Distal intersection syndrome (DIS) is a rare form of tenosynovitis affecting the second and third dorsal extensor compartments of the wrist, which is rarer and more distal than the classically described intersection syndrome between the first and second compartments. In this report, we present three cases of DIS, their inciting activities, and ensuing treatment courses. Diagnosis of DIS was confirmed via MRI in all cases. Treatment modalities consisted of non-steroidal anti-inflammatory medications and varying durations of immobilization in all three patients, initially. One patient ultimately underwent surgical debridement and partial tenosynovectomy. At the end of follow-up, all patients saw a reduction in symptomatology with a return to baseline activity levels. This case report provides an overview of the possible clinical courses of DIS, as well as treatment strategies that can be implemented. Providers must maintain a high index of suspicion for this condition and treat patients with a great deal of caution, as extensor tendon rupture is possible. Intersection syndrome was first described by Velpeau in 1842 as pain in the dorsal aspect of the forearm 4-8cm proximal to Lister’s tubercle of the distal radius and typically involves tenosynovitis between the first and second dorsal compartments of the wrist . DIS ariThe most frequent presenting symptoms in DIS are pain in the dorsoradial aspect of the wrist, tenderness over Lister’s tubercle, paresthesias, and the variable presence of edema or a mass . Formal Currently, there is little known regarding risk factors for DIS. The patients described herein reported videogame play, cheerleading, and tennis as their primary aggravators. Certainly, tennis has been implicated in a number of tendinopathies of the upper extremity -10. HoweCase 1Patient DM is a 29-year-old right-hand dominant male with no significant past medical history who presented with bilateral wrist pain beginning approximately four months prior to presentation. The pain was notably aggravated while playing video games, which he occasionally played for 24 hours straight, and improved when he refrained from playing. He noted swelling on the radial aspect of his wrists during flares.On examination, the patient’s skin was intact without swelling or deformity bilaterally. At the time of examination, there was point tenderness over the left scapholunate interval and none on the right wrist. He had a full painless range of motion of his wrists and fingers. The sensation was intact to light touch, and Tinel’s and Allen’s tests were within normal limits. Radiographs of both wrists were obtained and were unremarkable. He was diagnosed with a likely dorsal ganglion cyst, given removable wrist splints, and advised to lessen his video game play.Six months later, he returned to the office with continued symptoms despite intermittent splint wear, and he was then referred for MRIs of each wrist without contrast Figures -2. This Case 2Patient IA is a 14-year-old female with no past medical history who presented with right wrist pain. She participates in competitive cheerleading as a base support and tumbler and noted that her cheer activities are what most frequently bring on her symptoms. She described her pain as becoming increasingly severe over the month prior to presentation, though she has reported intermittent wrist pain for years prior to this most recent exacerbation.On examination, the patient’s skin was intact without swelling or deformity. She had tenderness to palpation along her ECRB and ECRL tendon insertions and over her lunate. She lacked full extension, obtaining only approximately 40 degrees of passive extension compared to 80 degrees on the contralateral side. Sensation was intact to light touch, and Tinel’s and Allen’s tests were within normal limits. Radiographs of the right wrist were obtained and were unremarkable with the exception of being slightly ulnar-positive.Due to the location of her tenderness and wrist stiffness, an MRI was obtained to evaluate for possible Kienböck's disease. However, it instead showed peritendinous edema along the distal aspects of the second and third extensor compartments with mild tendinopathy of the EPL, consistent with DIS Figure . Given hCase 3Patient CV is a 17-year-old male with no past medical history who presented with right wrist pain beginning approximately 3-4 years prior to presentation. At the time, he also had an associated mass and was diagnosed with a dorsal wrist ganglion cyst by another provider who aspirated the lesion and injected it with steroids. Despite gradual resolution of the mass, he continued to have pain. He noted that tennis was always the aggravating factor, but other activities including typing, writing, and video games had become bothersome if he was already experiencing a flare. Since his initial treatment, he had attempted periods of rest and exercise, as well as anti-inflammatory medications, but nothing had alleviated the pain.On examination, the patient’s skin was intact without swelling or deformity. At the time of examination, there was point tenderness over the right scapholunate interval. He had a full painless range of motion of his wrists and fingers, with the exception of moderate pain at full wrist extension. There was no instability or pain when stressing the distal radioulnar joint. Sensation was intact to light touch, and Tinel’s and Allen’s tests were within normal limits. Radiographs of the right wrist were obtained and were unremarkable. Given the duration of his symptoms and lack of palpable mass, an MRI was obtained demonstrating tenosynovitis surrounding the second and third dorsal wrist compartments at the level of their decussation Figure . In addiFollowing the MRI findings, treatment options were discussed with the patient and his family including immobilization, aspiration and steroid injection, and surgical debridement. Due to the extended course of the patient’s symptoms and despite multiple prior conservative treatments, they elected to proceed with surgical debridement of the tenosynovitis and excision of the dorsal ganglion cyst, if present.In the operating room, an incision centered over the intersection of the second and third extensor compartments at the base of the index and middle fingers was performed. Directly beneath the EPL tendon, a fluid collection and substantial tenosynovitis were encountered surrounding the ECRL and ECRB tendons Figure . A limitPost-operatively, a pathology report described the collected specimen as dense connective tissue consistent with tendon, with degenerative changes and focal lymphohistiocytic infiltrate. His cast was removed at two weeks, and physical therapy was initiated to improve his grip strength and wrist motion prior to training for the tennis season. One month postoperatively, he regained 60 degrees of active flexion and extension at the wrist with full passive motion. His strength was near baseline, and he was cleared to resume his training program.DIS is a rare condition with few documented cases in the literature. Herein we describe three cases of DIS brought on by videogame play, cheerleading, and tennis. All three of these patients underwent MRI studies that demonstrated edema and tenosynovitis between the second and third dorsal compartments of the wrist. Despite similar diagnostic findings, each patient displayed differing symptom severity and subsequently underwent different treatments. Two of the patients experienced relief with immobilization and anti-inflammatory medications alone, while one ultimately underwent surgical debridement with post-operative physical therapy following failed conservative treatment.Several authors have described their limited experiences with DIS. Parellada et al. reviewed five cases of DIS obtained via a retrospective analysis of 1,031 wrist MRIs obtained at their institution . Their aNam et al. discussed their experiences in three cases of DIS. The first was a 38-year-old housewife with two months of wrist pain aggravated by housework, in addition to stiffness and edema in the mornings . Anti-inIn a cautionary case, Mattox et al. described a 38-year-old female who presented with a painful bump on the dorsum of her wrist. Ultrasound evaluation identified tenosynovitis between the second and third dorsal compartments, the patient was diagnosed with DIS, and she was treated with immobilization . HoweverSunagawa et al. reported on two tennis players who developed DIS with partial attritional ruptures of the ECRB tendon. The first patient, a 20-year-old male, experienced swelling and tenderness over the distal second compartment with limited wrist extension after a few weeks of tennis play . UltrasoWhile reports of DIS have increased over the last decade, it is likely that this condition is far more prevalent than previously appreciated, as it can easily be misdiagnosed. Similarly concerning is the apparently high incidence of tendinosis seen in DIS, along with multiple reports of EPL rupture. Although the three cases included in this report identify three potential etiologies for this condition, it is likely that many activities that involve repetitive movements of the hand and wrist can cause DIS. Ultimately, this report is limited in that it involves a small number of patients without standardized treatment and long-term follow-up. However, we believe it provides valuable insights into a condition that often goes unnoticed, with multiple causative agents that had not been previously reported. In the end, a thorough history and physical exam along with a high index of suspicion for the condition can aid in the proper diagnosis and treatment of these patients. Further investigations are needed to establish the best treatment algorithm and the true risk of tendon rupture.DIS is a rare condition found to be associated with repetitive movements of the hand and wrist. Clinical suspicion coupled with MRI has proved effective for accurate diagnosis. Most patients afflicted with this condition can be treated non-operatively, however, those with no relief from non-operative treatment may be considered for operative intervention. It should be noted, possible EPL rupture can develop secondary to DIS.


Minimally invasive surgical (MIS) approaches to the spine are increasingly adopted for intradural pathology. In this setting, they may especially be useful to minimize risk of CSF leakage due to the decreased disruption to paraspinal musculature and minimal dead space. Herein, the authors demonstrate their technique for the resection of an intradural thoracolumbar schwannoma in a 30-year-old woman via an MIS approach using a nonexpandable tubular retractor. Salient points include the use of bayonetted instruments and the technique for dural closure in a small corridor. Indications for this technique are discussed in the context of a series of patients with intradural extramedullary lesions. MIS approaches to the spine are increasingly popular. These are associated with expedited recovery, decreased narcotic usage, decreased complications, superior clinical outcomes, improved cosmesis, and patient satisfaction.5 purely nonexpandable tubular approach to intradural lesions are less common.6 Here we present our technique for tubular MIS resection of an intradural schwannoma.For intradural pathology, these techniques may be especially useful to minimize risk of CSF leak due to the decreased disruption to paraspinal musculature and minimal dead space. While several have described the use of mini-open or expandable retractor approaches,The patient is 30-year-old female with history of type 1 diabetes who presented with 3 months of lower-back pain radiating to the left leg, as well as intermittent episodes of lower-body numbness triggered by sneezing.On neurological exam, she was full strength throughout, but did have decreased sensation in left leg in a nondermatomal distribution. Imaging showed a contrast-enhancing, intradural extramedullary lesion at the thoracolumbar junction, eccentric to the left. Differential diagnosis at the time was a schwannoma versus myxopapillary ependymoma.The patient was positioned prone on a Jackson table, neuromonitoring was used, and the operative level was identified using fluoroscopy. An incision was made 1.5 cm left of midline. The dissection was continued subfascially. Serial tubular dissection (Medtronic METRx) was carried out over the T12 lamina to final 22-mm tube diameter and 60-mm length. The tubular system was secured in place, the microscope was brought into the field, and a full T12–L1 laminectomy was performed.At the end of initial exposure, we see the dural sac, with screen left representing the cephalad direction.A midline dural incision is made using a 15 blade, and subsequently extended cephalad and caudad by cutting over a right-angle hone or blunt probe. Care is taken to preserve the arachnoid. The dura is tacked up bilaterally.At this point, we transition to bayonetted instruments when available to aid visualization. The arachnoid is sharply dissected. Gentle retraction of the nerve roots reveals the soft tumor mass ventrolaterally.Circumferential dissection using blunt dissectors is done to identify the rostral and caudal poles of the tumor. A patty is placed on either end. Neural elements are seen posterolaterally to the tumor on either side, and the ventral dural is identified behind it.After the extents of the tumor were identified, it is gently elevated out of the dural opening. This helps identify the afferent and efferent nerve rootlet. Care is taken to ensure the rootlet is indeed involved with the tumor and is not en passage. The rostral and caudal rootlets are stimulated to confirm no associated motor function. These are then coagulated and cut, and the free tumor mass is removed.After hemostasis is achieved, attention is turned to closure. The dura is reapproximated and closed with AnastoClips GC (LeMaitre). Prior to the final closure, the dural sac is filled with saline. The final clips are then applied, and a Valsalva maneuver is done to confirm dural closure. The dura is then covered with DuraSeal Exact (Integra). The tubular retractor is removed under the microscope to ensure hemostasis of the retractor tract. The soft tissue and skin are then closed in the usual fashion.The patient was kept on bedrest overnight, was mobilized liberally POD 1 and discharged home later that day. She had resolution of her left leg pain, with significant improvement in sensation, with only a mild residual numbness of lateral left thigh. Pathology confirmed the intraoperative findings of schwannoma. Postoperative imaging showed gross-total resection and a small, asymptomatic subfascial fluid collection with MR characteristics consistent with seroma. This significantly decreased in size by long-term follow-up.We used this technique in a series of 7 patients with intradural extramedullary lesions. Important selection criteria for this technique include posterolateral or ventrolateral location, especially when suspected pathology is a calcified meningioma in the cervicothoracic region. Other ventrally located tumors can be considered, provided the tumor is soft and can be manipulated laterally to facilitate access of the tumor from posterior approach. For lesions at the conus and below, the location of the tumor is generally not a concern due to the ability to manipulate the neural structures . Additional considerations are size of lesion: our cutoff is about two times the diameter of the tube or one vertebral body segment, especially for dural-based lesions which cannot be manipulated out of the dural defect like the schwannoma seen in the video case. Technical considerations specific for meningioma resection include internal debulking using long, angled ultrasonic aspirator to aid visualization.All patients were discharged home and had stable or improved functional status postoperatively. At long-term follow-up, we had no instances of clinically relevant CSF leak , and no other complications or readmissions. Delayed MRI imaging, which was available in a subset of patients, showed a small subfascial fluid collection with MR characteristics consistent with seroma, similar to that seen in the index case and often seen in open cases as well. These collections, again similarly to the index case, remained asymptomatic and significantly decreased in size over time.In summary, a nonexpandable tubular MIS approach to intradural extramedullary lesions can be used safely and with good outcomes in appropriately selected patients.Dr. Lu reported grants from Boston Scientific, Medtronic, and Abbott, outside the submitted work.Primary surgeon: Lu. Assistant surgeon: Harary. Editing and drafting the video and abstract: all authors. Critically revising the work: all authors. Reviewed submitted version of the work: all authors. Approved the final version of the work on behalf of all authors: Lu.The necessary patient informed consent was obtained in this study.


Ectopic ACTH-producing pituitary adenoma (EAPA) of the clivus region is extraordinarily infrequent condition and merely a few reports have been reported to date.The patient was a 53-year-old woman who presented with Cushing-like appearances and a soft tissue mass in the clivus region.The final diagnosis of clivus region EAPA was established by clinical, radiological and histopathological findings.The patient underwent gross total clivus tumor resection via transsphenoidal endoscopy.Half a year after surgery, the patient Cushing-like clinical manifestations improved significantly, and urinary free cortisol and serum adrenocorticotropin (ACTH) returned to normal.Given the extreme scarcity of these tumors and their unique clinical presentations, it may be possible to misdiagnose and delayed treatment. Accordingly, it is especially crucial to summarize such lesions through our present case and review the literature for their precise diagnosis and the selection of optimal treatment strategies. It makes up approximately 10% to 15% of all intracranial tumors. Ectopic pituitary adenoma (EPA) is defined as a pituitary adenoma that occurs outside the sellar area and has no direct connection to normal pituitary tissue. The most frequent sites of EPA are the sphenoid sinus and suprasellar region, and much less frequent sites including the clivus region, cavernous sinus, and nasopharynx.Pituitary adenoma arises from the anterior pituitary cells and is the commonest tumor of the sellar region. CS is classified into adrenocorticotropin (ACTH)-dependent and ACTH-independent CS depending on the cause, accounting for 80% to 85% and 15% to 20% of cases, respectively. Pituitary adenoma accounts for ACTH-dependent CS 75% to 80%, while ectopic ACTH secretion accounts for the remaining 15% to 20%. Ectopic CS is a very rare disorder of CS caused by an ACTH-secreting tumor outside the pituitary or adrenal gland. It has been reported that ectopic ACTH-producing pituitary adenoma (EAPA) can occur in the sphenoid sinus, cavernous sinus, clivus, and suprasellar region, with EAPA in the clivus region being extremely rare, and merely 6 cases have been reported in the English literature .2) with hypertension .A 53-year-old female presented to endocrinology clinic of our hospital with headache and dizziness for 2 years and aggravated for 1 week. Her past medical history was hypertension, with blood pressure as high as 180/100 mm Hg. Her antihypertensive medications included amlodipine besylate, benazepril hydrochloride, and metoprolol tartrate, and she felt her blood pressure was well controlled. In addition, she suffered a fracture of the thoracic vertebrae 3 month ago; and bilateral rib fractures 1 month ago. Physical examination revealed that the patient presented classical Cushing-like appearances, including moon face and supraclavicular and back fat pads, and centripetal obesity . ACTH levels were elevated at 90.8 pg/mL . The patient low-dose dexamethasone suppression test demonstrated the existence of endogenous hypercortisolism. High-dose dexamethasone suppression test results revealed that serum cortisol levels were suppressed by <50%, suggesting the possibility of ectopic ACTH-dependent CS. Serum luteinizing hormone and serum follicle stimulating hormone were at low levels, <0.07 IU/L  and 2.57 IU/L , respectively. Insulin-like growth factor-1, growth hormone (GH), prolactin (PRL), thyroid stimulating hormone, testosterone, progesterone and estradiol test results are all normal. Oral glucose tolerance test showed fasting glucose of 6.3 mmol/L and 2-hour glucose of 18.72 mmol/L; glycosylated hemoglobin (HbA1c) was 7.1%. Serum potassium fluctuated in the range of 3.14 to 3.38 mmol/L , indicating mild hypokalemia.Laboratory studies revealed high urinary free cortisol levels at 962.16 µg/24 hours  and absence of circadian cortisol rhythm (F High-resolution computed tomography (CT) scan of the sinuses revealed osteolytic bone destruction of the occipital clivus and a soft tissue mass measuring 20 mm × 30 mm × 46 mm Fig. A. The maSubsequently, the patient underwent gross total clivus tumor resection via transsphenoidal endoscopy. During surgery, the tumor was found to be light red in color with a medium texture, and the tumor tissue protruded into the sphenoidal sinus cavity and eroded the clival area. Histologically, the tumor cells were nested, with interstitially rich blood sinuses and organoid arrangement Fig. A. The tuWhen evaluated 2 months after surgery, her Cushing-like characteristics had well improved, and her blood pressure was normal. Furthermore, her serum cortisol and ACTH returned to the normal levels. Six-month postoperative follow-up revealed that serum cortisol and ACTH were stable at normal levels, and no signs of tumor recurrence were detected on imaging. ACTH promotes cortisol secretion by stimulating the adrenal cortical fasciculus. The clinical manifestations of hypercortisolism are diverse, and the severity is partly related to the duration of the cortisol increase. Clival tumors are typically uncommon, accounting for 1% of all intracranial tumors. There are many differential diagnoses for clival lesions, including the most common chordoma (40%), meningioma, chondrosarcoma, astrocytoma, craniopharyngioma, germ cell tumors, non-Hodgkin lymphoma, melanoma, metastatic carcinoma, and rarely pituitary adenoma. The commonest clival EPA is a PRL adenoma, followed by null cell adenoma, and the least common are ACTH adenoma and GH adenoma. The clival EAPA is extremely unwonted, and only 6 other cases apart from ours have been reported in literature so far . There was a obvious female predominance with a female-to-male prevalence ratio of 6:1. Only 2 patients  with reported clinical symptoms, including our patients, presented with overt clinical manifestations of CS. Compression of the mass on adjacent structures  may result in anosphrasia, visual impairment, headache, myalgias, decreased muscle strength, dizziness and facial sensory abnormalities. The diagnosis and localization of these tumors relied heavily on radiological imaging. Head MRI was the most basic method used for them detection, for localization adenomas and their invasion of surrounding structures to guide the choice of treatment and surgical options methods. Radiographic characteristics had been reported in 6 patients with EAPA in the clivus region. All of these patients  had initial positive findings of sellar MRI (or CT) identifying an ectopic adenoma before surgery. MR T1 was usually a low-intensity or isointense signal, while MR T2 was usually an isointense or slightly higher signal. The maximum diameter of the tumor was reported in 5 cases, with the mean maximum diameter was 35.2 mm  according to preoperative MRI and intraoperative observations. As summarized in Table  The most common method of EAPA resection in the clivus region was transsphenoidal sinus resection , followed by craniotomy  and maxillary osteotomy . Transsphenoidal endoscopic surgery allowed resection of the EAPA and manipulation of neurovascular structures and avoidance of cerebral atrophy, whereas craniotomy allowed full exposure of the suprasellar region, direct visualization or manipulation of the adenoma, and reduced the risk of postoperative CSF leak. Both approaches had their advantages, and there was no consensus on which surgical approach was best for the treatment of EAPA in the slope area. The choice of the best surgical approach was believed to be based on the condition of the adenoma, as well as the general condition of the patient and the experience of the surgeon. As summarized in Table The gold standard for the treatment of CS caused by EAPA was the surgical removal of EPA, which was essential to achieve remission and histological confirmation of the disease.In summary, due to the rarity of this disorder, an accurate preoperative diagnosis of EAPA in the slope area is extremely challenging for the clinician or radiologist. The final precise diagnosis relies on a combination of clinical symptoms, imaging findings, histology and immunohistochemical markers. For this type of tumor, surgery is an effective treatment to relieve the clinical manifestations caused by tumor compression or hormonal secretion. The choice of postoperative adjuvant radiotherapy is mainly based on the presence of invasion of the surrounding bone tissue. Further cases may be necessary to summarize the clinical features of such lesions and to develop optimal treatment strategies.We would like to thank the patient and her family.Conceptualization: Yutao He.Data curation: Ziyi Tang.Formal analysis: Na Tang.Methodology: Yu Lu, Fangfang Niu, Jiao Ye, Zheng Zhang, Chenghong Fang.Writing – original draft: Yutao He.Writing – review & editing: Yutao He, Lei Yao.


Ovarian cancer is a feared diagnosis for women and clinicians alike. Ovarian mucinous adenocarcinoma is a unique subset of ovarian cancer. As a primary tumor, massive ovarian masses, and more specifically mucinous adenocarcinomas, have been infrequently reported in the medical literature. Team approaches to massive tumor extirpations are essential, as patients often require the expertise of various subspecialists including, but not limited to, gynecologic-oncologists, general surgeons, and plastic and reconstructive surgeons. Here we present a case of a 71-year-old woman with a massive, incapacitating pelvic mass, later found to be a primary ovarian mucinous adenocarcinoma. Once medically optimized, a multi-service team approach was utilized for tumor extirpation and abdominal wall reconstruction. Involved surgical services included Gynecologic-Oncology, General Surgery, and Plastic and Reconstructive Surgery. Exploratory laparotomy for tumor extirpation, hysterectomy, bilateral salpingo-oophorectomy, omentectomy, peritoneal stripping, bilateral inguinal lymphadenectomy, and appendectomy was performed. Extensively thin, devascularized, and attenuated abdominal wall fascia that was adherent to the tumor was removed. The abdominal wall defect was reconstructed and reinforced with inlay and overlays of biologic monofilament mesh. Inverted-T of the vertical and horizontal skin components was performed in a tailor-tacking fashion, assuring the maintenance and protection of the abdominal skin flap vascularity through utilizing the Huger Zones of perfusion. Pathology revealed a stage IA grade 2 mucinous adenocarcinoma of the ovary without evidence of metastasis. No adjuvant therapies were required. The tumor’s weight was 140 pounds, and its dimensions were 63 x 41 x 40 cm. It is our hope that presenting this experience will raise awareness of this spectrum of diseases and allow for earlier diagnoses and treatments, as well as exemplify the virtues of a team-based approach in the successful extirpation and subsequent reconstruction of the abdominal wall and skin. Ovarian cancer is the seventh most common cancer and the eighth most common cause of cancer death in women ,2. OvariThis article was previously presented as a meeting abstract at the 2018 Keystone Chapter of the American College of Surgeons Meeting in Hershey, PA, on November 2, 2018, and at the 2018 Robert H. Ivy Pennsylvania Plastic Surgery Society Meeting in Hershey, PA, on April 21, 2018.The patient was a 71-year-old woman found to have a massive and incapacitating pelvic mass of unknown etiology for at least a 15-year timeframe. She initially presented to the hospital with left leg pain, cellulitis, and worsening shortness of breath, but was noted to have significant abdominal distension and increased weight gain over this time period. Complicating associated comorbidities included deep venous thrombosis (DVT), bilateral hydronephrosis, and morbid obesity with a body mass index (BMI) of 65.3 Figure . UltrasoOnce medically optimized, an interdisciplinary team discussion and approach were utilized for the planning of oncologic ablation and abdominal wall reconstruction. Involved surgical services included Gynecologic-Oncology, General Surgery, and Plastic and Reconstructive Surgery.With the patient unable to lay supine secondary to the size of the mass, she was positioned in the left lateral decubitus position with two operating room tables placed side-by-side. Skin resection and exposure of the abdominal wall were marked and performed in both horizontal (90 x 20 cm) and vertical (60 x 20 cm) directions, assuring to maintain and protect perforating blood vessels supplying zones 1, 2, and 3 of the abdominal wall, as first described by Huger et al. in 1979 [Secondary to massive volume shifts intraoperatively, a large volume of crystalloids, colloids, blood products, and vasopressors were required throughout her procedure. Post-operatively, she remained intubated and monitored in the intensive care unit due to hemodynamic instability and ventilator dependence. She was volume-resuscitated and subsequently extubated, and her diet and activity slowly advanced. An abdominal binder was worn at all times for 12 weeks post-operatively, only being removed for hygienic purposes. On postoperative day 20, she was discharged to a skilled nursing facility for continued rehabilitation with lifting restrictions of nothing greater than 10 pounds until eight weeks post-operatively.Pathology revealed a stage IA grade 2 mucinous adenocarcinoma of the ovary without evidence of metastatic carcinoma. The final tumor weight and dimensions registered 140 pounds and 63 x 41 x 40 cm, respectively Figure . The patMucinous adenocarcinomas typically arise from the gastrointestinal tract, endometrium, and/or endocervix . AlthougThe distinction between primary and metastatic mucinous ovarian cancers is made on histologic examination and immunohistochemical (IHC) staining. Common IHC markers include cytokeratin 7 (CK7), CK20, CEA, carbohydrate antigen 19.9 (CA19.9), caudal-type homeobox 2 (CDX2), and CA-125 . Of thesExtirpation and abdominal wall reconstruction were performed with great improvement in the patient’s health, ambulatory status, and reclamation of her independence. Pathology revealed stage IA grade 2 mucinous adenocarcinoma of the ovary that was negative for metastatic disease. This report presents a case of larger primary ovarian mucinous adenocarcinomas present in the current medical literature. The patient’s positivity for CK7 and CK20 confirms the diagnosis of primary ovarian mucinous adenocarcinoma, while monitoring of her levels of CEA and CA-125 normalcy signifies her oncologic remission. This patient is now in clinical remission and has resumed her normal daily function.Mucinous ovarian adenocarcinoma is a rare subtype of ovarian cancer that can present with an expanding, massive tumor, as seen with the current case. The tumor was positive for immunohistochemical markers CK7 and CK20, supporting its primary origin. Recurrence was monitored with CEA and CA-125 levels, which remained within normal limits post-operatively throughout multiple follow-up appointments. Although the surgery proceeded without complications and the patient recovered uneventfully, this case is an important contribution to the literature through further characterization of this tumor type, confirmation of histology and immunohistochemistry, and break-down of surgical techniques. Interdisciplinary team-based discussion and approaches are essential in patients presenting with complex surgical problems, as patients often require the expertise of various medical and surgical subspecialists. Only by working together can we provide the best outcomes for such patients.


Jejunoileal bypass (JIB) was an early bariatric procedure that involved bypassing most of the small bowel resulting in malabsorption and weight loss. Due to serious complications associated with the procedure, JIB was largely discontinued by the mid-1980s. We report the case of a 77-year-old woman with a history of JIB 31 years earlier. In 2022, she was hospitalized for acute abdominal pain. A computed tomography (CT) scan revealed a suspicion of internal hernia (IH) with a typical swirl sign. Due to the quick relief of symptoms an emergency surgery was not considered at the time. Nevertheless, a subsequent operation revealed a large mesenteric defect, adhesions and 100 cm of effective small bowel left. Although the procedure is no longer performed, some patients with JIB are still alive and develop late complications. To our knowledge, this is the first case report describing an IH in a patient who has undergone JIB. Jejunoileal bypass (JIB) was a surgical procedure used to treat obesity in the 1970s and 1980s, prior to modern bariatric operations, such as Roux-en-Y gastric bypass (RYGB) . The tecJIB typically resulted in weight loss of 45–64 kg or a mean body mass index (BMI) reduction from 48 to 32 over a few years , 3. ManyAlthough complications related to short bowel length were common after JIB, cases of intestinal obstruction due to adhesions or internal herniation are rarely reported. We present here a case report of a patient with small bowel obstruction due to internal hernia (IH) after 32 years of JIB.A 45-year-old female with a long-term history of obesity and a BMI of 56 (165 kg) was referred to bariatric surgery in 1990. At the time, she had no comorbidities other than musculoskeletal disorders. She had previously lost 15 kg with conservative means but regained the weight.In 1991, a laparotomy and JIB were performed. According to the old surgical report, the jejunum was divided 25 cm from the ligament of Treitz and anastomosed to the ileum 25 cm proximal to the ileocecal valve. The patient was discharged with calcium and iron supplements. In follow-up, the patient’s weight decreased to 114 kg (BMI 42) and low hemoglobin values were measured. She had no electrolyte imbalances or other signs of serious malabsorption. The patient reported a maximum weight loss of 60 kg.In late 2022, this now 77-year-old patient came to the emergency ward with intense abdominal pain. She had been experiencing transient colicky epigastric pain infrequently for the past few years. At this time, her medical history included hypertension, musculoskeletal disorders, diverticulosis, and a deep vein thrombosis in 2015. She took a daily multivitamin supplement and additional zinc, vitamin C and D, and received vitamin B12 injections every 3 months. A computed tomography (CT) scan revealed a suspicion of IH with a typical swirl sign in the mesenteric vascular structures . There wDue to heavy adhesion formation, bowel anatomy could not be resolved during the laparoscopy. Therefore, a laparotomy was performed and a myriad of bowel adhesions was released, and a long remnant segment of atrophied small bowel was identified. A large mesenterial defect under the jejunoileal anastomosis was identified and closed with sutures. In contrast to the 30-year-old surgical report, the patient had 100 cm of remaining effective small bowel left and she appeared to be able to manage well with that amount of bowel. A comprehensive set of laboratory findings were within normal range at 1 month postoperatively .JIB is a long-discontinued bariatric surgery procedure. Some patients who underwent it are still alive, and late complications have been reported .Similarly, to modern bypass operations, rerouting the small bowel continuity in JIB created an arbitrary mesenteric defect under the anastomosis. The 31-year-old surgical reports did not mention whether the defect was closed. Nowadays, it is advocated that all mesenterial defects should be closed after bariatric operations to prevent internal herniation , 8. PropWe found no case reports of IH occurring after JIB. Instead, the phenomenon is well-recognized after RYGB and may present with acute onset of colicky epigastric pain, sometimes even radiating to the back, and the symptoms may worsen with eating and be accompanied by vomiting due to bowel obstruction , 9. NeveIn conclusion, it is likely that the patient had an intermittent IH that caused her colicky abdominal pain. This is supported by the presence of a clear mesenteric swirl sign on the CT scan. However, we speculate that the herniation spontaneously resolved during her first hospital admission, which led to the relief of her symptoms. The exact nature of her previous bariatric operation was unclear at the time, as her old medical records were not available. The quick relief of her symptoms during the hospital admission led to the decision to refrain from emergency surgery.


Bronchopulmonary sequestrations (BPSs) are rare congenital anomalies characterized by non-functioning embryonic lung tissue receiving anomalous blood supply. They are most commonly located within the thorax (supradiaphragmatic) or into the abdominal cavity (infradiaphragmatic). Intradiaphragmatic extralobar BPs (IDEPS) are an exceptionally rare finding, representing a diagnostic and operative challenge. We report three cases of IDEPS and their surgical management, describing our experience and approach to such rare clinical entities. From 2016 to 2022, we treated 3 cases of IDEPS. Surgical techniques, histopathological findings and clinical outcomes were retrospectively evaluated for each case and compared. Three different surgical techniques were used to approach each lesion, from open thoracotomy to a combined laparoscopic and thoracoscopic approach. Histopathological analysis of the specimens revealed hybrid pathological features, proper of both congenital pulmonary airway malformation (CPAM) and extralobar pulmonary sequestration. IDEPS represent a surgical challenge for pediatric surgeons, given their complex surgical planning. In our experience, the thoracoscopic approach is safe and feasible when performed by trained surgeons, even though a combined thoracoscopic-laparoscopic approach allows for optimal vessels control. The presence of CPAM elements within the lesions supports their surgical removal. Additional studies are required to better characterize IDEPS and their management. Based oNo clear indication exists on whether IDEPS should be operated upon and their optimal approach. We hereby report our center's experience with the management of patients with IDEPS to describe the surgical techniques used and their histopathological peculiarities.2.Between 2016 and 2022 we managed 36 consecutive patients with CLM. Twelve had congenital pulmonary airway malformations, 18 had BPS (13 hybrid lesions), 3 had congenital lobar emphysema, 2 a bronchogenic cyst, and one a necrotic single pulmonary cyst. Out of 18 patients with BPS, 13 were ILS (10 hybrid lesions) and 5 were ELS, of which 3 IDEPS.The details of patients with IDEPS are as follows:2.1.A 5-month-old, asymptomatic, infant was referred for surgical evaluation of a left lower thoracic lesion detected on prenatal ultrasound (US). An angio-computed tomography (CT) scan was performed at birth, which confirmed the presence of the lesion located within the diaphragm and showed incidental finding of emphysema of the left lower lobe . An aberA thoracotomy on the fourth intercostal space was performed. Following formal left lower lobectomy, dissection of the diaphragmatic muscular fibers was performed: the BPS was pulled up, allowing the identification and sectioning of its large feeding aberrant artery, together with concomitant minor vessels. After the BPS was removed, the diaphragm was sutured with single-line non-absorbable stitches. A chest tube was left and removed on postoperative day (POD). The postoperative course was uneventful, and the patient was discharged at home on the 7th POD. At 2 years' follow-up, the patient was thriving well, free of symptoms and chest x-ray was normal.2.2.A 7-month-old asymptomatic infant was referred after prenatal diagnosis of left lung malformation, not otherwise specified. Pregnancy and delivery were regular, and the patient was asymptomatic at birth. Apgar score was 9 and 9 at 1 and 5 min, respectively. The neonatal period was uneventful too. A thoracic CT scan was performed which described a left lower lesion, fed by an aberrant artery arising from the celiac trunk .For the query diagnosis of left ELS, a thoracoscopic resection was planned at 7 months of age. However, at thoracoscopy, the postero-lateral portion of the lesion could be reached only partially, and a bulging of the diaphragm was identified. Therefore, the operation was converted to thoracotomy on the fourth intercostal space. This allowed better visualization of the diaphragmatic bulging in its postero-lateral portion that was covered by diaphragmatic serosa. The mass was isolated, the feeding artery arising from the celiac trunk was identified and clipped, and the BPS was resected. The diaphragmatic breach was sutured through single-line non-absorbable stitches. The postoperative course was uneventful. The patient was discharged home on POD 10. At 1-year follow-up, the patient was free of symptoms.2.3.A 7-month-old asymptomatic infant was referred to our Surgical Department with a prenatal diagnosis of CLM. A prenatal magnetic resonance imaging (MRI) study performed at 30th gestational week showed an intradiaphragmatic mass, with clear margins, imprinting the lower lobe of the left lung and apparently extending below the diaphragm, medial and posterior to the stomach. Pregnancy and vaginal delivery were uneventful. Again, the patient was asymptomatic at birth. Apgar score was 9- and 9 at 1 and 5 min, respectively. The neonatal period was unremarkable. A post-natal CT scan with contrast medium performed at 12 months of age confirmed the lesion, apparently limited to the left diaphragmatic pillar and receiving systemic blood supply from the celiac trunk, the lumbar arteries, the diaphragmatic arteries and a single small vessel from the splenic artery, thereby suggesting IDEPS . SurgicaGiven the systemic arterial supply originating mainly within the abdomen, the decision was made for an initial laparoscopic approach with readily available conversion into thoracoscopy, if necessary.During laparoscopy, two small arteries and one vein penetrating the diaphragm were identified posterior to the stomach and medial to the spleen. They were clipped and sectioned. However, even after careful dissection of diaphragmatic muscle, the mass was not clearly identified. Therefore, a thoracoscopy was performed, highlighting a bulging of the diaphragm in the left paravertebral region . The diaHistopathological examination of the surgical specimens of all cases revealed hybrid lesions. Indeed, they all displayed adenomatoid cystic components within nonfunctioning lung tissue supplied by one or more aberrant vessel .Classic hematoxylin-eosin staining was performed on all cases, identifying normal alveoli surrounded by inflammatory cells and cystic airspaces. Aberrant vascular walls were described concomitantly.Case 3 specimen was also submitted to desmin immunostaining to search for rhabdomyomatous dysplasia, suspected due to the complete inclusion of the lesion within diaphragmatic fibers.3.CLMs are rare malformations, arising during the embryonic development. BPS are considered to be the second most common CLM, as they account for the 0.15%–6.40% of all CLM –9. They The peculiarity and the exceptionality of this location carries great importance from a diagnostic and surgical point of view. Indeed, in many cases only surgical exploration can properly and correctly clarify the nature of the lesion, assuming not only a therapeutic role but also a diagnostic one. Differential diagnosis of an intradiaphragmatic mass involves a wide range of conditions and the anatomical relationships of this peculiar location hinder a straightforward verdict, requiring high expertise to orient within the broad spectrum of possibilities. Primary diaphragmatic tumors are an exceptionally rare finding, mostly being benign . The latThe exceptionality of IDEPS makes it difficult to reach consensus regarding the best approach and technique for their management. Some authors advocate the thoracoscopic approach , 4, 15 bThe first patient underwent thoracotomic IDEPS resection and left lower lobectomy, the second was started in thoracoscopy but required conversion to thoracotomy, in the third patient, resection and diaphragmatic reconstruction were eventually completed through thoracoscopy. In the first patient, after discussing with the parents the pros and cons of a lobectomy during the same thoracotomy to resect the IDEPS versus the risk of a second surgery should the emphysema had become symptomatic, the former approach was elected and pursued. It is possible that age at surgery may have had an influence on the possibility to avoid conversion. In fact, the second patient who required conversion was younger  that the third that did not require conversion. In this last patient we started through a laparoscopic approach due to the preoperative imaging evidence of feeding vessels originating in the abdomen. In fact, we were able to identify and ligate part of the feeding vessels laparoscopically, However, the main feeding vessel and the lesion were detected only after conversion to thoracoscopy. This approach also allowed us to isolate it from the diaphragmatic muscle, to clip and resect safely the main feeding vessel and to repair the diaphragm. The only concern for the thoracoscopy only approach is that, when closed through the thorax, aberrant feeding vessels will rapidly retract within the abdominal cavity and bleeding may not be spotted immediately, should it occur. Having ports both in the chest and the abdomen may facilitate the hemostasis and management of bleeding, thereby supporting the combined approach. Also in our small series, the change from thoracotomy to thoracoscopy was associated with a reduction of post-operative length of stay, while remaining a safe and effective approach.In all our patients, the histopathological analysis of resected IDEPS showed hybrid lesions with CPAM elements, with rhabdomyomatous dysplasia in one. As shown also by our series of CLM, CPAM elements are more frequently associated to ILS then ELS , 20–26. 4.IDEPS are exceedingly rare CLM. The presence of CPAM elements within the lesions in all our patients, one of which with rhabdomyomatous dysplasia, supports their surgical removal. Our small series favors the thoracic approach, ideally thoracoscopy, as the optimal one, although the possibility to have a combined laparoscopic approach may allow a safer control of possible bleedings from main feeding vessels when they arise from the abdominal Aorta. Given the rarity of IDEPD, a larger, multicenter series may help to better characterize their nature and management.


A highly vascular glomus tumor that develops from the paraganglion cells of the carotid body is called a carotid body tumor (CBT), also known as a chemodectoma or carotid body paraganglioma (CBP). It is situated near the carotid bifurcation, where the external and internal carotid arteries splay out characteristically. We present a case of a 30-year-old woman who had a slightly tender, slightly pulsatile, and slightly ballotable swelling over the lateral aspect of the neck on the right side. The surgical resection of the tumor was done based on the diagnosis made on clinical-radiological investigations as a carotid body tumor further confirmed by a histopathological study. We also provide a summary of the research on carotid body tumors clinical and imaging manifestations, assessment, and therapy. The carotid body is located on the medial side of the carotid bifurcation bilaterally, which is the biggest group of paraganglia in the head and neck . CarotidThe preferred course of treatment is surgical excision. Preoperative embolization and surgical planning both benefit from preoperative angiography. Embolization encourages tumor reduction and lessens bleeding during surgery. In cases where surgery is not an option or is not necessary, radiotherapy may be explored . A youngPatient information: a young 30-year-old female complained of right-sided neck swelling for 4 years and intermittent pain over swelling for 4-5 months. No history of fever, cough, weight loss, or anorexia was present. No history of movement of swelling with deglutition was noted. No history of swelling on the left side of the neck, bilateral axillary region, ptosis, loss of sweating, hoarseness of voice, and syncopal attacks was present. The patient was not a known case of tuberculosis, hypertension, or diabetes mellitus.Clinical findings: on local examination, a relatively well-defined swelling of approximate size 2 x 2 cm is noted at the anteromedial aspect of the sternocleidomastoid (SCM) muscle, just below the angle of the mandible on the right side of the neck  causing splaying of the external carotid artery (ECA) and internal carotid artery (ICA). No evidence of calcification was noted within this lesion. No evidence of adjacent inflammatory changes is noted (is noted . On colois noted . No evidThe patient was advised contrast-enhanced computed tomography (CECT) of the neck for further confirmation. On plain computed tomography (CT) sagittal (sag) section, an ill-defined soft tissue density mass lesion is noted on the right side of the neck anterior to the SCM muscle inferior to the angle of the mandible at the level of the hyoid bone extending superiorly up to suprahyoid space at C4-C6 vertebral level. No evidence of calcification was noted within . On the Diagnosis: a diagnosis of the well-defined homogeneously enhancing lesion at the bifurcation of the right CCA suggestive of carotid body tumor was made.Therapeutic interventions: the patient underwent surgical resection of a neck tumor. Post-operative image showing bilobed mass lesion. On histopathological examination, the definitive diagnosis came as carotid body paraganglioma.Follow-up and outcome of interventions: the patient returned to the clinic for follow-up but the further visits were inconclusive.Patient perspective: a patient was happy after receiving successful treatment.Informed consent: informed written consent was given by the patient.A paraganglioma is a tumor that can develop anywhere in the body from paraganglia, which are non-neuronal cells descended from neural crest cells . The carThe majority of the time, CBTs are discovered accidentally on imaging studies or through clinical assessment. Image analysis and pathological anatomy play a major role in the final diagnosis. Doppler ultrasound, CECT neck, contrast enhance magnetic resonance imaging (MRI) neck, and angiography plays an important role in the diagnosis of CBT. The best screening method for CBTs is a color-flow carotid duplex, and CBT is characterized by a well-defined hypoechoic mass causing splaying of the ICA and ECA. On color Doppler imaging hypervascularity is seen within the lesion with a low-resistance flow pattern. The “gold standard” diagnostic method for CBTs in the past was angiography, which provided a precise delineation of the vascular supply and confirmed the diagnosis. Surgical tumor resection depends on the relationship of the tumor with the artery bifurcation and the proximity of cranial nerves diagnosed accurately on CT angiography (CTA) or MR angiography (MRA). The accuracy of MRI is frequently higher than that of CT because it does not involve ionizing radiation. CTA can characterize the tumor's size and relationship to bony landmarks, which can change the surgical strategy. Other head/neck paragangliomas and contralateral tumors are also plainly discernible. On dynamic contrast-enhanced MRI and diffusion-weighted imaging (DWI), paragangliomas are better differentiated from other benign neoplastic tumors. On digital subtraction angiography (DSA), a tumor with an “early vein” visible due to arteriovenous shunting is detected by a high blush and the splaying of the carotid vessels (lyre sign).et al. [The primary contributing supply is the ascending pharyngeal artery. Successful diagnosis can be made using ultrasound and CT. An MRI was obtained for preoperative assessment. The left ECA and ICA were splayed as a result of a well-defined hypoechoic mass at the CCA bifurcation that had enhanced vascularity. On CT, this lesion was clearly enhanced and showed a soft tissue density. On MRI, the mass appeared hypointense on T1 weighted imaging (WI) and hyperintense on T2WI. Diffusion-weighted imaging showed a true restriction corresponding to low apparent diffusion coefficient (ADC) values. Our case is similar to the characteristics of the research of Ying Yuan et al. . That isIn our case, a thorough evaluation of a CBT, including history, clinical examination, and investigations, was carried out in order to reach a provisional diagnosis. The purpose of radiography is to identify CBTs and their effects, but surgery is the only way to make a definitive histological diagnosis.Carotid body tumors are rare, hypervascular, slow-growing neuroendocrine tumors. A preliminary diagnosis can be made on the patient's medical history, physical examination, and radiography. They frequently splay the ICA and ECA when imaging. Surgical resection is the preferred course of treatment for CBTs.


Craniopharyngioma is a common intracranial tumor located in the sellar-suprasellar region. Due to the involvement of adjacent structures, it can lead to increased intracranial pressure, visual impairment, and endocrine deficiencies. Surgical resection is the primary treatment, but it is a tough challenge to achieve total resection, which will led to the frequency of recurrences and progressions. Among them, distant spread is extremely rare, but important complication, identifying and providing proper therapy, is crucial.We report two cases of ectopic recurrence craniopharyngioma and make a literature review for the published similar case reports.Our literature review revealed 63 cases (including our patient). The onset age in children group and adult group ranges from 2–14 years old (6.70 ± 3.33) to 17–73 years old (40.63 ± 15.58), while the interval year between tumor initiation and ectopic recurrence ranges from 0.17–20 (7.28 ± 6.76) years to 0.3–34 (6.85 ± 7.29). Achieving gross total resection seems not to prevent the ectopic recurrence. The major pathology of ectopic recurrence craniopharyngioma is adamantinomatous type. The most common site of ectopic recurrence is frontal lobe. According to the pathogenesis, 35 cases were seeding along the surgical approach, and 28 cases were seeding via the CSF pathway.Ectopic recurrence craniopharyngioma is rare, but it can lead to serious symptoms. Delicate surgical procedure can help to reduce the risk of ectopic recurrence, and standardized follow-up can provide valuable information for treatment. Craniopharyngioma is a rare malformational tumor of low histological malignancy, and two primary subtypes have been recognized (adamantinomatous and papillary) as yet. It originates from the remnants of Rathke’s pouch and mainly occurs in sellar-suprasellar region . HoweverKi-67 = 3%). However, in 2021, it had been found tumor recurrence in the sellar region; even worse, there was a new isolated lesion in the right frontal lobe  cm. The pathological results of ectopic recurrence craniopharyngioma demonstrate that the adamantinomatous type constituted the majority with the number of 36, while the papillary type accounted for only 4 cases and 20 cases’ pathology was unclear. The Ki-67 index of ectopic tumor does not show a remarkable increasement than that of initial tumor. The most common site of ectopic recurrence is frontal lobe, followed by cerebellopontine angle (CPA), temporal lobe, parietal lobe, and others. Currently, there are two views on the mechanism about ectopic recurrence, along the surgical approach and the CSF pathway. Transcranial surgery for craniopharyngioma via pterion is the most frequently used approach that can achieve sufficient surgical field and better protection of nerves and vessels. But it is believed that the tumor cells would disseminate or seed during the operation, and that is the reason why frontal lobe was the most common site of ectopic recurrence, so did the recurrence in Sylvian fissure. The ectopic recurrence mechanism of case 1 in our study belonged to this type. Ectopic recurrence in CPA, temporal and parietal lobe, and lumber space, which far from the surgical route, were considered as the dissemination of tumor cells via CSF pathway. That is the mechanism of case 2; the recurrence site in temporal lobe was far away from the primary surgical area. After statistical analysis, 35 ectopic recurrence cases were due to the seeding along the surgical approach, and 28 cases were due to the seeding via the CSF pathway.Ectopic recurrence craniopharyngioma is rare, but it can lead to serious symptoms according the location such as hearing loss, disequilibrium, epilepsy, behavioral, and personality change. Thus, some delicate surgical procedure such as strictly separating the tumor by cottonoids, carefully aspirating the cystic fluid to avoid the contamination of CSF, and adequate irrigation in surgical field can help to reduce the risk of ectopic recurrence, and standardized follow-up can provide valuable information for treatment.


PDGFRA) gene. In this report, we present the case of a 74-year-old female with a solid tumour of the kidney, which presented as a bland proliferation of spindle cells with thin-walled blood vessels and an inflammatory infiltrate with eosinophilic granulocytes. Immunohistochemistry revealed a positivity for vimentin and a weak staining for CD99 and CD34 in the spindle cells. Because of the morphological similarity to IFPs of the gastrointestinal tract, a molecular pathology analysis was performed. This identified an oncogenic mutation in exon 18 of the PDGFRA gene, which is characteristic for inflammatory fibroid polyps of the gastrointestinal tract. To the best of our knowledge, this is the first case of an IFP in the urogenital tract.Inflammatory fibroid polyps (IFP) are rare and benign mesenchymal tumours of the gastrointestinal tract. They are submucosal spindle cell lesions with an eosinophilic-rich inflammatory infiltrate and mutations in the platelet-derived growth factor receptor alpha ( Inflammatory fibroid polyps (IFP) are known as rare benign mesenchymal tumours of the gastrointestinal tract. This entity was first described in 1949 as a gastric submucosal granuloma with eosinophilic infiltration by Vanek  suggesteHistologically, inflammatory fibroid polyps are polypoid submucosal lesions which may infiltrate the mucosa. They consist of spindle cells without atypia, and often a so called “onion skin” pattern can be found around blood vessels. The mixed inflammatory infiltrate in the background is commonly rich in eosinophilic granulocytes. On immunohistochemistry, the spindle cells of these tumours typically show a CD34 positivity.PDGFRA) gene [Mainly because of the bland cytology of fibrocytes and fibroblasts and the considerable inflammatory reaction, these lesions were long considered as reactive processes, just as Vanek had originally suggested. In 2008, Huss and Wardelmann et al. described that IFPs harbour mutations in the platelet-derived growth factor receptor alpha (RA) gene  and therPDGFRA is a proto-oncogene and belongs to the receptor tyrosine kinases (RTKs). Besides playing an important role in embryonic development, its role has been described in the pathogenesis of various haematopoietic malignancies [PDGFRA-exon 14 mutations besides the previously described exon 12 and exon 18 mutations. They suggested two different phenotypes, the “gastric” one which is associated with exon 18 mutations and the “small bowel” type which harbours exon 12 alterations.gnancies , glioblagnancies , and tumgnancies  and aforgnancies . In 2012gnancies  reportedAlthough inflammatory fibroid polyps have been described on various sites of the gastrointestinal tract, even in recent literature reviews , 9, the A 74-year-old female presented with recurrent haematuria; additional micturition disorders were negated. The patient had a history of apoplexy, gastric ulcer, recurrent urolithiasis, hypothyroidism, and arterial hypertension. Family history was without cancer. Urethrocystoscopy excluded the presence of bladder cancer; however, computed tomography indicated the presence of a tumour in the lower calyx of the left kidney. The patient underwent a diagnostic ureterorenoscopy. Endoscopically, a solid tumour was observed in the lower calyx; biopsies were taken; however, both samples did not allow to make a diagnosis due to lack of sufficient tissue. The patient underwent another diagnostic ureterorenoscopy; the tumour was contact vulnerable and bled easily upon touching; thus, it was not possible to obtain enough tissue for pathological examination. As imaging suggested the presence of a renal tumour Fig. a, it wasOn gross examination, the tumour was a white and well circumscribed, 9 × 13 × 16 mm mass protruding from the renal pelvis Fig. .Fig. 2ThTo determine the entity of the described spindle cell lesion, various immunohistochemical stains have been made. The spindle cells showed a positivity for vimentin and a weak staining for CD99 and CD34. The spindle cells were negative for desmin, S100, ALK1, STAT6, and PDGFRA. SMA and CD34 highlighted the blood vessels and pancytokeratin the entrapped and atrophic tubuli. The proliferation rate (Ki-67) was around 1%, with some hot spots in regions of an enhanced inflammatory component  renomedullary interstitial cell tumour , but this entity is not described as a CD34-positive lesion, or (b) something unusual in this anatomical region. Because of the morphological similarity to IFPs of the gastrointestical tract, a molecular pathology analysis was performed. This identified an oncogenic mutation in exon 18 of the PDGFRA mutation should occur in cells of the gastrointestinal stroma only. As mentioned above, the PDGFRA gene plays an important role in the embryonic development as well as the pathogenesis of various haematopoietic malignancies and glioblastomas. Some have reported the presence of IFPs in unusual sites; for example, two cases of inflammatory fibroid polyps were described in the gallbladder. One of these cases is based on conventional-histological and immunohistochemical findings [PDGFRA gene, thus confirming the diagnosis of an inflammatory fibroid polyp [Inflammatory fibroid polyps have been known as benign mesenchymal tumours for more than 70 years, but their aetiology still remains unclear. To our knowledge, these lesions have so far been described in the gastrointestinal tract, but as we are speaking of a neoplasm originating from stromal cells, there is no clear reason why the causative findings , but theid polyp . These fPDGFRA supports the neoplastic origin of these mesenchymal lesions. Multiple studies suggested that these polyps are caused by a chemical or physical trigger or trauma [Although the aetiology is still unclear, the identification of a pathogenic mutation in the protooncogen r trauma –14. The r trauma  that a c


Endometriosis is the presence of uterine glands and stroma outside of the uterus. It is highly prevalent in women of reproductive age. It is usually found in the pelvis, with most cases being found on the peritoneum, ovaries, or deep in the pelvis. Extraperitoneal endometriosis is uncommon. Perianal endometriosis has an incidence of only 0.2%. We present the case of a 37-year-old woman with recurrent pain and swelling in the perineum at the site of a previous episiotomy scar. Initial imaging and assessment determined this to be scar tissue. Following re-presentation, it was mistakenly diagnosed as a perianal abscess, and the patient underwent incision and drainage. The wound failed to heal with significant induration. Further assessment of the wound was undertaken under general anesthesia. An excision of the affected area was performed, with histological analysis confirming endometriosis. This case highlights that extra-peritoneal endometriosis is a rare but treatable cause of recurrent, cyclical pelvic pain and swelling in the perineum. A high index of clinical suspicion is required due to its ability to mimic other pathologies, including abscesses and cysts. The primary management of perianal endometriosis is surgical excision. Where complete excision is not possible, medical management with hormone therapy should be considered. Endometriosis is the presence of endometrial glands and stromal tissue outside the uterus . It commIt is an estrogen-dependent inflammatory disease . SymptomThe perineum refers to the area between the posterior commissure of the labia majora and the anus in women. Perineal masses can include benign pathologies such as perineal cysts, abscesses, and hemorrhoids, as well as malignant soft tissue masses . In thisA 37-year-old woman presented to a gynecology clinic with a one-year history of a perineal lump. She reported pain in movement and exacerbations of symptoms during menstruation. Her obstetric history consisted of six pregnancies with spontaneous vaginal delivery and one previous episiotomy. She denied any associated vaginal discharge, dyspareunia, urinary, or bowel symptoms.The examination of her abdomen and rectum was unremarkable. There was no evidence of fistulae, fissures, or hemorrhoids. A 1-cm tender swelling was noted directly beneath a previous episiotomy scar. Magnetic resonance imaging (MRI) was arranged and revealed a non-specific lesion in the perineum Figures . The gynThe patient re-presented to the colorectal surgery clinic five years later. She reiterated the same symptoms of tender perineal swelling aggravated by menstruation. She denied any other symptoms. A further MRI scan was arranged, which demonstrated a heterogeneous T2 signal in the perianal area, measuring 2.4cm x 1.1cm x 2.5cm. Additionally, a high T2 signal side branch was seen extending across the midline anteriorly and ending blindly on the left side. There was a low T2 signal around the heterogeneous signal, which suggested fibrosis. Based on these changes, the radiologist reported that this was likely to represent a chronic abscess Figures , 4.However, due to the cyclical nature of the patient’s symptoms, subcutaneous endometrial deposits remained within the differential diagnosis. Due to this diagnostic uncertainty, the patient was listed for an elective examination under anesthesia (EUA) to enable further assessment and management.While awaiting elective admission, she presented to the Accident and Emergency Department with a 3 cm x 4 cm tender swelling in the peri-anal region. A provisional diagnosis of a perianal abscess was made by the General Surgery team. She was taken to the theater for EUA, incision, and drainage. There were no internal openings or masses noted at EUA. A perianal incision was made over the area of fluctuance, and a very small amount of infected blood was drained.Postoperatively, the wound remained open for two months, with evidence of an underlying area of induration. She was relisted for a further EUA and excision of the area of concern. Due to the complexity of the case, both colorectal and gynecology consultants attended. The area was excised with 2-millimeter margins. The medial end of the lesion was closely related to the external anal sphincter; the margin was not completely achieved.On histological assessment, anal skin with extensive endometriosis in the dermis and subcutis, associated with decidual alteration and acute inflammation, was reported. There was no atypia or malignancy.At review postoperatively, the wound had healed well. The patient reported only minor bleeding at the wound site during menses but no further pain. Further excision of this area was not recommended due to the high risk of sphincter injury and the almost complete resolution of the patient’s symptoms. Consequently, she was referred to the gynecology team for the implementation of non-surgical management.Endometriosis is most commonly found in the pelvic region, with 80% of cases being superficial peritoneal endometriosis. Other pelvic subtypes include ovarian endometriosis and deep endometriosis. More rarely, extraperitoneal endometriosis has been documented in the upper abdominal viscera, diaphragm, pleura, abdominal wall, and nervous system ,5,7. PerThe etiology of endometriosis is uncertain, particularly when it is extraperitoneal. The most commonly accepted theory is that of retrograde menstruation, whereby the endometrial cells enter the pelvic cavity and adhere to peritoneal surfaces . HoweverA definitive diagnosis is usually made through visualization during surgery. Imaging modalities such as ultrasound and MRI have been found to be inaccurate compared to surgical evaluation but can assist operative planning ,8. The cEndometriosis is initially managed with simple analgesia, including paracetamol and non-steroidal anti-inflammatory drugs, and hormonal treatments such as the combined oral contraceptive pill . FurtherThis case highlights the importance of considering extraperitoneal endometriosis as a cause of persistent, recurrent, and cyclical pelvic pain and swelling in women of reproductive age. It should be strongly considered if the site of the pain is related to a previous episiotomy scar. A strong clinical suspicion is required due to its ability to mimic other pathologies, such as perianal abscesses. A multidisciplinary approach is needed to facilitate effective medical and surgical management of these cases.


Infantile myofibromatosis is an uncommon soft tissue neoplasm that may present at birth or in early infancy. Although rare, this neoplasm is one of the most common benign fibrous tumors of infancy. Even though these tumors do not spread, they can compress or damage nearby organs. There is not an established management protocol, but it is advisable to maintain periodic clinical and imagological control until stability. Watchful waiting is an option to consider in the absence of problematic symptoms and visceral involvement. We report a case of solitary infantile myofibromatosis, without visceral involvement. It showed an initial rapid growth, raising concern among medical doctors and motivating soft tissue biopsy, always recommended as the clinical picture deviates from the classic presentation. Histology interpretation is often challenging, making genetics and clinical evaluation essential to exclude and prevent the misdiagnosing of more aggressive lesions. Infantile myofibromatosis (IM) is an uncommon soft tissue neoplasm that may present at birth or in early infancy. Although rare, this neoplasm is one of the most common benign fibrous tumors of infancy -4. Even A female newborn was delivered at 40 weeks to a 30-year-old gravida 1, para 0. Her family history was unremarkable. Pregnancy was uneventful and no fetal anomalies were detected at the prenatal ultrasound. The mother underwent a vacuum-assisted delivery. Apgar score was 9, 10, and 10 at 1, 5, and 10 minutes, respectively. Anthropometric measurement at birth was appropriate for gestational age. The postnatal exam showed a firm purple nodule on the skin and subcutaneous layer, with 3 cm of diameter, of the inferior 1/3 and posterior aspect of the left arm and elbow, with hemorrhage and ulceration  depicted a high-density mass 42x30x13mm) on T2 weighted images with a feeding vessel near the humerus, suggesting a vascular tumor, without a bone lesion. A core biopsy was performed, and histology displayed a spindle and epithelioid cell tumor with a solid pattern. It also showed hipocelular hypocellular areas, collagen-rich alternated with others with higher cell density, and more epithelioid phenotype , caldesmon, and CD34 was strong and diffuse. No nuclear stain with beta-catenin was seen and no expression was detected with S100, EMA, STAT-6, desmin, CD30, or ALK  and RNA (gene rearrangements) levels. The panel includes comprehensive full exon mutation coverage for 140 genes, including PDGFRB, while also detecting rearrangements in 97 genes, including NTRK1, NTRK2, NTRK3, BRAF, RAF1, ALK, ROS1, among many others. The panel did not reveal any molecular alteration, including ETV6::NTRK3, lowering the probability of an infantile fibrosarcoma diagnosis. Thoraco-abdominopelvic computed tomography (CT) excluded asymptomatic lesions and cardiac and cranial ultrasounds were normal. After an initial rapid growth in the first 15 days of life, the lesion started to slowly involute. The lesion continued to regress without any treatment and, after four months, it completely involuted, without local atrophy but with no mobility impairment (Figure The diagnosis of an infantile myofibroma was suggested. A molecular study was performed using the NGS panel OncomineIM is a rare benign tumor characterized by single or multiple soft tissue nodular lesions ,2. A paiSolitary lesions, as the one described, have not been associated with a fatal outcome as they usually course with spontaneous resolution ,4. StillIM should be part of the differential diagnosis of any solitary or multiple tumors in the soft tissues. The diagnosis must be confirmed histopathologically, as the clinical presentation can be misleading. Treatment options should be weighted case by case since there are no established management protocols or guidelines. Solitary lesions have a good prognosis, with spontaneous regression usually occurring in the first few years after diagnosis.


Intrahepatic vascular shunts “IHVS” are abnormal communications between intra-hepatic vasculature involving the arterial, portal, or hepatic venous system. Arterio-portal fistula “APF” is an intrahepatic communication between the hepatic arterial system and the portal venous system without any communication with the systemic venous circulation. APF is considered a rare cause of portal hypertension and gastrointestinal bleeding in infancy.A 3-month-old Mediterranean female with known cardiac congenital anomalies presented to us with abdominal distension and diarrhea. Ultrasonography revealed massive ascites and computerized tomography (CT) abdomen with intravenous (IV) contrast revealed a left hepatic lesion. On further evaluation, an intrahepatic arterio-portal vascular malformation was detected. Attempted trans arterial embolization failed and radiology team successfully carried out direct trans hepatic ultrasound guided coiling of the aneurysmal venous sac followed by successful resection of segment 4 of the liver with the vascular malformation avoiding life threatening intra operative bleeding.Any child with recurrent gastrointestinal bleeding, failure to thrive, vomiting, diarrhea, steatorrhea, splenomegaly, or ascites should be investigated for intrahepatic arterio-portal fistula “IAPF”. Our novel technique of direct trans hepatic ultrasound guided coiling is an alternative method if trans arterial embolization “TAE” failed. Arterio-portal fistula “APF” is an intrahepatic communication between the hepatic arterial system and the portal venous system without any communication with the systemic venous circulation. The etiology of APF may be congenital “Primary” or acquired “Secondary”. The acquired form is most often due to trauma , surgicaThis case is unique because it highlights the importance of preoperative radiological interventions preoperative to reduce risks of fatal intraoperative bleeding, even in failed attempts of radiological interventions there are novel techniques to achieve ideal preoperative control.A 3-month-old Mediterranean female, full term after cesarean section “CS”, Apgar score of 8 which was normal and normal birth weight. with cardiac anomalies in the form of atrial septal defect “ASD”—3 × 3.5 ml—and patent foramen ovale “PDA” -closed spontaneously-, presented with failure to thrive, abdominal distention and diarrhea. Physical examination showed hepatomegaly and superficial dilated veins which are suggestive of portal hypertension. Ultrasound revealed massive ascites.On at admission the child weight was 2.5 kg and length 49 cm both were on the low centile for age.3/mm3, platelet count 500 × 103/mm3, normal prothrombin and partial thromboplastin times, serum sodium 120 mmol/l, potassium 6.2 mmol/l, chloride 80 mmol/l, CO2 22 mmol/l, urea 26 mg/dl, creatinine 0.5 mg/dl, aspartate aminotransferase 105 U/l, alanine aminotransferase 65 U/l, alkaline phosphatase 248 U/l, γ-glutamyl transferase 167 U/l, total bilirubin 0.8 mg/dl.There was negative family history of medical diseases and negative consanguinity hemoglobin was 8.6 g/dl, albumin was 2.8 g/dl, and prealbumin 13.6 mg/dl. Laboratory values were white blood cell count 10.6 × 10CT abdomen with IV contrast was done and revealed a well-defined lesion at the left lobe of the liver, which was suspected to be hemangioendothelioma, all liver and kidney functions were normal. MSCT angiography and portography “Multi-slice computed tomography” was done and revealed complex intrahepatic arterio-portal vascular malformation Figs. , 2, 3 inThe usual trans arterial route embolization through this complex vascularity was impossible therefore using a direct ultrasound guided using an 18G spinal needle trans hepatic obliteration of the cystic  component by histo-acryl which is a glue ratio 1:3 (histoacryl: lipiodol) and coiling as well a single coil 15 mm × 30 cm detachable coil while the second component the intraparenchymal multiple channels between the artery and vein at segment 4 was obliterated by gel foam. Follow-up controlled angiography showed that the vascular communication (cystic component) was closed. The remaining solid intraparenchymal component was surgically removed two days later by left medial segmentectomy -segment 4- since not all the channels were obliterated by gel foam  of affected patients, they have trisomy 21, however, a relationship between both of them is not defined yet. The only other association as in our case was congenital heart disease  as atrial, ventricular septal defects, and patent ductus arteriosus.Most symptoms and signs of IAPF Table  are causComplications of IAPF include hemorrhagic shock from variceal bleeding , high ouLaboratory investigations Table  mostly sHyperbilirubinemia has also been noted . UltrasoThe different presentations of IAPF as illustrated before are due to the different sizes and locations of the shunt . The morIn the literature, treatment modalities of IAPF include radiological embolization, surgery , liver resection (for example lobectomy), or liver transplantation. Combined approaches can be done as embolization and later ligation or resection.n = 24), while only 13 needed surgical intervention whether arterial ligation, portocaval shunt, liver resection or liver transplantation. Details of surgical intervention are summarized in Table Table In unilateral IAPF: Only one case needed liver resection after the failure of arterial ligation . Given tn = 5). Two patients were successfully managed by arterial ligation and another two went through liver resection to relieve the symptoms. Some authors [.In bilateral IAPF: all t patients were initially managed by embolization with a success rate of 55.6% only . Another three cases were managed successfully by liver resection and the last two cases with liver transplantation.On reviewing the 14 reported cases (including our patient) of complex IAPF, only 5 cases were successfully managed by embolization (35.7%). Three patients underwent arterial ligation and another one had portportocavalnt with a success rate of 100%  showed regression of the symptoms, normalization of the portal circulation, preservation of liver functions, and catching up with their growth curves. Only 11% (n = 5) of the affected children had persistent portal hypertension [All patients with IAPF after appropriate management have survived except for the first published case Table . Most ofrtension , 41, 48.rtension , 29, 41 Congenital intra-hepatic arterio-portal fistula is a rare, but treatable cause of portal hypertension in children. Early diagnosis and management will prevent further complications. Any child with recurrent gastrointestinal bleeding, failure to thrive, vomiting, diarrhea, steatorrhea, splenomegaly, or ascites should be investigated for IAPF. Doppler ultrasonography is the first line of investigation in such cases. Treatment modalities depend on the type and size of IAPF as mentioned before. Direct trans hepatic ultrasound guided coiling is a novel technique and an alternative method if TAE failed. Non-complex lesions usually respond to radiological embolization while complex lesions usually need surgical intervention.


Aneurysmal bone cysts (ABCs) are a rare, vascular, rapidly growing, benign, osteolytic lesions. Most ABCs involve the metaphysis of long bones, vertebrae, or flat bones. In this study, we review the literature to better understand the natural history, clinical presentation, and treatments.A 34-year-old man who presented with left intermittent otorrhea for months. Yellowish, pus-like discharge was noted. Mild tinnitus, hearing loss, and occasional headache was also found. The initial impression was chronic otitis media and ear drops were prescribed. However, his symptoms did not improve in the following months. The brain MRI with gadolinium enhancement revealed an extra-axial mixed signal intensity lesion on the T2-weighted image, multiloculated cystic components and rim enhancement was noted over the left middle cranial fossa. Left fronto-temporal craniotomy for tumor removal was performed. The pathological reports revealed an aneurysmal bone cyst.Typically, ABCs present with localized swelling and pain due to their rapid growth and expansion, with concomitant signs corresponding with the anatomical location of the lesion. MRI studies can reveal the cystic components of the lesion and multiple fluid levels within multiloculated cysts resulting from unclotted blood, separated from the soft tissue and medullary bone. Histopathologic diagnosis of ABC is the presence of multiple blood-filled cystic spaces separated by fibrous septa. The fibrous septa are composed of spindle-celled fibroconnective tissue with occasional osteoclast-type giant cells.ABCs are a rare, osteolytic lesions that rarely involve the skull. When the MRI shows a lesion with soap-bubble appearance in the calvaria, an aneurysmal bone cyst should be considered in the differential diagnosis, even if it is an extremely rare entity or the patient is relatively old. Surgical resection of the tumor is the first choice for treatment. •Aneurysmal bone cysts are rare, vascular, rapidly growing, benign, osteolytic lesions that rarely involve the skull.•Preoperative diagnosis of ABCs from another osteolytic lesion of the cranium is difficult. However, MRI shows the characteristics of the tumor, which include a multiloculated, expansile bony lesion with fluid–fluid levels in one or more granular spaces and a hypointense circular rim surrounding the entire lesion, an aneurysmal bone cyst should be considered, even if it is an extremely rare entity or the patient is relatively old.•Complete surgical resection of the tumor is the first choice for treatment if its location is assessed. Possible reconstruction after resection and postoperative adjunctive therapy for the complex lesion is an important issue to prevent tumor recurrence and restore neurological function. Yellowish, pus-like discharge was noted. In addition, mild tinnitus, hearing loss, and occasional headache was reported by the patient. There was no complaint of fever, dizziness, or ear pain. The initial impression was chronic otitis media and antibiotic ear drops were prescribed. However, his symptoms did not improve in the following month. Then, one evening after work in September 2022, he suffered from acute onset of vertigo and unsteady gait. He denied trauma and the symptoms lasted several hours. Moreover, his symptoms could not be relieved by changing position. Thus, he was sent to the emergency room the next day. At the ER, the physical examination showed normal extraocular movement (EOM), but horizontal nystagmus was noted. Otolaryngologist was consulted and fiberscope showed redness with scaling at the left inner two-thirds of the external auditory canal (EAC). Tympanic membrane (TM) thickening with brownish pus coating and turbid content behind the tympanic membrane were observed. Left eardrum effusion indicated the possibility of a cyst or otitis media with effusion (OME). Pure tone audiometry (PTA) revealed mixed type hearing loss, with an air-bone gap of 20–30 dB.Imaging studies were arranged for evaluation, including computed tomography (CT) and magnetic resonance imaging (MRI) . TemporaLeft fronto-temporal  craniotomy for tumor removal was performed in October 2022. Intraoperative findings showed a well-defined extradural lesion at the left temporal base with severe adhesion to the dura. It was composed of multiple cysts filled with yellowish fluid. Moreover, the tumor was soft and rich in vessels, but there was no gross brain parenchyma invasion. Gross total resection of the tumor was performed under microscope. Bone erosion of the temporal base was found after tumor removal. A piece of dura which had adhered to the tumor was also removed and duraplasty with artificial dura (Duragen-Plus) was done. We used Tisseel solution, Geofoam for hemostasis, and prevented CSF leakage after duraplasty. The pathological reports revealed an aneurysmal bone cyst. A blood-filled cystic space was noted with a cystic wall composed of spindle cells with osteoclast-like giant cells and reactive woven bone. Immunohistochemistry stains were done for epithelial membrane antigen (EMA), progesterone receptor (PR), signal transducer and activator of transcription 6 (STAT6), glial fibrillary acidic protein (GFAP), H3.3 G34W, p63 was negative, and ki-67 (weak expression) .Fig. 2HiThe follow-up non-contrast-enhanced brain CT is shown in Klebsiella aerogenes. Furthermore, the swelling wound had turned hard and had started to suppurate. We performed a combined surgery for debridement and possible CSF leakage. Epidural abscess at the temporal region and a mass-like lesion at the left EAC with some discharge were noted. No skull bone defect or CSF leakage was found. The pathological report revealed a granulation tissue with chronic active inflammation. The patient recovered well after finishing a course of antibiotics.Under the impression of meningitis, antibiotic treatments with vancomycin and ceftriaxone were prescribed, which were then changed to linezolid and ceftriaxone due to allergy to vancomycin. Culture studies revealed no pathogen growth in samples of discharge and CSF, but the middle ear effusion showed 3Aneurysmal bone cysts (ABCs) are rare, vascular, benign, expansible, osteolytic lesions that were first described by Jaffe and Lichtenstein in 1942. Jaffe and Lichtenstein coined the term aneurysmal bone cyst due to a specific entity consisting of an expanding bony lesion with a vascular lining and a soap-bubble radiologic appearance . They co3.1The origin and nature of ABCs remains unclear, though there are several theories that have been proposed to explain its origin. According to one theory, ABCs develop due to a reactive process following a trauma that induces a local circulatory disturbance. An abnormally increased venous pressure leads to hemorrhage, with subsequent osteolysis. A phase of active growth follows initial osteolysis, after which maturation and ultimately bony healing occur. This osteolytic lesion formation promotes additional hemorrhages and, in turn, results in the amplification of the developing cyst . In anot3.2Typically, ABCs present with localized swelling and pain due to their rapid growth and expansion, with concomitant signs corresponding with the anatomical location of the lesion ,7,9. ThePlain radiographs of aneurysmal bone cysts in the skull typically reveal an eccentric, ballooned, cystic expansion surrounded by a sclerotic rim . The perMRI studies can reveal the cystic components of the lesion and multiple fluid levels within multiloculated cysts resulting from unclotted blood, separated from the soft tissue and medullary bone. A low signal intensity rim surrounding the entire lesion correlates with the pathologic finding of a fibrous capsule. Fluid-fluid levels are an important cross-sectional imaging finding on MRI, but they are nonspecific and are more easily seen on an MRI than on a CT scan. The cyst contents consist of blood degradation products in different stages of evolution and, as such, the signal intensity of the degradation products varies, a finding considered to be attributable to methemoglobin . Other bOn angiograms, the features of cysts elsewhere in the body are usually characterized by a pathological circulation with a patchy distribution of contrast, as well as persistent venous circulation and occasional arteriovenous shunting. This finding may be absent when the lesion is located in the cranium, indicating that it is an avascular mass lesion .3.3Histological characteristics of ABCs are well defined and histologic evaluation is imperative for definitive diagnosis. Grossly, ABC is a relatively well-circumscribed, friable, multicystic, and hemorrhagic lesion . Histopa3.4Although ABCs have no malignant or metastatic potential, local mass effect and alteration of locoregional vascularity may be severe, necessitating treatment , and tre4Aneurysmal bone cysts are rare, vascular, rapidly growing, benign, osteolytic lesions that rarely involve the skull. Preoperative diagnosis of ABCs from another osteolytic lesion of the cranium is difficult. However, MRI shows the characteristics of the tumor, which include a multiloculated, expansile bony lesion with fluid–fluid levels in one or more granular spaces and a hypointense circular rim surrounding the entire lesion. When a lesion with soap-bubble appearance and fluid–fluid levels is found in the calvaria, an aneurysmal bone cyst should be considered in the differential diagnosis, even if it is an extremely rare entity or the patient is relatively old. Complete surgical resection of the tumor is the first choice for treatment if its location is assessed. Possible reconstruction after resection and postoperative adjunctive therapy for the complex lesion is an important issue to prevent tumor recurrence and restore neurological function. The patient described herein completely recovered, though complications with meningitis occurred during the postoperative course.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.Not commissioned, internally reviewed.Not required for case reports at our hospital. Single case reports are exempt from ethical approval in our institution.This research did not receive any funding agencies in the public, commercial, or not-for-profit sectors.Chia-Fang Shen: Operation, Conceptualization, Methodology, Validation, Investigation, Resources, Data Curation, Writing - Original Draft, Review & Editing, Visualization, Project administration.Chin-Chan Yang: Operation, Conceptualization, Methodology, Validation, Formal analysis, Writing - Original Draft.Szu-Yuan Liu: Operation, Software, Validation, Formal analysis, Investigation, Resources, Data Curation, Writing - Review & Editing, Visualization, Supervision.Chiung-Chyi Shen: Visualization, Supervision.Chiung-Chyi Shen– Chief of Neurological Institute, Head of Department of Neurosurgery, Taichung Veterans General Hospital, 1650, Taiwan Boulevard Section 4, Taichung, Taiwan 407, ROC.Not applicable.All authors declare that they have no competing interests.