Schwannoma generally occurs in the vestibular nerve. Cervical schwannomas are quite rare. Herein, we present a case of slow-growing asymptomatic supraclavicular schwannoma in an elderly woman of 74 years. The patient was managed conservatively with regular follow-up as the tumor showed slow progressive growth (presented after seven years) and asymptomatic. Schwannoma, also known as neurilemmoma, is a very slow-growing benign tumor arising from the Schwann cells -3. The SSchwannomas arising from the brachial plexus are quite rare; only 5% of all the Schwannoma cases arise from the brachial plexus [In this case report, we describe a case of cervical Schwannoma and also present a review of the existing literature in this regard.Herein, we present a case of cervical schwannoma in a 74-year-old elderly female. She reported with a longstanding swelling in the left collar bone area (supraclavicular region). The swelling persisted for more than seven years. She did not complain of weakness, abnormal sensation, or numbness in the left hand.On clinical examination, it was found that the swelling was firm in nature, non-tender, and non-pulsatile. It was located at the level 5 region and measured 4 ×4 cm. No other neck masses, such as cervical lymph nodes, were palpable.Neck computed tomography (CT), magnetic resonance imaging (MRI) with contrast, and fine-needle aspiration cytology (FNAC) were performed.CT and MRI findingsCT scan revealed a large well-defined mass located in the left supraclavicular region. It measured 3.5 ×3.5 cm  with a sheath except for optic and olfactory nerves, which lack a myelin sheath. Nearly 45% of all schwannomas occur in the head and neck area .In 1908, Jose Verocay (“the Prague Pathologist”) first established Schwannoma as a pathological condition . He firsIn the head and neck region, around 25 to 40% of all the Schwannomas appear in the parapharyngeal space . In the The tumors might vary in size ranging from a few mm in size to 24 cm. Signs and symptoms presentation may also vary depending upon the anatomical location of the tumors. Most of the patients present with painless swelling. However, if present, symptoms usually depend upon the site of the tumor. Other than pain, a tingling sensation and numbness along the course of the involved nerve are also reported. Other symptoms could be breathing difficulty, especially, when the tumor is located in the nose, painful swallowing in case a tumor in the pharynx, nose bleeding due to the presence of a tumor in paranasal sinuses, breaking of voice when a tumor is located in the larynx, or just a swelling in the neck in case of a tumor in the parapharyngeal space . In mostSchwannoma can affect people of any gender and age. However, the most common age of occurrence is in the third and fourth decades of life . In the In the present case, a 74-year-old woman presented with a painless swelling in the left supraclavicular region. The swelling gradually appeared over a period of seven long years. The tumor location assessment allowed categorizing the tumor in the lateral group of tumors and also suggested that the tumor probably arising from cervical or brachial plexus. Radiological findings (MRI) revealed that the tumor had emerged from peripheral nerves in close proximity to the upper part of the brachial plexus.Brachial plexus tumors are rare in occurrence; less than 5% of the upper extremity Schwannomas originate from brachial plexus . In 1995Confirmation of the diagnosis of Schwannomas located in the head and neck region before surgery is rather difficult. Commonly performed investigations include CT, MRI, and FNAC. MRI is an admirable diagnostic tool with a number of advantages including better soft-tissue contrast and excellent three-dimensional modeling. CT scan is useful if the tumor originates from bony structures like pterygoid plates or posterior body plates of the maxillary sinuses .If the situation allows, diagnosis can be confirmed by FNAC. Common diagnostic features include the presence of fibrous capsule, Antoni A and Antoni B areas, and Verocay bodies. In larger and older Schwannomas, degenerative changes, vascular sclerosis, and hemorrhagic changes are common. Sometimes, the formation of a microcyst is evident with a pseudoepithelial lining of the Schwann cells.In 2015, Yafit et al. published an algorithm regarding the choice of treatment for extracranial Schwannomas located in the head and neck region . AccordiIn our case, as the patient was asymptomatic, a conservative approach was adopted. Similar to our case, Keleş E and his colleagues presented a case report of the supraclavicular area, wherein a 71-year-old man presented with large swelling in the left supraclavicular area [Similar to our case, Ando et al. also presented a retrospective study with 23 Schwannoma cases diagnosed by MRI and concluded that majority of the asymptomatic Schwannomas are very slowly progressing and do not require surgical intervention, rather should be closely monitored for any increase in size or appearance of nerve compression .Common differential diagnoses include a tumor of the carotid body, cervical lymphadenopathy, thyroid cyst or nodule, teratoma, brachial cysts, lipoma, metastatic deposits, neurofibroma, etc. Location of the tumor, CT, MRI, and FNAC help in the establishment of diagnosis ,15.In elderly patients, presenting with supraclavicular swelling, thorough clinical examination and investigations should be carried out to rule out other conditions especially malignancy. Asymptomatic slow-growing Schwannomas can be managed conservatively with careful observations and regular follow-ups.


Case reports highlighting the complications of SCT surgical resection in resource‐limited settings particularly sub‐Saharan Africa are few. It is imperative to take into account that achieving the desirable cosmetic results may not be possible because of large tumor size and postoperative infection. It is therefore of necessity to consider integration of plastic surgical reconstructive programs into pediatric surgery follow‐up programs in resource‐limited settings. Antenatal care examinations during the 1st and 2nd trimesters were unremarkable. A routine obstetric ultrasound scan at 32 weeks of gestation, however, had confirmed the findings of a live intrauterine fetus with a sacrococcygeal mass.A 37‐year‐old PThe total weight gained during pregnancy was 15kg, and she was maintained on supplemental iron and folic acid.At birth, the female newborn had a birth weight of 3.800kg. Apgar score was 9/10 and 10/10 in the first and fifth minutes, respectively. There were no significant findings on systemic examination.Local examination revealed a solid‐cystic, firm mass measuring 10cmx7cm in the sacral region with deviation of the anal orifice posteriorly Figures .Plain radiographs and abdominal ultrasound scans confirmed a sacrococcygeal tumor stage I Altman classification arising from the coccyx. There was no bladder, genitalia, or bowel involvement. The echocardiogram, electrocardiogram, and brain ultrasound were normal. Abdominal CT and MRI scans were not possible due to financial constraints.4 + 0 was unremarkable.Postnatal examination of the PTreponema pallidum hemagglutination assay) were negative.All preoperative investigations on the newborn were essentially normal: Hb level 18g/dl, random blood sugar 105 mg/dl, serum alkaline phosphatase 110 IU/dl, PT 15, INR 1, BUN 30 mg/dl, hematocrit 33%, platelet counts 300000/l, and bilirubin 1.3 mg/dl. Cryptococcal antigen and syphilis serology  serological measurements were unable to be done due to financial constraints. Due to the unavailability of AFP titers, a decision of surgical excision was made. Tumor resection and coccygectomy were done 10 days after birth using the posterior sacral approach under general anesthesia Figure .An ulcerated cystic mass measuring 11cmX8cmX4.5cm with an ulcer measuring 4cmX3cm and weighing 175grams was resected. The mass contained cystic fluid and purulent material. Histopathological examination of the excised tissue revealed a multilocular cystic mature sacrococcygeal tumor with no evidence of malignancy. Immunohistochemical stains for AFP were positive.On postoperative day 2, the stitches at the wound site gave way and the wound became septic Figure . Blood cSince the baby did not have symptoms of hyperbilirubinemia, a decision was made to manage the baby with postoperative intravenous antibiotics—a first‐generation cephalosporin—ceftriaxone 100mg/kg, a broad‐spectrum antibiotic—metronidazole 35mg/kg, paracetamol 7.5mg/kg after conducting debridement, irrigation with warm normal saline solution and refashioning in the operating theater.The baby was managed with daily wound pressure bandage dressings in addition to saline wound cleaning. Baby was discharged on postoperative day 25.Follow‐up at 6 months revealed that the child had a well‐healed though poor cosmetic scar Figure  with no 3SCTs are congenital neoplasms that arise from Hansen's node or primitive germ cells and constitute tissue from all the three embryonic germ layers—endoderm, ectoderm, and mesoderm.Although there is a plethora of literature on SCTs, there are few case reports from developing countries particularly sub‐Saharan Africa because neonatal surgery is of low priority in these settings.Whereas other congenital anomalies, for instance, sacral bone defects, spina bifida, spinal dysraphism, sacral agenesis, imperforate anus, presacral masses, scimitar sacrums, meningomyeloceles, meningoceles, pulmonary stenosis, ventricular septal defect, patent ductus arteriosus, ectopic kidney, anorectal malformations, duplication of the uterus or vagina, clubfoot, polydactyly, and anorectal malformations, are associated in 5 to 26% of patients with SCTs,The ideal diagnosis of SCTs in neonates is by obstetric ultrasound scanning as was in our patient which not only allowed for delivery planning and early neonatal surgery but also determined the overall prognosis of our patient.Early diagnosis and surgical intervention also reduce the risk of malignant transformation seeing that less than 8% of SCTs at birth are malignant.Although the possibility of cesarian section was discussed with our patient, she declined elective surgery.Early surgical resection with coccygectomy as was in our patient is the primary treatment of SCTs. This not only carries a better prognosis but also is essential in ensuring a 30%‐40% reduction in tumor resurgence.Like any other surgical procedure, complications arising from surgical resection can either be short‐term—postoperative wound infection and perineal wound disruption Figure  as was iThis case report also demonstrates the dilemma of poor cosmesis Figure  followin4Case reports highlighting the complications of SCT surgical resection in resource‐limited settings particularly sub‐Saharan Africa are few. It is imperative to take into account that achieving the desirable cosmetic results may not be possible because of large tumor size and postoperative infection. It is therefore of necessity to consider integration of plastic surgical reconstructive programs into pediatric surgery follow‐up programs in resource‐limited settings.None declared.Consent of Ethics: Not applicable.Informed Consent: Obtained.CK: is the corresponding author; clinician; involved in the study, design, and analysis of data; and drafted and critically revised the manuscript.


Thymomas are typically slow-growing tumors and AB type thymomas are considered no/low risk tumors with a better prognosis. Extra-thoracic metastases are extremely rare. To the best of our knowledge, no patient with an isolated splenic metastasis from a thymoma has been reported. We report a patient who underwent laparoscopic splenectomy for a slow-growing, isolated splenic metastasis, eight years after thymectomy.The patient is a 78-year-old man. Eight years previously, the patient underwent extended thymectomy and postoperative radiation therapy for a thymoma. Five years after thymectomy, a nodule appeared in the spleen, and the lesion enlarged gradually for three years thereafter. The patient was referred for further examination and treatment. Computed tomography scan showed a sharply circumscribed 50 mm tumor slightly hypodense and heterogeneous lesion in the spleen. On T2-weighted images on Magnetic Resonance Imaging, the tumor had high intensity, equivalent to or slightly lower than that on T1-weighted images, and no decrease on diffusion-weighted images. The tumor was multinodular and showed a low-signal spoke-wheel sign in the margin, enhanced gradually in the dynamic study. Positron emission tomography-CT scan, showed relatively low accumulation. Surgical resection was undertaken, and pathological examination showed metastatic thymoma. The patient is without recurrence and has no other symptoms three years after splenectomy.This is the first report of an isolated splenic metastasis from a thymoma. Further cases are needed to standardize this surgery for such lesions. Thymomas are typically slow-growing tumors and type AB thymomas are considered no/low risk tumors with a generally better prognosis. Although recurrence and metastasis of type AB thymoma have been reported, their progression commonly occurs in patients with direct invasion or pleural dissemination, and extra-thoracic metastases are extremely rare. To the best of our knowledge, no patient with an isolated splenic metastasis has been reported in the literature. Here we report a patient who underwent laparoscopic splenectomy for a slow-growing, isolated splenic metastasis, eight years after undergoing extended thymectomy for a thymoma.The patient is a 78-year-old man referred to our department for splenomegaly seen on abdominal computed tomography (CT) scan. Eight years previously, the patient underwent extended thymectomy and postoperative radiation therapy for a thymoma  with subsequent follow-up. Five years after resection, a low density, isolated nodule in the spleen was seen on CT scan. Although follow-up continued for three years thereafter, the lesion was noted to continually increase in size, and the patient was then referred for further examination and treatment.The patient underwent appendectomy for acute appendicitis at the age of 23 years, treatment for hypertension since he was 61 years old, extended thymectomy at age 71 years, and laparoscopic left hemicolectomy for cancer of the descending colon (stage I) at age of 73 years of age. The remainder of the history and physical examination were unremarkable, except for healed surgical scars from the previous thymectomy and the laparoscopic left hemicolectomy. Laboratory studies showed no abnormalities. Serum tumor marker levels were within normal limits .CT scan showed a sharply circumscribed 50 mm tumor slightly hypodense and heterogeneous enhancing lesion in the spleen with no intraperitoneal lymphadenopathy Fig. . On MagnBased on these diagnostic imaging studies, we considered metastatic thymoma, hemangioma or lymphangioma with bleeding and organization, and sclerosing angiomatoid nodular transformation in the differential diagnosis. Surgical resection was then recommended to the patient and undertaken. The lesion was visually confirmed intraoperatively. No extracapsular invasion was observed. A laparoscopic splenectomy without lymphadenectomy was performed.Pathological examination showed that the spleen was 12 × 7 × 6 cm in size. A lobulated medullary tumor was seen, 6 × 5 × 4.5 cm in size, yellow-brown in color on cut surface (Fig. The patient is now three years status post resection of the spleen and is followed every three months. He is in good condition without recurrence or any other symptoms.Thymomas are anterior mediastinal tumors that usually arise in 40–70 year old patients. Thymomas are also associated with myasthenia gravis, pure red cell aplasia, and hypo-γ-globulinemia. Although thymomas constitute about one half of malignant tumors in the anterior mediastinum, they are rare, with a frequency of 1.5 per 1 million people [Typical progression of thymoma is direct invasion and dissemination into the thoracic cavity, then extra-thoracic distant metastases that arise through hematogenous spread are considered uncommon . Lewis eSplenic tumors are divided into two major classes, including metastatic and primary tumors. Most metastatic splenic tumors originate from hematological diseases, of which leukemia and malignant lymphoma account for approximately two-thirds. Splenic metastases from non-hematologic malignancies occur as part of widespread systemic disease in the end-stage of the disease usually, and an isolated splenic metastasis is quite rare . AutopsyThere are benign primary tumors of the spleen which include hemangiomas and hamartomas. In addition, primary malignant tumors of the spleen can include sarcomatous lesions, because the spleen is of mesodermal origin. Splenic primary neoplastic lesions include malignant lymphoma, hemangioendothelioma, lymphatic sarcoma, fibrosarcoma, and malignant fibrous histiocytoma. However, tumors other than malignant lymphoma and hemangioendothelioma are extremely rare.Although differentiation between primary splenic tumor and metastatic splenic tumors is difficult based on imaging studies, recent progress in imaging modalities have rendered MRI and PET-CT findings useful. Thymoma with low-grade malignancy shows characteristic uniformity with a low to intermediate signal strength on T1-weighted images and hyperintense signal strength on T2-weighted images. Despite variability, PET-CT scan have shown low accumulation for low-grade thymoma and high accumulation for malignant cases such as thymic cancer, reflecting the level of malignancy. These findings are similarly observed for metastases and are useful for diagnosis. Malignant lymphoma, which requires differentiation, exhibits an intermediate signal intensity on T1-weighted images, intermediate and uniform signal intensity on T2-weighted images, and high accumulation on PET-CT scan. Metastatic malignant tumors often exhibit low signal intensity on T1-weighted images, high signal intensity on T2-weighted images, and high accumulation on PET-CT scan. For benign tumors such as hemangioma and lymphangioma, the tumor appears non-uniform in T1 and T2-weighted images and exhibits low accumulation on PET-CT scan. Images acquired using these modalities are helpful for diagnosis. In the present patient, the findings were not consistent with any of these patterns, making diagnosis difficult to base on imaging data.In the present patient, the recurrence occurred eight years postoperatively during long-term follow-up. Furthermore, the metastatic tumor showed slow growth. Therefore, we selected surgical resection as the treatment. In the National Comprehensive Cancer Network Guidelines revised in 2014, staging/histological classification and treatment plans for thymoma are summarized in addition to those for thymus cancer . AccordiThymomas are rare lesions, and extra-thoracic spread of thymomas is extremely uncommon. Isolated splenic metastases from any primary lesion are extremely rare. This is the first report of an isolated splenic metastasis from a thymoma. Further cases are needed to standardize this surgery for such lesions.


Carinal resection (CR) with or without lung parenchyma sparing is one of the challenging issues in thoracic surgery and performed rarely. It is usually not used for the difficulty of the technique, or, in the majority of the situations, it is replaced by pneumonectomy when the patient conditions and the tumor characteristics allow the radical surgical approach. The difficulty includes the dissection of the trachea and main bronchi, the resection of the carina and the reconstruction of the trachea and bronchus. In spite of the knowledge of the technique, one of the most important problem is the incidence of postoperative complications which is higher compared to standard resections.We show two cases of carina resection for a bronchogenic tumor with lung parenchyma sparing and good postoperative outcomes.Our results demonstrate that this type of surgery is possible in selected centers with good quality of life for the patient after surgery. Most of218F-labeled fluoro-2-deoxyglucose Positron emission tomography–computed tomography (18F FDG PET-CT) showed a mild metabolic area at the level of the carina with no lymph nodes activity. A malignancy was suspected. No other metabolic activity was highlighted. Brain MRI showed no abnormalities. Preoperative assessments revealed a good pulmonary function test and no other comorbidities were declared by the patient. Tracheoscopy revealed a neoplasm in the opening of the right main bronchus, and pathology revealed highly differentiated mucoepidermoid carcinoma. He received a tracheal carina resection at the level of the right main bronchus and reconstruction with lung parenchyma preservation through a posterolateral thoracotomy. The operation time was 3 h and 40 min. Intraoperative bleeding was less than 200 ml. He was discharged 7 days after operation with no complications. Postoperative pathology revealed a 1.2 cm low-grade mucoepidermoid carcinoma involving the entire wall of the carina. The distal and proximal stump were found negative. The 2, 4, 7 and 10 lymph nodes stations were negative. After surgery patient has been sent to the oncologist for clinical monitoring. Bronchoscopy after 6 months from surgery showed a moderate stenosis at the level of the anastomosis. A biopsy was performed showing a granuloma treated by laser with completely effective result. No sign of recurrence of granuloma after 3 months from the laser procedure, as well as no sign of recurrence after 6 months from surgery.A 27 years old male patient suffering from cough and discomfort of throat for half a month was admitted to our Hospital. He referred a smoking history of 5–10 cigarettes per day for 5 years. Chest computed tomography (CT) showed a tumor infiltrating the entire wall of the carina at the level of the main right bronchus . 18F-lab318F FDG PET-CT showed a high metabolic area at the level of the carina with no lymph nodes involvement. Tracheoscopy confirmed a neoplasm in the tracheal carina at the level of its bifurcation with the left main bronchus. Preoperative assessments revealed a good pulmonary function test. The patient undergone tracheal carina resection at the level of the left main bronchus and reconstruction with no lung resection through a posterolateral thoracotomy. No complications after surgery. Postoperative pathology revealed a 2 cm sarcomatous high-grade carcinoma. The distal and proximal stump were negative. The 3 and 10 lymph nodes stations were negative. After surgery patient has been sent to the oncologist for treatment and follow up. After 6 months from surgery no significant abnormalities or signs of recurrence were noted.A 43 years old male patient with cough and bloody sputum for a week was admitted to our Hospital. Chest CT showed a solid mass between the tracheal carina involving mainly the left main bronchus . A malig4The most common approach for carina resection is right thoracotomy through the fourth or fifth intercostal space. Left side approach due to left aortic arch is difficult or sometimes impossible . HoweverOn the other hand, carina resection  is consiNo funding.For case series report NO ethical approval needs. Patient signed a consent for publishing the case report.Patients signed a consent for the publication of this case report.BA and JF wrote the case report. The other Authors read and revised the case report.Ethical Board approval is not required for case reports in our Center.Prof. Jiang Fan is the Guarantor of this case report.Not commissioned, externally peer-reviewedThe Authors have no financial and personal relationships to disclose.


Hemangioblastoma (HB) is a benign tumor that is typically located in the subtentorial region of the brain. HB that originates from dura mater is extremely rare.Herein, we reported a single case of a patient who presented with dizziness and headache lasting for 1 year that progressively aggravated within 1 month.After admission, the patient underwent head magnetic resonance (MR); a nodular long T1-T2 signal was found on the right side of parietal falx cerebri; the lesion appeared with high intensity on FLAIR and DWI, and with isointensity on ADC map. In addition, significant homogeneous enhancements were observed on the enhanced scan. According to clinical and imaging features, the lesion was diagnosed as meningioma. However, after performing tumor resection by craniotomy, the diagnosis of HB is clear. Additional pathological examination data were found: Ki-67(+1%), NSE(-), CD31(+), CD34(+), CD56(+), S-100(-), α-inhibin(+), Vimentin(-), EGFR-), GFAP(-), CK-pan(-), EMA(-), PR(-).The mass with abundant blood supply was removed.Ten days after operation, the patient was discharged from hospital and no signs of recurrence were observed three months later.To sum up, obvious high signal intensity in T2WI sequence and homogeneous enhancement are main characteristics that differentiate dural hemangioblastoma from meningioma lesion. Tumor that originates from dura mater is extremely rare.–4 Solid HBs can be easily misdiagnosed as intracranial tumors with abundant blood supply. In addition, the surgical removal of HB is extremely difficult. The safe resection of solid tumors involves preoperative embolization, circumferential dissection and wide exposure, which represent a challenge for the majority of neurosurgeons. Herein, we reported a single case of a patient with HB present in the cerebral falx with obvious uniform enhancement, which was misdiagnosed as meningioma.Hemangioblastoma (HB) is a benign tumor of the central nervous system that commonly arises from the erythrocyte precursor. HB may occur sporadically or in association with von Hippel-Lindau disease (VHL) (25% of cases).2A 70-year-old Chinese female who was experiencing headache for one month, was admitted to Our Hospital on April 5, 2018. The patient developed headache with no obvious inducement. No obvious relief from the headache was observed during the course of the disease. The pain was characterized by paroxysmal headache and was mainly located in the parietal with no pulsation and other accompanying symptoms. The headache occurred several times a day, lasting 3 to 5 minutes each time. In addition, the patient had no history of brain lesions.Consequently, the patient underwent neurological diagnostic examination; the size of both pupils were equal (3.0 mm in diameter); pupillary light reflex was sensitive; movement and sensation of limbs were normal; physiological reflex was present, and pathological reflex was not elicited. The remaining nerve system did not show abnormal activity. Next, the patient underwent head MR . A nodular long T1 and T2 signal was found on the right side of parietal falx cerebri . The patient had a good compliance. Postoperative review was preformed three months after surgery. The patient's symptoms disappeared without complications and other adverse reactions. In addition, no residual tumor or recurrence was found on MR. Both the doctor and patient were very satisfied with the treatment effect. The patient was advised to make a MR review every three to six months.3 The sporadic form is commonly solitary, and it frequently occurs in patients who are between 40 and 50 years old. Regarding the age presentation, it has been proposed that sporadic HB may arise from a two-stage mutation process. Herein, we reported a single case of a 70-year-old female, whose age characteristic was roughly consistent with the above inference.HB may occur sporadically in 75% of cases. HBs often occur in the parenchyma of the brain, especially in the posterior fossa, while tumors that originate from the dura mater are extremely rare. According to the WHO classification, the HBs derived from mesenchymal tissue are separately classified. HBs are highly vascular tumor types, most commonly detected in the posterior fossa and cervical spinal cord. HB rarely occur outside of the posterior fossa without VHL.,8 Herein we reported a single case of HB connected to the falx with a broad base. Imaging characteristics included a solid, parietal parafalx mass that was homogeneously enhanced. During surgery, the lesion was identified as originating from dura mater.Hemangioblastomas (HBs) are benign neoplasms (WHO grade I) that constitute roughly 2% of intracranial neoplasms. If HB is misdiagnosed as other intracranial tumors with abundant blood supply, such as meningiomas, this may increase the risk of surgery.,10 Consequently, it is essential to differentiate HB from meningioma. In the present study we reported a case of supratentorial HB, which based on close association with the falx cerebrum and avid enhancement, strongly resembled a meningioma. HBs of the central nervous system (CNS) are best visualized on gadolinium-enhanced MRI. While MRI findings are not pathognomonic, HBs are typically seen on MRI as a cystic mass with an enhancing mural nodule, most commonly in the posterior fossa. The nodule is dark on T1-weighted images, bright on T2-weighted images, and homogeneously enhancing. For this case, the solid hemangioblastoma manifested low signal in T1WI and high signal in T2WI. Meningioma is a common intracranial primary tumor. MRI is an effective means of diagnosing meningioma. Typical meningioma has equal or slightly longer T1 and equal or slightly longer T2 signal with homogeneous enhancement. In fact, the differences in T1 and T2 signals can be one of the main identifications between them. Flow void of the vessels can be more commonly found in HB. Although the lesion is similar to those observed in meningiomas, there are clues that can be identified in the imaging findings.Surgical removal of solid HB is a demanding and challenging task, with high morbidity and mortality. After surgical excision of the tumor was performed, there were no other follow-up treatments. Furthermore, no signs of recurring were found in the first review.HB does not usually recur after definitive treatment.4Although uncommon, HB is a tumor that should be considered when dealing with solid vascularized tumors, even in relation to the parietal falx cerebri mimicking meningioma. This case can be used as a useful supplement to the imaging findings of solid HB.Resources: Bingyang Bian, Hongli Zhou.Writing - Original Draft: Bingyang Bian, Bei Zhang, Junwei Tian.Methodology: Zhuo Wang.Software: Zhuo Wang.Writing - Review & Editing: Jiping Wang.


Retroodontoid pseudotumor (ROP) is a nonneoplasic lesion of unknown etiology, commonly associated with inflammatory conditions, and the term of pannus is usually used. Less frequently, ROP formation can develop with other noninflammatory entities, with atlantoaxial instability as most accepted pathophysiological mechanism for posttraumatic or degenerative ROP. As it can clinically and radiologically mimic a malignant tumor, it is paramount for the radiologist to know this entity. Magnetic resonance imaging is the modality of choice to reveal the possible severe complication of ROP in the form of a compressive myelopathy of the upper cervical cord. The purpose of the surgical treatment is the regression or complete disappearance of ROP, with posterior decompression by laminectomy and posterior C1-C2 or occipitocervical fixation. We present the case of an elderly patient with retroodontoid soft tissue mass secondary to a chronic atlantoaxial instability on os odontoideum, an extremely rare cause of ROP. The patient developed a posttraumatic cervical myelopathy related to the decompensation of this C1-C2 instability responsible for the formation of a compressive ROP. We will overview the retroodontoid pseudotumor and its differential diagnosis. Retroodontoid pseudotumor (ROP) is an entity that can mimic malignant tumors and is from uncertain etiology. Some consider it as a low-grade fibrosarcoma. ROP are mainly related to infectious processes and less frequently to inflammatory disorders. ROP might have neurological complications due to mass effect on the spinal cord.A 77-year-old female patient was admitted in our institution following a ground-level fall due to relatively sudden grade 3-4 right hemiparesis with lower limb predominance.This patient was not known for any systemic disease, no rheumatoid arthritis, or other joint-related generalized disease.An initial enhanced CT was performed for the suspicion of an ischemic stroke. The exam revealed a smooth and well-corticated bone ossicle measuring 14 mm and located superiorly to the odontoid process corresponding to an os odontoideum Figures . The ossA complementary cervical enhanced MRI with administration of Gadolinium confirmed a well-corticated ossicle and demonstrated a tissular retroodontoid process Figures . The tisThere was no enlargement of space between this os odontoideum and the anterior arch of C1 . A subceGiven the severity of the radiological findings and the clinical impact due to spinal cord compression and the life-threatening risk, patient was treated with cervical posterior screw fixation and a decompressive laminectomy at C1-C2 level Figures . UnenhanThe patient showed a progressive improvement of her neurological recovery, with complete neurological recovery 6 months after surgery. In the postoperative follow-up, entire cervical spine showed marked degenerative changes, best viewed on postoperative cervical spine X-rays Figures  as discoThe etiology of retroodontoid pseudotumor (ROP), which can mimic malignant tumors, is unknown. Some authors believe that this entity is a low-grade fibrosarcoma . When psIn 2004, Goel A. et al. identified that ROP indicated atlantoaxial instability (AAI) . Thus, dX-rays analysis allows estimating of the atlantoaxial instability, usually with dynamic study in flexion and extension. The radiographic characteristics as ossification of the anterior longitudinal ligament and ankylosis of the adjacent segments seem to be risk factors for the formation of a ROP . DistancThe surgical management of ROP aims to restore the AII and to relieve the mechanical stress at the C1-C2 junction, with spontaneous regression of ROP. Many cases report the complete disappearance of this degenerative and noninflammatory ROP following posterior C1–C2 fixation , 20–22. In this case, os odontoideum is the cause for the AII with ROP. This bone ossicle is situated superiorly to the dens of axis and differs morphologically from persistent ossiculum terminale or from odontoid fracture. According to the congenital hypothesis, it corresponds to a congenital anatomic variant, due to a failure of fusion of dens center with the body of C2. The other current hypothesis supports a traumatic origin, corresponding to an odontoid process fracture type II of Anderson and Alonso classification, sustained by history of traumatism in many patients . In our We present an extremely rare case of ROP, confirmed by surgery, secondary to chronic atlantoaxial instability on os odontoideum. Our case, being the fifth reported in the literature, gives us the opportunity to remind the reader of the recent knowledge about this anatomical variant suggesting a traumatic etiology rather than a congenital source.


In the recently published article entitled “Ocular ultrasound versus MRI in the detection of extrascleral extension in a patient with choroidal melanoma” Jacobsen et al. describe a case in which a hyper-intense extra-ocular lesion on MRI was erroneously diagnosed as an extrascleral extension of the tumor. Based upon this the authors conclude “the superiority of ocular ultrasound in the diagnostic management of extra scleral extension in choroidal melanoma”. In our view, there are numerous flaws in the investigation that cast doubt on this message.First of all, this is quite a bold statement when only one patient has been evaluated. Secondly, the manuscript only presents a post-contrast T1-weighted image, whereas multiple MRI-sequences need to be included to determine if a hyperintense region is an extrascleral invasion. Moreover, no modern MRI-techniques such Dynamic Contrast Enhanced (DCE) or Diffusion Weighted Imaging (DWI) have been included in the evaluation of this patient, making it hard to use this single case to compare the efficacy of MRI and Ultrasound. The presented data do, however, give clear clues that the hyperintense lesion is likely to be inflammatory.Although the study falls short in providing a comprehensive comparison between current MRI techniques and ultrasound, it does show that the evaluation of ocular MR-images should be made in a multi-disciplinary setting involving both ophthalmologist and radiologists, since the field of ocular MRI is continuously progressing. Given the recent attention on the use of MRI for the diagnosis of ocular lesions, especially for uveal melanoma, the article of Jacobsen et al.  is most In the presented post-contrast MR-Image indeed an abnormal hyperintense lesion can be seen at the arrow, but to conclude that this is an extrascleral invasion, multiple other sequences need to be included in the evaluation. First the pre-contrast T1 needs to be included to verify that this lesion is indeed enhancing, as it could already be hyperintense before contrast, similarly to intra-ocular hemorrhage possibly present in the temporal half of the vitreous. Secondly a T2-weighted image should be included, as UM is generally hypointense, while the signal intensity of inflammatory lesions depends on the balance between oedema and fibrosis, which can be used to differentiate between different types of orbital inflammation [Moreover, we have some concerns about the correlation between the MR-image and the presented ultrasound and histology images. The ultrasound and histology, only show a small part of the tumor and eye and no guarantee can be given that they include the region with the hyperintense lesion, especially since they could have been acquired perpendicularly to axial MR-slice.In our opinion the lesion would more likely be an artifact or inflammatory. However, we have never seen a type of artifact like this before in literature or in our clinic so inflammation is more likely. It could be periscleral cellulitis caused by sclerites which is more likely than an artifact as the patient also complains about pain. Unfortunately, no modern MRI-techniques such Dynamic Contrast Enhanced (DCE) or DWI have been included in the evaluation of this patient. DWI is one of the main diagnostic tools to differentiate between benign and malignant enhancing lesions and is valuable for diagnosing inflammatory disease , while o1 can easily be acquired at clinical 3 Tesla MRI, while at 7 Tesla an additional four-fold increase in resolution can be achieved [Although MRI has been proposed to evaluate UM from the eighties , 5, in tachieved .Although the study falls short in providing a comprehensive comparison between current MRI techniques and ultrasound, it does show two points that require more careful attention. Firstly, since the field of MRI in general, and ocular MRI specifically, is progressing continuously, the evaluation of ocular MR-images should be made in a multi-disciplinary setting involving both ophthalmologist and radiologists. Secondly, new studies are needed to assess if the older conclusion on the clinical value of MRI for uveal melanoma are still valid, as the diagnostic capabilities of MRI have significantly increased over the last years.


Muscle biopsy revealed a MFM. Muscle MRI demonstrated selective involvement of the tensor fasciae latae, semitendinosus, sartorius, gracilis, gastrocnemius, soleus, and peroneus longus muscles. In this family, the histological and MRI findings assisted in the interpretation of genetic testing results.Myofibrillar myopathies (MFM) are a clinically and genetically heterogenous group of inherited myopathies characterized by aggregation of Z-disc proteins. Mutations in desmin account for ~7% of MFM. We report here a Hmong family with an autosomal dominant MFM caused by a novel variant in the desmin gene. The proband presented with lower limb followed by upper limb weakness starting in the 5th decade. On examination, there was distal more than proximal muscle weakness. One sibling was similarly affected, while another had an asymptomatic elevation of creatine kinase. Genetic testing revealed a novel p.Ser13Tyr variant, which was predicted by  Myofibrillar myopathies (MFM) are a clinically and genetically heterogenous group of inherited myopathies histologically characterized by aggregation of Z-disc proteins . MutatioThe proband was a 47 year-old man of Hmong descent who presented with a 5-year history of progressive lower limb followed by upper limb weakness. Neurological examination revealed severe distal weakness in the upper and lower limbs, along with a mild to moderate degree of proximal weakness. The patient's 50 year-old sister was more severely affected, requiring assistance walking. She started noticing the weakness at age 37, and had no cardiac involvement. A 52 year-old brother had asymptomatic elevated CK level . An 80 year-old paternal aunt has become wheelchair bound from the myopathy, which started around age 50. The proband's father had died at age 53 of lung cancer without displaying any signs of neuromuscular disease. Family members were not available for detailed clinical evaluation.The proband had a creatine kinase level of 669 U/L . An electromyogram revealed rapid recruitment of complex short duration motor unit potentials in all muscles examined, mixed with long-duration motor unit potentials in some proximal muscles. Fibrillation potentials were present in most muscles. A biopsy of the left quadriceps showed non-specific changes. An echocardiogram did not reveal evidence of a cardiomyopathy, while an electrocardiogram showed a first-degree atrioventricular block.DES  and a homozygous VUS in RYR1 . Neither variant was present in population databases, nor known to be disease-causing. The DES variant was predicted by three in-silico algorithms to adversely affect protein function, while the RYR1 variant was predicted to be benign.A next-generation gene panel targeting 121 known myopathy genes revealed a heterozygous VUS in DES variant was present in the affected sister and in the brother with elevated CK level, but absent in an unaffected sister. By contrast, the RYR1 variant did not segregate with the phenotype. A repeat muscle biopsy of the right quadriceps showed findings typical of MFM (Segregation analysis was subsequently performed. The l of MFM . A muscll of MFM . By contHerein, we report a Hmong family with an autosomal dominant distal myopathy and asymptomatic hyperCKemia due to the p.Ser13Tyr missense variant in the desmin gene. The distal-predominant weakness observed in the proband is typical of desminopathy . CardiomDES. The serine residue at position 13 is highly conserved and serves as a phosphorylation site for protein kinase C (The findings observed on muscle biopsy establish the presence of a MFM and thus support the pathogenicity of the mutation in kinase C . Its funkinase C –10. The DES, in which a distinctive imaging pattern of muscle involvement has been described.Imaging studies have identified two distinct patterns of muscle involvement in MFM. Selective involvement of the semitendinosus, sartorius, gracilis, and peroneus longus muscles is typical of desminopathies and αB-crystallinopathies –13. By cThe datasets generated for this study are available on request to the corresponding author.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.SN: study design, data collection, and drafting of a first version of the manuscript. BH: review of the MRI images and critical revision of the manuscript. EN: study design, data collection, study supervision, and critical revision of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Deposition of tophus is a common feature in chronic gout; however, signs and symptoms are not always well-pronounced in cases of uncommon sites. We report a rare case with a tophaceous tendonitis on the flexor hallucis longus (FHL) tendon with tarsal tunnel syndrome (TTS). This is the first surgical case of TTS by gouty tophi in FHL.A 55-year-old woman presented with a 6-month history of mild discomfort at the right foot, which gradually worsened in the past 3 weeks. The patient visited our outpatient clinic due to persistent and aggravating foot pain and swelling around the tarsal tunnel.2). Conventional radiography examination showed negative pathology except soft tissue swelling. Magnetic resonance imaging revealed a fusiform mass within the FHL tendon and fluid collection around tarsal tunnel.The patient was diagnosed with hyperuricemia and diabetes mellitus with chronic kidney disease, and did not receive regular antigout treatments. Paresthesia was found along the distribution of medial and plantar nerve and tinel test was positive on tarsal tunnel. Biochemical examination showed she had raised serum uric acid (10.6 mg/dL) and decreased estimated glomerular filtration rate (69 mL/min/1.73 mSurgical exploration was performed to remove the mass. Inflammation fluid exploded out from FHL tendon sheath, which was later proven to have infiltration of monosodium urate crystal. Superficial dissection revealed a white chalky mass and posterior tibial nerve was significantly compressed by the tophus mass.The mass was removed and the symptoms were relieved at immediate postoperative period.A tophaceous tendonitis on FHL tendon can cause TTS and surgical decompression of the gout lesion can reduce the symptoms. Also, there are only few case reports of tarsal tunnel syndrome (TTS) due to gout tendonitis.Many studies report that the incidence of gout increases continuously for several decades.TTS is an entrapment neuropathy of the posterior tibial nerve or one of its branches within the tarsal tunnel. Many etiologies have been described and broadly classified as trauma, space-occupying lesions, foot deformities, etc. In a literature review of TTS, it was estimated that in 60% to 80% of cases, the specific etiology can be identified.The tarsal tunnel is an area of anatomic narrowing caused by tight ligamentous structures. It is a fibro-osseous tunnel bordered superficially by the flexor retinaculum, which passes obliquely from proximal to distal to anterior.We report a case of TTS caused by a tophaceous gout tendonitis with monosodium urate (MSU) crystal deposition at the FHL tendon that has been resolved with resection of tophus mass and tendon sheath.2Patient has provided informed consent for publication of the case. A 55-year-old woman presented in our outpatient clinic with mild discomfort at the right foot since 6 months ago, which gradually worsened in the past 3 weeks. Her discomfort was mainly pain with ankle movement and numbness which had been not relieved by nonoperative treatments, including activity modification, physical therapy, and oral anti-inflammatory medicine. There was no previous history of trauma, but she had swelling around the tarsal tunnel.2; mildly decreased renal function according to the Chronic Kidney Disease Epidemiology Collaboration calculation).Patient had a medical history of asymptomatic hyperuricemia  and diabetes mellitus . Patient was also noted to have decreased eGFR (69 mL/min/1.73 mOn physical examination, paresthesia was found along the distribution of medial and plantar nerve. She walked with an antalgic gait for plantar heel pain especially when she wore a hard soled shoe on the right foot. Tinel sign was positive and tenderness was positive along with FHL tendon pathway.The patient was then sent for nerve conduction studies and the study showed posterior tibial nerve entrapment at the tarsal tunnel area. But there was no abnormality found in the electromyography study.Conventional radiography examination of the ankle showed negative pathology except soft tissue swelling. Magnetic resonance imaging revealed a fusiform mass, which was heterogeneous isointense on sagittal T1-image within the FHL tendon. Fluid collection was detected around FHL tendon, adductor hallucis longus tendon, and calcaneal attachment of plantar fascia and it was heterogenous hyperintense on T2 image (Fig. A diagnosis of TTS caused by space occupying lesion with fluid collection was made, taking gouty arthritis with tophi as the most suspicious cause of the problem. As pain with the neurologic symptom aggravated over 6 months and obvious space occupying lesion in tarsal tunnel was found, the patient decided to take a surgery for excision of the mass.Surgical exploration was performed to remove the mass using a minimized conventional medial approach, making incision along the tarsal tunnel extending proximally. Inflammation fluid exploded out from FHL tendon sheath which infiltrated in MSU crystal Fig. A. SuperfAfter the surgery, the plantar foot paraesthesia subsided immediately and the patient satisfied with the symptom relief at the early and medium term follow-up period. At 1 year after the surgery, she is still pain free and returned to her daily activities only with some restrictions for sport activities.3–10 Lui reported a case of TTS caused by gouty tophus. Although there were many similar features to our case, they specified that FHL tendon was not involved in their case and the symptoms were not satisfactorily relieved.This is the first case of TTS provoked by gouty tendonitis on FHL tendon. The symptoms improved obviously after surgical removal of the tophi and surrounding inflammatory tissues. Our case is rare in 2 aspects; the first aspect is that no article makes mention of gouty tendinosis on FHL tendon; the second one is that only few case reports refer to gouty tophus as a reason of TTS.–19 There are some etiologies that compromises the tarsal tunnel from outside; osseous prominences, postsurgical scarring, generalized lower extremity edema, hind foot deformities, and inflammatory disorders including rheumatoid arthritis, ankylosing spondylitis, and synovial osteochondromatosis.–19 Each of the etiologies has been reported more commonly than the gouty tophus has been done, so that it is hard to make a suspicion on a gouty tendonitis as a culprit of TTS.As we briefly mentioned at the introduction, TTS can be attributed to various etiologies that courses within the anatomic boundaries of the tarsal tunnel; varicosities, venous congestion, ganglia, perineural fibrosis, lipoma, neurilemoma, hypertrophic flexor retinaculum, hypertrophic or accessory abductor hallucis muscle, flexor digitorum accessory longus muscle, partial rupture of the FHL tendon, fluid retention, and chronic phlebitis.In our case, no significant past gouty attack, family history, or past medical history of hypertension and diuretics consumption was found except asymptomatic hyperuricemia and diabetes with chronic renal disease. These atypical initial findings could mislead the clinician not to arrive at the initial diagnosis of tophaceous gout.,21 Predictable postoperative complications are poor wound healing, wound infection, recurrence of TTS due to tophaceous discharge, and postsurgical scarring. Surgeons are mandatory to take these complications into consideration while planning the treatment strategy.There is lack of studies on the natural course of the TTS caused by tophaceous gouty tendonitis on FHL tendon, which could make it hard to decide a treatment strategy. Some authors have reported that early surgical treatment is recommended when the cause of TTS is identified such as a space occupying lesion, based on some studies suggesting poor outcome with delayed surgery.4We present an unreported cause of a space-occupying lesion in the etiology of TTS, namely the combination of a tophaceous gout. Atypical symptoms and findings of gouty tendonitis could lead doctors to misdiagnose the disease as TTS caused by a simple FHL tenosynovitis, and not to care about the gout. Through the case, we suggest that gouty tendonitis with tophi should be considered in diagnosing and treating TTS. After the diagnosis, surgical excision of tophi and surrounding inflammatory tissues can resolve the symptoms and following treatment for gout is also needed.Conceptualization: Min Ki Lee, Young Yi.Data curation: Young Yi.Formal analysis: Young Yi.Funding acquisition: Young Yi.Investigation: Young Yi.Methodology: Young Yi.Project administration: Young Yi.Resources: Young Yi.Software: Young Yi.Supervision: Young Yi.Validation: Min Ki Lee.Writing – original draft: Yoon Seok Kim.


The huge size intrathoracic lipomas are very rare. Few cases have been reported worldwide. To our knowledge, this presented case is one of the few cases reported. Here we report a single case as very huge intrathoracic lipoma compressing the right lung and displacing the diaphragm and liver downward. It has been managed by right posterolateral thoracotomy and complete excision, with excellent outcome.A 32-year-old male presented with a symptomatic right intrathoracic mass, which was confirmed to be a lipomatous tumor using computed tomography. A penduculated tumor originating from the mediastinal pleura was resected through the conventional right posterior thoracotomy. Pathological examination indicated a diagnosis of fibrolipoma.The tumor was symptomatic and relatively huge when detected during a medical checkup. This enabled the successful tumor resection via conventional thoracotomy approach. Although intrathoracic lipomas are histologically benign, careful observation and follow-up are crucial due to the possibility of recurrence. The huge size intrathoracic lipomas are very rare. Few cases have been reported worldwide. To our knowledge, this presented case is the fourth reported . Herein A 32-year-old gentleman working as a hair dresser. His body weight is 100 kg, height 168 cm, Body Mass Index (BMI) was 35.43. Ex-smoker with a long history of smoking and long-standing history of chronic dry cough and shortness of breath but with no weight loss or hemoptysis. He had been managed as case of chronic obstructive pulmonary disease (COPD). He had history of surgical resection of multiple subcutaneous lipoma from the anterior abdominal wall. Recently, he was orthopneic with dull aching pain in the right lower chest to the right hypochondrial region. He was managed as a chest infection case then persistence of pain and dyspnea mandated performing the chest X Ray (CXR); it showed an apparent huge mass occupying most of the right hemi-thorax obscuring lung field  of 1.6 L (54% predicted), forced vital capacity (FVC) 2.3 L (61% predicted) and an actual FEV1/FVC ratio of 70%. Blood tests were normal with a normal white cell count, hemoglobin, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). An electrocardiogram showed normal sinus rhythm with iso-electric pattern.The patient was referred to our unit for surgical management. No history of trauma and examination was revealed absent breath sounds in the lower two-thirds of his right chest. Computed tomography (CT) scan with contrast of the thorax and upper abdomen Fig.  was perfSurgery was performed using posterolateral thoracotomy, single lung ventilation and epidural analgesia. Huge sized, lobulated mass, yellowish, smooth surface, soft in consistency with small areas of hard components in its lower part and occupied most of the pleural space. This intrapleural lipoma attached with one vascular pedicle to the mediastinal pleura just above the right hilum required clipping by a multi-firing clip applier which facilitated the controlling of the pedicle as the mass obliterating the space. Blunt and electrocautery dissection performed for the minimal adhesion to the surrounding are required. A complete excision of this benign tumor Fig. a took plThe postoperative course was uneventful, and the patient discharged home on the 6th postoperative day with a normal Chest X Ray.The Histopathlogical examination Fig.  revealinThe postoperative course was uneventful and the patient discharge home on 6th postoperative day with normal Chest X Ray. Post discharge, his physical capacity and respiratory status improved dramatically, the walking distance is more than 5 km daily. No evidence of recurrence and normal CXR after 6 months of follow-up shown in , in our case the plain CT was non-conclusive but with enhanced contrast there is clear plane of cleavage and with an adipose density. The CT scan allows the attenuation values of fat density to be assessed and help determine the origin and extension, as well as the involvement of adjacent organs [Additionally, magnetic resonance imaging (MRI), particularly with fat saturation, is supportive for assessing the lipomatous nature of the tumor. Furthermore, MRI helps in distinction between lipomas and well-differentiated liposarcomas based on margins, signal homogeneity, and septa or nodules . PositroLung malignancy especially in our case the pulmonary liposarcomas is the most important differential diagnosis in most unexplained CXR lesions particularly among heavy smokers. However, it is also important to consider benign disorders and intrapleural lipoma particularly when the lesion is with fatty pattern on CT. This can potentially avoid needless invasive investigations and alleviate patient anxiety . CT scanIn our case, despite the huge size of the tumor and there were minimal adhesions to the pericardium, lungs and diaphragm, and the phrenic nerve is intact, the diaphragm regains its normal contour and position after resection of the tumor. The origin is obviously from the mediastinal pleura just above the lung hilum with single wide vascular pedicle. The presence of extensive adhesion could be due to previous drainage procedures , 7.The management of pleural lipomas remains controversial. Once the Intrathoracic lipomas are detected should be surgically resected, because the possibility of liposarcoma occurrence and/or infiltrating development of the tumor cannot be excluded preoperatively , besidesConservative clinical and radiological follow-up is often used in small asymptomatic lesions or those unsuitable or higher risks for surgery . If compOpen thoracotomy is the only option for total resection of the huge intrathoracic lipoma as in our case, although advancements in VATS have greatly reduced the morbidity rate of these benign tumors , especiaThoracoscopic resection, in mediastinal cases, is generally considered to be a safe approach . When viThe tumor was symptomatic and relatively huge when detected during a medical checkup. This enabled the successful tumor resection of via conventional thoracotomy surgery. Although intrathoracic lipomas are histologically benign, careful observation and follow-up are crucial due to the possibility of recurrence.Additional file 1. Informed consent


We present two cases of cerebrovascular accidents. Case #1: A 24-year-old man presented with open fractures of the left femur and tibia after a motor vehicle collision. Within two hours, he developed left facio-bracial paresis. Although he arrived in the window period for thrombolysis, polytrauma precluded thrombolysis. His modified Rankin Scale (mRS) score at admission was five. Case #2: A 26-year-old man presented to the emergency department after eight hours with hemiplegia and global aphasia. His admission mRS score was four. Stroke workuprevealed hyperhomocysteinemia (>114 μmol/L).In Case #1, considering the background of trauma and imaging suggestive of luminal filling defect, we suspected an internal carotid artery (ICA) dissection.In the literature, luminal thrombus in the ICA has been described radiologically with various analogies such as “donut sign,” “crescent sign,” or “string sign.”4In summary, these images emphasize two practical points: 1) limitations in the interpretation of MRA-MIP image ; and 2) the significance of evaluating source images of head and neck in stroke workup.What do we already know about this clinical entity?Cerebrovascular accidents are the most common neurological emergencies. Magnetic resonance imaging (MRI) and MR angiography are the recommended modalities to identify stroke etiology.What is the major impact of the image(s)?These radiological images highlight the major limitation of maximum intensity projection images in detecting the intraluminal thrombus.How might this improve emergency medicine practice?Knowledge of basic MRI interpretation and its limitation will aid the emergency physician in prompt diagnosis, etiological differentiation and subsequent management of stroke.Documented patient informed consent and/or Institutional Review Board approval has been obtained and filed for publication of this case report.


Recognition of elderly-onset ulcerative colitis (UC) remains poor as the differential diagnosis in older patients with acute abdominal pain and bloody diarrhea is extensive and UC is generally not the obvious cause. A typical presentation in an elderly patient with acute severe UC can mimic surgical abdomen.An 80-year-old female had been presented with high grade fever, abdominal pain and diarrhoea. Physical examination showed sign of peritonitis and severe hypotension. A provisional diagnosis of perforated sigmoid diverticulitis was made. However, at the theater, there was only turbid yellowish ascites at cal-de-sac. Consequently, colonoscopy was performed and revealed continuous and circumferential erythematous with friable mucosa and multiple shallow ulcer along upper left side colon. Histologic examination of the colonic tissue was consistent with UC.As UC is uncommon in Thailand and clinical features of elderly-onset UC are much more non-specific; as a result, misdiagnosis at initial presentation is more common in elderly patients (60%) than that in younger population (15%). These might result in an unnecessary exploratory laparotomy; however, computed tomography scan can reduce the risk of that event.The diagnosis of severe acute UC in elderly patients with acute abdomen had been complicated by the distinctive physiology of this aged group with atypical presentation and markedly unreliable physical examination. Eventually, severe UC should always be kept in mind with a circumstance of abdominal pain in geriatric population. UC has a bimodal age distribution with 10–30% of the affected population older than 60 years . A typicThis work is compliant with the SCARE checklist, and also, has been reported in line with the SCARE criteria .2An 80-year-old female patient came to our hospital after suffering from diarrhoea, loss of appetite, fatigue and weakness for three months. She also had a high-grade fever for 3 days. Physical examination confirmed the high-grade fever and sign of severe dehydration. A per rectum examination revealed yellow stool. There was a presence of abdominal distention and generalized tenderness with marked tenderness at left side. Laboratory tests revealed a total white blood cell count of 11,000 per microliter and a neutrophil count of 80% also with high rising of creatinine and low glomerular filtration rate. Abdominal radiography showed mild dilatation of left-sided colon with no pneumoperitoneum. The initial clinical diagnosis of left side colitis was made. She was admitted for intravenous antibiotic and scheduled to investigate with computerized tomography (CT) scan of whole abdomen after adequate resuscitation with aggressive intravenous hydration.Three hours following the admission; however, the patient developed severe hypotension and abdominal pain. The patient’s vital signs were as follows: blood pressure of 80/50 mmHg, heart rate of 120/min and temperature of 39 °C. Her abdominal signs had gotten worse revealing increased distension, generalized involuntary guarding and marked tenderness at the left side of the abdomen. Abdominal radiography showed dilated small bowel at left side abdomen . Even af3Clinical presentation in UC can vary from mild to severe. In a small number of patients with acute severe form (15%), they suffer a fulminant course in which the presentation much likes an acute surgical abdomen and the condition is life-threatening which can be associated with significant morbidity . GeneralThe clinical features of elderly-onset UC are much more non-specific; as a result, misdiagnosis at initial presentation is more common in elderly patients (60%) than that in younger population (15%) . These mWith respect to the Truelove and Witt’s criteria that acute severe UC with a life threatening condition characterized by presence of more than 6 bloody stools/day along with any one of the following: tachycardia >90 beat per min, fever >37.8 °C, hemoglobin <10.5 g/dL, and/or erythrocyte sedimentation rate >30 mm/h , the proThe role of antibiotics in the primary treatment of UC is controversial, some study proposed the role of antibiotics as a therapy for UC to induce remission in an active disease and to prevent relapse. They are usually associated with a modest improvement . The pla4The diagnosis of severe acute UC in elderly patients with acute abdomen is still challenging. Not only is it uncommon in Asia compared to Western, but the distinctive physiology of this aged group with atypical presentation and markedly unreliable physical examination also lead to a difficulty in diagnosis. CT imaging is a diagnostic tool which can help physicians exclude non-surgical condition and reduce rate of negative surgery. Eventually, severe UC should always be kept in mind with a circumstance of abdominal pain in geriatric population.The authors declare that there is no conflict of interest regarding the publication of this article.This work received no funding.The consent form and information sheet using in the process of obtaining a consent were approved by IRB at our institution.The patient has been informed prior to the conduction of this manuscript and informed consent has also been obtained. A copy of the written consent is available for review by the editor-in-chief of the journal on request.Panutchaya Kongon and Vorapatu Tangsirapat collected data and wrote manuscript.Vittawat Ohmpornuwat, Kannakrit Sumtong, Vichack Chakrapan Na Ayudhya and Kobkool Chakrapan Na Ayudhya contributed to conceptualization.Paiboon Sookpotarom contributed to conceptualization, data curation, supervision and editing of the manuscript.Paisarn Vejchapipat finally edited this manuscript.It seems not necessary for this presentation since this is not a first-in-man case report.Panutchaya Kongon.Not commissioned, internally peer-reviewed.


Schwannomas are common benign neoplasms of the myelinating cells surrounding peripheral nerve axons. Though uncommon, lesions arising in the cervical spine may produce radicular pain and myelopathic weakness. Multiple sclerosis (MS) is a common autoimmune disorder with the capacity to mimic nearly any neurologic disease, including spinal cord neoplasms. We report the third case of synchronously presenting primary progressive MS and spinal schwannoma.A 65-year-old man presented with six months of progressive weakness and pain of the right shoulder, forearm, and hand. MRI demonstrated a contrast-enhancing transforaminal lesion at C7, most consistent with a benign nerve sheath tumor. Additional history disclosed several years of worsening fatigue, accompanied by bilateral weakness and lancinating leg pain. MRI of the neuraxis demonstrated abnormalities consistent with chronic demyelinating disease intracranially and within the spinal cord; cerebrospinal fluid (CSF) analysis revealed nine oligoclonal bands and an elevated IgG index, resulting in the diagnosis of MS. Given the symptomatic C7 lesion, the patient subsequently underwent right C6-C7 facetectomy, gross total resection of the tumor, and C6-T1 posterior instrumented fusion. Postoperatively, the patient rapidly recovered normal right upper extremity function, and pathology confirmed benign schwannoma.Synchronously presenting co-morbid neurologic diagnoses are exceedingly rare. Nonetheless, the high incidence and protean nature of MS make it particularly susceptible to such confounding clinical cases. Correspondingly, MS should be considered when neurologic abnormalities are not compatible with a focal radiographic lesion, and the present report emphasizes the value of a good history and exam in unraveling similarly challenging cases. Spinal schwannoma is the most common intra-dural extra-axial neoplasm, comprising nearly one-third of tumors found within that anatomic space, with an incidence of 0.3-0.5 per 100,000, and a peak distribution during the fifth decade of life -5. ConsiAlthough far from universally applicable, Dr. William Osler’s repurposing of Occam’s Razor-that a single, unifying diagnosis should be sought to explain all of a given patient’s symptoms-remains salient, and in many cases provides a helpful tool for scrutinizing the differential and eliminating diagnoses that are simultaneous unlikely and supported . NotwithA 65-year-old man presented with six months of progressive weakness and pain of the right shoulder, forearm, and hand. He was evaluated by his local neurologist and neurosurgeon, and an MRI was acquired and demonstrated findings consistent with a C7 nerve sheath tumor Figure . ElectroThese new findings prompted MRI of the total neuraxis, which reproduced the right C7 mass, while also identifying subtle, intrinsic T2 signal abnormalities of the thoracic spinal cord Figure , collectAlthough the diagnosis of MS provided a satisfactory explanation for the patient’s otherwise confounding symptoms, he remained with a demonstrably symptomatic cervical schwannoma, now complicated by the possible need for future immunosuppression. Correspondingly, the tumor was approached via a right posterior C6-C7 facetectomy; a gross total resection of the tumor was achieved; and a C6-T1 posterior instrumented fusion was completed, due to concern for possible destabilization in the setting of total facetectomy at a spinal level proximal to the cervicothoracic junction. Pathology confirmed a schwannoma. By post-operative day one, his right upper extremity weakness and radiculopathy were dramatically improved and had resolved by first neurosurgical follow-up at six weeks. The neurology service determined that the extent of his MS disease burden was such that initial management could be expectant; correspondingly, immunosuppression was not recommended and his other symptoms remained stable as of the last neurosurgical follow-up at one year.Although both spinal schwannomas and MS are relatively common diagnoses, their synchronous presentation is exceedingly rare, with ours marking only the third reported case. Moreover, our review of the literature did not find report of other demyelinating conditions such as neuromyelitis optica or transverse myelitis presenting synchronously with schwannoma, or MS coexisting with an extraspinal schwannoma. Schwannomas are benign neoplasms arising from the myelinating Schwann cell found throughout the peripheral nervous system, with a strong predilection for the cerebellopontine angle and the spinal nerve roots. When arising from spinal nerves, radiculopathy is the typical presentation, beginning with dermatomal pain, which may evolve into progressive focal motor weakness as the tumor grows and mass effect increases . MRI finMS is a truly protean disease, with common presenting symptoms spanning the breadth of neurologic dysfunction, including visual loss, diplopia, sensory disturbance, focal motor weakness, bowel/bladder dysfunction, ataxia, and other cranial neuropathies . CorrespWith these disease features in mind, we turn to the two previously reported cases of concomitant presenting spinal schwannoma and MS. In the index case, Salvi et al. described a 32-year-old man with progressive pain and weakness of the left lower limb, which eventually evolved to encompass the right lower extremity, with simultaneous urinary urgency . MRI of In many clinical circumstances, Osler’s Rule proves a still-relevant diagnostic principle-particularly with respect to neurologic diagnoses such as MS, which have the capacity to elicit simultaneous symptoms across a range of anatomically disparate domains, from sensation to locomotion, vision to micturition. Notwithstanding, although a single pathology is undoubtedly the “simpler” and more gratifying explanation to a diagnostic dilemma, clinicians are obliged to weigh all the evidence and to seek out a solution or set of solutions that incorporates all the pertinent history, exam, and imaging findings. As such, our report is not only the third case of synchronously presenting MS and spinal schwannoma, but a compelling reminder of the capacity for atypical cases to confound, and one which emphasizes the importance of bringing fresh eyes and an unbiased perspective to every neurosurgical referral.


De Garengeot’s Hernia is a rare type of femoral hernia in which the appendix is located inside the herniated sac. Diagnosis of the condition is challenging and its treatment must be performed without delay.We present the case of a 75-year-old patient with a femoral hernia in which an appendix with signs of inflammation was found. An appendectomy followed by hernia repair was performed under an open preperitoneal approach according to Nyhus technique. The patient did not present any complications and was discharged on the second postoperative day.This type of hernia is often unexpected and its preoperative diagnosis is difficult to perform. In most cases the clinical picture is indistinguishable from a common incarcerated hernia. Contrast-enhanced CT is the most useful complementary test, although it is not as accurate as desirable, so the diagnosis is frequently found intraoperatively. There is a wide variety of surgical options and there is no consensus on the most appropriate one. The preperitoneal approach enables the performance of an appendectomy and subsequent hernia reparation. The use of prosthesis should be considered if there are no signs of perforation or abscess.De Garengeot’s hernia is a very rare entity. The diagnosis and subsequent surgical treatment must be early to prevent the disease progression. The preperitoneal approach should be considered as the first choice technique, as it allows the exploration of the herniated sac and the performance of surgical procedures on its content. Its cli2Herein, we describe the case of a 75-year-old woman with no relevant medical history, who arrived at our emergency department complaining of right inguinal pain experienced over the last 12 h, and associated with the appearance of a lump at that same level. The patient did not present any intestinal obstruction and was afebrile upon presentation. Physical examination revealed a non-reducible right inguinal mass hard in consistency, painful and without signs of local swelling or warmth.Leucocytosis with associated neutrophilia was identified. The abdominal X-ray did not show any pathological findings.Due to the clinical and analytical findings, a diagnosis of incarcerated inguino-femoral hernia was made and the patient was transferred to the operating room.Under general anesthesia, a preperitoneal approach was performed according to the Nyhus technique. An incarcerated femoral hernia was found. The sac was opened, and an isquemic appendix without signs of abscess or perforation was revealed . The cecOral tolerance was initiated on the first postoperative day and no unexpected events ocurred. The patient was discharged 48 h after the operation in good general condition.The anatomo-pathological analysis reported an appendix with signs of ischemia.3Femoral hernias constitute an uncommon subtype of groin hernias, representing around 3% of all abdominal wall hernias, and usually appear in elder women . BecauseThe most frequent clinical scenario is the appearance of a groin mass  associated with abdominal pain. The presence of fever is found in 8–10% of the patients, and it is not related to the severity or the prognosis of the disease. Physical findings include abdominal pain, non reductable inguinal mass and local signs of inflammation  in one third of the cases . ObstrucOur patient showed a typical case of complicated hernia, as she presented an abdominal pain associated with the recent appearance of a right groin mass.Due to the lack of reports in literature and its low incidence, there’s not a management protocol to guide the diagnostic and treatment process in this pathology. In fact, a recent meta-analysis  didn’t eAn effective preoperative diagnosis is often hard to achieve, and will demand laboratory and imaging tests. An increase in CR-Protein or white blood cell count can be present in half of the patients, although it is not associated with the severity or outcome of the disease. Among the available imaging tests, the abdominal CT-scan is the most sensitive and specific, in spite of the report of a 40% sensibility and an accuracy of about 60–70% ,10. One As mentioned above, there is not an updated recommendation about the surgical approach to be carried out on these patients. In fact, the previously reported meta-analysis concludes that the surgical approach should be determined by each surgeon depending on his individual experience and the specific characteristics of the case . Among aLaparoscopic approach has emerged as an alternative in this scenario. It has evident advantages, such as the possibility of a complete abdominal exploration and the performance of easy procedures as appendectomy . It alsoIn our opinion, although the laparoscopic approach offers some clear advantages, we believe that it should not be go-to choice in complicated hernias. Only experienced surgeons capable of performing both laparoscopic intestinal resection and hernioplasty (uncommon fact at the present) should consider this approach, as more inexperienced practitioners could be unable to deal with the potential risks that could emerge. In other instances, additional laparotomy will be necessary to achieve a correct surgical treatment. Even in case of a De Garengeot’s hernia correctly diagnosed preoperatively and subsequent laparoscopic appendectomy successfully completed, a conversion will be necessary to perform a hernioplasty if a trained surgeon in this technique is not present.For the disadvantages associated with previous mentioned techniques, we believe that the open preperitoneal approach should be the first option to consider in a De Garengeot’s or in any other kind of complicated hernia. It allows an adequate exploration of the hernia sac and rapid action over its contents. Moreover, it permits the performance of a simple hernioplasty through a single incision. Besides, it does not require a high level technical skill and much experience to be executed correctly.Abdominal repair with or without prosthetic material is controversial, as the risk of mesh infection can cause great morbidity. Thus, up to two thirds of the surgeons perform anatomic repairs in these patients . It is cFor our patient, we decided on the open preperitoneal approach, which allowed us to perform a conventional open appendectomy followed by preperitoneal hernioplasty with prosthetic mesh in a quick and effective way.4De Garengeot’s hernia is an uncommon subtype of femoral hernia which can result in high morbidity if incorrectly managed. Preoperative diagnosis is often challenging and correct identification prior to surgery always necessitates imaging tests, among which the abdominal CT-scan shows the best results. Prompt surgical treatment should be performed to avoid further complications. In our opinion, the preperitoneal approach should be considered as the technique of choice for these patients. It enables a correct visualization of the hernia sac contents and simplifies the performance of surgical procedures such as intestinal resection or appendectomy. The placement of prosthetic material can be considered if there are no signs of abscess or local perforation. In any case, there currently exist a wide variety of surgical options for this particular entity, all of which have comparable results and a low rate of postoperative morbidity. For this reason, the surgeon should feel free to choose the surgical approach for each case, based on the pre- and intraoperative findings and his own experience.The authors received no financial support for the research, authorship, and/or publication of this article.Exception from ethical approval-case report only, consent from the patient provided at request.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.Dr. Bustamante Recuenco C.: study desing. Data analysis and interpretation, writing and submission of the paper.Sr. García-Quijada García J.: study desing. Data analysis and interpretation, writing and submission of the paper.Sr. Cendrero Martín M.: data analysis and interpretation, writing the paper.Sr. Serantes Gómez A.: interpretation of data.Sr. Sanz Muñoz P.: interpretation of data.Dr. Carabias Hernández A.: interpretation of data, writing the paper.Dr. Delgado Millán MA.: interpretation of data.Dr. Jover Navalon JM.: interpretation of data and submission of the paper.NA.Carabias Hernández A.Bustamante Recuenco C.García-Quijada García J.Jover Navalon JM.Not commissioned, externally peer-reviewed.The authors declare no conflict of interest.


Gastric schwannomas are an extremely rare presentation of mesenchymal tumors originating from Schwann cells, accounting for 0.2% of all gastric tumors. Patients are usually asymptomatic, so these tumors are frequently detected incidentally.68-year old male patient found to have a 5 cm mass in the lesser curvature of the stomach. After a careful preoperative evaluation, complete laparoscopic resection was performed. Pathology review confirmed a completely resected gastric Schwannoma. The patient’s recovery was uneventful. At a one-year follow-up he remains asymptomatic and with no evidence of disease.We present the uncommon case of a gastric schwannoma that was appropriately treated with a laparoscopic approach and present a current literature review focusing on diagnostic and treatment methods of these rare tumors.Schwannomas should be included in the differential diagnosis of gastric tumors and can be appropriately treated with a laparoscopic approach. Using the Surgical Case Report (SCARE) guidelines , we pres2A 68-year old male with a history of seminoma, currently with no evidence of disease, was referred to our surgical group after a routine check-up abdominal ultrasound (US) revealed a tumor in the lesser curvature of the stomach. An abdominal CT scan with oral and IV contrast confirmed a 5 cm homogenous mass in the lesser curvature of the stomach; there was no suspicious lymphadenopathy and no other suspicious lesions were identified. Patient was completely asymptomatic at the time, referring no weight loss, no changes in diet or appetite, as well as normal GI function. The patient’s case was discussed in a multidisciplinary tumor board and a laparoscopic resection was recommended .Fig. 1CTUnder general anesthesia, a laparoscopic exploration confirmed a 5 cm mass in the lesser curvature of the stomach, no suspicious lymphadenopathy and no other lesions were identified. An intraoperative upper GI endoscopy did not identify any other suspicious lesions on the upper GI tract. Using the laparoscopic technique, the gastroesophageal junction was retracted anteriorly and, using a harmonic scalpel, access to the lesser omentum was obtained. Using a 60 mm endoscopic stapler, the tumor was completely resected with 1.5 cm margins, and extracted with an endoscopic bag. Intraoperative pathology confirmed a spindle cell neoplasia with negative margins. A new upper GI endoscopy confirmed that the diameter of the gastric lumen had not been significantly reduced and that the staple line was airtight. No complications were reported. The patient was started on a soft diet the following day. His postoperative recovery was uneventful, and he was discharged home on postoperative day 3 , Fig. 4.The pathology report confirmed a 5.1 × 2.1 cm, lobulated, white-yellow tumor, with well-defined margins. In the immunohistochemical analysis, the tumor was positive for PS100 and SOX10, and negative for CD117 and DOG-1, confirming diagnosis of gastric schwannoma. The tumor was completely resected, and all margins were confirmed clear of tumor. At a one-year follow-up, the patient remains completely asymptomatic and a follow up CT shows no evidence of tumor recurrence.3Schwannomas are rare, benign mesenchymal tumors of the peripheral nerve sheath that arise from the Schwann cells; approximately 221 cases of gastric schwannomas have been reported worldwide . They ocSchwannomas can arise at any point of the GI tract, such as in the stomach, small intestine, colon, or rectum, ranging in sizes from 1 to 12 cm in diameter , and repGiven the fact that most gastric schwannomas are asymptomatic, the diagnosis can represent a challenge for the physician. Most gastric schwannomas are detected incidentally, usually as part of imaging studies performed for other reasons, such as a check-up, as in the patient currently presented. On computed tomography (CT), they tend to appear as homogenous masses, usually showing no signs of necrosis and do not tend to be associated with cystic changes or calcification. Approximately 75% of the masses appear lobulated [Histologically, gastric schwannomas, like GI leiomyomas and GISTs, are characterized by the presence of spindle cells, with wavy cigar shaped nuclei and collagen structures , which cThe definite diagnosis is established by anatomopathological and immunohistochemical analysis after the lesion has been removed . In ordeOnce the diagnosis has been established, surgical resection with clear margins remains the treatment of choice . Until nRecently, endoscopic submucosal resection and endoscopic full thickness resection have also been proposed as a non-invasive methods for treating these tumors . HoweverMost gastric schwannomas are located in the body of the stomach, and associated lymphadenopathy is not necessarily indicative of malignancy . GastricA comprehensive review of 137 cases of gastric schwannomas treated surgically yielded no cases of recurrence after a follow-up period ranging from 1 to 336 months . Therefo4Gastric Schwannomas are benign, slow-growing mesenchymal tumors. Although rare, they should be taken into consideration in the differential diagnosis of any gastric lesion. Definite diagnosis is established through pathological and immunohistochemical analysis. The treatment of choice remains surgical resection with clear margins. The laparoscopic approach is an excellent option for many of these patients. After an appropriate resection the prognosis is excellent, and recurrence is rare.None.Exception: Case report of interesting case encountered during normal medical practice.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.Fernando Cordera: treating physician, concept and design, data collection, writing.Andrea Salazar-Vitale: data collection, data analysis, writing.Estephany Mejía-Sánchez: data collection, writing.Rodrigo Arrangoiz: data collection, writing.David Caba-Molina: data analysis.Manuel Muñoz-Juárez: data analysis.Enrique Luque-de-León: data analysis.Eduardo Moreno: data analysis.N/A.Fernando Cordera.Not commissioned, externally peer-reviewed.None.


OKC) arising in the orbital floor, finding the common thread in rare pathology, and highlighting the aberration in our treatment plan by collating all the wealth of information published in the literature.The case illuminates the likelihood of a dental pathology presenting with discrete signs and symptoms and the importance of the differential diagnosis of some incongruent clinical entities. The purpose of this article was to present a case report of odontogenic keratocyst ( Physicians from other streams of medicine were unable to identify the source of pain. The ectopic tooth caused by odontogenic keratocyst (OKC) was enucleated with complete resolution of symptoms. We aim to capture the essence of current knowledge pertaining to OKC and discuss the location and recurrence rate with the treatment options available.Tooth development results from a complex array of interactions between the oral epithelium and the underlying mesenchymal tissue. A disruption in the tissue interactions during tooth development may potentially result in ectopic tooth development and eruption.Ectopic placement of third molars is relatively rare. Few anatomic sites where they can reside include the mandibular ramus, coronoid process, maxillary sinus, osteomeatal complex, sigmoid notch, and pterygomandibular space.Trauma, atypical eruption, irregular development of the tooth germ, and odontogenic pathologies are all theories that have been hypothesized. A handful of cases have been reported of tooth in the orbital floor caused by dentigerous cyst that expands the cortical plates may involve other teeth and cause destruction of tissues.The consensus opined the unremitting nature of a pathology to be categorized as neoplasm, which does not hold good in case of OKC. There is substantial evidence of complete regression of OKC following decompression and the lining of many decompressed cysts transform to normal oral mucosa than OKC histologically. Hence, the evidence to classify the cyst as neoplasm is currently lacking to justify the continuation of KCOT.The aim of this clinical report was to highlight the need for diligent clinical examination aided by mandatory investigations before we dismiss the source of pain as nonodontogenic.2A 22‐year‐old female patient reported to us with a vague pain on the left side of face which was throbbing in nature and radiating to the eye on the same side since 18 months. She was apparently in a good health and her medical history was unremarkable. She reported a transient diplopia in an upward gaze and epiphora occasionally. The epiphora could be ascribed to the tumor expansion causing compression of the nasolacrimal duct.3The term OKC, first introduced by Philipsen (1956), reflects its histogenesis as well as the characteristics of its keratinized lining epithelium, which is clearly discernible from other odontogenic cyst types. Its high recurrence rate and association with the nevoid basal cell carcinoma syndrome (NBCCS) seat OKC up in the pyramid of aggressive odontogenic lesions.Odontogenic keratocyst is a cystic lesion of odontogenic origin that demonstrates the behavioral characteristics of a benign neoplasm and has a propensity to recur after surgical treatment.Odontogenic keratocysts have distinctive histologic feature that can distinguish them from other cysts. It is characterized by a uniform epithelial layer that lacks rete ridges. In addition, it has a corrugated parakeratinized luminal layer and a prominent basal cell layer. OKCs have a high recurrence rate and develop more aggressively than any other jaw cysts.Odontogenic keratocyst may develop at any age, but presents most commonly in the second or third decade of life, usually in males. Multiple OKC may be associated with Gorlin's syndrome . An OKC usually presents as an asymptomatic or painful mass of the posterior mandible or maxilla. Alternatively, it may be discovered on routine radiographic examination as a unilocular or multilocular lytic lesion with well‐defined, scalloped, and sclerotic borders. The average diameter of an OKC is 20 mm with a range of 5‐70 mm. It may displace the roots of teeth, extend into the maxillary antrum, or result in pathologic fractures of the mandible.The incidence of OKC fortunately in the maxilla is very less compared to the mandible. , iatrogenic or can be one of the covert manifestations of aggressive odontogenic cyst and tumors. The other etiological factors that can push the tooth include developmental disorders such as cleft palate, trauma, infection, crowding, genetic factors, and high bone density.Individuals afflicted with nevoid basal cell carcinoma syndrome are young with multiple lesions which were absent in our case. Recurrences are higher with nevoid basal cell carcinoma syndrome, approximately 50% and with OKC diagnosed in second and eighth decade. Patients may seek care for maxillary lesions at an advanced stage because of its ability to spread to other structures such as the sinus with no remarkable symptoms leading to a higher recurrence rate and requiring more aggressive management.Myriad treatments are available Table  to enablThe recurrence rate associated with enucleation with adjunctive therapy such as cryosurgery and decompression (1‐8 percent) is lower than that associated with enucleation alone (17‐56 percent).4In conclusion, ectopic tooth in the floor of the orbit caused by an OKC is extremely rare. Third molar is the commonest tooth involved; also being the last tooth to erupt in the oral cavity is more likely to be displaced while competing for space. Clinicians need to be cognizant of missing tooth associated with hidden pathologies and its remote location far off from the dentoalveolar apparatus. A diligent clinical and radiographic evaluation, inclusive of few unusual locations, should be undertaken before dismissing teeth as being avulsed or congenitally missing.None declared.PS, SS, NA, and PS: operated the case, acquired the data, and prepared the manuscript. PS and SS: defined the intellectual content. PS, SS, and NA: involved in literature search and reviewed the manuscript. SS and NA: edited the manuscript.


Hemangiomas are benign tumors usually found in the lower extremity yet their surgical management on the location in the foot is rarely documented.We report a case of a plantar intramuscular hemangioma in 25-year-old patient with a history of percutaneous therapy. Patient had undergone intralesional sclerotherapy 3 years prior to his admission with persistent pain on weight bearing activities.MRI demonstrated a multi lobulated lesion of the 1st IMS with a peripheral enhancement on gadolinium injection. The patient underwent elective surgery with complete excision and no functional impairment at the last follow-up 3 years after surgery.Intramuscular hemangiomas are rare occurrences. Steroid injection and sclerotherapy are effective non-operative methods. Complete excision of isolated hemangioma lesions allows definite diagnosis with no recurrence. Intramuscular hemangiomas (IMH) are benign neoplasms accounting for less than 1% of all hemangiomas . Foot loThe patient is a 24-year-old male with no prior trauma who presented with a 7 year history of forefoot pain placed on several over-the-counter drugs and other conservative treatments including percutaneous therapy. The patient recalled steroid injection and intralesional sclerotherapy three years prior to her admission with no relief. Physical examination demonstrated a firm mass on the plantar surface of the first intermetatarsal space (IMS) without motor nor sensory deficit. Vascular examination was unremarkable.Plain x-ray demonstrated a soft tissue widening of the 1st IMS with phleboliths Fig. .Fig. 1PlThe patient underwent surgery after written and informed consent was obtained. A plantar longitudinal approach across the 1st interosseous metatarsal space was undertaken. After careful dissection, an intramuscular tumor taking up the interosseous muscles was excised. Fig. . ImmediaIntramuscular hemangioma or angioma (IMH) is a benign vascular neoplasm of the skeletal muscle. It occurs in young adults before the third decade with a slight feminine predominance observed in most cases  .MalignaAlthough its pathogenesis still remains unclear, a congenital origin is often suggested  and a hiA palpable mass is found on physical examination at time of diagnosis in 98% of reported cases [Plantar intramuscular hemangiomas are seldom reported in literature. Wisniewski et al.  reportedPlain films may reveal phleboliths that are round lumps of calcifications primarily due to thrombosis within the lesion . MRI is Surgical excision is the mainstay treatment  as it alCompressive sclerotherapy, using a variety of products, radiotherapy and laser ablation have also been suggested as treatment options in large diffuse hemangiomas where excision is impractical. Uslu et al.  demonstrIMH are rare benign tumors that do not undergo spontaneous regression. Plantar IMH are nuisance to weight bearing activities and their management could cause a therapeutic dilemma. This case report demonstrates a unique presentation of intramuscular hemangioma due to its localization. The hemangioma was surgically excised with no recurrence or functional impairment of the foot.


It is a tumor with intermediate malignancy potential, good prognosis after complete resection, slow growth, very high risk of local recurrence, but with low metastatic potential. Due to its rarity, very few studies have been devoted to it. We report an exceptional localization revealed by a mass in the breast. It is a 43-year-old patient who has consulted for an increase in the volume of the right breast, the clinical examination finds a mass ulcero-budding of 12cm/10cm. The biopsy shows the presence of a histiocytofibroma, a mastectomy was performed, and the histopathological examination with immunohistochemistry showed an intense and diffuse CD34 positivity, a focal positivity of AML (smooth muscle actin) and a constant negativity of desmin and PS100 thus confirming that it is a DFS. CT scan does not find any metastasis and a surveillance was adopted. It is a rare tumor and our observation is among of the first cases of mammary siege described in the literature. The main treatment remains a large surgery with margins of resection of at least 4 to 5cm, postoperative radiotherapy is advocated by second recurrence. Systemic chemotherapy is not recommended, rigorous clinical practice must be maintained, because of slow evolution and high recurrence of this tumor.Darier and Ferrand dermatofibrosarcoma (DFS) is a cutaneous mesenchymal tumor, rare, representing 0.1% of malignant skin tumors and less than 5% of adult soft tissue sarcomas. The favorite sites are the trunk, followed by the extremities proximal then the head and neck. It often occurs in patients in their 3