Canine melanocytic neoplasms have a highly variable biological behavior ranging from benign cutaneous melanocytomas to malignant oral melanomas that readily metastasize to lymph nodes and internal organs. This review focuses on the diagnosis and prognosis of canine melanocytic neoplasms. While pigmented melanocytic neoplasms can be diagnosed with fine-needle aspirates, an accurate prognosis requires surgical biopsy. However, differentiating amelanotic spindloid melanomas from soft tissue sarcomas is challenging and often requires immunohistochemical labeling with a diagnostic cocktail that contains antibodies against Melan-A, PNL-2, TRP-1, and TRP-2 as the current gold standard. For questionable cases, RNA expression analysis for TYR, CD34, and CALD can further differentiate these two entities. The diagnosis of amelanotic melanomas will be aided by submitting overlying and/or lateral flanking epithelium to identify junctional activity. Wide excision of lateral flanking epithelium is essential, as lentiginous spread is common for malignant mucosal melanomas. Combining histologic features  with the Ki67 index provides the most detailed prognostic assessment. Sentinel lymph nodes should be evaluated in cases of suspected malignant melanomas using serial sectioning of the node combined with immunohistochemical labeling for Melan-A and PNL-2. Melanocytic tumors are common in dogs and occur primarily in the skin and oral cavity, with oral melanocytic neoplasms comprising 30–40% of all canine oral neoplasms ,2. AlthoIn dogs, the term melanocytoma is used to describe benign cutaneous melanocytic neoplasms, while the term malignant melanoma is used to describe malignant melanocytic neoplasms regardless of their location ,10. For There are also a number of important morphologic features that are characteristic of the different entities of melanocytic neoplasms in dogs. “Dermal” is the term used to describe melanocytic tumors that are confined to the dermis and do not involve the epidermis  ,11. In cMost melanocytic neoplasms are easily diagnosed via cytology or histopathology. Cytology has been shown to have a sensitivity and specificity of 100% for the diagnosis of pigmented melanocytic neoplasms; however, both sensitivity (67–100%) and specificity (85–100%) decrease when attempting to diagnose amelanotic melanocytic neoplasms ,14,15. CPoorly differentiated neoplastic melanocytes often have increased cytologic atypia such as increased anisocytosis and anisokaryosis, multinucleated cells, multiple and variably sized and shaped nucleoli, variable chromatin patterns, and variable nuclear-to-cytoplasmic ratios with cytoplasm that may contain few to many, small to large, clear vacuoles ,14,15. NDifferential diagnoses include pigmented basal cell tumors, Schwannomas, and peripheral nerve sheath tumors. Immunocytochemistry (ICC) for Melan-A may be helpful to differentiate between these non-melanocytic tumors or to diagnose amelanotic melanocytic neoplasms. If Melan-A ICC is negative and amelanotic melanoma is still strongly suspected, histopathology is recommended. Histopathology generally allows for more accurate diagnosis, via assessment of other morphologic features and the ability to perform additional immunohistochemical markers, and also provides an accurate prognosis . AlternaHistologically, well-differentiated neoplastic melanocytes present as round to polygonal to spindloid cells with variable amounts of eosinophilic cytoplasm that contains varying amounts of brown melanin granules. Different cellular morphologies have been reported, the most common being epithelioid/polygonal, spindloid/fibromatous, and mixed epithelioid and spindloid  . MultiplWhile epithelioid/polygonal, spindloid/fibromatous, and mixed epithelioid and spindloid are still the most common cellular morphologies of poorly differentiated melanocytic neoplasms, other cellular morphologies can also be seen in these less differentiated tumors ,9. Such Amelanotic melanocytic neoplasms are the most challenging to diagnose  ,18. HistSeveral different parameters are used to prognosticate canine melanocytic neoplasms. Few of these parameters are only prognostically relevant for either cutaneous or oral melanocytic neoplasms. Histologic and molecular parameters are the most useful prognostic factors. Ultimately the Ki-67 index is thought to be the most reliable prognostic factor for canine melanocytic neoplasms ,23.While signalment has been associated with the prognosis of canine melanocytic neoplasms, it should never be used as a standalone prognostic factor, as specificity is low. Some breeds are more likely to develop benign melanocytic tumors, and others are more likely to develop malignant forms. One study reported that in Doberman Pinschers and Miniature Schnauzers 75% of melanocytic neoplasms exhibited benign behavior, and in Miniature Poodles, more than 85% of melanocytic neoplasms exhibited malignant behavior . Older dIn general, melanocytic neoplasms of the nail bed, at mucocutaneous junctions, or in the oral cavity have a worse prognosis than cutaneous melanocytic neoplasms located elsewhere ,25,26. O2)  . While a2, which equals 10 fields at 40× magnification with an FN 22 ocular [2. Regardless, even if a slightly differently sized ocular was used in some of the previous studies, the thresholds would not be expected to be affected significantly. For cutaneous melanocytic neoplasms, a mitotic count of 3 or more has been associated with shorter survival times compared to neoplasms with a mitotic count less than 3 [The mitotic count has been shown to be a reliable prognostic indicator for canine cutaneous and oral melanocytic neoplasms in numerous studies ,34,36,372 ocular ,29. Studs than 3 ,16,30,34s than 3 .Pigmentation is somewhat difficult to quantitate histologically, resulting in interobserver variation. Regardless, highly pigmented cutaneous and oral/lip melanocytic neoplasms do appear to have longer survival times, and a cutoff of equal to or more than 50% of cells being pigmented has been associated with a better prognosis ,30,33,34The level of infiltration of neoplastic melanocytes into the underlying stroma has been shown to be prognostically significant in both cutaneous and oral/lip melanocytic neoplasms ,30,37,38Blood or lymphatic vascular invasion is a strong prognostic indicator of malignant behavior for both cutaneous and oral/lip melanocytic neoplasms .The presence of ulceration is used to predict more aggressive behavior of cutaneous melanocytic neoplasms only . It is nTumor thickness is a more recently recognized prognostic parameter for cutaneous melanocytic neoplasms ,34. TumoSeveral molecular parameters have been evaluated as prognostic markers but only the Ki-67 index is currently extensively used in a diagnostic setting.Several studies have demonstrated that the Ki-67 index, as determined by IHC, predicts the prognosis of both cutaneous and oral/lip melanocytic neoplasms ,37,39,402 optical grid reticle can be placed into the eyepiece and is helpful to keep track of which cells have been counted. At 40× magnification, 1 cm/40 = 0.25 mm (0.0625 mm2). Five fields = 0.3125 mm2, and 10 fields = 0.625 mm2. A threshold of 15% or more Ki-67 positive cells has been associated with shorter survival times of dogs with cutaneous melanocytic neoplasms [For cutaneous melanocytic neoplasms, the number of positive nuclei in 500 cells is counted at a magnification of 40× and reported as a percentage of positive cells . A 1 cm2eoplasms . None ofeoplasms . The Ki-eoplasms .2 optical grid reticle at a magnification of 40× (5 grid areas counted) in the highest labeling area [For oral/lip melanocytic neoplasms, the Ki-67 index is reported as the average number of positively labeled neoplastic melanocyte nuclei per area of a 1 cm ing area . A thresing area . The Ki-ing area .While the above-described prognostic factors help to predict the overall biological behavior of melanocytic neoplasms, accurate assessment of surgical margins is an essential component for determining the likelihood of local recurrence ,41. ExciWhile routine microscopic examination is most commonly based on cross-sectioning  of the submitted neoplastic mass, such sectioning is insufficient to detect laterally escaping neoplastic cells, especially in the overlying epithelium . AccuratEvaluation of sentinel lymph nodes for metastasis of melanocytic neoplasms is an important component of staging and determination of treatment strategies. While the mandibular lymph node is the primary metastatic site for canine oral/lip melanocytic neoplasms, 50% of these tumors commonly metastasize to other lymph nodes, especially retropharyngeal lymph nodes . ContralThe detection of metastatic melanoma by cytology, or histology, can be challenging, but there are some methods that pathologists can use to improve the sensitivity and specificity of metastasis detection. Fine-needle aspiration and cytology of lymph nodes is an easy, minimally invasive way to detect metastasis. However, the sensitivity of this method is low if there is only micrometastasis, as it can be easy to miss the areas of neoplastic cells during aspiration. The consensus between routine cytology and histopathology for staging lymph nodes in patients with melanocytic neoplasms is poor ; howeverCanine melanocytic neoplasms have variable biological behavior regardless of their location and prognostic evaluation requires a combination of microscopic assessment for nuclear atypia, mitotic count, degree of pigmentation, level of infiltration, and vascular invasion along with immunohistochemical determination of the Ki67 index. For cutaneous melanocytic neoplasms, the tumor thickness and ulceration of the lesion should be included in such evaluation. The general diagnosis of canine melanocytic neoplasms is often accomplished with fine-needle aspirates, but histopathology is often needed to differentiate between benign and malignant forms. Surgical biopsy is most important for oral melanocytic neoplasms as they are often compound melanomas with wide lateral intraepithelial (lentiginous) spread. Surgical excision should account for this characteristic feature, and submission of intact epithelium flanking an ulcerated area over the primary mass is strongly recommended. Wide excision also increases diagnostic accuracy by allowing the pathologist to search for junctional activity. Furthermore, amelanotic spindloid melanomas have to be differentiated from soft tissue sarcomas. An immunohistochemical cocktail that contains antibodies against Melan-A, PNL-2, TRP-1, and TRP-2 is the current gold standard to identify melanocytic neoplasms. RNA expression analysis for TYR, CD34, and CALD can be used in some challenging cases to confirm the diagnosis. Radial and tangential sectioning should be combined to provide the most accurate margin assessment. As oral malignant melanomas readily metastasize to the tributary lymph nodes, sentinel lymph nodes should be evaluated when a malignant oral melanoma is suspected. Microscopic evaluation of such nodes is best performed by serial sectioning of the node combined with immunohistochemical labeling for Melan-A and PNL-2.


Dermoid cysts are rare lesions generally associated with embryological errors that occur during neural tube closure. Intramedullary lesions are extremely rare, especially within the upper thoracic spinal cord.We report a case of a 19-year-old male who had an intramedullary thoracic dermoid cyst presenting with progressive ataxia, lower limb weakness, and hyperreflexia. MRI demonstrated a 1.2 × 1.8-cm intramedullary thoracic dermoid cyst causing significant spinal cord compression, which was successfully removed via full resection. The patient had an uncomplicated postoperative course, with improvement in preoperative deficits.This is a unique case documenting a thoracic spinal cord intramedullary dermoid cyst not associated with trauma or congenital abnormality of the spinal cord.We highlight the importance of future inclusion of diffusion-weighted magnetic resonance (MR) imaging (DWI) with apparent diffusion coefficient (ADC), an imaging modality that detects differences in cellularity of spinal cord lesions, for earlier diagnosis of dermoid cyst. •This is a unique case of intramedullary dermoid cyst not associated with trauma or congenital abnormality.•Diffusion-weighted magnetic resonance (MR) imaging (DWI) with apparent diffusion coefficient (ADC) was used to detect differences in cellularity of the spinal cord lesion.•We recommend future use of DWI and ADC mapping for early detection of intramedullary neoplasms. They This work has been reported in line with the SCARE 2020 criteria .2We present a 19 year old male with two month history of ataxia secondary to an intradural intramedullary expansile dermoid cyst in the spinal cord. The patient reported to clinic with progressively worsening numbness of the lower extremities and with difficulty walking beginning three months ago. Physical exam showed 2/5 strength in right lower extremity and 3/5 motor strength in left lower extremity, spastic with exaggerated reflexes and bilateral positive Babinski signs. There was no history of incontinence, infection, spinal trauma or previous spinal surgery. The overlying skin of the thoracolumbar region was intact, showing no signs of inflammation, nevi, or local hair growth. Patient denied history of weight loss, night sweats, body aches. Family history was noncontributory. The patient underwent a lumbar puncture which demonstrated elevated protein count but was otherwise negative. MRI scan of the dorsal spine was performed with T1-and T2-weighted images, which evidenced a focal, well-defined space-occupying lesion measuring 3.5 × 3.8cm [The patient had an uncomplicated postoperative course without abnormal neurological sequelae. At the 6-month follow-up, he reported improvement in all of his preoperative deficits including right lower extremity strength and ambulation. Follow-up radiological evaluation showed no evidence of disease recurrence.3Intraspinal dermoid cysts are exceptionally rare and insidious tumors that account for less than 1% of all spinal tumors . They arInclusion dermoid cysts are classified as either congenital or acquired. From a congenital developmental perspective, dermoids arise from cells retained from defective closure of the neural tube between the third and fourth week of embryonic life . Many ofAcquired dermoid cysts most commonly arise secondary to trauma from spinal instrumentation or iatrogenic injury. Acquired dermoids have been documented in children who have undergone multiple lumbar punctures for treatment of tuberculous meningitis and after myelomeningocele repair . AcquireWe suggest future use of diffusion-weighted magnetic resonance (MR) imaging (DWI) with apparent diffusion coefficient (ADC), which reflects tissue cellular capacity and helps with early detection of lesions such as intramedullary neoplasms and demyelinating diseases to assess the feasibility of surgical resection, medical treatment, and follow-up . ConventThe DWI technique is based on the principle that regulate free water motion in cellular environments. The calculation of ADC provides quantitative measurement of molecular water movement . HyperceThe treatment of choice for dermoid tumor is the total excision of the mass at an early stage, which often difficult to achieve since the capsule adheres to the cord . Magneti4True intramedullary dermoid cysts are rare, especially in a thoracic or cervical location. Their etiology is likely developmental or iatrogenic, with most cases associated with congenital lesions such as spina bifida and dermal sinus tracts. We presented a patient with a mid-thoracic intramedullary dermoid cyst without history of trauma or congenital spinal lesions. Intramedullary dermoid cysts should be considered in the differential in a young person with progressive neurological symptoms. We support the potential value of DWI imaging with ADC mapping in early diagnosis of dermoid tumor and preoperative surgical planning.Not applicable.None.JA was involved in the writing of the manuscript. SKD was involved in the editing/supervision of the manuscript.1Name of the registry: N/A2.Unique identifying number or registration ID: N/A3.Hyperlink to your specific registration (must be publicly accessible and will be checked): N/ASohum K. Desai MD.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.Not commissioned, externally peer-reviewed.N/A.All authors declare no conflicts of interest.


Cases of large bowel closed-loop phenomenon with cecal perforation are extremely rare, especially when extracolonic epiploic appendage and peritoneal bands are the cause. However, sporadic cases exist in the literature with various presentations, but very few occur in patients in the abdomen without a previous scar.An 89-year-old Sudanese farmer was admitted to the emergency department with 9-day history of generalized colicky abdominal pain, abdominal distension, anorexia, persistent vomiting, and constipation. Given his clinical presentation and assessment, he was diagnosed with peritonitis due to a perforated viscus in a virgin abdomen. Operative exploration revealed an extraluminal left-sided omento–epiploic band that resulted in closed-loop colonic obstruction with secondary multiple cecal perforations. Standard right hemicolectomy with adhesiolysis was done. Postoperative wound infection and hypoalbuminemia were treated, and the patient was discharged on postoperative day 9 on a regular oral diet.Although this condition is rare, it can be extremely dangerous, requiring prompt investigation and surgical intervention. It usually occurs secondary to raised intraluminal pressure with subsequent ischemia of the cecal wall. Through this case report, we aim to reflect on this rare experience, shedding light on the benign, extracolonic pathologies that can be life threatening or even fatal. Colonic/large bowel occlusion (LBO) is a critical surgical condition that requires prompt investigation and treatment. Colonic obstruction caused by genuine mechanical blockage must be essentially distinguished from uncomplicated paralytic ileus or pseudo-obstruction. The age-dependent etiology of this surgical emergency can either originate from a mechanical pause in intestinal content flow or colon dilatation in the absence of a pseudo-obstruction/anatomic lesion. Tumors, diverticulitis, severe inflammatory processes, fecal impactions, and volvulus may be the causes. An epiploic appendage band is an infrequent cause of significant colonic closed-loop obstruction, leading to cecal perforation addressed by our case report. Hence, it presents unusual benign but serious causes that may lead to tremendous comorbidities and even mortality if unrecognized.An 89-year-old Sudanese farmer was admitted to the emergency department with a 9-day history of generalized colicky abdominal pain, abdominal distension, anorexia, persistent vomiting, and constipation. The pain started in the left iliac fossa and periumbilical region then progressed to be generalized and colicky in nature. It was moderate to severe, mainly aggravated by eating, while partially relieved after vomiting and analgesia. It was associated with fever, anorexia, nausea, and vomiting. Eventually, the pain became diffuse, generalized, severe, and continuous, with abdominal guarding, distension, and absolute constipation for 1 day before the presentation. The systemic review was clear, apart from bilateral lower limb edema.The patient had a previous history of left-sided and lower abdominal pain but no lower gastrointestinal symptoms, including bleeding. He had no history of weight loss or jaundice. He had a clear medical and surgical background. He was not allergic to any drugs or under any chronic medications.On examination, he was fully conscious and oriented to time, place, and person. He was not pale or jaundiced. His presenting pulse rate in the ED was 108 beats per minute, normotensive with 130/70 mmHg blood pressure, and good hydration status. Abdominal examination revealed generalized abdominal distension with full flanks, and diffuse tenderness in all abdominal regions with guarding but no rigidity. There was no palpable organomegaly or masses. There were absent bowel sounds suggestive of severe generalized peritonitis and a bowel perforation. A digital rectal examination (DRE) revealed an empty rectum.3, mainly neutrophils, adequate platelets count, and C-reactive protein (CRP) of 189 mg/dl . The liver function test revealed low serum albumin of 2.3 g/dl  with a preserved albumin globulin ratio. The carcinoembryonic antigen (CEA) tumor marker level was checked, as a perforated colorectal tumor was one of our top differentials, but it was within the normal range. Urinalysis and blood electrolytes were normal.Blood analysis was requested which revealed hemoglobin of 12.6 g/dl, TWBCs of 22,000 × 10Erect chest and abdominal X-rays showed dilated bowel loops of the small and large bowel, cecal diameter of ≥ 12 cm, and free peritoneal/subdiaphragmatic gas (air under diaphragm).Considering the patient’s clinical examination, radiology findings, and patient status, severe peritonitis due to large bowel perforation secondary to an obstructing left-sided tumor was the provisional diagnosis.The colorectal surgeon’s decision was emergency surgical exploration. The contrast-enhanced computed tomography (CECT) of the abdomen was deferred, as it would delay the surgical exploration.Management including intravenous fluoroquinolones and metronidazole antibiotics, fluids, and intravenous human albumin replacement was initiated. An emergency exploratory laparotomy through midline incision revealed a distended large bowel up to the level of obstruction, free intraperitoneal bowel contents, patchy ischemia of the lateral cecal wall with three perforations, and left-sided omento–epiploic extraluminal band causing distal descending colon obstruction (large bowel closed-loop obstruction) Fig. .Fig. 1A in situ, and standard mass closure of the abdomen with size one monofilament, nonabsorbable polypropylene suture was accomplished.Formal laparotomy and careful examination of the abdominal organs, cavity, and bowel were carried out. Furthermore, a simple release of the constricting band with diathermy, standard right hemicolectomy, and ileo-transverse functional end-to-end stapled anastomosis with linear GIA stapler reconstruction Figs.  and 3 waOral intake started on postoperative day 2 and advanced as tolerated by the patient, reaching regular dietary intake by day 7. However, wound infection with purulent wound discharge was discovered during the first dressing on day 3 with intact facial layer. The intraabdominal drain became dry on postoperative day 5.The patient was discharged on day 9 with wound dressing protocol every other day. Regular dressing was done until the wound was clean by day 14. Surgical stitches were removed during the third postoperative week, and a 3-month follow-up was planned.Large bowel obstruction (LBO) in elderly patients presenting to the ED represents a complex investigative process considering the broad spectrum of colonic and extracolonic etiologies. Usually, colorectal cancer is the top differential diagnosis for this age group , 2. EpipWe are reporting a rare, exciting case of an extraluminal constricting band on the left side of the abdomen formed by the adherence of the great omentum to the appendices epiploicae of the descending colon. This band resulted in distal large bowel obstruction against a proximal competent ileocecal valve causing massive cecal dilatation, raised intraluminal pressure, and subsequent cecal perforations.et al. reported colonic closed-loop obstruction due to adhesions crossing from sigmoid wall appendage epiploicae and attached to the pelvic wall [Since this patient had no surgical history of abdominal surgery, with adjunct episode of left-sided lower abdominal pain reported, the possibility of inflammation of epiploic appendages or an occurrence of diverticulitis was the primary suspected cause of the formation of the band , 4. In avic wall .Although colorectal cancer is the most common cause of large bowel obstruction in this age group, the attending surgeon should consider other causes and work with the patient comprehensively. In the emergency department, the primary imaging modality is the plain erect and supine abdominal X-ray to check for findings suggestive of bowel obstruction and associated complications. Moreover, a CECT of the abdomen is usually requested to know the exact cause and level of obstruction, with the aim of formulating an entire surgical plan preoperatively.However, the patient’s condition and the expected delay the CECT of the abdomen would cause led the consultant colorectal surgeon to go immediately to emergency surgical exploration. Other differential diagnoses included complicated diverticulitis, volvulus, or internal hernia . AdditioMost of the reported literature on diastatic perforations proximal to an obstructing colonic pathology was related to colorectal cancers. Only three cases were reported for closed-loop colonic obstruction causing cecal perforation in NCBI/PubMed database –10.Operative surgical management is the primary option in cases where frank peritonitis is evident, and conservative strategies can apply in select cases according to patient’s condition and provisional diagnosis. Standard right hemicolectomy or segmental resection and lysis of the band are adequate to maintain the integrity and function of the colon with excellent postoperative outcomes , 11.Cases of closed-loop colonic obstruction leading to cecal perforations are sporadic, happening because of raised intraluminal pressure with a secondary ischemic cecal wall. The extraluminal band causing this condition is rare and can be seriously dangerous, requiring prompt investigations and surgical intervention.


To study the previously discovered clinical entity of adult intestinal duplication and its treatment, and propose an extension to its existing classification.  We report the case of an adult male with abdominal pain, constipation and vomiting. This patient underwent surgical separation of adhesions, reduction of torsion and intestinal decompression. Postoperative pathological findings confirmed the rare diagnosis of intestinal duplication. Adult intestinal duplication is quite rare. Its clinical manifestations are nonspecific. From this finding of intestinal duplication originating at the opposite side of the mesenteric margin, a further extension of the existing anatomical classification is proposed. Digestive tract duplication is a rare congenital malformation that can involve any segment of the gastrointestinal tract.A 53-year-old male patient presented to our emergency department with the main complaint of abdominal pain and constipation for two days. His past medical and family histories were unremarkable. He had been smoking for 20 years (10-15 cigarettes a day). He denied having any allergies or previous illicit drug or alcohol use.On physical examination, the patient’s body temperature was 36.8 °C, the abdomen was soft and slightly bulged, there were no apparent bowel movements, no apparent mass on palpation, negative shifting dullness, no auscultated sounds of an overactive bowel and a digital rectal examination was negative for any mass or blood. Laboratory tests suggested slight elevation in white blood cell count. An abdominal radiograph revealed multiple air-fluid levels in the intestinal gut . AbdominThe patient was given symptomatic treatment consisting of antibiotics, antacids, antispasmodics and enema. After one day, he presented with noticeable abdominal swelling with unbearable abdominal pain, total abdominal tenderness, rebound tenderness and bowel sounds that had decreased in intensity.Subsequently, exploratory laparotomy was performed. On surgical exploration, around 100 ml of transparent ascites fluid and torsion of a dilated small bowel loop with surrounding edema were noticed. Moreover, a large cystic mass was detected hanging from the wall of the small intestine into the pelvic cavity, which had led to formation of inflammatory adhesions with adnexa. The adhesions were then bluntly separated, and the mass was found to be located at around 150 cm distally to the Treitz ligament. The mass was ischemic, dark in color, and covered with pus. The basal wall of the mass was weaker than the healthy loops around it, and the basal diameter was around 4.5 cm. After relieving the twisted mass and the surrounding small intestine, we noticed inflammatory edema, and dilation of the proximal intestinal wall. Several adhesive masses with punctate ischemia and inflammation, 20 cm proximally to the lesion, was also noted .We decided to loop-out the jejunum approximately 35 cm proximally and 5 cm distally to the base of the mass. After resection of about 40 cm of bowel, which included the mass and the ischemic small intestine, the remaining bowel segments were anastomosed using a stapler. An intraoperative diagnosis of intestinal duplication, obstruction and torsion of the small intestine was made. The pathological findings are shown in Postoperatively, the patient was kept under parenteral nutrition. He recovered well and began eating nine days after the surgery. He was discharged fifteen days after the surgery, and no sign of recurrence was observed after three months of follow-up.,,,,,,,,,,,,,,,,,,,Digestive tract duplication is more common in men and tends to occur most frequently in the small intestine. It characteristically arises from the mesenteric border of the bowel.The broadly accepted classification of intestinal duplication consists of five types: intestinal membrane type, intestinal wall cyst type, extra-intestinal cyst type, extra-intestinal tubular type and solitary type.We hypothesized that the course of this case would have begun with repeated duplication of the jejunum, thus resulting in repeated intestinal edema, enlargement and inflammatory changes. Subsequently, under gravitational traction, the inflamed bowel would have been able to twist easily. Abnormal duplication would then have occurred and the adjacent bowel walls would have aligned and compressed each other.The clinical presentation of intestinal duplication depends on the structure, size and site of the lesion in relation to the surrounding structures. Because of nonspecific signs and symptoms, it is often misdiagnosed as cases of other causes of an acute abdomen at the acute stage, or is labeled as Meckel’s diverticulum at the chronic or asymptomatic stages. Meckel’s diverticulum has a separate blood supply, while intestinal duplication shares a blood supply with the surrounding intestinal tract. Moreover, intestinal duplication is characterized by well-developed smooth muscle, which is absent from intestinal diverticula.,99mTc radionuclide imaging has diagnostic value for cases of suspected gastric mucosal ectopy.At present, the types of imaging that are suggested are ultrasonography, gastrointestinal radiography, computed tomography, radionuclide imaging and magnetic resonance imaging.In this disease, surgical treatment is the preferred option. The choice of surgical procedures depends on multiple factors, such as the location, type and relationship with the surrounding tissue.The classification of digestive tract duplication is diverse. This is the first case report on small intestinal duplication on the opposite side of the mesenteric margin. It potentially extends the anatomical classification of intestinal duplication.


Peroneal tendon subluxation is a rare pathology, generally associated with sport-induced trauma, that occurs due to the rupture of the superior peroneal retinaculum. The diagnosis is mainly clinical, but the use of imaging techniques, such as dynamic ultrasound and magnetic resonance imaging, may contribute to its clarification. Treatment may be conservative or surgical, although there is no consensus on the most appropriate technique to be employed. We report a case of subluxation of the peroneus brevis tendon, with no apparent traumatic cause, in which there was a need for a surgical approach after the failure of conservative treatment.A 25-year-old White woman presented pain and locking of the lateral side of the left foot 2 years earlier, with no history of trauma. The patient felt pain upon palpation and presented snapping during flexion–extension of the left ankle. On dynamic ultrasonography, an anterior subluxation of the peroneus brevis tendon occurred when the ankle was in dorsiflexion, suggesting superior peroneal retinaculum injury. Surgical correction was recommended after 2 months of conservative treatment with no improvement. The chosen surgical technique was isolated reattachment of the superior peroneal retinaculum, which proved successful.Peroneal tendon subluxation has no established preferred surgical technique. This case demonstrates superior peroneal retinaculum repair as an efficient surgical approach for this condition. Furthermore, the atraumatic mechanism of injury in this case, along with the unknown true incidence of peroneal tendon subluxation, highlights the need to consider this pathology in cases of ankle injuries. Peroneal tendon subluxation is a relatively rare condition, and while it has become more frequent due to an increase in sports practice, it remains scarcely described in literature . The mecClinically, the subluxation presents with lateral ankle edema, pain, increased sensibility, and mobilization difficulty. The lesion may appear on initial examination or exacerbated through maneuvers, such as active and passive plantarflexion and eversion of the foot against resistance . These mAlthough diagnosis is primarily clinical, some supplementary imaging methods, as high-resolution magnetic resonance imaging and ultrasound, are valuable. Dynamic ultrasound may show tendon subluxation during the dorsiflexion–eversion maneuver, so this is likely the most helpful tool for diagnosing peroneal subluxation, especially in cases of intermittent dislocation , 6.Conservative treatment may be implemented in acute lesions, consisting of repositioning the tendons inside the retromalleolar groove, followed by immobilization of the distal portion of the leg . HoweverA 25-year-old White woman attended orthopedic consultation with pain and locking of the lateral side of the left foot 2 years before, with no history of trauma and no previous diagnosis. On examination, she felt pain upon palpation of the fifth metatarsal diaphysis and presented snapping during flexion–extension of the left ankle.Ankle radiographs were considered normal, and dynamic ultrasonography demonstrated anterior subluxation of the peroneus brevis tendon with dorsiflexion, suggesting superior peroneal retinaculum injury Fig. A, B.Fig.After 2 months of conservative treatment, the condition did not improve. Therefore, surgical intervention was suggested. Having explained the procedure and its possible complications, the patient decided to proceed with the operative treatment.et al. [In this case, isolated anatomical reattachment of the retinaculum was performed, as described by Ferran et al. . The patSubsequently, the bony surface of the lateral malleolus was scraped until a bleeding surface was visible, and two anchors were inserted along the posterior border of the lower fibula Fig. A, B. TheThe surgical wound was closed, a crepe bandage was applied, and plaster immobilization was placed with the ankle in slight eversion and a neutral position of flexion and extension. The patient was discharged on the day after the surgery. After 10 days, the stitches were removed, and the ankle was immobilized with a synthetic cast for 4 weeks. Following its removal, partial weight-bearing was allowed, and physiotherapy was initiated. Cycling and swimming were introduced 2 weeks after the cast removal, and gradual stretching and strengthening exercises started after 8 weeks. Return to sports activities was authorized on the fifth postoperative month.There were no postoperative complications. Six months after surgery, magnetic resonance imaging was performed, where the reconstructed retinaculum was evident on T1 and T2 images Fig. A, B. AftThe patient presented with sudden pain and locking of the left ankle without reporting previous trauma, although this injury typically occurs in traumas such as ankle sprains, and mainly in athletes who practice activities requiring shortcutting movements, such as skiing, ice-skating, soccer, basketball, rugby, and gymnastics , 7, 8. HAlthough there is no consensus on the most effective approach for this condition, positive outcomes have been reported with surgical interventions after failure of conservative treatment. The four main surgical techniques are reattachment or repair of the superior peroneal retinaculum, deepening of the retromalleolar groove, bone-block procedures, and tissue-transfer procedures .Retromalleolar groove depth and shape have been described as possible predisposing factors for peroneal tendinopathies. Consequently, groove-deepening procedures may be performed, mainly when the sulcus is flat or convex , 11. HigIf an anatomical approach is preferred to treat this pathology, reattachment of the superior peroneal retinaculum seems the most appropriate technique . Both isThis case demonstrates the success of employing isolated reattachment of the superior peroneal retinaculum in peroneal tendon subluxation. Additionally, it encourages consideration of this pathology as a diagnostic possibility in both traumatic and atraumatic cases of ankle injuries, intending to avoid misdiagnosis or underdiagnosis, treatment failure, and injury reoccurrence.


An 89-year-old man presented with the chief complaint of a sore throat and a mass in the right side of his neck that tended to increase in size. He displayed the right Horner's sign, and imaging findings showed a 65-mm mass in the right side of the neck, invading the carotid artery. There were no other obvious lesions. The differential diagnosis was carcinoma of an unknown primary or neurogenic tumor. An incisional biopsy was performed, and the pathological diagnosis was lymphomatoid granulomatosis. The patient was started on oral prednisolone, but the disease progressed, and his general condition worsened. Therefore, supportive care was provided. This was a very rare case of a cervical lesion of lymphomatoid granulomatosis. Many diseases that present with cervical masses, such as inflammatory diseases and both benign and malignant neoplastic lesions. To differentiate these, pathological diagnosis by biopsy may be necessary. In this article, we report a case of lymphomatoid granulomatosis that was initially suspected to be a malignant tumor but was diagnosed by biopsy as lymphomatoid granulomatosis, which rarely presents as a cervical cancer lesion.An 89-year-old man was referred to our hospital for a thorough examination after a computed tomography (CT) scan revealed a tumor-like lesion in the right side of his neck. At the time of the initial examination, the swelling was observed from the right submandibular region to the upper neck, and submucosal swelling was observed on the right wall of the oropharynx. However, no obvious neoplastic lesions were observed in the oral cavity or pharynx. Right eyelid drooping and pupil contraction were considered to represent Horner’s syndrome. There was no evidence of laryngeal paralysis, but he experienced severe dysphagia due to swelling of the pharynx, weight loss, and decreased mobility.A neck-to-pelvis contrast CT showed a 65-mm-long bifurcated mass mainly in the carotid artery space, inferior to the right parapharyngeal space. The right common carotid artery bifurcation to the internal and external carotid arteries was entrapped by the tumor, which was enlarged compared to a previous CT scan obtained one month earlier. There were no obvious pathological findings except in the neck region Figure .Plain magnetic resonance imaging (MRI) of the neck showed an ill-defined soft tissue mass in the right side of the neck with an intermediate signal on T1-weighted images and a heterogeneously low-to-moderate signal on T2-weighted images , and many were positive on Epstein-Barr virus (EBV)-encoded RNA-in situ hybridization (EBER-ISH). Some cells were also positive for PAX-5 (a transcription factor expressed throughout B cell maturation) and CD30 (a marker of activated B cells and T cells), negative for CD15 and anaplastic lymphoma kinase (ALK), and had a relatively large number of CD3-positive small T cells. Based on these findings, the patient was diagnosed with lymphomatoid granulomatosis ) and extensive necrosis were found, and a diagnosis of grade 3 was made. However, after a review by the hematology department, it was determined that the patient's age and general condition did not warrant intense chemotherapy, and oral prednisolone was started at 35 mg per day. Although mild improvement of neck swelling was observed for about one week after the start of treatment, the effect was not long-lasting, and three weeks after the start of treatment, the patient was unable to take oral medication and was admitted to another hospital for palliative care.Lymphomatoid granulomatosis is a rare B-cell lymphoproliferative disease caused by the Epstein‒Barr virus -3. It isIn this case, there were no lesions other than those in the neck region, which has not been reported in any case previously. Although the pathogenesis and prognosis of cervical lesions are unknown, the rapid increase in size and worsening of the patient’s general condition in the month before diagnosis and the lack of response to steroids suggest that the disease was aggressive. Initially, cancer and neurogenic tumors were suspected, and lymphoproliferative diseases such as these were not considered in the differential diagnosis. Normally, incisional biopsy is not recommended for cancer metastases due to the risk of dissemination. However, in cases such as this patient, where the diagnosis cannot be narrowed down by imaging or cytology, biopsy should be considered promptly even though there is a high possibility of malignancy and even if the tumor is unresectable, and radiotherapy or chemotherapy is the main treatment option, to confirm the diagnosis and determine the appropriate treatment plan.We experienced a very rare case of lymphomatoid granulomatosis with neck involvement. Initially, cancer metastasis was suspected, but an incisional biopsy confirmed the diagnosis. Due to his advanced age and rapid progression of the disease, the patient had to be transferred to best supportive care (BSC) early after treatment. Through the accumulation of cases in the future, we await the establishment of diagnostic and therapeutic methods for this disease.


As a benign isolated and encapsulated tumor originating from the nerve sheaths, schwannomas rarely appear on the cranial nerves, among which infraorbital nerve schwannomas are highly uncommon. We report a case of isolated infraorbital nerve schwannoma in a 58‐year‐old male patient with a clinical manifestation of proptosis in the affected eye. As a benign tumor, schwannomas very rarely were reported to originate from the infraorbital nerve. Considering the reports of this tumor, diagnostic considerations when visiting patients with cystic masses in the infraorbital region are recommended. The patient did not report a history of previous trauma or any other significant medical history. There was no family history of any significant illnesses. A firm, localized, non‐tender, mobile, subcutaneous round mass of about 2 cm was seen in the left infraorbital region on clinical examination. The skin, which was located on the mass, was normal, without any lesion or inflammation. The visual acuity, visual field, and color vision were normal. Eye movements were normal and lack of restriction and pain. He had 5 mm axial proptosis measured by Hertel exophthalmometry in addition to around 4 mm superior displacement on the globe mentioned as dystopia Figure . The pup3Schwannomas are well‐differentiated, encapsulated, benign tumors arising from the Schwann cells of peripheral neural sheaths and can appear on any myelinated sheets. However, these tumors very rarely were reported to originate from orbital nerves and in particular infraorbital nerves. Altogether, orbital schwannomas represent 1%–4% of orbital tumors and usually arise from the supraorbital or supratrochlear nerves.Schwannomas generally manifest as solitary encapsulated peripheral nerve tumors with the age predisposition of the forties and are more prevalent in malesRegarding the diagnostic approach, all aspects need to be considered to specify the diagnosis, including thorough clinical history, physical examination, imaging modalities, and histopathological examination. Former works suggested that cystic mass that is captured as a partial high‐density enhancement within the cyst in the ocular computerized tomography and the signal findings observed on MRI of a schwannoma, has been characterized as hypo or isointense signals on T1, homogeneous hyperintense signals on T2, all suggestive of a slow‐growing benign process. If neoplasia is suspected, the use of preoperative imaging is important to help distinguishing between benign and malignant lesions. Our findings were congruent with these results.To prevent the compression of the optic nerve, surgical excision is the treatment of choice and the tumor should be removed intact at the earliest. This recommendation is based on the fact that most schwannomas are progressively growing and might lead to compression of the nerve and possible nerve atrophy. This is to an extent that incomplete excision can cause recurrence or even intracranial extension. Additionally, these high cellular tumors have a chance of recurrence and malignant transformation, and early treatment are therefore recommended to avoid the complications related to progressive growth of the tumor.Herein, a rare case of isolated infraorbital schwannoma presenting as a painless mass with no disturbance of visual acuity, merely manifesting a proptosis and dystopia in the left eye was introduced that was completely excised using a transconjunctival inferior orbitotomy approach. Considering the rarity of infraorbital schwannoma, diagnostic considerations for schwannoma as a possible diagnosis when visiting patients with infraorbital cystic masses are recommended. Imaging modalities including CT and MRI are recommended to make the diagnosis at this unusual location for schwannoma, and we also suggest a transconjunctival inferior orbitotomy surgical approach to enhance the cosmetic effects.The manuscript has been read and approved by all the authors. MS contributed to developing the research idea and design and composing and revising the manuscript. MM contributed to composing and revising the manuscript. MR contributed to developing the research idea and revising the manuscript.The authors have no conflict of interest to declare.This study was approved by the research and ethics committee of Tehran University of Medical Sciences. The patient has given his informed consent to publish this case.Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor‐in‐Chief of this journal.


Nasopharyngeal carcinoma is rare and affect mainly men between the fourth and sixth decades of life. The clinic is characterized to be nonspecific and the main complaints or findings related to this disease are: cervical mass, aural dysfunction, and headache. The basis of treatment is radiotherapy that involves a wide field of irradiation of normal tissues, which usually generates sequelae with direct implications for quality of life. We report a case of a nasopharyngeal carcinoma treated with radiotherapy and chemotherapy that evolved, after 8 years, into supraglottic stenosis. We emphasize the relevance of clinical follow-up after radiotherapy, particularly due to the late sequelae and the relevance of using radiotherapy devices with a more focal cancer field, in order to minimize complications. The mainstay of treatment is radiotherapy that must be added to chemotherapy from stage 2 onwards. Radiotherapy in nasopharyngeal carcinoma involves a wide field of irradiation of normal tissues and this is associated with doses that exceed the tolerance for radiation of these tissues. There are high rates of toxicity in up to ninety days (early) or beyond this period (late), which are potentiated with the use of chemotherapy, and promote a significant decrease in quality of life. The most common late sequelae resulting from radiotherapy in rhinopharyngeal carcinoma involve temporal lobe, optic nerve, trismus, osteoradionecrosis, and they often show a mean time of presentation of 18 months.Nasopharyngeal carcinoma is rare and presents an incidence of 1:100,000. This disease has a higher prevalence in Asians, affects 3 men to every woman, and shows a peak incidence between the fourth and sixth decades of life. The clinic is characterized by non-specificity so that, the main complaints or findings related to the disease are: neck mass (76%), aural dysfunction (62%), and headache (35%). Diagnosis occurs with locally advanced disease in 75-90% of cases, and commonly along with lymph node metastases.This was a 39-years-old woman that in February 2006 started to present nasal obstruction on the right side associated with postnasal drip, which evolved after a month with aural fullness, hearing loss on the right, and autophonia. Nasofibrolaryngoscopy showed a tumor mass in the rhinopharynx with occlusion of the ostium of the right auditory tube. An incisional biopsy was performed and the result was nasopharyngeal carcinoma in situ (T1N0M0). In June 2006, she underwent 35 sessions of 2D radiotherapy with 70Gy in primary and 30Gy in lymphatic drainage associated with 3 sessions of chemotherapy. In December 2006, the patient reported odynophagia and dysphagia. During the nasofibrolaryngoscopy exam, diffuse edema involving the epiglottis, aryepiglottic folds, arytenoid cartilages, and vestibular folds were observed. A complete regression of the condition was seen after treatment using amoxicillin with clavulanate, omeprazole, and speech therapy. In 2013, she reported dyspnea at rest, cough, and dysphagia. A videolaryngoscopy was performed with a 70° optic. This showed circular supraglottic stenosis of approximately 95% of the lumen at the level of the vestibular folds, hypoplasia of the epiglottis, and alteration of the anatomy of the valleculae  and B. N The patient of this case report was treated with an association between radiotherapy and chemotherapy, an approach that may have contributed to the late presentation of supraglottic stenosis.Radiotherapy represents the first line in the treatment of nasopharynx carcinoma, but it is related to several early adverse effects such as xerostomia, cutaneous fibrosis. Late complications include advanced age of the patient, clinical staging and chemotherapy as risk factors. They tend to appear in the first 5 years of clinical follow-up and they are related to the dose used in healthy tissue and its respective tolerability.i.e., after 96 months.Stevens et al., in a series of 8 cases with supraglottic stenosis observed that the most common cause was external beam irradiation followed by autoimmune diseases. In addition, they reported that time of presentation after radiotherapy was 18-120 months, which is a similar finding to our clinical case that presentation of supraglottic stenosis occurred late to treatment,  Our patient presented significant progressive ventilatory impairment associated with inspiratory and expiratory stridor, even at rest, which required intervention to ensure ventilation three tracheostomy. This procedures was performed in a surgical environment with local anesthesia, since it was not possible to perform the orotracheal intubation, and had no intercurrences.Supraglottic stenosis after radiotherapy is rare, corresponding to 3% of laryngotracheal stenosis, the clinical picture involves dyspnea, dysphagia, stridor, and changes in voice resonance. Depending on the degree of stenosis, orotracheal intubation can be a challenge, as can tracheostomy in a pre-irradiated area.,7Tissue-modulated intensity radiotherapy discriminates the radiation dose delivered to the peritumoral area and to the tumor, promotes better preservation of normal tissues and, consequently, reduces the incidence of complications of this treatment.In 2006, the patient was submitted to a 2D radiotherapy modality, which dose inflicted on healthy tissues surrounding the tumor was higher due to the unavailability of the tissue-modulated intensity radiotherapy system. We believe that this may have been a factor that contributed to the unfavorable outcome herein presented.2) or potassium-titanyl-phosphate laser, and application of mitomycin C or corticosteroids. The control of laryngopharyngeal reflux is essential, since its presence can contribute to the persistence or development of supraglottic stenosis. In most severe cases of upper airway stenosis, as reported here, tracheostomy is usually necessary to ensure airway patency.,7 In this case report, an initial approach by videolaryngoscopy was proposed with the use of CO2 laser, aiming to decannulate the patient, however, the patient still unsure about the benefits of the procedure.The treatment of post-radiotherapy stenosis involves several options such as: balloon dilation, open surgical or videolaryngoscopic approach with carbon dioxide (COLate complications related to radiotherapy are rare, whether or not associated with chemotherapy. Patients with tumors in the head and neck region, submitted to the treatment, are subject to the tumor appearance. When possible, tissue-modulated intensity radiotherapy should be indicated due to its lower morbidity and mortality. The follow-up of patients should be longer in an attempt to carry out an early diagnosis and treatment.


Retroperitoneal liposarcoma (RPLS) is a variety of soft tissue sarcoma that originates from mesenchymal cells. A tumor measuring greater than 30 cm is called a “giant liposarcoma.” A part of the neoplasm tends to grow in size, recur locally, or metastasize distantly. In those with such a condition, long-term survival is uncommon. Therefore, it is necessary to present a uniform and optimized program to improve the prognosis.By successfully treating a multiple-recurrent giant retroperitoneal dedifferentiated liposarcoma (RP DDLPS) in July 2010, we hope to devise more comprehensive strategies to improve diagnosis, therapy, and outcome.In July 2010, we thoroughly resected a giant multifocal RPLS with a concomitant part of the gastric wall. The histopathological examination revealed a high-grade (grade III) dedifferentiated liposarcoma. The patient was discharged uneventfully on the 15th postoperative day. She relapsed after 16 months and needed another complete excision. After 9 months, she died after the fourth recidive. The patient had experienced four recurrences and underwent operations with 15 years of follow-up.The above demonstrates that we were able to successfully treat the multirecurrent giant RPLS, despite the patient’s poor medical condition, with meticulous management. Moreover, this indicates that long-term survival could be achieved for high-grade RP DDLPS. Retroperitoneal sarcomas (RPSs) are rare malignancies that develop from mesenchymal tissues. They account for approximately 15% of all sarcomas, with an estimated incidence of 3–4/1,000,000 of the population per year . RPLS maen bloc resection of tumors and contiguous structures. Patients often undergo multiple operations after relapses, but the resection rate tends to decline gradually, leaving few long-term survivors , hepatorenal functions revealed hypoproteinemia , and tumor antigens showed CA125 185.80 KU/L. The chest radiography demonstrated bilateral pleural effusion and no space-occupying lesions.The features of abdominal and pelvic contrast-enhanced computed tomography (CT) included multifocal, giant tumors of roundish shape with adipose density that were suspicious for liposarcoma ; the nodAfter meticulous planning, we performed laparotomy through a right exploratory incision, indicating approximately 800 ml of light hemorrhagic ascites and extensive adherence of the omentum and intestinal loops. A giant tumor originated from the right middle and upper quadrant of the retroperitoneum, which crushed the liver upward to the right and posterior of the subdiaphragm, oppressed the flexura hepatica coli and abdominal wall rightward, pushed the mesocolon transversum downward to 10 cm below the umbilicus, and crushed the hepatogastric and gastrocolic ligaments anterior to the abdominal wall. The left margin of the tumor was adjacent to the hilus lienis. The tumor was shaped like a lobulated dumbbell, measuring 45 cm × 30 cm × 20 cm in size. Another yellow and white tumor in the mesocolon transversum measured 20 cm × 8 cm × 5 cm in diameter. Three small masses linked by the basis pontis of the greater gastric curvature extruded to the hilus lienis. In surgery, we separated gastrohepatic and hepatocolic ligaments, dissociated the capsule of the tumor, and separated the tumor from the adjacent tissues. Due to the enormous size, we had to separate a part of the mesocolon transversum and keep the tumor from metastasizing into it. We discovered that the tumor was hiding behind the transverse colon and the stomach, turned out it, and therefore, we detached the root of its capsule and severed and ligated the feeding veins before completely resecting the giant tumor. All tumors were well-encapsulated and completely removed with a concomitant part of the gastric wall . The speThe histopathological report indicated that in the retroperitoneal tumors, the oncocytes were heterogeneous and distributed like star networks with loose mesenchyme. Small fatty components were near the capsules in focal areas (diagnosed as dedifferentiated liposarcoma); in the tumors of the gastric wall, the nuclei were heterogeneous with clear cytoplasm. The lip blasts with abundant vessels were in focal areas  .The patient was discharged on the 15th postoperative day with an uneventful course. The follow-up was done every 3 months for 16 months, and no signs of recurrence or metastasis were detected.The patient was readmitted to our hospital on November 2011. The abdominal and pelvic CT revealed multifocal, class-round tumors originating from the hepatic hilar region and oppressing the adjacent intestinal canal, caudate lobe, inferior vena cava (IVC), and aorta abdominalis ; another rate is only 30% of the neoplasms with high grade III(GIII). Meanwhile, the high-grade II(GII) tumor usually causes death by recurrence or metastasis  classification of soft tissue and bone tumors, RPLS is classified into four main subtypes: well-differentiated, myxoid/round cell, dedifferentiated, and pleomorphic . The 5-yRadical surgery, including invading tissues and organs, is the mainstay of treatment that can effectively cure RPLS, reduce the risk of a recurrence, and improve disease-free survival (DFS) and overall survival (OS) rates . Lewis rMDM2, CDK4, HMGA2, et al., and the ligand for PPAR-γ have been developed. However, to reduce the impact of the adverse effects and resistance of MDM2 inhibitors, we should pay more attention to translating research with YEATS4 knockdown and the genes outside the amplicon. Therefore, inhibiting JUN, DDR2, FGFR3, NTRK1, lowering or absenting ZIC-1, and recovering the normal expressions of RB1 and CEBPA are all research approaches; hence, genomic treatment has been receiving a lot of attention recently. Given the recurrent tendency and genomic characteristics of RPLS, we may hope to establish genetic screening of primary and recurrent patients to prevent recidive by target therapy and consequently improve the prognosis.


Asymptomatic Meckel’s diverticulum cases are not uncommon, leading to diagnostic difficulties in cases of atypical presentations with only gastrointestinal symptoms other than bloody stool. A nine-year-old boy diagnosed as having cyclic vomiting because of recurrent abdominal pain and vomiting for 6 months was referred to our institute and hospitalized due to worsening symptoms. After admission, abdominal ultrasonography showed the multiple concentric ring sign and a pseudokidney sign at the lower ileum, leading to the diagnosis of ileo-ileal intussusception, but the gastrointestinal symptoms and ultrasonic findings disappeared spontaneously. Transanal, double-balloon, intestinal endoscopy demonstrated a pedunculated polyp-like structure, and surgical resection was performed. An inverted diverticulum was found in the resected intestinal lumen, and ectopic gastric mucosa was identified histologically, leading to the diagnosis of inverted Meckel’s diverticulum. In pediatric cases involving periodic attacks of vomiting and abdominal pain, unnecessary emergent surgery could be avoided by cautious imaging evaluation and consideration of ileo-ileal intussusception with advanced lesions of an inverted Meckel’s diverticulum as a differential diagnosis, without facilely diagnosing cyclic vomiting. In addition, previous reports of inverted Meckel’s diverticulum were reviewed, and the results were compared between adult and pediatric groups in each category. Typical cases of Meckel’s diverticulum are usually diagnosed by gastrointestinal symptoms such as acute abdominal pain, vomiting, and, especially, bloody stool. However, asymptomatic Meckel’s diverticulum cases are not uncommon, since approximately only 30% of Meckel’s diverticulum cases show clinical symptoms throughout their life, leading to diagnostic difficulties in cases of atypical presentations with only gastrointestinal symptoms other than bloody stool . TherefoIn this report, a case of cyclic vomiting-like symptoms such as periodic abdominal pain and vomiting with inverted Meckel’s diverticulum diagnosed using transanal DBE after abdominal ultrasonography is presented. Previous reports of inverted Meckel’s diverticulum were reviewed, statistics such as median values were calculated, and comparisons between adults and children were performed according to each parameter.The patient was a 9-year-old boy with no relevant past or family history.The patient was admitted to our institute with the chief complaint of a six-month history of recurrent abdominal pain and vomiting. He had been diagnosed as having cyclic vomiting by his family physician and referred to our institute for further treatment. At the time of referral, the patient was in the intermittent phase, and the fecal hemoglobin (Hb) level was 29 [reference range (RR) 0–100] ng/mL. Therefore, considering the possibility that the cyclic vomiting may resolve during the natural course of the disorder, the patient was followed without treatment. However, his symptoms worsened two days before admission, and he was admitted to our institute on the same day he visited as an outpatient.At admission, he was 133.3 cm (74.8th percentile) tall and weighed 28.3 kg (50.1st percentile), with weight loss of 2.7 kg over three months. However, no reduction of height gain was observed on the growth curve. The patient’s axillary temperature was 36.0 °C; his pulse was 60 beats/min; and his blood pressure was 93/49 mmHg. On physical examination, his facial color was slightly pale, but no obvious abnormalities of the eyelid conjunctiva, oral cavity, chest, or skin were found. His abdomen had normal bowel peristalsis and no distention, mass, or guarding, but there was mild tenderness of the lower mid-abdomen.Laboratory findings at admission were as follows: hemoglobin 13.9 (RR 12.6–16.5) g/dL and ferritin of 46 (RR 25–280) ng/mL, indicating no iron deficiency anemia; total protein 6.5 (RR 6.3–7.8) g/dL and albumin 4.4 (RR 3.8–4.8) g/dL within normal ranges; and inflammatory markers not increased. On the other hand, only fecal human Hb was mildly elevated (232 ng/mL).On imaging, the plain abdominal X-ray showed no remarkable abnormalities, but abdominal ultrasonography showed the multiple concentric ring sign and the pseudokidney sign in the ileum, which were not released spontaneously by intestinal peristalsis. A mass-like structure was observed at the tip of the stacked inner tract, and Doppler imaging showed a marked blood signal concentrating toward the tip. Based on the above findings, ileo-ileal intussusception with some pathological advanced lesions was diagnosed .After admission, the patient was kept fasted, and fluid replacement was started. After approximately two hours, the abdominal pain and vomiting resolved spontaneously with the disappearance of the pseudo-kidney sign on abdominal ultrasonography. On the second day of admission, DBE was performed under sedation, considering that normal colonoscopy could not reach the lesion based on the ultrasonographic findings, and a stalked polyp-like structure was detected at approximately 90 cm proximal to the ileocecal valve a,b. An iIt was decided to perform semi-emergent surgery rather than emergent surgery because the patient had a temporary small intestinal intussusception with spontaneous resolution of symptoms on ultrasonographic and clinical findings, with similar episodes, and parental consent could not be obtained immediately. Approximately two weeks after the last vomiting episode, because the patient suffered no symptoms at all during this period, the patient underwent laparoscopic-assisted surgery by pediatric surgeons and was found to have a diverticulum on the anti-mesenteric side of the marked ileum that inverted into the intestinal tract at approximately 90 cm proximal to the ileocecal valve c. No bowThe patient was diagnosed as having an inverted Meckel’s diverticulum based on the histological presence of ectopic gastric mucosa in the mass-like structure of the diverticulum d. Postopt-test and the Mann–Whitney U test. For the categorical data, the χ2 test was performed when there was a sufficient number of cases, and Fisher’s exact test was performed for the analysis involving a relatively small number of columns. The significance level was p < 0.05 in the two-sided test. In the comparison between adult and pediatric cases, pediatric cases with an inverted Meckel’s diverticulum were significantly less likely to show melena (p = 0.019) and had clinical features tending to cause intussusception (p = 0.001). In addition, the pediatric cases were operated on within a significantly shorter time from onset than the adult cases (p = 0.019)  .A pediatric case of inverted Meckel’s diverticulum diagnosed by abdominal ultrasonography and DBE, in which the patient was diagnosed as having cyclic vomiting due to recurrent abdominal pain and vomiting by a referring physician, was described. Initially, because of high fecal human Hb levels during abdominal pain and vomiting attacks, abdominal ultrasound was performed, and incomplete ileal intussusception was diagnosed with findings of multiple concentric ring signs and the pseudokidney sign, which resolved spontaneously during the disease course. Finally, laparoscopic-assisted resection of a pedunculated polyp-like structure identified at approximately 90 cm proximal to the ileocecal valve, which is a preferred site for Meckel’s diverticulum, led to the definitive diagnosis of inverted Meckel’s diverticulum with histological findings of ectopic gastric mucosa. After resection of the lesion, no recurrence of gastrointestinal symptoms has been observed.p = 0.019) (p = 0.001)  than in adults [3.5 (0.03–60) months]  and 2/9 (22.2%), respectively, of the adult patients and 14/74 (18.9%) and 8/9 (88.9%), respectively, of the pediatric patients. Abdominal ultrasonography was primarily used as a diagnostic modality in children, with a positive finding rate of 8/8 (100%) . TherefoA case of inverted Meckel’s diverticulum that mimicked cyclic vomiting due to recurrent abdominal pain and vomiting was presented. This case was promptly diagnosed by DBE, resulting in prevention of intestinal perforation and obstruction and exclusion of a small intestinal polyp and polyposis. In cases involving periodic attacks of vomiting and abdominal pain, unnecessary emergent surgery could be avoided by cautious imaging evaluation, considering ileo-ileal intussusception with an advanced lesion of an inverted Meckel’s diverticulum as a differential diagnosis, without facilely diagnosing cyclic vomiting. In addition, the novelty of this case consists of the fact that the inverted Meckel’s diverticulum did not result in an evolving intussusception in a child patient. Thus, the necessity of emergent surgery is not always related to a thorough clinical and imaging evaluation, but to the possibility of an inverted Meckel’s diverticulum causing an evolving intussusception, especially in adults. Thus, an inverted Meckel’s diverticulum alone is not an indication for emergency surgery, but complications of Meckel’s diverticulum such as unresolved intestinal intussusception with intestinal ischemia may prompt an emergent surgical exploration.


Craniosynostosis is often associated with raised intracranial pressure (ICP), especially when multiple sutures are involved. In this report, we discuss an unusual association in a patient with craniosynostosis. We report a case of a two-year-old Caucasian male with bilateral coronal synostosis (BCS) who was found to have a concomitant mega cisterna magna (MCM). Although counterintuitive, even in the presence of craniosynostosis, patients with this finding can also have intracranial CSF fluid collections such as the MCM reported here. We hope this report will enhance our understanding of some similar cases that are equivocal regarding raised ICP. Craniosynostosis, the premature closure of cranial sutures, is a common birth defect and is the second most common craniofacial anomaly after orofacial clefts . This coVirchow’s law describes how the fusion of cranial sutures causes compensatory growth along the non-fused sutures, resulting in a predictable pattern of skull deformity . BCS preDue to the wide heterogeneity of craniosynostoses, its treatment requires early diagnosis, surgical correction of the skull deformity within the first year of life, and long-term management of complications involving a multi-disciplinary team . Newly rThis study was conducted according to the requirements of the Declaration of Helsinki .A two-year-old Caucasian male presented to our clinic following a referral for an abnormal head shape. He was developmentally normal and the mother reported no symptoms. He was the first child of his mother, the product of 37 weeks of gestation, and had been delivered vaginally. No chromosomal abnormalities or syndromes were identified in this patient. The head circumference was at the 70th percentile for the age. On physical examination, the anterior fontanelle was close and two prominent ridges were palpated anteriorly consistent with the left and right coronal sutures. No midline or frontal ridging consistent with sagittal and metopic synostosis, respectively, were palpated. There was no plagiocephaly. The child moved all extremities and had brisk reflexes throughout. There were no cutaneous stigmata, and the fundoscopic exam was within normal limits. His pupils were symmetrical and reactive, and he followed objects presented to him. An MRI was performed, which revealed no hydrocephalus or intracranial masses, normal patterns of myelination for age, synostosis of the left and right coronal sutures, and a small cerebellum with MCM Figure .The lambdoid sutures were not synostotic. The remaining intracranial anatomy was felt to be normal, and so was the upper cervical spine.We presented a case of BCS with MCM, which is a malformation of the posterior cranial fossa ,12. ThisCraniosynostosis can be a part of various syndromes such as Apert’s syndrome, Gomez-Lopez-Hernandez syndrome, and Fontaine-Farriaux syndrome ,15. TherCentral nervous system malformations resulting from mutations/deletions of centrosomal protein 135 (CEP135), T-box brain transcription factor 1 (TBR1), and human zinc finger protein of cerebellum 1 (ZIC1) all contribute to syndromes with craniosynostosis as a common birth defect. TBR1 encodes a transcription factor important in corticogenesis . The traCounterintuitively, as raised ICP is often found in patients with craniosynostosis, especially with multiple-suture involvement, our case had no signs or symptoms indicative of raised ICP. Furthermore, the presence of an MCM indicated that the ICP was normal. Thus, this case presents a conundrum with regard to the relationship between BCS and MCM. We believe this report might improve our understanding of some similar cases that are equivocal regarding raised ICP.


Sialadenoma papilliferum (SP) is a rare minor salivary gland neoplasm that accounts for less than 1% of all salivary gland tumors. The tumor typically affects older people, presenting most commonly as a slow-growing tumor of the hard palate, although other anatomical subsites, comprising the oral cavity and parotid glands, have also been reported. We report a SP occurring in a 90-year-old female. The patient described feeling a nodule on her palate for several years. The lesion was painless and clinically resembled a round craterlike ulceration of diameter 3 mm. The excisional biopsy was diagnosed histologically as SP. Here, we report the clinicopathological and radiological findings of palatal SP.SP is a rare, benign salivary gland neoplasm, and there are only a few cases described in the literature. Although mostly benign, malignant transformation can occur and should prompt the clinician to ensure complete removal of the tumor tissue. Key words:Sialadenoma papilliferum, minor salivary gland tumor, histopathology, oral pathology, case report. Sialadenoma papilliferum (SP) is a rare, benign neoplasm arising from the minor salivary glands of the oral cavity ,2. It coThe main treatment for SP, as for many other benign SGTs, is surgical excision, and the recurrence rate seems to be low around 7.4%) –3,7,8. D.4% –3,7,A 90-year-old woman was referred for dental examination in the public Oral Health Care Center of Turku prior to planned arthroplasty and prosthetization of both shoulder joints. The patient, although elderly, was in stable general health and was taking Amitriptyline® for arthritic pain, and Furosemide® and Warfarin® daily for well-controlled cardiac failure and atrial fibrillation. Her teeth had been extracted more than 50 years previously, and her full-arch dentures fit well. Of note, the patient records revealed that a small, reddish lesion was described in the hard palate three years earlier. The lesion was regarded as inflammation of a minor salivary duct opening, and further investigations or follow-up were not arranged.Intraoral examination revealed a small, round, reddish ulceration of diameter 3 mm on the left side of the hard palate Fig. . The patA cone beam computed tomography (CBCT) examination was performed to rule out bone pathology and retained roots. No pathological changes of the bone underlying the lesion were detected Fig. . A complMicroscopic examination revealed a tumor consisting of oncocytic cells forming ductal structures in the lamina propria Fig. . Oncocytet al. (et al. (SP is a rare, benign SGT, with only a few cases described in the literature. Oncocytic metaplasia has been shown in the histology of SP previously , and recet al.  suggesteet al. ,10. Inte (et al.  showed tInflammation and sialolithiasis have been suggested as etiologic factors for SP. In our case, the inflamed salivary duct opening noted several years prior to SP diagnosis may have contributed to SP development . Importa


Hydatid disease affects a significant proportion of the world’s population, particularly in endemic areas, with substantial associated morbidity and mortality. However, the incidence of splenic involvement is rare, and isolated splenic disease is even more so; it is infrequently encountered in western countries. As such, their management is often limited to metropolitan tertiary centres with no fixed consensus on the best surgical approach. The author presents a case of the successful management of isolated splenic hydatid disease using a laparoscopic approach in a rural facility, in what is believed to be the first presented Australian case of isolated splenic hydatidosis. Hydatidosis is a chronic zoonotic disease that has a significant impact on public health due to its substantial morbidity and mortality, and subsequent economic ramifications for affected communities, to the point where the World Health Organisation listed it in the 2008-2015 strategic plan for control of Neglected Tropical Diseases (NTDs) . HydatidA 29-year-old female was seen in the general surgery outpatient clinic of a rural hospital for six years of left upper quadrant pain, but no other associated symptoms. This was in the context of previous exposure to sheep and dogs prior to immigrating from Iraq. She was otherwise well, with no comorbidities and no history of trauma or previous abdominal surgery. Examination revealed a palpable spleen, with tenderness in the left upper quadrant and flank. Preliminary investigation in the community included positive Strongyloides immunoglobulin G, and as such, arrangements were made for further investigation, including hydatid serology (positive), abdominal ultrasound  and CT portal venous of the abdomen and pelvis, which showed a 150x180x100 mm well-defined cyst with homogenous fluid density (Figure Despite counselling regarding the associated risks, the patient subsequently became pregnant, requiring the cessation of albendazole. An acute admission for progressive left abdominal pain was then required, and the risks of cyst rupture in pregnancy were reinforced; however, the patient elected to continue with the pregnancy and was discharged following adequate analgesia. Following the successful completion of her pregnancy, a planned surgical outpatient review was performed, and the patient was found to be experiencing ongoing symptoms with the addition of daily subjective fevers, and as such was recommenced on albendazole. This was well-tolerated; however, after a continuous six-month course of treatment, she required further admission for pain. At this time, repeat cross-sectional imaging Figure  showed aA laparoscopic-assisted splenectomy was performed later that month using a standard 10 mm Hassan entry and four other ports were placed under vision. The gastrosplenic ligament was taken down, and the splenic artery and vein were identified and controlled using a Hemoloc clip to the artery followed by an Endo-GIA 60 mm linear stapler across both the artery and vein Figure . InferioHydatid cysts of the spleen are usually slow growing and may be asymptomatic for long periods of time, with the onset of symptoms corresponding with the eventual impingement of surrounding organs, or development of complications such as elevated pressure within the cyst leading to rupture, secondary infection, intracystic haemorrhage, or fistulisation of the cyst . SymptomTreatment of splenic hydatid cysts includes conservative, percutaneous, and surgical options . Small, Surgical management of splenic hydatidosis tends to be preferred for symptomatic or larger lesions due to the risk of spontaneous or traumatic rupture and is divided between total splenectomy and organ-preserving procedures; however, the limited available literature varies between which is the superior approach, with some arguing the superior eradication rates and reduced risk of rupture in total splenectomy and others advocating for spleen-sparing measures due to the rates of sepsis-related mortality post-splenectomy -5. SpleeThe next area of discussion is the use of open versus the less invasive techniques of laparoscopic and robotic approaches. In more established facilities, laparoscopic approaches and the technical expertise required are commonplace and often selected, as they are considered to be a superior technique that is minimally invasive with a quicker recovery whilst maintaining safe and effective removal of hydatid cysts . HoweverThe incidence and associated management of isolated splenic hydatid disease is rare, even more so in non-endemic areas. However, given appropriate expertise and access to facilities, it can be safely and effectively managed laparoscopically in a non-tertiary centre, given the involvement of the multi-disciplinary team and the local hepatobiliary service, with no detriment to safety or outcome.


Water-borne infections like typhoid fever are common in the developing world. The emergence of extensively drug-resistant Salmonella typhi (XDR S. typhi) is of great concern for both local and global public health. Fever, diarrhea, and abdominal pain are the commonest manifestations of typhoid fever. Abdominal pain may be due to ileal and colonic inflammation/ulceration and mesenteric lymphadenitis. Sometimes, abdominal pain in typhoid is due to ileal perforation leading to peritonitis, and acute appendicitis which needs urgent surgical intervention. Delayed surgical intervention can result in morbidity and sometimes even death.We report a case of XDR S. typhi infection in a 17-year-old female who presented with fever and abdominal pain. During the course of the hospital stay, while she was on appropriate antibiotics, her abdominal pain worsened due to acute appendicitis. She underwent an appendectomy and had an uneventful recovery. This is the first case, to our knowledge, of acute appendicitis caused by XDR S. typhi.Although appropriate antibiotics are the mainstay of treatment for typhoid fever, physicians should be mindful that surgical consultation may be necessary in certain cases. In developing countries, where there is a lack of proper sewage disposal and clean drinking water, waterborne illnesses like cholera, typhoid fever, and viral hepatitis are still significant public health concerns . GloballFever, abdominal pain, and diarrhea are the most common manifestations of typhoid fever. Abdominal pain in typhoid fever is multifactorial. It may be due to inflamed ileum, perforation of ileum leading to peritonitis, ileocolonic inflammation, mesenteric lymphadenitis, or acute appendicitis. Rarely, typhoid fever is complicated by gastrointestinal bleeding, visceral abscesses, vertebral abscess, osteomyelitis, and encephalopathy .Acute appendicitis is a common surgical emergency, but it is rare to get acute appendicitis due to S. typhi. Cases of acute appendicitis due to drug-sensitive S. typhi in children and adults have been reported in the past -5. With Acute hepatitis, visceral abscesses in organs like the spleen and splenic and renal infarcts have been reported in association with XDR S. typhi -11. Duri0F. She also had watery diarrhea, about eight episodes per day, associated with abdominal pain. The pain was dull in nature, localized to the epigastrium and the right hypochondrium, with radiation to the right flank and right iliac fossa. She was diagnosed as having type 1 diabetes mellitus three years ago. She was on a basal-bolus insulin regimen with variable glycemic control. She used to take meals from nearby restaurants where food hygiene was substandard. None of her family members had similar symptoms.A 17-year-old girl presented to the emergency room of Hayatabad Medical Complex, Peshawar, Pakistan, with complaints of fever, loose stools, and abdominal pain for eight days. The fever was continuous, high-grade, spiking up to 104 0F, blood pressure of 100/60 mmHg, pulse of 105 beats per minute, and oxygen saturation of 98% on room air. She was tender in the right upper abdomen and bowel sounds were present. The rest of the physical examination was unremarkable.On physical examination, she had a temperature of 102 She was admitted to the medical unit for a workup. Food poisoning, enteric fever, amebiasis, acute viral hepatitis, and shigellosis were considered in the differential diagnosis. Blood culture, stool routine examination, and ultrasound of abdomen and pelvis were requested in addition to routine investigations. She was started on meropenem as empiric treatment for enteric fever and fluid replacement. The investigations are summarized in Table On day three of her admission, the abdominal pain increased in intensity, with severe tenderness in the right iliac fossa and right flank region. The surgical team advised contrast-enhanced computed tomography of the abdomen and pelvis. It revealed signs of a thick-walled appendix with free intraperitoneal fluid and mesenteric lymphadenopathy suggestive of acute appendicitis without definite evidence of perforation Figure .She underwent an emergent appendectomy. During surgery, 300 ml of reactive straw-colored fluid was drained, and a phlegmonous appendix was excised and sent for histopathological analysis. Meanwhile, the preliminary report of her blood culture suggested the growth of gram-negative rods, which was highly suggestive of S. typhi. She became pain-free after the surgery, but the fever persisted for the next two days. The final report of her blood culture demonstrated growth of XDR S. typhi sensitive only to imipenem, meropenem, and azithromycin, while resistant to ampicillin, fluoroquinolones, ceftriaxone, cefixime, co-trimoxazole, and chloramphenicol. She remained pain-free and afebrile and was discharged on the seventh postoperative day. She received meropenem for a further one week as an outpatient. She was asymptomatic during a follow-up visit in the outpatient department two weeks after discharge. The histopathology report was suggestive of acute appendicitis Figures -4.The surgical complications of typhoid fever cause significant morbidity and mortality in many parts of Africa and Asia where standard medical facilities are not yet readily available . The gasAcute appendicitis is one of the most common surgical emergencies and is caused by luminal obstruction of the appendix by fecolith, tumor, or submucosal lymphoid hyperplasia with superadded infection . S. typhWe report a unique case of a young girl with type 1 diabetes mellitus and acute appendicitis caused by XDR S. typhi. Gastrointestinal and hepatobiliary involvement in XDR S. typhi infection has been reported. Abscesses in various viscera like the spleen and infarcts in the spleen and kidneys caused by XDR S. typhi have been reported -11. SimiAbdominal pain in XDR S. typhi infection is multifactorial. Some causes of abdominal pain like ileocolic inflammation and ulceration and mesenteric lymphadenitis settle with appropriate antibiotic therapy. But the physician should be vigilant for ileal perforation leading to peritonitis and acute appendicitis as a cause of abdominal pain that needs surgical intervention. This case highlights the importance of having a high index of suspicion for the surgical complications of XDR S. typhi infection. Timely intervention for these complications would reduce morbidity and mortality.


Acute pancreatitis is a common gastrointestinal cause of hospitalizations across the world. The most common etiologies of acute pancreatitis include gallstones, excessive alcohol use, hypertriglyceridemia, or, rarely, trauma. Traction-induced pancreatitis is an uncommon but previously reported cause of acute pancreatitis. We present a 60-year-old male with a past medical history of cerebral palsy who presented to our facility with acute pancreatitis secondary to a congenital diaphragmatic hernia. Acute pancreatitis is an inflammatory condition of the pancreas defined by at least two of the following: abdominal pain, elevated serum lipase levels at least three times the normal level, and/or characteristic findings on imaging. The annual incidence rate of acute pancreatitis ranges from 4.9 to 35 per 100,000 patients in the United States making it one of the most common gastroenterological emergencies –4. DiaphDiaphragmatic hernias are defined by herniation of the abdominal viscera into the thoracic cavity. Typically, diaphragmatic hernias are congenital or acquired in adulthood due to blunt or penetrating injury . CongeniTo our knowledge, this is the first case of acute pancreatitis secondary to a congenital diaphragmatic hernia in an adult above the age of 60.w contrast showed pancreatic edema and moderate free fluid most pronounced at the pancreatic tail which was consistent with pancreatitis . Alkaline phosphatase was 13 and T Bili was 0.3. CT abdomen and pelvis wreatitis . There wFurthermore, a large diaphragmatic hernia with herniation of the entirety of the stomach and portion of colon into the right thorax with no evidence of bowel strangulation was also demonstrated on CT . There wAcute pancreatitis is the leading cause of gastrointestinal-related hospitalizations in the United States, and its prevalence is on the rise both nationally and internationally . In the The majority of cases of acute pancreatitis in adults secondary to hernia have been associated with hiatal hernias or traumatic diaphragmatic hernias. Acute pancreatitis secondary to a diaphragmatic hernia is an extremely rare phenomenon. Adult-onset pancreatitis secondary to a congenital diaphragmatic hernia is almost unheard of, with only 2 prior cases reported in the literature, one patient 27 years of age and the other 35 years of age , 10. To There is no clear pathophysiologic etiology for pancreatitis caused by diaphragmatic hernia; however, several purported mechanisms exist including abnormal pancreatic traction causing pancreatic duct drainage obstruction, incarceration of the pancreas within the hernia without volvulus, repetitive trauma through crossing of the hernial sac, and traction ischemia of the pancreatic vascular supply .Of the cases previously reported regarding acute pancreatitis in the setting of diaphragmatic hernia, all of them required emergent surgical intervention due to incarceration or volvulus. Our case is unique as our patient was treated conservatively with considerable improvement in his lipase level and symptomatology. In our case, the patient most likely had intermittent blockage of blood supply and/or pancreatic duct flow which spontaneously resolved.In conclusion, we report the first known case of acute pancreatitis secondary to a congenital diaphragmatic hernia in an adult above the age of 60. Moreover, although lipase is commonly not recommended to be trended for pancreatitis, this case shows some evidence that lipase trend may provide some clinical benefit in the specific setting of pancreatitis secondary to a diaphragmatic hernia. Further studies will be necessary to confirm this potential clinical association.


Glioblastoma sometimes develops with acute onset due to intracerebral hemorrhage. Although it is sometimes difficult to diagnose patients with hemorrhagic-onset glioblastoma at the acute phase of intracerebral hemorrhage (ICH), the progressive enlargement of perifocal edema or the development of contrast-enhanced lesion triggers the diagnosis of glioblastoma within six months. Herein, we present a rare case of glioblastoma in which the diagnosis was delayed as long as 17 months after ICH. A 62-year-old man presented with a headache and aphasia. Computed tomography revealed ICH in the left temporal lobe. Magnetic resonance (MR) images revealed that the hematoma had a mix of isointense and surrounding hypointense lesions on T1-weighted MR images and gadolinium-enhanced lesions at the wall and the septum of the hematoma. An endoscopic evacuation of the hematoma was performed. No causative lesions were found during intraoperative and histological examinations. After seven months, abnormal signals were completely resolved on MR images, except for the small and stable enhanced lesion on three-dimensional gadolinium-enhanced T1-weighted MR imaging (3D Gd-T1WI) at the base of the hematoma, which did not change in size for seven months. However, a large gadolinium-enhanced lesion at the left temporal lobe developed 17 months after ICH. He underwent total resection of the lesion and was diagnosed with glioblastoma. He received radiation therapy and temozolomide but died of disseminated recurrence 31 months after ICH. In conclusion, this report presents a didactic case of glioblastoma in which the diagnosis of glioblastoma was delayed 17 months after ICH whereas hemorrhagic-onset glioblastoma was previously considered ruled out in cases in which six months or more have passed after ICH. In order not to overlook these cases, follow-up with 3D Gd-T1WI is essential in the case of suspected tumor-related ICH and close follow-up is recommended when the enhanced lesion does not resolve after a long period even if it does not grow. Spontaneous intracerebral hemorrhage (ICH) is frequently associated with hypertension, excessive alcohol use, and cerebral amyloid angiopathy . BecauseGlioblastoma is one of the pathologies that frequently can cause spontaneous ICH . In patiThis report presents a didactic case of glioblastoma in which the diagnosis of glioblastoma was delayed 17 months after ICH. Consent for the publication of this case report was obtained from his family, and this study was approved by the ethical board of Tohoku University Hospital (No. 23888).Clinical courseA 62-year-old man, previously diagnosed with hypertension, first complained of headache and aphasia. He was subsequently admitted to another hospital on day three. CT obtained at onset revealed mixed hyperdense and surrounding isodense lesions in the left temporal lobe Figure . He was The nodular lesions were located anteriorly and caudally of the hematoma on three-dimensional gadolinium contrast-enhanced T1WI (3D Gd-T1WI) Figure . From thSeven months after the surgery, the hyperintense area in the cerebral parenchyma on T2WI was completely resolved Figure .Consequently, he underwent left frontotemporal craniotomy and tumor removal. On histological examination, relatively small atypical glial cells, showing marked nuclear atypia and pleomorphic features, proliferated with high cellularity. Microvascular proliferation Figure  and pseuTo the best of our knowledge, this case of hemorrhagic-onset left temporal glioblastoma, IDH wild-type, had the longest latency from hemorrhage to the diagnosis of glioblastoma. He was initially diagnosed with atypical ICH at the left temporal lobe and we presumed that he had causative pathology including malignant glioma, metastatic tumor, or cavernous malformation. Unfortunately, preoperative imaging, intraoperative finding, histological examination, or serial MR imaging by seven months could not detect the underlying glioblastoma in this case.In a report from a single institute and literature review of hemorrhagic-onset glioblastoma ,8, five Findings of the mixed intensity appearance of hematoma on T1WI and T2WI, delayed evolution pattern of the hyperintense area on T1WI, presence of irregular and discontinuous hemosiderin rim, and peripheral linear and nodular enhancement on Gd-T1WI suggest the ICH from the tumor ,18. HoweWe did not consider the residual enhanced lesion at seven months after ICH as glioblastoma because the lesion did not grow for seven months at that time. However, judging from the spatial correlations between the small enhanced lesions and progressive disease, the small enhanced lesion in Figure In conclusion, this report presents a didactic case of glioblastoma in which the diagnosis of glioblastoma was delayed 17 months after ICH whereas hemorrhagic-onset glioblastoma was previously considered ruled out in cases in which six months or more have passed after ICH. In order not to overlook these cases, follow-up with 3D Gd-T1WI is essential in the case of suspected tumor-related ICH and close follow-up is recommended when the enhanced lesion does not resolve after a long period even if it does not grow.