A 67-year-old woman came to the hospital because of difficulty in breathing. After an initial clinical assessment, contrast-enhanced computerized tomography (CT) of the chest revealed a well-circumscribed heterogeneous mass arising from the pleura adjacent to the superior and medial left pulmonary artery. The mass was invading the pulmonary vein and entering the left atrium. Histopathology of the biopsy of the mass was suggestive of solitary fibrous tumor (SFT) of the pleura. The patient underwent pneumonectomy and resection of the left atrial mass with pericardial patch repair of the left atrium. Solitary fibrous tumors (SFTs) are mesenchymal in origin, rarely metastasize and include hemangiopericytoma. Hemangiopericytoma is now preferably termed SFT by most pathologists . SolitarA 67-year-old woman presented to the emergency department with difficulty in breathing. She had a past medical history of hypertension, hyperlipidemia, and hemangiopericytoma of the neck treated by surgical resection and radiation therapy 20 years ago. At the hospital, her vital signs were stable with a heart rate of 96 beats per minute, respiratory rate of 20 per minute, blood pressure of 138/78 mmHg, and percentage oxygen saturation of 96% on room air. Review of systems was otherwise unremarkable. The cardiovascular, respiratory, and abdominal examination did not reveal any pathological findings. Complete blood count showed mild anemia with a hemoglobin level of 11 g/dL. The basic metabolic panel, venous blood gas, and liver profile were unremarkable.Chest X-ray showed a round mass-like opacity in the left suprahilar region Figure .Computerized tomography (CT) scan of the chest with intravenous contrast enhancement revealed a well-circumscribed heterogeneous mass arising from the pleura adjacent to the superior and medial left pulmonary artery Figure . At the inferior extent of the tumor, there was an invasion of the left inferior pulmonary vein with extension into the left atrium Figure .The lesion was biopsied confirming a mesenchymal neoplasm compatible with SFT Figure .The patient underwent pneumonectomy and resection of left atrial mass with pericardial patch repair of the left atrium. Postoperatively, her hospital course was complicated with left-sided pneumothorax requiring chest tube placement, septic shock requiring vasopressors, acute respiratory distress syndrome (ARDS) requiring mechanical ventilation and acute renal failure requiring hemodialysis. She underwent tracheostomy and percutaneous gastrostomy tube placement. Despite efforts of the multidisciplinary team, the patient did not show clinical improvement. The family then decided to do not resuscitate (DNR) in case of cardiac arrest. Unfortunately, due to above-stated complications, the patient died in the hospital on day 107.Prior terminology for “solitary fibrous tumor (SFT)" has included pleural mesothelioma, localized fibrous mesothelioma, and localized fibrous tumor. Our patient had a previous history of hemangiopericytoma of the neck, now referred to as SFT .The localized fibrous tumor can occur anywhere including soft tissue and viscera, with a preference for serosal membranes including the pleura, peritoneum, and meninges. The first histopathologic description of SFTP was published by Klemperer and Rabin in 1931. They distinguished localized mesotheliomas from diffuse mesothelioma and proposed that submesothelial cells were the cellular origin for a localized variety .SFTP is very rare, representing only 5% of all pleural tumors. Only 800 cases were reported in the literature between 1931 and 2002 . Cough, SFTP have a very low risk of recurrence or metastasis. Surgical resection is the mainstay of treatment with good prognosis in most patients. Although usually benign, occasionally SFTP may enlarge rapidly and transform into malignant variants. Therefore, complete surgical resection and careful long-term follow-up are recommended for all patients.


Ependymomas are neuroepithelial tumors that typically occur in the central nervous system. Ependymomas arising in the mediastinum are exceedingly rare, with only approximately 9 isolated cases reported in the literature to date.A 35-year-old woman was referred to our hospital with complaints of progressive back pain for 3 months. Physical examination revealed decreased breathing sounds and tenderness. Contrast-enhanced computed tomography showed a soft tissue mass with heterogeneous enhancement in the right posterior mediastinum.The diagnosis of primary mediastinal ependymomas (PMEs) was confirmed by postoperative histopathologic examination.The patient underwent surgical resection of the tumor and experienced local recurrence with neck metastasis 2 years postoperatively. She underwent reoperation for the recurrent tumors and received postoperative radiotherapy and adjuvant chemotherapy. Two years later, the patient is doing well, with no evidence of tumor progression or recurrence.Since PMEs are exceedingly rare, treatment options are limited. Surgical resection seems to be the mainstay of treatment. Further evidence-based studies are required to prove the benefit of radiotherapy and chemotherapy in the treatment of PMEs. Although occasional cases with regional lymph node or distant metastasis have been reported, PMEs are considered as low-grade tumors and have a relatively favorable prognosis. Due to their relative rarity, optimal treatment strategies are limited and not well-established. Surgical resection with a tumor-free margin seems to be the mainstay of treatment. The benefit of radiotherapy and adjuvant chemotherapy in the treatment of PMEs remain to be proven by conducting further evidence-based studies.Ependymomas represent a relatively rare group of glial tumors that originate from the ependymal lining of the ventricular system and central canal of the spinal cord.2A 35-year-old, nonsmoking, Chinese woman was admitted to our hospital with a 3-month history of progressive back pain. She denied any injury or significant medical history. Physical examination revealed decreased breathing sounds and tenderness in her right chest. Cardiac examination was normal, with a blood pressure of 120/65 mm Hg and a heart rate of 82 beats per minute. Routine laboratory test results were unremarkable. Chest roentgenogram showed a right paratracheal opacity. Computed tomography (CT) identified a well-defined soft tissue mass measuring 6.0 cm × 5.5 cm × 3.5 cm in the right posterior mediastinum at the T2-T3 level , followed by 10 cycles of adjuvant temozolomide (150 mg/m2/d for 5 days every 4 weeks). Two years later, she remains well with no evidence of tumor progression or recurrence.The patient declined any further treatment and was followed-up in the outpatient clinic. Unfortunately, local recurrence with neck metastasis was detected through enhanced CT 2 years after the initial surgery. The patient underwent reoperation for the recurrent tumors and received postoperative radiotherapy (59.4 Gy in 1.8 Gy fractions) with concomitant temozolomide . These patients had no clinical symptom or had only nonspecific symptoms, such as back pain and dyspnea. In addition, laboratory and radiologic findings were nonspecific. However, PMEs usually appear as a well-defined mass with variable homogeneous to heterogeneous enhancement on CT or magnetic resonance imaging. The scanning acquisitions may vary depending on the presence of underlying cystic degeneration, hemorrhage, and calcification.Ependymomas are neuroepithelial tumors with ependymal differentiation that typically occur in the central nervous system.Macroscopically, PMEs are described as fairly well-circumscribed soft masses measuring 2.8 to 9.0 cm in diameter. On the cut section, the tumors show mainly solid and partially cystic components. Histopathologically, these tumors demonstrate a variety of architectural patterns, including cribriform, trabecular, cystic, papillary, and solid formations. Characteristic perivascular pseudorosettes and true rosettes are frequently present. Tumor cells are cuboidal to columnar, containing abundant clear to granular eosinophilic cytoplasm, with round to oval nuclei. The mitotic rate ranges from 1 to 10 per 10 HPF. Necrosis is observed in some cases. Immunohistochemically, the tumor cells are positive for GFAP, CK7, ER, and PR, but negative for S-100, TTF-1, CAM5.2, and CK20. In particular, the CD99 expression pattern in PMEs is usually weak and patchy compared with the strong and diffuse staining observed in central nervous system cases. In adults, the most frequent subtypes are schwannomas and neurofibromas, while ganglioneuroblastoma and neuroblastoma occur most commonly in infants and children. Other less common but important differential diagnostic considerations include lymphoma, sarcoma, extra-gastrointestinal stromal tumor, intrathoracic desmoid tumor, and granular cell tumor.–14 In addition, noncancerous diseases such as foregut cysts, Wegener granulomatosis, and thoracic extramedullary hematopoiesis may occur in the posterior mediastinum.Primary posterior mediastinal masses are relatively uncommon. The majority of primary neoplasms in this location are of neurogenic origin.,16 However, lack of conventional teratomatous elements or other germ cell components seems to rule out this possibility. On the contrary, the paravertebral and posterior mediastinal location together with a microscopic view of adjacent sympathetic ganglia and nerves supports the displaced ependymal rests theory.,17There is no plausible unifying concept for the pathogenesis of PMEs. Germ cell origin, displaced ependymal rests, and neometaplasia are the most well-known theories. Since these tumors predominantly occur in women in the ovary, broad ligament, and mediastinum, they support the theory of germ cell origin.In summary, all 10 patients with PME exhibited an indolent clinical course, and 8 were followed-up. Among them, 6 patients were asymptomatic and showed no evidence of recurrence (follow-up time 12–108 months). Of the remaining 2 patients, 1 died due to complications 4 months postoperatively, and the other reported recurrence with distant metastases. Taken together, PMEs are slow-growing, low-grade tumors. Surgical resection with a tumor-free margin is the primary treatment of choice. There are no prior reports of chemotherapy or radiotherapy for PME. We have described the 1st case that received chemotherapy and radiotherapy in addition to surgical resection.4The PMEs are exceedingly rare with only a limited number of published reports worldwide. The differential diagnosis is challenging due to the rarity of the disease and its nonspecific clinical presentation. Complete surgical excision remains the primary treatment of choice. Further evidence-based studies are required to establish the benefit of chemotherapy or radiotherapy in the treatment of PMEs.The authors thank Yuan-qiu Liang for assistance with pathology images and immunohistochemical staining. In addition, they thank Wei-tao Li for helpful suggestions and technical assistance.Resources: Jian-ping Zhou.Supervision: Zhongjun Li.Writing – original draft: Wei-biao Ye, Yong-qiang Xu.Writing – review & editing: Bi-yan Lu.


Small bowel diverticular disease is uncommon, representing 1–2% of general population. The ileum diverticulum is very rare, especially if it is complicated by enterocutaneous fistula with abdominal wall abscess.Here, we report a case of small bowel diverticulum, ileum diverticulum with enterocutaneous fistula in a 65-year man presented with lower abdominal pain and an irreducible swelling for 5 days.Diverticulosis has no exact cause, but theoretically the diverticula result from peristalsis abnormalities, intestinal dyskinesia, or high segmental intraluminal pressures. Complications of small intestinal diverticulum include bleeding, diverticulitis and its complication  .This is considered rare and serious complication of small bowel diverticulum could occur if diagnosis is delayed. A small bowel diverticular disease is uncommon; the incidence is 1–2% of general population , however2A 65-year-old Russian male, not known to have chronic medical illnesses, came to the ED complaining of painful swelling in the lower abdomen which had been going on for five days. Abdominal pain was severe colicky in nature with no relieving factors, associated with nausea and vomiting multiple times. There had been no change in bowel habits, fever or change in appetite. The patient had a history of lower abdominal surgery at the age of two, but he had no medical reportOn physical examination the patient was conscious and had a normal body built. His blood pressure was 126/92, pulse was 88 and temperature was 36.2 °C. is symmetrically distended with a swelling in the lower abdomen 12 × 15 cm in size with negative cough impulse, erythema and tenderness on the overlying skin. The rest of the abdomen was soft on palpation with positive bowel sounds. Investigation of his hemoglobin gave 10.8 wbc’s with 11.5 sodium 139 potassium 3.2 creatinine 0.7.The patient was admitted as a case of abdominal pain for investigation. The CT of abdomen and pelvic with IV and oral contrast was done showing thickened terminal ileum with marked luminal narrowing which appeared adherent to the urinary bladder wall with no line of cleavage. Two fistula tracts were seen superior and inferior; the superior one lead to a pocket of collection filled by contrast 36 × 20 mm in size. The inferior tract was connected to an anterior abdominal wall collection measuring about 18.7 × 14.4 mm with marginal enhancement denoting an abscess. There was diffuse anterior abdominal wall fat stranded with subcutaneous pockets of air denoting infection. Subcentemetric mesenteric lymphadenopathy was observed .Fig. 1A Patient was taken to the OR for exploratory laparotomy and drainage of the abscess. Upon internce to the abdomen a large pocket of pus in subcutaneous layer was opened and evacuated and a swab was sent for culture and sensitivity. A firm mass inclosing the pelvic was dissected and found to be a large diverticulum 10 cm from the ileocecal junction. The mass was attaching to the urinary bladder and was fistulating to the subcutaneous pus collection. Urology was called in at this point and the urinary bladder was checked by injecting methylene blue dye; there was no leak. Limited right hemicolectomy was performed with a primary iliocolic anastomosis .Fig. 3ReHistopathology was consistent with diverticulum of the small bowel and serosal lipoma with a pocket containing multiple staghorn-type black stones, negative to tuberculosis . Patient3We should consider the bowel communication in abdominal wall abscess cases and use imaging modalities, like computed tomography, to optimize the pathway of the management and decrease morbidity rate.46, usually from the mesenteric border2. It is uncommon; the incidence is 1–2% of general population1. Jejunoileal diverticula are less common than duodenal diverticula [Small intestinal diverticular disease is defined as out pouching of intestinal wallDiverticulosis has no exact cause, but theoretically the diverticula result from peristalsis abnormalities , intestinal dyskinesia, or high segmental intraluminal pressures. There are two types: A true type that is formed of all intestinal layer, and a false type, formed of just mucosa and submucosa . MajoritIn literature, abscess was drained percutaneous in Alvarez’s patient; however, resection and anastomosis of affected segment was the treatment for two Japanese patients (Eriguchi’s and Fujisawa’s) . This waAn enterolith formation is not usually formed in a normal anatomy of bowel; however, it can develop in the setting of intestinal stasis in the presence of intestinal diverticula, surgical enteroanastomoses, blind pouches, afferent loops, incarcerated hernias, small intestinal tumors, intestinal kinking from intra-abdominal adhesions, and stenosis or stricture of Crohn’s disease and intestinal tuberculosis . In our All authors of the research disclose that there are no financial and personal relationships with other people or organisations that could inappropriately influence (bias) their work.All authors of the research disclose that there are no sources of funding for our research.The ethical approval for the publication of this case was exempted by our institution because all of the data were collected from clinical records and imaging systems for routine perioperative planning.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.MB and WA preformed the literature review, MB acquired and interpreted the data and drafted the manuscript. MA performed the operation and perioperative management of the patient. MB, WA participated in the operation, all authors participated perioperative management of the patient, postoperative-patient care, revision of the manuscript and gave final approval of the version of the manuscript to be published. All authors read and approved the final manuscript.Not relevant here.Mutlaq Almalki accept full responsibility for the work and had access to the data, and controlled the decision to publish.Not commissioned, externally peer reviewed.


Concha bullosa is the most common variation of the middle turbinate of the paranasal sinuses. When it causes nasal obstruction, osteomeatal unit dysfunction, or rarely chronic infection, surgery is required.We present a fungal infection of concha bullosa, which is a rare indication for surgery of the concha bullosa. A 59-year-old female patient presented with hemifacial pain on the right side, which had lasted for 2 months. There were no pathological findings in her endoscopic nasal examination. Advanced examination by paranasal computed tomography (CT) revealed bilateral concha bullosa variation and soft tissue density in the right concha bullosa. As the biopsy taken from concha bullosa demonstrated fungal hyphae, endoscopic surgical treatment was performed.We stress the importance of the CT in hemifacial pain by this rare case report, in which endoscopic nasal examination was normal. Fungal infection in the concha bullosa is rare, and infected concha bullosa is a pathology to be considered in the differential diagnosis in patients with complaints of hemicranial headache. Concha bullosa, the most common anatomical variation of the middle turbinate, which is defined as the pneumatization of it, can be asymptomatic or may cause symptoms such as nasal obstruction, headache, and decrease in the sense of smell. Different studies report the incidence of concha bullosa from 14% to 53.6% . In thisA 59-year-old female patient, who was monitored at a neurology clinic, was referred to our clinic due to sustained hemifacial pain on the right side. The patient had diagnosed diabetes mellitus type 2, which was under control. There were no pathological findings in the patient's anterior rhinoscopic or endoscopic nasal examination , althougThe pathological examination report stated fungal organisms and their hyphae in the necrobiotic material submitted to pathology . "AspergConcha bullosa, which is characterized by the pneumatization and expansion of the turbinates, is the most common variation of the osteomeatal complex. The condition is encountered in the middle turbinate most frequently, although it can be observed in other turbinates as well. Pneumatization can originate from the frontal recess, agger nasi cells, anterior ethmoidal cells, and middle meatus . Concha Fungal infections of the nose and paranasal sinuses can cause allergic fungal rhinosinusitis, acute or chronic invasive fungal rhinosinusitis, and fungal balls. The causative fungal agents are most commonly reported as Aspergillus fumigatus, Aspergillus flavus, Scedosporium, Pseudallescheria boydii, and Alternaria. By PNCT imaging, these agents are observed as a mass, which rarely contains calcifications, and which has heterogenous opacity.In our case presentation, we reported a case with a normal nasal examination, but a diagnosis was made following the PNCT imaging upon suspicion. Bacterial sinusitis, mucocele, pyocele, malignant and benign tumors should be considered in the differential diagnosis. Intraoperatively, the appearance of the fungus is gritty or clay-like. The recurrences are very rare after debridement . In our Aspergillus species have a widespread geographical distribution and are commonly found in nature, particularly in the soil. In our case, we detected Aspergillus oryzae in the cultured material, which is a subspecies rarely reported to cause disease in humans. According to some experts, this species is regarded as a variant of Aspergillus flavus . In a reDespite considerable fungal infection with Aspergillus subtips in concha bullosa in the literature -12, to tAlthough fungal infection in the concha bullosa is rare, infected concha bullosa is a pathology to be considered in the differential diagnosis in patients with complaints of hemicranial headache. A paranasal CT may provide input to the differential diagnosis in patients with chronic hemicranial headache and with normal anterior rhinoscopic and endoscopic examination.


Rupture of the ureter with extravasation resulting from an iliac aneurysm is extremely rare. Herein, we report a case of ureteric rupture with urinary extravasation secondary to an iliac aneurysm.An 80-year-old man was admitted to our hospital for sudden onset of severe abdominal pain. Contrast-enhanced computed tomography demonstrated a large left internal iliac aneurysm (6.5 cm in diameter) and a ureteric rupture with leakage of contrast media from the left ureter, indicating a spontaneous ureteral rupture. The patient was treated with placement of a ureteral double-J stent under endoscopic and X-ray fluoroscopic guidance and endovascular aortic repair. His postoperative course was uneventful and he was discharged on postoperative day 20. A computed tomography scan at 2 weeks after surgery showed no contrast extravasation from the ureter or end leak.Combination treatment with ureteral and endovascular stenting is effective in avoiding aneurysmal rupture and the serious consequences of a ureteral rupture, which include a perinephric or retroperitoneal collection, abscess formation, subsequent urosepsis, and graft infection. Spontaneous rupture of the ureter is an uncommon condition defined by the non-traumatic extravasation of urine. It is usually secondary to a downstream obstruction by urinary calculi, stricture, or extrinsic compression resulting from malignancies, retroperitoneal fibrosis, and so on , 2. HoweAn 80-year-old man was admitted to a nearby hospital for the sudden onset of severe abdominal pain. Plain computed tomography (CT) showed a large left internal iliac aneurysm (IIA). An aneurysmal rupture was suspected, and he was transferred to our hospital for surgical treatment. His past medical history was significant for hypertension and a lack of a history of renal calculus. On physical examination, his blood pressure was 135/75 mmHg; pulse, 90 beats per minute and regular; and temperature, 36.5 °C. His abdomen was distended and tender to palpitation, but was without peritoneal signs. Laboratory data revealed a normal hemogram, with the exception of increased leukocytes , normal serum electrolytes, blood urea nitrogen level of 20 mmol/L, and serum creatinine level of 1.2 mg/dl. Chest X-ray demonstrated no cardiomegaly or any abnormal findings.Contrast-enhanced CT revealed a large left IIA (6.5 cm in diameter) Fig. . Blood eTo avoid the potential risk of graft infection due to urinary extravasation, a ureteral double-J stent was placed under endoscopic and X-ray fluoroscopic guidance. Endovascular aortic repair (EVAR) was performed under general anesthesia on the same day to avoid aneurysmal rupture. The patient underwent endovascular coil deployment within the left IIA and endovascular stent grafting from the left common iliac artery to the left external iliac artery  Fig. . Final aHis postoperative course was uneventful, and he was discharged in good health on postoperative day 20. The progressive reduction of an urinoma was followed by serial CT performed 2 weeks later, which showed its complete resolution.Spontaneous rupture or extravasation of the ureter due to an iliac/aortic aneurysm is extremely rare; only seven such cases have been reported –9. The mTheoretically, the urine spilled into the retroperitoneal space is sterile. Akpinar et al. reported that the initial management of ureteric rupture is usually conservative . HoweverUreteral stenting is useful to avoid the serious consequences of ureteral rupture, including graft infection , 12, 13,Although combination treatment was selected to avoid aneurysmal rupture in this case, staged operation might be taken into consideration for unruptured cases to minimize the risk of graft infection as an alternative. The ureteral stenting together with the following antibiotics and surveillance of blood cultures might contribute to decide treatment strategy. Obrand et al.  and EdmoWe presented a rare case of ureteral rupture due to the expansion of an iliac aneurysm. Combination therapy, with ureteral stenting and EVAR, is useful in avoiding an aneurysmal rupture and the hostile consequences of a urinoma.


Cavernous malformations are congenital or acquired vascular abnormalities. They are uncommon entities with an incidence of 0.5% of the general population and usually are unnoticed until a hemorrhagic event occurs. Cavernomas can be concurrently seen with developmental venous anomalies (DVAs) in 20% (range 20%-40%) of cases, in which case they are known as mixed vascular malformations. We report a case of a healthy young adult, who presented with acute onset of headache, dizziness, and nausea with intermittent episodes of vomiting for four days. Brain tomography imaging at presentation revealed likely multiple foci of intracranial hemorrhage; however, magnetic resonance imaging (MRI) showed findings suggestive of an underlying cavernoma that had bled, in addition to a coexisting DVA. The patient was discharged home with no deficits. Outpatient follow-up five months later revealed no symptoms or neurologic deficits. Cavernous malformations are a rare type of cerebral vascular malformation. These are slow-flow vascular structures that undergo recurrent hemorrhage and are characterized by low and high intensities on magnetic resonance imaging (MRI) ,2. With We present a 35-year-old Hispanic male with no significant medical history and a social history remarkable for occasional cocaine and marihuana use who presented complaining of a right-sided parietal headache and dizziness. A review of his systems was also positive for intermittent nausea and vomiting for four days. Examination revealed an alert and oriented patient, with no focal deficits appreciated, moving all extremities with sensation grossly intact. Lung auscultation and abdominal examination did not disclose any abnormal findings. His laboratory workup was unremarkable, without significant electrolyte imbalances noted. A computed tomography (CT) scan of the brain was done, which revealed intracranial hemorrhages, with a prominent 12 mm hemorrhagic component layering along the right side of the fourth ventricle, trace hemorrhage along the bilateral tentorium and posterior interhemispheric fissure as well as a punctate hemorrhagic focus about the left paracentral frontal lobe, as can be seen in Figure Cavernous malformations are congenital or acquired vascular anomalies that occur in approximately 0.5% of the general population. Patients are usually asymptomatic but may present after an acute or recurrent hemorrhage usually around 40 to 60 years of age. Initial presenting features may include seizures, headaches, and neurologic deficits ,2,4,5,6.MRI is considered the most sensitive and specific modality for detecting cavernomas . It has Cavernomas tend to be supratentorial (80%) and are usually solitary. One third of patients with sporadic lesions may have more than one . Larger On MRI, cavernomas are better evidenced using special techniques such as gradient echo (GRE) or susceptibility weighted imaging (SWI). They usually have a characteristic popcorn, ball-like appearance with a low-signal-intensity rim due to hemosiderin deposition -4,9. SubCavernomas can be concurrently seen with DVAs in 20% of cases (range 2%-40%). When this occurs, they are known as mixed vascular malformations . In our Dystrophic calcifications may be seen in up to 30% of cases. DVAs demonstrate the classic appearance on post-contrast MRI and CT. Susceptibility weighted imaging is the preferred sequence for low flow venous anomalies. Angiography also demonstrates the classic caput medusae appearance during the venous phase with normal arterial phase and no shunting. No differential diagnosis is usually offered since DVAs tend to have a classic appearance. Cerebral DVAs can also be associated with head and neck venous malformations .Isolated DVAs require no treatment. Asymptomatic cavernomas can be treated conservatively. Symptomatic cases presenting with hemorrhage, edema with resultant mass effect and epileptic activity may require surgery. In these symptomatic cases, when possible, complete resection is curative. The current established indications for surgical management are overt hemorrhage, focal neurologic symptoms, and/or medically intractable epilepsy. It is imperative to inform the surgeon of the presence of associated DVA, since cauterization of collecting vein can result in venous infarct of the area of brain being drained.This case presents a patient with intracranial hemorrhage with an underlying cavernoma and likely associated DVAs. Cavernous malformation is an uncommon entity that might coexist with deep venous anomalies, therefore making management more challenging. The brain imaging findings and clinical presentation in our patient suggest that the cavernoma represents the primary cause of the hemorrhagic event with an underlying DVA. Magnetic resonance imaging is usually the diagnostic tool of choice to evaluate DVAs. In cases of isolated cavernoma, conservative treatment with periodic clinical monitoring and imaging is sufficient. This differs from cases that present with hemorrhage, in which case surgical intervention might be considered depending on the extension. It is important for physicians to be aware of the association of cavernous malformations and developmental venous anomalies.


A 42-year old male patient presented with marked swelling of the lower legs after direct impact to the calf muscles due to a motor vehicle accident. The lesion on the right side was larger than the contralateral lesion. On clinical examination, a fluctuating mass at the posterolateral aspect of the both knees and lower legs was seen.Ultrasound showed a well-delineated anechoic collection between the subcutaneous fat and the fascia of the calf muscles. The lesion were compressible with the ultrasound transducer. On the right side, there was extension of the lesion underneath the lateral collateral ligament. On images with compression, a small intralesional echogenic focus was seen  T2-weighted (WI) MRI of the right knee revealed a half-moon shaped hyperintense collection between the subcutaneous fat and the fascia of the calf muscle and lateral collateral ligament , followed by the thigh (24%) and the pelvis (19%). The knee is the fourth most common involved region (16%).On ultrasound, the lesion is anechoic or hypo-echoic and has a typical fusiform or oval shape. It is compressible with the ultrasound transducer. Intralesional fat globules may be seen as small hyperechoic foci. Some lesions may contain internal septations or a fluid-fluid level.Magnetic resonance imaging (MRI) may be used for more precise assessment of the lesion’s extent, particularly in large lesions. It provides the referring clinician with a more global overview and may be useful for evaluation of the shape of the lesion. In our case, the lesion on the right knee has a peculiar semilunar appearance. The signal of the lesion may vary depending on the signal of internal blood degradation products. In most scenario’s, the signal is hypointense or slightly hyperintense on T1-WI and hyperintense on T2-WI. As on ultrasound, fluid-fluid levels, internal septations or fat globules may be present.Treatment consists of aspiration and compression bandages. In chronic lesions in which a peripheral capsule has formed, resection of this capsule may be required in order to prevent re-accumulation of hemolymphatic fluid.In conclusion, the clues to the correct diagnosis of a Morel-Lavallée lesion are the history of a closed degloving injury and the typical location of the lesion between the fascia and the subcutaneous fat. Although most lesions are fusiform or oval, a more crescentic shape may be seen in larger lesions, such as in our case.The authors declare that they have no competing interests.


Ameloblastic carcinoma (AC) is an exceedingly rare odontogenic cancer about which there is limited information in the literature. We present a case of AC originating in the sinus cavity and extending to the skull base in a patient in the first trimester of pregnancy. Diagnostic work up was complicated by this pregnancy, which delayed radiation exposure with imaging. Once scans were obtained, diagnosis was further complicated by the radiographic similarities between possible lung metastases and previously undiagnosed sarcoid nodules. After thorough work up to rule out metastatic disease, the patient was successfully treated with primary surgical resection followed by adjuvant chemoradiation. The patient remained disease free at one year after therapy. This case demonstrates the importance of thorough work up in the diagnosis of AC, and is an opportunity to review the literature and discuss therapeutic methods to treat this rare, aggressive neoplasm. Ameloblastic carcinoma (AC) is a locally aggressive odontogenic malignancy of embryonic origin. It is most commonly identified in the mandible or maxilla . Less thA 27-year-old female with recurrent right-sided sinus symptoms was referred to an otolaryngologist by her primary care provider. She reported symptoms for 4-5 months, including right facial pressure and pain, right eye pressure, nasal discharge, and right nasal dyspnea. There was no nasal bleeding or visual disturbance at the time of presentation. She had been treated with two courses of antibiotics and a trial of saline irrigations with no relief. She was seven weeks pregnant at the time of initial presentation.Physical examination demonstrated left septal deviation and crusting around the right middle turbinate with visible granulation tissue. Cranial nerves were grossly intact. A flexible nasal endoscopy performed at the clinic revealed a granulomatous lesion filling the right superior nasal vault extending from the middle meatus to the medial septum. A biopsy of the mass was obtained under local anesthesia. Computed tomography (CT) imaging was postponed pending results of the biopsy due to fetal risk in pregnancy from radiation exposure and intravenous contrast.Differential diagnoses of a granulomatous nasal lesion include infection such as fungal rhinosinusitis; inflammatory causes such as trauma, intranasal cocaine abuse, and chronic granulomatosis; and neoplastic etiologies including inverting papilloma and nasal cancer .Pathologic analysis of the patient’s biopsy was suggestive of squamous cell carcinoma in situ, and diagnostic work-up proceeded with non-contrast CT imaging. This demonstrated a large intranasal mass measuring 2.6 x 4 x 4.3 cm, with associated bony destruction in the right medial orbital wall, cribriform plate, lamina papyracea, and planum sphenoidale Figures -2. MultiFurther imaging was performed with non-contrast magnetic resonance imaging (MRI), which confirmed findings found on CT as well as mucosal thickening of the right maxillary, sphenoid, and frontal sinuses. MRI also showed lateral bowing of the mass into the extraconal compartment of the right orbit, with no definite extension through the periosteum or involvement of extraocular muscles and no clear brain invasion Figure . There wThe patient experienced increasing pressure and pain in the nasal and facial regions, as well as proptosis and progressive nasal bleeding. The right nasal passages became completely obstructed within one month of presentation. She had no respiratory symptoms upon initial presentation, but began to develop progressive dyspnea that was present at rest. She did not experience hemoptysis or other respiratory symptoms.Biopsies of the patient’s lesion were sent for genomic and proteomic profiling through GPS CancerTM . This demonstrated normal levels of ERCC1 and TUBB3 markers, indicating that the tumor was sensitive to platinum agents and taxanes. Sensitivity to chemotherapeutic agents in clinical trials targeting MSLN-protein were performed but were inconclusive. No other targetable genes, tumor suppressors, or oncogenes were found.A positron emission tomography CT (PET/CT) was performed for further staging and demonstrated enhancement in the right nasal cavity, as well as enlarged fluorodeoxyglucose (FDG)-avid nodal activity in the mediastinum and bilateral hila. There were multiple bilateral FDG-avid pulmonary lesions including a 1.6 x 1.6 cm nodule in the right lung apex and a 7 mm nodule in the left lung apex Figures -5. No inSurgical excision with adjuvant chemoradiation was considered, as well as palliative treatment and comfort care measures. Due to the patient’s poorly defined tumor staging, it was decided that a surgical debulking would be performed with concurrent CT-guided percutaneous biopsies of lung lesions under anesthesia. The patient elected to terminate her pregnancy at 11 weeks gestation due to the risk of metastatic disease and the teratogenic effects of the associated treatments of radiation and chemotherapy.A primary endonasal endoscopic debulking surgery was performed. Tumor was found affixed to the skull base along the cribriform plate and anterior fossa region. The tumor was found to completely obstruct the maxillary antrum and had caused local destruction of the middle turbinate Figure . BiopsieDue to high risk disease and concern for recurrence, adjuvant chemoradiation was initiated with six cycles of cisplatin (40 mg/m2) and 5580 cGy radiation to the paranasal sinuses. The patient experienced resolution of her initial symptoms, with only minor complications of swelling of the face, likely due to radiation therapy.A PET/CT performed six months post-operatively demonstrated no evidence of disease at the primary site and improvement of hypermetabolic adenopathy of the chest Figure . There wThe epidemiology of AC is difficult to ascertain due to its extremely low incidence, but one collaborative study found that as of 2016 there were <120 cases of AC reported in the literature [The etiologies of this neoplasm include both primary and secondary AC. Approximately 2% of benign ameloblastomas will metastasize, causing metastatic ameloblastoma or secondary AC. Primary AC is a de novo development of a primary tumor with cytological atypia, including nuclear pleomorphism and high mitotic activity. This classification is made regardless of the presence of metastases at the time of diagnosis. Clinical outcomes are indistinguishable between the two classifications -7.The typical clinical symptoms of AC are more aggressive and develop more rapidly than those of ameloblastoma, and include swelling, pain, trismus, dysphonia, expansion of jaws, and perforation of the cortex. These findings are consistent with the initial presentation of this patient. AC metastases spread locally to regional lymph nodes, and can include distant hematogenous spread, most often to the lungs .Initial diagnosis of AC is made with imaging studies. MRI with contrast is the preferred study, although conventional CT with contrast can also be used. However, it can be difficult to distinguish an ameloblastoma from AC with CT and MRI imaging. A more definitive diagnosis of AC can be made with PET/CT imaging and FDG uptake . DefinitThis patient’s diagnostic workup was complicated by her pregnancy and sarcoidosis. A CT scan was not performed until after biopsy results suggested carcinoma in order to prevent radiation exposure to the fetus. Similarly, contrast-enhanced imaging with CT and MRI were not used initially due to its potential teratogenic effects. Concurrent sarcoid nodules in the lungs mimicked metastases and complicated disease staging. Sarcoidosis and metastatic disease may present with similar clinical and diagnostic findings, and cases have been reported of sarcoidosis first presenting in the setting of solid malignancy . For thiThere is no established consensus on treatment of AC due to the low incidence of the disease, although wide local excision is the mainstay of therapy for the primary tumor. As it has been minimally studied, it is unclear if there is a significant difference in cure rates in excision alone versus excision with adjuvant chemoradiation. Regional lymph node dissection is also done selectively and should be considered. Treatment of local extension and metastases usually involves some combination of chemotherapy and radiation. In rare cases, neoadjuvant radiation or chemotherapy is used to shrink a tumor prior to resection. Radiation therapy alone can be effective, but is reserved for local recurrences or cases where the primary tumor may not be surgically resected. In cases of systemic metastases, chemotherapy may be indicated, although studies have demonstrated mixed results. Targeted therapy focused at genomic aberrations is experimental ,11-13.The prognosis for a patient with AC is determined by many factors, including tumor size and histopathology. AC carries a more favorable survival rate when compared to other odontogenic malignancies, although the prognosis of AC is usually poor due to advanced disease at the time of presentation. A better outcome is associated with smaller tumor size, younger age at diagnosis, and ability to undergo surgical resection and radiation therapy ,14. ApprThe existing fund of knowledge regarding AC is limited by the rarity of this disease, and most information is presented in the form of single case reports or case series . This prAC is a rare odontogenic malignancy that is often found late in its course and therefore carries a poor prognosis. Due to its low incidence, there is little existing knowledge in its diagnosis and management. Most primary neoplasms are found in the mandible or maxilla; it may arise primarily or as secondary metastasis of an existing ameloblastoma. Diagnosis of AC is best accomplished with radiologic imaging and histopathology, but the diagnostic approach can be complicated by factors such as pregnancy. Due to its propensity to metastasize to the lungs, it is important to obtain pulmonary imaging in any patient with suspected AC. Although a rare malignancy, it is important for clinicians to be aware of the signs and symptoms of AC so that early diagnosis and intervention can be initiated.


Primary benign neurogenic neoplasms of the pleura are exceedingly rare. Neurofibromas rarely involve the pleura. A review of the literarture reveals only a single reported case of isolated pleural neurofibroma. Herein the authors describe another case of isolated primary pleural neurofibroma. A 39-year-old nonsmoker woman presented to the emergency room with complaints of progressively worsening chest pain of one month duration. A computed tomography of the chest revealed a crescent shaped, pleural based mass suspicious for a neurogenic tumor such as an intercostal schwannoma. A PET-CT skull base to midthigh failed to reveal any other masses or abnormalities. A surgical excision of the mass was performed due to the patient's intractable pain. The resected specimen consisted of an ovoid fragment of soft tissue with pale yellow, smooth and glistening cut surface. Microscopic examination revealed the tumor to be composed of spindle cells with wavy nuclei arranged haphazardly in loose collagenous and pale myxoid stroma with rare interspersed mast cells. The spindle cells were diffusely positive for S100 protein and SOX-10, and focally positive for neurofilament. In the absence of any other masses in the patient and no pertinent history, a diagnosis of primary pleural neurofibroma was made. This case emphasizes the need to consider neurofibroma in any spindle cell neoplasm of the pleura irrespective of age or singularity. Pleural neoplasms are more commonly metastatic than primary. Primary neoplasms of the pleura are exceedingly rare . They arNeurofibromas are benign neurogenic tumors that rarely involve the pleura . A revieThe patient is a 39-year-old woman who presented to the emergency room with complaints of progressively worsening chest pain of one month duration. The pain was of gradual onset, moderate in intensity, constant, and localised to the left upper quadrant. She was nonsmoker with no significant medical history. Physical examination was within normal limits. A computed tomography of the chest revealed a crescent shaped, pleural based mass, measuring 6 × 4.9 × 3.8 cm, with some modelling and cortical irregularity of the superior aspect of the left lateral fourth rib suggestive of a long standing process . These iA surgical excision of the mass was performed due to the patient's intractable pain. Intraoperatively, the pleural mass was ovoid, smooth, well-circumscribed and could be separated from the lung parenchyma. It was resected and sent to pathology.The resected specimen consisted of an ovoid fragment of soft tissue measuring 7 × 5.3 × 2.4 cm. The cut surface was pale yellow, smooth and glistening Figures . MicroscThe patient's post-surgical course was uneventful and continues to be in follow-up with no new complaints at the time of this report.Primary benign pleural neoplasms are infrequent . HoweverDue to the extensive nerve supply throughout the thorax, neurogenic tumors arise in this location and account for approximately 9% of primary mediastinal tumors in adults . Ribet eBenign nerve sheath tumors encountered in the thorax include schwannomas, ganglioneuromas, and neurofibromas . Ratbi eNeurofibromas originate from Schwann cells and fibroblasts and may arise in any peripheral nerve. They most often affect patients between 20 and 30 years of age and have no sex predilection . ApproxiPleural involvement by neurofibroma is exceedingly rare with only three cases reported so far , 13. Of The differential diagnosis for neurofibromas in the pleura includes but is not limited to neural neoplasms, such as schwannoma and ganglioneuroma, as well as a variety of nonnerve sheath tumors, in particular solitary fibrous tumor, mesothelioma, synovial sarcoma, fibrosarcoma, and undifferentiated pleomorphic sarcoma. The malignant neoplasms such as mesothelioma, synovial sarcoma, fibrosarcoma, and undifferentiated pleomorphic sarcoma can be excluded due to the absence of any features of malignancy in conventional neurofibromas while benign neoplasms such as ganglioneuroma have characteristic histologic features that preclude confusion with neurofibroma.Differentiating a neurofibroma from a schwannoma and solitary fibrous tumor may sometimes be challenging. The presence of mast cells, which is integral in the development of neurofibromas, is one of the most specific hisopathological features that help clinch the diagnosis of neurofibroma , 15. ImmTreatment of localized neurofibromas is complete surgical resection. Neurofibromas grow within and cannot be separated from normal nerve, and complete excision of the neoplasm requires sacrifice of the nerve. This is acceptable in cases of pleural neurofibroma as they do not involve major nerves. Local recurrence after complete excision is unusual .This case emphasizes the need to consider neurofibroma in any spindle cell neoplasm of the pleura irrespective of age or singularity. The main differential diagnosis includes schwannomas and solitary fibrous tumor which can be excluded in most cases by histopathology supplemented with immunohistochemistry. Complete surgical resection is curative.


Cholecystocutaneous fistula is an extremely rare complication of gallstones. The majority of the fistulae localize into the right upper quadrant of the abdomen. Diagnosis is not easy because the symptoms are nonspecific. External biliary fistula is more common in females between the 5th-7th decades because in this age group the frequency of cholecystitis is increased.A 65-year-old man presented with a swelling in the right hypochondrium. He had not complained of any serious symptoms. Laboratory investigations were normal. Both abdominal ultrasound and Multislice computed tomography (MSCT) showed that the gallbladder contained stones, in addition to a cystic mass in the abdominal wall. The previous findings suggested that there was an abscess. So, the patient underwent laparoscopic procedure, and we found a fistula between the gallbladder and the abdominal wall causing the abscess. The greater omentum was adherent to the inflamed gallbladder. So that we transformed into open procedure to perform cholecystectomy and resect the fistula.Biliary fistulae have two types, external and internal. The most common type is internal. External biliary fistulae emerge like a complication of cholecystolithiasis in general. Spontaneous cholecystocutaneous fistulae occur due to acute inflammation caused by cholecystitis or chronic gallstones disease. The most common clinical manifestation is an abscess in the abdominal wall that discharges bile to the outside.Computed tomography is considered the gold standard in diagnosing a spontaneous cholecystocutaneous fistula, and it should be considered as a differential diagnosis for any abscess that is evident in the abdominal wall. Thelisus was the first one who reported cholecystocutaneous fistula in 1670. Then, 169 cases of biliary fistula in the 19th century defined by Courvoisier . The maj23, lipase 17 U/l, ALT of 0.7 U/L, AST of 23 U/L. Abdominal ultrasound showed a cystic mass in the abdominal wall and thickened gallbladder containing stones; on the other hand, common bile duct (CBD), liver, spleen, kidneys were all within normal. Multislice computed tomography (MSCT) showed the cystic mass in the abdominal wall (4.6 × 7.8) cm [A 65-year-old man presented with a complaint of a swelling in the right hypochondriac area. There was no vomiting or nausea, no changes in the weight, no hyperthermia, but the patient was a smoker and had hypertension. Physical examination showed slight localized tenderness, no redness was noticed, and the rest of the abdominal examination was normal. Weinberg’s test was negative. Blood tests revealed a white blood cell count of 8800/mm 7.8) cm . Then, t 7.8) cm a and b. 3Biliary fistulae have two types internal and external. Internal fistulae are more common than external fistulae, considering that 75% of internal fistulae connect with the duodenum, 15% connect with the colon, and 10% connect with the stomach or jejunum or have a connection with many organs [External biliary fistulae usually occur as a complication of cholecystolithiasis. However, external biliary fistulae can occur secondary to cholangiocarcinoma and biliary laceration during the surgical procedure ,7. Spont4The spontaneous cholecystocutaneous fistula is rarely reported in the medical literature. Fistulae can form in any elderly patient who underwent previous percutaneous treatment for acute cholecystitis and had recurrent cholecystitis. CT is considered the best investigation in the diagnosis. Treatment includes surgical and pharmacological therapy. This disease should be considered as a differential diagnosis for any abscess in the abdominal wall.There are no sources of funding.Not required for case reports at our hospital. Single case reports are exempt from ethical approval in our institution.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Kusay Ayoub: managed the patient and did the surgery, design of the study, data interpretation and analysis, revision.Mohamad shadi Alkarrash: data collection, revising critically, wrote the manuscript.Mohammad Nour Shashaa: review and editing, data analysis, wrote the manuscript.Aya Zazo: patient care, revision, corresponding author.Roaa Rhayim: design of the study, revision, Validation.Nihad Mahli: the supervisor, patient care, revising critically.All authors read and approved the final manuscript.NA.Dr.Kusay Ayoub.Not commissioned, externally peer-reviewed.The authors declare that they have no conflict of interest.


Abdominal tuberculosis is rare in immunocompetent infants. We report on two infants with peritoneal tuberculosis (6 and 8 months) who underwent laparotomy for suspected intussusception. In the first patient, characteristic lesions of peritoneal tuberculosis were observed intraoperatively with presence of multiple granulations. Tuberculin intradermal reaction (IDRt) was positive and tuberculous contagium could be cultured. In the second patient, the IDRt and GeneXpert tests were negative. In both patients, the histopathological examination of the biopsy specimens confirmed the diagnosis of peritoneal tuberculosis. The clinical courses under tuberculostatic therapy were favorable in both cases. Childhood tuberculosis (TB) is a public health problem around the world. According to the World Health Organization (WHO), the percentage of TB in children varies from 3% to over 25%, depending on the country.A 6-month-old female infant  with an unremarkable medical history was transferred to our pediatric ward because of postprandial vomiting for 5 days. On clinical examination, she was subfebrile (38°C) and had a distended but soft abdomen. No mass was palpable. Abdominal ultrasound suggested the possibility of intussusception. As an enema to reduce intussusception was no therapeutic option at our center, the abdomen was surgically explored. On laparotomy, blood-stained but clear ascites was found as well as intestinal adhesions. Moreover, we saw diffuse granulations, mesenteric lymphadenopathy, and ischemia of the terminal ileum and2. An 8-month-old  boy from Mauritania with no particular pathological history was transferred from a health center near the Senegal–Mauritanian border for the management of peritonitis. The clinical picture had evolved for 15 days, with the appearance of abdominal bloating associated with vomiting and cessation of bowel movements. On clinical examination, he had a temperature of 38°C, and was tachycardic at 148 beats per minute. He showed nutritional edema and flank dullness. His abdomen was distended and had peritonitis on palpation. Therefore, the boy was taken to the operating room. Surgical exploration revealed clear ascites associated with small intestinal granulations and adhesions. We performed adhesiolysis, biopsies, and drainage of the peritoneal cavity. Postoperatively, GeneXpert tests were performed on the peritoneal fluid and the IDRt was negative. Anatomopathological examination of the operative specimens revealed the presence of caseous necrosis compatible with peritoneal TB. The medical treatment and the evolution were identical to Case 1.The most common digestive tract localization of pediatric TB is the peritoneal serosa.Peritoneal TB is rare in infants, and diagnosis can be challenging. In children with abdominal pain, low-grade fever, and ascites, this differential diagnosis should be taken into consideration, especially in endemic arias. Medical treatment is usually effective.


Spindle cell xanthogranuloma is a rare variant of juvenile xanthogranuloma that most commonly presents in adults as papulonodules. We describe a vascular-appearing case of spindle cell xanthogranuloma on the nose of a 10-year-old boy. The lesion was a dark red, well-demarcated, dome-shaped papule. Histopathology revealed spindle-shaped histiocytes in a storiform pattern that stained positive for cluster of differentiation 68 (CD68) and the nuclear antigen Ki-67. No vascular features were found. To our knowledge, this is the first reported spindle cell xanthogranuloma to mimic an angiomatous lesion. Juvenile xanthogranuloma (JXG) is a benign proliferative disorder of dermal histiocytes that typically presents as yellowish to reddish papulonodules . SpindleA 10-year-old male patient presented with a 13-mm well-demarcated, dome-shaped, dark red nodule on the left ala  was also high on our differential diagnosis since it also presents as a rapidly growing reddish nodule in children . NakamurHistological examination of SCXG typically reveals Touton-type multinucleated giant cells and spindle-shaped histocytes in a storiform pattern . The macSCXG is a rare form of JXG that may clinically masquerade as various other neoplasms, including angiomatous lesions and Spitz nevi.


Pulmonary benign metastasizing leiomyoma (PBML) is rare, usually occurs in women who underwent hysterectomy during the reproductive years, and has no obvious clinical symptoms. A full understanding of the characteristics of PBML is important for its sequential treatment and prognosis.In this report, a 36-year-old female patient with previous uterine leiomyoma who underwent 3 surgical resections of the uterus, bilateral fallopian tubes, and partial omentum was investigated. The physical examination revealed a tumor in the right lower lobe and mediastinum and a solid nodule in the right middle lobe.Chest computed tomography (CT) confirmed a tumor in the right lower lobe and mediastinum and a solid nodule in the right middle lobe. Further positron-emission tomography computed tomography (PET-CT) with 18F-fluorodeoxyglucose (FDG) of the whole body showed mildly intense accumulation of 18F-FDG in the tumor . A pathological examination then confirmed the presence of fibrous and vascular tissue after CT-guided percutaneous biopsy of the tumor in the right lower lobe. Additionally, surgical resection of the tumor and nodule was performed for histological analysis and immunohistochemical assays for estrogen receptor (ER) and progesterone receptor (PR).The patient underwent complete tumor surgical resection and nodule wedge resection.No postoperative complications occurred. No recurrence or other signs of metastasis were found during an 18-month follow-up observation period.In this case, lung and mediastinal metastasis of uterine fibroids was observed. However, depending on only a postoperative histological analysis is insufficient for the diagnosis of PBML. Histological analysis combined with an evaluation of the expression levels of ER and PR is crucial for the diagnosis and treatment of PBML. PBML is more common in women aged 34 to 55 years than in women in other age groups and has an average age of 47 years. The period from hysterectomy to nodule detection varies from 3 months to 20 years, with a median interval of 14.9 years. PBML has no clinical symptoms and is often found by physical examination or for other reasons. Immunohistochemistry plays an important role in confirming the diagnosis. Here, we present a case of uterine leiomyoma with rare metastases to the lungs and mediastinum with a fusion growth pattern. We used immunohistochemistry to detect estrogen receptor (ER) and progesterone receptor (PR) expression to confirm the diagnosis.Pulmonary benign metastasizing leiomyoma (PBML) is a very unusual disease that occasionally occurs in women who underwent a hysterectomy during the reproductive years. In 1939, Steiner first reported a case of death from pulmonary heart disease caused by multiple benign metastatic leiomyoma in the lung and mediastinum,2This study was approved by the Ethics Committee and Institutional Review Board of the Fourth Hospital of Hebei University, Shijiazhuang, China. The patient provided informed consent for publication of this case.A 36-year-old woman was found to have a right lower lobe tumor on a computed tomography (CT) chest examination in March 2018. She had no cough, no phlegm, no blood in the phlegm and no other clinical symptoms. A routine physical examination showed no signification abnormalities. The patient previously underwent uterine leiomyoma excision in 2009 and 2012. In 2017, the patient was found to have an omental mass on a CT examination, and she then underwent resection of the uterus, the bilateral fallopian tubes and the omental tumor. The postoperative pathology of the omental tumor was leiomyoma. The tumor marker levels were normal.A chest CT examination indicated that a mass located in the right lower lobe that involved the right hilum and mediastinum showed a fusion growth pattern. The mass was characterized with an irregular form and sharp margins, and its size was approximately 13.2 cm × 11.1 cm × 8.9 cm, without cavities and calcifications  is very rare and is defined as a tumor with a histological appearance similar to that of uterine leiomyoma and grows outside the uterus. BML can metastasize to the lung, mediastinum, retroperitoneal area, inferior vena cava, right atrium, brain, vertebra, and skin; however, the lung is the most common site, and the resulting lung metastases are known as PBML. PBML usually has no clinical symptoms and is often found during a physical examination or unintentionally for other reasons. However, in some cases, patients may complain of chest pain, cough, hemoptysis and other symptoms; these are related to the location, size and number of metastatic tumors.Uterine leiomyoma is a common benign uterine tumor that occurs in women of reproductive age. Approximately 50% of women over 30 years old suffer from uterine leiomyoma. retrospectively studied 150 patients and attempted to determine the origin and mechanism of BML. At present, there are 3 main theories regarding the development of PBML: 1. PBML originates from well-differentiated sarcoma of uterus.,7,8 2. PBML originates because of the independent development of multiple centers stimulated by abnormal hormones. and 3. The vascular transfer theory, which is the most widely accepted theory,,10 states that the pathological morphology of the tumor is similar to that of uterine leiomyoma, including positive ER and PR expression, but ER and PR was uniformly negative in extrauterine leiomyomas. In addition, recent cytogenetic studies–15 have shown that PBML has the same genetic pattern as uterine leiomyoma, and cloning studies have confirmed that benign PBML is consistent with the characteristics of uterine leiomyomas. The metastasis pattern may appear as follows: the uterine leiomyoma invades the uterine blood vessels, and the tumor cells form a leiomyoma plug along with the blood circulation in the pulmonary artery. They then adhere to the blood vessel wall before implanting and proliferating to form new leiomyoma nodules. Hence, hysteromyoma resection increases the possibility of metastasis. This report supports the theory of vascular metastasis.Awonuga et al,17–19 of benign metastatic leiomyoma of the lung are similar to those of other metastatic tumors. The manifestations are multiple solid nodules in the lungs; they are rarely found as a single nodule and occasionally present as miliary nodules. The nodules vary in size, ranging from a few millimeters to a few centimeters. The nodules are usually well circumscribed and have no lobulations and cavities or calcifications. Contrast-enhanced scans usually show no enhancement or mild enhancement. Mediastinal lymph node enlargement and pleural effusion are rare. PET/CT usually shows mildly intense accumulation of 18F-FDG in the nodules. In this case, a mass with an atypical location invaded the right hilum and mediastinum and involved the blood vessels and bronchi in the right lower lobe. This behavior is very rare and very similar to that of a malignant tumor. PET/CT and CT-guided percutaneous biopsy are important methods for distinguishing between benign and malignant tumors in the lungs. The maximum SUV value on PET/CT for the tumor was approximately 2.6, and the CT-guided percutaneous biopsy in this report found fibrous hemangiomatous tissue. All of these findings suggested benign tumors. The CT-guided percutaneous biopsy failed to obtain a correct diagnosis, probably due to the small number of tissue samples and the absence of additional immunohistochemistry to diagnose the tumor. However, the right middle lobe nodules conformed to the imaging findings of metastases.The imaging findings,10,16–19: 1. multiple or single solid nodules in the lungs with clear boundaries; 2. in general, no obvious clinical symptoms, but nonspecific symptoms, such as cough and chest pain, may be present; 3. no history of primary malignancy in other systems; 4. a history of hysteromyoma or hysteromyoma resection; and 5. histopathological morphology of the intrapulmonary leiomyoma similar to that of the uterine leiomyoma with positive ER and PR expression. In this case, the tumor showed atypical performance and was difficult to distinguish from malignant tumors. The patient had a history of two hysteromyomectomy procedures and a history of omentum leiomyoma. Omentum tumors are considered to be metastatic from the uterus. One year after surgery to treat the omentum leiomyoma, 2 masses in the right lung were unintentionally found on a chest examination, and their postoperative pathological morphology was consistent with leiomyoma. An immunohistochemical analysis revealed positive ER and PR expression, suggesting that the origin was the uterus; these findings met the diagnostic requirements for PBML.The diagnosis of PBML requires 5 findings indicating that patients require close observation after surgery. No tumor recurrence or other signs of metastasis were found in a follow-up examination of our patient performed at 18 months after the operation. PBMLs are hormone-dependent tumors. Hormone therapy,21–23 is an important adjuvant therapy and the main treatment method for tumors that cannot be surgically removed . The aim of these methods is to reduce estrogen levels and control tumor growth. Tumors may stop growing or shrink during pregnancy or after menopause,,21,24 but there are also cases in which metastatic tumors were found in postmenopausal women.PBML progresses slowly and has a favorable prognosis. There are currently no treatment guidelines for PBML. The specific treatment depends on the number, size, and location of the tumor, its receptor expression, the progression of the lesion, and the patient's own state. Surgical resection of metastatic tumors is an important treatment for isolated tumors. Kayser et al reported that the median postoperative survival period of 10 patients with PBML was 94 months,Uterine leiomyoma is a common benign gynecologic tumor that can present malignant tumor behavior. Chest X-ray or CT examination can reveal solid nodules in women of reproductive age who have a history of uterine leiomyoma or surgical resection of uterine leiomyoma. We must be aware that the nodules may metastasize from the uterus. Positive ER and PR expression is an important indicator for the diagnosis of PBML that affects the choice of treatment and prognosis of patients.Formal analysis: Liqiang Huang.Investigation: Gaofeng Shi.Project administration: Gaofeng Shi.Resources: Liqiang Huang, Gaofeng Shi, Yuwei Guo.Software: Mengdi Cong.Writing – original draft: Liqiang Huang, Yuwei Guo.Writing – review & editing: Gaofeng Shi, Qi Wang.Liqiang Huang orcid: 0000-0002-8966-414X.


Mature presacral  teratoma is very rare. We report a case in which a mature retrorectal teratoma in an adult was successfully treated with laparoscopic surgery.A 44-year-old woman was diagnosed with a presacral tumor during a physical examination. Endoscopic ultrasonography (EUS) revealed a multilocular cystic lesion; the lesion was on the left side of the posterior rectum and measured approximately 30 mm in diameter on both contrast-enhanced pelvic computed tomography (CT) and magnetic resonance imaging (MRI). The presumptive diagnosis was tailgut cyst. However, the histopathological diagnosis after laparoscopic resection was mature teratoma. It is still difficult to preoperatively diagnose mature retrorectal teratomas.Laparoscopic resection of mature retrorectal teratomas is a feasible and promising method that is less invasive and can be adapted without extending the skin incision. Teratomas are composed of mesodermal, endodermal, and ectodermal tissue. The cystic components of teratomas mainly contain sebum and hair , 2. TeraA 44-year-old woman presented with a submucosal rectal mass found incidentally during a physical examination. On digital rectal examination, the mass was soft with a smooth surface and was located on the left posterior wall of the rectum. The results of routine laboratory tests were all within the normal range. The patient underwent colonoscopy with endoscopic ultrasonography (EUS), but EUS-guided needle biopsy was deferred to avoid the risk of tumor seeding or infection in the pelvic cavity. The ultrasound showed a multilocular hypo- and anechoic 20-mm mass on the posterior wall of the rectum, which exhibited clear boundaries. Some of the tissue had calcified, and there was no internal blood flow. Only the cyst wall was enhanced by contrast during contrast-enhanced ultrasonography (CE-US) Fig. .Fig. 1COn contrast-enhanced pelvic computed tomography (CT), the multilocular cystic lesion had a diameter of approximately 32 mm and was without enhanced solid components or calcification (white arrowhead). Blood was supplied to the lesion from the middle sacral artery (white arrow). There were no signs of lymph node metastasis  led us to suspect that the mass was strongly adhered to the left rectal wall (white arrows). The MRI also showed non-enhancing cystic components accompanied by solid components (white arrowhead) Fig. .Fig. 3MThe presumptive diagnosis was retrorectal tailgut cyst, and we decided to perform a laparoscopic tumor resection because we could not exclude the possibility of malignancy.At laparoscopy, there was no evidence of liver metastasis or peritoneal dissemination. The capsule wall was free along the fascia propria of the rectum and could be seen in the left posterior wall of the rectum, free along the dorsal side of the tumor to the caudal side of the tumor Fig. . The bloMacroscopically, the tumor measured 43 × 35 × 10 mm and contained multiple cysts of different sizes, which contained white mucinous contents. Histologically, the inner surfaces of the cysts were smooth and even and the cyst walls were composed of smooth muscle, glial fibers, nerves, blood vessels, and fat. The immunohistochemical examination showed that the lesion had biphasic properties, containing tubular sweat gland-like structures composed of secretory cell-like cells as well as S100-positive myoepithelial cell-like cells, suggesting that the lesion contained eccrine sweat glands (Fig. Retrorectal tumors are extremely rare, with a reported occurrence of 1 in 40,000 registered patients . DevelopPreoperative imaging including CT, MRI, and CE-US can assist with proper preoperative diagnosis of retrorectal tumors. CT can provide information about the size and density of the tumor and its spatial relationships, but it lacks specificity for differentiating between tumor types . MRI is Recently, CE-US has also been utilized for clinical diagnosis. However, it is still difficult to distinguish a teratoma from a tailgut cyst by this method, as was demonstrated in our case. Preoperative biopsy of retrorectal tumors is generally not recommended because of the risk of infection or tumor seeding in the pelvis. As such, definitive diagnosis is best obtained following complete resection of the tumor . ResectiThe first laparoscopic removal of a benign pelvic retroperitoneal cyst was reported in 1995 , and theIn summary, we describe a very rare case of a mature retrorectal teratoma. The laparoscopic management of mature retrorectal teratomas is feasible and promising because of its reduced invasiveness and the fact that it can be adapted without extending the skin incision.


T2 spectral presaturation with inversion recovery sequences, with no enhancement after administration of contrast medium, are suggestive for this kind of benign neoplasm. The purpose of this report is provide an anthological case of liver lipoma, helping to define the diagnostic features with imaging techniques.Liver lipoma is a rare benign mesenchymal tumour without malignant degeneration. Lesions may be asymptomatic, nevertheless they may sometimes cause abdominal pain depending upon the size. Usually liver lipomas are an incidental finding during radiological examinations performed for other reasons, and there is no evidence of familiar genetic cluster or predisposing factors but it seems to have a strong association with impaired lipidic profile. In this report, we describe the case of a 72 year old female with a giant liver lipoma observed during an ultrasound examination. The clinical examination was completed with CT and MRI scans. Features of the lesion such as negative attenuation values on multiphasic CT examination and MRI signal drop-out on  A 72 year old female, with no significant past medical history, was sent to our hospital by her primary care physician for vague abdominal pain and dyspepsia. The patient had no history of alcohol abuse neither abdominal operation. We performed an abdominal ultrasonography, which revealed a large and well-defined mass of mixed echogenicity (iso-hyperechoic), with posterior attenuation, in the left lobe of the liver . The maxAdenoma with fat component, angiomyolipoma, metastases from liposarcoma, fatty changes in hepatocellular carcinoma.2, was placed in the core of the lesion and the attenuation values varied from −80 to −60 Hounsfield units (HU) in all acquisition phases. Lesion neither dislocate organs nor infiltrate omentum and capsule. Diagnostic refinement has been obtained with contrast-enhanced MRI scan, a 1.5T magnet  was used to perform MRI examination by a four channels phased array coil. Patient referred to being claustrophobic and in order to reduce the examination time it has been necessary to increase the P-reduction factor (P = 2). The imaging protocol included a T2 weighted axial , T2 weighted axial spectral presaturation with inversion recovery , T1 weighted axial , DUAL , T2-balance on coronal plane , T1 high resolution isotropic volume excitation . The examination confirmed a well defined mass, with lobulated borders, hyperintense both at T1 weighted images and T2 non-fat suppressed images. , a surface protein positive in angiomyolipoma and negative in lipoma. MRI scan is the most predictive exam for differential diagnosis. Only lipoma contains fat cells, it should have the same signal intensity as retroperitoneal or subcutaneous fat on all sequences6 and provides a signal drop-out on fat-suppressing techniques. Lesions are seen as hyperintense on T1 weighted images and hypointense on T2 weighted fat suppressed sequences. Dual echo sequences are pivotal, unlike other imaging modalities, chemical shift MRI scan is a useful technique for confirming the presence of fat in hepatic lipomas. On out-of-phase T1 weighted gradient echo sequence (GRE), hypointense chemical shift artefacts occur around hepatic lipomas since the signal from fat within a voxel cancels out the signal from water proton in the same voxel. Some MRI scanners have a sequence called “Dixon” which is a T1 weighted Gradient Recalled Eecho (GRE) or Fast Field Echo (FFE), which allows through a single acquisition to obtain, in the post-processing, a T1 weighted in-phase, a T1 weighted out-of-phase, a defined image water , and a defined image fat (short T1 inversion recovery). Our scanner did not have the use of that sequence.Although lipoma can arise from any site, there are only anthological cases dealing with primary lipoma of the liver. Histologically these lesions consist of mature adipose tissue, and have no risk of malignant degeneration.T1 weighted GRE sequences and uniform signal loss at Out-Phase T1 weighted GRE.6 Instead, focal nodular hyperplasia appears as a well -circumscribed nodule with intense and uniform enhancement with rapid wash-out associated with a peripheral focal low signal intensity.6Other focal liver alterations can show a lipomatous component and must be considered in differential diagnosis  but their clinical behaviour is not as indolent as liver lipoma. In particular, liver adenoma is made up by cells filled with glycogen and fat but it has a different behaviour at MR, with hyperintensity In-Phase This case report emphasizes the importance of diagnostic imaging, that enables a multiparametric evaluation of several lesions. Diagnosis and characterization of fat in the liver is a diagnostic challenge in radiologist everyday practise. Atypical features of fatty liver and fat containing tumours may be a frequent cause of pitfalls in diagnosis. This case report summarizes the features of the liver lipoma with different imaging techniques.Usually lipoma is a tumour hyperechogenic at ultrasound, but could be also iso-hypoechogenic owing to its heterogeneity, or in a condition of steatosis/fatty liver diseaseIn CT scan, it is hypoattenuating in all acquisition phases, with no increased attenuation during administration of contrast medium. The attenuation values must be less than −20 HU. If the attenuation values increased after infusion of contrast medium you have been considered another kind of lesion similar to lipoma (e.g. angyolipoma and angyomiolipoma).T1 and T2 weighted images, with no drop-out signal in Out-of-Phase sequences and hypointense in T2 fat sat. Usually there is no significant contrast enhancement after administration of contrast medium.In MRI scan, it appears hyperintense in An informed consent was obtained from the patient for all the procedures.


We present a complicated case of recurrence of gestational trophoblastic neoplasms (GTN), mixed ETT and choriocarcinoma at an abdominal cesarean scar. This tumor consisted of typical morphologic and immunophenotypic features of ETT and choriocarcinoma. The tumor recurred despite the patient undergoing chemotherapy. The patient had this abdominal mass resected three times. The elements of ETT and coexisting choriocarcinoma varied each time. Due to re-recurrence of the tumor, the following decisions had been made: total abdominal hysterectomy, bilateral salpingectomy, right-sided inguinal lymph node biopsy. At the time of this report, recurrence was negative. Gestational trophoblastic neoplasms (GTN) are a group of neoplasms from fetal trophoblastic cells including choriocarcinoma (CC), epithelioid trophoblastic tumors (ETT), and placental site trophoblastic tumors (PSTT) . They moWe present a case of mixed ETT and choriocarcinoma in proximity to a well healed cesarean delivery scar. This case is rather rare. Surgery may be the best treatment for mixed GTN.A 39-year old previously healthy woman went to an external institute after noticing an abdominal mass in her cesarean scar in December 2014. She had undergone two previous cesarean deliveries in 2005 and 2011 and also a surgical abortion in 2010. She claimed that she had not any previous history of malignancy, family history of malignancy, or using tobacco either.This woman received the first mass resection in early June 2015 at the external institute mentioned above. She was diagnosed as having malignant endometriosis in a nonuterine site, and having hyperplastic and atypical trophoblastic cells by histological examination. These cells resembled squamous cell nests with necrosis and hemorrhage. This patient was referred to our institute.α-feto-protein, CA-125, and carcinoembryonic antigen (CEA) were at normal serum levels. Further investigations with computed tomography (CT) of the chest and pelvis, and magnetic resonance image (MRI) of her head suggested negative for metastases. A pathologist specializing in gynecological malignancies in our institute diagnosed her with CC and ETT after examining her abdominal mass excision specimen provided by the external institute. Microscopically, there were sections of medium-sized cells with discernible nucleolus arranged in nests. Moreover, the tumor cells had polygonal nuclei with moderate nuclear pleomorphism and were surrounded by extensive necrosis. Immunohistochemistry (IHC) showed a highly positive staining for cytokeratin (CK), epidermal growth factor receptor (EGFR), human placental lactogen (HPL), p40 and p63; diffusely positive staining for inhibin-alpha and calretinin, and focally positive for HCG. The Ki-67 index was expressed in 50% of the tumor cells.The patient firstly attended to our clinic at the end of June 2015. Via laboratory analysis, we understood that total-human chorionic gonadotropin (t-HCG), 2 and cisplatin 20 mg/m2 on Days 1 through 5 of 21-day cycles and continued for five courses.The patient received endometrial curettage in late June 2015. Biopsy of the lesion showed proliferative endometrium. Then, the patients received etoposide 100 mg/mAfter finishing chemotherapy, the patient received follow-up measurements monthly with serum t-HCG level, abdominal ultrasound, pelvic ultrasound, and chest X-ray. On 7th Jan. 2017, ultrasound at external institute indicated two hypoechoic nodules of sizes 18 × 5 mm and 7 × 5 mm, respectively, in subcutaneous soft tissues close to abdominal cesarean scar and normal t-HCG level (0.592 IU/L).On 10th Jan. 2017, levels of t-HCG increased (6.17 IU/L) and subsequent abdominal ultrasound revealed two oval hypoechoic masses of sizes 17 × 5 mm and 8 × 5 mm, respectively, in subcutaneous soft tissues close to abdominal cesarean scar in our hospital. The two masses were approximately 8 mm and 4 m, respectively, away from the skin. The patient underwent her second time abdominal wall mass resection using ultrasound guidance . Macroscopically, the surface of the tumor was white-tending to brown, with varying amounts of hemorrhage and necrosis Figures . MicroscA diagnosis of ETT was also made by the Obstetrics & Gynecology Hospital of Fudan University after a biopsy curettage of the endometrium was done on 17th March 2017. The biopsy showed only endometrial hyperplasia without any endometrial evidence of ETT or CC.3 in the abdominal cesarean scar.The patient had been monitored at outpatient  for 4 months until t-HCG increased to 7.20 mIU/mL in early July 2017. An ultrasound showed recurrence of an abdominal wall tumor of size 2.0 × 3.1 × 1.0 cmDue to re-recurrence of the tumor, the following decisions have been made: total abdominal hysterectomy, bilateral salpingectomy, the third time abdominal mass resection , right-sided inguinal lymph node biopsy and repair of abdominal wall defect . Her serThe uterus, bilateral fallopian tubes, left-sided ovarian cyst and right-sided inguinal lymph node had no sign of metastasis or malignancy, while confirming isolated ETT and CC to the scar .Microscopically, the tumor infiltrated adipose and fibrous tissue and was surrounded by necrosis in the abdominal wall . Most ofCurrently, the patient is receiving outpatient follow-up measurements, including serum t-HCG level, abdominal ultrasound, pelvic ultrasound, and chest X-ray. The frequency of these follow-up measurements decreases as time goes on. The follow-up measurements started after the third time local tumor resection. In the first six months, measurements will be given weekly; then every three months since the seventh month and lasts for one year; then every half year and lasts for five years; then yearly for lifetime. This patient cooperates very well. At the time of reporting, no sign of recurrence. Follow-up is going on.Our case showed features of ETT and CC, so we regarded it as a mixed GTN. GTN, including both CC and ETT, is rarely seen in the abdominal wall, as it mostly presents in parts of the uterus . HoweverIn 2015, Zhang et al. . In mixeThe most common symptom of mixed GTN is abnormal vaginal bleeding, with possible increase of serum t-HCG levels . The patLow-risk GTN (FIGO Stages I–III: score <7) is treated with single-agent chemotherapy; High-risk GTN (FIGO Stages II–III: score <7 and Stage IV) is treated with multiple agent chemotherapy . In prinTherapeutic schema for mixed GTN is based on the differentiation of the neoplastic trophoblasts. Surgery is the primary treatment for mixed GTN . The patAll other specimens  were benign. With hindsight, we think resection of uterus, fallopian tubes, ovarian cyst, inguinal lymph nodes are not the appropriate management, because all specimens  were benign and twice endometrial curettage demonstrated endometrial hyperplasia. But abdominal scar mass re-resection may be the appropriate management. The extent of abdominal scar mass re-resection was larger in the third time and at the time of reporting, the patient was negative for recurrence. So the extent of abdominal scar mass re-resection may be a successful management for this case.The pathogenesis of ETT and CC remains unclear. In a model, proposed by Shih and Kurman, all three GTN  are derived from trophoblastic stem cells. However, their levels of differentiation are different, this explains how they can coexist , 10. ImmThe tumor recurred despite the patient had chemotherapy. Based on my study, not only because of chemotherapy insensitivity, but also the difficulty for chemotherapeutic drugs to reach the abdominal wall. So the patient did not receive the second time chemotherapy.We report this case of coexisting ETT and CC next to the cesarean scar and in the subcutaneous tissues. In addition, detailed histopathologic examination with cytological analysis may be a diagnostic aide. Due to the rare presentation of this neoplasm, our understanding of its long-term prognosis and better treatments are limited. Therefore, long-term epidemiologic studies are necessary for better understanding of this neoplasm.


We present a rare case of pelvic splenosis, and its imaging findings, in a 54-year-old female complaining of pelvic pain and vaginal bleeding for several months. Splenosis is a benign acquired condition defined as heterotopic auto-transplantation of splenic tissue to other compartments of the body and occurs after rupture of the spleen, either traumatic or iatrogenic. Symptoms are unspecific and vary according to the location of the implants; commonly the presenting symptom is abdominal pain or enlarging abdominal mass. Owing to its intrinsic properties and safety, magnetic resonance imaging is a valuable imaging modality, in which the splenosis implants may be securely identified, showing the same signal characteristics and enhancing patterns of the normal spleen, especially visualization of serpiginous enhancement on the arterial phase is virtually diagnostic. It is estimated that splenosis develop in up to 67% of splenic injuries.1 The main mechanism of this entity is the disruption of the splenic capsule, either from trauma or surgery, allowing direct dissemination of splenic tissue to other locations.3Splenosis is a benign acquired condition defined as heterotopic auto-transplantation of splenic tissue to other compartments of the body.1 Symptoms are non-specific and vary according to the location of the implants.Splenosis differs from accessory spleens and polysplenia, both congenital conditions, unrelated to splenectomy. Accessory spleens, usually fewer in number, are supplied by the splenic artery, in contrast to splenosis in which the implant’s blood supply derives from the nearby vessels.2 Owing to the excellent soft tissue contrast resolution, MRI may be the imaging method of choice.Splenosis is usually an incident finding in ultrasound or computed tomography (CT), which cannot definitively determine a splenic origin for the masses, although on unenhanced and contrast-enhanced CT these masses have similar attenuation to the expected normal splenic tissue.A 54-year-old female was admitted to our institution owing to complaints of pelvic pain and vaginal bleeding for several months. There was a history of appendectomy and splenectomy, the latter owing to abdominal trauma in childhood. In the physical examination there was pelvic tenderness. The remaining physical examination was unremarkable.Laboratory tests were within normal values, including tumour markers, including cancer antigen 125 (CA-125), cancer antigen 19-9 (CA 19-9), beta-human chorionic gonadotropin (β-HCG) and alpha-fetoprotein (AFP).Endovaginal ultrasound revealed multiple uterine fibroids and heterogeneous adnexal solid masses, showing rich vascularity on colour Doppler examination.T1 signal and homogeneous intermediate to high T2 signal. Both lesions were hypervascular on the arterial phase, showing strong and heterogeneous enhancement, the largest one showed serpiginous-like arterial enhancement, progressing to homogeneous signal intensity on venous and late phases images. On the upper abdomen, the native spleen was notably absent with multiple small left subphrenic solid nodules. These features were prospectively suggested of pelvic splenosis.Gadolinium-enhanced magnetic resonance imaging (MRI) was performed for further characterization . The uteAccording to the clinical presentation and imaging findings, the differential diagnosis included pedunculated fibroids or adnexal lesions, including primary ovarian and tubarian tumours, and metastatic tumours. Primary ovarian neoplasms included (divided by histologic origin) epithelial tumours (most frequently serous and mucinous tumours), germ cell tumours (most frequently teratomas) and sex cord–stromal tumours (most frequently fibrothecoma).Owing to the history of splenectomy, in the context of splenic trauma, pelvic splenosis was also included.In order to treat the vaginal bleeding, hysterectomy with bilateral adnexectomy was performed through laparotomy . The larHistopathological analysis of the nodule attached to the uterine body revealed thin and dense fibroelastic outer capsule, surrounding red and white pulp, showing central arteriole with lymphocytes areas. It was possible to see a primary and a secondary follicle containing a germinal centre . These fThere were no surgical complications and after few days of recovery the patient was discharged asymptomatic. During follow-up (3 years) the patient remained asymptomatic.1 However, patients may remain asymptomatic, being often incidentally diagnosed during unrelated surgery or imaging studies for other causes.3Our patient presented with vaginal bleeding, pelvic pain and tenderness. We believe that these symptoms were primary related to the adenomyosis, while pelvic splenosis was an incidental finding. Supporting this assumption is the fact that symptoms resolved after surgery, even after leaving in place the largest splenosis implant. Pelvic splenosis commonly presents with pelvic pain or pelvic mass.T1 weighted imaging (WI) and hyperintensity on T2 weighted images (in case of iron deposition they may show hypointensity on T2 weighted images).4 Similar to normal spleen, splenosis shows an arterial heterogeneous/ serpiginous enhancement pattern with later progressive homogenization during the dynamic studies;4 however, recognition of this arterial pattern may depend on the implant size, being easier to recognize in larger implants. This contrast enhancement pattern is also seen on dynamic CT imaging; however, MRI has the advantage of routine use of dynamic multiphasic acquisitions and lacking ionizing radiation.2 Furthermore, using superparamagnetic iron oxide (SPIO), a tissue-specific contrast agent for liver and spleen will allow the definitive diagnosis.3 SPIO is taken up by reticuloendothelial cells; therefore, splenosis demonstrates decreased signal on post-SPIO T2 weighted images compared with pre-SPIO T2 weighted images indicating the presence of splenic tissue.5 Therefore, SPIO imaging may be accepted as the reference test for the diagnosis of splenosis.On MRI splenosis implants have the same signal characteristics and enhancing patterns of the expected normal splenic tissue. On unenhanced sequences, splenosis implants show homogenous hypointensity on 1Although MRI with administration of SPIO is specific for diagnosis, the current diagnostic tool of choice is still scintigraphy with agents that distribute in the reticuloendothelial system such as Tc-99 m sulphur colloid, Tc-99 m heat-damaged erythrocytes or In-111 labelled platelets, allowing to detect small nodules missed on MRI.6 Previous case reports of pelvic splenosis have also emphasize this difficulty.8 Primary ovarian tumours with epithelial origin are the most frequent ovarian neoplasms, accounting for 60% of all neoplasms and 85% of malignant ovarian neoplasms.9 Thus, the most frequent epithelial tumours, cystadenoma and cystadenocarcinoma, should be considered. Distinctive to our case, these neoplasms are cystic lesion, frequently with large dimensions and they show areas of very high signal intensity on T2 weighted images, and thickened progressive enhancing septations and papillary projections. Furthermore, cystadenocarcinoma may show ascites, peritoneal implants, direct locoregional invasion and elevation of tumour markers . Teratomas are by far the most frequent germ-cell tumour. Mature teratoma is a benign lesion, showing a broad spectrum of findings, ranging from purely cystic, with very high signal intensity on T2 weighted images and no enhancement on post-gadolinium MRI sequences, to heterogeneous or non-cystic mass, the latter composed predominantly of fat, showing high signal intensity on T1 weighted images and drop of signal on fat-suppressed MRI sequences. None of these features was seen on our case. Regarding sex-cell tumours, fibrothecoma are the most frequent lesions. Fibrothecomas, techomas and fibromas tend to share similar features including hypointensity on T2 weighted images and very little enhancement on early phases, with variable progressive enhancement. On the other hand endometriomas show very high signal intensity on unenhanced T1 weighted images, shading on T2 weighted images and little to no appreciable enhancement after gadolinium injection. Furthermore the characteristics of the pelvic nodules in our case were not specific of germ-cell and sex-cell tumours, the tumour markers associated with these entities were also negative.Pelvic splenosis in a woman can be a challenging diagnosis because of non-specific clinical presentation and the multiple gynaecological differentials.10 characteristic of pedunculated fibroids, was not present.Pedunculated fibroids are expected to have similar heterogeneous signal and enhancement as other fibroids. Moreover, the bridging vascular sign ,Metastases are not rare to the adnexa, usually from the endometrium, breast, colon, stomach and cervix primary tumours. Our patient had no history of neoplastic disease.11 However, the prevalence may be underestimated because it is difficult to differentiate it from epithelial ovarian carcinoma.9 Imaging findings vary, and may appear as a fluid-filled tubular adnexal structure containing nodular or papillary solid components or as a multilocular cystic mass. On MRI the solid component is usually hypointense on T1 weighted images and iso to hyperintense on T2 weighted images.12 There are also associated findings such as intrauterine fluid collection, peritumoural ascites and hydrosalpinx.11,12 The appearance of the pelvic nodules in our case was not suggestive, ancillary findings were absent and tumour markers were negative.Primary fallopian tube carcinoma is very rare, accounting for approximately 0.14–1.8% of female genital malignancies.6 Nevertheless, surgery is the ideal treatment of choice in symptomatic cases, while minimally invasive surgery such as laparoscopy may be the ideal treatment.6In this case the diagnosis of pelvic splenosis was suspected based on imaging characteristics of the nodules on MRI, especially the hypervascular and serpiginous enhancement seen in the largest lesion, which was confirmed by histopathological analysis of the resected nodule. Pelvic splenosis is a benign disease and in asymptomatic cases usually there is no need for further treatment.11,12 Our case emphasizes how challenging a diagnosis of pelvic splenosis can be, especially in a woman as there are various differential diagnoses to take into consideration.Splenosis may also occur in other locations in the abdomen and may mimic, e.g. liver or colon tumours.In conclusion, pelvic splenosis is a rare benign condition whose radiological diagnosis is difficult on US, CT and routine MRI without the history of trauma (blunt or penetrating) of the spleen. Despite the number of differential diagnosis it is important that radiologists be alert for this diagnosis and recognize the MR imaging characteristics of splenosis as it may allow the definite diagnosis. Splenosis show an arterial heterogeneous/serpiginous enhancement pattern with later progressive homogenization during the dynamic studies; however, recognition of this arterial pattern may depend on the implant size, making it easier to recognize in larger ones. For the definitive diagnosis of small ones, routine MRI may not always be a useful modality.MRI is useful detection and characterization of splenosis.Splenosis implants show similar signal intensity and enhancement to those of a spleen in all sequences.Identification of serpiginous enhancement on the arterial phase is virtually diagnostic, but it’s not seen in all splenosis cases, especially in small sized ones, so the diagnosis may be sometimes challenging.Informed consent to publish this case (including images and data) was obtained and is held on record.