Chiropractors are primary healthcare providers who diagnose and manage various health conditions, including rare cases like desmoid tumors. Desmoid tumors are locally aggressive soft-tissue tumors originating from fibroblasts. This report presents the case of a 30-year-old woman who initially sought chiropractic care for persistent neck pain that was later discovered to be a symptom of a sporadic desmoid tumor. The patient presented with severe right upper neck pain, which was diagnosed as myofascial pain syndrome and yielded no significant improvement after various treatments. Physical examination by a chiropractor revealed a soft-tissue mass in the right upper trapezius and rhomboid region. In addition, magnetic resonance imaging revealed an intramuscular lesion measuring 8 × 4 cm in the right rhomboids, and subsequent biopsy confirmed the diagnosis of a sporadic desmoid tumor. The patient underwent successful surgical excision of the tumor. Postoperatively, the chiropractor initiated a comprehensive 12-week rehabilitation program that significantly improved the patient's range of motion and muscular strength and alleviated pain. The remarkable aspect of this case was the location of the tumor in the right rhomboid muscle, a less common site for desmoid tumors. This case underscores the crucial role of chiropractors as primary healthcare providers in the early detection of oncological cases and management of post-surgical rehabilitation. As primary healthcare providers, chiropractors play a significant role in diagnosing and managing various health conditions . Their cDesmoid tumors are rare, soft-tissue tumors that originate from fibroblasts and exhibit a locally aggressive behavior . AlthougThis case report presents a novel example of a chiropractor playing a crucial role in the initial detection and subsequent management of a sporadic desmoid tumor in a patient presenting with severe, persistent neck pain. This report highlights the significant role played by chiropractors in the early detection of oncological conditions and their critical involvement in the management and post-surgical rehabilitation of such patients.A 30-year-old woman presented to the chiropractic clinic with a chief complaint of right upper neck pain rated 8/10 on a numeric pain scale. She described the pain as a spasm in the right upper trapezius that radiated to her upper neck, midback, suboccipital region, and collar bone on the same side. The patient had been experiencing this pain for the past three years, with a strong exacerbation for a week, leading to decreased cervical range of motion, particularly affecting neck extension. The pain interfered with her daily activities and sleep. There was no significant family history or genetic predisposition to oncological conditions. The patient's psychosocial history was unremarkable. Her quality of life was rated as 72% based on the World Health Organization Quality of Life score (WHOQOL-BREF).Before her visit to the chiropractic clinic, an orthopedic surgeon performed cervical radiography, which showed no abnormalities Figure . The patOn physical examination, the chiropractor did not observe any visible abnormalities or asymmetries in the cervical and thoracic regions. The range of motion was restricted to the cervical and thoracic regions, particularly during extension, right lateral flexion, and rotation. Right arm abduction was rated 4/5 without any other motor or sensory deficits or signs of muscle atrophy or weakness. However, a soft-tissue mass with localized tenderness and mild swelling was detected in the right upper trapezius and rhomboid regions.Due to persistent pain and the detected mass, the chiropractor prescribed a magnetic resonance imaging (MRI) scan for the upper back region, which revealed the presence of an intramuscular lesion of 8 × 4 cm. This lesion was found to penetrate the cervical area of the right rhomboid muscle, without any involvement of the superficial subcutaneous tissues or the skin Figure . DetectiAn incisional biopsy was performed by an oncologist in the same clinic, who established the diagnosis of a sporadic desmoid tumor. The prognostic characteristics of desmoid tumors depend on their size, location, and growth rate. Although benign, they can cause significant morbidity owing to local invasion and potential recurrence.The chiropractor and the affiliated surgeon engaged in a discussion over the potential option of adopting a vigilant approach to monitoring the patient's condition before contemplating surgical intervention. Nevertheless, the patient made the decision to have surgical intervention, a choice that was deemed rational in light of the symptoms she was presenting. The oncologist and associated surgeon successfully excised the sporadic desmoid tumor in the right rhomboid region, ensuring complete removal with clear margins to minimize the risk of recurrence.Postoperatively, the patient was referred back to the chiropractor to initiate a comprehensive 12-week rehabilitation program. The program aimed to restore her full range of motion, improve muscular strength and endurance, and alleviate any residual pain or discomfort. Throughout the postoperative rehabilitation process, the patient attended regular follow-up appointments with the chiropractor to monitor her progress and adjust her exercise program, as needed.At the end of the 12-week rehabilitation program, the patient reported significant improvements in her range of motion, muscular strength, and overall function. The chiropractor also utilized manual therapy techniques, such as joint mobilization, instrument-assisted soft-tissue mobilization, and soft-tissue release, to complement the exercise program and further facilitate patient recovery. Her pain score decreased from 8/10 to 1/10 on the numeric pain scale. Her quality of life rating improved to 100%, and she adhered well to the therapeutic interventions and reported no adverse or unanticipated events. The patient was advised to continue a maintenance exercise program and follow-up with her chiropractor and oncologist, as needed, to monitor her long-term recovery and ensure the absence of tumor recurrence.Desmoid tumors are rare benign tumors with an incidence of three to five cases per million people per year . These tIn this case report, we highlight the pivotal role that a chiropractor can play in the early detection of rare oncological conditions, such as desmoid tumors, and in patient management during postoperative rehabilitation. The patient initially sought chiropractic treatment for persistent neck pain, a common complaint in the field. However, the chiropractor’s keen clinical judgment uncovered an uncommon pathology. This emphasizes the importance of thorough physical examinations by chiropractors as primary healthcare providers and their ability to manage a wide spectrum of health conditions, including rare oncological cases.A remarkable aspect of this case was the chiropractor’s insightful recommendation of an MRI, despite the patient's prior diagnosis of myofascial pain syndrome. This critical step led to the detection of the desmoid tumor, highlighting the significance of maintaining a high level of suspicion when dealing with persistent or unusual symptoms. However, the rarity and atypical presentation of desmoid tumors present a diagnostic challenge, possibly leading to delayed detection and management. The uniqueness of the patient's presentation and rarity of the condition may limit the generalizability of this case.Although no specific treatment for desmoid tumors has been approved, current guidelines suggest several options, such as active surveillance, surgery, systemic therapy, and locoregional therapy . TreatmeThis case report underscores the vital role of chiropractors in the early detection of oncological conditions and their significant contribution to managing and rehabilitating patients postoperatively. This serves as a reminder to chiropractors to be vigilant when faced with persistent and nonresponsive symptoms.This case report illuminates the multifaceted role of chiropractors as a part of an interdisciplinary healthcare team. It underscores how vigilant assessment and clinical judgement can lead to the detection of rare and unusual pathologies, such as desmoid tumors. The case also emphasizes the importance of maintaining a high level of suspicion for atypical presentations, especially in patients with persistent, non-responsive symptoms. Furthermore, the successful postoperative rehabilitation managed by the chiropractor demonstrates the significance of comprehensive, holistic patient care. This case serves as a reminder of the potential impact chiropractic care can have on patient health outcomes and reinforces the need for ongoing research into rare conditions, such as desmoid tumors, to improve their diagnosis and treatment.


Xanthomas are well-circumscribed benign proliferative lesions seen mainly in soft tissues. Usually, they are found in hyperlipidemia and familial hyperlipoproteinemia. Histologically, are characterized by macrophage-like mononuclear cells, multinucleated giant cells and abundant foam cells. The bone involvement, however, is notoriously rare and rib localization is extremely rare.A 55-year-old man performed a chest X-ray and a subsequent chest Computed Tomography scan showing a rib lesion that was surgically removed and a diagnosis of rib xanthoma was made. The patient presented an unknown condition of hyperlipidemia.Rib xanthoma can be discovered accidentally and can be helpful in identifying an unrecognized condition of hyperlipidemia. Xanthomas (or Xanthofibromas) are well-circumscribed benign proliferative lesions seen mainly in soft tissues such as skin, tendons, fasciae and occasionally in the periosteum. On physical examination, they appear as semi-solid areas such as macules or papules or large nodules, generally yellow (Greek xanthos = yellow), due to the presence of carotene contained in the lipids .Histologically, they are characterized by macrophage-like mononuclear cells, multinucleated giant cells, and abundant foam cells formed by macrophages because of the gradual intracellular accumulation of lipids captured by specific receptors or by the mechanism of phagocytosis .Recently, their interest has increased for three reasons: the mechanisms involved in the development of these pathological lesions appear to be similar to those involved in the early stages of atherosclerotic plaques ; their dBone xanthoma is rare  appearinA 55-year-old man with depressive disorders and grade I obesity performed clinical and radiological exams at the Department of Urology to undergo a biopsy of prostatic lesion, suspected for adenoma. A preoperative chest X-ray showed an indefinite opacity in the left anterior arch of the 6th rib Fig. a, b. A cIn the suspicion of a primary bone tumor a 99m-technetium hydroxydiphosphonate (99m-Tc HDP) bone scan Fig. d was perThe patient had no previous history of chest pain, trauma or cardiovascular disease. On physical examination, no further lesions appeared. Routine laboratory tests, including blood count and C-reactive protein, were normal.After a multidisciplinary consultation with oncologists and radiotherapists and the placement of a CT-guided percutaneous marker Fig.  the lesiOn gross, a nodular, well defined, yellowish lesion, centred in bone marrow and measured cm 1, 5 was evident Fig. . HistoloDue to the histological findings and suspecting an unknown hyperlipidemia, the lipid panel was performed showing hypercholesterolemia (345 mg/dl) and hypertriglyceridemia (589 mg/dl). The patient had never performed these laboratory tests before.He also performed a color-Doppler Ultrasound of the supra-aortic vessels showing the presence of atherosclerotic plaques. He was referred to a family physician, began lipid-lowering therapy with statin drugs and a low-calorie diet. During the follow-up, the patient had lost weight, blood tests showed a reduction in lipid levels and no recurrences of xanthoma.Xanthomatous lesions of skin, blood vessels, abdominal viscera, and reticuloendothelial organs occur commonly as a complication of hyperlipidemic states. Mainly, they appear in male and obese patients in whom the lipids form deposits in soft tissue. Usually, they are found in hyperlipidemia and familial hyperlipoproteinemia, but only few have been seen in its absence .The bone involvement, however, is notoriously rare. Generally, the most frequent localizations are the diaphysis of long bones, especially the tibia, but also the skull may also be included as mastoid air cells –10, mandXanthomas can be discovered accidentally or more commonly due to the appearance of pathological fractures and stinging pain. Sometimes patients may also have soft tissue involvement.These tumors are described radiographically as sharply defined, lytic lesion with an expansible border that can often extend into the surrounding soft tissue , which iBone scintigraphy allows for mapping of the lesions and post-therapy follow-up . TherefoXanthomatous variant xanthomatous changes in advanced stage of skeletal benign or malignant pre-existing lesions;Secondary xanthoma forms in the skeletal system of type-2 and 3 hyperlipidemic patients;Primary xanthoma with normal lipid metabolismBased on the mode of onset and the contextual state of hyperlipidemia, it’s possible to classify bone xanthoma as reported:This classification may be helpful to allow diagnosis and treatment –21.Xanthoma of rib is an exceptional localization and has been previously described in other nine cases as a condition frequently associated with thoracic trauma Table .Table 1SBertoni et al.  had idenWe have reported a case of Rib Xanthoma. However, it has some difference from the aforementioned cases. The patient had no history of chest pain or thoracic trauma. On physical examination, no other xanthomas were present. The radiological finding was very ambiguous, due to the prostatic lesion, and was suspected to be a bone metastasis. We decided to surgically remove the lesion with limited resection. After receiving the histological diagnosis, the patient performed a lipid panel which showed a hyperlipidemia’s disease. The patient had not performed these investigations for years and, due to depressive disorder and sedentary lifestyle, he had gained weight.In conclusion, the xanthoma can represent an alarm signal of hyperlipidemia disease and atherosclerotic plaques of main vessels and its accidentally discovery can prevent the occurrence of cardiovascular disease.


Colonic lipomas are rare benign submucosal tumors that are mostly asymptomatic. With increasing size, they may develop symptoms and complications. The acute presentation may be intestinal obstruction secondary to intussusception or gastrointestinal bleeding. The chronic presentation may be subtle and mimic a colonic malignancy. Symptoms include altered bowel habits, abdominal pain, lower gastrointestinal bleeding, and weight loss. Diagnostic evaluation includes advanced imaging such as Computed Tomography, Magnetic Resonance Imaging, and Endoscopy. With the advent of endoscopic submucosal dissection techniques, the therapeutic capabilities of endoscopy have expanded over the decade. However, surgical interventions were reserved for large, symptomatic lipomas, and resection varies from segmental colonic resection to hemicolectomy. Size and clinical presentation determine the therapeutic approach. We, with this, report two cases of giant colonic lipoma in the right colon causing a colo-colic intussusception. Lipomas in the gastrointestinal tract are uncommon and can occur anywhere along its length. In the large intestine, their incidence ranges from 0.2% to 4.4%. Gould et al. stated that they usually occur in the fifth decade of life and affect women more than men . The comCase 1A 45-year-old female presented with complaints of right-side lower abdominal pain, abdominal distention, and intermittent episodes of vomiting for 15 days. She was able to tolerate liquids only. She underwent imaging, given her alarming symptoms. Her CT scan . The sensitivity of a CT scan to diagnose intussusception is 71.4%-87.5%, and its specificity is 100% in adults. Intussuscepted lipomas may not demonstrate normal fat attenuation and may have a heterogeneous appearance reflecting the degree of infarction and fat necrosis, leading to a diagnostic dilemma. Magnetic resonance imaging is an alternative in the diagnosis, which shows a signal intensity characteristic of adipose tissue on T1 weighted and fat suppression images . Barium Colonoscopy is mandatory for diagnosis and therapeutic for colonic lipomas less than 2cm. Lipomas appear as a well-delineated, soft, sessile, or pedunculated mass in a colonoscopy. Sometimes ulceration and erythema can be seen on the mucosa, giving the impression of a malignancy. The three critical endoscopic signs of colonic lipoma are the 'cushion sign' (probing the polyp with a closed biopsy forceps will often yield a pillow-like indentation), 'tenting effect' (grasping the overlying mucosa with biopsy forceps presents a tent-like appearance), and the 'naked fat sign' (biopsies may result in extrusion of yellowish fat). Endoscopic ultrasound helps differentiate a lipoma from other submucosal lesions like schwannoma and leiomyoma. Extension of the lesion into the deeper of the submucosa can also be detected by endoscopic ultrasound .Endoscopic resections like Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Resection (ESD) have expanded the size criterion. Endoscopic deroofing has also been reported, allowing spontaneous lipoma expulsion just by deroofing the mucosa over the summit . ApplicaColon lipomas >2 cm are considered for surgery due to the high risk of complications, such as bleeding and perforation with endoscopic resection. Surgery is the mainstay of treatment for lipomas causing complications, those with increased risk for endoscopic resections and suspicion of malignancy. Standard colonic resections are preferred over segmental colonic resections. Standard hemicolectomy is more standardized and practiced more frequently. Segmental colonic resections have fallen out of favor because the colonic blood supply is variable. Owing to the sparse blood supply in the watershed areas of the colon, segmental colectomy has a high chance of anastomotic leaks due to postoperative ischemia. It is not recommended to deviate from the standard procedure, i.e., hemicolectomy . We suggest a D2 lymphadenectomy if there are doubts about diagnosis in emergencies where colonoscopy was not feasible. One such scenario is an intussuscepting giant lipoma with heterogeneous imaging features wherein a colonoscopy was deferred because of acute presentation.Postoperative complications, like intra-abdominal abscesses, postoperative ileus, wound infection, and respiratory failure occur more often following open procedures. Postoperative chronic pain is less likely to occur in patients undergoing laparoscopic resection than those undergoing open laparotomy . The surColonic lipomas, greater than 2 cm in size, may present with symptoms. CT, MRI, and colonoscopy aid in the diagnosis of colonic lipomas. Endoscopic resection is the preferred method for treating both incidental and symptomatic lipomas, but there are limitations. Surgery remains the choice of treatment for lipomas having acute presentations. Based on imaging findings, an appropriate lymphadenectomy may be included when there is suspicion of malignancy in acute presentation.


Rosai-Dorfman disease (RDD) is a rare histiocytic disorder that can present with painless bilateral symmetrical cervical lymphadenopathy, mimicking lymphomas. RDD is characterized by excessive tissue infiltration by dendritic cells, macrophages, or monocyte-derived cells, with a histopathologic diagnosis based on the presence of CD68+, CD163+, and S100+ histiocytes, which differentiate it from other histiocytic neoplasms. In this case report, we present a young Hispanic female with recurrent subcutaneous growths and lymphadenopathy, initially thought to be lymphoma, who was diagnosed with RDD after a significant diagnostic workup. Treatment initially consisted of surgical excision; however, due to recurrence, the patient was successfully treated with corticosteroids and a steroid-sparing agent, 6-mercaptopurine, with significant improvement in symptoms. RDD should be considered a differential diagnosis for patients with cervical lymphadenopathy, and an interdisciplinary approach is essential to managing this rare disorder effectively. The report highlights the need for an interdisciplinary approach to managing this rare disorder effectively and underscores the importance of multimodal treatment in disease suppression. As a rare disease with slow advancement of defined guidelines for diagnostic and treatment strategies, this case report adds to the existing literature on RDD. Rosai-Dorfman disease (RDD), also known as Rosai-Dorfman-Destombes syndrome, is a rare histiocytosis disorder of sinus histiocytosis with massive lymphadenopathy with 1:200000 prevalence and estimated 100 new cases reported yearly in the United States [We present a case of a young Hispanic female who presented with recurrent subcutaneous growths in the neck and lymphadenopathy, which was initially believed to be lymphoma. After a significant diagnostic workup, the patient was diagnosed with Rosai-Dorfman syndrome. Treatment initially consisted of surgical excision; however, due to recurrence, the patient was successfully treated with corticosteroids and a steroid-sparing agent with significant improvement of symptoms. This case report highlights the importance of multimodal treatment in disease suppression in patients with RDD.The patient is a 40-year-old Hispanic lady who presented to the rheumatology clinic referred by her otolaryngologist (ENT) for complaints of recurrent right-sided neck mass growth. The first time she noticed the growth was in 2010 when she felt a small bump growing on the right side of her neck. At that time, she had a surgical excision in Mexico and had a repeat excision due to recurrence a few years later. The patient reported that her excisional biopsies were benign, requiring no further treatment or follow-up. However, 10 years later, she started noticing regrowth of the mass at the same site with a progressive increase in size. Because of the rapid progression of the mass, the diagnosis of lymphoma was entertained, and the patient was subsequently referred to an ENT. Computerized tomography (CT) of the chest/neck with contrast revealed asymmetric left axillary adenopathy, largest in the left deep axillary region extending slightly subpectoral, measuring up to 3.9 × 1.6 cm, and severe bilateral neck lymphadenopathy most prominent on the right , and pathology results revealed a benign heterogeneous population of small- to medium-sized lymphocytes, without findings of malignant cells. The patient underwent an excisional biopsy of the enlarged right lymph node to completely rule out Hodgkin’s lymphoma. Her biopsy reports of lymph node sections showed a paracortical expansion associated with sinus histiocytosis. An immunohistochemical panel of stains showed CD45 that highlights the lymphocytic milieu of the lymph node; B cells highlighted in a cortical and follicular pattern by CD20, PAX5, BOB1, and OCT2; a minor subset of B cells highlighted by MUM1 in a paracortical distribution; T cells highlighted in a paracortical distribution by CD3, CD5, and CD43; sinus histiocytes highlighted by BCL1 (cyclin D1), CD68, CD163, S100, and OCT2; lymphocytes highlighted by Ki-67 in a paracortical distribution pattern; and CD15 and CD30 highlighted nonspecifically in a paracortical pattern and negative for AE1/AE3, EMA, and CD1a , and she was diagnosed with RDD. The case was discussed in the tumor board, the decision was taken for the patient to be started on oral steroid prednisone, and the patient was referred to rheumatology for medical treatment in the setting of recurrent tumor growth despite excisions. While awaiting her rheumatology appointment, she was noted to have an improvement in size with steroids and was tapered down the regimen; however, she developed rapid regrowth of the mass. She had no associated symptoms, fever, chills, visual changes, ear discomfort, dysphagia, night sweats, weight loss, joint pain, Raynaud's phenomenon, photosensitivity, malar rash, discoid lesions, vasculitic lesions, livedo reticularis, oral ulcers, sicca, and subcutaneous nodules. Her physical examination revealed vital signs within normal limits and a 7 × 5 cm mass at the right cervical region extending to the postauricular region  activity came back normal, and she was seen with an excellent clinical response to the steroids in two weeks. She was started on a tapering regimen for steroids along with steroid-sparing agent 6-mercaptopurine 50 mg daily, as the total duration of treatment is 12-16 weeks.RDD is a rare medical disorder with a prevalence of 1:200000 initially described in 1965 by a French pathologist, Pierre-Paul Louis Lucien Destombes, and four years later by Rosai and Dorfman in 1969, as sinus histiocytosis with massive lymphadenopathy .Our patient’s presentation was consistent with the nodal disease. The etiology of RDD is still unclear; it is reported to be associated with some autoimmune diseases, various viral infections, and Hodgkin’s lymphoma, which can precede or follow the diagnosis as initiation triggers. There have been many advancements in research studies in other histiocytic disorders; however, clinical spectrum and treatment methods have yet to be well-defined for RDD due to the rarity of the disease. The latest studies have identified NRAS, KRAS, MAP2K1, and ARAF mutations in patients with features of RDD; however, further research studies need to be done . It is cA comprehensive evaluation for RDD should also include assessing IgG4 levels and the IgG4/IgG ratio, since some RDD patients have elevated serum IgG4 levels and the presence of IgG4-positive plasma cells in lymph nodes and tissues . DiagnosIn the literature, it can be seen that RDD is a benign but progressive disease, with 20-50% of nodal presentations having spontaneous remissions. Treatment strategies are usually individualized on a case-to-case basis. Surgical resection is usually preferred for unifocal disease or for debulking in case of complicated presentations causing compressive symptoms . In our trials.gov.This brings us to the discussion on treatment options when it comes to recurrence. Immunosuppressive therapy with steroids has been shown effective in a few studies for size reduction and symptom management. However, the duration and dose of therapy are not well defined. In a study done among 64 patients in a tertiary referral center over 23 years 1994-2017) by Goyal et al., cladribine showed a high overall response rate . Further94-2017 bIn conclusion, this case report on RDD emphasizes the importance of a diagnostic strategy for RDD, differentiates it from malignant lymphoma, and discusses available treatment options for refractory or recurrent presentations.RDD is a rare histiocytic disorder characterized by excessive tissue infiltration by dendritic cells, macrophages, or monocyte-derived cells. The presented case highlights the challenges of diagnosing RDD, the initial misdiagnosis, and the successful treatment with corticosteroids and 6-mercaptopurine after surgical excision. Considering the rarity of the disease and slower advancement regarding defined guidelines for diagnostic and treatment strategies, we hope the case report can add to the existing literature.


Odontogenic keratocyst has been of particular interest due to its distinctive behavior and its tendency to frequently recurrence and the diversity of treatment methods. Researchers have differed over the past decades about the nature of this lesion, sometimes it was classified as a cyst and sometimes it was classified as a tumor because of its specific histopathologic features, high recurrence rate and aggressive behavior. We discuss a case of a large odontogenic keratocyst (OKC) that was treated by marsupialization followed by peripheral ostectomy. Based on our findings, we conclude that the marsupialization followed by peripheral ostectomy was a conservative and effective option for the management of large OKC. The first description of odontogenic keratocyst (OKC) was published in 1956 by Philipsen. The lesion has been of particular interest because of its specific histopathologic features, high recurrence rate and aggressive behavior [This lesion was excluded in 2005 from the WHO classification of the odontogenic cysts, and it was classified as a neoplasm and was called keratocystic odontogenic tumor (KCOT) .Several options are available for the treatment of OKC depending on several factors. These options include: enucleation, curettage, resection and marsupialization. The resection and enucleation are considered invasive surgical procedures, but they are the most common treatments . The marThe marsupialization was first described by Partsch for the cystic lesions of the jaws . The priPeripheral ostectomy is a technique that involves enucleation of the lesion with peripheral bone removal using rotary instruments .We discuss a case of a large OKC that was treated by marsupialization followed by peripheral ostectomy.A 22-year-old male patient presented to the Oral and Maxillofacial Surgery Department at Tishreen University Hospital with chief complaints, recurrent fistula at the right retromolar area and clear yellow liquid discharge intraorally from the fistula 1 year ago. The patient was recommended an Orthopantomogram (OPG) which showed radiolucent lesion, including most of the right ramus area . ComputeUnder general anesthesia, an incision was made around the fistula to remove the overlying mucosa and expose the lesion. A 1 cm size window was made into the cyst cavity . The cysAfter 12 months, the second stage was performed to remove the lesion . Under g. However, reclassification of these lesions as odontogenic cysts in 2017 is due to new evidence regarding their behavior and histological composition especially that they tend to regress after decompression.A major shift occurred in our understanding and management of keratinous cysts in 2005 when they were classified as tumorsIn recent years, many scientific papers have been published on the efficacy of the marsupialization for the treatment of various types of cystic lesions in the oral region , 8, and Several studies have shown that the rate of recurrence of keratinized cysts is the highest when the lesion is managed by enucleation alone, but it is the most common surgical option for the treatment of OKCs in literature . The lowMarsupialization are currently considered as non-definitive therapies in KCOT treatment by the majority of authors due to the odontogenic epithelium remains in the cyst cavity . Marsupiet al. [Simple enucleation differs from enucleation with peripheral ostectomy in that the enucleation with peripheral ostectomy is followed by the removal of 1.5–2 mm of bone with a handpiece in KCOT margins . Severalet al.  reportedBased on our findings with the limitations of our case report, we concluded that the marsupialization followed by peripheral ostectomy was a conservative and effective option for the treatment of large OKC. No postoperative complications and no recurrence were observed after 36 months.


An oral fibroma is a benign scar-like reaction frequently resulting from chronic mouth irritation. It is also called an oral polyp, fibrous nodule, localised intraoral fibrous hyperplasia, and traumatic fibroma. Chronic irritation from things like biting one's lips or cheek, orthodontic treatments, rubbing against a hard tooth, or wearing dentures or other dental prostheses is frequently the cause. It is often the same colour as the surrounding mouth lining, but occasionally, it can be paler or appear darker if it has bled. Trauma can cause the surface to become rough and scaly or ulcerated. It is primarily dome-shaped and similar to a pedunculated polyp. A traumatic fibroma most frequently occurs on the inside of the cheek. The inside of the lower lip, the gingiva, and the sides of the tongue are other frequent locations. The given case series reported traumatic fibroma associated with anterior teeth and buccal mucosa treated with a conventional scalpel and diode laser techniques, respectively. Diagnosing and treating the aetiology and educating the patient about the same is essential in fibroma cases. The clinical features of both claims and mere aetiology confirmed the diagnosis. The sole option available when therapy is needed is a surgical fibroma excision. Surgical excision is the most popular method for treating oral or traumatic fibromas. Two ways are available for the surgical removal of an oral fibroma: with a scalpel or using a diode laser. Both case presentations demonstrate that surgical excision with a scalpel and diode laser was discovered to be a simple, efficient, and affordable method for treating traumatic fibroma in this report, which presents two traumatic fibromas with different locations with varying aetiology. Traumatic fibromas reported here were in the aesthetic zones, which need to be treated as they can cause traumatic occlusion and difficulty chewing and speech. The patients reviewed for the next three months revealed complete satisfactory healing and no recurrence in both cases. Traumatic fibroma is the most common benign lesion of the oral mucosa. In 1967, Barker and Lucas established criteria for identifying true fibromas. It is also known as a traumatic fibroma, focal intraoral fibrous hyperplasia, fibrous nodule or oral polyp, or irritational fibroma. They mainly arise from the gingival connective tissue or periodontal ligament . FibromaThis report involves two cases of traumatic fibroma associated with the maxillary anterior region and buccal mucosa, which were treated with surgical intervention and reported with aesthetic concern and functionality issues during speech and mastication.Case 1A 22-year-old female patient reported to the department of periodontics with the chief complaint of gingival swelling in the upper anterior region for two months, approximately 6 mm to 8 mm. Initially, it was small but progressed later. No significant medical history or dental history was present. Considering a history of calculus deposits and traumatic occlusion, the diagnosis of traumatic gingival fibroma was obtained. The lesion was present on the anterior maxillary teeth between the two maxillary central incisors, which was a painless, round, and oval swelling with a broad base and darker colour than the surrounding tissue, as shown in Figure Differential diagnoses included fibroma, lipoma, mucocele, and neurofibroma. A provisional diagnosis of traumatic fibroma was obtained based on clinical evidence and patient history. The patient was advised for the surgical removal of the lesion. Routine haematological tests, such as haemoglobin, bleeding and clotting time, and random blood sugar level, revealed test results within normal ranges. Scaling and oral hygiene maintenance counselling were performed before surgical intervention. Informed written consent was obtained. Under all aseptic conditions, precautions, and local anaesthesia, the surgical excision was done using a scalpel, as appreciated in Figure An excised lesion specimen was sent for histopathological examination, confirming the diagnosis. Postoperative instructions were given to the patient. The patient was recalled for follow-up evaluation after seven days and three months post-operatively. After seven days, the patient was re-evaluated, which revealed complete recovery and satisfactory healing of the traumatic fibroma lesion, as shown in Figure Case 2A 26-year-old male patient reported to the periodontics department with a chief complaint of soft tissue growth over the right buccal mucosa of the mouth. Considering the clinical history and examination, the diagnosis of traumatic fibroma was framed. The lesion occurred six months back. Since then, it has been present in the mouth. Initially, it was small, pedunculated, stalk-like, and firm, and gradually increased with no history of bleeding pain. The patient had a history of traumatic biting due to orthodontic treatment nine months prior, and the main aetiologic factor for the same was orthodontic bands and brackets. The overlying mucosa was normal in colour, with no evidence of ulceration. The growth was soft in consistency, sessile, and non-tender, as shown in Figure The lesion was 5 mm wide and 9 mm long. The patient was informed about the surgical procedure and written consent was obtained. Under local anaesthesia and by maintaining proper laser safety protocol, surgical lesion removal was done using a diode laser with a wavelength of 880 nm. Figure The excised specimen on histopathological examination confirmed the diagnosis. The patient was recalled seven days after surgery, which revealed complete satisfactory wound healing and no scar formation, as seen in Figure Various pathological processes can cause tissue enlargement in the oral cavity, leading to diagnostic difficulties. The most frequent benign lesion in the oral mucosa is traumatic fibroma, which develops from gingival connective tissue or the periodontal ligament. The growth has a smooth surface, normal-coloured mucosa, a sessile or pedunculated base, and a firm consistency. Due to decreased vascularity, the lesion appears as a round or oval, sessile, broad-based swelling that is painless and has a lighter colour than the surrounding tissue. Histopathologically, it seems to be a nodular mass composed of collagen-containing fibrous connective tissue . GingivaThis case report demonstrates that surgical excision of traumatic fibroma with a scalpel and diode laser was discovered to be a simple, efficient, and affordable method for treating traumatic fibroma and giving aesthetic and functional clearance to the patient. In contrast, the removal using a diode laser demonstrates no bleeding and less discomfort and pain during the surgery than the conventional scalpel technique. However, the scalpel method is less expensive than diode laser. The patient's clinical history and varying aetiologic factors should be considered for non-recurrence of the lesion, and the patient should be evaluated on recall and educated about the traumatic habits to stop the recurrence. This case report involves two cases of traumatic fibroma, which were reported with aesthetic concern and functionality issues during speech and mastication and regressed later on surgical intervention.


Rosai-Dorfman disease (RDD) is a rare benign non-Langerhans cell histiocytosis. The most common site of extranodal involvement is the skin. Cutaneous involvement without lymphadenopathy is extremely rare. It is often difficult to diagnose primary cutaneous RDD secondary to the non-specific nature of its clinical and histologic features. Consequently, diagnosis can be significantly delayed. To our knowledge, about 220 reports of purely cutaneous RDD are documented in the literature to date. We present an additional unique case of cutaneous RDD and emphasize the challenging nature of accurate clinical and histopathologic diagnosis. Rosai-Dorfman disease (RDD), also known as sinus histiocytosis with massive lymphadenopathy, is a rare benign non-Langerhans cell histiocytosis. Rosai and Dorfman first described it as a clinicopathologic entity in 1969 . The mosA 65-year-old African American male presented to the clinic with asymptomatic nodules on the right lower abdomen. It initially started three years prior as a small papule that enlarged and resolved spontaneously. It recurred within the past year but persisted, increased in number, and enlarged to its present size. He denied bleeding, draining, or preceding trauma. Review of systems was negative for fevers, chills, unintended weight loss, night sweats, lymphadenopathy, gastrointestinal symptoms, or similar lesions elsewhere. Past medical history was significant for type 2 diabetes mellitus, hypertension, and atrial fibrillation. He denied a history of cancer. He denied a family history of any skin conditions or similar lesions. Physical exam of the right lower abdomen revealed pink to yellow firm, indurated, nodules coalescing into a 3 cm tumor with two similar appearing nodules of smaller size located inferiorly Figure . All lesA 4mm punch biopsy of the right lower abdomen demonstrated acutely inflamed granulation tissue and proliferation of capillary-like blood vessels with some vascular channels and cystic spaces lined by foamy histiocytes with plump nuclei. A lymphoplasmacytic infiltrate extended to the deep dermis. CD-31 showed excessive background staining. CD-34 highlighted a few small capillary-like blood vessels. CD-163 highlighted numerous histiocytes. SOX-10 and pan-cytokeratin were negative. Four months later, an excisional biopsy was performed for definitive diagnosis. It showed a nodular proliferation of non-lymphoid histiocytic infiltrate consisting of eosinophilic appearing histiocytes containing multiple nucleoli Figure . The foaThe patient was instructed to obtain a complete blood count with differential and computed tomography of the abdomen/pelvis with IV contrast to rule out systemic associations and lymphadenopathy. No adenopathy was seen on imaging. He was offered excision of remaining nodules.Compared to patients with systemic RDD, cutaneous RDD presents at an older mean age of about 43.5 years, is more common in White and Asian females, and has no lab abnormalities. Cutaneous manifestations are non-specific with asymptomatic red-brown to yellow papules, nodules, or plaques of varying size that can be confined or disseminated, without predisposition for any distinct anatomic site. The most common sites of involvement are thought to be the extremities [A large series of cutaneous RDD was described by Kong et al. in their clinical and histopathologic study of 25 patients in China . Eleven Histopathology of cutaneous RDD typically shows a dermal infiltrate of large polygonal histiocytes with abundant pale to eosinophilic cytoplasm admixed with an inflammatory infiltrate . EmperipThe recommended management of RDD is close observation, as it is usually an indolent, benign self-limited condition. If treatment is desired, surgical excision is considered most effective for both solitary disease and multifocal disease. Improvement has been observed with topical, intralesional, or systemic corticosteroids, cryotherapy, radiation, retinoids, methotrexate, high-dose thalidomide, vincristine, dapsone, and imatinib with mixed results. Diagnosing cutaneous RDD is challenging due to the variations in its clinical and histologic presentation. Our case is unique as this patient was over 20 years older than the mean age of diagnosis, African American, and male, all factors that are less typically seen in this condition. This case also emphasizes the challenging nature of accurate clinical and histopathologic diagnosis. Key features of histopathology include emperipolesis and dermal infiltrate of histiocytes that stain positively for S100 and CD68 and negatively for CD1a. Management involves observation although surgical excision, and several treatment options are available if therapy is desired.


Pericardial cysts are a rare benign disorder with a variable clinical presentation depending on their size and location. The diagnosis of pericardial cysts is usually based on imaging examinations. The definitive treatment is surgical resection.A 36-year-old woman presented with progressive left-sided chest pain and exertional dyspnea, with symptoms resembling pleural effusion.The patient was diagnosed with a pericardial cyst based on imaging and video-assisted thoracoscopic surgery (VATS).VATS was performed.The patient’s symptoms improved after successful removal of the pericardial cyst. Follow-up chest computed tomography exhibited no evidence of recurrence.Clinicians should include pericardial cysts in the differential diagnosis of pseudopleural effusion. VATS is a feasible and safe method to treat symptomatic and large pericardial cysts. More than 50% of such patients have no symptoms, but the cysts are occasionally revealed by routine chest radiological examinations. The exact clinical presentation and complications depend on the size, location of the cyst and presence of involvement/invasion into adjacent structures. We present an interesting case of a woman with a large pericardial cyst in an uncommon location, mimicking unilateral pleural effusion. Informed consent was obtained from the patient and her family.Pericardial cysts are rare and benign congenital malformations with a variable clinical presentation, and these mediastinal abnormalities occur in 1 person per 100,000.A 36-year-old woman presented with progressive left-sided chest pain and exertional dyspnea for 4 months. Before being referred to our institution, she had been treated with thoracentesis and an indwelling pleural catheter, with a total of 2500 mL of drainage from the effusion. Diagnostic antituberculosis treatment was offered, but no response was observed. Her medical history was unremarkable except for chest trauma from a fall while riding a bicycle 10 years ago. The physical examination was remarkable for decreased breath sounds with dullness to percussion on the left. Further electrocardiographic tests and laboratory investigations were mostly negative. A chest computed tomography (CT) scan showed loculated left-sided pleural effusion , trauma, complications of cardiac surgery and chronic hemodialysis. The etiology of this case may be congenital, and the pericardial cyst was discovered in middle age during the 4th decade of life, which is consistent with the majority of cases reported in previous literature. However, our patient had a definite history of chest trauma 10 years ago, so a traumatic origin could not be excluded.The most common etiology of pericardial cysts is congenital causes due to failed fusion of mesenchymal lacunae during the embryogenic state. CT and magnetic resonance imaging are helpful in showing detailed information on the density of the mass, anatomical location of the pericardial cyst and the association with surrounding structures and in differentiating cysts from other malformations, such as chest malignancies.,12 However, each imaging modality has its own limitations, and histological examination is warranted to obtain a consolidated diagnosis and established a definite diagnosis.Pericardial cysts are usually discovered and monitored by radiological modalities. They are usually revealed as an incidental finding during chest X-ray scans carried out on asymptomatic patients. Transthoracic echocardiography provides the exact location and characteristics of the lesion, providing better recognition. In most patients, close follow-up with serial transthoracic echocardiography is sufficient for monitoring and to ensure a benign course in which the pericardial cyst can resolve spontaneously. Other treatments include percutaneous aspiration, surgical intervention with VATS or surgical excision.,14 Our patient’s cyst was large enough to cause symptoms, so surgical intervention was necessary. Initially, we tried to perform percutaneous aspiration for further workup to establish the diagnosis, but this approach was unsuccessful. The histochemical examination of the fluid from the cyst and aspiration biopsy was unhelpful and nonspecific for diagnosis. Finally, the definitive diagnosis was confirmed by VATS, and the pericardial lesion was removed. Therefore, VATS is a feasible and promising method in symptomatic patients with cardiorespiratory repercussions, as described in the present case.The need for changes in management depends on the patients’ symptoms and complications and the size and location of the cyst.We reported a rare case of a large pericardial cyst located in an uncommon location mimicking unilateral pleural effusion and finally confirmed the diagnosis and achieved resolution through VATS. Therefore, clinicians should include pericardial cysts in the differential diagnosis of pseudopleural effusions. VATS is a feasible and safe method to treat symptomatic and large pericardial cysts.Conceptualization: Minfang Li, Wei Xie, Jinlin Wang.Formal analysis: Minfang Li, Jinlin Wang.Funding acquisition: Wei Xie.Investigation: Minfang Li, Chunfeng Yang, Jinshuai Li, Dan Jia, Yaqiong Wang, Wei Xie, Jinlin Wang.Methodology: Minfang Li, Dan Jia, Jinlin Wang.Validation: Minfang Li, Jinlin Wang.Visualization: Minfang Li, Wei Xie, Jinlin Wang.Writing – original draft: Minfang Li, Jinshuai Li, Dan Jia, Yaqiong Wang, Wei Xie, Jinlin Wang.Writing – review & editing: Minfang Li, Chunfeng Yang, Dan Jia, Yaqiong Wang, Wei Xie, Jinlin Wang.


The occurrence of synchronous acute cholecystitis and appendicitis is rare. There are few cases reported and small series in the literature. We report the case of a 77-year-old male who presented to the emergency department with right-sided abdominal pain. He was diagnosed preoperatively with acute calculous cholecystitis. During the initial laparoscopy, a complicated appendiceal phlegmon was found and was treated with a one-step laparoscopic approach and subsequent antibiotics. The patient had an uneventful recovery and was discharged on postoperative day (POD) 2. The pathology report confirmed both diagnoses and an incidental low-grade appendiceal mucinous neoplasm. Although uncommon, it is important to be aware of the possibility of both simultaneous pathologies in a patient who presents to the emergency department with abdominal pain. Acute appendicitis is the most common diagnosis for emergency abdominal surgery worldwide . MeanwhiWe aim to report the incidental finding of complicated acute appendicitis during laparoscopic cholecystectomy for acute calculous cholecystitis in an elderly patient. This highlights the importance of a proper presurgical evaluation and of laparoscopic exploration of the entire abdominal cavity in all patients presenting with surgical acute abdomen, as various pathologies may coexist.A 77-year-old male, with no relevant medical history, presented to the emergency department of our hospital with a history of 12-hour intense, non-radiating right upper quadrant pain of sudden onset. The pain was described as sharp, and it was triggered by copious food ingestion; no nausea or vomiting was reported. He denied jaundice, fever, changes in bowel movements, or urinary symptoms.He reported having visited another healthcare facility 10 days ago complaining of diffuse abdominal pain associated with nausea, vomiting, and diarrhea. Upper abdominal ultrasonography was done at that time with no significant findings, and blood tests were within normal limits. He was diagnosed with inflammatory enterocolitis and was referred to a gastroenterologist, who treated the episode symptomatically with oral rehydration, a proton pump inhibitor, and probiotics. The symptoms resolved completely within two days.Upon new admission, he had normal vital signs, no fever, and no tachycardia. Abdominal examination was remarkable for distension, diminished bowel sounds, and tenderness on light palpation on the right hemiabdomen with local guarding. Pain limited the exploration of signs of peritoneal irritation, and there were no palpable masses.3  with 84%  neutrophils, a C-reactive protein of 60.1 mg/L , and normal liver function tests. A new upper abdominal ultrasound was ordered, which reported a markedly dilated gallbladder with a volume of 116 mL, a 5-mm wall with diffuse thickening, and hyperechogenic multiple small clustered images inside suggesting biliary sludge. The common bile duct diameter was within the normal range. There was no free peritoneal fluid present  and analgesia. He was admitted with a diagnosis of grade I (mild) cholecystitis applying the Tokyo 2018 criteria  and planThe surgical approach began with an umbilical incision, and an open technique was used for pneumoperitoneum creation. During the initial laparoscopy, an inflammatory phlegmon involving the greater omentum, cecum, terminal ileum, gallbladder, and appendix was identified. Scarce free peritoneal fluid was found in the right paracolic gutter down to the pelvis. Additional ports were placed under laparoscopic guidance: a 10-mm subxiphoid port, two right upper quadrant 5-mm ports, and a left flank 5-mm port Figure .The appendix was difficult to locate because of adhesions and medial rotation of the cecum with the appendiceal tip pointing anterosuperiorly. Necrosis and perforation were identified in the middle third of the vermiform appendix Figure . The galThe postoperative course was uneventful. Liquid oral intake was reinitiated 12 hours after the surgery and was well tolerated. The patient tolerated oral intake on his postoperative day (POD) 1. The drain output was low and serosanguinous. The patient reported passing flatus on POD 1. The patient was discharged on POD 2 after drain removal. Oral antibiotics were prescribed for five more days. The histopathology report confirmed acute cholecystitis (with microlithiasis) and necrotic acute appendicitis plus an incidental finding of a low-grade mucinous neoplasm on the distal third (pTis).Finding acute cholecystitis simultaneously with appendicitis is a rare condition, although individually both are very common acute conditions in the emergency department. In the USA, gallbladder disease affects approximately 20 million individuals yearly, and more than 200,000 people are diagnosed with acute cholecystitis each year .According to the literature, patients with those two simultaneous conditions are difficult to evaluate in the emergency room. They generally present with right upper quadrant pain and right-sided or diffuse abdominal tenderness, so it can be challenging to reach a high level of suspicion based on the clinical picture alone ,5. Each Upper abdominal ultrasound is the standard of care when gallbladder pathology is suspected, while contrast-enhanced computed tomography (CT) has become the choice to evaluate lower abdominal pain. Abdominal CT scan has led to reduce false negatives for appendicitis and decrease misdiagnoses. In terms of cholecystitis, a sonogram is preferred over CT as approximately 8% of gallstones are isodense to the surrounding bile . Still, Alkhurmudi et al. , in a prIn a retrospective analysis, it is relevant to consider that our patient presented an episode of abdominal pain 10 days before the latest admission that was treated as inflammatory enterocolitis and had full resolution of symptoms. At that time, no apparent abnormalities were found in complementary studies. We suspect that this previous episode could be the initial manifestation of acute appendiceal inflammation, which then led to complicated appendicitis and contiguous inflammation of the gallbladder. Nonetheless, we cannot rule out the biliary sludge (microlithiasis) as the culprit of concomitant cholecystitis ,7.Histopathologic and trans-operatory findings are consistent with our hypothesis as the most compromised organ was the appendix. While necrosis was present in the appendix specimen, the gallbladder only showed mild acute cholecystitis without signs of gangrene. The incidental finding of a low-grade mucinous neoplasm (pTis) at the tip of the appendix does not influence the management, and their implications are beyond the discussion of this report .Finally, regarding the surgical approach, previous studies have demonstrated that a one-step laparoscopic procedure is feasible and safe for treating both illnesses . Our patAmong the most common causes of abdominal pain that require surgical intervention are acute appendicitis and acute cholecystitis. Although a rare occurrence, it is important to consider the possibility of both occurring simultaneously in a patient presenting with nonspecific abdominal pain to the emergency department. The condition can be safely solved by a simultaneous laparoscopic appendectomy and cholecystectomy without delay to avoid complications such as intra-abdominal sepsis. Surgeons must be aware of this circumstance so that preoperative workup can be successfully done and optimal treatment planned. It is imperative that a thorough exploration of the abdominal cavity be always performed as the first step of laparoscopic surgery.


KIT/PDGFRA/SDH/RAS-P  mutations, thereby classifying this patient as quadruple WT GIST (qGIST). Treatment with imatinib was initiated, and after 2.5 months, recurrence of the tumor and multiple metastases around the surgical site were observed. Consequently, the patient was switched to sunitinib treatment and responded well. Although she responded well to sunitinib, the patient died of tumor dissemination within 4 months. This case study highlights the potential efficacy of imatinib and the VEGFR-TKI sunitinib in treating qGIST patients harboring a TP53 missense mutation.In this report, we present a case study of a 64-year-old female who was diagnosed with gastrointestinal stromal tumors (GISTs) and subsequently developed liver metastases despite undergoing radical resection. Next-generation sequencing (NGS) assays indicated that the tumor lacked  KIT or PDGFRA mutations, and the remaining GISTs that do not harbor any mutation of the KIT and PDGFRA genes are defined as wild-type (WT) GISTs. Among WT GISTs, 20-40% of tumors are SDH-deficient GISTs that show loss of function of the succinate dehydrogenase complex (SDH). Approximately 15% of KIT/PDGFRA WT cases harbor mutations in BRAF/RAS or NF1 and are referred to as RAS-pathway (RAS-P) mutant GISTs. In addition, a small subset of all GISTs (5%) that lack KIT/PDGFRA/SDH/RAS-P  mutations can be referred to as quadruple WT GISTs or quadruple negative GISTs  are the most common of all sarcomas . Most GIve GISTs . To dateTP53 is a critical tumor suppressor gene that encodes a 64 kDa protein   imaging on July 8, 2022, showed a mass on the lower edge of the right upper abdominal liver lobe approximately 33 X 48 mm, and the boundary was unclear Figure 1Histopathological examination of the excised mass showed spindle cells and epithelioid cells were mixed. The spindle cells were arranged in bundles, in a braided and palisade manner, with varying cell density, no significant pleomorphism, and visible nuclear vacuoles. Epithelioid cells were distributed in sheets with clear cell boundaries. Multinucleated giant cells were observed in some areas and mitotic images could be seen. Fibrous demarcation was observed between the spindle cells and epithelioid cells. Focal stroma exhibited myxoid alteration Figure 2c-KIT and PDGFRA genes, including exons 9, 11, 13 and 17 of KIT and exons 12, 14 and 18 of PDGFRA. This patient lacked mutations in RAS-P . Therefore, this GIST patient had quadruple WT GIST (KITWT/PDGFRAWT/SDHWT/RAS-PWT). Interestingly, NGS revealed the presence of a TP53 exon 4 p. A88fs (81.56% abundance in tissue) and NF2 exon 5 p. L176fs (79.53% abundance in tissue) somatic mutation , TKIs could offer a treatment option with relatively good responses for wild-type GISTs. Thus, postoperative adjuvant imatinib therapy was recommended for this patient. The patient received imatinib (400 mg/day) treatment from July 22, 2022, to October 7, 2022. The CT result on October 8, 2022, indicated tumor recurrence and multiple metastases around the surgical area, liver, abdomen, pelvis, and right lower abdominal wall, with a lesion size of 14*11*8 cm in the liver area.TP53 exon 4 p. A88fs indicates that patients with solid tumors might be sensitive to VEGFR-TKIs , followed by the small intestine (20-25%), while occurrence in other locations, such as the rectum, colon, and esophagus, is infrequent  treated with first-line sunitinib  for the publication of any potentially identifiable images or data included in this article.LC: Funding acquisition, Supervision, Writing – review and editing, Conceptualization, Resources. YC: Writing – original draft, Investigation. JC: Writing – review and editing, Data curation. LL: Writing – review and editing, Methodology. XM: Formal Analysis, Project administration, Software, Writing – review and editing. YS: Formal Analysis, Software, Writing – review and editing. YZ: Formal Analysis, Software, Writing – review and editing. HC: Writing – review & editing, LH: Data curation.


Biopsies were obtained, which confirmed colonic adenocarcinoma. Eight hours after the endoscopy, the patient developed massive hematochezia, followed by hemodynamic instability . After stabilization with intravenous fluids, norepinephrine, and transfusion of 1 unit of red blood cells, endoscopy was repeated and ruled out ongoing bleeding. A computed tomography scan confirmed a mass of the sigmoid colon, which extended along the inferior mesenteric artery and to the os sacrum. Within the sigmoid wall, extravasation of the contrast medium was seen into a structure of 2.3 × 1.7 cm. Computed tomography reconstructions suspected pseudoaneurysm of the inferior mesenteric artery . In the absence of distant metastases, surgical resection was attempted urgently. However, owing to infiltration of the aortic wall, curative resection was impossible and colostomy was performed. Angiography confirmed a large pseudoaneurysm of the rectal superior artery, and embolization was performed successfully. The further course was unremarkable.An 86-year-old man without significant comorbidity presented with weight loss, diarrhea, and iron deficiency anemia. No signs of gastrointestinal bleeding were noticed. Colonoscopy was performed, and sigmoid cancer was suspected (Pseudoaneurysm of the inferior mesenteric artery is rare. To our knowledge, a case with hemorrhagic shock after endoscopic biopsy caused by cancer-associated pseudoaneurysm has not been reported so far.Author contributions: A. Probst: conception and design, analysis and interpretation of the data, drafting of the article. M. Ayoub, F. Sommer, and F. Schwarz: analysis and interpretation of the data. H. Messmann: critical revision of the article, final approval of the article.Financial disclosure: None to report.Informed consent was obtained for this case report.


Compressive postoperative seromas in the cervical spine are a rare but significant complication following cervical laminectomy and instrumented fusion. There is a paucity of cases reported in the literature, with a majority of the reported cases attributing seroma formation to the use of recombinant human bone morphogenetic protein-2 (rhBMP-2). In this article, we report four cases of compressive postoperative seroma in the absence of rhBMP-2 use and highlight similarities in their clinical presentations. We postulate that seroma formation is a significant complication of the dead space that results following posterior instrumentation in the cervical spine, with or without the use of rhBMP-2. The typical presentation is one of the gradual delayed neurological deterioration several days following the index surgery and after drain removal. Neurological deterioration can be reversed rapidly with early recognition and drainage of the seroma. Postoperative seromas causing spinal cord compression in the cervical spine are a rare but significant complication following cervical laminectomy and instrumented fusion. While seromas are not uncommon following posterior spinal surgery, the accumulation of sufficient amounts of fluid to cause mass effect on the spinal cord and neurological deficits and/or myelopathy are much rarer. A large majority of information in the literature on this condition is from case reports that focused on the role of recombinant human bone morphogenetic protein-2 (rhBMP-2) in seroma formation -4, rhBMPCase 1A 67-year-old gentleman with a significant past medical history of severe cardiomyopathy on dual antiplatelet therapy, diabetes mellitus, and chronic kidney disease presented with a one-year history of predominantly left-sided upper and lower limb dysfunction requiring a wheelchair for ambulation. On examination, he had significant spasticity and weakness over his left upper and lower limbs (3-4/5), with positive Hoffman’s sign bilaterally. Magnetic resonance imaging (MRI) of the brain revealed no stroke disease to account for his predominantly unilateral symptoms, while MRI of the cervical spine demonstrated multilevel degenerative changes with severe cord compression over C3-C6 and myelomalacia at C4-C5 as well as a mild kyphotic deformity over the involved segments  putty mixed with morselized autograft from the laminectomies in the lateral gutters following decortication. Hemostasis was secured using an oxidized regenerated cellulose (ORC) hemostatic agent, and vancomycin powder was applied to the implants. The wound was closed in layers over a closed suction drain placed deep into the fascia. Surgery was uneventful with stable neuromonitoring throughout.The patient awoke from surgery with no new neurological deficits, and the drain was removed on postoperative day three after the drain output turned serous and drainage was 60 mL over 24 hrs. Initial rehabilitation in the first week progressed uneventfully. On postoperative day seven, the patient complained of mild weakness of his left-hand grip strength (4/5), which had previously been intact. This subsequently progressed to involve the previously uninvolved right upper limb with loss of motor power in elbow flexion (4/5) and extension (3/5). An MRI was performed in view of his progressive upper limb neurological deterioration, which revealed a large posterior fluid collection that was homogeneously T2 hyperintense compressing the spinal cord  after a Valsalva maneuver. All intraoperative cultures were negative. The wounds were closed in layers over two suction drains placed beneath the fascia. A postoperative MRI scan was performed to confirm the re-expansion of the thecal sac  accompanied by an upgoing plantar reflex in the right lower limb as well as significant ataxia with an inability to stand without support. Motor power was full in the upper limbs. Imaging revealed multilevel degenerative changes with segmental ossification of the posterior longitudinal ligament (OPLL) and severe cord compression over C3-C6 with cord signal changes at C5-C6  following laminectomy, while the left upper limb MEP, bilateral lower limb MEP, and bilateral somatosensory evoked potentials (SSEP) all remained stable.The patient woke up from surgery with no new neurological deficits. The drain was removed on day four after the drain output decreased to 30 mL over 24 hours. On postoperative day six, the patient was noted to have new-onset decreased motor power of his left shoulder abduction, elbow flexion and extension, and wrist extension (3/5). An urgent MRI was performed, which revealed a large T2 hyperintense fluid collection that was compressing the cord  following decompression of the seroma and subsequently recovered back to his preoperative baseline one month later. His ambulatory status improved following a period of rehabilitation. By four months postoperatively, he was able to regain independent ambulatory status.Case 3A 73-year-old gentleman with a known history of hypertension, hyperlipidemia, and cervical myelopathy, for which he had previously declined surgical intervention, presented to the emergency department with an incomplete cervical spinal cord injury  following a fall onto his face on the same day. On admission, he was noted to have significant weakness in his bilateral upper and lower limbs 2-3/5) with a neurological level of injury at C5. Urgent MRI revealed multilevel degenerative changes with severe cord compression over C3-T1, cord signal changes at C3-C4 and C6-C7, and mild cervical kyphosis at C3-C5 . Imaging revealed a cervical kyphosis, which was correctable to <10 degrees on neck extension, as well as multilevel degenerative changes with severe cord compression over C3-C6 and myelomalacia at C3-C4  and grip strength (4/5) compared to his examination on postoperative day one, and an urgent MRI was performed. This revealed a large T2 hyperintense fluid collection that was compressing the cord Figure , Panel BUnlike in the preceding cases, an image-guided aspiration of the collection was performed, which yielded 75 mL of dark hemoserous fluid. No drain was placed. A post-aspiration MRI confirmed adequate drainage of the seroma Figure , Panel CA summary of the four cases is presented in Table Seroma formation is a known complication of spinal surgery, which in the literature has been most commonly attributed to the use of rhBMP-2 ,8. WhileOur four cases presented, which occurred over the course of a short two-year period, highlight that this complication may not be as rare as portrayed in the literature and does not solely occur with the use of rhBMP-2. The clinical course is typically one gradual and delayed neurological deterioration that begins several days postoperatively and after the removal of surgical drains, which would have prevented further fluid build-up, given the serous nature of the fluid. Other cases reported in the literature have described neurological deterioration occurring as early as three days and up to six weeks postoperatively -6,9. NeuThis typical sequence of events is in keeping with the pathophysiology of seroma formation, which authors have attributed to an inflammatory cytokine-mediated response resulting in soft tissue swelling and the production of fluid in the surgical field ,7,8. ThiThe majority of papers on this subject have proposed rhBMP-2 as the main risk factor responsible for seroma formation. Instead, we postulate that in addition to rhBMP-2 use, a variety of other contributing factors may also increase the risk of compressive seroma formation. First, the use of instrumentation using an open technique, in which a wide subperiosteal elevation of the paraspinal muscles is performed, leaves a large dead space for seromas to accumulate. This has been previously raised by other authors as a likely risk factor , and we Second, the use of not only rhBMP-2 but, in fact, any biologically active foreign material, such as allograft , hemostaFinally, the fact that in all four cases, neurological deterioration only occurred after postoperative day five suggests that fluid accumulation in the surgical field likely only peaks beyond this time frame. Premature removal of surgical drains prior to this peak may increase the risk of compressive seroma formation. We recommend keeping surgical drains until daily fluid output is on a consistent downward trend and below 30 mL over 24 hours. In some cases, this may necessitate drains being kept longer than routinely performed.Management of this complication lies first and foremost in its early detection, which begins with being aware of the typical sequence of events and having a high index of suspicion in a patient who may only have mild or non-specific but progressive symptoms in the postoperative course. Early drainage of the compressive seroma generally results in immediate symptomatic improvement. While we elected to re-open the wound for exploration and drainage in Cases 1 to 3, an image-guided percutaneous aspiration was performed in case 4, which yielded equally satisfying results without the morbidity of repeat surgery. This technique was described in a recent study , and we We acknowledge the limitations of our study. Having only small case numbers without a control group, we are unable to draw any definitive conclusions regarding the causation of this complication. However, we believe that the similarities in the cases presented brought forth several hypotheses regarding the risk factors potentially predisposing to postoperative seromas as discussed earlier, which can then be investigated further in future larger-scale studies.These four cases add to the currently limited body of literature describing this complication and highlight the typical presentation of compressive postoperative seromas in the cervical spine. Our cases refute the prevailing understanding that rhBMP-2 is the main culprit for postoperative seroma formation, and we postulate that compressive seroma formation may not be as rare a complication as the literature seems to suggest, with multiple contributing risk factors. We urge clinicians to have a high index of suspicion in the event of gradual neurological deterioration in the days following drain removal, and advocate early MRI scan to confirm the diagnosis. Early drainage of the fluid collection allows good relief of compressive symptoms, and radiologically-guided aspiration may be a feasible alternative to open drainage in selected cases.


Teaching Point: Female urethral diverticulum is a rare condition that is often a diagnostic challenge; magnetic resonance imaging (MRI) is efficient to confirm the diagnosis , to assess the diverticulum prior to surgery, and to detect related complications including intra-diverticular neoplasm. A 76-year-old female patient presented to the emergency room for persistent metrorrhagia. Gynecological examination revealed erosions of the anterior vaginal mucosae with an underlying palpable para-vaginal mass.An MRI was performed to assess this mass with T2-weighted images in coronal, sagittal, and axial planes, DWI  and T1-weighted fat-suppressed images with and without contrast injection. T2-weighted images in sagittal  and axia–6 s/mm2)  . These cThe enhancement of the intra-diverticular neoplasm is also well seen on sagittal T1-weighted fat-suppressed images  with a sThe patient underwent anterior pelvectomy. Anatomopathology confirmed the malignancy and the diagnosis of clear cell carcinoma.Female urethral diverticulum is a rare condition affecting 0.6 to 6% of women, mostly between the third and sixth decades. Clinical presentation includes a large variety of urologic symptoms , and the diagnosis remains a diagnostic challenge .Urethral diverticula are located between the fibromuscular layer of the urethra and the anterior wall of the vagina. Endovaginal ultrasound is an effective first-line exam to confirm or exclude the diagnosis, especially in younger women. Because of its soft tissue contrast, MRI is accurate to assess the urethral diverticulum’s morphology before surgery and to evaluate its internal content .The location of the cystic lesion in the postero-lateral side of the mid-urethra, and the evidence of communication between the cyst and the urethral lumen are the key features to differentiate urethral diverticulum from vaginal cysts. Urethral diverticula may also have horse-shoe configuration that can occasionally almost completely surround the urethra .MRI also allows assessment of the possible complications of urethral diverticulum including infection, calculi formation, and intra-diverticular neoplasm that usually appears as a gadolinium enhanced mass in the diverticulum .


Spinal surgical procedures are becoming more common over the years, and imaging studies can be requested in the postoperative setting, such as a baseline study when implants are used, or when there is a new postoperative issue reported by the patient or even as routine surveillance. Therefore, it helps the surgeon in the appropriate management of cases. In this context, there is increasing importance of the radiologist in the adequate interpretation of postoperative images, as well as in the choice of the most appropriate modality for each case, especially among radiographs, computed tomography, magnetic resonance imaging and nuclear medicine. It is essential to be familiar with the main types of surgical techniques and imaging characteristics of each one, including the type and correct positioning of hardware involved, to differentiate normal and abnormal postoperative appearances. The purpose of this pictorial essay is to illustrate and discuss the more frequently used spine surgical interventions and their imaging characteristics, with an emphasis on classical decompression and fusion/stabilization procedures.Plain radiographs remain the main modality for baseline, dynamic evaluation, and follow-ups.CT is the method of choice for assessing bone fusion, hardware integrity and loosening.MRI should be used to evaluate bone marrow and soft tissue complications.Radiologists should be familiar with most performed spinal procedures in order to differentiate normal and abnormal.This article discusses the main surgical procedures involved in the spine, which can be didactically divided into decompression, stabilization-fusion, and miscellaneous, as well as the role of diagnostic imaging methods and their main findings in this context. Spinal surgeries are among the most frequently performed orthopedic-neurosurgical procedures  and partThe postoperative evaluation of spine is sometimes complex and time-consuming, with imaging being essential for the management of such patients . It is uThis pictorial essay provides an overview of basic spine surgical interventions, as well as the hardware involved and the adequate imaging modality to assess each procedure.Plain radiographs are the most frequent modality used for postoperative spine evaluation due to its easy access and cost-effectiveness , usuallyPanoramic radiographs play a major role in the preoperative evaluation for the detection of scoliosis, malalignment, vertebral counting, and assessment of transitional vertebrae to ensure that the surgery occurs at the correct level, serving also as a reference for intraoperative fluoroscopy, especially to check spine levels and confirm appropriate position and location of implants , 2, 4.Reasons to perform postoperative imaging include reassuring the patient about adequate healing and surgery success, identifying asymptomatic hardware migration or failure, and documenting clinical status in the medical record .CT is the most accurate modality for assessing mineralized bone structures, including evaluation of spine fusion progression Fig. B, which MRI is the most reliable choice to assess postoperative complications due to its excellent soft-tissue resolution . It allo®), WARP , and slice encoding metal artifact correction  [Although there are no major concerns regarding spinal fusion-hardware for the safety of the patient undergoing an MR procedure, they can still significantly impair the evaluation of MRI images due to magnetic susceptibility artifacts . Some alineers®) .Fig. 2TeNuclear medicine studies are also part of the diagnostic workup of the postoperative spine. These examinations are typically used in certain situations, such as in patients in whom MRI is contraindicated or if MRI and CT are equivocal. The most important studies in this setting are gallium scan, indium 111-tagged white blood cell (WBC) scan, single-photon emission computerized tomography/computed tomography (SPECT/CT), and positron emission tomography (PET) scan –16.Ga-67 scintigraphy combined with SPECT/CT can be used to evaluate suspected spinal infection in patients who have undergone recent spine interventions. Although Ga-67 is less sensitive (73%), it is more specific (61%) than skeletal scintigraphy. Moreover, a dual Ga-67 and Tc-99m-MDP study can increase the overall specificity of the examination to 81% with a sensitivity of 73% .SPECT/CT can provide information on metabolic activity with anatomical localization and may identify postoperative complications like pseudarthrosis, radiculopathy, adjacent segment degeneration, hardware failure, and radiographically occult fractures . OverallPET using the fluorine-18-2-fluoro-2-deoxy-D-glucose (FDG) tracer with CT has gained a lot of role in post-operative assessment, especially in cases where infection is suspected . StudiesThe most common indications for spinal surgery are refractory back or neck pain and neurologic deficit related to nerve root or spinal cord compression, especially related to degenerative disc disease. Surgical technique, incision approach and hardware chosen will vary depending on the anatomic features of each segment, surgery indication and surgeon's experience .Spinal surgeries can be didactically classified into three main categories: (1) decompressive; 2) stabilization-fusion (including those for deformity correction); and (3) miscellaneous procedures  stabiliz, 17. In ligamentum flavum, tumors, abscesses, or hematomas [These techniques are performed to remove compressing factors to the nerve roots and/or the spinal cord. Such compression may be caused by a herniated disc, hypertrophic facets (bone spurs), synovial cysts, thickened ematomas , 18.The most used lumbar decompression techniques, along with discectomy, are laminotomy and laminectomy  . The choLaminotomy or “laminae fenestration” , which can be unilateral or bilateral. When bilateral , it also involves the removal of the spinous process. In order to gain maximum exposure to the spinal canal and foramina, medial facetectomy can be associated, but it is important to preserve the facet joint as much as possible to prevent instability [omy Fig. . Complettability , 4. The Minimally invasive surgeries, including endoscopic and microscopic tubular surgeries, are becoming more frequent, with microdiscectomies being performed for small disc herniations, occasionally with minimal resection of posterior elements. These characteristics lead to a challenge in recognition of these surgeries through images, especially after a long postoperative time .LaminotoThe goal of these techniques is to maintain correct alignment and prevent abnormal motion of spine. They are also used to replace excised components of the spine. Stabilization is achieved by fusion of vertebral bodies and/or posterior elements through instrumentation and bone graft, which provide support until bone fusion (arthrodesis) occurs , 20.Indications include degenerative disc disease, deformity correction, spondylolisthesis, tumors, trauma, and infection .Although it might be challenging for the radiologist to remember the name of all devices used in spine surgery, it is possible to learn the treatment principles and basic categories of the hardware based upon their objectives .The cervical spine is approached anteriorly and posteriorly, while the thoracic spine is more often approached posteriorly.The lumbar spine may be manipulated anteriorly , laterally  and posteriorly (posterior lumbar interbody fusion—PLIF). Alternative approaches are posterior transforaminal  and a posterolateral intertransverse (intertransverse lumbar interbody fusion—ILIF).Plate with screws attached to the vertebral body , lesion excision procedures and vertebral body replacement.Since the evaluation of the postoperative spine is challenging, it is of utmost importance to have a basic understanding of indications and objectives of the main surgical procedures, as well as the hardware instrumentation materials and their normal appearance through imaging. One should be familiar with the most appropriate imaging modality for each setting, including radiographs, CT, MRI, or nuclear medicine studies. Comparison with previous exams and access to surgical descriptions are always helpful and support imaging evaluation. The ultimate goal is to create efficient reports to assist the surgeon in continuous patient care.


Neuroendocrine tumors are growths occurring in various organs including the pancreas which contain endocrine tissue. Pancreatic neuroendocrine tumors are rare in occurrence with an incidence of <1 per 100,000 individuals. But the incidence is rising and the said tumors are becoming more common in the world. Herein we report a case of a 49-year-old female with a background history of poorly controlled type 2 diabetes mellitus for 7 years, dyslipidemia, and bronchial asthma for 19 years on regular inhaler therapy presenting with a history of back pain for 3 months duration. With serial investigations, she was found to have a neuroendocrine tumor involving the head of the pancreas with no local infiltration and distant metastases. Whipple’s procedure was performed after which she developed thrombocytopenia from post-operative day 1 itself. Following this, she was diagnosed as having immune thrombocytopenic purpura and being managed with oral corticosteroids, after which she made a successful recovery from the acute condition but with multiple relapses from time to time.  Neuroendocrine tumors are usually sporadic in nature but on the contrary, they can occur as a consequence of a germ-line mutation and can cause multiple hereditary endocrinopathies including multiple endocrine neoplasia type 1 or 4 (MEN 1 & 4), neurofibromatosis type 1, tuberous sclerosis, von Hippel Lindau disease, etc. Clinical manifestations of pancreatic neuroendocrine tumors can vary depending on the type of hormonal secretion to which the tissues are attributed. In the case of insulinoma excess insulin secretion is noted while if it is gastrinoma, glucagonoma, or vasoactive intestinal peptidinoma, gastrin, glucagon, and vasoactive intestinal peptide secretion, respectively, can be noted . Those pA 49-year-old female with a background history of poorly controlled type 2 diabetes mellitus for 7 years complicated with peripheral neuropathy, currently on oral hypoglycaemics along with dyslipidemia and bronchial asthma for 19 years on regular inhaler therapy presented with a history of back pain and gastroesophageal reflux symptoms for 3 months duration. Back pain was of gradual onset and it was a pain of moderate severity. Diurnal variation of the pain was not noted and no exacerbating or relieving factors for the pain were not noted either. The pain did not seem to radiate to any other area and didn’t seem to progressively worsen over time either. She denied pain affecting her activities of daily living but due to the persistent nature of the pain she has thought of seeking medical advice. During the course of illness, she has taken simple analgesics to which the pain seems to have slightly responded but not completely. Along with back pain, she denied a history of diarrhea, loss of weight, loss of appetite, flushing suggestive of carcinoid syndrome, erythematous skin rashes suggestive of glucagonoma, recurrent hypoglycaemic spells suggestive of insulinoma, no unilateral lower limb pain and swelling suggestive of deep vein thrombosis (DVT), no past history or present history of gall bladder calculi, no other joint symptoms or focal neurological deficit, and abdominal pain, no recurrent severe muscle weakness. She has had no similar symptoms before and has no family history of neuroendocrine disorders as well. The onset of her gastroesophageal regurgitant symptoms was around the same time she developed her back pain but she has not sought any medical advice to that. She had a past surgical history of drainage of a frontal cerebral abscess 22 years back, excision of an abdominal wall lump 17 years back, and a history of right superior percutaneous nephrolithotomy done 8 years back. However, she has had no significant surgical complications after any of the above surgeries. No history of known allergies. She had no history of alcohol consumption and no exposure to passive smoke either. Upon examination, she was an averagely built lady whose appearance was consistent with her chronological age. She had a BMI of 22 kg/m2. She was afebrile, there was no conjunctival pallor, plethora, or icterus noted. There were no skin rashes or growths noted during the general examination. No generalized lymphadenopathy was noted. She had a pulse rate of 82 beats per minute with a blood pressure of 130/80 mmHg. She had a dual rhythm with no pulmonary stenosis/tricuspid regurgitant murmurs in specific and the respiratory system examination was unremarkable. Upon neurological examination, there was no spinal tenderness, tone, power, reflexes were normal, and sensory, and joint position sensation was intact. There were no tender areas noted during the back examination and the modified Schober’s test was negative. Abdominal examination was unremarkable with no organomegaly, free fluid, or palpable gallbladder.In view of arriving at a diagnosis, serial investigations were performed as follows Table . Based oFrom postoperative day 1 she was noted to have severe thrombocytopenia which was progressively worsening over time along with a reduction in hemoglobin levels. Postoperative bleeding was suspected at initial stages and the investigations done postoperatively suggested the possibility of disseminated intravascular coagulation (DIC) being the causative factor for the above presentation. Among the other differential diagnoses that were postulated at this stage included drug-induced thrombocytopenia or reduction of platelets secondary to sepsis.Since her hemoglobin was low, she was given two units of red cell concentrates along with two units of platelets. She did not show any superficial bleeding manifestations either. Furthermore, the bone marrow biopsy done showed hypercellular megakaryopoiesis, hence excluding the possible differential diagnoses, a diagnosis of immune thrombocytopenia was made and she was initiated on oral prednisolone 40 mg daily dose. It was tapered over a 4-week duration as there was a rise in the platelet count following prednisolone treatment. 9/cumm3. During this presentation repeated ultrasound scan of the abdomen was done and it showed no residual mass in the pancreatic region but a hepatomegaly of 16.9 cm along with grade 2 fatty liver was noted. Neither any other definitive intra-abdominal mass nor para-aortic lymphadenopathy was noted.During the subsequent clinic visits, 6 months following surgery, she was found to have ecchymotic patches mainly distributed over the chest. During that presentation, she was found to have a very low platelet count with the minimum count being 3*10Hence the diagnosis of immune thrombocytopenia was well established and she was initiated on intravenous methylprednisolone 1 g daily three doses along with an increased dose of oral prednisolone 60 mg to be taken daily. A few days later, a rise in platelet count was noted. She was also given eltrombopag, which is a thrombopoietin receptor agonist, 50 mg daily to stimulate thrombocyte regeneration.Among all pancreatic tumors, pancreatic neuroendocrine tumors account for a very small proportion . They arAmong the risk factors for the development of pancreatic neuroendocrine tumors, diabetes mellitus, smoking, genetic susceptibility, and a previous history of chronic pancreatitis play a major role . In thisSince this is a neuroendocrine tumor with a foregut origin, the European Neuroendocrine Society suggests the staging and grading of these tumors be done according to the proliferative potential of the tumor, which can be measured based on the Ki-67 index ,5. In thDiagnosis of pancreatic neuroendocrine tumors is based on imaging modalities and tumor markers ,7. ImagiTumor markers are beneficial in the diagnosis, determining the prognosis, and therapeutic options. Chromogranin A (CgA) is a non-specific tumor marker to detect neuroendocrine tumors. It is usually elevated in 50-100% of individuals with neuroendocrine tumors . The speConsidering the management options available, surgical resection is the most well-known curative option available for these patients . OctreotThrombocytopenia can occur as a result of myelosuppression, due to sepsis, as a result of an adverse reaction to pharmacological management, due to disseminated intravascular coagulation, etc. ,10. In tSecondary autoimmune thrombocytopenia is when immune-mediated thrombocytopenia resembles idiopathic thrombocytopenia due to different causes. Immune-mediated platelet destruction can be a causative factor for thrombocytopenic syndromes noted in patients with solid tumors. Yet this can only be diagnosed by antibody or kinetic verification tests, which were not performed in this case. Autoimmune thrombocytopenia is found in patients with solid tumors, including lung, prostate, breast, kidney, ovaries, and testis . They wiConsidering the fact that she responded to corticosteroids, the diagnosis of immune thrombocytopenia was made in this patient. Following treatment with prednisolone, a rise in platelet count was noted. It was further accentuated by the fact that the second refractory episode, which was resistant to steroids, was well controlled with eltrombopag. Among the other available options for ITP are plasmapheresis and IVIG. Second-line options include eltrombopag (which was administered during the second episode), rituximab, and splenectomy. Third-line options are mostly immunosuppressants such as azathioprine or cyclosporine .Non-functional pancreatic neuroendocrine tumors are a rare type of malignancy. Surgical resection is the mainstay of management offered to these patients. Among the complications noted in these patients, thrombocytopenia is a manifestation that could be a consequence of myelosuppression, drug-induced, disseminated intravascular coagulation, or as a part of immune-mediated mechanisms. In this case, the patient developed immune thrombocytopenia following surgical enucleation of a neuroendocrine tumor that responded to steroids. Active surveillance and prompt intervention are mandatory to prevent these complications from becoming life-threatening in due course.