Mirizzi syndrome (MS) is a rare complication of chronic gallstones. Mirizzi syndrome is characterized by a set of symptoms that results from obstruction of the common hepatic or common bile duct (CBD). This may be due to extrinsic compression from an impacted gallstone in the gallbladder neck or cystic duct because of inflammatory changes secondary to chronic gallstone cholecystitis. We present a case of an 86-year-old patient with chronic gallstones who presented with abdominal pain and jaundice. The patient was diagnosed with MS type V after endoscopic retrograde cholangiopancreatography (ERCP). CBD stone fragments/debris were removed, and the patient was referred for surgical intervention for the repair of cholecystoduodenal fistula. MS must be in the differential diagnosis in elderly patients with chronic gallstone cholecystitis presenting with obstructive jaundice. Multiple diagnostic and therapeutic approaches are required to diagnose and manage the different types of MS. We aim to present the case to highlight and raise awareness of MS, particularly in patients with chronic gallstones. In 1948, Mirizzi syndrome (MS) was first described as a rare complication of long-standing gallbladder stones. It refers to the set of symptoms that result from obstruction and fistula formation of the common hepatic or common bile duct (CBD) due to long-standing gallstones. This may be due to extrinsic compression from an impacted gallstone in the gallbladder neck or cystic duct because of inflammatory changes secondary to chronic gallstone cholecystitis. Over time, the stones can erode and form cholecystoduodenal or cholecystoenteric fistulas which further complicate the pathology. In patients presenting with obstructive jaundice or ascending cholangitis, it is crucial to have a high index of suspicion for MS, as it could be easily missed . DistingAn 86-year-old male with a past medical history of recurrent gallstone cholecystitis presented in the emergency department (ED) with intermittent right upper quadrant abdominal pain, diarrhea for the last two to three weeks, and scleral icterus. His medical history was remarkable for chronic lower extremity edema, deep venous thrombosis with inferior vena cava filter, and incision and drainage of septic arthritis of the right hip. The patient was unable to provide detailed history secondary to poor memory; history was ascertained from family and electronic medical records. One year ago, the patient had similar abdominal pain and a computed tomography (CT) scan of the abdomen and pelvis showed a distended gallbladder with cholelithiasis, including one stone possibly impacted in the gallbladder neck. He subsequently underwent a hepatobiliary iminodiacetic acid (HIDA) scan which confirmed an obstructed cystic duct stone. The patient was medically not stable for the surgical approach and interventional radiology placed a percutaneous cholecystostomy tube. The patient received intravenous antibiotics and was clinically improved. One month later, the patient underwent a cholangiogram which revealed a patent biliary duct, confirming the safe removal of the cholecystostomy tube. He was advised to undergo elective cholecystectomy at that time, which he declined and did not follow up. During this admission, the patient complained of intermittent severe abdominal pain. There were no aggravating or alleviating factors associated with the pain. He denied weight loss, nausea, emesis, chest pain, and shortness of breath. In the ED, vital signs were remarkable for hypotension and tachycardia. On physical examination, the patient was alert and oriented to self. Pertinent physical findings include scleral icterus and tenderness in the right upper abdomen.Pertinent labs include elevated white blood cells (13.5x10³/µL), total bilirubin (15.7 mg/dL), direct bilirubin (11.7 mg/dL), aspartate aminotransferase (98 U/L), and alanine aminotransferase 41 U/L). Urinalysis showed tea-colored urine. CT scan of the abdomen and pelvis revealed a collapsed gallbladder with CBD obstruction and bile duct dilation consistent with chronic inflammation. Endoscopic retrograde cholangiopancreatography (ERCP) was then performed which demonstrated cystic duct stone eroding into the common hepatic duct, hence the diagnosis of Mirizzi syndrome was made. Cholangioscopy confirmed the eroding stone, chronic inflammatory changes, and destruction of the bile duct. A cholecystoduodenal fistula with pus drainage was noted in the duodenal bulb. The patient was diagnosed with MS type V according to the ERCP findings. The stone was not amenable to endoscopic removal, but stone debris, clots, and pus  of developing gallbladder cancer, likely from chronic biliary stasis causing persistent and recurrent irritation of the area . AlthougIn patients with MS, preoperative CT, and magnetic resonance cholangiopancreatography (MRCP) should be done to rule out gallbladder cancer. Alarming tomographic findings representing cancer in MS are the presence of a mass filling or replacing the gallbladder and local involvement of the liver with anterior surface focal protrusion .The understanding of MS and its different classifications/types are crucial for accurate diagnosis and optimal treatment. Gallstones are a common medical issue that may lead to chronic complications like MS; early diagnosis and appropriate management significantly impact the lives of patients. High suspicion of MS should be kept in the differential diagnosis in elderly patients who present with fatigue and obstructive jaundice, especially in the background of chronic cholecystitis. As in our case, the patient had a past medical history of recurrent cholecystitis and presented with fatigue, intermittent right upper quadrant pain and scleral icterus. Hence, physicians should keep MS in mind when managing patients with chronic gallstone cholecystitis.


Cardiac metastases are rare. Herein, we report a case of a 37-year-old female patient with a history of borderline breast phyllodes tumor (PT) treated by surgery, admitted to our department for concomitant cardiac and pulmonary metastases of malignant PT. Cardiac metastasis occurred through direct extension from pulmonary metastasis to the left atrium via the right inferior pulmonary vein, causing severe mitral valve obstruction. Although the total surgical removal of metastases, the patient had a huge relapse of the mediastinal metastasis resulting in her death. CT: computed tomographyLA: left atriumLSPV: left superior pulmonary veinMRI: magnetic resonance imagingPts: Phyllodes tumorsTTE: trans thoracic echocardiography PTs predominantly occur in women aged 35-50 years, and they range from benign to malignant forms according to the histological features. Malignant PTs account for 16% to 30% of all PTs and they have an inherent recurrence and/or metastasis potential., Cardiac metastases are more frequent than primary cardiac tumors. Herein, we report a case of concomitant cardiac and pulmonary metastases of malignant PTs, causing severe mitral valve obstruction.Phyllodes tumors (PTs) represent a rare category of breast neoplasm, with a prevalence accounting for <1% of all breast tumors.A 37-year-old Maghrebian female patient was presented to the cardiology department due to complaints of dyspnea, progressing over one month. She had a dry cough and had been resistant to symptomatic treatment. The patient was diagnosed with borderline breast PTs ten years earlier. Tumor size was 8 × 7 × 5 cm removed surgically with no skin involvement and safe margin of resection. No recurrence was noted during the first years of follow-up. Upon examination, her dyspnea was classified as class IV on the New York Heart Association Functional Classification with orthopnea. Her transcutaneous oxygen saturation was 92%, and pulmonary auscultation revealed bibasilar crackles. Additionally, the patient’s chest x-ray showed a homogeneous opacity located in the basal part of the right lung. Transthoracic echocardiography (TTE) revealed 5 × 4 cm homogenous mass occupying nearly all the left atrium (LA), resulting in severe mitral valve obstruction (mean gradient = 17 mmHg) .A second huge mass compressed the right atrium posterior wall. Following respiratory stabilization, transesophageal echocardiography confirmed TTE results and revealed an extended mass into LA via the right inferior pulmonary vein (RIPV) . CardiacThe Cardiac magnetic resonance imaging (MRI) results showed low signal on T1-weighted imaging and high signal on T2-weighted imaging of the mediastino-pulmonary mass . The pat These types of tumors are commonly manifested in the breast tissue and are usually benign; however, they might rarely be malignant., A malignant tumor has a potential to metastasize to distant organs, such as lung, bone, and liver. Our case revealed concomitant pulmonary and cardiac metastases, which is unusual, and it is associated with poor prognosis. It has been reported that cardiac invasion could be caused by hematogenous spread, direct extension, or via the lymphatic route. In the case of this patient, direct extension from pulmonary metastasis to RIPV is the probable route of metastasis. Reported cases of cardiac metastasis are mostly located in the right heart with the possibility of right ventricle outflow tract obstruction. To the best of our knowledge, this is the first case of LA location, complicated by severe mitral obstruction and acute heart failure. The clinical expression of cardiac metastasis is mainly dependent on the tumor burden and location. As in the case of our patient, cardiac metastasis can manifest with dyspnea and chest pain, or it can be asymptomatic. Previously, malignant cardiac metastasis had poor prognosis and very rare cases were identified at autopsy. However, advances in imaging tools such as echocardiography allows for detection and confirmation of intra-cardiac mass and eventual valve or cavity obstruction. However, echocardiography is limited in the differentiation between PTs, myxoma, fibroadenoma, and thrombus. In our case, echocardiography revealed severe mitral obstruction by an intra-LA mass. Cardiac CT and MRI provide multiple views in different axes with a precision of limits as well as intra, and extra cardiac extension, thus allowing a better distinction between the thrombus and other masses. The results of the echocardiography, cardiac CT, and MRI for our patient confirmed the intra and extra cardiac location of the tumor and its LA access from RIPV to the mitral valve. Therapeutic approaches, including chemotherapy, radiotherapy, and hormonal therapy are still controversial. The surgical excision of cardiac metastasis from a malignant PTs was described in few reports. This type of intervention could be an urgent life-saving therapeutic strategy in case of right ventricle outflow obstruction or mitral obstruction, and it can also improve the patient’s quality of life in the short term, as it was in our case., However, intra-operative mass manipulation could cause tumor dissemination, thus leading to a risk of further metastasis development., This may explain the hudge relapse of mediastinal mass with tracheal invasion in our patient. In this case report the major limitations were the delay in diagnosing cardiac and pulmonary metastases and the lack of immunohistochemical analysis of the tumor.PTs or cystosarcoma is a rare breast neoplasm.Cardiac metastases from PTs are rare. Tumor surgical excision might be indicated to avoid sudden death and to improve the patient’s quality of life despite the extremely unfavorable prognosis. Nevertheless, urgent surgical removal could be unavoidable in case of valve obstruction. Early diagnosis and immunohistological analysis of PTs, especially the malignant type, is imperative given that there is little effective treatment for metastatic disease.All data underlying the results are available as part of the article and no additional source data are required.NA, AA and AB were actively involved in data collection and processing. IC and RK were involved in manuscript preparation. CK, SJ and FM were involved in manuscript reviewing. All authors have read and approved the manuscript.A written informed consent was received from the patient’s brother. I approve this manuscript for indexing.Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?YesIs the case presented with sufficient detail to be useful for other practitioners?YesIs sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?PartlyIs the background of the case’s history and progression described in sufficient detail?YesReviewer Expertise:Breast and plastic surgeryI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. This is a rare case of mitral valve obstruction by metastatic malignant phyllodes tumor. They provide clear and complete images for a complete preoperative assessment and they can keep patients alive for more than three months after surgery for such a severe mitral valve obstruction. They did a great job but this case report still needs further revision and correction.The authors write “we report a case of a 37-year-old female patient with a history of borderline breast PTs”, please add previous breast PT surgery treatments.“The patient had an uncommon complication”, please mention the complication. In the report itself:“The patient was diagnosed with borderline breast PTs ten years earlier, which was treated by surgical excision.” Which breast, tumor size, skin involvement, safe margin of surgical resection, recurrence or not?What is the operation of metastatic malignant phyllodes tumor resection, including resection of mitral valve or cardiac tissue, lung resection (lobectomy) or debulking surgery? Reconstruction or not?“The patient was discharged from the hospital after having an echocardiographic check-up, which demonstrated no residual tumor.” Please show the echocardiographic image.“Three months after the surgery, she died from a huge relapse of mediastinal mass with tracheal invasion.”, please show the CT image.In discussion, I could find more than a dozen articles on metastatic malignant phyllodes tumor of the heart, please summarize and discuss the differences between your case and theirs.There are many errors in the references, please correct them. In the abstract:Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?YesIs the case presented with sufficient detail to be useful for other practitioners?YesIs sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?PartlyIs the background of the case’s history and progression described in sufficient detail?YesReviewer Expertise:breast and plastic surgeryI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Dear editorial board Thank you for giving me the opportunity to submit a revised draft of my manuscript. We have highlighted the changes within the manuscript. Here is a point-by-point the response to the reviewers’ comments. In the abstract: 1. The authors write “we report a case of a 37-year-old female patient with a history of borderline breast PTs”, please add previous breast PT surgery treatments Response: changes made in the new version  2. The patient had an uncommon complication”, please mention the complication. Response: mediastinal location of metastasis In the report itself: 1.“The patient was diagnosed with borderline breast PTs ten years earlier, which was treated by surgical excision.” Which breast, tumor size, skin involvement, safe margin of surgical resection, recurrence or not? Response: Tumor size was 8 x7 x5 cm, removed surgically with no skin involvement and safe margin of resection (added in the new version) 2. What is the operation of metastatic malignant phyllodes tumor resection, including resection of mitral valve or cardiac tissue, lung resection (lobectomy) or debulking surgery? Reconstruction or not? Response: Surgery consisted on total intra cardiac metastasis resection with mitral valve conservation and right pneumonectomy without reconstruction.( added in the new version) 3. “The patient was discharged from the hospital after having an echocardiographic check-up, which demonstrated no residual tumor.” Please show the echocardiographic image. Response: no echocardiographic image was available 4. “Three months after the surgery, she died from a huge relapse of mediastinal mass with tracheal invasion.”, please show the CT image. Response: CT image added in the new version 5. In discussion, I could find more than a dozen articles on metastatic malignant phyllodes tumor of the heart, please summarize and discuss the differences between your case and theirs. Response: changes were made in the new version 6.There are many errors in the references, please correct them. Response: errors were corrected This is an excellent case report of a young patient presenting with dyspnea class IV on the New York Heart Association functional classification, including a cascade of exploration including Transthoracic echocardiography, Transesopheagal echocardiography, CT-scan and cardiac magnetic resonance imaging as well as the histological study, concluded that the mitral valve was obstructed by a metastatic malignant phyllodes tumor. The patient required emergency valve surgery with the particularity of preserving the native valve and removing only the metastatic mass (urgent life-saving therapeutic strategy). It is a very rare cause of mitral obstruction where only the histological examination allowed to differentiate it with certainty. The iconography is well done. Discussion is sufficient with a good review of the literatureAre enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?YesIs the case presented with sufficient detail to be useful for other practitioners?YesIs sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?YesIs the background of the case’s history and progression described in sufficient detail?YesReviewer Expertise:CardiologyI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.


Ogilvie’s syndrome refers to a massive dilation of the colon without mechanical obstruction. Although this syndrome is well-known in the clinical literature and may sometimes be encountered as a complication of abdominal, pelvic, or hip surgery, it has only been reported sporadically in the forensic literature. We present the case of a forensic autopsy carried out on a patient whose death was related to cecal necrosis with acute peritonitis due to Ogilvie’s syndrome following hip surgery. This diagnosis was based on clinical data, post-mortem imagery, autopsy findings, histological analysis, post-mortem chemistry, and microbiological analysis. A review of the literature and possible physiopathology of this disease are performed, while focusing on medico-legal perspectives. Ogilvie’s syndrome (OS) or acute colonic pseudo-obstruction refers to distention of the colon without evidence of mechanical obstruction , 2. It wEven though this syndrome is well-known in the clinical literature, it has seldom been reported in the forensic literature , 9, as w2), with other comorbidities such as active smoking, dyslipidemia and arterial hypertension. Surgery was performed under general anesthesia with an anterior approach, without immediate surgical complication. The intervention lasted for an hour and fifteen minutes. Post-operative pain was managed with opioids. Additional post-operative medications included enoxaparin, ibuprofen, oxazepam and paracetamol. One day after surgery, the patient developed abdominal pain and tenderness, along with the absence of stool passage and diminished bowel sounds. Clinicians deemed those findings consistent with postoperative paralytic ileus. Treatment was then initiated, with rectal enema, laxative and fasting, though no parenteral nutrition nor gastric aspiration were introduced. Also, opioid treatment was withdrawn. On the third post-operative day, he further developed hypotension and tachycardia. Laboratory values then showed leukocytosis . Abdominal plain radiography revealed dilation of small intestine loops (diameter of 6 cm) with multiple air-fluid levels. On the fourth day, his clinical state worsened with desaturation and tachypnea. At that time, laboratory workup revealed increased C-reactive protein  considered unspecific due to the postoperative state and increased leukocytosis (19.5 G/l). Subsequently, the patient developed acute confusion, followed by cardio-respiratory arrest then death. In this context, the case was reported to local authorities and the public prosecutor ordered medico-legal investigations to assess the cause and manner of death.A 67-year-old man was admitted to the hospital for an elective total right hip replacement surgery in the context of osteoarthritis. This patient was known to be overweight  and morphine . The cause of death was then attributed to acute peritonitis in the context of Ogilvie’s syndrome with acute cecal necrosis. This death was considered a complication of hip surgery and no medical malpractice was retained by the public prosecutor.Post-mortem computed tomography (PMCT) was then carried out, revealing a dilated colon up to 9 cm in diameter at the level of the cecum without pneumoperitoneum Fig. a. Post-mIn the field of orthopedics, Ogilvie’s syndrome has been diagnosed after elective total hip arthroplasty (THA), hip fracture, elective knee arthroplasty, and spinal surgery , 12–21. To this day, the physiopathology of Ogilvie’s syndrome remains uncertain and is most certainly multifactorial . NumerouIt is worth mentioning a recent hypothesis suggesting that micro-thrombosis and hypoperfusion of the bowel wall might lead to OS. This hypothesis was based on one case of OS that occurred after discontinuation of a patient’s low molecular weight heparin treatment without switching to non-heparin anticoagulant because of severe gastrointestinal hemorrhage . HoweverEscherichia coli found within the peritoneal cavity on post-mortem cultures. A case of fatal bacterial peritonitis secondary to OS has previously been described in the literature [Escherichia coli and necropsy revealed cecal necrosis without perforation. As opposed to our case, the authors were then unable to define the infectious mechanism displayed by the causative germ to achieve infection of the peritoneal cavity.In our case, OS developed after elective right THA due to degenerative osteoarthritis, as most frequently described in the literature, and with a comparable clinical presentation , 14, 17.terature . In the To evaluate the involvement of the enteric nervous system in the development of OS in the current case, we investigated the integrity of the Auerbach and Meissner’s plexus as well as interstitial cells of Cajal. We found that the enteric nervous system was morphologically intact in the ascending colon, just distal to the cecal dilation and necrosis. This suggests the absence of morphological disturbance of the enteric nervous system in cases of OS. However, the possibility of physiological impairment of this system remains uncertain.Diagnosis of OS is challenging in forensic practice. Therefore, clinical data, if available, should be thoroughly reviewed in search of potential risk factors contributing to the development of OS, such as surgical intervention, trauma, infection, drug reaction as well as a cardiac, neurological and metabolic disease. Moreover, OS should especially be suspected in cases of death following orthopedic surgery. Diagnosis should then solely be based on the presence of both colonic distention and lesion, since bowel distention alone can be encountered on post-mortem imaging and during necropsy. However, caution should be carried not to overvalue this finding as evaluating colonic distention during the autopsy is hazardous. Indeed, putrefactive gas production in the post-mortem period can exacerbate distention. For this reason, one should carefully evaluate the integrity of the colonic wall in search of perforation and early signs of ischemic necrosis. Additionally, post-mortem computed tomography could help in the diagnosis of bowel perforation if pneumoperitoneum is present. Histological analysis remains the most reliable diagnostic tool in assessing ischemic changes in the colon and would also exclude another differential diagnosis such as post-mortem dilation and colitis. Post-mortem chemistry and microbiological analysis will also help in assessing bacterial peritonitis and the general inflammatory response in relation to the cause of death. Concerning the post-mortem differential diagnosis of OS, only the other types of functional obstruction should be a matter of concern.Clostridium difficile). The diagnosis of paralytic ileus, on the other hand, should be retained when both colon and small bowel show dilation, though usually predominant in the latter.On the one hand, toxic megacolon should be differentiated from OS when bowel dilation occurs in association with systemic toxicity, usually in the context of inflammatory bowel disease  or infectious colitis  or acute colonic pseudo-obstruction refers to distention of the colon without evidence of mechanical obstruction, affecting mainly hospitalized patients admitted for surgery.The most devastating complications of OS are cecal necrosis and perforation, which can lead to death.OS has only been reported sporadically in the medico-legal literature, and represents a challenging diagnosis to establish in the forensic practice.Since hospital deaths occurring shortly after surgery are frequently referred to forensic pathologists in order to rule out medical malpractice, forensic pathologists and medical examiners should be aware of the occurrence of this postoperative complication.Post-mortem diagnosis of OS should be based on post-mortem imaging, autopsy, histology, along with toxicological and microbiological analysis.


Lipomas are tumors composed of mature adipocytes, originating from the mesoderm, and are the most common soft tissue tumor. According to the World Health Organization classification of human soft tissue and bone tumors, there are 14 types of benign tumors, including mature adipose tissue. Osteolipoma is known as the rarest subtype of lipoma.A 63-year-old female presented to our hospital for the evaluation and treatment of a palpable mass with pain in the right knee.The diagnosis was confirmed as lipoma with osteocartilaginous metaplasia.Surgical removal of the tumor was performed.The main symptoms improved immediately after the surgery and recovered without any complications or recurrence until 2 years after surgery.Lipoma with osteochondral degeneration is a rare variant of lipoma and it is important to differentiate it from other malignant tumors. Pathological confirmation should be performed after marginal resection of the mass. Histologically, a membrane made of fibrous tissue separates the periphery and the border of lipoma, and it is filled with mature adipocytes and cells of mesoderm origin. Lipomas can occur in any part of the body, mainly in the subcutaneous tissue of the neck, back, and extremities.,2 Normal lipoma consists only of mature adipocytes, but there are several variants depending on the other components of it.,2 The World Health Organization classification of human soft tissue and bone tumors describes 14 types of benign lipomas containing mature adipose tissue. Among them, osteolipma is known as the rarest subtype of lipoma, and the first case was reported in 1959. Lipomas containing both bone and cartilage degeneration are even rarer. Lipomas formed around the knee joint are mostly observed through follow-up, but if they cause tenderness or mechanical symptoms such as joint movement disorders, they may be surgically removed and also removed for cosmetic purposes.,2 In addition, it is important to differentiate these lipomas from other malignant or benign soft tissue tumors containing bone tissue components. The authors would like to report a case of lipoma with osteochondral degeneration that occurred in the infrapatellar fat pad of the knee, along with a literature review.A lipoma is a tumor composed of mature adipocytes, originating from the mesoderm, and is the most common soft tissue tumor.This study was approved by the Institutional Review Board of CHA Bundang Medical Center (CHAMC 2022-08-028) at the CHA University School of Medicine (Korea). This study was conducted in accordance with the principles of the 1975 Declaration of Helsinki (revised in 2008).We obtained patients’ clinical and radiological data. Informed written consent was obtained from the patient for publication of this case report and accompanying images.A systematic literature review was conducted using 3 different databases  using the keywords and search terms “Osteolipoma” OR “Chondrolipoma.”A 63-year-old female patient visited our outpatient clinic with pain in the right knee joint that occurred approximately 1 year ago without any particular trauma. Conservative treatment, including drug treatment, was administered at another hospital. However, symptoms did not improve, and computed tomography performed at another hospital revealed a mass within the infrapatellar fat pad.On physical examination performed at our hospital, a palpable mass accompanied by tenderness was observed on the anterior part of the right patellar tendon. The range of motion was limited to 30° of flexion and 130° of further flexion. The blood test was normal, and a simple radiographic examination revealed a lesion suspected of being a 3.4 × 2.1 cm ossified mass inside the infrapatellar fat pad (Fig. Under general anesthesia, a capsule-enclosed mass in the infrapatellar fat pad was identified through the medial approach of the patella to the joint cavity. The mass was completely separated from the surrounding tissues, and marginal excision was performed. The extracted mass was approximately 5.1 × 2.2 × 4.0 cm in size. The interior of the mass was composed of bone and cartilage tissues of various sizes and irregular shapes Fig. . MacroscJoint movement and weight-bearing were allowed immediately after the operation. Anterior knee joint tenderness and flexion restriction improved immediately after the operation and recovered without any complications related to surgery. It was confirmed that daily life was possible without recurrence until 2 years after surgery. The cause of lipoma degeneration is not yet clear, but there are claims that it is caused by chronic stimulation or trauma. In addition, 2 representative hypotheses exist regarding the origin of the osteochondral degeneration of lipoma. First oncogenic mutations occur in various mesenchymal cells that directly differentiate into adipocytes, osteoblasts, and chondroblasts simultaneously. The second hypothesis is that secondary neoplastic mutations gradually occur within the lipoma, and undifferentiated mesenchymal cells in the stroma differentiate into chondroblasts and osteoblasts. In recent years, chromosomal rearrangement abnormalities have been observed in lipoma degeneration, and further research on chromosomal abnormalities as the cause of the occurrence is needed. In addition, it is argued that there is also the influence of growth factors such as transforming growth factor-β, latent transforming growth factor-β binding protein-1, and bone morphogenesis protein.Although benign lipomatous lesions are common, it is difficult to determine the exact frequency of incidence because they are difficult to recognize clinically or are observed even though they are recognized. This case is a lipoma with osteochondral degeneration, which is a variant of a lipoma that occur in the infrapatellar fat pad. Lipoma with osteochondral degeneration is a rare variant, most of which has been reported in the head and neck. One case has been reported in the right hip in Korea. Two cases of infrapatellar fat pad have been reported worldwide,,9 but no such case has been reported in Asia.The infrapatellar fat pad is an intra-capsular and extra-synovial structure. Common neoplastic lesions occurring in the infrapatellar fat pad include peri-articular chondroma or osteochondroma, focal pigmented villonodular synovitis, synovial lipoma, synovial chondromatosis, and synovial hemangioma. It is difficult to confirm the diagnosis with a simple radiographic examination alone. In particular, it is important to differentiate lipoma from soft tissue malignancies such as liposarcoma and osteosarcoma. In the study by Gaskin and Helms, among the tumors suspected of liposarcoma on magnetic resonance imaging, it was reported that 64% of them were benign lipoma variants, and 18% of them were osseous or cartilaginous lipomas. Therefore, the diagnosis of lipoma accompanied by osteochondral degeneration should be made through pathological examination to differentiate it from malignant lesions. The absence of cytological atypia is a distinguishing point from malignant tumors. In the pathological findings of this patient, bone and cartilage tissue without cytological atypia was observed in the tumor composed of benign adipocytes.Lipoma accompanied by osteochondral degeneration can be confirmed as a calcified mass on simple radiographic examination, but these findings are also observed in chondroma, enchondroma, chondrosarcoma, and liposarcoma.Lipoma with osteochondral degeneration is a rare variant of lipoma that rarely occurs in the lower extremities. We encountered a case of lipoma accompanied by osteochondral degeneration that occurred in the infrapatellar fat pad, and the final diagnosis was made by pathologic examination after marginal resection. The patient had no recurrence until 2 years after the final diagnosis.Conceptualization: Wonchul Choi.Data curation: Segi Kim, Cheungsoo Ha.Formal analysis: Segi Kim, Cheungsoo Ha.Investigation: Segi Kim, Cheungsoo Ha.Methodology: Segi Kim, Cheungsoo Ha.Project administration: Wonchul Choi.Writing – original draft: Segi Kim, Cheungsoo Ha, Ah-Young Kwon.Writing – review & editing: Wonchul Choi.


An 86-year-old woman with Alzheimer disease collapsed in her nursing home and was not able to be resuscitated. At autopsy, the major findings were in the larynx where a pedunculated oncocytic cystadenoma had occluded the glottis. Oncocytic cysts or cystadenomas of the larynx are rare histologically benign lesions that account for only 0.1–1% of laryngeal lesions. While the usual presentation is of a sensation of a mass in the throat, hoarseness, or stridor, very occasionally, there may be acute airway compromise and sudden death. Oncocytic cystadenoma should, therefore, be included in the differential diagnosis of potentially lethal obstructive laryngeal lesions. An 86-year-old woman with Alzheimer disease was resident in a nursing home. She had a past history of Takatsubo cardiomyopathy, uterine prolapse, depression, and a right frontal lobe meningioma with epilepsy. She died after being found collapsed on a corridor floor.At autopsy, the major findings were in the larynx where a pedunculated 15 × 8 × 7-mm pale brown translucent cyst arose from the mid-portion of the left laryngeal ventricle  and projected upwards over the base of the epiglottis Figs. , and 3. Other findings included mild pulmonary emphysema and mild left ventricular hypertrophy and dilatation of the heart with no significant coronary atherosclerosis. Neuropathological examination of the brain identified a right frontal meningioma  measuring 46 × 28 mm which had compressed but not invaded the right frontal lobe of the brain. Only minor cortical reactive changes were seen in the brain adjacent to the tumor. Elsewhere, the brain showed changes in keeping with Alzheimer disease. There were no features of raised intracranial pressure or of tentorial or cerebellar tonsillar herniation. There were no other organic diseases present which could have caused or contributed to death and there was no trauma.Toxicological evaluation of blood revealed no alcohol, with a greater than therapeutic level of carbamazepine and a therapeutic level of paliperidone, a metabolite of risperidone. No other common drugs were detected.Death was attributed to upper airway obstruction by a laryngeal oncocytic cystadenoma against a background of Alzheimer disease and epilepsy.A wide variety of lesions and conditions may result in acute upper airway obstruction in children and adults . These mCritical swelling may also be caused by anaphylaxis or may be due to edema from burns . One of Benign tumors may also cause acute obstruction sometimes resulting in sudden death, as in a case of a polypoidal hemangioma in a previously-well 42-year-old man . PolypoiOncocytic cysts or cystadenomas of the larynx are rare histologically benign lesions that account for only 0.1–1% of laryngeal lesions . They weThe usual presentation is of a sensation of a mass in the throat, hoarseness, or stridor. Very occasionally, there may, however, be acute obstructive symptoms and as the current case shows death . This ca


Abdominal lymphangiomas are an uncommon form of congenital lymphatic malformation. We describe a case of a six-year-old male child who presented to our hospital with pain in the abdomen after an alleged history of minor trauma to the abdomen. On per abdomen examination there was a visible mass that was cystic on palpation.Abdominal ultrasound and magnetic resonance imaging showed large multiloculated, septated intra-abdominal cystic structures. The patient underwent sclerotherapy with doxycycline and resolved completely after one session without complications. Doxycycline sclerotherapy is very effective and safe in treating macrocystic lymphatic malformations. Lymphatic malformations (LMs) are vascular low-flow malformations as classified by the International Society for the Study of Vascular Anomalies (ISSVA) . LMs areAbdominal LMs can be classified based on the anatomic region as purely intra-abdominal, mesenteric, retroperitoneal, and pelvic. Symptoms vary depending on the location, size, and extent of involvement of neighboring organs . AbdominA previously healthy six-year-old boy was admitted to ER in January 2021 with a three-day history of abdominal pain and distention after minor trauma. No fever, nausea, vomiting, constipation, or change in bowel habits were reported, and there was no significant past medical or surgical history.On physical examination, he looked well and comfortable with normal vital signs. The abdomen was distended in the left upper quadrant with a palpable tender cystic mass. Ultrasound of the abdomen showed multiple large multiloculated, septated cystic structures, the largest measuring 15.48 x 4.79 cm Figures .Magnetic resonance imaging (MRI) showed the same cystic lesions involving the abdominal cavity and displacing the small bowel to the right upper quadrant Figure . The diaThe patient underwent ultrasound and fluoroscopy-guided sclerotherapy under GA and this procedure was done by an interventional radiologist. The cystic structures were targeted with an 18-gauge needle and then an 8 Fr. pigtail catheter was inserted followed by aspiration of the turbid serous content. Water-soluble contrast was injected to identify possible leak or communication with other structures, then the same amount of aspirated fluid was replaced with doxycycline mixture that was prepared to give a final concentration of 10 mg/mL. The total volume of doxycycline solution that was used was 300 mL after removing approximately 320 mL of fluid through three different pigtail catheters in three different cystic structures. There was no immediate complication. The patient had only one session of sclerotherapy and was discharged home on the same day after full recovery. The patient was seen in the clinic one week later. He was well with no active issues, and the abdomen was normal on examination.Ultrasound of the abdomen done three months after the procedure showed a small cystic structure seen adjacent to the spleen in the left upper quadrant measuring 0.5 cm. No other cystic lesions were identified. A follow-up MRI six months after the sclerotherapy showed complete resolution of the intra-abdominal lymphangiomas Figure . The patLMs are benign and usually present at birth or within the first few years of life . They arThe LM can occur anywhere in the body except in the central nervous system . Up to 7According to a study conducted on 25 patients with LM in Seoul National University Children’s Hospital from 1991 to 2011, the most common presenting symptoms were abdominal pain in 17 patients, whereas four patients presented with vomiting and four patients with palpable mass .Abdominal ultrasound is an excellent modality for initial evaluation and it is the gold standard to monitor their clinical evolution as it does not require sedation and lacks ionizing radiation. MRI may be used to confirm the diagnosis, and better identify anatomy and relation to other structures.The current primary treatment modality for macrocystic and combined LMs is percutaneous sclerotherapy . DoxycycA study conducted on 10 patients with macrocystic LM and one patient with the combined disease showed that in abdominal LM, doxycycline sclerotherapy is helpful for volume reduction and long-term symptom resolution. After therapy, many patients have no residual or noticeable LM . There aThere is no agreement in the literature regarding the choice of sclerosant in the treatment of LMs. Doxycycline appears one of the choices that promise good results with a low risk of side effects and complications, but a standard dosage or concentration is again lacking in the literature. In our case, doxycycline as a sclerosant and the used concentration were chosen in collaboration with our interventional radiologist to hopefully provide maximum results with minimum complications. Our patient had multiple giant intra-abdominal LMs and responded completely after a single session of sclerotherapy without immediate or late complications. We conclude that doxycycline sclerotherapy is safe and effective in cases of multiple intra-abdominal LMs in children.


Gallstone ileus is an uncommon condition that is difficult to diagnose clinically. Although several cases have been reported in the literature, radiolucent gallstones in the setting of gallstone ileus are an exceedingly rare occurrence, and we have not identified any authors who used magnetic resonance imaging (MRI) for the acute diagnosis of this condition. While an MRI is the gold standard for visualizing gallstones, inpatient MRIs are difficult to obtain, even in resource-rich settings. However, if given a high index of suspicion for gallstone ileus, it is pertinent to advocate for an inpatient MRI despite a resolution of patients’ symptoms due to the nature of the disease symptomology. Gallstone ileus is a rare condition caused by the impaction of the gallstone within the intestinal tract and constitutes 0.095% of small bowel obstructions . The patDue to the nature of the obstruction, it is frequently described as a “tumbling” advancement, an alternating aggravation and resolution of the ileus as the calculous moves along the intestinal lumen. Patients describe intermittent abdominal pain, bloating, and distention. However, obstructive symptoms, including vomiting, can predominate in the emergency setting .Computed tomography scans are a reliable tool and often the first imaging modality in these patients. However, in certain cases, they may not visualize the gallstone. Magnetic resonance imaging, on the other hand, is the gold standard imaging modality for radiolucent gallstones; however, in Asia-Pacific, it is infrequently used as the first-line investigation, especially in intra-abdominal surgical conditions due to scarcity and cost .Surgical management remains the mainstay of treatment, with three predominating procedures: enterolithotomy, concurrent enterolithotomy, cholecystectomy and fistula repair (in a single operation), or a two-stage procedure comprising enterolithotomy first and cholecystectomy later .This article was previously presented as a meeting abstract at the 13th International Conference on Clinical Gastroenterology & Hepatology Meeting on March 17, 2022.A 69-year-old male presented with a one-day history of epigastric pain associated with vomiting. He had no history of biliary disease or medical comorbidities and did not give a history consistent with biliary colic. Bloodwork revealed an inflammatory rise , a raised bilirubin of 38 mcmol/L, and normal liver function tests (LFT).Initial computed tomography (CT) scan of the abdomen reported findings suspicious for chronic cholecystitis and secondary cholecystoduodenal fistula, with mild dilatation of the common bile duct. CT also revealed prominent dilated loops of the small bowel with air-fluid levels and distal transition points concerning for small bowel obstruction Figure .He was initially treated with antibiotics, a nasogastric tube, and diet restriction with a plan for magnetic resonance enterography (MRE). Given delays in the MRE for logistical reasons, a gastrograffin follow-through (GGFT) study was performed the next day, showing a resolving bowel obstruction, with contrast flowing into the colon Figure . BilirubHe re-presented one day later with worsening symptoms of the right upper quadrant and epigastric pain and vomiting. Examination revealed he was Murphy’s negative but tender with a mildly distended abdomen. LFTs were again normal, with a slightly raised bilirubin of 24 mcmol/L. He was kept fasting and given antibiotics.An urgent MRE was performed showing gallstone ileus with a 25 mm calculus in the mid-small bowel and bowel obstruction Figure . It alsoThe patient subsequently underwent an exploratory mini-laparotomy revealing a dilated proximal small bowel dilatation with collapsed distal loops. Inspection of the gallbladder and liver demonstrated dense omental adhesions. An obstruction was found in the mid ileum and an enterotomy was created at the site revealing a 25 mm gallstone Figure . After tThe patient developed an ileus postoperatively, with a follow-up CT abdomen on Day 6 postoperatively revealing no bowel obstruction. After tolerating a full ward diet and reporting active bowel movements, he was managed conservatively and discharged on Day 8.On his one- and eight-month postoperative follow-up, the patient reported no new or ongoing symptoms of abdominal discomfort and tolerated a full ward diet. The patient was offered a definitive cholecystectomy and fistula repair. However, he decided not to proceed and opted to monitor and re-present to his local emergency department if similar symptoms develop.Gallstone ileus is an uncommon diagnosis and rare complication of cholelithiasis constituting less than 0.1% of small bowel obstructions . SymptomBecause of the typically vague and wide range of symptoms, imaging can be broadly prescribed. Abdominal radiographs may show pneumobilia, small bowel obstruction, and an aberrantly located gallstone, otherwise known as Rigler’s triad . The widWhile our patient displayed symptoms of bowel obstruction, blood tests and imaging were not definitive. Despite the CT suggesting a fistula, no stone was found within the small bowel and a transition point was not well-defined. Rigler’s triad was also not demonstrated on abdominal radiographs. Furthermore, his symptoms completely resolved with the administration of a GGFT, which again did not illustrate pneumobilia or an obstructing stone. Complete resolution is uncommon, and typically involves evacuation of the culprit calculus, which was not demonstrated in this case.Magnetic resonance imaging (MRI) is well-regarded as the gold standard for detecting radiolucent and isoattenuating stones otherwise missed on X-ray and CT scans . HoweverThe management of gallstone ileus is contentious. There are three main operative strategies. Enterolithotomy, concurrent enterolithotomy, cholecystectomy, and fistula repair, or a two-stage procedure to the aforementioned . Our patThis case was a demonstration of a difficult diagnosis of a radiolucent gallstone ileus with a series of negative CT and radiograph findings with a rapidly resolving bowel obstruction after GGFT. Clinicians with a high index of suspicion should advocate for inpatient MRE to confirm the diagnosis and be cognisant that the resolution of symptoms may not suggest the resolution of pathology. Enterolithotomy is safe and highly successful. Follow-up for consideration of definitive management is warranted given the risk of recurrence.


Visceral hemangiomatosis is a benign tumor (rarer than hemangioma) that has not been reported to occur in the pancreas, duodenum, or choledoch. It can be easily confused with other pancreatic tumors or choledocholithiasis. Herein, we describe a case of a child with pancreaticoduodenal and choledochal hemangiomatosis and the key characteristics for the accurate diagnosis of pancreatic tumors based on previous reports and our findings.We report a case of a 2-year and 9-month-old child who presented with repeated and fluctuating jaundice for 3 months with a history of endoscopic stone removal in a local hospital, following the diagnosis of choledocholithiasis. An abdominal computed tomography revealed a previously undiagnosed pancreatic head tumor and celio-mesenteric trunk (a rare vascular variation). This was misdiagnosed as a pancreatic neuroendocrine tumor. Since the patient’s parents refused FNA biopsy and insisted on surgery, pancreaticoduodenectomy was performed; however, postoperatively, the child was correctly diagnosed with pancreaticoduodenal and choledochal hemangiomatosis. Although the patient was in good condition and had gained 4 kg in weight 3 months postoperatively, pancreaticoduodenectomy could have been avoided if an accurate diagnosis had been established before or during the operation.Our report highlights the difficulty in diagnosing visceral hemangiomatosis. Radiologists, endoscopists, and surgeons should consider this possibility in cases of repeated and fluctuating jaundice that cannot be explained by choledocholithiasis alone. Tumors of the pancreatic head, duodenum, and choledoch cause obstructive jaundice, and surgical treatment is usually warranted. Some of these rare tumors remain undiagnosed or are easily misdiagnosed. Hemangioma is a common benign tumor that occurs mostly in the liver and spleen; however, pancreatic hemangioma only accounts for 0.1% of pancreatic tumors . FurtherA male patient aged 2 years and 9 months with abdominal pain and sclera jaundice was referred to a municipal children’s hospital from a county hospital. He was diagnosed with choledocholithiasis by magnetic resonance imaging (MRI) with liver dysfunction Fig. , Table 1Visceral hemangioma is a common benign tumor, which occurs mostly in the liver. Hemangioma is a vascular malformation, which can be divided into sclerosing hemangioma, hemangioendothelioma, capillary hemangioma, and cavernous hemangioma according to the amount of fibrous tissue it contains. Hemangiomatosis is an uncommon benign vascular malformation representing errors in normal vascular morphogenesis. Different from hemangioma, it is characterized by a diffuse excess of dilated, capillary-sized flat endothelial-lined blood vessels in normally vascular tissue. The cause of the disease is unknown; however, it may be formed by local proliferation and differentiation of some hemangioblasts that detach from the vascular network in the embryonic developmental period. Recent studies have shown that its production may be related to vascular production stimulating factors, such as basic fibroblast growth factor and vascular endothelial growth factor (VEGF) , 6. HemaVisceral hemangiomatosis may be asymptomatic or subside spontaneously. The symptoms are mostly related to the location, such as abdominal pain, melena, and anemia. It can be accompanied by some rare clinical syndromes such as Klippel–Trenaunay syndrome, Kasabach–Merritt syndrome, and Von Hippel–Lindau syndrome –9. The pIn retrospect, choledocholithiasis was likely formed by bile duct obstruction, caused by a combination of pancreatic head compression and proliferation of diffuse hemangioma in the duodenum and the lower end of the bile duct. In our hospital, an unclear boundary lesion was observed on CT, and the case was misdiagnosed as panNET. The misdiagnosis may be attributed to the inexperience of the radiologists or to the poor accuracy of CT or MRI for diagnosis. Hence, more attention was needed to differentiate hemangiomatosis from more common pancreatic tumors, such as panNET, cavernous hemangioma, and Kaposi’s hemangioendothelioma, which can be identified by key characteristics.panNET accounts for 1.3% of all pancreatic tumors . On MRI,Cavernous hemangioma is mainly composed of enlarged vascular cavities with a complete capsule. CT scans show an analogous round, solid-cystic mass with mixed density. After enhancement, it exhibits obvious marginal nodular enhancement in the arterial phase and filling progressively from margins to the center in the venous phase.Histologically, Kaposi’s hemangioendothelioma has the characteristics of both hemangioma and Kaposi sarcoma and is accompanied by Kasabach–Merritt syndrome . MRI T1 Endoscopy can help find duodenal hemangiomatosis by locating dilated blood vessels in the mucosal layer and blue hemangioma under the mucosa. Two previously reported cases , 4 showeFor pancreatic tumors, fine-needle aspiration (FNA) biopsy was suggested by some scholars . HoweverWe believe that histology is the most accurate method of diagnosing hemangiomatosis. Histologically, there are two types of hemangiomatosis. The first is a mix of veins, cavernous blood vessels, and capillaries, with thick vascular walls and small vessels forming clusters at the bulge. The other type is diffuse hyperplasia of capillaries, which appears as hyperplastic small to medium-size vessels with irregular shapes under a light microscope: compared with the first type, vascular walls are thin and may show lymphocyte infiltration. Usually, vascular markers, CD31F and CD34, are positive.A notable feature of the present case is fluctuating jaundice. Jaundice was the first symptom exhibited by the patient, with the total bilirubin level reaching approximately 164 μmol/L. Although it decreased dramatically (31 μmol/L) after endoscopic stone removal, jaundice reappeared quickly (148 μmol/L). Therefore, fluctuating jaundice can be considered the main factor that necessitated surgery. Obstructive jaundice is often characterized by stones in the bile duct or tumors in the pancreatic head, and fluctuating jaundice indicates the presence of lesions in the ampulla of Vater , 13.Surgical intervention may be needed once acute gastrointestinal hemorrhage or obstructive jaundice appears , 4. HoweIn our case, PD was performed after the diagnosis of panNET because the patient’s parents refused FNA biopsy and insisted on surgery. So far, only two cases of obstructive jaundice caused by pancreatic head hemangioma have been reported , 17  are separate, and different openings are formed. However, an anastomotic artery can persist and may be the basis of CMT development with an incidence of less than 1% .Changes in the origin of the celiac trunk can lead to variations in the LGA. Overall, the variation rate of LGA is approximately 2.8% , and LGAAlthough hemangiomatosis is a rare disease, if we can improve the level of reading imaging data before surgery or strengthen communication with the patient’s parents to perform FNA, it may be possible to establish an accurate diagnosis before surgery. Therefore, the child may avoid surgical trauma and receive better treatment. Furthermore, we consulted with an outside pathologist who recommended that this lesion should be classified as a pediatric pancreatic capillary hemangioma rather than hemangiomatosis, which is a lesion described by the WHO as primarily located in the lungs. Hence, further consideration of differential diagnosis is warranted to improve our understanding of this disease.


Coexistence of a catecholamine-secreting tumor and an adrenal cortical tumor is quite rare which makes both diagnosis and management challenging. The purpose of this article is to describe the presence of this condition, share a stepwise approach for preoperative evaluation, and review the related literature.A 44-year-old male patient had a history of hypertension and aggravating hypokalemia for years. Abdominal computed tomography incidentally found concomitant bilateral adrenal and left para-aortic tumors. Comprehensive adrenal hormone tests revealed a high aldosterone renin ratio and mildly elevated 24-h urine vanillylmandelic acid and norepinephrine levels. Subsequently, a metaiodobenzylguanidine scan showed uptake over the left para-aortic tumor, and NP-59 adrenal scintigraphy showed uptake over the left adrenal tumor. Further confirmatory tests, including captopril suppression, irbesartan suppression, and saline infusion, all confirmed the diagnosis of hyperaldosteronism. Adrenal venous sampling following 2 months of preparation with an alpha blocker demonstrated a left aldosterone-producing adrenal adenoma. Combining hormonal analysis, imaging studies, and adrenal venous sampling, the patient was diagnosed with left adrenal aldosteronoma, right adrenal nonfunctional tumor, and left para-aortic paraganglioma (PGL). Accordingly, laparoscopic left adrenalectomy and left PGL excision were performed smoothly under alpha blocker maintenance. The pathology report confirmed left adrenal cortical adenoma and left para-aortic PGL. Postoperatively, the blood pressure, biochemical tests, and adrenal hormone assays returned to normal, and related symptoms disappeared and were relatively stable during the follow-up period of two years.This is the first case of left para-aortic PGL coexisting with an ipsilateral aldosterone-producing adenoma presenting as a left para-aortic tumor associated with bilateral adrenal tumors. Awareness of the rarity of this coexistence can avoid unexpected disasters during the process of evaluation and management. Among all hypertensive patients, primary hyperaldosteronism is frequently diagnosed with a prevalence varying from 3.2% to 12.7% in primary care , the incThe incidence of pheochromocytoma and paraganglioma (PGL) has been reported to be approximately 0.6 cases per 100,000 person-years in the States  and 0.04The coexistence of catecholamine-secreting tumors and adrenal cortical tumors is quite rare and leads to not only diagnosis but also management challenges. Here, a case of para-aortic PGL coexisting with an ipsilateral aldosterone-producing adenoma presenting as left para-aortic tumor associated with bilateral adrenal tumors, following a stepwise evaluation using up-to-date adrenal diagnostic modalities that leads to a successful surgical intervention, is reported, and the related literature is reviewed.A 44-year-old male patient presented with years of hypertension since 2012) and received regular follow-up and medical treatment at a cardiovascular outpatient clinic. Some nonspecific symptoms, including chest tightness, palpitations, flushing, and bilateral leg weakness, were described. Neither headache nor sweating was complained. According to the guidelines from the National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure , indicat2 and recTo verify the hormonal function results, a MIBG scan was performed that revealed high uptake over the left para-aortic but not the bilateral adrenal tumors, indicating the diagnosis of left para-aortic PGL Fig. . For susnd postoperative day, and hypokalemia was corrected in two days. The patient was then transferred to the general ward with a stable condition on the third postoperative day.Accordingly, laparoscopic left adrenalectomy followed by para-aortic PGL excision were performed under the use of antihypertensives (spironolactone (25 mg) 1# bid, amlodipine/valsartan (5/80 mg) 1# bid, and terazosin (2 mg) 3# hs) with a preoperative blood pressure of approximately 130/90 mmHg. Operative findings showed one 2.4*2.0*2.0 cm soft homogenous yellowish left adrenal cortical tumor and one 4.5*4.5*2.2 cm para-aortic flesh tumor surrounded by renal vessels, the aorta, celiac trunk, and superior mesenteric artery , ATRX, BRAF, CSDE1, EGLN1 (PHD2), EPAS1 (HIF1α), FGFR1, HRAS, IDH1, MAML3, MAX, NF1, NGFR, RET, SDHA, SDHAF2, SDHB, SDHC, SDHD, SETD2, TMEM127, TP53, VHL, CDKN2A, H3F3A, IDH2, KMT2D, MDH2C, MERTK, and MET, using next-generation sequencing revealed no major genetic variants, although gene variants related to large genome insertion, large genome deletion, inversion, and complicated rearrangement may not be totally excluded.His blood pressure returned to approximately 120/85 mmHg with all the antihypertensive drugs being withdrawn three months after the operation. Urine VMA, catecholamine profile, and serum aldosterone, renin, and potassium levels returned to normal quickly postoperatively and have remained relatively stable. The patient had no symptoms of bilateral leg weakness, chest tightness, or palpitations during the follow-up period of two years.The coexistence of catecholamine-secreting tumors and adrenal cortical tumors is extremely rare and the manifestation of this combination requires further description. Regarding this combination, catecholamine-secreting tumors can be either pheochromocytomas or PGLs, and adrenal cortical tumors can be aldosterone-secreting, Cushing or subclinical Cushing tumors, hyperandrogenic, or nonfunctioning tumors. Regarding manifestation, the coexistence of catecholamine-secreting tumors and adrenal cortical tumors can manifest as ipsilateral or contralateral tumors, and each tumor can manifest as unilateral or bilateral. From the literature reported after 1985, there were 38 cases of pheochromocytoma coexisting with adrenal cortical tumors, including 13 cases of hyperaldosteronism –25, 8 caThe key point regarding the appropriate management of this complicated case is the challenging stepwise diagnostic approach, including the confirmation of the suspicious PGL that can mimic many presentations and the distinction between bilateral adrenal hyperplasia and unilateral aldosterone-producing adenoma– both being difficult to diagnose. Following initial hormonal screening studies, primary hyperaldosteronism was highly suspected; however, the evidence for the possible existence of a catecholamine-secreting tumor was not strong enough due to mild elevation of VMA and norepinephrine (lower than the twofold reference range). Based on the Mayo Clinic, the diagnostic cutoff point for pheochromocytoma is approximately twofold higher than the normal population reference range. Nevertheless, individuals with only mild or borderline elevations of urinary total metanephrines or catecholamines are not inappropriately labeled as potentially having a pheochromocytoma . The stuSecond, the potential risk during the evaluation process for primary aldosteronism in the presence of a catecholamine-secreting tumor, in contrast to its absence, needs to be addressed in this particular setting. PGL is a catecholamine-secreting tumor that can result in cardiac arrest, respiratory failure, or other associated diseases if treated incautiously . TherefoLastly, there are many debates regarding the necessity and number of positive confirmatory tests needed for primary aldosteronism evaluation. Various confirmatory tests may differ in terms of sensitivity, specificity, and reliability, and the choice of confirmatory test is commonly determined by considering cost, patient compliance, laboratory routine, and local expertise . The EurIn summary, we present a case of left para-aortic PGL coexisting with an ipsilateral aldosterone-producing adenoma presenting as a left para-aortic tumor associated with bilateral adrenal tumors. The rare combination and unprecedented presentation make the differential diagnosis complicated and challenging, including both the confirmation of the great mimic PGL and the distinction between unilateral and bilateral hyperaldosteronism. The preparation with the alpha blocker before adrenal venous sampling and operation afterward in this setting is also worth of emphasis.


Thrombosis of the pulmonary vein stump is a common complication after a left upper lobectomy and can be a source of embolism in various organs, such as the kidneys. A renal infarction, on the other hand, is a rare and often lethal condition that is usually diagnosed postmortem. Here, we present a case of renal infarction associated with pulmonary vein stump thrombosis after a left pneumonectomy, which was treated successfully with edoxaban.A 73-year-old man was diagnosed with squamous cell lung cancer (cT1miN0M0 stage IA1). Due to pneumoconiosis, extensive lymph node infiltration into the pulmonary artery was noted and necessitated an open thoracotomy. Ultimately, a left pneumonectomy was performed. Atrial fibrillation occurred on postoperative day 3, and the patient complained of left-sided abdominal pain. Contrast-enhanced computed tomography revealed a left upper pulmonary vein thrombosis and a left renal infarction. Anticoagulant therapy was immediately initiated with heparin and warfarin. On postoperative day 13, warfarin was replaced with the direct oral anticoagulant edoxaban since the patient’s compliance and drug response to warfarin were poor. On postoperative day 19, contrast-enhanced computed tomography revealed a reduction in pulmonary vein stump thrombosis and improvement in renal infarction. Subsequently, the patient was discharged. Three months post-surgery, no infarct lesions or reduced renal function was observed on imaging.The direct oral anticoagulant edoxaban could be effective in preventing recurrence or exacerbation of pulmonary vein thrombosis associated with renal infarction without bleeding complications. Renal infarction (RI) after lung resection is rare and sometimes lethal. In contrast, the incidence of pulmonary vein stump thrombosis (PVST) after left upper lobectomy is as high as 13.5% –4. PVST Here, we report a case of PVST associated with RI after a left pneumonectomy for lung cancer, effectively treated with the anticoagulant edoxaban.18F)-fluorodeoxyglucose (FDG) positron emission tomography. Additionally, FDG accumulation up to the maximum standardized uptake value of 6 was observed in the bilateral hilar and mediastinal lymph nodes  showed a polypoid nodular shadow in the left superior lingual bronchus  1. Atrial fibrillation (AF) occurred on POD 3, but sinus rhythm was re-established with verapamil. On POD 4, the patient began complaining of left abdominal pain. He experienced rapid increases in lactate dehydrogenase (LDH) and leukocyte levels, reaching 1129 IU/L and 13,100 cells/mcl, respectively. A thoracoabdominal contrast-enhanced CT (CE-CT) revealed left upper PVST and left RI  via a catheter. Adaptation to PTA generally takes approximately 6–12 h. However, it has been reported that, beyond 24 h after onset, there is no significant difference in the response rate between intravenous thrombolysis combined with anticoagulant therapy and anticoagulant therapy alone , 21. TypWe presented a rare case of RI that developed shortly after left pneumonectomy. Following surgery, the patient developed AF, and a CE-CT imaging investigation detected PVST. With the use of edoxaban as an anticoagulant therapy, the patient experienced a favorable clinical outcome but will require a strict long-term follow-up.


Hepatic metastases are the major determinants of morbidity and mortality in these patients, with surgery being the treatment of choice or even curative in these cases. Therefore, aggressive surgeries should be considered in patients with liver only disease. In this context, hepatectomy and metastasectomy have emerged as promising techniques for improving survival in patients with metastatic disease, also providing long-term cure. The use of liver volumetrics, tridimensional reconstructions with vessel extraction and 3D virtual surgery simulations allows better surgical planning and potentially decrease transfusions, surgery time and complications. For major hepatectomies (>4 resected segments), surgical planning with computed angiotomography and liver remnant volume calculation potentially increases the safety of surgery. We report a case in which preoperative 3D surgical simulation was crucial for conducting a safe major hepatectomy in a patient with multiple colorectal liver metastases.Colorectal cancer represents the most common malignancy of the gastrointestinal tract and the second most frequently diagnosed malignancy in adults. The most common site of metastases is the liver and 40% of patients in stage IV have liver only disease. A 57-year-old otherwise healthy male patient presented with 5 months history of change in bowel habits and abdominal pain, associated with weight loss of 10 kg. He had family history of colorectal cancer .Then, he went for a colonoscopy which showed a vegetative, friable and obstructive lesion in the distal sigmoid colon, and a biopsy was performed. The anatomopathological study of the biopsy revealed a moderately differentiated tubular adenocarcinoma .Magnetic resonance imaging (MRI) performed for staging showed an infiltrative and stenosing lesion of the middle/distal third of the sigmoid colon 8.5 cm long, with signs of transmural extension and infiltration of mesosigmoid fat up to de peritoneal reflection . , regional lymph nodes (SUV max = 26.1) and liver metastases (SUV = 21.4).A rectosigmoidectomy with colorectal anastomosis was performed. Final anatomopathological diagnosis was invasive adenocarcinoma, without angiolymphatic or perineural invasion, free margins, and no compromised lymph nodes. The surgical staging was pT3N0M1.Liver lesions were considered inoperable at diagnosis due to invasion of the three hepatic veins. It was chosen to start chemotherapy with FOLFOXIRI  for downstaging and new images were scheduled afterwards to discuss the possibility of hepatic metastasectomy.After 12 weeks of starting chemotherapy, the CEA was 4,05 ng/mL and a CT and CT-angiography for preoperative planning of liver surgery were performed with the following technical parameters: Canon Aquilion Vision 320 multislice CT scanner with triple-phase contrast acquisition , with intravenous injection of 130 ml of non-ionic iodinated contrast (iobitridol 350 mg/ml) at 4.5 ml/s rate of injection.Multiple hepatic metastases were found involving the right and left lobes, but with preserved hepatic artery and portal vein Although there was invasion of the three hepatic veins, two accessory inferior right hepatic veins were observed., with sufficient venous and biliary drainage, as well as adequate arterial and portal irrigation. While no data exist regarding the minimum amount of remnant liver following resection, most agree that 25–30 and 40% of the preoperative volume should be preserved for those with normal and abnormal parenchyma , respectively.Additionally, collateral veins responsible for draining the territory of the right hepatic vein to the accessory veins were depicted, allowing to continue with the surgical plan. It is worthwhile to mention that resectability depends on the volume of the liver remnant (after neoadjuvant chemotherapy)Virtual surgical 3D planning was created using a dedicated system , which performs automated extraction of the liver, portal veins, inferior vena cava and hepatic arteries and veins and semiautomated segmentations of the liver segments, bile ducts and tumors. Using this tool, it was possible to estimate the tumor volume, simulate the hepatectomy and liver remnant. An extended left hepatectomy and two metastasis resections (metastasectomies) in the segment VII was planned based on the automatic segmentation of the parenchyma perfused by the posterior segmental branch of the right portal vein, with estimated 32,4% of remaining liver .The patient recovered well after surgery, staying in the ICU for 2 days and was discharged from the hospital 5 days after the procedure in good general conditions, with no signs of liver failure or other complications.A decision was made by the Oncology team not to perform adjuvant chemotherapy. Clinical follow-up 6 months after surgery showed no signs of disease with a serum CEA of 2.16 ng/mL . On the other hand, the vascular anatomy of the remnant liver is an important factor in determining resectability and, therefore, an adequate surgical planning becomes decisive.Indications for hepatectomies for colorectal liver metastases are covering more and more patients, regardless of age and number of metastases.Maki et al discuss a new two-stage surgical technique in cases of multiple liver metastases near the venous confluence of the cava using virtual reconstructions in preoperative surgical planning to better assess intrahepatic venous supply and avoid postoperative liver failure.The surgical plan is based on the technical resectability of the disease to leave a reasonable amount of normal liver after resection, which is an even greater challenge in patients after neoadjuvant chemotherapy, which are often associated with hepatic steatosis.In conclusion, virtual 3D hepatectomy and metastasectomy using an automated and semiautomated tool have emerged as promising techniques for delivering personalized surgical planning in patients with metastatic disease, potentially improving safety and the chances of a curative surgical treatment.Help define resectability,Devise personalised treatment approach,Allow better surgical planning, andPotentially reduce significant intraoperative complications.Virtual 3D hepatectomy and metastasectomy using an automated and semiautomated tool:


Primary cerebral epithelioid angiosarcoma (PCEA) is a rare malignant tumor of the central nervous system. To the best of our knowledge, only three cases have been reported in the English language literature thus far.Here, we report a fourth case in a 73-year-old man admitted for headache. Radiological examination revealed a mass in the right occipital lobe, which was removed by right occipital craniotomy. Histopathological examination revealed epithelioid angiosarcoma. The patient received radiotherapy after resection but survived for only nine months due to recurrence of the tumor and his declining further surgery.In this report, we add to the knowledge base on this exceedingly rare tumor, review the small number of relevant cases published previously, and analyze and summarize the clinical and pathological characteristics, treatment options and prognosis of this cancer. Epithelioid angiosarcoma (EA) is a rare, highly malignant vascular endothelial cell tumor. It can occur in any part of the body, mainly in deep soft tissues, including the adrenal gland, thyroid gland, breast, bladder and uterus, but also in skin and bone . HoweverA 73-year-old male patient had had a history of headaches for one month, with symptoms significantly worsening 5 days before admission to hospital. On admission, results of physical and  neurological examinations were normal. Magnetic resonance imaging (MRI) indicated a mass in the right occipital lobe, with low and high mixed signals on T1-weighted (T1w) Fig. A. ImmunoEpithelioid angiosarcoma, which is a particular subtype of angiosarcoma, is a rare malignant vascular tumor . KlijaniThe etiology of epithelioid angiosarcoma is still unknown, but it has been suggested that exposure to toxic chemicals, irradiation, Thorotrast contrast agents, vascular grafts, trauma, chemotherapy, and chronic lymphedema may be implicated , 4. PathThe clinical manifestations of cerebral epithelioid angiosarcoma are related to their anatomical locations in the brain. When they occupy crucial space, focal signs may appear, accompanied by symptoms of increased intracranial pressure, including hemiplegia, headache, and vomiting. Because of the high malignancy of the tumor, the general onset time is short, and the tumors bleed easily. Of the three earlier cases in the literature, two with bleeding have been reported Table . AlthougHistological examination revealed that classical angiosarcomas  are compPCEA is difficult to definitively diagnose before surgery because of the lack of typical imaging features and the low incidence of the disease. This easily causes misdiagnosis because PCEA must be differentiated from glioblastoma and epithelioid glioblastoma, as well as metastatic tumors, melanoma, and other brain diseases. Identifying differences between these malignant tumors of the brain depends mainly on pathological examination. GFAP and S-100 are found in glioblastoma, and Olig2 and S100 are found in epithelioid glioblastoma , but notCurrently, treatment of PCEA is mainly surgical resection, supplemented by radiotherapy and chemotherapy, which can be used alone or in combination. Due to the small number of cases known at present, no optimal treatment plan can be determined at this stage. Based on the existing literature Table , it is rPCEA is characterized by a high recurrence rate at the original site, poor prognosis, and short survival time. Previous research reports have shown that the median survival time of patients with primary cerebral angiosarcoma is about one year . In the Primary cerebral epithelioid angiosarcoma is a rare malignant tumor of the central nervous system. Diagnosis by preoperative imaging is often difficult; definitive diagnosis depends on histopathological and immunohistochemical examination. The disease has a high degree of malignancy, a high recurrence rate, and a poor prognosis. After diagnosis, surgical resection is recommended as the main treatment, supplemented by radiotherapy and chemotherapy. Because of the scarcity of case reports of this cancer currently, an optimal treatment plan is lacking.


Ewing’s sarcoma is an aggressive primary malignant bone tumor that affects long and flat bones and is commonly seen in children and adolescents. The involvement of the foot especially the talus is an extremely rare entity with less than 15 cases reported in the literature. The rarity and atypical symptoms often lead to delays in diagnosis affecting the prognosis and survival. We present a 14-year-old female with pain and swelling of the left ankle for 18 months. She was being treated previously for an ankle sprain and was later suspected of avascular necrosis of the talus, before presenting to us. Clinicoradiology-pathological workup confirmed the diagnosis of Ewing sarcoma of the talus. Further, the metastatic workup revealed multiple skeletal metastases at the time of diagnosis. The metastatic lesion of the right femur required prophylactic fixation, otherwise, the patient was treated with palliative chemotherapy and radiotherapy. Ewing’s sarcoma of the foot involving the talus is extremely rare and is a commonly misdiagnosed entity, affecting the overall prognosis of the patient. A high index of suspicion and a multidisciplinary approach is imperative for its early diagnosis and definitive management. Ewing’s sarcoma (ES) is an aggressive primary malignant bone tumor that is commonly observed in the age group of less than 20 years . It is tEwing’s sarcoma commonly involves the axial and appendicular skeleton but is rarely seen in the foot especially in the talus . AlthougA 14-year-old female presented to the outpatient clinic with chief complaints of pain and swelling around the left ankle for 18 months. She had a history of a twisted ankle 18 months ago, for which she was treated conservatively. However, the pain and swelling around the ankle gradually progressed and were not relieved completely by medications. Before presenting to us, she had taken treatment for an ankle sprain and subsequently was suspected of avascular necrosis of the talus. The pain was aggravated by strenuous activities and relieved on rest. It was not associated with constitutional symptoms of night cries, weight loss, fever, etc. There was no clinical involvement of other joints. The past and family history were irrelevant. On physical examination, an ill-defined, firm, tender swelling at the left ankle joint was noted  of the ankle joint that demonstrated a heterogeneous lesion of the talus; predominantly hypointense on the T1-weighted image, and hyperintense on the T2-weighted image and fat saturation (FAT SAT) image with soft tissue extension and cortical destruction Figure . Based oFor histopathological diagnosis, an ultrasound-guided (USG) biopsy was performed which revealed a malignant round-cell tumor Figure , a. ImmuAs the primary malignant tumor was not suspected clinicoradiologically, systemic staging was performed after the biopsy. The staging was done with whole body positron emission tomography (PET)/computed tomography (CT) scan with 18-fluoro-deoxyglucose (FDG) which revealed multiple skeletal metastases  Figure .The patient became symptomatic with pain in the right thigh during the course of diagnosis. A radiograph of the right femur was performed, which revealed permeative destruction with a periosteal reaction involving the femoral diaphysis Figure , a. The The case was discussed in the institutional tumor board and, in view of extensive skeletal metastasis and a poor prognosis, it was decided to treat the patient with palliative chemotherapy and radiotherapy. Currently, the patient has received the fourth dose of chemotherapy and is under follow-up.Ewing’s sarcoma is a small round-cell tumor that can affect any part of the skeleton. It is the second most common malignant bone tumor in children younger than 20 years. It shows a predilection for males with a ratio of 1.4 to 1. It usually arises from the diaphysis or meta-diaphyseal region of the long bones. Pelvic bones and ribs are also commonly affected. Less frequent and rare locations are the skull bones, scapula, vertebra, and the small bones of the hand and feet .Foot involvement is seen only in 0.93% to 4.2% of ES, most commonly involving the calcaneum and metatarsals ,7. TalusOur review of the literature revealed a mean age of 14.4 years (range: three to 30 years), with a female-to-male ratio of 1.14:1. The most common symptom reported was ankle pain and swelling with a mean duration of symptoms of 10.76 months (range: two to 30 months). It was also noted that 42.8 % of the patient had distant metastasis at the time of presentation. Most of the patients were treated with radiation therapy &/or chemotherapy, while three patients underwent amputation below the knee and one patient underwent limb salvage.The most common symptom is pain and swelling in the ankle and around 20% of patients have an associated history of trauma , which wThe plain radiographs are often characterized by a ‘permeative’ or ‘moth-eaten’ pattern of a destructive osteolytic lesion, seen most commonly in long bones. Bone destruction is often more marked than periosteal reaction in the foot and ankle, and may have an atypical appearance that mimics a benign lesion, which was also seen in our case. The classical periosteal reaction ‘onion skin peel' is more often seen in diaphyseal tumors, as is evident in our case of right femur metastasis . The lesThe gold standard of the diagnosis is histopathology, which requires a biopsy. Although open biopsy is considered the gold standard procedure, core needle biopsy being minimally invasive provides adequate tissue in the majority of cases. Therefore, open biopsy is only required when repeated attempts at obtaining adequate tissue with core biopsy have failed. In our case, an ultrasound-guided core needle biopsy was performed and sent for histopathological evaluation. Microscopically, it is composed of sheets of small round blue cells with a high nuclear-to-cytoplasmic ratio . Ewing'sTreatment of ES depends on the stage of the disease; multimodal treatment involving radiotherapy or surgery for local control and chemotherapy for systemic control is usually recommended . In caseEwing’s sarcoma has the worst prognosis and has the shortest median time to death compared with any other osseous foot malignancy . PatientEwing’s sarcoma of the talus is extremely rare which poses challenges in the diagnosis because of its atypical location and non-specific symptoms. Delay in diagnosis often compromises treatment due to metastases and results in a poor prognosis in these patients. Therefore, a high index of suspicion is required in young children with chronic symptoms and aggressive osseous lesions on imaging. They should be thoroughly and timely evaluated to achieve a better outcome.


External inflammatory root resorption (EIRR) is one of the most undesirable potential repercussions of various types of trauma and traumatic injuries to the tooth and its structure. This detrimental phenomenon may lead to severe complications, the consequent destruction of dental tissues, and eventual tooth loss. In the presented case, following the autogenous transplantation of tooth #17 as the host-tissue replacement for tooth #18, signs of EIRR were radiographically detected after 6 months. However, the thorough preparation of root canals, which involves complete cleaning and shaping, in addition to the application of a modified combination of triple antibiotics, consisting of penicillin G, metronidazole, and ciprofloxacin (PMC), managed to arrest EIRR. Moreover, the obturation of root canals using calcium-enriched mixture (CEM) cement as the endodontic biomaterial as well as the proper management of EIRR resulted in the healing of periradicular pathosis, abatement of clinical symptoms, and finally refunctionalisation of the tooth during a follow-up period of 2 years. It seems that the appropriate disinfection of the root canal system using PMC next to the prevention of microbial recontamination using CEM cement can perfectly manage EIRR. Resorption of dental hard tissues is shown to be associated with osteoclastic cell activity , an unweFurthermore, disinfection of the root canal system as well as maximum removal of intracanal microbiota seems to be a necessity in order to achieve successful outcomes in all endodontic treatments. To reach the best possible results, achieve the optimal removal, and attain plausible eradication of intracanal microorganisms, next to chemomechanical preparation of root canals, the application of intracanal medication has been endorsed , 11. A cNumerous studies have introduced calcium silicate-based cements, such as mineral trioxide aggregate (MTA), calcium-enriched mixture (CEM) cement, biodentine, and bioactive glass, as the commonest bioactive materials for use in endodontic applications –22. CEM The prime objective of the current case is to report the management of severe EIRR due to autogenous transplantation of tooth #17 using PMC as the intracanal medication and CEM cement as the biomaterial for root canal obturation and root-end filling.A 36-year-old female patient was referred for consultation, possible evaluation, and probable retreatment of tooth #18 with an inappropriate previous root canal therapy and large periapical radiolucency shown around the mesial root in periapical radiography. The patient expressed severe pain as well as extreme discomfort in the mandibular left region during mastication and complained about a localised swelling around the abovementioned tooth.Initially, medical and dental histories were comprehensively taken, and extraoral as well as intraoral examinations were carefully conducted. In intraoral inspection, a prominent red-coloured swelling confined to a small area with no active pus discharge was seen on the left mandibular region, and tooth #18 was found to be highly sensitive to percussion. In mobility testing, mobility of grade III was seen, and in periodontal examination, the corresponding probing showed deep pockets (=9 mm) around the mesial root. Diagnostic radiographic evaluation of tooth #18 primarily showed broken instruments and large periapical radiolucency around the mesial root, involving the bifurcation area attributed to previous poor endodontic therapy . In the st treatment session, despite the healing of bone around the mesial root, the furcation and distal root seemed involved, and signs of EIRR appeared to progress; consequently, the coronal restoration was removed, proper access cavity was created, canal preparation (thorough cleaning and shaping) was performed, and the mesial as well as distal canals were medicated using PMC as the intracanal medicament to remove possible causative microbiota . Root resection was carefully performed to create an appropriate matrix (the mentioned 3 mm cavities) so as to be filled and sealed with CEM cement and thus avoid further root canal treatment. Next, CEM cement  was prepared via mixing its powder and liquid according to the manufacturer's instructions, and then, the root-end cavities were filled and sealed with CEM cement. Afterwards, tooth #17 was gently transplanted into the socket and stabilised using two figure 8 sutures in its mesial and distal aspects. After the radiographic confirmation of the procedure and the proper placement of the transplanted tooth, the patient was given verbal and written postsurgical instructions and dismissed for future follow-ups . During crobiota . The toocrobiota . The arrcrobiota .Enterococcus faecalis, a dominant microorganism in endodontic failure [In the present reported case, EIRR was caused by autogenous tooth transplantation for the replacement of a hopeless inappropriately endodontically treated tooth, whose initial signs were radiographically detected after 6 months. EIRR is reported to be the commonest type of external root resorption and may occur on various parts of the dental root. EIRR is classically defined as a resorptive lesion resulting from trauma, orthodontic treatment, or periodontal infection (microorganisms), causing an inflammatory response in PDL, leading to characterised deep resorptive defects, affecting and penetrating dentine as well as cementum, and triggering possible exposure of dentinal tubules . The lat failure . Besides failure , 31, 32. failure –35. When failure , better  failure . Further failure . The lonIn the reported case, immediate root-end filling with CEM cement was performed and canals were medicated afterwards; however, the root canals were completely obturated following initial bone and periapical healing as well as the appearance of EIRR, causing successful outcomes. The deferral in the complete obturation of root canals follows the findings investigated by Shah and Logani and Jha et al., who have shown that the healing of periapical lesions could occur without immediate obturation of root canals, provided that the radicular system is flawlessly disinfected and completely sealed , 40. NonThe presented case report was conducted over a follow-up period of ~2 years. However, the lengths of follow-ups differ from one investigation to another. In his study, Abbott gave a period of 12 to 15 months for the treatment time when interceptive management of EIRR was taken into account . Almost The outcomes of the current case report showed a possible potential approach for the arrest and treatment of EIRR using a modified combination of triple antibiotics next to root canal therapy for the maximum removal of involved microorganisms and their by-products. Nevertheless, more clinical studies and detailed evaluations of conceivable long-term consequences or complications in addition to further well-designed clinical trials are mandatory.


Giant focal nodular hyperplasia (GFNH) is rarely seen in children, presenting complex diagnostic and management considerations. Pathognomonic radiographic findings can be absent in this population, and the nuances of pathologic examination are critical. We present a child with a GFNH involving the right side of the liver arising in the background of hepatic steatosis. The details of the diagnosis and therapeutic decisions involved in his treatment are discussed. Focal nodular hyperplasia (FNH) is an uncommon diagnosis in children . LesionsA 14-year-old boy presented with abdominal pain. Abdominal ultrasonography and CT scan revealed a liver mass 21 cm in greatest dimension . The rigHistologically, the non-neoplastic liver revealed moderate microvesicular and macrovesicular steatosis with mild inflammatory infiltrate. No significant fibrosis was noted. H&E-staining of the liver mass demonstrated proliferation of well-differentiated hepatocytes displaying nodular architecture separated by bands of fibrosis highlighted by trichrome staining. Endothelialization of sinusoids was observed with an incomplete pattern of CD34 staining. Reticulin staining emphasized that most cell plates were no more than 2–3 hepatocytes in thickness. Bile duct proliferation was noted at the periphery of the nodules, best appreciated with the aid of cytokeratin 7. Glutamine synthetase (GS) staining showed a geographic pattern with hepatocyte sparing close to the fibrous band . Glypica2). Given the patient’s symptoms and the possibility of malignancy, we proceeded with right hepatectomy. The patient was discharged home on post-operative Day 9 due to rehabilitation requirements, an episode of opiate-induced delirium and a surgical wound complication (seroma). Post-operative follow-up demonstrated a normalization of the patient’s AST and ALT. After unremarkable MRIs at 3 and 6 months, the patient was discharged from clinic.The geographic pattern of GS staining coupled with the imaging findings pointed to a probable diagnosis of FNH, although well-differentiated HCC and hepatic adenoma could not be entirely excluded. The etiology of the steatosis in this patient was unclear, but it may be associated with his increased body mass index  revealed a well-circumscribed nodular lesion  and declare no conflicts of interest.