Epididymal leiomyosarcoma is an extremely rare tumor. In this study, we describe the sonographic features of this uncommon tumor.A case of epididymal leiomyosarcoma diagnosed at our institute was retrospectively analyzed. Ultrasonic images, noted clinical manifestations, treatment procedures, and pathology results were collected for this patient. The same information was collected from a systematic literature search on epididymal leiomyosarcoma, including the PUBMED, Web of Science and Google Scholar databases.The literature search resulted in 12 articles; we were able to extract data from 13 cases of epididymal leiomyosarcomatosis. The median patient age was 66 (35–78) years, and the average tumor diameter was 2–7 cm. All patients had unilateral epididymal involvement. The lesions were all solid, irregular-shaped in almost half of the cases, featured clear borders in six cases, and had unclear borders in four cases. The internal echogenicity was heterogeneous in the majority of lesions: six cases were hypoechoic (7/11) and three cases moderately echoic (3/10). Information on blood flow within the mass was provided in four cases, but all were noted with significant vascularity. Surrounding tissue invasion was discussed in 11 cases, with 4 featuring peripheral invasion or metastasis.Epididymal Leiomyosarcoma demonstrates sonographic characteristics common to many malignant tumors, such as increased density, irregular shape, heterogeneous internal echogenicity, and hypervascular. Ultrasonography is helpful to differentiate benign epididymal lesions, and can provide some reference for clinical diagnosis and treatment. However, compared with other malignant tumors of the epididymis, it has no characteristic sonographic features,and pathological confirmation is required. Reviewed the ultrasound images of a patient with EL diagnosed at our institution, and summarized the ultrasound manifestations of epididymal leiomyosarcoma in the existing literature. We aimed to determine whether there are ultrasound imaging features can be used to assist clinical diagnosis, and provide a reference for treatment.Ultrasonography provides high resolution and real-time, dynamic images; it is the first choice for diagnosis of scrotal diseases. In the past, ultrasound findings of epididymal leiomyosarcoma were limited to case reports, and the description was relatively simple. In this study, we collected ultrasound imaging findings from patients with confirmed EL: one patient from our own institution, and the remaining patients 2We retrospectively collected data from a patient at our institution with epididymal leiomyosarcoma, including basic patient information, clinical manifestations, ultrasonic imaging manifestations, treatment procedures, and pathological results.In July 2022, we systematically reviewed the literature on epididymal leiomyosarcoma in PUBMED, the Web of Science and Google scholar. The search terms used were “Leiomyosarcoma” and “Epididymis,” with the “full text” filter utilized to ensure that no relevant papers were excluded. We used the system evaluation and meta-analysis (PRISMA) preferred reporting project flowchart Figure 12.1Qualitative data is presented as numbers and percentages. Quantitative data is presented as mean with standard deviation (SD), or median and interquartile range (IQR).33.1via computerized tomography (CT).A 58-year-old man presented with a painless mass in the left epididymis without obvious inducement 1 year ago. Recently, the mass had enlarged, and he was admitted to our hospital on June, 2022. On examination, there were no renal masses, distention, or flank/ureteral pathway tenderness on palpation. There was no suprapubic tenderness or percussive dullness. External genitalia was visually normal, and the right testis and epididymis were normal; however, a 3 × 4 cm hard knot was palpated in the left epididymis. Blood results were normal, and tumor markers were negative. On ultrasound imaging, an heterogeneous hypoechoic mass was seen in the tail of the left epididymis, approximately 3.0 × 2.0 cm in size, with a clear boundary, unsmooth margin, local angulation, and no obvious lateral shadow, Doppler US revealed that the tumors were hypervascular. Figure 2The patient underwent resection of the mass in the left epididymis at Wujin Hospital Affiliated with Jiangsu University. During the surgery, a solid tumor was found at the tail of the left epididymis, with a maximum diameter of approximately 3 cm and an unclear boundary. The tumor was gray, braided, tough, and unclear. Pathology demonstrated a smooth muscle tumor, suggestive of a highly differentiated leiomyosarcoma. Microscopic hematoxylin and eosin staining showed high numbers of cells with spindle, whirlpool, and braided arrangements. There was obvious cell heterogeneity with visible mitotic figures: eosinophilic cytoplasm, rod-shaped nuclei with some irregularities and visible nucleoli, rough nuclear chromatin, and an increased nucleocytoplasmic ratio.Immunohistochemistry showed that caldesomon and desmin were strongly expressed in the tumor cells. In the epididymal tissue, expression of smooth muscle actin (SMA), prostate-specific antigen (PSA), and compound prostate-specific antigen (CPSA) had increased Figure 3One month after the operation, the patient was re-admitted for radical resection of the left testis and epididymis. Postoperative pathology showed no residual tumor cells in the left testis, epididymis, and spermatic cord. No chemotherapy or radiotherapy was administered to the patient. Periodic axial computed tomography scans of the thorax, abdomen, and pelvis have remained normal, and he has remained free of recurrence for the past 6 months.3.2In July 2022, we systematically reviewed the literature on epididymal leiomyosarcoma, searching the PUBMED and Web of Science databases. We screened11 studies featuring 12 cases, and also included the case from our institution, resulting in total 13 cases. The median age of the patients was 66 (35–78) years, and the average diameter of the tumor was 2–7 cm. All patients had unilateral epididymal involvement, including five cases with the right epididymis affected, six with the left epididymis affected, and two with unspecified locations. Twelve cases described the invasion information of the surrounding tissues, of which five cases featured peripheral invasion and seven cases featured local tumor growth only. Intraoperative information was supplied for two invasive tumors and one localized tumor.3.3Thirteen cases of epididymal leiomyosarcoma examined using ultrasound were solitary masses, with all lesions appearing solid (100%). Among the 11 cases with echoic description, most masses (eleven cases) were hypoechoic , three were isoechoic 27.3%), and one was hyperechoic (9.1%) when compared to the testis. Seven cases described echoic homogeneity, including one case with homogeneous echogenicity (14.3%) and six cases with heterogeneous echogenicity (85.7%). The shape of the tumor was described in ten cases: four round or oval (40%) and six irregular (60%) tumors. Ten cases included a description of the mass boundary, of which six tumors had clear boundaries (60%) and four had unclear boundaries (40%). Only four cases described the blood flow inside the mass, but all of them were hypervascular (100%) Table 1.According to the existing literature, epididymal leiomyosarcoma has common sonographic features of malignant tumors, such as solid changes, irregular shape, heterogeneous echo and with hypervascularity. Ultrasound imaging examination is helpful to differentiate benign epididymis lesions and can provide some reference for clinical diagnosis and treatment.4The epididymis originates from the mesonephric duct of the embryo and is mainly composed of output tubules, epididymal ducts, and connective tissue. It is divided into three sections: head, body, and tail. The head and body regulate early and late sperm maturation, respectively, whilst the tail stores mature sperm. Epididymal leiomyosarcoma (EL) can develop at any age, with incidence peaking between 60 and 70 years . LeiomyoThe clinical manifestations of epididymal tumors are non-specific making it difficult for clinicians to distinguish between benign and malignant masses; therefore, patients are easily misdiagnosed. There is no effective method for the preoperative diagnosis of EL; diagnosis is dependent on postoperative pathology and immunohistochemistry. Macroscopically, the cut surface of a leiomyosarcoma appears gray, hard, and elastic. Microscopically, the cells contain bundles of polymorphic spindle cells, with heteromorphic nuclei, abnormal mitotic figures, and sometimes multinucleated giant cells. Histologically, tumor cells are diverse, ranging from well-differentiated to multi-type undifferentiated tumor cells. Immunohistochemistry is required to determine the presence of smooth muscle .Ultrasonic examination is the most commonly used method in the diagnosis and differential diagnosis of reproductive system diseases due to its obvious advantages of convenience, real-time dynamic imaging and non-radiation. However, there is still controversy on the differential efficacy of benign and malignant epididymis space occupying lesions. Frates M C et al.’s research suggests that ultrasound is ineffective in differentiating benign from malignant epididymal tumors . SeveralBeginning in 1949, when the first primary epididymal leiomyosarcoma was reported , we idenGiven the different treatment methods required, it is important to differentiate epididymal leiomyosarcoma from benign epididymal tumors. Adenomatoid tumors are the most common benign mesothelial tumors and are often associated with no clinical symptoms . Their hLeiomyomas are composed of single smooth muscle cells, arranged in bundles or braids. The clinical manifestations of epididymal leiomyoma and EL are similar; however, there are significant differences in diagnosis, treatment, and prognosis. Clear boundaries and multilayer spiral echoes are characteristic sonographic manifestations of leiomyomas; therefore, ultrasonography is valuable in the diagnosis of this tumor.Smart et al. summarizeEpididymitis is a common, nonspecific infectious diseases of the male reproductive system that may be misdiagnosed as EL. Acute epididymitis has typical clinical manifestations—scrotal swelling and pain that can radiate to the lower abdomen and thighs, poor cold tolerance, fever, and elevated white blood cell count. Ultrasound demonstrates enlarges testis and epididymis, with reduced internal echogenicity that appears heterogeneous. Color Doppler flow imaging shows abundant blood flow in the epididymitis, its clinical manifestations combined with ultrasonic imaging were easy to differentiate from EL. Ultrasound images of chronic epididymitis often show heterogeneous echogenicity and unclear boundaries, with reduced or no blood flow signals in some areas on Doppler imaging. This can lead to misdiagnosis and confusion with EL. Other clinical examination data, such as a history of acute epididymitis, should be integrated to avoid misdiagnosis.Granulomatous inflammation is chronic proliferative inflammation characterized by granulomas, secondary to infection or autoimmune disease. The diversity of causes leads to varied and complex histology, morphology and sonographic findings, making diagnosis difficult. However, most granulomatous inflammations show hypovascularity on ultrasonography, allowing them to be distinguished from EL.In recent years, the incidence rate of urinary tuberculosis has increased due to the increasing prevalence of drug-resistant tuberculosis. The epididymis is the most vulnerable part of the male reproductive system to tuberculosis infection; Drudi et al.  reportedIn summary, Epididymal leiomyosarcoma is a rare disease with atypical clinical manifestations and difficult differential diagnosis., making it easy to confuse with benign and other malignant tumors. By reviewing the existing literature and analyzing the cases found in our institute, we summarized the ultrasonic characteristics of ELare solid changes, irregular shapes, heterogeneous internal echogenicity, and hypervascular. This is helpful to differentiate benign and malignant tumors of epididymis. Ultrasonography can provide some reference for clinical diagnosis and treatment. However, compared with other malignant tumors of the epididymis, it has no characteristic sonographic features.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding authors.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.RS, JX and HS performed the experiments, analyzed the data, and wrote the manuscript. ZX and HL were involved in performing the experiments. XY conceived the study and assumed overall responsibility for this work. All authors contributed to the article and approved the submitted version.


Torsion of the gravid uterus is very rare in obstetric practice. We report a case of torsion in the uterus didelphys at term which is rare and a lifetime experience for an obstetrician.The patient, a 25-year-old gravida 2 para 1 was admitted to the labor ward at 37 weeks and six days of gestation with abdominal pain. Her previous delivery was a caesarean section performed four years back. She was taken to the operating room for an emergency caesarean section for fetal distress and the lie was transverse. On entering the peritoneal cavity, we found an engorged infundibulopelvic ligament with the fallopian tube and ovary covering the lower segment of the uterus. The baby was successfully delivered by breech extraction. Due to uterine torsion of more than 180 degrees, the posterior surface of the uterus was placed anteriorly, and the incision was made on the posterior surface of the uterus. There was a hemi uterus on the left side of the pelvic cavity with the fallopian tube and ovary attached to it; a diagnosis of uterus didelphys was made. The diagnosis of uterine torsion is intraoperative and prompt and timely decision by surgeons is crucial. We had favorable maternal and fetal outcomes in this rare and interesting case. The diagnosis, though rare, should be kept in mind in all cases of abdominal pain during pregnancy, especially in those with malpresentation. Torsion of the uterus is a rare condition which is infrequently encountered in clinical practice. Encountering a patient with an unusual and rare combination of torsion in the uterus didelphys at term makes it a lifetime experience for an obstetrician . There aA 25-year-old, gravida 2 para 1 was admitted to the labour ward with abdominal pain at 37 weeks and six days of gestation. Her last childbirth was by caesarean section four years back. Her antenatal period was uneventful with regular check-ups as per schedule. She had transverse lie and was planned for elective repeat caesarean section at 39 weeks.On examination, there were mild uterine contractions and the lie was transverse. Ultrasound was done which showed a single live fetus with an estimated fetal weight of 3.2 kg. The placenta was anterior and low-lying, ending 1 cm above the internal os. A mass of 12 x 7.6 cm was found in the pelvis which was suspected to be a cervical myoma. Cardiotocography indicated fetal distress and she was prepared for an emergency caesarean section. The abdomen was opened by Pfannenstiel incision. On entering the peritoneal cavity, we were surprised to see the engorged infundibulopelvic ligament with the fallopian tube and ovary stretched across the operative field  Activity Respiration (APGAR) score of 9 with a birth weight of 3.17 kilograms. After the separation of the placenta, it was observed that due to uterine torsion, the incision was made on the posterior surface of the uterus. Manual untwisting of the uterus was done in the direction opposite to that of the torsion. The uterus had torsion by more than 180 degrees on its own longitudinal axis, at the level of the junction of the cervix, the corpus and the right adnexa was covering the operative site. The posterior surface of the uterus was placed anteriorly due to torsion Figures -3. Another intact uterus was found on the left side of the pelvic cavity (about 12 weeks in size) with a tube and ovary attached to it. The final diagnosis was uterus didelphys with torsion of the gravid uterus. The uterine incision was repaired in two layers and anti-adhesive barrier gel was placed posteriorly. After ensuring hemostasis, the abdomen was closed. The post-operative period was uneventful. Both mother and baby were discharged on the third postoperative day.Uterine torsion is defined as the twisting of the uterus by more than 45 degrees around its long axis at the junction between the cervix and the corpus . TorsionVery few cases of torsion in uterus didelphys have been published as of date. Only two cases of torsion of uterus didelphys (one at term pregnancy and the other in labour) were published in 1954 .In our case, malpresentation (transverse lie) and Mullerian anomaly (uterus didelphys) predisposed to torsion of the uterus. The diagnosis of uterus didelphys was missed during the previous Caesarean section which was operated on for fetal distress in emergency hours. During the current pregnancy, the other uterus was thought to be a myoma in ultrasound and was a surprise during surgery. Moreover, the torsion of more than 180 degrees placed the anterior surface of the uterus posteriorly and vice versa. The baby was delivered through a transverse incision on the posterior surface of the uterus.From the literature review, it has been observed that a pre-operative diagnosis of uterine torsion is not possible. It is also difficult to correct uterine torsion before the delivery of the fetus. Maternal and perinatal morbidity and mortality depend on the degree of rotation of the uterus and the period of gestation.In this case, prompt intraoperative planning and decision by the surgeon enabled a favourable outcome for both the mother and the baby. In cases of uterine torsion, a prompt and timely decision by the surgeon is crucial. The uterine incision should be planned to avoid injury to vital structures. The diagnosis, though rare, should be kept in mind in all cases of abdominal pain during pregnancy, especially in those with malpresentation. A pelvic mass in pregnancy can rarely be a uterus too in case of Mullerian anomaly.


Carcinosarcoma of the gallbladder is a rare cancer characterized by presence of a carcinomatous and a sarcomatous component. In our work, we report the case of a 66-year-old male patient, presenting with isolated abdominal pain evolving for more than 6 months. contrast-enhanced computed tomography enabled identification of a gallbladder mass, invading liver, duodenum and abdominal wall. A cholecystectomy, extended to liver, duodenum and abdominal wall was performed. The final diagnosis of gallbladder carcinosarcoma was obtained by pathological assessment. Gallbladder carcinosarcoma has a poor prognosis. Since it is rare, no established chemotherapy or radiation protocols exist. Further studies about case series are needed to establish better therapeutic protocols. Gallbladder carcinosarcoma is a rare cancer with a rapid progression making therapeutic decisions difficult. All these factors contribute to the poor prognosis of this cancer. Carcinosarcoma is a relatively rare gallbladder cancer , with only about 100 reported cases in the English literature [Gallbladder carcinosarcoma (GBCS) has a poor prognosis, worse or similar to that of gallbladder adenocarcinoma . In our Patient information: we report the case of a 66-year-old male patient, with a history of peritonitis secondary to gastric ulcer perforation 36 years ago. He presented for isolated abdominal pain on the right hypochondriac region evolving for more than 6 months. No jaundice was reported.Clinical findings: physical examination was unremarkable, showing stable vital signs and normal abdominal examination: no mass was identified through clinical examination.Diagnostic assessment: biological explorations showed marked elevation of total bilirubin (10.1 mg/dL), of alanine aminotransferase (ALAT) and aspartate aminotransferase (ASAT) with values of 224IU/L and 124 IU/L respectively and of alkaline phosphatase (880 IU/L), serum carcinoembryonic antigen level (CEA) was elevated. Other biological abnormalities include a biological inflammatory syndrome with elevated C reactive protein (CRP) at 85mg/L and anemia with a hemoglobin value at 15 μg/L. The patient underwent a contrast-enhanced computed tomography (CE-CT), which showed a large enhancing mass filling the hole gallbladder lumen, with extension to adjacent organs: liver, duodenum and abdominal wall.Therapeutic interventions: the patient underwent a cholecystectomy, extended to liver, duodenum and to invaded abdominal wall. Macroscopic examination showed a tissular friable large, 15 x 8 x 6 cm mass filling the hole gallbladder lumen. Extension was identified towards the duodenal wall, the abdominal wall and to the liver. Cut section of the mass showed a heterogenous appearance with many diffuse necrotic and hemorrhagic foci (gic foci . Microscgic foci . This epgic foci . Two hetgic foci . The secgic foci .Diagnosis: these morphological and immunohistochemical observations were consistent with a gallbladder carcinosarcoma. The tumor was invading the duodenal wall and the cystic canal resection margin with neoplastic margins. Extension to liver and abdominal wall were also confirmed microscopically.Follow-up and outcome of interventions: follow-up of the patient with routine imaging and laboratory studies has shown appearance of hepatic metastases and patient´s death 4 years after resection.Informed consent: the patient did give informed consent.et al. [Among all tumors of the biliary tract, cancer of the gallbladder is the most frequent. However, carcinosarcomas, characterized by a combination of both carcinomatous and sarcomatous components, are relatively rare. There are only about 100 reported cases in the English literature . The firet al. . A male et al. . Howeveret al. . The affet al. . Pathogeet al. . In thiset al. . This laet al. .In our case, the epithelial markers were expressed in the carcinomatous part and not in the sarcomatous part. The sarcomatous component may present in different appearances, with undifferentiated spindle cell proliferation being the most frequent one. The occurrence of a heterologuous component in form of rhabdomyosarcomatous component, as in our case, osteosarcomatous, chondrosarcomatous or a leiomyosarcomatous component have been reported in the literature . The epiClinical features are not specific, and include, as for other gallbladder cancer types, anorexia, vomiting, abdominal pain and jaundice . AbdominImaging may only help to categorize the observed lesion as a malignant lesion without being able to guide diagnosis toward a carcinosarcomatous lesion. In the literature, and as in our case, no case of GBCS has been diagnosed preoperatively. There is no consensus regarding the treatment of GBCS, although few reports about use of chemotherapy have been published . Most caet al. [et al. a median survival of 5 months with a 3-year survival rate of 16% has been reported [et al. [Other types of gallbladder resection can be theoretically efficient, depending on extension of the carcinosarcoma. These include simple cholecystectomy or extended cholecystectomy including liver bed resection and pancreaticoduodenectomy. In terms of prognosis, and even with an aggressive surgical treatment, the prognosis and survival of GBCS cases remain poor. A median survival of 7 months with a 3-year survival rate of 31% has been reported by Okabayashi et al. . In a sireported . In the  [et al. .Although gallbladder carcinosarcoma is a relatively rare neoplasm, it is certainly a very aggressive neoplasm, with usually a rapid progression. More studies are needed to identify different prognostic factors related to this highly malignant neoplasm, and to establish a consensus about therapeutic management. In our work, we report the case of a locally advanced gallbladder carcinosarcoma in a 66-year-old man. The patient has undergone curative surgical resection. Follow-up of the patient with routine imaging and laboratory studies has shown the appearance of hepatic metastases and patient´s death 4 years after resection.


Ovarian fibromas are benign tumors that consist of spindle cells in bundles or storiformly arranged with collagen fibers in the stroma. Thecomas resemble theca interna ovarian cells, and there is lipid material in their cytoplasm. There is an overlap in histological and immunohistochemical characteristics of these two benign tumors, and the term “fibrothecoma” was coined to describe such cases. Their incidence is extremely rare in adolescents. The subject of our study is a 15-year-old, unmarried, virgo intacta patient who was referred to us due to profuse vaginal bleeding and the loss of consciousness. A right ovary ultrasound examination exposed the formation of a hyperechoic tumor with a diameter of 41.2 mm × 29.5 mm. Findings of cancer antigen 125 (CA 125) in the amounts of 621.1 U/mL and 142.87 mIU/mL of the B-human chorionic gonadotropin (B-hCG) serum were determined. After preoperative preparation, we operated on the patient to remove a tumor with a diameter of 37 mm × 30 mm × 22 mm, smooth outer surface, solid cross-section, and yellowish white color. The diagnosis of fibrothecoma was made based on pathohistological examination. An unusual finding of fibrothecoma in a virgo intacta adolescent with profuse vaginal bleeding and increased levels of CA 125 and B-hCG may serve as a basis for broader thinking about the pathology of juvenile bleeding. Ovarian fibromas and fibrothecomas are rare tumors of the ovarian stroma. These tumors represent an overall of 1% to 4.7% of ovarian tumors . In the A fibroma is characterized as a benign non-hormonal tumor. On the other hand, it is acknowledged that it is estrogenic and can cause abnormal uterine bleeding .Best known as the ovarian cancer marker, the cancer antigen 125 (CA 125) may also be elevated in certain benign genital and non-genital conditions . ElevateElevated levels of serum B-human chorionic gonadotropin (B-hCG) are usually consistent when it comes to pregnancy or any pregnancy-related conditions, such as gestational trophoblastic tumors. Conditions other than those related to pregnancy can also show the findings of elevated B-hCG levels. Along with placental syncytiotrophoblasts, other tissues such as the testes, colon, liver, lungs, and stomach can produce B-hCG .12/L erythrocytes (RBC); 110 g/L hemoglobin (Hgb); 0.325 L/L hematocrit (Hct); 23.09 × 109/L leukocytes (WBC); and 241 × 109/L platelets (PLT). These counts showed a decline in subsequent repeated determinations , so two units of blood of the appropriate blood group was administered to the patient to restore levels.The subject of our study is a 15-year-old unmarried, virgo intacta patient who was referred to us by a surgeon from the intensive care unit after a fall due to the loss of consciousness that resulted in a head injury . There were no signs of acute pyramidal deficiency or subconjunctival hemorrhage. A computed tomography scan (CT) of the endocranium did not show the existence of trauma. On the first day of menstruation, the complete blood counts (SCC) were as follows: 3.75 × 10The results of a transrectal sonography (TRS) conducted by a gynecologist showed that the uterus was in anteversoflexion (AVF) of a regular shape and size. The uterine cavity was dilated up to 15 mm and filled with hyperechoic coagulum. The right hyperechoic tumor formation was 41.2 mm × 29.5 mm in diameter, with little fluid in the Douglas space, which was 21.6 mm × 8.4 mm in diameter . The lefThe patient was admitted to our clinic, where she underwent anamnestic, clinical, ultrasound, and laboratory examinations. The subject’s menarche started at the age of 12, and she has an established regular menstruation cycle that occurs on every 28 days, lasts 3–5 days, and is not painful. Her last menstruation episode started the day before the examination, with bleeding that was sparse at first but became abundant on the same day.A rectal bimanual examination showed that the uterus was in AVF, had a normal size, and was smooth and insensitive. A solid tangerine-sized tumefaction was palpated in the area of the right adnexa. The left adnexa was easily palpated and painfully sensitive. The working diagnosis was metrorrhagia juvenilis, Tu adnexorum l. dex.12/L RBC; 88 g/L Hgb; 0.259 L/L Hct; 13.45 × 109/L WBC; and 172 × 109/L PLT. Measurements of ovarian tumor markers showed 0.8 ng/mL carcinoembryonic antigen (CEA), normal 0.0–5.0; <2.0 U/mL cancer antigen 19-9 (CA19-9), normal 0.0–37.0; 6.0 ng/mL alpha-fetoprotein (AFP), normal 0.0–8.8; and 123 U/L lactate dehydrogenase (LDH), normal 125–220.Upon admission to the gynecology clinic, the laboratory findings were as follows: 2.87 × 10The patient was initially administered antibiotic therapy, progesterone depo, and iron (Fe) supplementation.12/L RBC; 81 g/L Hgb; 0.239 L/L Hct; 8.20 × 109/L WBC; and 198 × 109/L PLT. As the patient was clinically stable with only scanty bleeding, according to the law of our country, the operative therapy of adolescents was performed by a pediatric surgeon at the Institute for Children’s Diseases with the assistance of a gynecologist from our clinic. The patient was referred, with Microgynon and iron supplementation therapy, to a pediatric surgeon to plan surgery. As the patient clinically improved, examinations were repeatedly carried out over three days, with the following findings: 211.3 U/mL CA 125; 58.27 mIU/mL of B-hCG; 2.69 × 10Repeated findings after ten days showed 49.26 U/mL CA 125 and 11.1 mIU/mL B-hCG , which hA tumor nodule with dimensions of 37 mm × 30 mm × 22 mm and a smooth external surface, solid cross-section, and yellowish-white color  was submThe tumor samples were formalin-fixed, paraffin-embedded, and stained with hematoxylin/eosin (HE). Immunohistochemistry (IHC) staining was performed using Vimentin (Ventana (V9) Mouse monoclonal antibody), Actin, Muscle specific (Ventana (HHF35), Mouse monoclonal antibody), and Inhibin , Mouse monoclonal antibody). A section 4 mm thick from the paraffin-embedded block was cut, and fully automatized immunoassays were performed on a Ventana BenchMark GX autostainer . The microscopic analysis revealed that the tumor nodule contains bundles of spindle-shaped, uniform cells. The cells were medium-sized, oval, and mitotically inactive. Subgroups of tumor cells were observed to have a more abundant and light cytoplasm that was spindle- to oval-shaped. Between the bundles of tumor cells, moderate amounts of collagen fibers were present . Immunohistochemically, the spindle-shaped tumor cells were positive for vimentin and SMA (smooth muscle actin), whereas the more abundant and brighter spindle-to-coastal shaped cytoplasmic cells tested positive for vimentin and inhibin and histochemically positive for oil red O .The patient was discharged after four days, and the postoperative findings were within normal limits.12/L RBC; 122 g/L Hgb; 0.378 L/L Hct; 20.5 U/mL Ca 125; <1.2 mlU/mL B-hCG.) Transabdominal sonography (TAS) showed the dimensions of the right ovary to be 24.2 × 19.3 mm, normal shape, with more clearly visible follicles.Postoperatively, the examinations were repeated twice, and the findings were in order  level was increased. Using CA 125 serum as an ovarian cancer tumor marker has been proposed as a valuable tool to help distinguish between benign and malignant neoplasms . HoweverThe CA 125 serum levels in pregnant women are known to increase to a certain degree in the first trimester of pregnancy and then to start descending during the second and third trimesters to the scope found in non-pregnant women . The maxNormal levels of B-hCG serum are 0.0–5.0 mIU/mL. In our case report of fibrothecoma, the B-hCG level (142.87 mIU/mL) was increased in a 15-year-old patient, virgo intacta, coming from a conservative family. Nigam et al. described a case of distorted ovarian fibroma with elevated B-hCG levels and ascites that mimic an ectopic ruptured pregnancy in a young married woman who had not given birth. Elevated levels of B-hCG in this case were attributed to chemical pregnancy . Measurable levels of B-hCG serum is generally consistent with pregnancy or pregnancy-related conditions, such as gestational trophoblastic tumors. B-hCG can also be discovered in non-pregnant conditions . If elevIn our case, we cannot give a clear explanation for the drop in Ca 125 and HCG levels without any treatment. We hypothesize that Ca 125 spikes may be due to mechanical irritation of the peritoneum or pelvic inflammatory disease and that B-hCG spikes may be due to false-positive hCG or “phantom hCG”. We were considering early pregnancy and possible abortion. However, we obtained information from the anamnesis that the patient was virgo intacta. This was confirmed by a clinical bimanual rectal examination, where the intact hymen was clearly visible. We also thought about possible petting as a possibility of becoming pregnant, but since the presence of the patient’s mother is mandatory, we gave up on further anamnestic examination.Sonography is predominantly used as a first choice imaging technique to assess pathological ovarian abnormalities. In the case of transabdominal sonography (TAS) giving a blurred picture and transvaginal sonography (TVS) not being able to be used or having relative contraindications, as in the cases of virgo intacta, agenesis of the vagina, and remature rupture of the membranes, we used a transrectal sonography (TRS). In a study by Timor-Tritsch et al., in which a TAS and TRS results of 42 patients have been compared, TRS indication for 23 patients was a virgo intacta diagnosis . RegardlSurgery is the advisable treatment for ovarian fibromas, and conservative treatment should be used with caution. As with other ovarian tumors, surgery is the treatment of personal choice for solid tumors. Conservative surgery with unilateral salpingo-oophorectomy or the excision of the ovarian mass is recommended for patients of reproductive age, whereas more radical surgeries should be considered in older patients. In the literature, laparotomy has been used for removal of ovarian fibromas in most cases, and laparoscopic access has rarely been reported. Leung et al. performed laparotomy in 78.3% of cases and laparoscopic surgery in 21.7% of cases [2 would compromise the respiratory pattern.Laparoscopic surgery has many advantages in terms of result, hospital stay, postoperative pain, better cosmetic result, better visualization of the ovary during surgery, etc. The laparoscopic surgery in this particular case could not be performed because the child has congenital persistent pulmonary hypertension. The insufflation of COOf course, a definitive diagnosis is obtained microscopically, and histological findings generally allow for a diagnosis to be made without difficulty. However, in some cases, differential diagnosis is more difficult for thecomas, especially fibrotic thecomas, stromal tumors, fibromatosis, and massive ovarian edemas . DiagnosThe incidence of fibrothecomas in adolescents is extremely rare. This case report involes the investigation of a virgo intacta adolescent patient with profuse vaginal bleeding and increased levels of CA 125 and B-hCG. This case report can serve as a basis for broader thinking about the pathology of juvenile bleeding.


Alveolar echinococcosis is a zoonotic disease that mostly affects the liver, with vascular invasion and a protean clinical symptom. However, no reports of sympathetic nerve infiltration in hepatic alveolar echinococcosis have been reported. Here, we report a case of hepatic alveolar echinococcosis in a 33-year-old man. In this end-stage case, the lesion was heavily involved in the large vessels and biliary tract, and immunohistochemistry also incidentally revealed extensive nerve infiltration in the specimens after surgical treatment. Subsequently, neural classification was identified.We herein report a case of advanced hepatic alveolar echinococcosis with macrovascular invasion and sympathetic nerve infiltration. In this case, inferior vena cava (IVC), the portal vein and bile duct were infiltrated. Ultimately, according to our experience, ex vivo liver resection and autotransplantation (ELRA) was the optimal treatment way to perform for this unresectable patient. Samples were collected from normal liver tissue, junction tissue and the lesion. Hematoxylin–eosin (HE) staining was used to confirm the diagnosis. Neural infiltration was observed by immunohistochemical staining with protein gene product 9.5 (PGP9.5). Fluorescence colocalization was determined with PGP9.5 and tyrosine hydroxylase (TH). These results suggest that a large amount of sympathetic nerve infiltration occurred at the junction.This study suggests that advanced hepatic alveolar echinococcosis shows infiltrating growth, often invades the large vessels and biliary ducts, and may be accompanied by sympathetic nerve infiltration. Echinococcus (family Taeniidae), remains a major public health issue. Alveolar echinococcosis (AE) is mainly caused by infection and prevalent in humans and animals. Its main pathological feature is the presence of metacestode (larva) of E. multilocularis in the internal organs, which destroy normal organ tissue and result in alveolar echinococcosis. The most targeted organ for echinococcosis is the liver (95%) [Echinococcosis, a zoonotic disease caused by cestodes of the genus er (95%) . In facter (95%) . We repoThe patient was a 33 years-old male who was a herder living in Tibetan Plateau. He denied any history of smoking, alcohol, food allergy and drugs, and had no evident past medical history or history evident in family members. He was admitted to our hospital because of intermittent jaundice and scleral icterus. Also, he complained of bloating and an occasional bout of diarrhea. The patient did not receive any medications prior to admission. Physical examination revealed an epigastric mass and mild pitting edema in both lower limbs.9/L, the platelet count was 184.0 × 109/L, the international normalized ratio was 1.17, glucose was 4.15 mmol/L, and blood urea nitrogen was 3.28 mmol/L. Liver function tests showed the bilirubin total/direct was 285.70/136.31 µmol/L. Aspartate aminotransferase was 75.70 U/L, alanine aminotransferase was 44.45 U/L, and gamma glutamyl transferase was 79.47 U/L. Alpha-fetoprotein (AFP) was 1.99 ng/mL, CA 125 (cancer antigen 125) was 153.50, and carcinoembryonic antigen (CEA) was 1.69 ng/mL. Contrast-enhanced abdominal CT showed a 19.32 cm × 13.85 cm mass in the right hepatic lobe, encroaching the second hepatic hilum and compressing the inferior vena cava (IVC), and a large number of calcifications were observed. The right portal vein, middle and right hepatic veins and bile duct were all involved. Signs of portal hypertension, such as cavernous transformation of the portal vein (CTPV), ascites, and splenomegaly, were observed . The jaundice quickly declined after 3 weeks. Subsequently, emergency endoscopic hemostasis was conducted for upper gastrointestinal bleeding due to portal hypertension. The patient underwent ex vivo liver resection and auto transplantation (ELRA) after the extrahepatic lesions were resected. Samples were taken from the liver lesion, normal tissue, and the junction between each other Fig. C. All liechinococcus multilocularis mature in the intestinal tract of the definitive host, it produces a large number of eggs which are released into the environment through the feces of carnivores. Humans are usually indirectly involved in E. multilocularis eggs transmission as intermediate hosts. The eggs hatch in the human intestine after being ingested by humans in the contaminated environment, a small amount larvae pass through the intestinal wall into lymphatic vessels or portal vein. It usually settles in the liver and develops as larvae [AE is a regionally endemic disease . The fecs larvae . They als larvae , 7, lungs larvae , 9, and s larvae , 11.E. multilocularis. The pathological morphological characteristics are mainly shown as vesicle aggregation, with different sizes. The gross anatomy is often characterized by a large or single nodular, yellowish or white cystic mass with a hard texture. The growth of AE is characterized by strong invasiveness and unclear boundary with surrounding organs and tissues. Lymphatic or vascular invasion provides an opportunity for distant metastasis [Liver is the main target organ of tastasis . The mostastasis .In terms of treatment, radical surgery often needs to be combined with albendazole medication to achieve the purpose of radical treatment, which is considered as the major treatment for clinically diagnosed AE patients. Surgical procedures include radical hepatectomy, ELRA, classical allogeneic liver transplantation, and palliative treatment . Liver transplantation is the main indication for patients with end-stage hepatic alveolar echinococcosis –16. The The liver is one of the most highly innervated organs in mammals. Autonomic innervation includes vagus and sympathetic fibers, which coordinate with each other to achieve the balance of normal functions. Hepatic nerves are involved in the regulation of various physiological functions, such as carbohydrate metabolism, glucose regulation, lipid metabolism, food intake, and biliary secretion . To dateIn addition, there is an overwhelming body of evidence that the sympathetic system participates in the so-called “fight and flight response” , which iIn conclusion, this case demonstrates aggressive growth in patients with advanced hepatic alveolar echinococcosis. There is a large amount of sympathetic infiltration in liver tissue around the lesion, which may be involved in immune regulation.


BRAF V600E oncogene mutations have been reported in multiple central nervous system (CNS) tumor types, and emerging evidence supports the use of targeted therapy in BRAF-mutated gliomas. BRAF oncogene mutations have been recently identified in Rosai-Dorfman disease (RDD)—a rare non-Langerhans cell histiocytosis. This series describes three patients from two neurosurgical centers in Ireland with BRAF V600E-mutated CNS tumors. The study participants include a 19-year-old male patient with ganglioglioma with anaplastic features, a 21-year-old male patient with CNS involvement of RDD, and a 28-year-old female patient with ganglioglioma with anaplastic features. Two patients received radiation with concurrent temozolomide before BRAF-targeted therapy. This case series describes clinical and radiological responses to BRAF-targeted therapy in BRAF V600E-mutated gliomas across multiple tumor grades and is only the second published report of response to targeted therapy in BRAF-mutated RDD. The durability of disease control with BRAF-targeted therapy was generally superior to that achieved with chemoradiation; one patient has experienced ongoing disease control for 5 years. The reported case of treatment response in BRAF-mutated RDD supports the strategy of genotyping and utilization of targeted therapy in this rare disease. The optimal sequencing of BRAF-targeted therapy in BRAF-mutated gliomas/glioneuronal tumors remains unclear, and further prospective studies are required to guide the use of genome-matched therapy in this patient population. BRAF oncogene are well described in many central nervous system (CNS) tumors. A large study assessing more than 1,000 CNS tumors of various types identified a 7% incidence of BRAF mutations (most commonly in pleomorphic xanthoastrocytoma (PXA) and World Health Organization (WHO) grade 1 ganglioglioma subtypes)  is a rare non-Langerhans cell histiocytosis. CNS involvement occurs in less than 5% of cases  of the brain demonstrated a 4.7-cm cystic lesion within the roof of the right lateral ventricle with a 3-cm solid component involving the corpus callosum. The patient proceeded to surgical resection, and operative histology demonstrated a mixed tumor with glial and neuronal components. Cells were largely NF52 positive on immunostaining with occasional positive staining for GFAP and CD34. The appearances were consistent with a ganglioglioma, WHO grade 1.BRAF V600E expression, and further genotyping using the Idylla™ BRAF mutation test confirmed the presence of a BRAF V600E mutation.Approximately 8 months post-surgical resection, the patient presented with increasing headaches. An MRI of brain with contrast was performed, which demonstrated a significant increase in the size of an enhancing mass lesion on the inferomedial aspect of the right frontal lobe consistent with tumor progression. The patient underwent further tumor debulking. Histology demonstrated cells with piloid morphology with regularly interspersed dysplastic neurons see . Glial cSTUPP regimen  approximately 5 years following initial diagnosis.BRAF genotyping using the Cobas® 4800 BRAF V600 mutation test assay demonstrated a BRAF V600 mutation.Approximately 3 years post-completion of whole-brain radiotherapy, the patient developed a new left-sided visual disturbance. MRI of the brain revealed the progression of the previously visualized pituitary tumor. The patient proceeded to endoscopic transsphenoidal debulking and biopsy of the suprasellar tumor. Morphological appearance remained consistent with RDD. BRAF/MEK inhibitor combination therapy with encorafenib and binimetinib. Interval MRI of the brain was performed 4 months post-commencement of BRAF/MEK inhibitor therapy, which demonstrated treatment response .BRAF genotyping was performed using the Cobas® 4800 BRAF V600 mutation test assay and demonstrated a BRAF V600 mutation. Sequencing did not identify a BRAF fusion. She proceeded to adjuvant radiotherapy with concurrent temozolomide as per the STUPP regimen. She completed a further 6 months of temozolomide therapy. Three months post-completion of temozolomide MRI of the brain demonstrated re-accumulation of the cystic changes within the right basal ganglia/thalamus and right brain stem consistent with disease progression.Approximately 4 years post-resection, the patient developed headaches and progressive ataxia. MRI of the brain revealed a significant increase in the size of the medial temporal lesion. The patient underwent near-complete tumour debulking. Histology demonstrated increased nuclear atypia within the pleiomorphic cell population, and mitotic figures visible within the ganglion cell-derived population consistent with tumor transformation to ganglioglioma with anaplastic features . BRAF-targeted therapy in the form of the BRAF inhibitor encorafenib in combination with the MEK inhibitor binimetinib. MRI of the brain 3 months post-initiation of BRAF-targeted therapy demonstrated interval reduction in the size of the cystic tumor lesions in the right basal ganglia and midbrain suggestive of treatment response  reported an objective response rate of 25% across all gliomas studied  for the publication of any potentially identifiable images or data included in this article.CC and SO’R: conceptualization and methodology. CC: data curation and writing of the original draft. CC, RM, FB, MJ, NB, and LL: investigation. CC, FB, MJ, NB, and LL: visualization. CC, SO’R, RM, FB, MJ, NB, LL, GW, LG, and PM: writing—reviewing and editing. All authors have read and agreed to the published version of the manuscript.


Endometriomas are a type of ovarian cyst composed of degenerated blood products from hemorrhage of ectopic endometrial tissue. Endometriomas can rupture, causing hemoperitoneum, and present with signs and symptoms similar to other, more common abdominal emergencies. Therefore, they are not often diagnosed preoperatively. Ultrasound and cross-sectional imaging can assist in diagnosis of endometriomas. We present a case of ruptured endometrioma causing massive hemoperitoneum that was initially suspected to represent malignancy with carcinomatosis.A 32-year-old Hispanic woman presented with sharp abdominal pain and 15-pound unintentional weight loss over 6 months. Laboratory work was significant for a negative pregnancy test and elevated cancer antigen-125. Computed tomography of the abdomen and pelvis demonstrated a 13-cm complex cystic mass in the left adnexa with moderate hyperdense ascites and omental nodularity. Ultrasound demonstrated a large left adnexal complex cystic structure with internal echoes, and chest computed tomography showed no signs of intrathoracic neoplastic or infectious processes. Her presentation was concerning for malignancy with carcinomatosis. Fluid from a paracentesis was sent for culture and cytology. Diagnostic laparoscopy revealed that the left ovary had been completely replaced by an endometrioma, which had a small ruptured area superiorly. Brown deposits of endometriosis were present on the cyst, omentum, and various peritoneal linings. Tissue samples of the endometrium, myometrium, cervix, ovaries, fallopian tubes, peritoneum, omentum, and paracolic spaces were taken and showed no hyperplastic, dysplastic, or malignant cells on pathology.Ruptured endometrioma and ruptured hemorrhagic cyst should be included in the differential diagnosis when a premenopausal female presents with hemoperitoneum in combination with complex adnexal cystic masses in the absence of trauma. Cancer antigen-125 and cancer antigen 19-9 can be falsely elevated in the setting of ruptured endometrioma. Endometriomas, a type of ovarian cyst, occur in 17–44% of women with endometriosis . HoweverAccording to current literature, ruptured endometriomas are rarely diagnosed preoperatively, as they share similarities with other, more prevalent abdominal emergencies . In thes3/MCL , aspartate aminotransferase (AST) 273 U/L , alanine transaminase (ALT) 149 U/L , and cancer antigen-125 (CA-125) 4663 U/ML . Urinalysis was positive for protein, ketones, and red blood cells.A 32-year-old Hispanic woman presented with sharp pain in her upper to mid abdomen. She had no significant medical history but reported 15-pound unintentional weight loss over the past 6 months. However, her abdomen grew in size during the same period. At time of admission, her abdomen was distended, and a 3/6 systolic murmur was heard at the left upper sternal border. Laboratory values were significant for leukocytosis to 17.5 × 10Contrast-enhanced computed tomography (CT) of the abdomen and pelvis demonstrated a 13-cm complex cystic mass in the left adnexa with moderate hyperdense ascites and omental nodularity, suspicious for ovarian neoplasm with carcinomatosis Figs. , 3. PelvSubsequently, the patient underwent a diagnostic laparoscopy and tissue sampling by gynecologic oncology. The left ovary was found to be completely replaced by an endometrioma with a thickened outer rind deeply adherent to the pelvic wall. The cyst had a small ruptured area superiorly. Brown deposits of endometriosis were present on the cyst as well as the omentum and various peritoneal compartments sampled. Biopsy of the anterior abdominal wall was obtained, which later revealed a minute fragment of fibrous tissue with few pigmented macrophages and benign mesothelial cells.Given that this patient had completed childbearing, she elected to undergo a modified radical hysterectomy with bilateral salpingo-oophorectomy, omentectomy, and peritoneal biopsies. Pathologic evaluation of the endometrium, myometrium, cervix, ovaries, fallopian tubes, peritoneum, omentum, and paracolic spaces demonstrated fibromuscular tissue with hemosiderin-laden macrophages and chronic inflammation suggestive of multiple foci of endometriosis Fig. . No hyped-dimer [In this patient with a painful adnexal mass, recent weight loss, elevated CA-125, and ascites suspicious for carcinomatosis, malignancy was initially considered as the most likely diagnosis. However, it is important for clinicians and radiologists to consider the possibility of a ruptured endometrioma in patients with these findings. A ruptured endometrioma can cause marked elevation of CA-125 as well as cancer antigen 19-9 (CA 19-9) and Imaging can be helpful in distinguishing between malignancy and endometrioma. On ultrasound, an endometrioma will typically appear as a cystic structure with low-level internal echoes . This isDespite these distinct imaging findings, laparoscopy is considered the gold standard for diagnosing endometriosis and endometrial cysts . EspeciaWhen premenopausal women present with hemoperitoneum in combination with complex adnexal cystic masses in the absence of trauma, differential diagnoses should include ruptured endometrioma and ruptured hemorrhagic cyst. CA-125 and CA 19-9 can be falsely elevated in the setting of ruptured endometrioma.


Ectopic Cushing syndrome (ECS) is a sporadic condition. Even uncommon is an ECS that derives from a carcinoid tumor of the thymus. These tumors may pose several diagnostic and therapeutic conundrums. This report discusses the differential diagnosis, clinicopathological findings, and effective treatment of a rare case of ECS using a minimally invasive approach.A 29-year-old woman with Cushing syndrome presented with facial flushing. Physical examination revealed hypertension (blood pressure: 141/100 mmHg). A mediastinal tumor was discovered to be the cause of the patient’s chronic hypokalemia and hypercortisolemia. Cortisol levels increased in the morning, reaching 47.7 ug/dL. The levels of the hormones ACTH, aldosterone, and renin were determined to be 281 pg/mL, 3.0 ng/dL, and 2.1 pg/mL, respectively. The presence of hypertension, hypokalemia, and alkalinity suggested Cushing’s syndrome, which was proven to be ACTH-dependent ECS by a dexamethasone suppression test. A chest CT scan revealed inflammation in the posterior basal region of the right lower lobe. The superior anterior mediastinum was characterized by round-shaped isodensity lesions with distinct borders. She underwent thoracoscopic anterior mediastinal tumor excision via the subxiphoid technique (R0 resection); following surgery, her blood pressure returned to normal, and the hypernatremia/hypopotassemia resolved. The tumor was determined to be a thymic carcinoid. Most notably, cortisol levels fell to half of their presurgical levels after one hour of surgery, and other abnormalities corrected substantially postoperatively.Thoracoscopic excision of thymic tumors by subxiphoid incision may be a useful treatment option for ECS caused by neuroendocrine tumors of the thymus Cushing syndrome is caused by chronic exposure to an excess of endogenous or exogenous glucocorticoids that affect the normal function of the hypothalamic-pituitary-adrenal axis. Ectopic Cushing Syndrome (ECS) is a rare and complicated condition with serious morbidity concerns. A female patient was diagnosed with ECS caused by a thymus neuroendocrine tumor, an extremely rare cause of ECS. The single subxiphoid incision could be a novel approach in this setting; however, to the best of our knowledge, it has not been employed in the context of ECS involving anterior mediastinum tumors. After a comprehensive diagnostic assessment, we could successfully manage this complicated case by thoracoscopic resection via a single subxiphoid incision, demonstrating that if there are no metastases, thoracoscopic resection via the subxiphoid incision of the whole lesion can be effectively performed.Cushing syndrome (CS) affects 2–25 people per million in the general population each year . It is pNeuroendocrine tumors pose unique diagnostic and treatment difficulties in this setting due to their ability to form at a variety of anatomical sites. Patients with these types of tumors frequently suffer an elevated risk of morbidity as a result of diagnostic and therapeutic delays. Because of advancements in minimally invasive technology, the thoracoscopic method has grown more common among other treatment modalities in recent years. The single subxiphoid incision is a novel way to perform such operations; however, to the best of our knowledge, it has not been employed in the context of ECS involving anterior mediastinum tumors , 13. TheThe primary symptoms were face flushing for one month and hypertension for one day.A 29-year-old non-smoking and non-alcoholic woman was admitted. A functional examination showed no mood swings, impatience, dread, tiredness, hunger, polyphagia, palpitation, or paroxysmal sweating. There was no apparent impairment in vision, chest discomfort, fever, cough, or cough, and sputum throughout the course of the disease.She had a history of polycystic ovary syndrome diagnosed five years ago.The patient had a normal obstetric history and no significant family or surgical history. Her social history was also normal.oC body temperature. The BMI was 25.18 kg/m2, and the waist-hip ratio was 0.98. The abdomen has a little bloated appearance. She had the face of a full moon, the back of a buffalo, and central obesity  but no abnormalities of the lungs or heart. Initial vital indicators included 118 bpm heart rate, 20 bpm breathing rate, and 36.2 3 = 30.5 mmol/L , and Na 147.1 mmol/L . She had a WBC count of 8.56 × 109/L . The seven items of regular stool testing + occult blood and tumor markers revealed no apparent abnormalities. Sinus tachycardia electrocardiogram (ECG) revealed ST-T alterations consistent with hypokalemia/alkalemia. The fasting glucose level was determined using an oral glucose tolerance test (OGTT); the glycated hemoglobin level was 6.3% , and all three diabetes autoantibodies were negative. Hormonal tests to determine the cause of hypertension are listed in Table On admission laboratory findings revealed K = 2.62 mmol/L , HCOCS detection was carried out by measuring 25-hydroxy vitamin D, which was found to be 21.3 ng/mL (20.1–30.0 ng/mL/vitamin D deficiency). Hormonal examinations showed that 17-hydroxyprogesterone was 22.54 ng/mL , dehydroepiandrosterone sulfate was 799.50 µg/dL , androstenedione was more than 10 ng/ml , anti-Müllerian hormone was 11.64 ng/ml , 17-ketocorticosteroid was 88.3 mg/24 h , and 17-hydroxycorticosteroid was 63.4 mg/24 h . Morning cortisol levels were increased to 1750 nmol/L , ACTH levels were increased to 57.5 pmol/L . Because cortisol levels increased as a result of disruption of circadian rhythm, a dexamethasone suppression test was performed. The morning cortisol level was not suppressed to < 50 nmol/l after the low dose (2 mg) dexamethasone suppression test, while ACTH remained substantially elevated, suggesting ACTH-dependent CS. There were no apparent abnormalities with respect to urine vanilla mandelic acid, urine catecholamines, thyroid function, parathyroid hormone, IGF-1, growth hormone, or gonadotropin. The ambulatory blood pressure was 196/117 mmHg, with a maximum systolic blood pressure of 227 mmHg, a maximum diastolic blood pressure of 127 mmHg, a minimum systolic blood pressure of 178 mmHg, and a minimum diastolic blood pressure of 101 mmHg. The mineral density of the bones was normal.Detailed imaging tests were performed to identify the underlying pathology. In the renal arteries, kidneys, and adrenal glands, color Doppler ultrasound did not reveal apparent abnormalities. The brain computed tomography (CT) scan and magnetic resonance imaging (MRI) revealed no pituitary adenoma. A chest CT scan revealed inflammation in the posterior basal region of the right lower lobe. The superior anterior mediastinum was characterized by round-shaped isodensity lesions with distinct borders Fig. B. The maThe presence of masses in the anterior superior mediastinum soft group led us to suspect thymoma. Other noteworthy imaging findings were diffuse hyperplasia of both adrenal glands and multiple small stones in both kidneys. Based on biochemical and radiologic tests, the cause of her CS was suspected to be ectopic ACTH production , 10, 13.The final diagnosis of the presented case was CS due to ectopic ACTH production.Minimally invasive thoracoscopic surgery via subxiphoid single-incision Fig. C was perHistological morphology and immunohistochemical results revealed that it was a carcinoid neuroendocrine tumor G1) . The surgical incision below the xiphoid has healed absolutely then (Fig. CS is a rare endocrine disorder, presenting a cluster of symptoms caused by an excessive level of glucocorticoids . It is oClinical features of CS include violaceous striae, muscle weakness, bruisability, and bone loss . HoweverNeuroendocrine tumors can occur in multiple organs and tissues , while gACTH may be secreted by thymic carcinoid and thyroid medullary cancer . In our Although the clinical signs and symptoms of CS are minor, metabolic abnormalities are more noticeable. Importantly, hypokalemia can be detected in up to 58% of people . Our patDespite extensive research, the pathogenesis of thymomas and the best treatment options are still open for discussion . RemovalIn essence, our case indicates that if there are no metastases, thoracoscopic resection of the whole lesion can be performed. According to our previous surgical experience, minimally invasive thoracoscopic surgery via a single subxiphoid incision has less trauma and can shorten the operation time. It can also greatly reduce the postoperative pain of the patients and make the postoperative recovery faster compared with the surgical resection of the thymic tumor through traditional lateral thoracic wall incision. In addition, thoracoscopic surgery via a single subxiphoid incision can remove the thymic tumor in a larger area, sweep the adipose tissue around the thymus more thoroughly, and has no significant increase in surgical complications. However, if preoperative CT confirms a huge mediastinal tumor or local invasion, thoracoscopic excision of the tumor via the subxiphoid incision would not be a preferred treatment option. A more intensive surgical approach is desired via thoracotomy or sternotomy in the case of advanced disease.Thymic carcinoids are uncommon; nonetheless, if an ectopic Cushing syndrome diagnosis is suspected, these lesions should be investigated, and a chest radiograph followed by CT should be performed to screen for this critical source of ectopic ACTH production that leads to CS. Rapid resolution of hypercortisolemia in our case suggests that thoracoscopic resection is an effective surgical therapy for such patients. If the surgical guidelines are followed correctly, thoracoscopic surgical excision of the thymic tumor by a subxiphoid incision would be an advanced and safe surgical procedure.


It is usually asymptomatic thus it is generally found incidentally in radiologic evaluations. Computed tomography is the best radiologic modality for its evaluation. The characteristic findings are ground-glass lesions surrounded by a rim or shell of reactive bone.This study presents a 52-year-old male patient with a huge chest wall tumor arising from the posterolateral aspect of the right fourth to seventh ribs measuring 38 cm. He underwent a thoracotomy and the tumor was resected. For safe margin, the third and eighth ribs were also resected. The defect was reconstructed with a prolene mesh patch and a pectoralis major flap. The final pathology report stated a tumor composed of spindle cells without pleomorphism or mitotic figures with intervening branching and anastomosing bone trabeculae. The margins were tumor-free and on the follow-up, the patient's condition was decent.Primary tumors of the rib account for 5 % to 7 % of all primary bone neoplasms. Fibrous dysplasia makes up 0.8 % of primary bone tumors. Fibrous dysplasia usually causes no symptoms although it can get massive enough to get symptomatic. Its diagnosis is made through clinical, radiological, and histopathological investigations. CT scan findings are the cornerstone for radiologic evaluations. An individualized approach based on the patient's age and symptoms should be considered.Considering that the malignant degeneration of the tumor is uncommon, early diagnosis and surgical resection of the tumor can be curative. •A 52-year-old male patient with a huge chest wall tumor arising from the right fourth to seventh ribs•Histology: spindle cells without pleomorphism or mitotic figures with intervening branching and anastomosing bone trabeculae•An intramedullary lesion with a ground-glass center and cortical thickening measuring 38 cm in diameter•Primary tumors of the rib constitute 5% to 7% of all primary bone neoplasms.•Fibrous dysplasia usually produces no symptoms. The lesions are detected accidentally during radiological investigations. Bone lesions have ground-glass patterns in plain x-ray images due to the replacement of normal bone with radiolucent tissue. Bone lesions are surrounded by rims or shells of reactive bone and are a characteristic finding 2This study presents a 52-year-old middle-eastern male patient with a huge slow-growing chest wall mass located on the right chest wall. His past medical and surgical history was unremarkable and he had no known allergies albeit he was a smoker. The patient's vital signs were all within the normal range . Except for the large firm chest wall mass located on the right chest wall, his physical examination was unremarkable. Chest X-ray and computed tomography (CT) displayed a giant intramedullary lesion with a ground-glass center and thickening of the cortex arising from the posterolateral aspect of the right fourth to seventh ribs measuring 38 cm in diameter. The pulmonary function test (PFT) of the patient, who was a smoker, revealed the following: FEV1, 55 %; FVC, 53 %; FEV1/FVC 0.79; FEF25–75: 47 %. A 3-dimensional reconstruction of the CT scan was performed and in 3Primary chest wall tumors are infrequent. Primary tumors of the rib constitute 5 % to 7 % of all primary bone neoplasms. Benign bone tumors of the chest wall consist of osteochondroma, fibrous dysplasia, chondroma, and eosinophilic granuloma Fibrous dysplasia accounts for 0.8 % of primary bone tumors and was first described by Lichtenstein in 1938. It is characterized by the replacement of normal bone with fibrous tissue and immature bone structures Fibrous dysplasia usually produces no symptoms. The lesions are detected accidentally during radiological investigations. However, in rare cases, they may become symptomatic as they grow in size. They can also cause pathologic fractures, neuropathy, and deformities sα at the Arg201 codon are positive and the tumor cells do not express the proliferating cell nuclear antigen Clinical, radiologic, and histopathological investigations are the pillars for the diagnosis of fibrous dysplasia. CT scan findings are the cornerstone of radiologic evaluations. The “ground-glass” appearance is the result of medullary space replacement by the mixture of woven bone and fibrous components In an asymptomatic patient with typical radiologic features consistent with the diagnosis of fibrous dysplasia, a biopsy can be withheld. In that case, conservative management with a close clinical and radiological assessment for tumor progression is reasonable Surgical intervention is indicated when symptomatic lesions or deformities and pathologic fractures are present. Regarding skeletal maturity and the possibility of tumor progression and maturation, age is an important factor in decision-making for surgical treatment Complete resection of the lesion is sufficient and the defect has to be reconstructed. In our case, we used both a pectoralis major flap and a prolene mesh. As far as we know, few reports have described huge fibrous dysplasia of the chest wall. Mahadevappa et al. reported a case report of a 70-year-old female with a chest wall mass measuring 10 × 9 cm in size, However, this tumor was smaller than the one we observed in our case 4Fibrous Dysplasia is a rare bone tumor with slow progression. Considering that the malignant degeneration of the tumor is uncommon, early diagnosis and surgical resection of the tumor can be curative in symptomatic patients.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Investigations were in accordance with Helsinki Declaration of 1964 and all subsequent revisions.This study did not receive any specific backing from funding agencies in the public, commercial, or non-profit sectors.Amini Hesam.N/A.Ershadi Reza: Writing – original draft, Resources. Amini Hesam: Conceptualization, Writing – original draft, Investigation, Resources, Methodology, Validation, Supervision, Writing – review & editing. Soltanmohammadi Sara: Writing – original draft, Resources. Rafieian Shahab: Writing – original draft, Resources.N/A.


An encephalocele is a congenital tube defect in which there is an extension of intracranial structures outside the normal confines of the skull. Its presentation at birth provokes a lot of anxiety amongst parents, guardians and care providers with regards to compatibility with life, surgical treatments and effects on developmental milestones and higher mental functions. This report is on our initial experience in the first six months following surgical treatment of four consecutive cases presenting in infancy. The aim of this case series is to report our initial experience of the management of encephaloceles using four consecutive cases that presented in infancy. A review of four infants who presented to our neurosurgery service was conducted including patterns of presentation, neuroimaging findings, scope of surgical intervention and neurological outcome at the six-month review. The results are presented in short case reports and summarized in a table. Two five-month-old females, one six-month-old female and one two-month-old female infants presented to our neurosurgery clinic with progressively increasing encephaloceles at different locations. Brain MRI revealed meningo-encephalocele in all, but with associated hydrocephalus in two cases only. They all had excision and repair of encephalocele under the same general anaesthesia while only two had a ventriculoperitoneal (VP) shunt. Developmental milestones were on course at 6 months follow-up following discharge. Although the presentation of encephaloceles can be frightening to parents and care providers, careful clinical and radiological evaluation is a recipe for sound surgical planning and improved outcome. Encephalocele is a congenital neural tube anomaly that is characterized by an extension of the normal intracranial structures outside the normal confines of the skull . It is sCase 1A five-month-old female child presented with a five-month history of progressive occipital swelling that was noticed from birth. Her mother did not attend any antenatal service during pregnancy and was not on any folic acid before conception. Clinical examination showed a stable and playful child with a large fluctuant, transilluminating occipital swelling almost the size of her head. Occipitofrontal circumference (OFC)was 58 cm with bulging and tense anterior fontanelle. Brain MRI scan showed features in keeping with a large meningo-encephalocele with hydrocephalus Figure . She hadCase 2A five-month-old female infant presented with swelling at the back of the head, however, her mother attended an antenatal clinic and was on her routine antenatal medications. Clinical examination showed a stable infant, with marked craniofacial disproportion, tense anterior fontanelle and OFC of 57 cm. She had a huge fluctuant non-tender occipital, transilluminating mass, measuring 15 cm by 8 cm. Brain MRI done showed features in keeping with occipital meningo-encephalocele and hydrocephalus Figure . She hadCase 3 and was on folic acid. Clinical examination showed a multilobed non-tender cystic mass originating from the nasal bridge and overlying the face. The OFC was 45 cm. Brain MRI showed features in keeping with frontoethmoidal meningo-encephalocele  camp with swelling at the back of the head. The mother did not attend any antennal clinic for obvious reasons. Clinical examination showed a stable infant, with a normal OFC of 37 cm. She had a huge fluctuant non-tender occipital, transilluminating mass, measuring 15 cm by 8 cm. Brain MRI done showed features in keeping with occipital meningo-encephalocele but no hydrocephalus. She had a repair of the occipital encephalocele and suffered wound infection and breakdown which increased hospital stay to 4 weeks but subsequently discharged to outpatient follow-up. At six months review, milestones were satisfactory (Figure Table Encephalocele commonly is a congenital anomaly but can be acquired following intracranial space-occupying lesions like brain tumours . Based oBoth genetic and environmental factors have been suggested in the etiology, however, details of its cause remain poorly understood. This condition is seen more in children born in families with low socioeconomic status, and maternal folate deficiency has also been implicated, but there is still a paucity of data to confirm . From thRadiologic evaluation of these patients includes CT and MRI, which characterized the lesion and its contents as well as the anatomy of the bony defect. But perhaps, more important for surgical planning and safety is angiography studies for vascular involvement . This isThe choice and extent of surgery are determined by pre-operative clinical and radiological findings. For the two cases with encephalocele associated with hydrocephalus, the surgical principle adopted was to first construct a VP shunt to divert the CSF from the encephalocele. Then followed on the same general anaesthesia with muscle relaxation by the excision and repair of the hernial defect. Following the excision of redundant brain tissue which is believed to be non-viable, the overlying dura is repaired in a watertight fashion with a continuous 3.0 vicryl suture. Then the galea layer and finally the skin is repaired with 3.0 nylon after excising the redundant skin to achieve a reasonably acceptable cosmetic look. Diversion of the CSF flow from the repair prevents fistula and wound breakdown. The other two cases that did not have associated hydrocephalus had a straightforward repair of encephalocele under general anaesthesia as outlined above. Wound healing was perfected in 10 days post-op and three cases were discharged within two weeks. Unfortunately, one of the cases stayed extra two weeks following suboccipital wound breakdown due to infection and undernutrition.It appeared that all the four cases studied were on schedule with developmental milestones at 6 months follow-up. They had all achieved psychomotor milestones appropriate for age, however, further follow-up over the years will determine appropriate higher mental functions development. The probable determinants of outcome perhaps have been documented to include the volume and eloquence of herniated brain tissue content as well as the size of the encephalocele. Larger size and increased volume of herniated brain tissue confer a worse prognosis . It is fAlthough the presentation of encephaloceles can be frightening to parents and care providers, careful clinical and radiological evaluation is a recipe for sound surgical planning and improved outcome. In our case series, the initial six-month follow-up revealed acceptable psychomotor development, although a longer term follow-up is required to achieve better determination of higher mental function development. In the meantime, parents and care providers have a lot to savour in terms of the magical cosmetic transformation and quality of life for these cases. There should therefore be an intensified effort towards sensitization and advocacy towards early presentation of these cases.


Lymphangiomas are benign hemartomatous tumors that can occur in all parts of the body, but most frequently in the neck (75%), as well as in the axilla and inguinal areas. Surgical removal is very difficult, as it is very fragile and tumor dissection is very difficult. Ultrasound-guided bleomycin injection directly into the cyst collapses the cyst and shrinks the tumor. It reduces proptosis, discomfort, and cosmetic blemish. We present this case who had gross defective vision and relative afferent pupillary defect in her right eye for 10 days which tremendously improved after injection. Lymphangiomas are non-encapsulated branching lesions lined by a single layer of flat endothelium . The undA 6-year-old girl came to us with complaints of acute prominence of her right eye since 10 days. The child has had blurred vision in the right eye since then. The parents gave history of previous prominence of the right eye which aggravated with respiratory tract infection Figure 1 . On examUnder general anaesthesia, the area was cleaned and draped. Lateral canthotomy and cantholysis was done to relieve compression. The cyst was located using an ultrasound B-scan with the help of a retinal surgeon in orbit mode. A 23-gauge needle was passed through the inferior orbital compartment and it was navigated under guidance of the B-scan. The cyst can be clearly visualized as a well-encapsulated lesion with hyperechoic borders and a hypoechoic center. The needle track can be visualized on the screen of the B–scan; and once it punctures a cyst, the fluid is aspirated, then the needle is kept in place, and bleomycin is injected using another syringe. We injected 0.5 IU/kg body weight of bleomycin to the cyst. The ratio of aspirated fluid and bleomycin should be 5:1. Cyst aspiration and sclerosant injection can be done safely.Post–operatively, the patient was given a course of intravenous steroids followed by oral steroids. The patient responded very well to the first injection. She came back with gross reduction in the proptosis and great improvement in vision Figure 2 . UnfortuIncreased orbital pressure can compress the optic nerve and can lead to irreversible vision loss in a few minutes. Rishiem et al.  have repLymphangiomas are low-flow vascular lesions that can be classified based on the location as superficial , deep (lesion extending to the orbit), combined , and complex (involving structures of head and neck). Lymphangiomas can also be classified based on the size as macro and microcyst .Orbital lymphangiomas are ill-defined, non-encapsulated, cystic, and solid orbital lesions that commonly involve the whole orbital spaces including preseptal, postseptal, intraconal, and extraconal compartments. Removal by complete surgical excision is hazardous as it can cause iatrogenic damage to adjacent structures. Moreover, surgical excision can cause disfigurement due to an ugly scar as well. Incomplete excision can lead to recurrence. Since the diagnosis is very characteristic with imaging findings, we did not open the orbit and did not perform histopathology. Hence nonsurgical methods such as intralesional sclerosing agents have been tried as an alternative. Adjunct therapies are safe and effective as well. Non-invasive sclerosant therapy is an efficient alternative for surgery in cases with lymphangioma.Bleomycin causes a sclerosant effect on the endothelium and collapses the cyst wall . It alsoThere is no fixed protocol regarding the number of injections. Raichura et al.  gave up An acute tense globe tends to compress the optic nerve and can cause an irreversible loss of vision. Hence, our article aims to stress the fact that such conditions have to be managed in an emergency by performing a simple canthotomy and cantholysis to relieve the pressure on the nerve. Ultrasound-guided bleomycin is an excellent treatment of choice. However, if there is no access to B-scan or bleomycin, a wiser option would be to perform a simple decompression (canthotomy and cantholysis), as this could save an eye.Intralesional bleomycin is a very safe and noninvasive method to treat orbital lymphangioma. There are a lot of case series reporting the efficiency of this drug. Not much is reported about the efficacy of the drug with respect to the duration of the problem. However, treatment of lymphangiomas with non-invasive techniques can be tried in such tense globes irrespective of the duration.Informed consent has been obtained from the patient’s legal guardian for the publication of this case report.The authors declare that they have no competing interests.


Glomus tumors (GTs) are benign tumors formed at the anastomosis of arteries and veins, affecting blood flow and temperature control. The tumor can occur in any part of the body. Owing to little data concerning tracheal glomus tumors (TGTs) of uncertain malignant potential, more accumulated cases are required to clarify its characteristics. In this report, we also review relevant literature and discuss the common features and treatments of GTs.A 53-year-old female presented with a one-year history of cough and intermittent shortness of breath without hemoptysis or smoking history. She was admitted to the Respiratory Department due to an initial diagnosis of chronic obstructive pulmonary disease (COPD). No improvement in shortness of breath was observed after receiving long-term treatment for spasm and asthma. Spiral computed tomography (CT) with three-dimensional reconstructions in conjunction with tracheal CT enhancement scan showed enhanced tissue in the initial segment of the trachea, measuring approximately 1.4 × 0.9 × 1.4 cm . A polypPostoperative pathology B revealeGlomus tumors are rare soft tissue neoplasms derived from modified smooth muscle cells.Clinically, symptoms associated with airway irritation are common in bronchial and tracheal GTs, but asymptomatic GT usually occurs in the peripheral pulmonary parenchyma.While there is currently no consensus on the treatment of TGTs. Masoum et al.To the best of our knowledge, there are 77 published articles regarding GT in the English language medical literature , most ofWe suggest that as respiratory symptoms cannot be effectively resolved, it may be necessary to perfect examinations for rare diseases conscientiously, especially GTs can be easily missed and misdiagnosed. Although there is no cure in this case, initial bronchoscopy intervention plays a key role in timely and effectively restoring the airway of patients with severe symptoms and providing preoperative diagnostic information. The bronchoscopy biopsy should be avoided due to the tumor’s rich vasculature. Complete resection of the tumor remains the basic procedure of treatment. Long-term followup of tracheal conditions after surgery is certainly necessary.Tracheal GTs of uncertain malignant potential, while uncommon, currently have no uniform standards for the surgical treatment of GTs and can be easily mistaken for a pulmonary disease if the symptoms are atypical, we should pay attention to it. Radical resection is still worthy of consideration because of the possibility of recurrence in the clinic. Additionally, tracheal stenosis is the most likely complication of concern.The authors declare no conflicts of interest.


Described by Dandy in 1921, the posterior interhemispheric transcallosal approach provides an operative corridor to the pineal region, posterior third ventricle, and upper midbrain. Intervenous-interforniceal and paravenous-interforniceal variants have been utilized for midline and paramidline pathology, respectively. The intervenous-interforniceal variant capitalizes on the natural separation of the internal cerebral veins, which are found medial to the forniceal crura at this level, to provide a safe corridor to the tumor while minimizing the risk of injury to the fornices. Here, the authors describe a posterior interhemispheric transcallosal approach using the intervenous-interforniceal variant for resection of a periaqueductal pilocytic astrocytoma.https://youtu.be/mtQKEXEveTg.The video can be found here:  In this video, we describe a posterior, interhemispheric, transcallosal intervenous-interforniceal approach to a periaqueductal tegmental tumor.The patient was a 15-year-old female who presented with headaches. Imaging revealed obstructive hydrocephalus secondary to a mass centered in the periaqueductal region of the tegmentum.T1- and T2-weighted MRI sequences demonstrated a T2 hyperintense mass centered along the periaqueductal region, measuring approximately 1.3 cm in all three planes. There was nodular rim enhancement of the lesion. Mild tumoral edema was visualized extending along the posterior and medial margins of the mass, with mass effect resulting in obstruction of the cerebral aqueduct.Coronal views demonstrated that the posterior commissure was draped over the mass, and sagittal views indicated that the tectum was displaced posteriorly by the lesion.Initially, an endoscopic third ventriculostomy was performed. Using the same burr hole, an endoscopic biopsy of the mass was attempted. However, an ependymal layer overlying the mass resulted in poor visualization and localization of the lesion, and a biopsy could not be performed safely. Therefore, an open biopsy and resection of the mass via a posterior transcallosal intervenous-interforniceal approach was recommended. More posteriorly directed approaches, such as the supracerebellar infratentorial approach and the occipital transtentorial approach, were considered suboptimal due to the posterior displacement of the tectum by the tumor, placing this structure in the path of surgical dissection.A key feature of the posterior transcallosal intervenous-interforniceal approach is the anatomical relationship of the internal cerebral veins and forniceal crura. There is a natural separation of the internal cerebral veins at the posterior aspect of the corpus callosum, just proximal to their confluence with the vein of Galen. The forniceal crura are always lateral to the internal cerebral veins at this level. Therefore, by maintaining a plane of dissection between the two internal cerebral veins, the fornices remain protected.This anatomical relationship is highlighted by the patient’s preoperative imaging. The coronal T2-weighted MRI demonstrates the separation of the forniceal crura posterior to the body of the fornix, and the lateral location of the crura relative to the internal cerebral veins. This view illustrates that a midline, posterior interhemispheric, transcallosal intervenous-interforniceal approach would provide a direct path to the underlying tumor.With this in mind, a posterior transcallosal intervenous-interforniceal approach was performed. The patient was placed in the MRI-compatible carbon graphite pin head holder. She was secured in the supine position with her neck flexed. Using stereotactic navigation, the sagittal sinus was marked and a modified zigzag bifrontal incision was marked at the frontoparietal junction. Burr holes were placed on either side of the midline, and a bifrontal craniotomy was turned at the posterior aspect of the frontal region. The dura was opened on the right in a C-shaped fashion and flapped towards the sagittal sinus.Upon opening the dura, the brain was noted to be quite full. The frameless stereotactic navigation system was used to make a small corticotomy in the parietal region and a catheter was guided into the right lateral ventricle. Using the frameless stereotactic system, we opened the posterior corpus callosum using bipolar coagulation. Once the callosotomy was complete, we entered the body of the right lateral ventricle.The choroid plexus and fornix were identified. Next, the septum pellucidum was fenestrated and opened. This allowed us to view both fornices as they separated with the internal cerebral veins at the posterior aspect of the corpus callosum.After confirming our location with our stereotactic neuronavigation, we opened into the vellum interpositum. The velum interpositum forms the roof of the third ventricle and contains the paired internal cerebral veins and medial posterior choroidal arteries. We continued to expose the internal cerebral veins. The thin, translucent tela separating the internal cerebral veins came into view and was opened. This facilitated separation of the internal cerebral veins.Once the roof of the third ventricle had been fully opened, the white matter of the posterior commissure was transected. Gray, gelatinous tumor was immediately encountered. Biopsies were taken for permanent specimen. The ultrasonic aspirator was then brought into the field and used to gently remove the tumor by suction. We continued to slowly resect tumor using the ultrasonic aspirator. Eventually, we were able to open the cerebral aqueduct. However, at its margins, the tumor appeared to become infiltrative and appeared to involve the periaqueductal region. This area felt firm. Additionally, it did not aspirate easily with the ultrasonic aspirator. Given that this region appeared to be infiltrated on imaging and was only visualized on the T2 sequences, we did not pursue further resection in this area. Hemostasis was secured, the wound was irrigated, and all cottonoids and Gelfoam were removed.Intraoperative MRI revealed a gross-total resection of the enhancing portion of the tumor, though there was a significant residual infiltrative component in the periaqueductal region. Given that the tumor appeared to be infiltrative at this level, the decision was made not to resect further.The patient was noted to have intact extraocular movements upon awakening from surgery. She initially reported mild diplopia, which resolved by discharge on postoperative day 3.The histology was consistent with a pilocytic astrocytoma, and discussions regarding adjuvant treatment are currently pending.


Intracranial xanthoma is a rare benign intracranial tumor. It often occurs in patients with hyperlipidemia. Intracranial xanthomas grow slowly, and clinical symptoms only appear when the mass compresses the surrounding tissues, so early diagnosis of the disease is difficult. Intracranial xanthoma is a rare benign intracranial tumor. It often occurs in patients with hyperlipidemia. Intracranial xanthomas grow slowly, and clinical symptoms only appear when the mass compresses the surrounding tissues, so early diagnosis of the disease is difficult.Figure 2D) and familial hypercholesterolemia; the patient’s LDL-R genetic test showed a T-G mutation at position 97 in exon 6 , supporting the diagnosis of homozygous familial hypercholesterolemia (HoFH); her parents had no relevant medical history, and her brother was diagnosed with heterozygous familial hypercholesterolemia (HeFH). Positive sign: the right eye was incompletely closed, the right frontal lines and nasolabial fold became shallow, right ear hearing loss was observed, and multiple masses were seen in the skin of the right popliteal fossa and buttocks , and excision of a left elbow mass . MRI showed the following: right middle posterior skull base mixed density mass (size of 4.6 cm × 4.1 cm × 3.7 cm), focal bone destruction ; Coronary CTA showed: Moderate stenosis at the origin of the left common carotid artery; cholesterol (TC): 14.9 mmol/L, low-density lipoprotein (L-DL): 12.87 mmol/L. After admission, ezetimibe was taken orally to reduce blood lipids. All tumors were removed by a surgray throwed retrosigmoid sinus approach under electrophysiological monitoring. Postoperative pathology showed xanthoma .A 25-year-old female complained of right-sided facial paralysis and hearing loss for 4 years, and an intracranial mass was found for 1 week. The patient had a history of left elbow xanthoma resection (The formation of xanthoma may be due to vascular adventitial cells ingesting lipoproteins and macrophage aggregates. Following lipoprotein exudation, these cells transform into vacuolized foam cells, within which serum lipoproteins are metabolized. Subsequent aggregation of cholesteryl esters, cholesterol, and phospholipids leads to the formation of xanthomas. According to whether companion has hyperlipoproteinemia, it can be divided into two kinds: hyperlipoproteinemia xanthoma and nonhyperlipoproteinemia xanthoma . Here, wThe pathogenesis of xanthoma is still controversial. At present, there are two theories about the formation mechanism of xanthoma. One theory is that local trauma or hemorrhage leakage causes lipids to enter peripheral tissues from blood vessels. The lipids accumulate in the cells and are swallowed by macrophages to form foamy macrophages and extracellular cholesterol. Crystals enter the gap and induce inflammation in macrophages and fibroblasts. The other theory is that abnormal elevation of blood lipids leads to an inflammatory response in undifferentiated mesenchymal cells. After a series of inflammatory reactions, they are phagocytosed by macrophages to form foam cells. This article reports that the formation of intracranial xanthomas may be related to the deposition of cholesterol crystals or the blockage of the adjacent mastoid air cells, leading to local tissue hypoxia and blood cell necrosis , 3.It has been reported in the literature that intracranial xanthomas mostly occur in the temporal occipital region . The MR Xanthoma is a rare benign intracranial tumor that needs to be differentiated from meningioma, cholesteatoma, lipoma, and other intracranial tumors. Early diagnosis of HoFH and effective drug treatment may reduce the incidence of xanthoma. For xanthomas with clinical manifestations, complete or partial resection of the tumor is required to relieve symptoms, and drugs are given for etiological treatment to prevent recurrence after surgery. In the future, gene therapy is worth looking forward to, and it may fundamentally solve this problem.


Testicular choriocarcinoma is a rare and aggressive subtype of nonseminomatous germ cell tumors accounting for <1% of all germ cell tumors. We report an unusual case of testicular choriocarcinoma metastasis that presents as hemorrhagic shock. Diagnosis was unsuspected and difficult with vast other potential causes. This case highlights the importance of proper foundational workup and management that ultimately led to the appropriate definitive treatment of unusual manifestations of undiagnosed metastatic choriocarcinoma in a critical patient. Choriocarcinoma is an uncommon type of a germ cell tumor. These neoplasms are trophoblastic in origin and are known to hematogenously metastasize to the lung, central nervous system and other genitourinary sites. Liver metastases is less common, occurring in 10% of patients with metastatic trophoblastic disease .A 44-year-old male with a past medical history of alcohol abuse presented to the emergency department with 2 days of right upper quadrant abdominal pain and vomiting. The patient was reported to have hematemesis prior to arrival. The patient was unable to give a comprehensive history due to altered mental status and was noted to be diaphoretic, pale and hypotensive on arrival. Hemoglobin, hbg, was noted to be 10.1 upon arrival; however, subsequent hbg was 5.3. Bedside arterial blood gas showed significant metabolic acidosis with a pH of 7.03 and lactic acid of 11. Massive transfusion protocol was started and vasopressor therapy was initiated. Bedside Focused Assessment with Sonography in Trauma, FAST, exam was performed and positive for fluid in the right upper quadrant. At this time, the patient had been stabilized and the decision was made to obtain a computed tomography angiography (CTA) of the chest, abdomen and pelvis. CTA revealed hemoperitoneum anterior to the left lobe of the liver, a large para-aortic and aortocaval mass with peripheral enhancement suggesting neoplastic adenopathy, measuring 5.2 × 8.1 cm, and a complex septated lesion in the right scrotum  and B.The patient was immediately taken from radiology to the operating room for exploratory laparotomy. Active bleeding was noted in the left lobe with lesions on the medial and lateral border of the left lateral segment. Argon beam coagulator was used to achieve hemostasis. An incisional biopsy of one of the lesions was performed.On postoperative Day 1, scrotal ultrasound was performed. The ultrasound findings were significant for a 6 cm complex cystic mass in the right scrotum . ImmunohTesticular cancers are categorized as either germ cell or non-germ cell tumors, with germ cell tumors further split between seminoma and non-seminomatous germ cell tumors. Choriocarcinoma is the rarest, comprising 1–3% of all testicular neoplasms . Our patIn a patient presenting with hemorrhagic shock, suggestive of intra-abdominal hemorrhage, it was pertinent to consider causes such as trauma, rupture of diseased blood vessels, hemorrhagic pancreatitis and vascular tumors. Rupture of metastatic hepatic tumors is rarer due to their fibrotic and less vascular nature; choriocarcinoma is an exception due to being a primarily vascular and hemorrhagic tumor with a propensity to rupture.Possible mechanisms of rupture that have been proposed include direct pressure by the tumor against the capsular surface due to increased intra-abdominal pressure or increased intravascular pressure secondary to tumor emboli, resulting in intra hepatic venous obstruction , 4.Hemorrhagic shock is a critical finding with a vast differential diagnosis. The key to management is prompt recognition and proper treatment. In this case, the clinical presentation of choriocarcinoma was subtle as CT imaging depicting multiple enhancing masses in the liver and lungs cannot be easily differentiated from other hyper vascular tumors . In the