Odontoma is the most common benign odontogenic tumor of epithelial and mesenchymal origin. The standard treatment involves a conservative approach. While this procedure is generally well accepted and tolerated, some difficulties may arise in case of odontomas associated with cystic lesions. In general, the expansive nature of cystic lesions requires their surgical excision, different from isolated nonsymptomatic odontomas that can be monitored radiographically. However, to the best of our knowledge, there is scarce evidence currently available reporting on the presence of odontoma-associated cystic lesions in the oral cavity. Therefore, the present case report is aimed at describing the diagnostic clinical, radiological, and histological features together with the surgical management of a dentigerous cyst associated with a compound odontoma. Following surgical removal of the lesion, no recurrence was observed after 12 months of follow-up. Odontomas are benign proliferations of odontogenic origin, characterized by a mixed histopathological composition, being formed by epithelial and mesenchymal cells with dental hard tissues –5. They From a histomorphological standpoint, odontomas are divided into two different entities according to the latest classification of the World Health Organization : compounOdontomas can be observed in both the jaws, are generally symptomless, and are typically discovered accidentally following routine radiological examinations performed for other oral conditions. Radiographically, they appear as radiopaque lesions, consisting of a cluster of more or less developed tooth structures. A radiolucent band is often visible around the radiopaque mass. In this context, odontomas and osteomas can be hardly distinguishable radiographically. The calcified component has a mixture of enamel, tubular or dysplastic dentine, epithelial-connective matrix producing enamel, and connective tissue .If the diagnosis of odontoma is certain, it is generally not necessary to remove the lesion, unless it prevents tooth eruption or gives rise to complications, such as the development of cystic lesions. In these cases, surgical removal might be indicated.Both odontomas and odontogenic cysts are frequently encountered in dental practice; however, the simultaneous presence of both lesions in the same anatomical region is somewhat rare. In addition, the diagnostic hypothesis is solely based on the radiographic appearance. The interpretation is therefore uncertain, as these lesions can be misdiagnosed for other radiographically similar fibro-osseous lesions, such as fibrous dysplasia and fibroma ossificans . In thishttp://www.care-statement.org) for improving the quality of reporting of case reports. All treatment procedures were performed in compliance with the Declaration of Helsinki on ethical principles for medical research involving human subjects.The present clinical case is reported in accordance with the CARE guidelines  scan in 2010 and two different orthopantomographs, in 2013 and 2019, respectively Figures 1. From thUpon clinical examination, the interforaminal region showed no signs or symptoms of swelling, redness, or inflammation despite the patient's poor oral hygiene conditions. The lower incisors presented with no mobility, although they were splinted with composite resin to the neighboring teeth. The patient was asymptomatic.The surgical procedure was performed on an outpatient basis under local anesthesia induced with mepivacaine hydrochloride 20 mg/mL with epinephrine 1 : 100.000  injections. Bacterial decontamination was achieved with an antiseptic rinsing solution consisting of 0.2% chlorhexidine digluconate for 1 minute. To access the lesion, an intrasulcular incision was made with divergent releasing vertical incisions distally with respect to the right canine and the left lateral incisor. After flap elevation and soft tissue debridement, a thinned and more transparent buccal cortical wall was appreciated in correspondence with the lesion. A circular osteotomy was made with a surgical handpiece under copious irrigation with sterile saline to create a bony window and expose the lesion. At this point, a careful isolation of the encapsulated lesion and complete removal were accomplished with Lucas-like surgical curettes of different sizes and shapes. The entire lesion was excised in toto with the help of mosquito surgical forceps. The surgical defect was debrided to remove any soft tissue remnants and expose macroscopically healthy bleeding bone tissue. The surgical site was irrigated vigorously with sterile saline, and the flap was finally repositioned and sutured with 4/0 silk single stitches. The lesion measuring 15 × 10 × 7 mm was sent to the anatomical pathology department for histopathological examination (Figures 5From an initial macroscopic evaluation, the resected specimen consisted of a cystic lesion with a thin 1 mm diameter regular wall, associated to a tooth-like structure measuring 7 mm in its long axis. Histologically, the cyst had a thin fibrous wall with brown hemosiderin deposits, covered by a hyperplastic nonkeratinizing squamous epithelium, consistent with a dentigerous cyst. The tooth-like structure was mainly composed of dentin with a thin outer layer of cement and little inner dental pulp-like tissue, compatible with compound odontoma . No recuThe present report described the surgical management of a compound odontoma associated with a cystic lesion in the interforaminal area. Heterogeneity can be found in literature regarding the epidemiology of odontomas. In this matter, our findings are inconsistent with other studies reporting that compound odontomas are more frequently diagnosed in patients during the first two decades of life  in the pOdontomas are odontogenic in nature, as they derive from the epithelial and/or mesenchymal tissues from which the teeth originate, and can induce cystic proliferation . This cyClinically, odontomas can present as intraosseous or extraosseous lesions. Intraosseous odontomas develop within mandibular or maxillary bone structures and, in some cases, may also erupt into the oral cavity. Peripheral ones arise at the level of extraosseous soft tissues, are very rare, and tend to exfoliate . In the Typically, treatment of odontomas involves surgical removal, while therapeutic strategies reported for dentigerous cysts range from marsupialization to enucleation. This complies favorably with the therapeutic plan adopted in the present report, where surgical removal of the lesion was considered as the treatment of choice. Conversely, marsupialization is more commonly used in children when compared to enucleation because it is surgically less invasive and preserves the eruption of permanent teeth. Other factors favoring marsupialization include young age, lack of patient compliance for more invasive surgical treatment, tooth position and development, and eruptive potential , 18.In the present case, the bidimensional radiographic features of the lesion were initially inconclusive for diagnostic purposes. Additional radiographic evaluation with CBCT scan, at a relatively low radiation dose and high resolution, was necessary to determine the real extent and characteristics of the lesion. Indeed, the bidimensional limitations of periapical and panoramic images did not allow a complete three-dimensional visualization of the anatomical region. In this regard, CBCT images are necessary not only to assess the lesion itself but also to identify possible associated pathologies, the proximity to noble structures, and to formulate a correct treatment plan –21.The imaging features of fibro-osseous lesions are very difficult to be distinguished among the large group of similar pathologies such as fibroma ossificans and fibrous dysplasia.In those cases, CBCT is an important tool for the differential diagnosis of such lesions . In the In the present report, the odontoma was associated with another lesion with cystic features. In this regard, a dentigerous cyst could have been probably the result of cystic degeneration and had to be chosen as the diagnostic hypothesis. This was confirmed after surgical removal of the lesion, as the histopathological analysis showed a compound odontoma associated with a dentigerous cyst. Despite their benign nature, these lesions are well recognized by their growth pattern and should be completely removed to avoid secondary complications and possible sequelae for the patient, with an excellent prognosis following surgery. As a matter of fact, no recurrence was observed after 12 months of follow-up.


Blunt abdominal trauma infrequently leads to vascular injuries, and common iliac artery (CIA) injuries after motor vehicle accidents due to seat belt injury are very rare. Its posterior anatomic location and the pelvic bones usually protect the CIA. We describe a case of a young female presenting with acute blunt trauma to the abdomen after being a restrained driver in a motor vehicle accident and was found to have acute left CIA occlusion. The purpose of this case is to stress the importance of maintaining a high index of suspicion for vascular injuries in blunt abdominal trauma; we recommend early imaging diagnosis and timely treatment to mitigate its complications. Common iliac artery (CIA) injuries after motor vehicle accidents are rare but require complex clinical management, leading to significant morbidity and mortality. Compared to penetrating iliac trauma, blunt iliac arterial injury is frequently associated with major pelvic fracture. Although rates of early hemorrhagic deaths are low, the incidence of septic complications increases with time . CIA bluA 54-year-old female presented to our hospital as a level 2 trauma resuscitation status after a motor vehicle accident. She was a restrained driver of a vehicle that rear-ended a parked car at high speed. There was significant damage to the front end of the patient's car, and airbags were deployed. The patient was found to be intoxicated on the scene of the accident. She sustained blunt head trauma with loss of consciousness. On arrival to the emergency department, the patient was somnolent but arousable. She reported that she had significant abdominal pain predominantly in the left lower quadrant. On examination, her breath sounds were clear and equal bilaterally with equal chest rise bilaterally. She had equal pulses in all four extremities. An abrasion was noted over the left lower abdomen along with small lacerations over the right hand. She demonstrated midline thoracic and lumbar spine tenderness to palpation without any focal neurological deficits.A stat portable chest and pelvis radiograph was performed in the resuscitation room. Chest radiograph was negative for any acute intrathoracic process. Pelvic radiograph demonstrated no acute fracture or dislocation. The patient underwent a computed tomography (CT) scan of the head, abdomen, and cervical, thoracic, and lumbar spine. CT of the head was negative for any acute intracranial hemorrhage. The cervical and thoracic spine CT scan was negative for any acute fractures. CT scan of the abdomen demonstrated findings suggestive of sigmoid colon traumatic injury along with diffuse small bowel edema. The CT scan demonstrated active contrast extravasation in the left lower quadrant suggestive of active bleeding from traumatic mesenteric injury along with moderate amount of hemoperitoneum. Acute occlusion of the left CIA with reconstitution of the external and internal iliac arteries was also noted on the CT scan of the abdomen Figures , 1J, 1K.The patient became hypotensive in the emergency department, massive transfusion protocol was initiated, and the patient was urgently taken to the OR for surgical intervention. The patient required exploratory laparotomy with sigmoid resection stapled side-to-side functional and end-to-end antiperistaltic colorectal anastomosis.MRI of the lumbar spine was performed for further evaluation, which demonstrated mild compression deformity of the L3 vertebrae along with superior articulating facet fractures and interspinous and ligamentum flavum disruption at L2-3. A small amount of blood products was also present within the posterior epidural space at L3 without significant mass effect. The patient underwent posterior percutaneous fusion of the L2 to L4 vertebrae with vertebroplasty of the L2, L3, and L4 vertrebraes. Post-fusion CT scan demonstrated vertebroplasty changes at L2, L3, and L4 with transpedicular screws in good alignment Figure .Vascular surgery was consulted for the management of acute left CIA occlusion secondary to blunt trauma. The patient denied any left leg pain, numbness, tingling, or weakness. On physical examination, although the left lower extremity was colder than the right lower extremity, it demonstrated normal capillary refill without any visual discoloration and appeared well perfused. Clinically, the patient did not demonstrate any signs of acute limb ischemia. A bilateral lower extremity arterial duplex ultrasound scan was performed, which revealed a left ankle-brachial index of 0.39, indicating severe arterial insufficiency Figure . The rigThe patient underwent left femoral cutdown and iliac thrombectomy. During the thrombectomy, a small filling defect was noted in the left CIA, which was interpreted as an intimal flap, and hence bilateral kissing common iliac arterial stents were placed. The patient later developed chest pain, and a CT angiography of the thorax and abdomen was performed, which demonstrated a large aortic arch dissection extending from the left subclavian artery to the bilateral common iliac stents. The aortic dissection from the aortic arch up to the diaphragm was thrombosed and was treated with an endovascular stent placement.The patient’s chest pain has resolved but she still continues to have some difficulty in walking. Hence, she has been discharged to a rehabilitation service for further monitoring and physiotherapy.Majority of the vascular injuries are due to penetrating trauma. Motor vehicle accidents leading to blunt trauma account for 7% to 9% of vascular injuries . Seat beCIA injuries are usually diagnosed and evaluated based on clinical suspicion such as the presence of pulse deficit, bruit, expanding hematoma, arterial bleeding, poor capillary filling, and cold extremities. Advancement in imaging modalities has played a critical role in early diagnosis and management of these vascular injuries. Contrast-enhanced CT scan performed for our patient not only delineated the colonic and spinal injuries but also assisted in the timely diagnosis of the left CIA occlusion. Symptoms of vascular injuries are commonly delayed but may progress to severe outcomes such as acute limb ischemia; hence, timely diagnosis and management of vascular injuries is critical in such cases. Acute limb ischemia is a rare clinical presentation for blunt aorto-iliac arterial injuries, and most patients are initially asymptomatic with a median delay in operative repair of 15 days (range: 2 days to 36 years) . AdvanceAcute CIA occlusion is a rare vascular injury associated with blunt abdominal trauma secondary to a motor vehicle accident of a restrained passenger. Seat belt injuries are most likely due to shearing forces generated during rapid deceleration leading to an intimal flap, which leads to thrombosis of the vessel. These injuries are associated with rapid lower extremity amputation and death even after aggressive surgical revascularization. Although surgical revascularization appears to be the main choice of treatment, endovascular techniques may have an increasing role in the future. Through this case, we not only stress the importance of maintaining a high index of suspicion for CIA vascular injuries in patients with blunt abdominal trauma but also delineate the significance of early imaging diagnosis and aggressive treatment to mitigate its complications.


Liver resection is still the most effective treatment of primary liver malignancies, including hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), and of metastatic disease, such as colorectal liver metastases. The type of liver resection (anatomic versus non anatomic resection) depends on different features, mainly on the type of malignancy (primary liver neoplasm versus metastatic lesion), size of tumor, its relation with blood and biliary vessels, and the volume of future liver remnant (FLT). Imaging plays a critical role in postoperative assessment, offering the possibility to recognize normal postoperative findings and potential complications. Ultrasonography (US) is the first-line diagnostic tool to use in post-surgical phase. However, computed tomography (CT), due to its comprehensive assessment, allows for a more accurate evaluation and more normal findings than the possible postoperative complications. Magnetic resonance imaging (MRI) with cholangiopancreatography (MRCP) and/or hepatospecific contrast agents remains the best tool for bile duct injuries diagnosis and for ischemic cholangitis evaluation. Consequently, radiologists should be familiar with the surgical approaches for a better comprehension of normal postoperative findings and of postoperative complications. In the recent years the number of liver resections is globally rising, according to the increase in occurrence of primary and metastatic cancers ,2,3,4. LIn the field of liver resection, according to the Brisbane 2000 terminology, liver resections could be classified as anatomic and not anatomic resection . The typUltrasonography (US) is the first-line diagnostic tool to use in post-surgical phase. However, computed tomography (CT), due to its comprehensive assessment, allows a more accurate evaluation and more normal findings than the possible postoperative complications. Magnetic resonance imaging (MRI) with cholangiopancreatography (MRCP) and/or hepatospecific contrast agents remains the best tool for bile duct injuries diagnosis and for ischemic cholangitis evaluation .The purpose of this narrative review is to report the main liver resection, focusing on the definition of anatomic versus non anatomic resection, and on the main regular postoperative radiological features.Hepatectomies can be classified as anatomic and non anatomic resections.Anatomic liver resection is defined as the complete removal of the liver parenchyma confined within the responsible portal territory. The portal ramifications define anatomical portions of the liver. In particular, the first order division of portal ramification defines the “hemi-liver”, the second order division defines the “section”, while the third order division defines the segment.Therefore, according to the Brisbane classification, anatomic liver resection is defined as segmentectomy , sectionThe term anatomic segmentectomy is utilized to describe the surgical approach that determine the elimination of a portion of liver parenchymal which correspond to a Couinaud segment. Otherwise, with “subsegmentectomy”, we identify a surgical approach to determine the partial removal of liver tissue within the portal territories of less than a Couinaud’s segment .Anatomic sectionectomy corresponds to the comprehensive elimination of tissues of the second order portal venous branches. these approaches are classified considering the eliminated section. For example, the right anterior is the elimination of the right anterior, including segments 5 and 8, while the right posterior is the elimination of the right posterior, including segments 6 and 7.The surgical procedure that causes the elimination of the liver to the right of the middle hepatic vein is defined as right hepatectomy. This resection includes segments 5, 6, 7, and 8. When in addition to right hepatectomy, segment 4 is resected, we obtained an extended right hepatectomy, also named right trisectionectomy.With regard to the elimination of the liver parenchyma to the left of the middle hepatic vein, this approach is the left hepatectomy and includes the segments 2, 3, and 4. For extended left hepatectomy, also named as left trisectionectomy, the additional removal of segments 5 and 8 is intended.The surgical procedure known as parenchyma-sparing hepatectomy (PSH) is a limited non anatomical liver resection . In contThe PSH procedure should allow an R0 resection (corresponds to resection for cure or complete remission) with negative surgical margins. Compared to the anatomical resection (AR) approach, it is more technically challenging, since anatomic landmarks, as lobar or sectorial vessels, are not used as a guide to identify the resection margins. Therefore, intraoperative ultrasound plays a key role during PSH, allowing the identification of lesions, the relationship of the lesion with the vital structures , and the parenchymal transection plan .Although the cut off to obtain negative margins has usually been 1 cm, the introduction of new chemotherapeutic agents has allowed the reduction of this margin at 1 mm, in colorectal metastases (CLM), with good oncological results . MoreoveIn addition, according to the new surgical oncology group suggestions, in the absence of extrahepatic disease, the only limits to surgical treatment of CLM patients is correlated to the post procedural liver parenchymal that should be sufficient to prevent liver failure (PLF) .Thanks to the use of the intraoperative US, it is possible to detach lesions from major vessels and to perform accurate flow analysis, preserving communicating vessels among main hepatic veins that should assure an adequate outflow to the liver even after main hepatic vein resection ,22,23,24Among all the complex parenchymal sparing strategies, we cite systematic extended right posterior sectionectomy , mini upTwo stage hepatectomy and associating liver partition with portal vein ligation for staged hepatectomy (ALPPS) are two strategies of treatment for liver disease in patients with insufficient liver function .With regard to two stage hepatectomy, this approach includes two phases: In the first, to obtain hypertrophy of future liver remnant (FLR), the surgeons and/or radiologists perform a surgical ligation or radiological embolization of the portal vein, so that, the redistribution of portal flow induces parenchymal hypertrophy. In the second phase, the surgical approach is performed to remove target lesions.The ALPPS includes parenchymal splitting and portal vein ligation in the first stage . CompletImaging, with regard to hepatic resection, should be employed in different phases: staging, treatment planning, intra-treatment evaluation, and treatment response assessment, which includes technical success, treatment efficacy, and complications ,58,59,60With regard to “technical success”, this is due to the ability of treating the lesion according to the procedure , while “Different diagnostic techniques may be utilized, alone or as a multimodality approach ,78,79,80Ultrasound assessment, also with the employment of contrast medium (CEUS), is a relatively new tool, utilized for problem solving during treatment phases and surveillance ,131,132,Usually, US is the first tool employed during the post-surgical phase to assess abdominal complications and to evaluate treatment efficacy. CT with contrast agents, normally, is utilized as a follow-up tool to evaluate efficacy and recurrence, while it is the first tool employed in emergency setting ) ,36,37. MThe post-surgical radiological assessment should be distinguished early, during the first hours after surgery, with a follow-up at the time of discharge and an oncological follow-up taking into account the main guidelines in relation to the type of cancer treated ,134,135.Normally, a diagnostic assessment, during the first hours after surgical procedure is only required in case suspected complications, such as a bleeding or biliary lesion ,138,139,In this phase, radiologist should evaluate: (a) the presence of free fluid, (b) the state of the surgical margins and the remnant liver parenchyma, (c) vascular evaluation  as well as any other sites subjected to resection ,146,147.At US assessment, free fluid may present a hypoechoic collection in the posterior recesses or, in the presence of blood, inhomogeneously iso-hypoechoic or hyperechoic ,146,147.To assess active bleeding and to identify bleeding causes, a multiphasic CT evaluation is mandatory  149,150,153,154.At US assessment, surgical margins may appear hyperechoic compared to surrounding liver parenchymal. In addition, the radiologist should evaluate the presence of post-surgical fluid collections. These entities may be due to the presence of haematomas (50%), bilomas (25%) and abscesses (25%) .Hematoma may appear as a biconvex or growing intraparenchymal lesion, with suprafluid echogenicity at US or density at unenhanced CT (between 50 and 60 HU) ,163,164.Biloma is an encapsulated collection of bile outside the biliary tree . At US aAir artefacts within a supra-fluid collection that do not show central perfusion at color Doppler assessment in patients with high grade fever is suggestive of an abscess . CT confThe radiological appearance of remnant liver parenchymal is complex and is correlated to the type of surgical procedure, the segment resected (ore more segment), the quality of residual parenchymal (cirrhotic or chemotherapy-induced steatohepatitis) . A non-tVascular assessment provides for the evaluation of the flow of the main arterial and venous branches ,188,189.Clinically, vein thrombosis may be asymptomatic or may cause abdominal pain if the superior mesenteric vessels are involved due to bowel congestion or ischemia ,190,191.On US assessment, a limited thrombus is seen as an echogenic area within vessel, in the absence or with a slow portal flow on Doppler images. In addition, on color Doppler US, vein thrombosis is characterized by the loss of a triphasic waveforms pattern with a decrease in hepatic vein velocity and in portal flow ,193. On During the follow-ups scheduled in relation to the patient’s cancer history, the findings described at discharge change .In the patient with a functioning liver, free effusion disappears , the intThis tissue should be correctly distinguished from new lesions, expressions of disease recurrence ,202,203.With regard to remnant liver parenchyma, hepatitis is replaced by hepatic regeneration, so radiologist should know the type of surgical procedure to correctly localize new lesions . OtherwiWith regard to two stage hepatectomy and ALLPS radiological evaluation, these procedures cause a selective portal vein occlusion to obtain a hypertrophy of future liver remnant ,33,34. SThe knowledge of the main type of liver resection is necessary for the radiologist to recognize the radiological common features of post-operative findings and identify the possible postoperative complications.US is the first-line imaging examination during the postoperative monitoring. However, CT is of greater value for identifying normal findings after surgery, and the possible postoperative complications. MRI is the best modality for the diagnosis of early postoperative bile duct injuries and to assess recurrence.


Ossicular pathology is a recognized etiology of conductive hearing loss. Ossicular pathology includes 2 main categories, that is, ossicular chain fixation and ossicular discontinuity. Ossicular discontinuity can be congenital or acquired. Auto-incudotomy is an uncommon form of acquired ossicular discontinuity that usually occurs as a sequel of spontaneous expulsion of cholesteatoma. Typically, it manifests with conductive hearing loss without evidence of cholesteatoma. In this report, we presented CT imaging finding of a 34-year-old male with tympanic membrane perforation and defective long process of the incus (auto-incudotomy) with minimal middle ear granulation tissue and adhesions, sequela of cholesteatoma. Radiologists should pay attention for evaluation of ossicles especially in patients presented with conductive hearing loss. The primary conduction apparatus for sound waves to the inner ear consists of the tympanic membrane and the ossicular chain Ossicular chain pathologies are a leading cause of CHL and can be divided into ossicular chain fixation (OF) or ossicular discontinuity (OD) Cholesteatomata can lead to ossicular erosions early in the course of the disease, most often affecting the long process of the incus Cholesteatomata can present in subtle ways with opacification of the Prussak's space In this report, we present a case of CHL secondary to a spontaneously expulsed acquired cholesteatoma which complicated chronic otitis media. The disease resulted in erosion of the mastoid bone and the incudal long and lenticular processes, with replacement of a fibrous band in its place.A 34-year-old man with a past medical history significant for right chronic otitis media status post multiple myringotomy tube placements as a child presented with several years of right-sided conductive hearing loss and tinnitus, and intermittent ear pressure.Otomicroscopy revealed an area of granulation tissue of the medial external auditory canal adjacent to the annulus of the right posterior tympanic membrane, with retraction of the posterior pars tensa just medial to this granulation tissue. The retraction pocket appeared extending towards the incudo-stapedial joint, concerning for involvement of the ossicles. The combination of the patient's history and physical findings were concerning for cholesteatoma. A high-resolution non-contrast CT scan (HR-NCCT) of the temporal bone was subsequently requested to better assess the middle ear and mastoid.A high resolution 0.6 mm isotropic HR-NCCT of the temporal bone revealed a hypoplastic right mastoid air cells with increased osseous density and small, mildly dysplastic ossicles. There was demineralization, resorption, and fibrous replacement of the distal long process of the incus near its incudo-stapedial articulation  and 2.Fi2 laser was used to perform a myringoplasty to address the tympanic membrane retraction.Due to concern for cholesteatoma, the patient subsequently underwent a right middle ear exploration with a transcanal tympanoplasty. Evaluation of the ossicles confirmed erosion of the long process of the incus with adhesions around the stapes and chorda tympani. These adhesions were lysed with a Rosen needle. Palpation of the stapes confirmed normal mobility. The remnant incus was subsequently removed and a frisbee partial ossicular replacement prosthesis (PORP) was placed on the capitulum to reconstruct the ossicular chain and tragal cartilage graft placed lateral to this as a buttress. A COPost-operatively, the patient was noted to have healed appropriately with no resultant perforation or granulation tissue. Post-operative audiogram demonstrated partial closure of the air bone gap in the right ear .Fig. 3 can play an important role in preoperative and postoperative evaluation of cholesteatomas. MRI signal intensities of cholesteatomata have a characteristic hypointense T1, hyperintense T2, with mild to moderate restricted diffusion on diffusion-weighted (DWI) sequences compared to the normal brain parenchyma . DWI andA spontaneously expulsed acquired cholesteatoma appears as an elliptical air cavity surrounded by granulation tissue on NCCT. The cavity can expand into the medial or lateral attic walls in patients with chronic ear discharge . Prior iAbsence of the incus is the most observed developmental middle ear anomaly . It maniAcquired resorption of the long and the lenticular processes can be caused by cholesteatomata or inflammation ,10,28. TOur case demonstrates an individual with the sequela of cholesteatoma: autoincudotomy, tympanic membrane perforation, with subtle granulation tissue density, and adhesions. On surgical exploration, however, no cholesteatoma was noted. A spontaneously expulsed acquired cholesteatoma is suspected in this case.HR-NCCT scan is a useful imaging tool for diagnosing ossicular abnormalities, for example, epitympanic fixation, ossicular malformation, discontinuity ,8,9, andOssiculoplasty is the reconstruction of ossicles and can be performed by using either an autograft , homograft  or most commonly from a synthetic materials such as titanium, hydroxyapatite and other materials . OssiculCareful evaluation of the ossicles and tympanum on HR-NCCT of the temporal bone is essential in patients presenting with conductive hearing loss. Ossicular pathologies range from developmental absence, traumatic disruption, and resorption from aging, or due to cholesteatomata. Focal absence of an ossicle, most commonly the long process of incus, expansion of the tympanum, granulation tissue, and adhesions can be clues to for a spontaneously expulsed cholesteatoma.The authors have written informed consent for the publication of this case report.


Rupture of ovarian dermoid‐cyst is rare case. We report the case of a woman admitted for acute post‐traumatic abdominal pain due to ruptured ovarian cyst. The patient was operated and we found a very abundant peritoneal effusion with left ovarian cyst which was broken. we performed a left adnexectomy. Rupture of an ovarian teratoma with dermoid peritonitis is a diagnosis that we should think of in case of an acute peritonitis in a women whatever her age is. It is a rare diagnosis especially when have eliminate other diagnosis such as appendicitis, cholecystits, or bowel perforation. This is the most common complication after torsion. The rupture can be in another organ or in the peritoneal cavity.2A 75‐year‐old patient, with no particular pathological history, admitted for acute post‐traumatic abdominal pain. Indeed, she was the victim of a domestic accident: She was fallen from her height.The clinical examination found the temperature at 38°C, she has a stable hemodynamic state with diffuse abdominal tenderness and maximum pain at the pelvic level and significant abdominal distension. She has not an abdominal impact point.3 with a CRP at 78 mg/L.Biology showed a biological inflammatory syndrome with hyperleukocytosis at 16,500 elements/mmCT scan found a left ovarian cyst with a dermoid appearance  associated with abundant intraperitoneal effusion with diffuse infiltration of intra‐abdominal fat. A ruptured ovarian cyst in the peritoneum was concluded.The patient was operated urgently. We found a very abundant peritoneal effusion made of sero‐hematic fluid, sebum, tufts of hair, and some hard calcium debris Figure . There wThe postoperative course was simple after 2 days in intensive care unit.3The dermoid cyst is a very common ovarian tumor (approximately 25% of ovarian tumors).In half of the cases, it is asymptomatic.Diagnosis is based on imaging data, particularly ultrasound and CT, which highlight the presence of heterogeneous calcium and fatty components.Rupture in the peritoneum is complicated by chemical peritonitis.Cystectomy is the standard procedure in young women, while oophorectomy or adnexectomy is most often performed in postmenopausal women.Abundant washing of the peritoneal cavity should be performed with saline solution and all visible particles of dermoid material  should be removed.Examination of the anatomo‐pathological specimen is essential and mandatory in order to confirm the diagnosis and to look for an immature dermoid component, in which case further surgery or chemotherapy should be discussed.Rubod and then El Moussaoui have reported a similar case treated by adnexectomy as we have done to our patient.4Dermoid peritonitis is a rare condition secondary to sudden rupture (acute form) or cracking (torpid form) of an ovarian teratoma. This diagnosis should be considered in case of peritonitis with nonexplained etiology, especially when the CT scan reveals a mature teratoma. It is important to evoke the acute form in a woman of childbearing age, presenting with severe pelviperitonitis.S Fendri conceived the idea for the document and contributed to the writing and editing of the manuscript. H Rejab contributed to the writing and editing of the manuscript. A Trigui, B Abid, Y Majdoub, A Bouzid, and K Fourati reviewed and edited the manuscript. S Boujelbene contributed to the literature review, manuscript writing, editing, and review of the manuscript. All authors read and approved the final manuscript.No fundings needed for this publication.None for all authors.Personal data have been respected.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


Appendiceal neoplasms are uncommon; most are identified by pathologic examination after appendectomy for presumed appendicitis or as an incidental finding. When found incidentally, patients are typically asymptomatic. If the neoplasm has perforated, patients may present with symptoms that mimic acute appendicitis. In advanced disease, patients may have systemic symptoms associated with peritoneal disease, including abdominal distension, weight loss, and diffuse abdominal pain. Because of their rarity, as well as rapidly evolving research on the subject, the nomenclature of appendiceal mucinous neoplasms has proven challenging. This lesion was identified as a low-grade appendiceal mucinous neoplasm (LAMN), previously termed mucoceles or mucinous cystadenomas. LAMNs are non-invasive neoplasms that have the potential to proliferate outside the appendix in a malignant fashion. All mucinous appendiceal neoplasms can perforate and spread mucin production throughout the abdominal cavity, known as pseudomyxoma peritonei (PMP). The presence of PMP designates LAMNs as malignant, though the neoplasm itself is non-invasive. When appendiceal neoplasms have peritoneal involvement, cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is the standard of care. Complete cytoreduction has been shown to be an independent predictor of survival. Here we describe a case of a 30-year-old male involved in a motor vehicle collision with a grade IV splenic laceration, who is also found to have a large appendiceal mass. His traumatic injuries required emergent intervention, which delayed treatment of his malignancy. Incidental findings are common in trauma patients that undergo whole-body computed tomography (CT) scans. Studies on patients receiving whole-body CT scans found incidental findings in 35-50% of patients ,2. HowevA previously healthy 30-year-old male presented to the emergency department after being involved in a motor vehicle collision. Exam and subsequent CT imaging revealed a grade 4 splenic laceration, as well as fractures of the left 6th, 8th, 9th, and 10th ribs, and a chip fracture of the left olecranon. Incidentally, the tip of the appendix was also noted to have a 5.6 x 4.9 cm, peripherally calcified, low-density lesion  for serial hemoglobin and cardiac monitoring. His hemoglobin trended down slightly from 12.1 to 9.9 g/dL over the course of three days. During this period, a discussion was held with the patient and family by the trauma team regarding his incidental appendiceal lesion - imaging characteristics were consistent with a mucinous neoplasm, though, without a tissue diagnosis, the malignant potential was unknown. He denied having any symptoms prior to admission, any family history of cancer, or ever having a colonoscopy.Seven days after his initial injury when the patient was fully recovered from his splenic embolization and his pain well-controlled from his rib fractures, he was prepared for surgical exploration. At a minimum, the size of the lesion warranted a partial right colectomy. However, this lesion was concerning for a mucinous neoplasm; if mucin were present in the abdomen, he would require hyperthermic intraperitoneal chemotherapy (HIPEC), which would require transfer to a cancer center. The abdomen was entered using the Veress needle technique, and upon inserting the laparoscope into the abdomen, we identified mucin-like material spread throughout the abdomen Figure .The sequelae of his splenic injury were also noted, with pooling of coagulated blood throughout the abdomen. Additional laparoscopic ports were placed to aid in collecting specimens for pathology. A peritoneal biopsy was obtained for permanent pathology, a sample of mucinous-appearing peritoneal fluid was sent for cytology, and the operation was concluded. Microscopic examination of the peritoneum revealed fibroadipose tissue with reactive mesothelial cells, interstitial mucin, and microcalcifications without evidence of neoplastic cells or overt malignancy. Few atypical epithelioid cells were noted on cytology. Tumor markers obtained prior to surgery demonstrated CA 125 of 23 U/mL , CA 19-9 12 U/mL , CEA 7.2 ng/mL .Post-operatively, the patient was referred to a facility with HIPEC capabilities due to our finding of pseudomyxoma peritonei. His procedure was postponed for four months to allow for recovery from his polytraumatic injuries and delays related to the COVID-19 pandemic. Prior to surgery, he underwent a colonoscopy in which two tubular adenomas and two hyperplastic polyps were removed; no abnormalities were noted at the appendiceal orifice.The patient then proceeded with exploratory laparotomy with the intent of cytoreductive surgery, hyperthermic intraperitoneal chemotherapy, and a partial right colectomy. Prior to surgery, cystoscopy and bilateral ureteral stent placement were performed. A midline laparotomy incision was made, and upon entering the abdominal cavity, mucinous deposits were encountered throughout the abdomen - on the surface of the right liver, small bowel mesentery, wall of the anterior rectum, the surface of the terminal ileum, and peritoneum of the right upper quadrant, right lower quadrant, and right mid-abdomen. The peritoneal carcinomatosis index (PCI) score was 13. The appendix was dilated, and the tip had perforated.A total omentectomy was then performed, followed by resection of the right-sided peritoneum. Mucinous nodules of the liver and anterior rectum were removed bluntly, and nodules of the small bowel mesentery were removed by a combination of sharp dissection and Argon beam. A right partial colectomy with ileocolonic anastomosis was performed, as well as a cholecystectomy. HIPEC was then performed in a standard fashion. No visible disease was noted; the complete cytoreduction (CCR) score was 0. The abdomen was then closed, and surgery was concluded.The final pathology report revealed a low-grade mucinous neoplasm of the appendix with no invasive component. No further surgical treatment will be necessary at this time. He will undergo continued monitoring through the cancer center.Appendiceal neoplasms are uncommon; they represent less than 1% of all gastrointestinal malignant neoplasms . They arBecause of their rarity, as well as rapidly evolving research on the subject, the nomenclature of appendiceal mucinous neoplasms has proven challenging. The Peritoneal Surface Oncology Group International (PSOGI) and American Joint Committee on Cancer (AJCC) have only just recently developed guidelines for a more simplified classification of appendiceal neoplasms ,5. EpithAll mucinous appendiceal neoplasms, both invasive and non-invasive, have the propensity to perforate and spread mucin production throughout the abdominal cavity, known as pseudomyxoma peritonei (PMP) ,7. ThougWhen appendiceal neoplasms have peritoneal involvement, cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is now considered the standard of care ,4,8,9. TIncidental findings are very common in trauma patients and vary tremendously in their clinical significance. This case highlights an incidentally found rare malignancy in a trauma patient. Although his injuries delayed the treatment of the malignancy, the trauma facilitated the diagnosis and without it, it is unknown if he would have been diagnosed in a timely manner. His care was furthered by excellent communication between a rural trauma center and a quaternary care cancer center which allowed him to undergo a lifesaving cancer operation within four months of sustaining his trauma. This case highlights the importance of diligence and a high index of suspicion with incidental findings in trauma which can allow a trauma surgeon to save a patient’s life well beyond the realm of acute injuries.


Parry Romberg syndrome (PRS), also known as progressive hemifacial atrophy, is a very rare self-limiting disease, which affects the skin and subcutaneous tissues, underlying musculature, cartilage, and bony structures of one half of the face with a resultant hemiatrophy and alopecia areata. It presents in children and young adults, with a slow progression of the atrophy for several years, and then becomes stable. Magnetic resonance imaging (MRI) or computed tomography (CT) scan of the cranium demonstrates the radiological feature of hemiatrophy very clearly. We report a case of PRS in a nine-year-old girl with characteristic features which was diagnosed based on medical history, clinical signs, and radiological findings on cranial CT scan and MRI. Parry Romberg syndrome (PRS) is a rare disease, with a prevalence of at least one in 700,000 births. The initial sign is thinning of the cutaneous and subcutaneous tissues, which is often preceded by alopecia areata. It involves the nose, mouth, or ear, and damage is usually limited to the distribution of the trigeminal nerve. These lesions do not cross the midline and craniofacial asymmetry results, which causes esthetic discomfort, thus reducing self-esteem and affecting the growth and intellectual development of the individual -3.Parry was the first to describe this condition in 1825 followed by Romberg in 1846. In 1871, Eulenberg named it progressive hemifacial atrophy [Magnetic resonance imaging (MRI) or computed tomography (CT) scan of the head reveals varying degrees of bone and soft tissue atrophy on the affected side. Another common neuroimaging finding is white matter hyperintensities on T2 and fluid-attenuated inversion recovery (FLAIR) sequences on brain MRI and intracranial calcifications on CT. Advanced neuroimaging and metabolic/functional techniques like diffusion tensor imaging (DTI) and magnetic resonance spectroscopy (MRS) can also be utilized. MRS can also show abnormal spectral patterns and decreased N-acetyl aspartate level in the affected region of the brain and DTI, and a fractional anisotropy mapping reveals a decrease in anisotropy of the water molecules in the white matter of the affected area ,8-11.A nine-year-old girl with a provisional diagnosis of PRS was referred to the radiology department for a CT scan of the head. She is the first-born of three siblings who are all healthy. No known family member has abnormal features. Her antenatal, peri-natal, and post-natal periods were uneventful. She was born by spontaneous vaginal delivery, cried at birth, and her birth weight was 3.0 kg. She had no relevant previous medical history. She had normal developmental milestones and is currently in school and doing well academically. She weighed 37 kg with a height of 1.39 m. Routine blood investigations were all within normal limits.Her mother complained that from age four, there was a gradual progressive reduction in the size of her face on the left side, hypopigmentation of the skin of the frontal scalp, and ipsilateral loss of hair which preceded the hemifacial atrophy. On physical examination, there was left facial hemiatrophy resulting in a small nasal cavity, a depression of the left frontal skull, alopecia areata, hypopigmentation of the ipsilateral skin of the frontal scalp, and eyebrow alopecia. There was no tongue atrophy, and she was a very active girl with no neurological deficits. Her complaints were nasal congestion, occasional headaches, anxiety about her facial asymmetry, and constant questioning from her classmates. Figure Ultrasound scans of the parotid and submandibular glands were unremarkable. A head CT scan was done without a contrast medium Figure . MRI with gadolinium was also done using a 1.5 Tesla MRI machine Figure .The patient and her family were counseled and symptomatic treatment was given. She is being followed up.PRS is a rare neurocutaneous disease of sporadic occurrence, which is characterized by a one-sided self-limiting facial atrophy . The disClinically, the initial signs are thinning of the skin and subcutaneous tissues, usually preceded by alopecia areata, or vitiligo as seen in our patient ,6. The sThe diagnosis of PRS is mostly a clinical one, aided by findings on histopathology and imaging. There are no accepted standardized diagnostic criteria; however, reported photographs of the individual should be kept and followed throughout the course of the disease and follow-up ,11. ThisCT scan best demonstrates calcifications and bony changes of the hemicranium and facial skull while MRI is sensitive in identifying gliosis and atrophy. These abnormalities are usually non-enhancing, but iodinated contrast medium and gadolinium were useful in a few cases in showing areas of active inflammation on head CT and MRI, respectively . TypicalThe differential diagnosis of PRS includes other forms of juvenile localized scleroderma, Rasmussen encephalitis, Barraquer-Simons syndrome, primary hemifacial hypertrophy, and congenital hemiatrophy. Others are congenital deformities such as “wry neck” fat necrosis, either from infection like bulbar poliomyelitis, connective tissue disease, or trauma ,16-19. TThis rare condition can easily be missed or misdiagnosed during a routine doctor-patient consultation, as it is often very subtle initially. The accurate and early diagnosis of PRS demands an in-depth knowledge of this condition among the practitioners who may be involved in the initial encounter with the patient and management. A detailed review of the patient’s medical history, previous photographs, and an extensive physical examination are required to look for signs of progressive loss of skin, fat, muscle, and bone. Patients with facial asymmetry may develop psychological problems; hence, clinical psychologists must be involved very early in the management. This case report documents the classic features and hence contributes to the understanding of the disease.


Aberrant pancreatic tissue in the gastrointestinal tract is a relatively common finding. However, malignant transformation is extremely rare. Herein, we report a case of ectopic pancreatic ductal adenocarcinoma in the stomach wall.A 38 year old male presented with nausea, bloating, abdominal distention and weight loss for 4 months.Endoscopy of upper gastrointestinal tract was performed twice with 2 months interval and a stenotic pyloric part was observed with a suspected submucosal lesion. It was sampled both times, however the pathology findings of the mucosal biopsies were unremarkable with no identifiable neoplastic structures. CT scan and MRI was performed and showed a thickened pyloric wall with a submucosal lesion 15 × 15 mm in diameter. Blood levels of tumor markers carcinoembrionic antigen and carbohydrate antigen 19-9 were within a normal range.Pyloric stenosis progressed and the patient underwent a Billroth type I distal gastric resection with D2 lymphadenectomy. Pathologic examination revealed a well differentiated ductal adenocarcinoma arising in the heterotopic pancreatic tissue (Heinrich type III). The resection margins and lymph nodes were free of tumor. The patient received adjuvant chemotherapy with 6 courses of XELOX.No disease recurrence is reported in 12 months follow-up.Aberrant pancreatic ductal adenocarcinoma in the stomach is a rare finding, however this pathology should be included in the differential diagnosis of gastric submucosal lesion causing pyloric stenosis. This is the 18th case of well documented aberrant pancreatic ductal adenocarcinoma in stomach. A symptomatic protruding submucosal stomach lesion, even with negative multiple biopsy results, should prompt suspicion of malignancy and early surgical aggressive treatment should be considered.,2 The lesion is usually small (<1 cm in diameter) and asymptomatic. The AP tissue can be found in up to 1.2% of gastrectomy specimens, and even more commonly in autopsy series ranging from 0.55% to 13.7%. The most common locations for AP are the stomach, duodenum and jejunum. The lesion is usually detected endoscopically and presents as a submucosal mass protruding into the lumen.An aberrant  pancreas (AP) is defined as a pancreatic tissue with its own vascular, neural and ductal system outside the normal pancreas without any communication with the latter. We present the 18th case of this rare disease with literature review of AP adenocarcinoma in the stomach indexed in the PubMed database (up to February 2022). Our case is the first malignant AP adenocarcinoma diagnosed in a Lithuanian patient. Literature review provides insight into this rare pathology and better understanding of clinical findings, treatment and prognosis.Malignant transformation of AP is extremely rare. Up to date only 17 well documented cases of AP adenocarcinoma in the stomach have been reported in the English language literature.A 38 year old male presented to our department with symptoms of intermittent bloating, nausea, abdominal distention in the epigastrium. Symptoms usually presented 1 to 3 hours after a meal. Weight loss of 10 kg over 4 months was also noted.The patient suffered from previously mentioned symptoms for 2 weeks before he visited local gastroenterologist. During the initial diagnostic workup esophagogastroscopy was performed and a submucosal lesion obstructing the pylorus was observed. It was not possible to pass the endoscope to duodenum. The stenotic pyloric part was sampled suspecting a scirrhous type gastric carcinoma. However, the pathology findings were unremarkable, showing either normal mucosa or a superficial ulceration with surrounding fibrosis, but no identifiable neoplastic structures.The patient was previously diagnosed with gastroesophageal reflux disease. He denied other chronic diseases, smoking or alcoholism. He was not taking any medication at the time.The patient had no significant personal and family history.Physical examination revealed abdominal distention, ballottement and mild discomfort during palpation of the epigastrium.Complete blood count and routine biochemical investigations were unremarkable. Blood tumor marker tests – carcinoembryonic antigen and carbohydrate antigen 19-9 showed normal values.At our institution esophagogastroscopy was repeated, combined with endoscopic ultrasound, to visualize the lesion. Endoscopy revealed a significant gastric retention (despite previously inserted nasogastric tube) and stenotic pylorus with protruding submucosal lesion in the posterior wall Fig. A. EndosoAbdominal computed tomography showed marked wall thickening of the pylorus and the lesion was enhanced by contrast agent. Perigastric tissues were not infiltrated and no pathological lymph nodes identified Fig. A and B. Stenosis progressed and patient underwent operation. During the initial inspection of the abdominal cavity a distended stomach with stenotic pylorus were observed. A fibrous subserosal lesion of the pyloric wall was sampled for frozen section. Ductal type adenocarcinoma (with possible origin of pancreatic tissue) was reported by the pathologist. A decision was made to perform a Billroth type I distal gastric resection with D2 lymphadenectomy (splenic lymph nodes spared).The sample  had intact mucosa with no visually identifiable superficial tumor or defects, but there was an area of flattened folds Fig.  overlayi However, thorough sampling revealed a few nonmalignant pancreatic ducts scattered in between the tumor glands  in the pyloric wall pT3N0M0, R0.6 weeks after the surgery the patient received adjuvant chemotherapy with 6 cycles of XELOX . No serious adverse events were recorded.At 12 months follow- up no disease recurrence documented . AP is not a rare finding reported to be found in 0.5% to 13.7% of autopsies. The most common locations are the stomach (25–60%), duodenum (25–35%) and jejunum (0.5–27%), though different locations have also been reported such as mesocolon,,11 Meckel diverticulum, rectum or even biliary system, liver, lung, mediastinum and brain.First ectopic pancreas was described back in 1727 in an ileal diverticulum.,15,16Three main theories have been proposed to explain the occurrence and possible pathogenesis of AP. The misplacement theory states that, during foregut rotation, several primitive pancreatic elements become separate and are deposited ectopically, forming mature pancreatic tissue. The metaplasia theory proposes that heterotopic pancreas arises from areas of pancreatic metaplasia of the endoderm which migrate to submucosa during embryogenesis. The third theory states that ectopic pancreatic tissue occurring in anatomically remote sites may have different pathogenesis, with the possibility of origin from teratomas. If symptoms are present, the site usually influences the clinical manifestation which includes abdominal pain, dyspepsia, bleeding, or obstruction resulting from inflammation or malignancy.,17AP tissue is usually of no clinical importance.AP can be found at any age, however it is usually diagnosed in middle-aged group. It is usually situated in the submucosa and only occasionally expands into the muscularis propria. The mass is broad based, appears to project into the lumen of the stomach or bowel, and is rarely pedunculated. Another possible finding is umbilication as the pancreatic duct opens into bowel lumen. However, this feature is present in less than 45% of cases.AP generally appears as a smooth nodule and occasionally as a mass with an irregular surface.Diagnosis is usually challenging due to the lack of specific signs on imaging and multiple non-diagnostic endoscopic biopsies. Some CT findings have been proposed by Liu et al for gastric submucosal mass differentiation  which include location , the presence of peritumoral infiltration or fat-line (more common for AP), necrosis (more common for GST) and degree of attenuation (higher Hounsfield units for AP), DEAP [the CT attenuation value of arterial phase minus unenhanced phase] (higher for AP).Only pathological examination of the specimen after surgical resection frequently determines the correct diagnosis. Type I is described as a typical pancreatic tissue with ducts, acini, and islet cells; type II – numerous acini, few ducts, and no islet cells; and type III numerous ducts, few to no acini, and no islet cells. This classification was later modified by Gaspar Fuentes et al, by describing another type of aberrant pancreas (type IV) which consists of endocrine islets without exocrine pancreatic tissue.Pathologists further subdivide the AP using a widely accepted Heinrich’s classification. To our knowledge to date there are only 56 well-documented cases reported of malignancy of AP tissue.,7,22 The most common site for malignant transformation is the stomach (35.2%), followed by duodenum (22.2%) and jejunum (14.8%).The same carcinogenic conditions can affect both the aberrant pancreatic tissue and the normal pancreas. Malignant transformation is a rare event, occurring from 0.7% to 1.8% of all heterotopic pancreata.,7,22When AP undergoes a malignant transformation, it is usually symptomatic (84%) with the most common complains being abdominal pain (49%), nausea or vomiting (25%), dyspepsia (15%), weight loss (15%) and gastrointestinal bleeding (8%). Endo et al reported the case of an AP adenocarcinoma diagnosed by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). They suggest that EUS-FNA may be useful for the preoperative diagnosis.However, upper endoscopy with conventional biopsy often fails to identify a correct cause because the ectopic pancreatic malignancy is usually located deep in the submucosa. are required for a carcinoma to be described as arising from ectopic pancreas:The three criteria proposed by Guillou et alThe tumor must be found within or close to the ectopic pancreatic tissue.A direct transition must be observed between pancreatic structures and the carcinoma .The non-neoplastic pancreatic tissue must comprise fully developed acini and ductal structures. Our case is 18th. Including our case the patients’ age ranges from 31 to 85 years (56.8 on average). There were equal numbers of male and female patients. Most of the patients (89%) were symptomatic with the most frequent presentation of epigastric pain, nausea or vomiting (44%) or gastric distention due to gastric outlet obstruction (33%). Less frequently patients presented with bleeding from gastrointestinal tract (5.6%) or dysphagia (5.6%). In 8 cases no information about tumor markers was reported. Of the remaining 10 cases carcinoembrionic antigen and carbohydrate antigen 19-9 were elevated in 30% of cases,34,36 and Ca72-4 elevated only in one case. Majority of the tumors were located in antropyloric region (78%) with submucosal stenotic lesion protruding into the lumen and intact mucosa (61%). Ulceration was described in 5 cases.We reviewed literature in English of AP adenocarcinoma in the stomach indexed in the PubMed database up to 2022, February Table . We founDiagnosing malignant transformation of aberrant pancreas in the stomach is a great challenge. Endoscopic biopsy is usually nonspecific, because the lesion is situated deep in the gastric wall. In our case multiple biopsies under ultrasound guidance were obtained, however no neoplastic process was found. as an enlarged perigastric lymph node was observed and the mass in the gastric wall changed over time in size and shape. In other cases, including this one, only heterogenous hypoechoic submucosal lesion or thickened gastric wall was observed without any obvious features of malignancy.,28,33,37Endoscopic ultrasound (EUS) is suggested for identification of submucosal gastric lesions in order to obtain deep biopsies. EUS was performed for our patient and 5 other cases of the reviewed literature. Malignant lesion evaluated with EUS was suspected in a case reported by Ura et al On the other hand, if the lesion is smaller and asymptomatic, no specific treatment is necessary. In our review of the literature, the maximum diameter of the lesion ranged from 1.7 to 12.5 cm (4.1 cm on average) and in one case 2 cm lesion had multiple metastasis to bone and the patient died 1 month after distal gastrectomy because of spread of the disease. Xiong et al suggested that a symptomatic lesion in the gastric submucosa, causing obstruction or weight loss with at least 1 cm in diameter should be treated early and aggressively.Some authors have suggested that a submucosal gastric lesion of more than 2 cm in diameter should raise suspicion of malignancy.Of all well documented cases of ectopic pancreas adenocarcinoma, the malignancy usually arises from type I heterotopia (46%), followed by type II (33%). In our case the rarest type of heterotopia (III) was observed. Adjuvant chemotherapy regimen was reported only in three cases of our literature review. These include gemcitabine, S-1 with cisplatin and folinic acid, fluorouracil and oxaliplatin (FOLFOX). Xiong et al reported changing chemotherapy regimen from FOLFOX to gemcitabine because of side effects and increasing tumor marker CA72-4. In our case we selected XELOX with good tolerance and no relapse at 12 months.It is not clear what kind of adjuvant chemotherapy regimen should be effective for aberrant pancreatic ductal adenocarcinoma in the stomach.This is probably related to earlier symptoms and diagnosis. In our literature review majority of the patients were followed up less than 1 year (37.5%) and there were 3 patients (18.7%) disease free at 1 year, and 1 patient (6.2%) did not have recurrence at more than 5 years of follow up. In 6 cases (37.5%) disease recurrence or death was reported. Therefore, it is very hard to draw conclusions on prognosis of aberrant pancreas adenocarcinoma in the stomach, however, the prognosis might be poor.It is observed that heterotopic pancreas adenocarcinoma yields a better prognosis (40% were disease free at 1 year of follow up) than orthotopic pancreas carcinoma.Diagnosing aberrant pancreatic adenocarcinoma in the stomach is a great challenge with nonspecific imaging findings and multiple negative biopsies. However, a symptomatic submucosal lesion with progressing abdominal distention should raise suspicion of a malignancy. Early diagnosis with surgical treatment for symptomatic lesions >1 cm in diameter is mandatory to avoid distant spread of the disease.VP and EP designed the study. VP wrote the initial draft of the manuscript and literature review. UM and RS wrote the pathologic report. RL evaluated radiologic findings. EP and KS reviewed the manuscript. EP provided critical appraisal of the manuscript. All authors have read and approved the final manuscript.Conceptualization: Vidas Petrauskas, Kestutis Strupas, Eligijus Poskus.Data curation: Rokas Stulpinas, Ugnius Mickys, Raminta Luksaite – Lukste.Formal analysis: Vidas Petrauskas.Methodology: Eligijus Poskus.Supervision: Kestutis Strupas, Eligijus Poskus.Validation: Ugnius Mickys, Raminta Luksaite – Lukste, Eligijus Poskus.Visualization: Rokas Stulpinas, Ugnius Mickys, Raminta Luksaite – Lukste.Writing – original draft: Vidas Petrauskas.Writing – review & editing: Vidas Petrauskas, Eligijus Poskus.


Primary neuroendocrine tumors are exceedingly rare and often misdiagnosed. The combined methods of ultrasonography, computed tomography ,and magnetic resonance imaging are typically applied. The diagnosis of the disease mainly depends on the histopathological examination. Surgical resection is the most effective treatment.In the report, we describe the case of a patient with a primary hepatic neuroendocrine tumor (PHNET) associated with hypertension. The patient suffered from uncontrolled hypertension before the operation, and the blood pressure was not well controlled by oral antihypertensive drugs such as nifedipine, valsartan, and hydrochlorothiazide, but the patient's blood pressure completely returned to normal after the operation without drug control.via careful screening noticed by the patient at work; furthermore, we hope to collect more cases and find the relationship between neuroendocrine tumors and hypertension.We encountered a rare case of a PHNET associated with hypertension  Primary neuroendocrine tumors are those derived from embryonal neural crest cells, also called Argentaffin or Kulchitsky cells, which have the potential function of regulating hormone secretion , 2. ThesHere, we report the case of a patient with a PHNET that was incidentally discovered due to severe hypertension. A PHNET was not considered initially since no clinical symptoms were observed but was diagnosed after the histopathological analysis.A 26-year-old male was admitted to Lanzhou University Second Hospital with a 2-year history of hypertension. His blood pressure (BP) went up to 280/170 mmHg, and he needed to take a quadruple dose of antihypertensive drugs to control hypertension. There was no history of hepatitis, Cushing syndrome, diabetes, heart diseases, carcinoids, or other remarkable diseases. In terms of the physical examination, the patient was anicteric with a soft abdomen. The laboratory test results were all normal. The tumor markers α-fetoprotein (AFP), carcinoembryonic antigen (CEA), CA19-9, and CA125 were all within normal ranges. The thyroid hormone level is normal. Vanillylmandelic acid (VMA), urine17-ketosteroide (17-ks), and 17-hydroxy-cortico-steroid (17-OHCS) were within normal ranges. The serum cortisol level was normal. With the use of a liver-specific contrast agent, an abdominal contrast-enhanced computed tomography (CT) was performed, and a round, solitary hepatic mass in the left lobe of the liver was observed that measured 7.5 cm × 6.1 cm × 6.2 cm and had a clear and smooth border as well as homogeneous density as seen on the enhanced scan. A proper hepatic artery branch had enveloped the lesion in the arterial phase. There was no evidence of other diseases or lymphatic metastasis. Enhanced magnetic resonance imaging (MRI) showed an oval mass with a high signal intensity that measured 7.7 cm × 5.1 cm × 6.6 cm . An atypAfter multiple discipline discussions and the blood pressure was well controlled, left hepatectomy was conducted, and a single exophytic nodule approximately was observed in the left lobe of liver. No metastases were identified upon exploration. Grossly, the tumor section appeared as a gray-yellow and dusty-red solid mass that was well circumscribed and was 7.5 cm × 7 cm × 5 cm in size, and it had an intact capsule and a clear border with hepatic tissue .The tumor cells with consistent sizes were arranged as solid nests and were funicular, gland-like structures; the blood sinus was rich in the nests among neoplastic cells. The cells had an abundant cytoplasm with a pinkish color, and the borders of the tumor cells were clear. The tumor cells had round or ovoid nuclei that were slightly enlarged, a dark cell nucleus, light cell cytoplasm, and a low mitotic rate. A clear demarcation between the tumor and surrounding liver tissue was observed.The pathological diagnosis of neuroendocrine tumors was made, and the tumors measured 7.5 cm × 7 cm × 5 cm in size. The mitosis rate was 2 mitoses per 10 high-power fields. Hematoxylin-eosin (HE) staining was performed with the peroxidase-conjugated dextran polymer complex: liver tumor cells revealed Syn (+), CgA (+), CD56 (+), CK8/18 (+), CK (+), hepatocyte (−), and AFP (−). Vessels of the tumors showed CD34 (+) and positivity for Ki-67 > 3%. Syn, CgA, CD56, CK8/18, and CK were positive in the liver tumor cells, while other markers, including hepatocytes and AFP, were negative. CD34 was positive in the vessels of the tumor, and positivity was found for Ki-67 more than 3%. It was classified as G2 .The patient recovered well after operation, and the blood pressure returned to normal without drug control. He was cured and discharged 1 week after operation. One year after operation, the patient has no abdominal pain and abdominal distension, There was no recurrence on enhanced CT during reexamination, as shown in PHNETs are exceedingly rare, for its absence of specificity and low incidence rate. The disease can be easily misdiagnosed due to the fact that its clinical features are common to hepatic hemangioma, hepatocellular carcinoma, or cholangiocarcinoma. Therefore, the diagnosis of PHNETs is still a debatable point, and the final diagnosis depends on careful analysis and pathological examination by surgery. No PHNET associated with hypertension in the literature has been reported. In our case, accelerated hypertension was diagnosed and PHNET was incidentally found the highest blood pressure even 280/170 mmHg, yet sometimes fail to get BP under control despite having antihypertensive medications intensified. After surgery, the blood pressure went down to a normal level without taking any antihypertensive drugs. It showed that PHNETs may aggravate hypertension. It is speculated that the occurrence and severity of hypertension may correlate with the elevation of serotonin or the metabolites 5-hydroxyindoleacetic acid released by NET .Some previous studies reported that primary hepatic neuroendocrine tumors mostly happened in middle-aged patients and more frequently happened in females. Right lobe incident rate is higher than that of the left lobe. In our study, the patient was 26 years old and had no manifestation of carcinoid syndrome other than hypertension.An abdominal ultrasound contrast was performed and an echogenic lesion in the left hepatic lobe arterial phase as well as peripheral nodular arterial enhancement was detected, enhanced earlier than the liver parenchyma. The persistent enhancement was found and the lesions were enhanced centripetally in the portal phase that resembled hepatic hemangioma. From our experience, Doppler ultrasonography can be used as preliminary screening of PHNETs, to distinguish the blood flow in lesion tissue from normal tissue, same inference with Piscaglia . CT and The treatment of PHNET mainly include: (1) hepatectomy, (2) hepatic regional therapy , (3) local ablative therapy (radiofrequency ablation (RFA), cryotherapy, and microwave), and (4) interferon therapy. Surgical resection was mostly effective and used by hepatectomy and lymphadenectomy . For patBy using pathology and the 2019 WHO classification of PHNET, our case was defined as G2, well-differentiated NET , which hEither primary or secondary hepatic carcinoids are effective when treated by surgical treatment, with the 5-year survival rate for PHNET being 74%–78% and a 5-year recurrence rate of 18% after hepatectomy , 14–16. The current literature reports that secondary hypertension caused by neuroendocrine tumors is related to the following factors: (1) pheochromocytoma, with a prevalence of 0.2%–0.6% ; (2) ectThe patient was hospitalized because of high blood pressure, and further examination revealed liver tumor. After resection of liver tumor, the patient's blood pressure accidentally returned to normal without drug control. This is a very rare and interesting case. The patient's endocrine hormone level was normal, he had no endocrine related complications, the relationship between hepatic neuroendocrine tumor and hypertension is not clear yet, with the lack of enzymes or catabolite proofs, and more such cases will need to be collected for further research in the future.


Panniculitis is an inflammatory process localized to subcutaneous tissue, with etiologies including infection, malignancy, external insults, enzymatic destructive processes, and inflammatory disorders. The incidence of panniculitis manifesting as necrosis of subcutaneous fat tissue associated with pancreatic diseases is low, which may encompass associated periarthritis with bone necrosis and panniculitis . Pancreatitis, panniculitis and polyarthritis syndrome is considered to derive from the systemic activity of enzymes within the pancreas, which leads to disturbances within the microcirculatory system, and fat necrosis of medullary bone marrow; however, the exact pathophysiology remains unknown. Here, we present a case of a 53-year-old male with a history of chronic pancreatitis who presented with lower abdominal pain found to have osteolytic pelvic lesions considered to be panniculitis secondary to pancreatitis. Our patient provided an interesting clinical picture given his alcohol use disorder, and lytic lesions which lead the team initially towards a malignant etiology of panniculitis such as myeloma; however, given his negative studies, it was presumed his panniculitis was derived from his chronic pancreatitis. Overall, additional literature is warranted regarding the extensive workup of lytic bone lesions that present in patients who have acute vs chronic pancreatitis. Panniculitis, inflammation of subcutaneous adipose tissue, was first identified in association with pancreatic disease in the late 1800s A 53-year-old male with a history of type 2 diabetes mellitus, hypertension, dyslipidemia, hypothyroidism, major depressive disorder, alcohol use disorder, and chronic pancreatitis presented with lower abdominal pain and was found to have acute descending colon diverticulitis with an abscess, with an incidental finding of lytic pelvic lesions, who was subsequently worked up for myeloma and was treated with fluid and antibiotics.Within the past 2 years, the patient had 2 prior episodes of acute pancreatitis and endorsed daily alcohol consumption. Computed tomography of the abdomen and pelvis demonstrated acute diverticulitis of the descending colon with associated abscess, liver parenchymal disease, chronic pancreatitis, and an incidental finding of lytic pelvic lesions and a posterior left iliac bone/left acetabular cyst sclerotic lesion .Fig. 1CoThe patient underwent serologic workup for multiple myeloma, which was negative. A skeletal survey demonstrated lucent lesions within the bony calvarium and questionable re-demonstration of lucent lesions in the bilateral pelvic bones and a cortically based sclerotic lesion along the distal femur, with chronic rib fracture of the right 11th posterior rib A and B.FGiven his findings, the patient's osteolytic pelvic lesions were considered to be panniculitis secondary to pancreatitis, and much less likely secondary to a malignant process. The patient was treated with Piperacillin-Tazobactam for diverticular abscess and intravenous fluids for his pancreatitis and he was discharged home following clinical improvement and resolution of his diverticular abscess on repeat imaging.The pathogenesis behind panniculitis secondary to pancreatitis is not well described; however, it is thought to be a result of a systemic release of pancreatic holoenzymes, which in turn promote vascular damage and increased permeability Pancreatic panniculitis may present clinically in a variety of ways. Variable cutaneous lesions have been described in the literature and may even precede the diagnosis of pancreatic disease in up to 45% of cases Then there is Pancreatitis, panniculitis and polyarthritis (PPP) syndrome, where the third, “P,” or polyarthritis is thought to be a result of periarticular fat pad necrosis Bone harbors marrow which is composed mostly of adipose tissue, 40% of red marrow, and 95% of yellow marrow, which leaves it susceptible to hydrolysis by the pancreatic enzymes Making the diagnosis of PPP and pancreatic panniculitis begins with diagnosing the underlying pancreatic pathology. In the case of pancreatitis, this involves the evaluation of serum amylase and lipase, where amylase cannot be used alone, and lipase is preferred The treatment of pancreatic panniculitis and PPP syndrome involves resolving the underlying pathology In summary, panniculitis has rarely been demonstrated to be secondary to pancreatitis An ethical review is not necessary, because this is a case report.This case report was presented as a poster presentation at the American College of Gastroenterology conference in 2022.Informed consent for publication of their case was obtained from the patient.Anas Mahmoud and Isaac Soliman are the article guarantors. Anas Mahmoud, Isaac Soliman, and Brooke Kania performed the literature review and wrote the manuscript. All authors assisted in the collection of the patient's clinical data. All authors took part in the medical management of the patient and edited the final manuscript for submission.


Appendiceal intussusception is exceedingly rare. Although there are few case reports of concurrent ileocecal intussusception and acute appendicitis, to our knowledge, this is the first reported case of concurrent Type III appendiceal intussusception and acute appendicitis. We present the case of an 11-year-old male who underwent appendectomy with partial cecectomy for a Type III appendiceal intussusception with concurrent acute appendicitis. Appendiceal intussusceptions are exceedingly rare with an estimated incidence of 0.01% . InteresAppendiceal intussusceptions are rarely diagnosed preoperatively, with one review reporting only 12 cases described in the medical literature . PreoperNon-surgical reduction of appendiceal intussusception with barium, water-soluble contrast, and air enema has been unsuccessfully attempted in the pediatric population -6.An 11-year-old male presented with a one-week history of worsening generalized abdominal pain that subsequently localized to the right lower quadrant. Physical examination was pertinent for a soft, non-distended abdomen which was tender to palpation in the right lower quadrant with a positive Rovsing sign and obturator sign. Incidentally, a cardiac murmur was also noted on the examination. Workup revealed leukocytosis with a white blood cell count of 18,000, and coronavirus disease 2019 (COVID-19) polymerase chain reaction (PCR) testing was negative. He underwent a CT of the abdomen/pelvis that demonstrated a dilated fluid-filled appendix visualized in the right lower quadrant measuring up to 12 mm in diameter with mucosal hyperenhancement consistent with uncomplicated appendicitis. There were no appendicoliths or signs suggestive of perforation or abscess formation. Cardiology was consulted and the patient was cleared for surgery. The patient received ceftriaxone and metronidazole per our institution’s appendicitis management protocol.The patient was taken to the operating room for routine laparoscopic appendectomy for acute appendicitis. As we attempted to identify the appendix and define the anatomy, we encountered the base of the appendix intussuscepted into the cecum Figure . MultiplIn 1941, McSwain described an anatomical classiﬁcation based on the region of the appendix that is intussuscepted . There aA few cases of ileocecal intussusception and concurrent appendicitis have been described in the medical literature. However, to our knowledge, this is the first report of a Type III appendiceal intussusception and concurrent acute appendicitis. Due to concerns about damaging the already inflamed appendix and/or causing injury to the cecum, traditional approaches to performing a laparoscopic appendectomy were not feasible. Fortunately, in our case, the appendix was partially intussuscepted at the base, and we were able to remove a small portion of the cecum while preserving the ileocecal valve. The optimal surgical approach depends on appendiceal intussusception classification. For example, for those with Type V appendiceal intussusceptions, other surgical options may include ligation of the mesoappendix which will lead to necrosis and sloughing of the fully intussuscepted appendix into the bowel lumen .Typical appendiceal intussusceptions can be either idiopathic or due to predisposing factors such as anatomical variation, duplications, neoplasm, angiodysplasia, fecalith, foreign bodies, lymphoid hyperplasia, or underlying disorders such as cystic fibrosis . It is uAppendiceal intussusceptions are rare and can also lead to acute appendicitis. They are typically discovered intraoperatively. Here, we present a concurrent Type III appendiceal intussusception with acute appendicitis managed laparoscopically with appendectomy with partial cecectomy. Laparoscopic management is feasible and safe.


Chronic ischemic gastritis (CIG) requires early diagnosis and treatment as complications of thromboembolism can be fatal. Although computed tomography (CT) is useful in the diagnosis of CIG, it is difficult to diagnose from a patient's history, endoscopic findings, and tissue biopsy. Identification of the key findings that motivate computed tomography is an important issue. We report a case of CIG diagnosed by endoscopic findings of white patches of mucosa over time. A 63‐year‐old man presented with epigastric pain. He had a history of repeated gastric ulcers of an undetermined cause. We performed upper endoscopy and observed the appearance of multiple white patches on the gastric mucosa. Central vessel stenosis was considered, and aortic computed tomography revealed complete occlusion of the superior mesenteric artery and stenosis of the celiac artery. We carried out a surgical bypass and found no postoperative endoscopic mucosal changes or abdominal pain. White patch changes in the gastric mucosa over time during endoscopy may indicate CIG. This finding may help in the future diagnosis of CIG. Chronic ischemic gastritis (CIG) is a rare disease, with only 26 cumulative cases reported over the past 40 years. The diagnosis is difficult based on clinical symptoms, which include chronic abdominal pain that worsens with food, weight loss over several months, vomiting, gastric paresis, diarrhea, and constipation.We report a case of CIG, including a video clip, diagnosed after upper endoscopy revealed patchy white changes in the gastric mucosa, and a background blood flow disorder was detected. Although various endoscopic findings of CIG have been reported in the past, there have been no reports focusing on changes in mucosal coloration over time, particularly on video. This finding may help in the future diagnosis of CIG.Heliobacter pylori antibodies and had no evidence of previous eradication. He also did not use nonsteroidal anti‐inflammatory drugs or anti‐thrombotics. The biopsy results showed only inflammatory findings. The cause of the ulcer was unclear, and the gastric mucosa improved with the administration of proton pump inhibitors. The patient developed repeated gastric ulcers; however, the mucosal damage was not as severe as at the initial presentation.A 63‐year‐old man presented for investigation due to recurrent gastric ulcers. Five years prior, an upper endoscopy was performed to investigate the cause of his persistent severe epigastric pain, which revealed multiple erosions and ulcers in the stomach Figure . The patIn the present case, the patient has similar epigastric pain, and he was introduced to our hospital to investigate the cause of the pain. We performed upper endoscopy and found that the gastric mucosa became white over time due to gastric dilatation by endoscopic air insufflation Video . Tissue We considered the possibility of ischemic changes in the perigastric vessels and performed aortic CT on the same day. The results indicated complete occlusion of the superior mesenteric artery (SMA) and stenosis of the celiac artery Figure . No obviHere, we report a case of CIG diagnosed during upper endoscopy with a change over time in mucosal color with dilation of the gastric wall. This finding enabled early detection of central vascular obstruction and avoided a fatal outcome.CIG is a rare disease, reported in a limited number of cases, and no clear diagnostic criteria have been established.The possible causes of the change in mucosal coloration were the following: (1) complete occlusion of the SMA or (2) stenosis of the celiac artery resulting in insufficient blood flow to the stomach. Furthermore, (3) the stretching of the gastric wall by endoscopic insufflation may have further stretched and compressed the internal vessels of the stomach, resulting in a decrease in blood flow. The possibility of (1) and (2) is plausibly supported because these mucosal changes were no longer observed after the surgical bypass. Hypothesis (3) was assumed because the stomach was dilated by insufflation and mucosal changes were observed, although no white color changes were observed in the collapsed gastric mucosa. Further, once the stomach was fully dilated, no white mucosal development was observed. However, there is no previous literature to explain these findings, and further case series and animal experiments are needed to prove this hypothesis.Previous reports have shown that diagnosis is difficult to make based on endoscopic and histologic findings.Surgical bypass is the most common treatment for CIG.We experienced a case in which mucosal changes were identified over time during upper endoscopy, enabling early diagnosis of CIG. When endoscopic patchy white changes of the gastric mucosa are observed, the vascular disease should be suspected, and aortic CT or angiography should be recommended.None.Video S1 Video of gastric mucosal changesClick here for additional data file.


GNAS and TP53 mutations, and the diagnosis of OS arising from FD was strongly supported. This case highlights the characteristic images and molecular features of the malignant transformation of FD.Fibrous dysplasia (FD) is a benign fibro-osseous lesion that frequently involves the craniofacial bones and femur. Malignant transformation of FD is a rare occurrence. We report a 38-year-old woman with osteosarcoma (OS) arising from FD of the femur. Magnetic resonance imaging revealed a well-defined lesion in the medulla of the femur, with cortical thinning and local bone destruction. Wide excision of the femur was performed. Grossly, the inner part of the mass was hard and tan-gray in color, and the outer part of the mass adjacent to the cortex showed myxoid discoloration with infiltrative borders. Microscopically, most of the tumor consisted of curvilinear woven bone and fibrous stroma with bland spindle cells, which transitioned to the outer portion of the tumor, showing cellular proliferation of pleomorphic cells with frequent mitotic activity. Next-generation sequencing revealed