 4% of intestinal occlusions in adults , where aThe clinical presentation is polymorphic and often nonspecific: progressive installation of subocclusive syndrome over several days, acute intestinal occlusion, and nonspecific abdominal syndromes , sometimes evolving over several months, with or without deterioration of the general state , 6.Classically, in adults, the evolution is chronic with intermittent abdominal pain associated with subocclusive seizures. The acute form is mainly the prerogative of the ileoileal forms. For Mondor, the acute form would be the final stage of a chronic invagination for which an early diagnosis would not have been made . This isThe clinical presence of a palpable mass is a sign of great value in particular, if it appears to be of different location and consistency during repeated examinations it corresponds to the invagination coil, which should be carefully sought in the right and left lateral decubitus, in the dorsal decubitus, and Trendelenburg position .Abdominal X-ray shows air fluid levels related to the occlusive syndrome, which is the case of our patient. Abdominal ultrasound can be useful to visualize the classical target sign with a thick peripheral hypoechoic band with central echogenicity zone. These correspond to the bowel wall surrounding hyperecohoic mesenteric fat contained within the intussusception, and it often remains hindered by the presence of air.Abdominal CT scan confirms the diagnosis of the occlusive syndrome and shows the invagination, its precise location, and etiology. It can detect an organic cause in 71% of cases . In CT, Treatment modalities for intussusception are variable. Because ileocolic is the most common type seen in children, reduction is often successful by using pneumatic or hydrostatic edema. Moreover, enteroenteric intussusceptions usually reduce spontaneously. This approach should be employed with great caution to avoid missing potentially serious underlying conditions such as malignancy. The operative approach is necessary in patients who present with bowel obstruction, those with mass seen on imaging, those with constitutional symptoms of malignancy , and those with colocolic and ileocolic intussusception  .When surgical intervention is performed, if underlying malignancy is suspected, oncologic en bloc resection of the involved intestine and the associated mesentery should be sought . This isLaparoscopy is currently a real means of diagnosis and sometimes treatment of intestinal intussusception . In the The prognosis is related to the duration of evolution, the extent of the lesions, and the nature of the cause .Colocolic invagination in adults remains a rare condition. The abdominal CT scan is essential for the diagnosis of the invagination and its etiology. Concerning the treatment, a carcinological resection is necessary when a tumor with evidence of malignancy is discovered.


A 29-year-old male visited the outpatient department of Acharya Vinoba Bhave Rural Hospital, Sawangi with chief complaints of swelling in the left lower jaw for 15 days. He had a past history of similar swelling on the right side of the jaw, for which he underwent intervention. The patient was referred from oral surgery to the Department of Radiodiagnosis for computed tomography scan of head and neck to know the extension of the lesion and underlying bony erosion. There was no significant family history or cutaneous manifestations. On computed tomography, there were multiple cystic lesions in the left hemimandible and maxilla. Histopathology revealed it to be Odontogenic keratocysts. Other findings included bilamellar falx cerebri and tentorium cerebelli calcifications, bridging sella, intracranial lipoma, spina bifida of C6 vertebra. The scalp was thickened with multiple foci of calcifications. Diagnosis of Gorlin-Goltz syndrome was made.


Deep venous thrombosis (DVT) is the most common cause of unilateral lower limb swelling. Common differential diagnosis includes superficial thrombophlebitis and ruptured Baker's cyst. DVT is one of the most common complications diagnosed following lower extremity orthopedic surgery. However, many less frequent causes are often easily overlooked. Here we present a case of a 65-year-old man with a previous hip replacement who developed left-sided progressive leg swelling for years, which was managed initially with anticoagulation for provoked DVT and with compression stockings for post-thrombotic syndrome with no improvement. There was arterialization and spectral broadening of the venous waveform in the Doppler study. Computed tomography angiogram of the lower limbs showed evidence of arteriovenous fistula (AVF) with opacification of the deep left leg veins. Angioplasty and embolization of the fistula resulted in the resolution of leg swelling. We also discussed similar cases found in the literature. AVF needs to be considered in patients presenting with unilateral leg swelling following lower extremity orthopedic surgery. Lower extremity deep venous thrombosis (DVT) is one of the most common complications diagnosed following lower extremity orthopedic surgery . Venous A 65-year-old man with well-controlled type 2 diabetes mellitus and hypertension was referred to our clinic for worsening left leg swelling for one year. He underwent left hip replacement for hip fracture three years before his presentation. He was diagnosed with left leg DVT and treated with oral anticoagulants for three months following his surgery. There was no clear evidence of DVT at that time on review. On examination, his left leg was grossly larger than its counterpart. There was diffuse pitting edema, pigmentation, and lipodermatosclerosis. There were no ulcerations, and pulses were present Figure . He did We searched the literature for similar cases. We found two case reports of patients with no preceding orthopedic surgery presenting with progressive leg swelling and were found to have AVF after clinical suspicion of DVT. One patient developed acute kidney injury due to venous infarction, and the other developed neurological deficits ,5. We foThe main feature common in the case reports we reviewed and our patient is the persistence or progression of symptoms despite adequate anticoagulation after initial diagnosis of DVT. Fortunately, this patient did not develop other complications seen in the reviewed case reports. Thus, lack of improvement with adequate anticoagulation should raise suspicion of alternative diagnoses such as AVF.Although DVT is one of the most common causes of leg swelling following lower extremity orthopedic surgery, we have to consider AVF, especially with worsening symptoms despite optimal standard therapy, presence of neurological deficits, heart failure, ulceration, cyanosis, or findings of an arterialized venous waveform on venous Doppler examination.


Ganglion cysts usually occur around the wrist. Occasionally, they can also occur around the shoulder in the spinoglenoid and suprascapular notches. Rarely they can be found on the long head of biceps as it traverses the glenohumeral joint. Such lesions are usually diagnosed on MRI and might need minor surgery. We present the case of a young athlete with a rare location of ganglion cyst, successfully diagnosed and managed non-invasively by using sonography. This represents a time and cost-conscious approach as compared to traditional methods.  Ganglion cysts are articular or tendon-sheath lesions possibly originating as a result of herniation of the synovium or arising from the tendon fibrils. They occur mostly in women aged 30-50 years, most commonly around the wrist and are occasionally associated with trauma as well . Some gaA 13-year-old female gymnast with no significant medical history was referred to sports medicine by her primary care physician for right shoulder pain ongoing for six months. The symptoms might have been triggered after a week of aggressive CrossFit training. The pain had two components to it: posterior shoulder pain due to a snapping scapula (which is beyond the scope of this article), and more significantly, dull and achy pain in the front of her shoulder, radiating down her biceps, worsened with lifting weights and shoulder extension, and relieved by rest. The patient had tried nonsteroidal anti-inflammatory drugs (NSAIDs), rest, and activity modification with minimal relief. Physical examination revealed a well-developed and well-nourished female in no apparent distress. The head, eyes, ear, nose, and throat (HEENT), respiratory, cardiovascular, abdominal, skin, vascular, and neurological examinations were within normal limits. Inspection of the right shoulder revealed no bruising, rash or visualized swelling. Palpation elicited no pain over the deltoid, acromioclavicular joint, clavicle, sternoclavicular joint, coracoid or the pectoralis minor. There was tenderness to palpation over the right proximal biceps with the patient complaining of some radiation down the biceps as well. There was periscapular pain on palpation of the right scapula as well. Both shoulders had normal strength and range of motion in all planes but moderate scapular dyskinesis was noted. The patient demonstrated positive Hawkin’s, Mayo Shear, Speed’s and Empty Can tests on the right side. Orthopedic examination of the other joints was within normal limits. A magnetic resonance imaging (MRI) scan revealed the long head of the biceps tendon to be intact, normal in signal, and normal in position. However. a 12x6x23 mm lobulated collection was visualized along the long head of the biceps tendon in the bicipital groove. Differential diagnosis included a ganglion cyst versus focal tenosynovitis. A linear probe ultrasound was used to visualize the lesion which appeared to be hypoechoic and was found to be minimally compressible (Figure After discussions with the patient regarding possible management options, the lesion was approached under ultrasound guidance along the long axis in the lateral to medial direction as the patient lay supine with the arm at 90 degrees to the body. The humeral circumflex artery was visualized inferolaterally and was avoided. Lidocaine was administered with a 25 gauge needle in the surrounding tissues and 0.5 cc of thick mucous fluid was aspirated from the ganglion. The cyst was punctured and injected with 2.5 cc of lidocaine and 40 mg of methylprednisolone. Post-procedure, immediate pain relief was experienced. On a follow-up appointment three months later, the patient had significant pain relief during activities and no pain was elicited on physical examination. Repeat sonographic imaging showed a small incompressible remnant of the lesion. Repeat MRI six months after the procedure was within normal limits.On ultrasound, a ganglion cyst appears as a hypoechoic/anechoic lesion with well-defined margins and occasional internal septations. On MRIs, it appears as a unilocular or multilocular rounded or lobular fluid signal mass, adjacent to a joint or tendon sheath . Both ofGanglion cysts are soft tissue lesions usually found around the wrist. It is extremely rare for a ganglion cyst to be associated with the biceps tendon. When this occurs, it can cause symptoms of impingement and injury to the rotator cuff or biceps. Ultrasound can be of high diagnostic and therapeutic yield in such cases, while also conserving time and money.


The present study analyzes diagnostic and therapeutic surgical aspects of primary small bowel melanoma, describing the clinical case and reviewing the literature. Malignant melanomas represent 1–3% of all malignant tumors of the gastrointestinal tract and are therefore uncommon. Only a few cases of metastatic melanoma (1–5%) are diagnosed in the early stages, while still asymptomatic. They show up as imaging exam findings and have better chance of treatment. Most of the time, the diagnosis is late and made in the presence of complications. The final diagnosis frequently depends on the surgical intervention after a serious complication.This case report refers to a 55-year-old male patient, complaining of abdominal pain, blackened stools, and palpable tumor in the abdomen for ~30 days. A tomography scan was performed, which revealed the thickening and parietal enhancement of the small intestine loops with mesenteric adenomegaly and intermingled collection. For diagnostic confirmation, a laparoscopy was performed, which revealed a tumor at the jejunal level, and its resection was performed in the same act. The anatomopathological examination revealed that it was a primary small bowel melanoma.The bibliographic research of the small bowel melanoma demonstrated that, in this situation, the lesion can be interpreted as a primary site or metastatic lesion, considering the possibility of a single primary lesion, whose diagnosis becomes more laborious. In such cases, adjuvant therapy must be considered. The expected 5-year survival is about 9–13%. Malignant melanomas represent about 1–3% of all malignant tumors of the gastrointestinal tract . Most ofOnly a few cases of metastatic melanoma (1–5%) are diagnosed in the early stages, while still asymptomatic . They shMost of the time, the diagnosis is late and made in the presence of complications, such as intussusception, acute bleeding, obstruction, and perforation. This is due, mainly, to non-specific symptoms at the beginning of the disease, and also, the available examinations are not accurate enough to determine a definitive diagnosis. In most of the cases, the final diagnosis depends on the surgical intervention, after a serious complication. Symptoms, such as weight loss, abdominal pain, constipation, hematemesis, diarrhea, anemia, fatigue, palpable abdominal mass, and blood in the stool may also be present .We present a rare case of a primary small bowel melanoma, showing the challenges in its diagnosis and the importance of early surgical treatment, which can provide better quality of life and higher survival rates.We present a case of a 55-year-old male that came to the Emergency Department with abdominal pain and black stools for 30 days. The decision of not looking for a medical evaluation earlier was due to the lack of other associated symptoms. He had no fever, fatigue, anorexia, diarrhea, nausea, or vomiting, but he did have marked hyporexia in the last month.A more detailed family history of cancer was not provided. He was hypertensive, dyslipidemic, and a former smoker, and had no history of previous abdominal surgery.On physical examination, he reported epigastrium pain. The abdomen was swollen and there was a palpable mass extending from the mesogastrium to the hypogastrium.-ray was normal. His oxygen saturation was monitored and remained above 97% without supplemental oxygenation. At the moment of hospitalization, the exams showed 8,000 leukocytes, C-reactive protein (CRP) was 5.1, hemoglobin was 9.8, and hematocrit was 30.2%, keeping hemodynamic stability and not showing large variations during the whole monitoring period. All serologies for infectious diseases were normal.He was normocardic and his axillary temperature measured 36.5°C. The chest XThe investigation was proceeded by a CT of the abdomen with endovenous contrast. A confluence of small bowel loops with parietal thickening and partially defined limits, located in the infraumbilical quadrant and the left iliac fossa, was visualized. In addition, there was an unorganized collection, as well as a slight blur of mesenteric fatty planes, which suggested the presence of a regional blockade. Mesenteric adenomegaly was noted. The investigation continued by performing an upper digestive endoscopy (EDA), colonoscopy, and abdominal nuclear MRI.The MRI examination showed non-obstructive and asymmetric circumferential parietal thickening of a segment of the small bowel located on the left flank, ~10.6 cm in length. Dilation of the respective lumen, was also noted, where the images suggested ulcerations. It is possible to observe the tumor on axial magnetic resonance , and itsThe colonoscopy showed diverticulosis of the right colon and hemorrhoidal disease. An upper digestive endoscopy showed no abnormalities. Tumor markers were measured, and they were all negative. The hypothesis of adenocarcinoma of the small bowel or abdominal tuberculosis (TB) were considered. The tuberculin skin test (PPD) was suspicious, with 12 mm of skin reaction and, due to the presence of the tumor of the small bowel and enlarged mesenteric lymph nodes; there was a need to rule out the possibility of extrapulmonary TB as well.An enteroscopy was performed, it showed mild erosive gastritis and an increased jejunal lesion, about 150 cm after the Treitz angle, with a calcified, ulcerated appearance, and a friable necrotic bottom, with signs of recent bleeding, circumferentially involving the loop to an extent of 5 cm. The anatomopathological examination of the biopsies taken from the lesion was inconclusive.A diagnostic laparoscopy was performed. During the procedure, blocked loops adhered to the colon were seen, located 55 cm from the Treitz angle and 300 cm from the ileocecal valve. The blockage was released and the small bowel tumor was identified. Segmental enterectomy of the jejunal loops with adequate surgical margins and retroperitoneal and pelvic lymphadenectomy were performed. The reconstruction of the small bowel was performed with simple enteroanastomosis by videolaparoscopy.As the colon was involved, the resection of the descending and sigmoid colon was performed with the reconstruction through latero-lateral anastomosis. Intraoperative pathological study was not possible.The anatomopathological analysis of the small bowel segment and of the resected colon revealed an ulcerated sessile lesion and the presence of intestinal perforation by the tumor itself, with an extension to the adjacent adipose tissue and the formation of a tumor mass of 13.0 cm × 4.5 cm, which adhered to the large intestine. A tumor implant area measuring 5.0 cm × 4.5 cm × 3.5 cm was noted and it did not infiltrate the intestinal wall. The mucosa showed usual folding. After opening the small bowel, an ulcerated lesion with high edges was noted. When sliced, the lesion was 6.5 cm thick and had a perforation involving the surrounding adipose tissue adhered to it. There was a 13.0 cm × 4.5 cm peritoneal tumor involving the colon, which measured 17.0 cm × 3.0 cm in diameter.The microscopic study revealed a metastatic melanoma in the jejunum and melanoma metastasis in one of the 22 regional lymph nodes dissected. Additionally, the metastatic melanoma was also observed in three pieces of adipose tissue from the pelvic lymphadenectomy.Histological sections from the jejunal resection and left colectomy demonstrated the metastatic melanoma and traces of intense and diffuse expression of S100-protein and Melan A in the immunohistochemical analysis.The patient had a good postoperative evolution and, when the diagnosis of small bowel melanoma was defined, he was referred for outpatient follow-up to start cancer treatment.After confirming the diagnosis of metastatic melanoma, no evidence of a previous cutaneous lesion on a repeated physical examination was found, and also, there were no other gastrointestinal lesions. Therefore, the conclusion was a primary small bowel melanoma.After 3 months, a control CT scan showed an increase in the dimensions of mesenteric lymph nodes of the left flank, with signs of necrosis in between. An expansive, infiltrated, and lobulated mass was observed in the hypogastric, involving tributary branches of the superior mesenteric vein. These findings are probably related to a secondary neoplastic process, which leads to the conclusion that it is a T4 N1M1 tumor. A PET-CT exam showed fat obliteration and thickening of the peritoneal planes in the left flank and iliac fossa, associated with diffuse 18F-Fluordeoxyglucose (FDG) uptake. Mesenteric lymph nodes were observed in the region of the left flank and in the right axillary region, with radiopharmaceutical uptake suggestive of secondary neoplastic involvement.After a few months, another PET-CT showed an increase in the dimensions of the mesenteric lymph nodes in the left flank, and the formation of an expansive mass, with irregular contours, heterogeneous enhancement, and hypodense necrotic center in contact with an enteric segment. A nodular tumor was noted in the left rectus abdominis muscle with FDG uptake, which suggested neoplastic tissue and signs of tumor progression.The patient seemed to have understood the necessity of treatment and was referred for immunotherapy, but never returned for follow-up. For that reason, it was not possible to know if the patient was assisted in oncological treatment.Small bowel melanoma rarely occurs as a primary lesion, but it can appear as a metastatic tumor of undetermined cutaneous melanomas. In this case, the patient had no history of previous cutaneous involvement or any other site that suggested an initial injury. In such cases, the diagnostic investigation must be extensive to define if the tumor is primary or secondary. A thorough dermatological and retinal examination must be done, as there are many cases of ocular melanoma described as the primary tumor. The diagnosis is not easy , since mSmall bowel melanoma usually occurs as a secondary site of a skin lesion. There are only a few cases of primary melanoma of the small bowel itself, as in the presented case. Therefore, it is a complex task to differentiate the metastatic melanoma from a primary gastrointestinal tract melanoma , but theThe primary malignant gastrointestinal melanoma may affect different portions of the gastrointestinal system; 33% of the nasopharynx, 5.9% of the esophagus, 2.7% of the stomach, 2.3% of the small intestine, 1.4% of the gallbladder, 9% of the colon, 22% of the rectum, and 31% of the anal tract . About 2According to Clark level of the primary lesion, in the analysis of intestinal metastatic progression, it may represent <6% for level I, 6–24% for level II, and more than 70% in cases of level III . In non-Blecker et al.  suggesteTumors with distant metastases are considered stage M1, receiving subclassification M1a, for distant skin metastases, subcutaneous, or lymph node metastases; M1b for pulmonary metastases; M1c for visceral metastases; and M1d for brain metastases. Gastrointestinal tract metastases occur in about 20% of patients in stage IV .The most common symptom is rectal bleeding. Perforation and intussusception are very rare and occurs in acute cases. The diagnosis, through colonoscopy and endoscopy, may fail to identify illness of the small bowel  and the In this case, an enteroscopy and a laparoscopy were performed, since no previous exams were able to define the diagnosis. Prakoso and Selby  proposedThe enteroscopy undoubtedly facilitates the diagnostic investigation. It can be better than the endoscopic capsule, since it allows tissue biopsy and marking of the surgical site for more accurate identification of the lesion. It can be used on patients with bowel obstruction, but with proper care, while an endoscopic capsule must not be done .Complete gastrointestinal resection and metastasis resection, with a safety margin, are highly relevant prognostic factors related to the long-term survival . The defUpfront surgical procedure is indicated for the most severe cases with symptoms that need urgent treatment, such as bleeding or obstructive gastrointestinal lesions. Surgical resection can increase the long-term survival .In advanced cases, in which curative surgery is not possible, palliative tumor resection can be done, reducing symptoms and decreasing the chance of future complications. Metastasis treatment includes chemotherapy and immunotherapy .Establishing a diagnosis and staging the tumor are essential steps. Adjuvant cancer treatment can improve the quality of life and slow the progression of the disease. Metastasis recurrence must be considered, they are often synchronous, can indicate progression of the disease, and result in the need for a second surgical intervention. The malignant melanoma has a poor prognosis and a 5-year survival rate of only 9–13% .Multidisciplinary treatment, with adjuvant immunotherapy, can improve the prognosis. In cases of metastatic melanoma, systemic immunotherapy with monoclonal anti-CTLA4 ipilimumab has shown to be effective , 15. ImmThe follow-up includes colonoscopy, in case of new episodes of gastrointestinal bleeding, and endoscopy, in cases of gastric melanoma. More rarely, metastatic deposits have the potential of provoking chronic anemia. Endoscopic studies are part of the follow-up and may include patients with bland gastroenteric symptomatology , 16. PETThe median overall survival was 10.0 months for patients who received ipilimumab plus gp100, when compared with 6.4 months in the case of patients that received gp100 individually. The time-period of 10.1 months was estimated as an overall survival with ipilimumab isolated .In the study with immunotherapy, after ipilimumab treatment, the patient was proposed to begin a second modality of treatment with the anti-PD-1 monoclonal antibody pembrolizumab .This phase II study established a comparison between two types of doses (2 vs. 10 mg/kg every 3 weeks) of pembrolizumab vs. chemotherapy scheme , monitoring patients with the clinical condition of metastatic melanoma that previously received ipilimumab as therapy. It was stated that both dosages of pembrolizumab had advantageous results compared with the chemotherapy in terms of progression-free survival .Regarding the perspective of treatment, identifying the important points that should be addressed with the patient, according to the medical evaluation, and considering the severity of the condition, it is essential to emphasize the need for surgical treatment. This allows the patient to understand the importance of the surgical approach, its health conditions, and impact on the quality of life. This made it possible to recognize that the patient seemed confident about the surgical procedure, providing opportunities for clear communication about the neoplasia and its evolution prospects.This article shows a case of a primary small bowel melanoma, a rare pathology, with a tricky diagnosis, emphasizing the importance of establishing an accurate protocol for its treatment.Early diagnosis and rapid resection surgery can provide better quality of life and longer symptom-free survival. When dealing with a metastatic melanoma of the small bowel, the possibility of other primary sites may be considered, but the possibility of a single primary lesion cannot be discarded. In the presented case, after confirming the diagnosis of metastatic melanoma in the small bowel biopsy, no evidence of a previous cutaneous lesion on a repeated physical examination was found. Additionally, there were no other gastrointestinal lesions. Therefore, the conclusion was a primary small bowel melanoma. The investigation should include imaging exams and consider enteroscopy, which allows a better study of the lesion. The surgical treatment of intestinal metastasis with a curative approach is viable only in a few situations. A surgical therapy is essential to treat the sickened portion of the small bowel and to resect any signs of lymphoproliferative disease. It allows primary diagnosis and can result in the increased patient survival. Primary intestinal melanomas have an aggressive course and worse prognosis, making follow-up necessary, as it carries a risk of recurrence. Patients with metastatic melanoma should be carefully screened for gastrointestinal symptoms and a timely colonoscopy may benefit these patients in detecting the early metastatic disease. Regarding the perspective of treatment and considering the severity of the condition, it becomes essential to emphasize the need for surgical treatment. It is a rare case that addresses surgical aspects in depth and discuss the surgical behavior with the scientific community.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.The studies involving human participants were reviewed and approved by Ethics Committee of São Leopoldo Mandic Faculty. The Ethics Committee waived the requirement of written informed consent for participation.AG and BZ: conception, design, and administrative support. AG and WS: provision of study materials or patients, collection, and assembly of data. AG, WS, and BZ: data analysis and interpretation. AG, WS, AC, MF, and BZ reviewed the literature and contributed to manuscript drafting and manuscript writing. All authors issued final approval for the version to be submitted.This work was supported by the Beneficência Portuguesa of São Paulo Hospital. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.