Dermatofibromas are common benign fibrohistiocytic lesions, usually appearing as slow growing firm dermal nodules with a predilection for the extremities (mostly the lower legs). They are found mostly in middle-aged women and are usually smaller than 2 cm in diameter. Giant dermatofibromas exceeding 5 cm in diameter are rare. In recent years, reports have suggested a relationship between the primary size of dermatofibromas and rates of local recurrence and metastases after surgery. This relationship is however debated. The present report describes the case of a giant muscle invasive tumor in a 51-year-old female patient who presented with a large ulcerated mass in the right upper arm. The tumor appeared clinically malignant, measuring approximately 12 cm × 6 cm in size, with ulceration and invasion of surrounding muscle. Wide resection of the tumor was performed with myocutaneous flap-plasty. Histopathological examination showed evidence of a dermatofibroma. No recurrence, metastases, or other complications were noted at 5 years after surgery. The present case demonstrates that although dermatofibromas are essentially benign, they may present with atypical features including large size, ulceration, and muscle invasion, clinically mimicking malignant tumors. Dermatofibromas, also known as benign fibrous histiocytomas, are common harmless cutaneous nodules arising from reactive fibroblastic proliferation of unknown etiology. They are most frequently found in the extremities and are more common in women . They usHere we present a case of giant muscle invasive dermatofibroma, clinically suspicious of a malignant tumor. Successful wide resection was performed, and the patient remains healthy without recurrence for 5 years.A 51-year-old female patient presented to our orthopedic outpatient department with a rapidly enlarging ulcerated right upper arm swelling which was growing gradually over the past six months. She recalled that it had been a pea-sized lesion and had remained the same size over the past 30 years. No history of preceding episodes of trauma or local irritation was found. The initially asymptomatic lesion had recently become painful and pruritic with slight bleeding. On examination, a large nodulo-ulcerative plaque was noted on the right upper arm, measuring approximately 12 cm × 6 cm in size . MagnetiDermatofibromas are common, usually benign, soft-tissue tumors often found on the extremities, particularly the lower limbs. They typically present as asymptomatic, firm, slow-growing, red-brown, or yellow-brown dome-shaped nodules, measuring between a few millimeters to 1 to 2 cm in diameter . AlthougThe differential diagnoses of dermatofibromas include other benign lesions such as nodular fasciitis, neurofibromas, and leiomyomas, as well as malignant tumors such as DFSP . On immuIn conclusion, the present report describes the case of a giant muscle invasive dermatofibroma, which was clinically suspected to be malignant owing to its appearance. Giant dermatofibromas that invade the muscle may recur or metastasize after surgery. In these cases, adequate surgery, thorough histopathological examination, and careful follow-up are essential for better outcomes.


A solitary fibrous tumor (SFT) arising in the paratesticular region is a rare event. Typically most SFTs present as a lung mass and have a characteristic microscopic appearance. Although uncommon, SFTs may present at just about any anatomical site. Here we present a case of a SFT arising along the right spermatic cord, with histologic features mimicking a cellular angiofibroma. We describe the diagnostic immunohistochemical markers useful for arriving at its diagnosis. We also summarize our current understanding of the structural and molecular features that make up SFTs and discuss how these features may help us better understand the pathophysiology of pluripotent mesenchymal stem cell differentiation. SFTs have no sex predilection, except for the extrapleural fat-forming SFT variant, which is seen slightly more often in males than females. SFTs usually are benign and slow-growing; however, 10% of patients will have tumors that behave aggressively. To date, SFTs have not been linked to any etiologic agent [SFTs typically present as a lung mass arising from the visceral pleura; however, since its description in 1931, extrapleural tumors have been identified at various other anatomical locations [Herein we report a case of a SFT arising along the right spermatic cord, with features mimicking a cellular angiofibroma. The diagnosis of SFT was ultimately confirmed by nuclear expression of STAT6 in the tumoral cells.A 48-year-old male presented in surgery clinic with a clinical history of benign prostatic hyperplasia and a 6-year history of an enlarging right inguinal hernia, with associated increase in discomfort. On physical examination, a cystic mass was palpated on the superior right testicle, and a firm, solid mass was found in the right groin. The testicular mass was fully mobile within the subcutaneous space and minimally tender and did not appear to be connected to the external ring. The patient had no other complaints, and the rest of his physical examination was unremarkable. A follow-up computed tomography (CT) scan revealed a partially visualized, heterogenous, and enhancing right inguinal mass, raising the concern for a peripheral nerve sheath tumor or sarcoma of the spermatic cord .The mass was surgically excised from the spermatic cord. During surgery, it was noted that the mass was located inside the external cord, but outside of the internal spermatic fascia. It had eroded through the aponeurosis of the external oblique muscle. Nonetheless, the mass could easily be separated from the spermatic cord and was submitted to pathology for evaluation. Macroscopically, the mass weighed 67.5 grams and measured 7 x 5.5 x 2.5 centimeters. Its outer surface was smooth, pink/white in color and covered by a thin membrane. The cut surface of the mass was white and firm and had a whorled texture containing occasional small cysts . The tumMicroscopically, the tumor had a heterogeneous pattern-less architecture with alternating hypocellular and hypercellular areas, interstitial hyalinization, and intermixed with ropy collagen bands . The mosThe neoplastic cells were ovoid to spindle-shaped with scanty pale cytoplasm and oval to fusiform nuclei . MitosisInitially SFTs were believed to be tumors of pericytic origin; however, over the years and through ultrastructural studies, it was discovered that SFTs are tumors with neoplastic cellular heterogeneity consisting of undifferentiated perivascular cells, fibroblasts, myofibroblasts, pericytes, smooth muscle cells, and endothelial cells, all possibly arising from adult mesenchymal stem cells , 29, 30.The presentation along the spermatic cord in our patient had led to a misdiagnosis of inguinal hernia for several years, thus delaying tumor removal. Therefore, even though spermatic cord SFT is a rare tumor, it should be considered in the differential diagnosis of spermatic cord masses, by the clinician. Another benign mesenchymal tumor in the urogenital region that can be confused with a spermatic cord SFT is cellular angiofibroma which is typically seen in the superficial soft tissue of the genital region, with the inguinal region being the most common site in men . Histolo RB1 and FOXO1 loci on chromosome 13q14 may be helpful [ RB1 and FOXO1 loci would also support a diagnosis of cellular angiofibroma.The tumoral cells expressed CD34, ER, and PR, but not SMA or S100. This phenotype initially supported a diagnosis of cellular angiofibroma; however, additional staining of the spindle cells demonstrated CD99 and BCL-2 expression, raising the suspicion for SFT. Ultimately, the strong diffuse positive nuclear staining for STAT6 in the neoplastic cells established a diagnosis of spermatic cord SFT , 32. If  helpful . Desmin  helpful . The delOf note, another important diagnostic consideration along the spermatic cord is the possibility of a dedifferentiated liposarcoma (DDLPS). Although rare, more cases have been reported of DDLPS along the spermatic cord than SFT . HoweverThe vessels themselves did not share the same immunohistochemical pattern as the tumoral cells but expressed the staining patterns typically seen in normal vessels including CD34 positivity and STAT6 negativity. It may well be possible that the vascular myocytic proliferation seen in our case represents an angiogenic response to mitogens produced by the tumor, such as platelet-derived growth factor (PDGF) . In 2013SFT is a great example of how next-generation sequencing has opened the doors of our understanding regarding tumor initiation and development over time. As we continue to learn more about this uncommon but interesting tumor, we may find that this tumor yet holds secrets to the pathophysiology of pluripotent mesenchymal stem cell differentiation.


Primary bronchial Ewing sarcoma (ES) is a rare endobronchial tumor.A 65-year-old male presented with six-month history of progressive shortness of breath. Flexible bronchoscopy showed an endobronchial polypoid tumor in the left main stem bronchus about 2 cm from the carina. The tumor was resected by a left bronchial sleeve resection using a right postero-lateral thoracotomy approach. Pathology showed complete tumor resection with negative margins. The morphological and immune-phenotypical features of the resected specimen were compatible with ES. He had an uneventful post-operative recovery. He did not receive adjuvant radiation or chemotherapy and remains disease free at 9 months follow up.A review of the literature identified six other cases of primary bronchial ES. In addition, there were three reported cases of primary ES involving the trachea and thirteen involving the lung parenchyma. Bronchial ES appeared to have a relatively better prognosis than ES involving the trachea or the lung. Our case demonstrates that primary bronchial ES may be treated safely with limited resection, lung preservation and without the need for adjuvant therapy if negative margins can be achieved.Sleeve resection without adjuvant therapy may be a safe treatment option for primary bronchial ES. They arise from undifferentiated neuroectodermal cells and share a common neural histogenesis and tumor genetics . They tyThis case report has been written in line with the SCARE guidelines .2A 65-year-old white male presented with symptoms of progressive shortness of breath and cough over a 6-month period. His past medical history was significant for a minor stroke at age 43 years due to a drug overdose with residual concentration and memory deficit. Otherwise, he had well-controlled hypertension, dyslipidemia, benign prostatic hypertrophy, and depression. He had an uneventful left hip replacement about 5 months prior to presentation. He had a 20-pack year history of smoking cigarettes and had quit a year ago. His family history included his father who had bladder cancer and mother with coronary artery disease. His physical examination was within normal limits.Computed tomographic (CT) of chest with intravenous contrast demonstrated numerous punctate lung nodules measuring less than 3 mm as well as a 16 mm partially occluding endobronchial mass in the left main stem bronchus. Flexible bronchoscopy showed a polypoid mass in the left main stem bronchus. Initial biopsy was suggestive of a sarcoma. Positron emission tomography (PET) scan showed mild FDG avid endobronchial lesion (SUV 3.2), hypermetabolic consolidative process in the lingula (SUV 7.3) and left lower lobe (SUV 8.2). The micronodules seen on CT were below the resolution of PET scan. A bone scan and Brain MRI scan showed no signs of metastatic disease.The patient was referred to our thoracic surgery clinic after the above work up. We repeated the bronchoscopy that included both a flexible and rigid scope. The left main stem tumor appeared as a polypoid, whitish, firm lesion about 2 cm from the main carina. The lesion was causing a near complete obstruction of the left main stem with a ball-valve effect. A partial endoscopic resection of the tumor was performed to improve ventilation to the left lung. Patient’s dyspnea and cough markedly improved after the procedure.Pathology showed the tumor was composed of uniform small round cells in a solid architecture  & 2 . ThA subsequent CT chest with intravenous contrast showed expected interval decrease in size of the left endobronchial tumor as well as complete resolution of the tiny peripheral nodules and the left lung consolidative process suggesting an inflammatory process due to prior airway obstruction .Fig. 3CTPatient was presented at our Multidisciplinary Sarcoma Tumor Board. The recommendation was to proceed with surgical resection as this was the only site of disease. Our surgical plan was to proceed with left bronchial sleeve resection with primary anastomosis through a right posterolateral thoracotomy due to proximity of the tumor to the main carina. The chest was entered through the fifth intercostal space including harvesting the intercostal muscle as a long pedicled muscle flap. The subcarinal level 7 nodal station was removed allowing excellent exposure of the left main stem bronchus and the main carina. Intra-operative flexible bronchoscopy was used to confirm the location of the tumor and guide in resection with negative margins. The two ends of the left main stem bronchus were then re-anastomosed without tension using interrupted 2-0 Vicryl sutures. The intercostal muscle flap was used to buttress the bronchial suture line. Patient was extubated without any difficulty. Post-operative chest roentgenogram showed well expanded lungs with no pneumothorax. There was no air leak noted. He did have a low volume mild chylous pleural drainage for the first two post-operative days that resolved with low fat dietary management. The chest tubes were removed on the fifth post-operative day and he was discharged home on day 6.Gross examination of the resected specimen showed an exophytic sessile rubbery tumor arising from the bronchial wall with adequate resection margins. The morphological and immune-phenotypical features were like the previously resected specimen.Clinical and imaging follow up using CT chest with intravenous contrast at 3 months intervals showed no evidence of recurrence. At 9-month post-operative follow up, patient was doing well and Alpine skiing. His case was presented once again at the Tumor Board. Seeing that the tumor was completely resected with negative margins, and no signs of metastatic disease, the recommendation was to keep the patient under strict surveillance without adjuvant chemo-radiation therapyWritten 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.3The diagnosis of ES depends on histopathologic and immunohistochemical findings. Histological examination shows the tumor to be composed of diffuse compact sheet of small round cells that strongly express MIC-2 gene product (CD99). Although the later expression is not in unique to ES, over 95% of them are CD99 positive. Nonrandom chromosomal translocation (22q12) involving the Ewing sarcoma breakpoint region gene 1 are reported to be present in ESFT but have also been observed in clear cell sarcomas and desmoplastic small round cell tumors. Fluorescence in situ hybridization (FISH) has a high specificity 100% but only a moderate sensitivity 50–60% in the diagnosis of ES [Our patient represents the seventh reported case of primary bronchial ES in the literature . It is tBronchial ES tumors are usually pedunculated, exophytic tumors involving a portion of the bronchial circumference and may be amenable to snare resection through a bronchoscope, however this approach may be associated with a higher risk of local recurrence as these tumors may invade into the underlying submucosa, muscle and cartilage . While tSurgical resection with negative margins when possible appears to offer the best chance for disease free survival compared with additional use of neoadjuvant or adjuvant therapy. In one series of patients with localized extra-skeletal ES who underwent wide local excision, overall 5-year survival was 100%, patients who underwent suboptimal resection had an overall 5 year-survival of 58%. No other variables such as tumor size, location, stage of disease or radiation therapy were found to improve survival .We agree with the observations made by Chen and colleagues that the clinical features, curative effects and prognosis of primary trachea-bronchial ES may be different and probably better than those of pulmonary ESFT . In a liBased on the current evidence in the literature, our group’s recommendation for the treatment of trachea bronchial ESFT would be to perform up front a complete surgical resection while attempting to preserve as much lung parenchyma by using sleeve resection techniques. Neoadjuvant systemic therapy would be recommended if lesions are not amenable to complete surgical resection at the time of presentation and reserve adjuvant chemoradiation for patients with positive margins.None.Study is exempt from ethical approval as patient received standard treatment.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.All authors were involved in the management of this patient and in preparation of the manuscript.Dr Farah Khalil: pathology interpretation.Dr Amit Tandon- interventional pulmonary medicine – assisted with rigid/flexible bronchoscopy.Dr Eric Toloza, Dr Jacques Fontaine, Dr Hamid Mumtaz: performed the surgery, and peri-operative care of the patient.Not applicable.Dr Jacques-Pierre Fontaine.Not commissioned, externally peer-reviewed.No conflict of interest for all authors


The aim is to discuss four cases of gingival reactive hyperplastic lesions in patients with a history of excision of oral neoplastic lesions and rehabilitation by a free revascularized flap of the iliac crest. One female and 3 male patients were referred due to the presence of exophytic lesions at the rehabilitated sites. The clinical examination revealed that the poor oral hygiene was the common trigger factor in all the cases, in addition to trauma from the upper left second molar in the first case, pericoronitis related to a partially erupted lower right third molar in the third case, and poor stability of an upper removable partial denture in the fourth case. All the cases were subjected to elimination of these suspected triggering factors, exclusion of dysplasia, excisional biopsy by CO2 laser, and five follow-up visits. The histological examination of all the cases confirmed the diagnosis of pyogenic granuloma. These presented cases suggest that the limitations in oral functions and maintaining the oral hygiene measures following the free revascularized flap reconstruction surgery probably played a role in the development of gingival reactive hyperplastic lesions with presence of trigger factors such as local trauma, chronic infection, or inadequate prosthesis. Reactive hyperplastic lesion is defined as an excessive proliferation of connective tissue in response to chronic irritation. In the oral cavity, the gingival reactive hyperplastic lesions are pyogenic granuloma (PG), peripheral fibroma, fibroepithelial hyperplasia, peripheral ossifying fibroma, and peripheral giant-cell granuloma. The gingival reactive hyperplastic lesions are commonly described as “epulides,” which is a Greek word, means “on the gingiva.” However, this commonly used term is only describing lesions clinically present on the gingiva without specifying the nature of the lesion , 2.PG was firstly described in 1897 by Poncet and Dor . It is dPG has a more female incidence than male with a ratio of 3 : 2. The most common site is the keratinized gingiva in about 75% of cases, followed, respectively, by tongue, lips, and buccal mucosa. It occurs more commonly in the maxilla than in the mandible and in the anterior region than the posterior . PresencThe reconstruction of bone continuity defects and solving some complications such as facial contour disfigurement by a free revascularized flap (FRF) have become a valuable part in the management of head and neck cancers. The idea of FRF is the transplantation of bone segment with muscle and skin allowing a simultaneous reconstruction of hard and soft tissues .The high success rate of FRF reconstruction is about 95–97% due to the refinement of microvascular and magnification instruments; however, rare complications still occur. The complications are divided into recipient site and donor site complications. The most common complications of recipient site are related to vascular thrombosis .Many cases of hyperplastic/inflammatory response and formation of granulation tissues around implant abutments in the orally rehabilitated sites by FRF are reported. Some authors speculate that the unsuitability of skin tissues around implants and the negative reaction of the skin in the oral cavity may be the reason of this complication .Presented here are four cases of gingival reactive lesions (mainly PG) in patients with a history of excision of oral neoplastic lesions and rehabilitation by a FRF of the iliac crest.The cases are 1 female and 3 males. The management was started with full clinical examination consisting of medical, dental history, and radiographic investigation.Suspected triggering factors were diagnosed and eliminated for each patient. Conventional blade incisional biopsy was performed after two weeks of the first visit. All the collected biopsy samples were fixed in a 10% neutral buffered formalin solution. The histopathological evaluation confirmed the absence of dysplasia in all the samples.All the patients were informed about the advantages and disadvantages of laser surgery, signed an informed consent, and managed by the same surgeon.2) laser , with these parameters: power of 1.5–1.7 watts on pulsed wave (PW), frequency of 100 Hz, , and spot diameter of 400 μm [Excisional biopsies were performed with local anesthesia (mepivacaine) by carbon dioxide  and a 0.5 ml of amino acids and sodium hyaluronate gel  were prescribed three times daily for one week. The patients were informed to eat cold and soft food and to avoid hot and spicy food on the day of the intervention.Five follow-up visits were performed according to this schedule: one week, three weeks, three months, six months, and one year after the surgery, in order to evaluate the healing process and the possibility of recurrence.A 28-year-old female complained of an intraoral swelling in the lower left region. This swelling appeared few months ago. There was a complaint of bleeding on brushing without pain. Regarding her medical and dental history, she was suffering from ossifying fibroma at the left premolar-molar region of the mandible . It was The oral examination revealed that an erythematous exophytic sessile lesion with granulomatous appearance and soft-elastic consistency on the lower left retromolar region. This lesion developed after approximately 2 years of the reconstruction by FRF .A presence of mechanical irritation at the lesion area related to the upper second left molar was observed. Radiographic investigation did not show any bone resorption in relation to the lesion.The provisional diagnosis was probably a reactive lesion like PG or peripheral giant-cell granuloma. Routine blood tests, exclusion of dysplasia by cold-blade incisional biopsy, and elimination of contributing triggering factors were done. Smoothing of the cusp tips of the upper left second molar was done in addition to improvement of the oral hygiene.2 laser was performed under local anesthesia with the help of Allis forceps. The histological examination of the excised lesion confirmed the diagnosis of PG . The radiographic investigation did not show any bone resorption at the site of the lesion.2 laser under local anesthesia were performed. The histological examination revealed a benign lesion with vascular structures and diffuse inflammatory infiltrate of granulocytes and neutrophils, in addition to focal aspects of abscess formation.Contributing triggering factor was the poor stability of RPD. It was decided not to wear the RPD for two weeks. Routine blood tests, exclusion of dysplasia by cold-blade incisional biopsy, and the excision of the lesion by CO2 laser after the three-week follow-up has been done responding to a request from the prosthodontic department, to remake the RPD with better stability.Deepening of the buccal vestibule by COThe management of head and neck cancer has been improved by the introduction of microvascular surgery and FRF reconstruction. The ability of tissue transfer from a distant site enables the surgeons to reconstruct the bone and the soft tissues in a single-staged procedure . The mosFew complications of FRF in the recipient sites are reported such as vascular thrombosis and second primary squamous cell carcinoma (SCC). Many factors have been proposed to be associated with the development of complications after FRF reconstruction such as patients' age, tobacco use, and prolonged surgical time –10.There are four suggested hypotheses for the development of SCC as a complication of FRF; which are the presence of cancer cells into the flap during the implementation of tumor ablation, lymphatic dissemination of the original tumor, the existence of another tumor in the donor site before raising the flap, and the exposure of the skin of the flap to a stimulus in the oral environment that is not normally experienced .The etiology of PG is still unclear. About 30–50% of the patients with PG have a history of local trauma. Infection and poor oral hygiene are frequently reported as triggering factors. Also, the hormonal cause may be added to these factors .In a retrospective study by Jané-salas et al., it is suggested adding incorrect or inadequate prosthesis  as possible causative factors . In geneIn the literature, it is reported a presence of hyperplastic/inflammatory response and formation of granulation tissues around implant abutments that are implemented in orally rehabilitated sites by FRF . Anitua In the presented cases, there is only one case of PG around implants in the rehabilitated sites. The poor oral hygiene was the common trigger factor in all the cases, in addition to trauma from the upper left second molar in the first case, pericoronitis related to a partially erupted lower right third molar in the third case, and the poor stability of an upper RPD in the fourth case.The incidence of recurrence of PG is estimated to be between 2.9 and 8.2%, with a slight increase in cases associated with implants . In the It seems that the triggering factors are aggravated due to the limitation in oral functions, the difficulty of maintaining the oral hygiene measures following the reconstruction surgery, and the difference in nature between the skin of flap and the normal oral tissues when they are subjected to stimuli, resulting in the development of PG in relation to the site of reconstruction rather than in the common sites that are reported in the literature.PG is histologically characterized by a prominent capillary growth in hyperplastic granulation tissue. The presence of little vascular fibrotic septa separating a clustered or medullary pattern of the blood vessels leads sometimes to considering PG as a polypoid form of capillary hemangioma .The histological reports of the third and the fourth cases were not with a definitive diagnosis; therefore, these cases were confirmed to be PG through the consultation of an oral pathologist and the clinical picture.The differential diagnosis of PG includes peripheral giant-cell granuloma, peripheral ossifying fibroma, hemangioma, conventional granulation tissue, and hyperplastic gingival inflammation. In some cases, malignant lesions, such as metastatic carcinoma, melanotic melanoma, or non-Hodgkin's lymphoma, can be a differential diagnosis .These presented cases suggest that the limitations in oral functions and the difficulty of maintaining the oral hygiene measures due to the FRF reconstruction surgery with the presence of trigger factors such as local trauma, chronic infection, or inadequate prosthesis probably played a role in the development of gingival reactive hyperplastic lesions.


Recurrent respiratory papillomatosis is a chronic disease of viral origin affecting the larynx, trachea, and lower airways. Inverted papilloma, most commonly originating from the lateral nasal wall, is typically a single, expansile, locally aggressive tumor that remodels bone around the site of origin.in situ hybridization studies demonstrated evidence of human papillomavirus in both the septum and middle turbinate subsites. Repeat nasal excision with margin analysis is planned.We report a case of histopathologically proven inverted papilloma occurring in a 50-year-old Caucasian man with recurrent respiratory papillomatosis affecting his nasal cavity, larynx, and trachea. This constitutes the first report of nasal involvement in recurrent respiratory papillomatosis. Viral This report emphasizes the importance of considering a broad differential diagnosis in patients with papillomata, and obtaining comprehensive histopathologic evaluation of lesions in multiple subsites in order to rule out inverted papilloma or overt malignant transformation, particularly if high-risk human papillomavirus (HPV) subtypes are identified.4 Recurrent respiratory papillomatosis (RRP) is a chronic disease of viral origin most commonly affecting squamous and ciliated epithelia of the larynx, trachea, and lower airways, particularly at the laryngeal ventricle and carina . The bimWe present this case of histopathologically proven inverted papilloma (IP) occurring in a patient with RRP affecting the nasal cavity, larynx, and trachea. This constitutes the first report of histopathologically confirmed nasal involvement in RRP.In situ hybridization (ISH) studies for HPV were negative for high-risk subtypes.A 50-year-old Caucasian man with adult-onset RRP was referred for rhinology consultation for multiple unilateral nasal papillomata. He had undergone endoscopic potassium titanyl phosphate (KTP) laser ablations for diffuse laryngotracheal disease nearly every 3 months prior. Previous biopsies showed evidence of moderate to severe dysplasia on some of the tracheal lesions. Repeat airway debulking and nasal biopsy at our institution revealed squamous papillomata without evidence of dysplasia in both specimens. Three months later, his examination exhibited increased nasal involvement with lesions of the middle and superior turbinates and posterior septum while sparing his nasopharynx. Computed tomography (CT) imaging showed mucosal irregularities consistent with examination findings without hyperostosis or posterior ethmoid involvement Fig. .Fig. 1NoIntraoperative frozen sections were consistent with benign respiratory papilloma. However, permanent section pathologic analysis revealed inverted type Schneiderian papilloma in all nasal specimens and benign squamous papillomata with mild to moderate atypia in the larynx and trachea. His surgical resection included removal of the majority of the lesion with an attachment site centered on the middle turbinate. The mucosal surface of the posterosuperior septum and a small portion of skull base were also removed, as they were involved with papilloma see Fig. . It is uPrior to coming to our institution, he underwent previous treatments that included KTP laser, cidofovir injections, and indole-3-carbinol. He did endorse a history of smoking cigarettes and has recently decreased consumption from one pack per day to half a pack per day. Based on the initial presentation and pertinent medical history, our patient is at increased risk for malignant transformation of papillomata, particularly in the larynx . Now at The case presented in this report is the first of its kind to demonstrate IP occurring within the context of RRP. Furthermore, the same strain of HPV was isolated in both lesions, providing support to the theory of HPV involvement in the pathogenesis of both IP and RRP lesions.negative papilloma, tobacco use, and previous cidofovir administration may increase the risk of malignant transformation [While single, exophytic papillomata in the nasal vestibule are fairly common, diffuse intranasal papillomatosis has only been reported in cases without coexistent RRP. Recurrence was noted soon after initial resection in two cases, suggesting a natural history similar to RRP . Althougormation . In contormation .Schneiderian papilloma refers to all squamous papillomata of the nasal or paranasal sinus mucosa. The inverted type, most commonly originating from the lateral nasal wall, are polypoid lesions where metaplastic squamous epithelium replaces and interdigitates with respiratory pseudostratified ciliated columnar epithelium, thus creating multiple squamocolumnar junctions; this mechanism of development has been correlated in previous studies with the similar metaplastic transformation zone that forms on the cervix with the progression of cervical cell turnover, and subsequent increased susceptibility to neoplastic cell transformation , 8. The While there continues to be contention in the existing literature as to the existence of malignant transformation of HPV-infected IPs and RRP lesions, this report provides histopathologic support for the hypothesis that such an association exists. Further studies are warranted to determine the potential role of HPV in the pathogenesis of both disease processes.This represents the first report of IP occurring within the context of RRP. Interestingly, the same strain of HPV was isolated in both the IP and RRP lesions. The proposed pathogenesis of HPV in IP lesions remains controversial in the literature, and is less known currently than the mechanism of HPV driving the transformation of IP to squamous cell carcinoma. Our case provides support to the theory of HPV involvement in the pathogenesis of both IP and RRP lesions. We were unable to find any additional reported cases of diffuse sinonasal papillomata.Key lessons learned from this case include the importance of histopathologic analysis of papillomata to rule out the presence of alternative subtypes, dysplasia, or malignant transformation. Furthermore, the identification of this lesion was confounded by coexistent laryngotracheal disease, an uncommon attachment site, previous negative biopsies, and absence of classic imaging features. ISH studies to determine HPV subtype are valuable in assessing the risk of dysplastic conversion. Wide excision of sinonasal papillomata with tumor-free margins is recommended to decrease the risk of recurrence.


Appendiceal mucocele is a rare disease and has a clinical picture that resembles acute appendicitis. A correct diagnosis before surgery is very important for the selection of surgical technique(appendicectomy/colectomy)to avoid severe intraoperative and postoperative complications. The work has been reported in line with the SCARE criteria .We present a case of 70 year old female admitted with chief complaints of right iliac fossa pain intermittent in nature with nausea and generalized weakness since 1 month. With the help of USG and CECT preoperative diagnosis of Appendiceal Mucocele was made. Midline incision Laparotomy was performed. Preoperative diagnosis of Appendix Mucocele changing the course of management has been reported rarely in literature.Intraoperatively a cystic mass of appendix with dimensions 8 cm × 5 cm with broad base and inflamed walls communicating with caecum but without perforation was discovered in right iliac fossa. Extended right hemicolectomy with ileotransverse anastomosis was done. Histopathological diagnosis of Mucinous Cystadenoma with Mucocele was reported. After 6 months of surgery patient is doing well with no postoperative complications.In our opinion every patient more than 50 years old presenting in emergency department with clinical symptoms of acute appendicitis must undergo CT and open surgery should be favoured against laparoscopic surgery. Besides2A 70 year old female came to Out Patient Department of Department of Surgical Gastroenterology, with 1 months history of vague pain abdomen, more localized to right lower abdomen, associated with generalized weakness, nausea and decreased appetite from last 6 months, no history of surgeries in the past. Patient reported mild right iliac fossa tenderness on palpation. She was afebrile. Laboratory investigations showed Leucocytosis with neutrophilia. Abdominal Ultrasonography showed encapsulated cystic lesion in the lower quadrant of the abdomen with a liquid content of variable echogenicity -? Appendicular Abscess /Mucocele Appendix. Abdominal CECT was done which showed Well circumscribed low attenuating tubular mass contiguous with the base of the caecum showing thin curvy linear mural calcifications with few low attenuating areas along the surface of the lesion f/s/o Mucocele of Appendix , Fig. 2.3The mucocele of the appendix - The cystic dilation of the appendix caused by the accumulation of mucus secretion. This process is slow and gradual, with no signs of infection inside the organ. It results from the lumen obstruction in the appendix, which is secondary to the inflammatory or neoplastic proliferation of the appendix mucosa, or of lesions in the cecum, adjacent to the appendiceal ostium. While some articles confirm its prevalence among women ,6, other•Simple mucocele  -degenerative epithelial changes and results in the obstruction and the distension of the appendix. There is no evidence of hyperplasia or mucosal atypia.•In hyperplastic mucocele, the appendix dilation occurs due to the hyperplastic growth of the appendix or cecal mucosa, just like hyperplastic polyps in the colon.•The mucinous cystadenoma is an appendix neoplasm with dysplastic epithelium similar to colon adenomatous polyps•The mucinous cystadenocarcinoma presents high grade cellular dysplasia and stromal invasion, besides muscularis mucosae•pseudomyxoma peritonei.In both types described, the mucus material contains epithelial adenoma cells with low or high grade of dysplasia. The rupture of the appendix may lead to the dissemination of the epithelium that produces mucins in the abdominal cavity, causing mucinous ascites or Mucocele in the appendix may be classified according to the histological characteristics of lumen obstruction  Fig. 6)Fig. 6)•SThe clinical flow of the disease does not have a specific picture. It often flows asymptomatically. In about 50% of cases it is discovered accidentally during radiologic and endoscopic examinations or at surgery. A patient’s clinical symptoms may include pain in the right lower quadrant of the abdomen, palpable abdominal mass, nausea, vomiting, weight loss, gastrointestinal bleeding, and signs of intussusception of the intestines. Preoperative diagnosis of appendicular mucocele is very important for the selection of an adequate surgical method to prevent peritoneal dissemination, to prevent intraoperative and postoperative complication, and repeated surgery ,11. USG,(1)whether or not a mucocele is perforated;(2)whether the base of the appendix (margins of resection) is involved in the process; and(3)whether there are positive lymph nodes of mesoappendix and ileocolicAn algorithm for the selection of the type of surgery has been furnished by Dhage-Ivatury and Sugarbaker . It enviAs a result patients may require different operations: appendectomy to the right colectomy, including cytoreductive surgery, heated intraoperative intraperitoneal chemotherapy, early postoperative intraperitoneal chemotherapy . In our Treatment of pseudomyxoma peritonei is variable, both due to the rarity of the disease and to its frequently slow-growing nature . Current4Appendiceal mucocele is a rare disease and has a clinical picture that resembles acute appendicitis. A correct diagnosis before surgery is very important for the selection of surgical technique to avoid severe intraoperative and postoperative complications. USG, particularly CT, should be used extensively for this purpose. In our opinion, every patient more than 50 years old who arrives at the emergency department with clinical symptoms of acute appendicitis must undergo CT and open surgery should be favored against laparoscopic surgery.The authors have no conflict of interest to disclose.No source to be stated.For case report our Institute exempted to take ethical approval.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.Pranav Jasuja – Wrote the manuscript.Sunil Kumae B.B. – Operated the patient.This is not a study, but a case report.Dr. Pranav Jasuja.Not commissioned, externally peer-reviewed.


Ossified spinal meningiomas are a rare form of spinal tumors. These tumors increase surgical morbidities due to their hard consistency and strong adhesion to the neural tissue and relatively narrow surgical space. Here, the authors describe the clinical findings, surgical strategies, and histological findings of a patient with an ossified meningioma. Preoperative diagnosis of these tumors can prevent surgical morbidities. Total resection can be curative with the application of meticulous microsurgical techniques. Metaplastic meningiomas are a subtype of meningioma characterized by focal mesenchymal differentiation with osseous, cartilaginous, lipomatous, myxoid, or xanthomatous changes.A 22-year-old female presented with progressive heaviness in the lower limbs with gait disturbance, paresthesia of the lower limbs, and sphincter disturbances for approximately 5 weeks. Neurological examination revealed motor power grade of 3 for all muscle groups of the lower limbs and hypoesthesia with a sensory level below T4. Reflexes were exaggerated with positive Babinski and pathological reflexes. Radiological workup including magnetic resonance imaging (MRI) of the dorsal spine showed an intradural extramedullary spinal meningioma opposite the T4 to T5 level with hypointense signals on T1- and T2-weighted images of the tumor that indicated calcification andB. Including this report, a total of 33 cases of ossified spinal meningioma have been published till 2019 according to PubMed . For thSpinal meningiomas arise from the arachnoid villi of spinal nerve roots and are located within the intradural space in most cases.The clinical features of ossified spinal meningiomas include motor, sensory, and sphincter dysfunctions, which exhibit different phenotypes according to the tumor location and neural compression.Ruggeri et al observed a statistically significant relationship between postoperative neurological status and the degree of meningioma ossification wherein surgical morbidity increased with calcified and ossified tumors.The surgical strategy for ossified meningiomas differs from that for other classical cases of meningiomas because central tumor debulking can be challenging. Using an ultrasonic surgical aspirator is helpful for hard tissue removal, including bone removal; however, it may result in neurovascular damage. This method can be safely used at the tumor periphery. Meticulous microsurgical dissection between the pia mater and tumor surface can facilitate en bloc tumor removal.When attempting a complete resection, wide resection of the dural attachment tends to reduce the rate of recurrence; however, dural coagulation can also be performed.Approximately 90% of spinal meningiomas can be surgically resected with Simpson's grade-1 resection. The rate of recurrence during long-term follow-up reportedly ranges from 4 to 10%.Adjunctive radiation therapy is considered for cases requiring subtotal resection; those with recurrent meningiomas, anterior tumor location, and en plaque and calcified meningiomas; and those wherein the surgical risk is extremely high, given patients' comorbidities and tumor location.Spinal meningiomas with a hypointense signal on MRI should indicate surgeons about the possibility of calcified or ossified meningiomas. The authors recommend the use of preoperative CT to detect sites of ossification. Intraoperative neuromonitoring of MEPs and SSEPs, use of a wide surgical corridor with total laminectomy, wide dural opening, identification of upper and lower poles, and early CSF drainage are helpful in decreasing neural retraction, thereby facilitating safe total resection. The authors recommend dural resection or coagulation to reduce the rate of recurrence and to avoid redo surgeries.


Bezoars are concretions of foreign indigestible material accumulating in the gastrointestinal tract leading to intraluminal mass formation that impairs the gastrointestinal motility and can lead to gastric obstruction of the small or the large bowel. There are different types of bezoars, named according to the material they are made of. These include phytobezoar, lactobezoar, pharmacobezoar, trichobezoar, and polybezoar. Trichobezoars  are usually located in the stomach but may extend through the pylorus into the duodenum and small bowel (Rapunzel syndrome).Herein, we report a case of a young adult female known to have a long-standing trichophagia who presented with gastric outlet obstruction due to a large trichobezoar.Endoscopy revealed a large and hard gastric trichobezoar not amenable to endoscopic retrieval leading to surgical extraction as a last resort.They are almost always associated with trichotillomania and trichophagia or other psychiatric disorders. Trichobezoar can be treated either surgically by laparotomy/laparoscopy or by endoscopic intervention.Treatment should be coupled to psychiatric evaluation and therapy to prevent recurrence. TrichobAlthough not common, trichobezoars can result in devastating complications including death if left undetected .Surgical intervention is often required in the management of large trichobezoars .Herein, we present a case of a young female presenting with gastric outlet obstruction by large trichobezoar, diagnosed by cross-sectional imaging and treated surgically after failure of endoscopic intervention.The work in this case has been reported in line with the SCARE criteria .2A14-year-old female patient known to have Pica disorder since the age of 2 years with a history of recurrent trichophagia was admitted to the emergency department for nausea, vomiting, and unintentional weight loss of 7 kg in 1 month.On physical examination, the vital signs were stable, the patient appeared pale.Abdominal exam revealed a large, firm and hard mass in the epigastric and left upper quadrant areas.The result of the blood tests including complete blood count, electrolytes, BUN, creatinine, liver function tests, amylase and lipase were unremarkable.The patient underwent a computed tomography (CT) of the abdomen and pelvis, revealing a large mass measuring 30 × 17 × 12 cm, well defined, multi-layered, heterogeneous, solid appearing, non-enhancing mass in the gastric lumen, extending from the gastric fundus to the pyloric canal. Some of the layers of this mass were heterogeneously hyperdense . The lesConsequently, esophagogastroduodenoscopy (EGD) was done, revealing a collection of a large hard hairball occupying the entire lumen of the stomach from the fundus through the pylorus reaching the duodenum. Endoscopic intervention failed to retrieve the mass due to its large size and hard nature.Subsequently, surgical intervention was planned through a midline laparotomy. A large solid fixed mass was palpated in the stomach. A 7 cm longitudinal gastrotomy was done on the anterior gastric wall, 6 cm from the pylorus. A large trichobezoar, filling the entire stomach and the first portion of the duodenum, was identified and removed . The gas3Trichobezoar is a rare disorder that almost exclusively affects young females. Most patients with trichobezoar suffer from psychiatric disorders including trichotillomania and trichophagia . The sitHuman hair is resistant to digestion as well as peristalsis due to its smooth surface, leading to its accumulation between the mucosal folds of the stomach. Over a period of time, continuous ingestion of hair leads to the impaction of hair together with mucus and food, causing the formation of a trichobezoar ,9.In most cases, the trichobezoar is confined within the stomach. However, in some cases, it extends through the pylorus into the jejunum, ileum or even colon. This condition is called Rapunzel syndrome, first described by Vaughan Jr. et al. in 1968 .Affected patients remain asymptomatic for many years. Symptoms develop as the bezoar increases in size. The most common presentations are abdominal pain, nausea/vomiting, obstruction and peritonitis. Less often, the patients present with weight loss, anorexia, hematemesis and intussusception ,10.Other complications include gastric ulceration, obstructive jaundice, acute pancreatitis and gastric emphysema. In addition, malabsorption related complications include protein losing enteropathy, iron deficiency and megaloblastic anemia .Different therapeutic options have been employed to treat this condition, including laparotomy, endoscopic removal and laparoscopic removal ,5,12. Co4Physicians, surgeons and radiologists should consider trichobezoars among the differential diagnosis for young females with abdominal pain and presence of an upper abdominal mass. Endoscopic or surgical removal can be performed safely and effectively. Treatment should be coupled to psychiatric evaluation and therapy to prevent recurrence.No potential conflict of interest relevant to this article was reported.There are no sources of funding for this research.Not applicable. The study is exempt from ethical approval in our institution.Consent has been obtained from the patient mother’s on behalf of the patient. No identifying details have been used in the article.DIRANI M, HAYEK M, SAIKALY E – acquired and interpreted the data and drafted the manuscript with editing. CHAHINE E, BAGHDADY R. – performed the operation and perioperative management of the patient, revision of the manuscript. All authors read and approved the final manuscript.CHOUILLARD E – study concept, and final approval. CHAHINE E, EL KARY N, Not available.CHOUILLARD E, CHAHINE E.Not commissioned, externally peer-reviewed


A history of frequent surfing can be a key finding when a patient comes in with subcutaneous lesions on bilateral anterior lower chest. MR imaging could lead to the diagnosis with its characteristic finding for collagenous mass lesions, though most cases do not require imaging unless with atypical presentation. This enables clinicians to avoid unnecessary invasive procedures. A 43‐year‐old male presented with painful bilateral chest lesions started a few months prior. The lesions were located anterior lower chest and painful during surfing. While his medical and family histories were unremarkable, his personal history revealed that he was a surfer with 20 years’ of experience. Neither palpation nor CT images Figure , which sNone declared.AB: drafted the article. All authors participated in critical review and the revision of the articles. All authors gave the final approval of the article. All authors have accountability for all aspects of the work.


Choroidal osteoma is rare clinical entity of unknown etiology, characterized by formation of mature cancellous bone within the choroid. It typically affects young females, with no racial predilection. Vision loss occurs mainly due to photoreceptor degeneration secondary to decalcification and/or development of choroidal neovascularization especially if located at the subfoveal area.Our case is 9-year-old Indian (Indo-Aryan) boy identified incidentally with clinical features suggestive of choroidal osteoma with marked diminution of vision. Spectral domain optical coherence tomography demonstrated high reflectivity from the choroid and atrophy of the overlying retinal layers and B-scan ultrasound demonstrated multiple highly reflective calcified lesions within the choroid.Although available literature shows that the occurrence of this rare clinical entity is more commonly seen in young females, our case report has shown that it may be seen at a very early age. The treatment options are still not available if significant atrophy of retinal pigment epithelium has already occurred; however, vision loss due to associated choroidal neovascularization may be treated with currently available treatment options. In our case, the vision loss was due to the significant atrophy of the retinal layers. Choroidal neovascularization was not seen and our patient was advised to attend follow-up regularly. The exact etiology is still unknown. The first case was presented at a meeting of the Verhoeff Society in 1975 and the case was published by Gass  in 1978 . There i in 1978 . It typi in 1978 . The mos in 1978 , 6, 7.A 9-year-old Indian (Indo-Aryan) boy diagnosed as having pan-sinusitis was referred to us from an Ear, Nose, and Throat (ENT) department with complaints of swelling over the left side of his face involving left lower lid to rule out any ocular manifestation. He gave a history of swelling over the left side of his face of approximately 10 days’ duration. It was insidious in onset, gradually progressive in nature, and involved the left lower lid; it was not associated with pain and fever. There was no associated systemic disease. On examination, the best corrected visual acuity (BCVA) for his left eye was hand movement and for his right eye it was 6/6. He was unaware of diminished vision in his left eye. On dilated fundus examination we observed two yellowish white lesions with well-demarcated borders located superotemporally indicative of active lesions, which were associated with nearby areas of RPE depigmentation and pigment clumps extending into the macular area, which were suggestive of degeneration of overlying retinal layers indicative of decalcified lesions in his left eye  revealed areas of early granular hyperfluorescence corresponding to the areas of RPE depigmentation and late hyperfluorescence over the calcified lesion with some interspersed areas of hypofluorescence corresponding to the areas of pigment clumps in the left eye Fig. .Fig. 2FuSpectral domain optical coherence tomography (SD-OCT) was performed and revealed high reflectivity from the choroid with marked thinning of overlying retinal layers including photoreceptor inner/outer segment junction Fig. .Fig. 3SpB-scan ultrasound (USG) of his left eye demonstrated a large irregular echogenic calcified lesion of 7.1 × 3.9 mm in the posterior choroid near to the optic disc region and extending up to optic disc, and another smaller echogenic calcified foci in the posterolateral choroid both nasally and temporally. The nasal lesion was 1.3 mm and temporal lesion was 1.5 mm Fig. .Fig. 4B-Examination of his right eye was normal. All routine blood investigations were normal including serum calcium and parathyroid hormone level. As there was already a setup of decalcification with loss of RPE/photoreceptor and marked diminished vision, and the lesion extended into the foveal region, we asked our patient to attend follow-ups at monthly intervals to monitor the subsequent progression or regression of the tumor, because of the non-availability of a reliable treatment option.Choroidal osteoma is a rare benign ossifying disorder of the choroid. In our case, our patient was a 9-year-old boy. In the largest case series on choroidal osteoma including 74 eyes of 61 patients followed up for a period of 26 years, Carol and colleagues demonstrated that choroidal osteoma is a disease of young females . The optet al. also reported a case of extrafoveal CNV successfully treated with PDT [The etiology of choroidal osteoma is still unknown. It has been suggested that it is an osseous choristoma . This suwith PDT . HoweverChoroidal osteoma is a rare benign disorder of unknown etiology; the literature showed a higher incidence in young females. However, it may occur at a very early age. Treatment options are still not available; also, early detection of the condition is incidental. Most of the time, a patient presents with symptoms of diminished vision when significant atrophy of retinal layers has already occurred. If diagnosed incidentally, the patient should be followed up regularly to detect the development of CNV or atrophy of retinal layers, so that loss of vision can be minimized. The strengths of this case report include its novelty; we describe a rare disease process involving the retina, with significant reduction in vision. The workup of our patient was quite thorough, as it involved multiple hospital admissions and subspecialty evaluations. The limitations of this case report include no follow-up data, as our patient did not turn up for follow-up. Curative treatment options are not yet available for this entity.


Thymic neuroblastoma with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) in adults is an extremely rare and malignant neoplasm. Although the tumor is known to grow rapidly and have a poor prognosis, its etiology is still uncertain. In 2009, we described a case of thymic neuroblastoma with SIADH. We report here the clinical course over the last 10 years.A 70-year-old Japanese male with a history of thymic neuroblastoma with SIADH was regularly followed up on an out-patient basis after complete surgical resection for more than 10 years. He remains free of the disease and asymptomatic.Complete surgical removal is considered as one of the treatment options for this tumor if clearly separated from the surrounding tissue with no invasion. Till da2In 2008, a 60-year-old Japanese male patient was admitted to our hospital for further examination and treatment of an abnormal shadow seen on his chest x-ray during a regular health check-up. An enhanced chest computed tomography scan revealed a 47-mm solid mass with a clear rim in the anterior mediastinum . Magneti3Neuroblastoma is considered a pediatric malignancy since over 95% of the cases are diagnosed in children aged less than 10 years . These tIn adult neuroblastomas, localized tumors can frequently recur, and reports suggest that recurrence or metastasis inevitably appears following treatment with surgery alone or combination of either radiation or chemotherapy . However4In the present case, complete surgical removal is considered to be an option for the treatment of this tumor when it is clearly separated from the surrounding tissues and with no invasion. However, further investigations are necessary to confirm whether it could indeed be a treatment strategy in this disease.The author declares no conflicts of interests.The author did not receive any fund.This case report is exempted from ethical approval by our institution.The author states that they have written and signed consent from the patient to publish this report.Yukitoshi Satoh: Conceptualization, Methodology, Validation, Investigation, Writing – original draft, Writing – review and editing, Visualization, Supervision.The author does not need to register this work.Dr. Yukitoshi Satoh.Not commissioned, externally peer-reviewed.


Cutaneous squamous cell cancer (cSCC) is a common condition, with straight forward and well-known heuristics regarding diagnosis, treatment, and surveillance. cSCC arising in an epidermal inclusion cyst is rare, but not unheard of. In contrast, the authors’ are unaware of any prior reports of cSCC arising in an epidermal inclusion cyst within an atypical cavernous and cavitating lesion in the perineum.A 48-year-old male presented with a cavitating and rapidly growing cutaneous perineal lesion. Preliminary diagnostic procedures (biopsy) showed benign pathology and imaging showed no involvement of perineal organs such as prostate or rectum. Discordance between initial diagnostics and clinical features prompted multi-specialty consultation, including dermatological pathology. Repeat biopsy yielded in situ, possibly invasive squamous cell cancer, arising in the background of an epidermal inclusion cyst. Wide excision with advancement flap reconstruction was employed, with temporary diverting colostomy to avoid perineal sepsis.Location and appearance of this lesion provided a diagnostic and treatment challenge requiring multi-specialty involvement for diagnosis and successful treatment. Specialists from urology, general surgery, dermatology, general and dermatological pathology, plastic and reconstructive surgery, colorectal surgery and medical and radiation oncology were involved in diagnosis, treatment plan and execution. None of the specialists involved had seen this singular presentation before, and this created an ownership and management challenge.The cavitating, atypical appearance of lesion complicated diagnosis. Location required pre-treatment coordination and deliberation between dermatology, urology, general surgery, and plastic surgery. Malignant degeneration of inclusion cysts, although rare, has to be kept in mind, especially when presenting with rapid growth, and persistence in ruling out malignant diagnosis is fundamental. Squamous cell carcinoma arising in a perineal epidermal inclusion cyst is rare, this is the 5 to date . This ma2This case was managed in a community hospital in the Midwest within a multi-hospital, not-for-profit system. A 48-year-old male patient presented to his primary care physician complaining of a tender perineal mass of about one month of evolution. Patient has history of metabolic syndrome defined by type 2 diabetes mellitus, obesity, coronary artery disease, ischemic cardiomyopathy, congestive heart failure and hypertension. He is a social drinker and smokes about a pack of cigarettes per day. Physical examination showed a rubbery, tender and cavitating lesion in perineum, in midline, about equidistant from scrotum and anal verge. This lesion measured about 5 cm in diameter, with associated underlying soft tissue induration, extending from scrotum anteriorly to about one centimeter from anal verge posteriorly.  The caviPatient was seen later that morning by urology who in turn obtained immediate evaluation by general surgery. No clear cut etiology could be determined by physical examination by either specialist; therefore, the decision was made to perform abdomen pelvic CT scan and biopsy. CT scan showed a cavitating cutaneous lesion, without any involvement of anorectal or urological structures . Lesion The benign nature of initial histological diagnosis was discordant with the patient’s history of rapid growth, which suggested a malignant etiology. Therefore, biopsy under anesthesia was repeated, with wider and more aggressive sampling of the lesion. Histological analysis once again showed benign results: keratinizing squamous epithelium with inflammation and fibrosis.Despite consecutive benign biopsy results, we were convinced this lesion had to be malignant. Given the risks of prolonged disability or permanent mutilating complications associated with oncological excision of skin in this anatomical location, we felt that obtaining accurate preoperative diagnosis was fundamental for a sound informed consent from patient. We therefore requested evaluation and second opinions from dermatology and dermatological pathology. A repeat biopsy yielded in situ, and possible invasive squamous cell cancer, arising in the background of an epidermal inclusion cyst, probably related to HPV infection a–c.Fig. The case was presented to Tumor Board and an independent evaluation by colorectal surgery in tertiary medical center was obtained. The summary of the multi-specialty panel was to treat this cutaneous lesion by wide excision. Radiotherapy was discussed as a non-surgical management. Radiation oncology opined that radiation would only be indicated in the setting of positive margins where re-excision would be destructive or permanently disabling to patient. Given the size of the lesion, closure of wound would require either a skin graft or advancement flap, a decision to be made by plastic and reconstructive surgery at time of operation. To avoid perineal sepsis and improve odds of successful wound healing, it was decided to perform a temporary diverting colostomy.Patient received preoperative evaluation by cardiology and preoperative risk factors were optimized. Following laparoscopic end colostomy and Hartmann pouch as the first step in surgery, wide excision of the perineal lesion was performed by a urology and general surgery team a. Recons3This case presented a diagnostic and treatment challenge. It was a cutaneous malignancy located in an anatomical location that proved to be a no man’s land for all specialties involved. None of the specialist involved had seen a case like this before. Perineal inclusion cysts are rare, and malignant degeneration even more so, with only 4 cases reported previous to this case.(2) Every involved specialty was essential to final outcome, yet no single specialty was qualified to provide diagnosis and treatment by itself. Successful management required pre-treatment coordination and deliberation, to work around the ownership problem. Dermatology provided definitive diagnosis. Urology provided expertise as to scrotal skin excision. General surgery provided diverting colostomy and perineal/perianal excision. Plastic surgery provided wound closure via advancement flap. Advancement flap closure was significantly enhanced by the elasticity of the scrotum. We believe that avoiding a skin graft facilitated greatly this operation and patient’s recovery.The etiology of the squamous cell carcinoma is not certain. Possible Human Papilloma Virus (HPV) infection was investigated with in situ hybridization; however, no high risk HPV was identified.4Squamous cell cancer of skin is a common diagnosis. Its presence in an epidermal inclusion cyst, is not. There are a handful of case reports of malignant degeneration of inclusion cysts, most of them occurring in head and neck .There arThe location of this lesion, in the central portion of perineal skin, presented a treatment challenge requiring a multidisciplinary team both for diagnosis and for definitive treatment. Neither urology, colorectal or general surgery felt in complete ownership of the condition, unlike cystic lesions that are clearly located in genitalia or anorectal structures ,6. The lGiven the potentially catastrophic nature of possible complications, a temporary colostomy was placed pre-operatively. This decision may be challenged in future similar cases. We believe it was the right decision, given the patient’s characteristics. An accurate pre-operative diagnosis made treatment decisions easier on the treatment team, and facilitated patient’s acceptance of treatment options, especially the temporary colostomy. We hope that the heuristics used in management of this case will help guide other multidisciplinary teams in future decision making when faced with similar pathology and anatomical location.The authors declare no conflicts of interests or competing interests.There were no sources of funding.I declare that ethical approval has been exempted by my institution for this case report by the OhioHealth Office of Human Subjects Protections.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.Jose Vale MD: wrote paper, collected pictures, assembled treatment team, principal attending in care of patient.Yujing Pang MD: pathological analysis, provided pictures of pathology specimen.Arthur Kumpf MD: plastic and reconstructive surgeon in charge of wound closure.David Fitkin MD: urologist, received initial referral, assisted during surgery in scrotal excision.Scott Drew DO: provided second opinion and obtained specimen that proved malignancy in lesion.Not applicable.Jose Vale.Not commissioned, externally peer reviewed.None.


Primary cardiac lymphomas (PCL) represent extremely rare cardiac tumors which are accompanied by poor prognosis, unless they are timely diagnosed and treated.Herein we present a 28-year-old, immunocompetent man who presented to our hospital due to progressively worsening symptoms and signs of superior vena cava syndrome. Multi-modality imaging demonstrated a large intracardiac tumor, which was proven, by biopsy, to be a PCL. The patient received targeted chemotherapy which led to total remission of his disease, with no relapse over a 15-month follow-up period.Although PCLs are rare, they should always be kept in mind in the differential diagnosis of cardiac tumors. Timely diagnosis of PCLs and appropriate chemotherapy, alone or in combination with radiotherapy, seems to provide the best results. Primary cardiac tumors are extremely rare, appearing in less than 0.1% of cases in a large series of 12,000 autopsies . PCLs arHerein we present the case of a 28-year-old man, with a free medical history who presented to the allergology department of our hospital due to progressively worsening over the past 3 months facial oedema and erythema of the upper thorax markedly aggravated by bending forward.At presentation, the patient demonstrated facial plethora with oedematous eyelids, dilated jugular veins and dilated chest wall collaterals Fig. , panel aA transthoracic echocardiogram (TTE) depicted a large, non-mobile mass infiltrating the interatrial septum and extending to both atria, mainly to the right atrium Fig. , panel bA total body contrast-enhanced computed tomography (CT) scan demonstrated a dilated azygos vein Fig. , panel fThe patient was started chemotherapy with rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (RCHOP). The first cycle drugs doses were divided in 2 with 15 days interval to minimize complications as arrhythmias and tissue rupture according to the literature [Our patient represents one of the rare cases in which prompt diagnosis of PCL and initiation of appropriate treatment can lead to excellent clinical outcomes, despite the initial severe presentation.PCLs are rare clinical entities which usually manifest after the fifth decade of life . They arMacroscopically, PCL have been characterized as lymphomas only involving the heart and pericardium . HistoloPCLs typically present with dyspnea, arrhythmia or pericardial effusion . The rarPrognosis of patients with PCL is poor. Median survival after treatment is approximately 7 months . SurgicaDespite the rarity of PCLs, they should always be kept in mind in the differential diagnosis of cardiac tumors. Timely diagnosis of PCLs and chemotherapy with RCHOP, alone or in combination with radiotherapy, seems to provide the best results.


Tracheal granular cell tumors are rare neurogenic neoplasms characterized by an indolent behavior. We report the case of a young woman affected by this tumor with non-specific clinical presentation. We performed a literature search in order to identify all the cases of tracheal granular cell tumor and to summarize the current state of knowledge about this rare disease. Althoug2A 42-year-old former smoker woman (30 pack-years) presented to the Emergency Department with acute onset of dyspnea, cough and fever. The patient had no comorbidities and the physical exam was within normal limits. In order to exclude a pulmonary thromboembolism, a computed tomography angiography was performed, revealing bilateral hilar and mediastinal lymphadenopathy and various areas of ground glass of both the inferior lobes. Several blood tests were done in order to exclude an infectious disease; the tests were negative, including QuantiFERON-TB Gold test. Bronchoscopy showed a marked thickening of the tracheal carina extending for a few millimeters to the medial aspect of both mainstem bronchi .Fig. 1FiHistopathology examination of the bronchial biopsies performed in this area revealed sheets of epithelioid cells with eosinophilic granular cytoplasm, positive for S100 and NSE and negative for CAM5.2 ; Fig. 3,3GCTs  were reported by Weber in 1854 . GCTs usWe performed a literature search for the present study. The search included PubMed, EMBASE and Google Scholar, and used the following search terms: “tracheal granular cell tumor”, “granular cell tumor”, “rare airway tumors”, “tracheal malignancies”. The inclusion criteria were as follows: all types of articles, articles published in PubMed and related only to humans. Articles for which full text was not available were excluded. The Medline search of GCT of the trachea found altogether 41 cases. Overall, forty-two cases of GCT have been identified. The clinical and pathological findings of all cases are summarized in As stated before, median age at diagnosis of tracheal GCTs appears to be around 33 years, with a higher incidence in African and African American women . NeverthThese neoplasms are asymptomatic in the vast majority of patients . ClinicaTreatments in tracheal GCT include tracheal resection, or endoscopic removal assisted by laser, electrosurgery or argon plasma coagulation . As stat4We herein report a case of tracheal GCT in a young woman presenting with dyspnea. Diagnosis of tracheal GCT requires a high index of suspicion given a clinical presentation which often mimics typical signs and symptoms of bronchial asthma or recurrent pneumonia, as in our case. We encourage the need for large case series in order to provide further information concerning tracheal GCTs, taking into account the paucity of data currently available in literature and the extreme rarity of the disease.AR: has made substantial contributions to conception of the study, and drafted the manuscript; EDS: has contributed on pathological data and has made substantial contributions to conception of the study; ADR: has helped to draft and revised the manuscript; MN: has been involved in revising the manuscript critically for important intellectual content and have given final approval of the version to be published; MS: has helped to draft and revised the manuscript; AC: has provided the pathological data; DP: has helped to draft and revised the manuscript; RT: has been involved in revising the manuscript critically for important intellectual content, has provided surgical data and have given final approval of the version to be published; Maria AP: have made substantial contributions to conception of the study and has been involved in revising the manuscript critically for important intellectual content and have given final approval of the version to be published.The patient provided written informed consent.The author(s) received no financial support for the research, authorship, and/or publication of this article.The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.


Angioinvasive rhinocerebral mucormycosis is an acute fulminant infection caused by fungi of the order Mucorales that targets uncontrolled diabetics and other immunosupressed individuals. Early imaging features of angioinvasiveness include the presence of thrombosed vessels, especially in the orbital regions and the “black turbinate” sign representing devitalized paranasal sinus mucosa. Intracranial extension carries a grave prognosis, with death reported in 90% of cases. This case report highlights the early and key imaging features of angioinvasive rhinocerebral mucormycosis and a rare complication of complete internal carotid artery thrombosis. Angioinvasive rhinocerebral mucormycosis is an acute fulminant infection caused by fungi of the order Mucorales that targets uncontrolled diabetics and other immunosupressed individuals. Early imaging features of angioinvasiveness include the presence of thrombosed vessels, especially in the orbital regions and the “black turbinate” sign representing devitalized mucosa. Complete thrombosis of internal carotid artery (ICA), a rare complication, can add to higher morbidity rates.A 51-year-old female presented with recent onset mild headache and epistaxis to the otorhinolaryngology outpatient department. She was a known diabetic and hypertensive for 8 years, on irregular treatment.–1; GE Healthcare, Shanghai, China)  , which s, China) . It was –1 ; glycosylated haemoglobin 18.8%; C-reactive protein 228 mg l–1 ; neutrophilic leukocytosis and thrombocytosis on peripheral smear; urine and cerebrospinal fluid were positive for protein, glucose and ketones. Plain CT scan followed by contrast-enhanced MRI using Gadodiamide  was performed, which showed worsening of the sinusitis  owing to the propensity to involve the lenticulostriate and thalamostriate arteries. Additionally, ring-enhancing lesions representing a granuloma or abscess can be seen with or without enhancing meningeal exudates. Rhino-orbital disease is uncommon in such a scenario.11 Treatment of rhinocerebral mucormycosis includes prompt control of hyperglycaemia, i.v. antifungals such as amphotericin and anti-oedema measures. Renal toxicity induced by amphotericin should be closely monitored with the use of alternative drugs in renal dysfunction. Surgical debridement of the necrotic tissue until normal perfused healthy tissue is seen can reduce the disease burden.Another rare cause of rapidly progressing vascular thrombosis is the antiphospholipid antibody syndrome. The severe form of this entity is called “catastrophic” and causes multiorgan involvement secondary to thrombus formation developing over a short time.The uniqueness of mucormycosis is its spread to the intracranium through the arteries and veins without causing any bone or dural destruction. The common arteries of spread are the ophthalmic and ethmoidal arteries. The presence of ophthalmic artery thrombosis in the setting of sinusitis with a “black turbinate” and uncontrolled diabetes is an early clincher for the diagnosis of angioinvasive fungal sinusitis. Management at such an early stage would reduce substantial morbidity.5Angioinvasive rhinocerebral mucormycosis is an acute fulminant infection caused by fungi of the order Mucorales that targets uncontrolled diabetics and other immunosupressed individuals. Early imaging features of angioinvasiveness include the presence of thrombosed vessels, especially in the orbital regions and the “black turbinate” sign representing devitalized mucosa. Intracranial extension carries a grave prognosis, with death reported in 90% of cases.Rhinocerebral mucormycosis is an acute severe, rapidly progressing, life-threatening condition affecting uncontrolled diabetics and immunocompromised individuals.“Black turbinate” sign on MRI is useful in the diagnosis of fungal sinusitis.Thrombosis of the ophthalmic vessels can suggest and predict angioinvasiveness and subsequent development of cerebral infarcts.Cerebral involvement carries a grave prognosis and hence aggressive treatment is essential.The informed consent to publish this case was obtained and is held on record.


Presacral epidermoid cysts are uncommon, usually benign cysts caused by developmental abnormalities in the fetal period. We present a rare case of squamous cell carcinoma arising from a presacral epidermoid cyst.A 59-year-old woman complained of tenesmus and discomfort in the buttocks. Computed tomography revealed a 50-mm well-defined cystic mass in the presacrum and a 70-mm solid mass extending from the cyst into the rectum, vagina, and left sciatic spine. On T1-weighted magnetic resonance images, the cyst was unilocular and the mass was marginated with low intensity. On T2-weighted images, the mass had high intensity. A malignant presacral developmental cyst was diagnosed, without obvious metastasis. Using abdominal and parasacral approaches, Hartmann’s operation was performed with multiorgan resection, including the sacrum, coccyx, left sciatic spine, internal obturator muscle, rectum, and uterine appendage. Histopathology of the excised specimen revealed a squamous cell carcinoma originating from the presacral epidermoid cyst.Reports of malignant transformation of epidermoid cysts in the presacral space, as in the present case, are extremely rare. Because of their unusual location and slow growth, epidermoid cysts tend to remain asymptomatic. Because the patient had a malignant tumor with suspected invasion of adjacent organs, combination surgery was selected.Although further research is required, presacral epidermoid cysts are extremely rare and may be malignant. Thorough preoperative image evaluation is crucial for complete resection. Presacr2A 59-year-old woman consulted a primary care doctor with the chief complaints of tenesmus and discomfort in the buttocks. A rectal submucosal tumor was suspected after colonoscopy, and she was referred to our hospital. She had no past medical or surgical history; however, her brother had rectal cancer. On physical examination, her abdomen was soft and flat, with no tenderness.Biochemistry tests revealed elevated levels of squamous cell carcinoma-related antigen (26.4 ng/mL) and carbohydrate antigen 125 (40.5 U/mL). Levels of carcinoembryonic antigen, carbohydrate antigen 19-9, carbohydrate antigen 72-4, and alpha-fetoprotein were within normal limits. Colorectal examination showed exudation from outside the rectal wall, consistent with a rectal submucosal tumor . There wContrast computed tomography revealed a 50-mm well-defined cyst in the presacrum and a 70-mm solid mass extending from the cyst into the rectum, vagina, and left sciatic spine. There was no metastasis of the lymph nodes A. The soBased on the above findings, the patient was diagnosed with a malignant presacral developmental cyst. There was no obvious metastasis, and surgical management was adopted. Using the abdominal and parasacral approaches, Hartmann’s operation  was performed with multiple organ resection including the sacrum, coccyx, left sciatic spine, internal obturator muscle, rectum, and uterine appendage. The sacrum was dissected at the S4 level. A gynecologist and an orthopedic surgeon performed the complete resection. The operative time was approximately 842 min, and intraoperative blood loss was approximately 4,210 mL.We removed the rectum including the tumor, sacrum, coccyx, and uterine appendage A. MacrosMicroscopic examination demonstrated that the luminal surface of the cyst was covered with squamous epithelium C, with cThe patient recovered uneventfully and was discharged 39 days after surgery. The preoperative symptoms of tenesmus and discomfort in the buttocks disappeared. No recurrence was found in the first follow-up computed tomography 3 months after surgery. However, 7 months after surgery, computed tomography showed recurrence of the metastasis in the pelvic lymph nodes. Because the patient refused therapeutic intervention, best supportive care was adopted. She died 10 months after the surgery. No autopsy was performed.3Presacral tumors are uncommon, which occurs in 1 of 40,000–63,000 patients, and 60 % of presacral tumors are congenital . DevelopThe reported incidence rate of malignant tumors arising from epidermoid cysts is 0.011 %–2.2 % ,9. The eComputed tomography and magnetic resonance imaging are useful for diagnosing presacral tumors. They have low-signal intensity on T1-weighted magnetic resonance images and high-signal intensity on T2-weighted images. Epidermoid cysts contain fatty elements, such as desquamated debris, cholesterol, keratin, and water .Preoperative biopsy should not be performed in patients with epidermoid cysts because it can lead to tumor dissemination, abscess, fecal fistula, or meningitis . MalignaThere is still no definitive policy on adjuvant or recurrent treatment for epidermoid tumors, and further research is needed. Radiation therapy and chemotherapy may be useful, as they have been shown to prolong survival ,19. In o4Presacral epidermoid cysts are rare and require further study. Owing to their malignant potential, thorough preoperative imaging evaluation is important for complete resection. Multidisciplinary treatments may be effective.The authors declare that this study was not funded externally.As a case report without Protected Health Information, no ethics approval was required for this project.Written informed consent was obtained from the patient for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.MO and TK drafted the article and performed the literature search. MO, TK, RO, NK, SH, IN, HT, NT, and TK contributed to patient care and participated in the critical revision of the article. All authors have read and approved the final article.This is a case report.Manato Ohsawa.Not commissioned, externally peer-reviewed.The authors declare no conflicts of interest.


Jejuno-ileal diverticulitis is an uncommon, acquired clinical entity, with higher prevalence among patients aged between 60 and 70. The condition is usually silent and has been regarded as relatively innocuous. Sometimes patients complain chronic vague symptoms like malabsorption, pain or nausea, that easily lead to misdiagnosis. Acute complications are rare, however, they have been reported and can result in major surgery and high overall mortality.We are presenting a case of a 67-year-old patient who presented to our department with abdominal pain and signs of peritonitis. The CT scan displayed an inflammatory mass with a fair amount of free liquid in the abdomen, as well as multiple diverticula at different levels of the intestine. The patient had to underwent immediate surgery, during which a resection of 25 cm jejunum and 80 cm of ileum has been performed.Jejuno-ileal diverticula are a very uncommon finding that can present formidable challenges in diagnosis and treatment. The course can be completely asymptomatic, however, in rare cases, the condition can lead to severe complications that often require surgery. Multi detector CT (MDCT) with intravenous contrast should always be the modality of choice for investigating a suspect of small bowel diverticula. There are no specific guidelines respect the management of jejuno-ileal diverticulitis, nevertheless, in the acute setting, bowel resection is the treatment of choice.As well as setting out the rarity of this case, our work intends to review the current literature regarding the epidemiology, natural history, diagnosis and management of jejuno-ileal diverticula The incidence ranges from 0.03% to 8.0% on autopsy series, and between 0.02% and 7% on patients studied with contrast examinations [The probability of finding diverticula decreases towards the ileocecal valve . 10% of 2A 67-year-old Caucasian man presented to the emergency room because of a 4 days’ history of abdominal pain, with one episode of vomiting.The patient’s past medical history was significant for colonic diverticulosis and an episode of gastrointestinal bleeding one year before. The event had been investigated by two different gastroscopies, a colonoscopy and a MDCT, which produced inconclusive results. Ten months later he was newly admitted because of abdominal pain and fever at 38.0 C°, with valid urination and defecation. A CT of the abdomen was performed, which confirmed the colonic diverticulosis and revealed the presence of multiple diverticula of the small intestine, fat stranding, signs of inflammation as well as a small amount of free liquid in the abdomen. The patient was hence diagnosed with jejunal diverticulitis and managed conservatively with intra-venous antibiotics, with an apparent complete recovery.He re-presented to the emergency department two months later with acute abdominal pain. The pain was described as severe and constant, localized mainly in the lower abdomen with clinical signs of peritonitis. No change in bowel habits nor urinary symptoms were complained. His vital signs were stable, with a temperature of 37.2 C°; he appeared fully oriented and not in any acute distress. Laboratory examination reported a hemoglobin of 121 g/dL, a WBC count of 12.2 × 10E9/L and a CRP of 249 mg/L. Other laboratory data were within normal limit. An abdominal and pelvic contrast-enhanced computed tomography, with administration of oral contrast, was performed. Jejunum and ileum showed several diverticula as well as an inflammatory thick-walled mass involving different loops of the intestine. In addition, free fluid in the abdomen and a small amount of subdiaphragmatic air were reported , Fig. 2.The patient underwent a diagnostic laparoscopy which revealed plenty of purulent yellowish liquid collected in the right abdomen and a conglomerate of intestinal inflamed loops. We hence decided to convert immediately the procedure to laparotomy. Large multiple diverticula were found covering a section of small intestine approximately 2.5 m long, without signs of obvious macro perforation. Among the middle distal tract of the jejunum and the middle distal tract of ileum, strong adhesions were identified . The inv3Sommering was the first to report acquired jejuno-ileal diverticula in 1794 . These lPerforation of jejunal diverticula is a severe complication that occurs in 2.3%–6.4% of the cases, and it is often due to inflammation and subsequent necrosis of the mucosa. Even micro-perforations can produce a local inflammatory process. The bowel response results in the formation of an abscess, with migration of the surrounding intestinal tracts and soft tissues, causing adhesions between loops. Perforated jejunal diverticula can further complicate with fistulas between intestinal loops, abdominal wall abscesses and suppurative pyelophlebitis ,11.Diagnosis of jejuno-ileal diverticula is arduous, even in presence of symptomatic complications, therefore a highly clinical suspicion on the part of physicians is required. Endoscopic methods and abdominal ultrasounds identify with difficulties pathology of the small bowel. Abdominal or chest radiograph can show signs of perforation, evidences of intestinal obstruction or ileus. MDCT may really help to recognize the condition, exposing signs of inflammation such as fat stranding, free liquid and air in the abdomen, in presence of out-pouching lesions with thickened walls . HoweverNo consensus has been reached about therapeutic management of patient with symptomatic jejunal diverticular disease. When only mild inflammation signs are shown, bowel rest and use of antibiotics can be attempted . In caseWhen the perforation causes localized peritonitis but the patient has stable vital signs, conservative treatment with a percutaneous Ct-guided aspiration of the intraperitoneal collection can be performed with good results, avoiding the need of surgery ,14. Less4Even if jejuno-ileal diverticula are extremely rare and usually do not request surgical treatment, they should not be regarded as an insignificant finding, given that when these lesions produce complications, the consequences can be serious. In conclusion, because of the morbidity and mortality associated with a delay diagnosis, it is important to raise awareness of the fact that a presentation of abdominal pain could be due to jejuno-ileal diverticulitis, especially in older population with a history of gastrointestinal hemorrhage of unknown origin.All Authors disclose any financial and personal interestThis study has not received any sponsorshipThis is a case report and not a retrospective or perspective study and doesn’t need ethical approvalWritten informed consent has been obtainedA.M. Ramistella: Writer of paperM. Brenna: Study concept ideatorF. Fasolini: SupervisorM. De Monti: Data check and literature research – Corresponding authorWe present a case reportMarco De Monti M.D.