Perforation of Meckel’s diverticulum with enteroliths is a rare complication. Here, we report a case of perforation of Meckel’s diverticulum with one enterolith, which could not be accurately diagnosed by preoperative computed tomography.A 16-year-old male patient with acute onset of severe abdominal pain and a localized muscle guarding in the right hypochondrium had a solitary stone detected in the right abdomen by radiography. Abdominal computed tomography revealed a saclike outpouching of the small intestine, which contained fluid levels and an enterolith, with a mesenteric inflammatory change in the right paraumbilical area. He was diagnosed with peritonitis due to appendicitis or Meckel’s diverticulitis with enterolith, and emergency operation was indicated. The perforated Meckel’s diverticulum was identified approximately 30 cm proximal to the ileocecal valve. The diverticulum was transected at the base and removed. The patient’s postoperative course was uneventful.It is crucial for clinicians to thoroughly examine patients and appropriately request investigations that consider perforation of Meckel’s diverticulum as a possible diagnosis to facilitate prompt treatment. The German anatomist Johann Friedrich Meckel first described the embryological and pathological features of Meckel’s diverticulum in 1809 , 3. HoweA 16-year-old male patient with no prior abdominal surgery presented to our department with 2 days of abdominal pain. He complained of nausea and vomiting. He had had occasional lower abdominal pain for 7 years prior to presenting to our department. Physical examination of the patient revealed abdominal tenderness and localized guarding in the right hypochondrium. The vital signs were a bit unstable, with a blood pressure of 98/60 mmHg, heart rate of 102 beats/min, and body temperature of 39.6 °C. The blood test revealed a raised white blood cell count of 18,900/μl and a high C-reactive protein level of 4.77 mg/dl. The patient had normal renal function and a normal hemoglobin level. The laboratory findings upon admission are shown in Table Abdominal radiography showed a solitary stone with peripheral calcification and a lucent center in the right abdomen Fig. .Fig. 1PAbdominal computed tomography (CT) confirmed that niveau formation and a substance with calcification in the outer shell were observed in the extended intestine in the lower abdomen Fig. a–c. The When the operation was started with single-port laparoscopic surgery, a small amount of turbid ascites was found in the abdominal cavity Fig. a. The apThe macroscopic findings of the surgical specimen of the diverticulum confirmed a narrow-necked diverticulum lined by noninflamed small bowel mucosa containing one enterolith Fig. a. MicrosMeckel’s diverticulum is the most common congenital abnormality in the gastrointestinal tract, occurring in 2% of the population, with a 4.2 –6.4% risk of complication [Enteroliths within Meckel’s diverticulum are thought to be rare; however, the incidence is difficult to ascertain because its existence has only been documented in case reports. Primary enteroliths are thought to result from precipitation and deposition of enteric contents associated with hypomotility and stasis, whereas secondary enteroliths include foreign bodies that clump together and serve as a nidus for intestinal content deposition . It is tMeckel’s diverticulum perforation is a serious and often life-threatening complication, usually secondary to diverticulitis, gangrene, or peptic ulceration due to ectopic gastric mucosa. Other various pathologies leading to perforation are Littre’s hernia and tumors such as leiomyosarcoma, lymphatic sarcoma, and poorly differentiated stromal tumors . PerforaA symptomatic or complicated Meckel’s diverticulum diagnosis is difficult to confirm on the basis of history, physical examination, laboratory findings, and imaging because a variety of conditions mimic Meckel’s diverticulum both clinically and radiologically  . TraditiManagement of symptomatic or complicated Meckel’s diverticulum is generally through open or laparoscopic resection of the diverticulum. With respect to this specific complication, several approaches have been described, including milking the enterolith distally into the cecum or proximally into a healthy small bowel and performing an enterotomy to extract it . AlternaIf an inflammatory process is visualized on CT in the lower abdomen or pelvis, particularly at midline, or if there is evidence of distal small bowel obstruction, one should carefully search for the presence of a complicated diverticulum. If a normal appendix is identified, the likelihood of this diagnosis increases. Meckel’s diverticulum complications present with a wide range of clinical and imaging manifestations, from benign indolent findings to acute life-threatening conditions. CT findings of complicated Meckel’s diverticulum are very polymorphic and should be considered during the evaluation.


Epidermoid cyst within an intrapancreatic accessory spleen (ECIAS) is a rare disease. While the detection of solid components relevant to an accessory spleen is a key diagnostic finding, the differential diagnosis between ECIAS and malignant tumors is difficult without resection in patients with no other findings of an accessory spleen.A 73-year-old male was found to have an elevated carbohydrate antigen (CA) 19-9 level (95 U/mL) at an annual checkup, and a cystic lesion in the pancreatic tail was located by abdominal ultrasound. Abdominal magnetic resonance imaging (MRI) revealed a multicystic mass, 24 mm in diameter, which exhibited varying intensities on T2-weighted images. There were no findings suggesting solid components on contrast-enhanced computed tomography and magnetic resonance imaging. Re-evaluation of serum CA 19-9 level revealed a rapid increase to 901 U/mL, which declined to 213 U/mL 3 weeks later. Ruling out the lesion’s malignant potential was difficult, and the patient underwent distal pancreatectomy with splenectomy. Histological findings revealed an ECIAS including multiple cysts, with the mucinous component of each cyst exhibiting different stages of biological reaction; one ruptured cyst exhibited inflammatory changes.Careful observation for changes in serum CA 19-9 level and MRI findings might facilitate the diagnosis of ECIAS without a solid component by imaging studies. Epidermoid cyst within an intrapancreatic accessory spleen (ECIAS) is a rare, benign disease that does not require resection; however, most patients with ECIAS undergo distal pancreatectomy because of challenges in the accurate diagnosis without histopathological examination. Several retrospective analyses of the clinical characteristics of ECIAS suggest that the detection of solid components relevant to an accessory spleen might be a key diagnostic finding , 2, wherA 73-year-old male, who had been undergoing annual blood tests and abdominal ultrasound for more than 10 years as part of health checkups, was found to have elevated CA 19-9 level (95 U/mL) and a cystic pancreatic lesion. The patient was asymptomatic and had an otherwise normal laboratory examination. Abdominal ultrasound revealed a cystic lesion in the pancreatic tail, and a slightly hyperechoic component was detected in the cystic lesion Fig. a, b. TheRe-evaluation of the patient’s serum CA 19-9 level after the completion of imaging studies revealed a rapid increase to 901 U/mL, which declined to 213 U/mL 3 weeks later (Fig. Macroscopic inspection of the resected specimen revealed that the entire lesion consisted of multiple cysts and accessory spleen Fig. a. HistolBased on the operative and histopathological findings, the definitive diagnosis was ECIAS. The patient was discharged following an uneventful postoperative course. The CA 19-9 level was confirmed to have declined to below the upper normal limit 4 weeks after the resection.As illustrated in the present case, patients with an ECIAS in the pancreatic tail might follow a characteristic course of an abrupt increase in CA 19-9 levels, followed by a decline; this feature, which is atypical for malignancies, provides support for the diagnosis of a benign disease. One retrospective analysis revealed that approximately 60% of reported ECIAS cases were associated with elevated CA 19-9 levels , 7–9. FuThe present case also illustrates that the cystic components in ECIAS can exhibit different intensities on T2-weighted images on MRI. This finding, which has not been reported as a characteristic finding of ECIAS, can be plausible based on the histological findings of the present case. Specifically, the lesion comprised multiple cysts, including some with viscous mucin and others with organized mucin. Organized mucin in the cysts contained different properties including cholesterol clefts, macrophages, and fluid in the absence of cells and crystals. Similar findings in the cystic components have been previously reported in a patient with ECIAS . Mainly,The accurate diagnosis of ECIAS is challenging, especially in cases where there is no sign of a solid component that represents the accessory spleen by radiological evaluation. Solid components suggesting an accessory spleen on CT or MRI can be evaluated further by superparamagnetic iron oxide-enhanced MRI to confirm the accessory spleen . HoweverECIAS is a rare disease that poses a challenge for diagnosis without resection, especially in the absence of any findings suggesting the presence of an accessory spleen. However, the presence of multiple cystic lesions in the pancreatic tail exhibiting varying intensities on T2-weighted images should raise the suspicion of ECIAS. Although a high serum CA 19-9 level is observed in patients with ECIAS, we propose a close observation and re-evaluation of serum CA 19-9 levels after excluding malignancies associated with high serum CA 19-9 levels.


A 47-year-old female with metastatic cervical cancer and diverting colostomy presented with abdominal distention and minimal stool output from her colostomy. A computed tomography (CT) scan revealed a metastatic mass causing partial obstruction at the colostomy level and significant proximal colonic dilation. Her obstruction was relieved by the endoscopic placement of a metal stent through the stoma, with the stent’s distal edge visible externally but not protruding beyond skin level. Two months later, the stent remained patent and did not migrate. This case highlights a viable palliative treatment option for patients who are not operative candidates. Malignant obstruction of colostomy is a rare occurrence that is traditionally treated with surgical intervention. However, when surgery is not a feasible option, the recommendations for its management are unclear . Self-exThis case report was presented as a poster at the 2019 American College of Gastroenterology (ACG) Annual Meeting, San Antonio, Texas, and it was published as an accepted meeting presentation in The American Journal of Gastroenterology, October 2019, supplement issue.A 47-year-old female with a past history of hypertension and metastatic cervical cancer presented with abdominal distention and minimal stool output from her ostomy for two weeks duration. She described having small amounts of liquid stools which gradually decreased to the point of only mucous discharge from her ostomy. She had anorexia, abdominal cramping, and bloating with food intake, but no nausea or vomiting. Three years prior, she was diagnosed with stage IIB cervical cancer after presenting with abnormal vaginal bleeding. Her disease progressed rapidly despite chemotherapy and radiation. It was complicated by rectovaginal fistula for which she underwent laparoscopic diverting colostomy years prior to presentation. The patient had recently noted an enlarging mass near the ostomy site which was biopsied and showed metastatic adenocarcinoma of endocervical origin.On presentation, examination revealed a soft but distended abdomen with palpable peristomal subcutaneous masses. A CT scan of the abdomen and pelvis showed a large heterogeneous mass adjacent to the colostomy with both intra-abdominal and extra-abdominal components. The mass was causing compression and partial obstruction at the level of the colostomy with significant proximal colonic dilation measuring up to 8 cm in the cecum and ascending colon Figure .As a temporizing measure, a red rubber catheter was passed through the stoma to irrigate and decompress the colon. Given the extensive metastatic disease, she was not a candidate for any operative intervention, and subsequently, endoscopic stent placement was pursued.Colonoscopy was performed under moderate sedation. Examination showed a severe stenosis 4 cm in length at the surgical stoma which was traversed with the adult colonoscope. A 25 mm x 6 cm covered self-expandable metal stent (SEMS) was successfully placed with the distal edge visible externally but not protruding beyond skin level Figures , 2b.No complications occurred during or after the procedure. After the placement of the stent, her abdominal discomfort resolved. She started to have good stool output and tolerated a regular diet.She presented two months later with draining fistula tracts around the ostomy, and a CT scan showed a patent stent still in place without recurrent colonic obstruction Figures , 3b.Stoma construction is a common procedure performed in the setting of colon cancer, trauma, diverticulitis, ischemic colitis, inflammatory bowel disease, and fistulas . StenosiSEMS can be used both as a bridge to surgery or as a palliative measure in patients with a malignant colonic obstruction due to metastatic disease and unresectable colon cancer tumor. There is no data on whether SEMS has lower morbidity or mortality when compared to palliative surgery in this group of patients. There are a few case reports describing the use of either covered or uncovered SEMS for colostomy obstruction, all of which remained patent until the patients’ death 1.5 - 6 months later , 4.In conclusion, metal stent insertion for malignant obstruction of colostomy could be a viable palliative treatment option in patients who are not operative candidates. Further studies are needed to assess the effectiveness and safety of metal stents in improving obstructive symptoms compared with palliative surgery.


Background: Sclerosing epithelioid fibrosarcoma (SEF) is an extremely rare fibrosarcoma variant. There is no complete imaging data on SEF involving the pancreas. Herein we report the computed tomography (CT) and magnetic resonance imaging (MRI) data of a patient with SEF that primarily involved the pancreas.Case Presentation: A 64-year-old man was found to have a solid mass in the tail of the pancreas on unenhanced CT. He had no constitutional symptoms. Contrast-enhanced abdominal CT and MRI were performed, and the results of the latter provided the diagnosis of a pancreatic neuroendocrine tumor. Laparoscopic distal pancreatectomy and splenectomy were performed. Anatomopathological examination and immunohistochemistry confirmed that the tumor was a SEF of the pancreas. The patient had no signs of recurrence or metastasis during a 12-months follow-up.Conclusion: We report an extremely rare case of SEF in the pancreas and its characterization with CT and MRI. Sclerosing epithelioid fibrosarcoma (SEF) is an extremely rare variant of fibrosarcoma, first reported by Meis-Kindblom and grouped under low-grade fibrosarcoma in 1995 . SEF typA 64-year-old man was referred to the Department of Hepatobiliary Surgery of the First Affiliated Hospital of Wenzhou Medical University due to a solid mass of the pancreas found by unenhanced CT, with no abdominal pain, bloating, nausea, vomiting, or jaundice. The patient had a prior history of hypertension for 8 years and diabetes for more than 20 years. Routine serum tumor biomarkers, including carcinoembryonic antigen (4.9 μg/L), carbohydrate antigen 125 (CA125 7.3 U/ml), carbohydrate antigen 199 (CA199 12.7 U/ml), alpha fetoprotein serum (2.31 ng/ml), and prostate-specific antigen (0.310 ng/ml), were found by chemiluminescence enzyme immunoassay to be within normal ranges.The results of axial unenhanced CT showed the mass to be isoattenuating and barely perceptible . The conBased on these findings, on March 29, 2018, laparoscopic distal pancreatectomy and splenectomy were performed. The tumor was well-encapsulated, located in the tail of the pancreas, and close to the spleen. The size of the tumor was 1.5 cm in maximum diameter. There were no ascites and no visible metastatic nodules found in the pelvis, liver, or omentum. Upon histological staining, it was revealed that the fibroblastic epithelioid cells were ovoid and arranged in nests , cords, After 12 months of follow-up, the patient had no signs of recurrence or metastasis.SEF is an extremely rare fibrosarcoma variant that is grouped under low-grade fibrosarcomas . SEF maiSEF is histologically characterized by fibroblastic epithelioid cells arranged in cords, nests, or sheets within a collagenous extracellular matrix , 5. The The rapid development of clinical imaging has been shown to be of great value in pre-operative oncological diagnosis. No detailed imaging report on SEF of the pancreas has been published so far. Our case is the first in which the patient has both CT and MRI imaging data. The image analyses provide information regarding the size, location (head/body/tail), shape , margins (regular/irregular), density on CT  or signal intensity on MRI , and the dynamic enhancement pattern as well as the presence or absence of necrosis, hemorrhage, or cyst formation. Furthermore, it can reveal the presence or absence of vascular invasion, pancreatic or bile duct expansion, lymph node metastasis, or distant metastasis. The dynamic enhancement patterns of common tumors of the pancreas are as follows : type I,The treatment regimen for SEF has not been fully established. Surgical resection of localized tumors remains the most effective treatment for SEF . The effWe present an extremely rare case of SEF in the pancreas and its characterization with CT and MRI. Imaging is highly valuable for pre-operative oncological diagnosis.All datasets generated for this study are included in the article/supplementary material.The studies involving human participants were reviewed and approved by The First Affiliated Hospital of Wenzhou Medical University Biomedical Research Ethics Committee. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.WX performed the data acquisition. WX and YH performed the data analysis and interpretation. YY performed the radiological analysis of MRI and CT images. YH and YY performed the manuscript preparation. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Synovial sarcoma is a rare tumor to be encountered in the head and neck region and is always a challenge in terms of diagnosis, treatment, as our case.We present a 23-year old female patient with synovial sarcoma of posterolateral pharyngeal wall. The radiological and clinicopathological features along with various diagnostic tests and treatment options are discussed.The objective of this study is to describe - from a clinical case reported from our institution, and from literature review- the clinical, radiological and histological features of pharyngeal synovial sarcoma and to discuss its therapeutic management.Synovial sarcoma of pharynx is extremely a rare tumor in current practice. Synovial sarcoma is a rare malignant neoplasm that arises from the primitive pluripotent mesenchymal cells near to or remote from the articular surfaces . It commThe objective of this study is to describe - from a clinical case reported from our institution, and fromliterature review- the clinical, radiological and histological features of pharyngeal synovial sarcoma and to discuss its therapeutic management.2A 23-year old female patient reported to the Department of Head and Neck surgery, with a chief complaint of cervical algia and left otalgia sinceone year. Patient also gave a history of mouth breathing, snoring, dysphonia and dysphagia associated with taking solid foods over the last 4 months. All evolving in a context of weight loss without been unencrypted.During initial clinical examination, on inspection, a huge circumscribed growth at the posterolateral wall of pharynx. The swelling was covered by normal mucosa . The exaPanendoscopy showed a regular bulge of the posterolateral wall of the oropharynx and the hypopharynx, approximate size 6*6 cm, without laryngeal involvement, covered by normal mucosa, and it was firm, well limited, and non tender on palpation.The scan of face and neck revealed aheterogeneous mass of the left paropharyngeal space and retropharyngeal of the oropharynx6 cm wide, evoking a necrotic tumor .Fig. 2ThThe biopsy after incision of the mucosa objectified a fusocellular mesenchymal proliferation  on slideBased on clinical examination, histopathological examination with IHC and radiological interpretation, the diagnosis of soft tissue sarcoma of the posterolateral pharyngeal wall was made.The extension assessment includes a chest CT scan, abdominal ultrasound and bone scintigraphy, shows no evidence of any metastatic lesion.The patient was put under chemotherapy while waiting for radiotherapy according to the decision of the multidisciplinary staff. The evolution was marked by the installation of typical respiratory symptomatology: dry cough, chest pain and dyspnea at rest, after the 2nd course of chemotherapy. The thoracic CT showed multiple metastatic lesions. So, the patient was put on palliative chemotherapy.3Sarcomas of the head and neck are rare, accounting for only 1 % of all head and neck malignancies . SynoviaSynovial sarcoma is an intriguing entity owing to its rarity, controversial origin, challenging diagnosis and restricted treatment protocols It is frequently misdiagnosed as a benign lesion due to its smooth margins, an associated cystic component and lack of aggressive infiltration . Ithas bThe tumor usually occurs as an asymptomatic mass until it attains sufficient size to cause pressure effects on neighboring structures. This process is usually more rapid in head and neck Synovial sarcoma than those in the extremities . HistopaSynovial sarcoma of head and neck has an aggressive nature and a guarded prognosis .A multidThere was also no statistical significant difference when comparing the different therapy modalities used: surgery vs. surgery with radiotherapy alone vs. surgery with chemoradiotherapy . AdjuvanLocal excision is followed by high recurrence rates (60–90 %), usually within 2 years. Daveau et al. study supports the use of adjuvant radiotherapy as it improved the overall survival rates with few recurrences in patients in whom the primary tumour was treated with surgical resection and radiotherapy ,16. Role4Synovial sarcoma of pharynx is extremely a rare tumor in current practice, it is also a difficult tumor to be diagnosed beside that Literature presents with few cases with no universal consensus for treatment which makes the challenge.The authors declare having no conflicts of interest for this article.None.I declare on my honor that the ethical approval has been exempted by my establishment.Written informed consent was obtained from the patient for publication of this case report and accompanying images.Chaker Kaoutar: Corresponding author writing the paperAhmed Brahim Ahmedou : Corresponding author writing the paperYoussef Oukessou: study conceptSami Rouadi: study conceptReda Abada: study conceptMohamed Roubal : correction of the paperMohamed Mahtar : correction of the paperresearchregistry2464Dr Ahmed Brahim AhmedouDr Chakir Kaoutar.


Fecalith is a concretion of dry compact feces or hard stony mass of faeces in the intestinal tract. Though appendicular fecoliths are commonly encountered, caecal fecoliths are rare entities. Fecoliths are amenable to conservative management with laxatives and enemas but surgical management prevents recurrence. We present a case of 27 years old male who was diagnosed with acute appendicitis with peritonitis. He was intraoperatively diagnosed as gangrenous and perforated retrocaecal appendix with multiple small fecaliths and a large fecalith on cecum with perforation. Appendectomy and primary repair of caecal perforation done. Histological examination of perforated margin confirmed as an inflammatory lesion. The pathophysiology of fecalith formation is usually related to slowed peristalsis of the lower GI tract, dehydration and low fiber diet intake. Fecal impaction if left untreated can lead to the hardening of stools and the formation of fecalith. Caecal fecalith causing acute appendicitis has not been reported in the literature.2 Here, we present a rare case of giant fecalith causing caecal perforation and with multiple small fecaliths causing appendicular perforation.Fecalith of the caecum is very rare and may present as a mass in the right iliac fossa which may be mistaken for a carcinoma.A 27 years old male presented in the Emergency Department with a chief complaint of pain abdomen for 4 days and fever for 1 day. Pain abdomen was initially on the paraumbilical region later migrated to right iliac fossa and was localized. Pain was acute in onset, dull in nature, no aggravating and relieving factor and severity of pain is moderate to severe. For last one day pain was generalized. He had a history of nausea and vomiting three episodes which contained food materials. He also complained of fever, the maximum temperature recorded was 101 degrees Fahrenheit not associated with chills and rigor. He had not to passed stool for 4 days but had normal bladder habits. There was no significant medical and surgical past history. On examination, vitals were within the normal range. Per abdomen, examination showed generalized guarding and bowel sound was absent.Investigation showed leukocytosis and neutrophilia. USG abdomen and pelvis showed features suggestive of acute appendicitis. Based on the above finding diagnosis of peritonitis secondary to perforated appendicitis was made and planned for exploratory laparotomy with appendectomy. The intraoperative finding was around 250 ml of purulent fluid mixed with fecal content, acutely inflamed gangrenous perforated retrocaecal appendix with multiple small fecalith and perforation of cecum at anterior aspect 2cm distal to the base of the appendix with 2×2 cm fecalith .Fecolith was extracted  and caecThe culture of peritoneal fluid showed Pseudomonas Aeruginosa. Histopathology of the perforated margin of cecum and appendix showed inflammatory features.2 If the accumulation of faecal matter is slow and desiccation is fast then the mass becomes hard and dry and is called a fecalith.3 Appen- dicoliths  are descrete, hard but crushable, mostly ovoid, brown concretions within the appendix; They are often concentrally laminated and frequently calcified.5 Our case illustrates that fecalith can have an extremely rare presentation in the caecum. The fecalith caused the intestinal obstruction which explains not passing stool in our patient. An increase in intra-abdominal pressure caused by the fecalith decreases capillary perfusion and can lead to ischemic necrosis.6 This explains the inflamed gangrenous perforated retrocaecal appendix and perforated caecum.The first detailed description of an appendicolith was by Wegeler in 1813.7 Blotner reported a case of perforation of cecum caused by a fecalith trapped in a cecal haustration.8 Walker reports two cases of caecal fecalith presenting as a mass in the right iliac fossa and found audible borborygmi in his case but in our case bowel sound was absent.3 An unusual case of caecal perforation in a child due to caecal fecalith was reported by Simpkin and Lakhoow in which they found perforated caecum but normal appendix.9 However in our patient we found perforated caecum and perforated appendix.This case is an adult man with fever and pain in right iliac fossa who was diagnosed as acute appendicitis with peritonitis. Caecal fecalith might have obstructed the appendix orifice and resulted in acute appendicitis. Peritonitis resulted due to perforated appendicitis. Perforation of caecum is an uncommon differential diagnosis for an acute appendicitis.9In our case we refreshed the margin of wound and sutured it. The treatment of our patient similar treatment done by Simpkin and Lakhoo.1 This complication challenges the surgeon because of the wide range of issues that need to be considered for establishing the etiology and therapeutic strategy.10 So Fecalith of the caecum has to be surgically removed as it cannot be removed by conservative measures.Although the fecalith of the caecum is rare, it has to be considered in the differential diagnosis of the right iliac fossa pain. The complication of the fecalith of the caecum can lead to iliocolic intussusception.JNMA Case Report Consent Form was signed by the patient and the original article is attached with the patient's chart.None.


Fibroepithelial lesions of the breast are commonly encountered tumors comprised of stromal and epithelial components. Fibroadenoma and phyllodes tumor are both fibroepithelial lesions, but their management differs. Phyllodes tumor requires surgical excision, whereas fibroadenoma requires no further workup. Both have many overlapping histological features making it difficult to distinguish between a benign fibroadenoma versus the more aggressive phyllodes tumor. This case details a breast mass that was initially believed to be a fibroadenoma, but interval growth at one year follow up resulted in surgical excision with final pathology revealing phyllodes tumor. Fibroepithelial lesions of the breast occur in approximately 10-15% of women , 3. PhylA 64-year-old woman with a past medical history of type 2 diabetes mellitus and hypertension presented for her annual bilateral screening mammogram. The patient reported no relevant family, medical, or surgical history. Screening mammogram images of the left breast demonstrated a 17 mm oval-shaped mass with circumscribed margins at the three o’clock position in posterior depth, 13 cm from the nipple . A fibroadenoma is the most common solid breast mass in a woman under the age of 30 but can be seen in older women as well.The factors that significantly helped to identify phyllodes tumors upon univariable analysis consisted of the presenting symptoms , increased size on clinical examination, hyperdense mass on the mammogram, and the following three ultrasound features: heterogeneous echogenicity, presence of round cysts within the mass, and presence of clefts within the mass. The pathologist's suggestion of a phyllodes tumor is also helpful. The symptoms of breast pain, the presence of clefts on ultrasound, the presence of round cysts on ultrasound, and the pathologist favoring of phyllodes tumors from a core needle biopsy specimen are factors that remained statistically significant upon multivariable analysis .Ultrasound findings (clefts and round cysts), suggestive pathological diagnoses, and clinical symptoms are all useful for the decision to surgically remove fibroepithelial lesions diagnosed from the core needle biopsy.This case shows the challenge of distinguishing a fibroadenoma from phyllodes tumor on both breast imaging and tissue analysis. In cases where the pathologist reports fibroepithelial lesion and cannot definitively call fibroadenoma on a core needle biopsy sample, a radiologist can help diagnose phyllodes tumor earlier by recommending surgical excision immediately for patients over 40 years old or by recommending short interval follow up imaging in six months to detect interval growth.


Differential diagnosis of retroperitoneal masses may become complex and requires careful anamnesis, physical examination and several complementary tests. We present the clinical case of a male patient aged 45 years who was diagnosed with a 4cm paraaortic lesion compatible with neuroendocrine tumor in the abdominal computed tomography (CT) exam. The workup performed with SPECT-CT, somatostatin receptors scintigraphy, MIBG scintigraphy, 24-hour urine total and fractionated catecholamines and 24-hour urine 5-OH indoleacetic did not confirm the first diagnostic impression. Finally, the lesion was biopsied and presence of micro-organisms was revealed. Further exams confirmed schistosomiasis as the cause of the paraaortic lesion. Histological diagnosis can be helpful with regard to the differential diagnosis of retroperitoneal masses. Retroperitoneal masses constitute a heterogeneous group of lesions, originating in the retroperitoneal space, that pose a diagnostic challenge with view to histology and malignant potential . The majSchistosomiasis is a parasitic disease very common in tropical and subtropical areas, particularly in the African continent and relatively rare in western countries . Its pseA 45-year-old Caucasian male patient was referred to our clinic of endocrinology, because of an incidental finding in a CT scan, suggestive of paraganglioma, performed in the work up for abdominal pain. The abdominal CT scan revealed a 4cm nonspecific retroperitoneal, paraaortic lesion, between celiac trunk and superior mesenteric artery, suggestive of neuroendocrine tumor as the first possibility . He had Trypanosoma cruzi; cytomegalovirus; Ac HBs; Ag HBs; Ac HBc T; HIV 1 + 2; Toxoplasma gondii; Entamoeba histolytica; Echinococcus granulosus; Taenia solium (IgG); Leishmania spp.; strongyloides and schistosoma. All results were negative and do not showed acute infection, except schistosoma with IgM and IgG positive.After multidisciplinary discussion, it was decided to perform a CT-guided biopsy of the lesion . MicroscBased on the results obtained in the serological tests, a schistosoma infestation (schistosomiasis) was diagnosed and praziquantel was prescribed. During the follow-up the patient referred remission of the abdominal pain and a CT control one year later showed a shrink in size of the paraaortic lesion.The retroperitoneum is the part of the abdominal cavity that lies between the posterior parietal peritoneum and transversalis fascia. The majority of retroperitoneal masses arise from retroperitoneal organs and are therefore not considered primary retroperitoneal masses . PrimaryThe clinical manifestations of retroperitoneal masses are nonspecific, depending on their location and relation with the adjacent structures. These masses are usually diagnosed as an asymptomatic incidental impalpable tumor . AlthougParaganglioma is a rare NET ,9. On crBiochemical testing of urinary and/or plasma fractionated metanephrines and catecholamines is indicated for all paragangliomas, even if clinically non-functional . RadioloDue to the inconclusive results of the workup, the final pathology could only be confirmed with histological examination. There is a concern regarding core biopsies of retroperitoneal masses. A biopsy is contraindicated in a patient suspected of having paraganglioma unless the results of biochemical screening for catecholamine secretion are first negative or the patient is prepared with alpha-adrenergic blockade, because otherwise it can cause severe hypertension from catecholamine crisis. In patients suspecting malignant tumors was though that biopsies of these lesions led to frequent seeding of the tumors, but more recent studies confirm that this risk is extremely low ,16. A coSchistosoma mansoni, S. japonicum and S. haematobium. The first two cause intestinal tract disease, while S. haematobium causes genitourinary tract disease [Schistosomiasis is the second most frequent parasitosis after malaria. The three major species are  disease . Most in disease .Manifestations of acute infection are generally observed among individuals not living in endemic areas, such as travelers. Manifestations of chronic infection are generally observed among individuals with ongoing exposure in endemic regions. Disease is caused by the host immune response to migrating eggs leading to an eosinophilic granulomatous reaction . DiagnosSchistosoma mansoni is infrequent and can clinically simulates malignant neoplasms. The preferential site is the large intestine, at the level of the sigmoid colon and of the rectum (over 60% of cases) [Schistosoma mansoni. Another type is characterized by a diffuse fibrosis associated or not with the large number of eggs of Schistosoma mansoni, usually calcified, with a little tendency to form granulomas [The pseudotumoral form of f cases) . The mosanulomas . Treatmeanulomas .The finding of a retroperitoneal mass presents many challenges not least of which are the relative rarity and the myriad of diagnostic possibilities. Careful analysis of the history and physical examination may give a clue for the diagnosis. However, most retroperitoneal lesions will not have an obvious diagnosis based on clinical presentation, and will require further careful investigations. Serum catecholamines or tumor markers may point to a specific tumor but good quality imaging either with contrast-enhanced computed tomography scans or magnetic resonance imaging may reveal a characteristic pattern that points to a clear diagnosis. In many cases only the histology examination will provide the final pathology.


Anal cancer is a rare cancer with chemoradiation being the mainstay of treatment for locoregional presentation. In North America, the most common subtype is anal squamous cell carcinoma (epidermoid). A surgical approach is considered for persistent or recurrent anal disease and systemic chemotherapy for metastatic disease. We are presenting a unique case of recurrent anal cancer with isolated peritoneal malignancy, an oligometastatic state which is rare in itself. It was treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. There are currently no clear guidelines for the aforementioned presentation. The discussion drew on the feasibility and safety of this approach.A 68-year-old woman diagnosed with an epidermoid anal cancer (stage 3B) was initially treated with chemoradiation therapy (Standard Nigro Protocol) in 2014. At the 5-year mark post-treatment, she was diagnosed with a recurrent anal epidermoid cancer in the form of isolated peritoneal carcinomatosis proven by biopsy. After declining systemic chemotherapy, she underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy with Mitomycin-C©. Peritoneal carcinomatosis index was evaluated at 10, and intraoperative frozen sections were positive for carcinoma of epidermoid origin compatible with anal cancer. A completeness of cytoreduction score of 0 was achieved during the cytoreductive surgery, and her hospital course was unremarkable. She remains disease-free 12 months later.To our knowledge, this is the first case reporting the disease presentation of anal cancer with oligometastatic dissemination to the peritoneum. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy were performed. Thus far, this approach seems to be a safe and feasible option for short-term control of the disease. Anal cancer (AC) is a rare malignancy which accounts for 0.5% of all new cancer cases and represents 2.7% of all gastrointestinal (GI) cancers , 2. In NA 68-year-old woman was diagnosed with poorly differentiated, human papillomavirus positive, basaloid SCC  and treated with CRT  in 2014 at another healthcare institution. The tumor was located at the proximal anal canal, without extension to the external anal sphincter or intersphincteric fat, and it did not reach the peritoneal reflection  scan done 4 months earlier at the referring institution revealed multiple hypermetabolic pelvic peritoneal nodules. The largest and most intense nodule was anterior to the left common iliac artery measuring 1.8 cm. An abdominal-pelvic computed tomography (CT) also described these prominent pelvic implants, the first and largest at the left common iliac chain measuring 2.6 × 2 cm, with a smaller second satellite lesion (1 cm) located inferiorly. The third implant lay anterior to the mid-sigmoid colon and posterior to the uterus (2.5 × 1.6 cm). The fourth implant was located lateral to the uterus and medial to the sigmoid colon (0.8 cm).In light of these results, a full diagnostic work-up was undertaken to investigate the probable recurrence of her AC. At this point, the patient had not received any local or systemic treatment before being referred to our group, and no tissue biopsy had been obtained. A new PET scan study done in our institution reported a mild progression of the nodules, with a dominant implant still along the left common iliac chain Fig. . There wA diagnostic laparoscopy, colonoscopy, and complete anal and gynecological examination were performed under general anesthesia as part of the work-up. The anal canal and the inferior portion of the rectum were normal. A formal vaginal examination was impossible because of a stenosis secondary to prior radiation therapy, but the accessible vaginal mucosa was soft and normal. During the colonoscopy, biopsies were taken in the anal canal and were all found to be negative. Biopsies of peritoneal implants (parasigmoid and left pelvic) confirmed the diagnosis of metastatic epidermoid AC with basaloid traits. Moreover, immunochemistry studies were positive for CK5/6 and P40 markers, hence reinforcing the proposed diagnosis of recurrence of her initial 2014 epidermoid AC.The patient’s chart was subsequently discussed at the institution’s tumor board and among international experts. The patient hesitated for several months to undergo surgery or to have systemic treatment. A PET scan in early November 2018 demonstrated a slight progression of peritoneal carcinomatosis (PC) with no other lesions reported. Management options were discussed with the patient and her family. After declining systemic chemotherapy, she agreed to undergo CRS with HIPEC to address her recurrent AC.The patient underwent surgery 1 week later. A midline laparotomy was performed, and the peritoneal cavity was thoroughly inspected for all sites of metastatic disease. The peritoneal carcinomatosis index (PCI) was evaluated at 10. The patient underwent complete CRS including an omentectomy, ileocecal resection, anterior resection of the recto-sigmoid colon to address nodules on the mesentery, and on the wall of the sigmoid colon, as well as a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The remaining nodular implants were also removed at the angle of Treitz, on the small bowel mesentery, on the right retroperitoneum, and in the pelvis. Intraoperative frozen sections were positive for epidermoid carcinoma, hence compatible with the initial AC. A completeness of cytoreduction score (CC) of 0 was achieved during the CRS (disease completely resected). After completion of intestinal continuity, a closed-technique HIPEC was performed with Mitomycin-C© (fixed 20 mg) at 42 °C for 90 min. The surgery was well tolerated, and the patient was transferred to the post-anesthesia care unit in a stable condition. Her post-operative course was unremarkable, and she was discharged on post-operative day 17. The final pathology report of the peritoneal implants was positive for poorly differentiated basaloid SCC. Since the patient had already refused systemic chemotherapy preoperatively and was now considered disease-free, she was not given adjuvant therapy. She was followed at the outpatient clinic every 4 months with a physical exam and alternating CT scans and PET scans. At 12 months, she remains disease-free, with no sign of recurrence at the last PET scan study.Anal cancer is a rare condition, and CRT is the mainstay treatment for locoregional disease. Stage I/II ACs have a 5-year relative survival rate of 80% . A studyOligometastatic disease is a particular presentation of anal SCC, and recent literature has demonstrated that organ-directed therapies in carefully selected patients may offer long-term disease control , 13. A mTo our knowledge, this is the first case reported in the literature of recurrent epidermoid AC with PC treated with CRS and HIPEC. CRS ± HIPEC is a standard treatment for primary peritoneal surface malignancy (PSM), as well as PSM arising from colorectal and appendicular cancers, including pseudomyxoma peritonei –19. ThisThe exact mechanism for peritoneal dissemination of anal SCC is unknown. Peritoneal metastases usually develop from intra-peritoneal cancer origins, which are almost always adenocarcinomas. A few cases of SCC from other sites  have been reported in the literature, without clear explanation for such an uncommon metastatic pattern . AdvanceAnal cancer with oligometastatic dissemination to the peritoneum is a very rare disease presentation. Although this is the first case reporting such an approach for this etiology, CRS and HIPEC seem to be a safe and feasible option, at least for short-term control of the disease.


Synovial sarcoma is a mesenchymal high grade tumor. It is found in soft tissue mostly lower extremities. It is rarely found in the head and neck area with paraspinal neck accounting for the most common location. In rare occasions, it can be found in nasal cavity.A 46-year-old female patient presented with recurrent epistaxis for 7 months. A 0-degree rigid scope examination revealed a left nasal cavity mass. A non-contrasted CT scan of the paranasal sinus showed heterogeneous and hypodense lesion in the left nasal cavity. Functional endoscopic sinus surgery was performed and multiple nasal-mass biopsies were taken which showed high grade spindle cell sarcoma favoring synovial type. Further workup and management were done from MRI, cranial tumor resection with skull base reconstruction to adjuvant radiotherapy. Patient has regular follow up with involved specialties and thus far is doing well.Spindle cell synovial sarcoma is a rare lesion found in soft tissue. It is unusual to be found in nasal cavity. Thus crucial attention to the clinical, radiographical and histopathological manifestation should be taken for more accurate diagnosis and further appropriate management. It is a rare tumor that is unlike its name not related to synovial membrane. It is mostly found in lower extremities. It accounts 5–10% of all adult sarcoma. Around 5–15% of synovial sarcoma can be found in head and neck areas.It is considered as a high grade malignant tumor. The paraspinal neck accounts for the most common location of this neoplasm in the head and neck region.However, it could also be found in nasopharynx, oropharynx and thyroid gland in some cases with rare occasions found in nasal cavity and maxilla. No gender predisposition was found in synovial sarcoma. However, it seems to affect patients mostly in their third decade. Presenting symptoms are mostly determined by location of tumor. Management depends mostly on surgical resection with consideration of radiotherapy. Prognosis of head and neck synovial sarcoma has similar rates of all sarcomas with a 5 year-survival rate reaching up to 50% .This project has been reported according to the SCARE criteria .2A 46-year-old female, known case of rheumatoid arthritis on Methotrexate, hypothyroidism on Levothyroxine and unremarkable surgical history referred to otolaryngology clinic as a case of recurrent epistaxis from the left nostril for the last 7 months, required nasal packing at one point. Her chief complaint was associated with hyposmia, nasal discharge, nasal obstruction, left ear fullness, mouth breathing and dryness. She had intentional weight loss, insignificant for the past 3 months, decrease in appetite with on and off night sweat.She had unremarkable family history except of a sister with breast cancer. She had no known allergies. Upon examination, 0-degree rigid nasal scope was used and showed an easily bleeding swelling. It was blocking the left nostril with difficulty in determining its origin whether it was from the septum or lateral nasal wall. Scope through the right side revealed patent nasal cavity and clear nasopharynx.Urgent sinus computed tomography (CT) revealed large left nasal cavity heterogeneous and hypodense mass with faint central enhancement. It was seen extending to the left maxillary sinus, with opacification of anterior ethmoid air cells and left frontal sinus and widening of the left osteo-meatal unit. It showed as well severe thinning of the left maxillary sinus wall, nasal septum and inferior left orbital wall with possible dehiscence of the left lamina papyracea, bilateral cribriform plate and medial part of the fovea ethmoidalis with clear nasopharynx .Fig. 1PrPatient underwent examination of nasal cavity under general anaesthesia and debulking of the left nasal mass. Left nasal cavity was completely obstructed with a nasal mass, its origin could not be identified precisely but it was seen below and separable from the middle turbinate. It seemed attached to the inferior turbinate and to the nasal septum. Multiple biopsies were taken for histopathology and debulking was done using a debrider and forceps until reaching the nasopharynx which was clear from any obstruction. After that, left middle sac was opened through the natural ostium which revealed some secretions.On histological examination, the biopsy showed monotonous population of plump to spindle cells with indistinct cytoplasm and oval dark stained nuclei, arranged in solid sheets and short fascicles. These are alternating with less cellular areas showing myxoid change and perivascular hyalinization  A&B. ThePatient was later admitted for full workup of left nasal high grade spindle cell sarcoma. Sinus magnetic resonance imaging (MRI) revealed left nasal cavity mass expanding to the left frontal recess with extension to the left frontal sinus. The lesion showed involvement of the left lamina papyracea and cribriform plates with small extension to the left intra-orbital compartment. The lesion showed an intermediate to low signal lesion in T2 weighted images with heterogeneous enhancement. It was approximately 3 × 2.7 × 3.5 cm in dimension . Neck CTPatient’s clinical, radiological and pathological results were discussed in tumor board. Final decision with medical oncology, radiation oncology, and neurosurgery was to go for surgery followed by adjuvant chemoradiotherapy.Rheumatology advised to stop Methotrexate 2 weeks prior to surgery.Patient underwent anterior cranial tumor resection, bicoronal craniotomy and skull base reconstruction, by otolaryngologist and neurosurgeon.Left external ethmoidectomy, left medial maxillectomy, bilateral sphenoidotomy were performed with ligation of the left anterior ethmoidal artery. lamina papyracea and periorbital fat on the left side were resected. The nasal septum was separated from the face of sphenoid and maxillary crest with anterior preservation of the nasal caudal septum. Bicoronal incision, pericranial flap and frontal craniotomy were performed. Resection of the tumor from the anterior cranial fossa was done; at the area from the right cribriform plate to the left fovea ethmoidalis, anterior to the level of crista galle and posterior to the face of sphenoid. Left temporalis muscle fascia was harvested to reconstruct the left periorbital area.Post operation, patient was kept intubated in the intensive care unit (ICU). CT done day one post operation and revealed no intracranial haemorrhage . PatientPatient was discharged home on second week after surgery with normal facial nerve and vision, healing wound and stable condition. She was given follow up with otorhinolaryngology, neurosurgery, medical and radiation oncology and rheumatology.Patient completed full course of adjuvant radiotherapy with monthly follow up in otorhinolaryngology clinic for debridement and examination.Seven months post-operation, findings using 30 degree rigid scope revealed healed nasal cavity mucosa except for a small frontal area with no water discharge.Patient is following on regular basis with new MRI every 4 months with no evidence of local recurrence .Fig. 5Po3Synovial sarcoma is a mesenchymal spindle cell tumor found in soft tissue and unlike its name is not related to synovial membrane. It originates from embryogenic mesoderm ,5. It isIn literature, synovial sarcoma is described as a high grade malignant tumor with the paraspinal neck being the most common location of this neoplasm in the head and neck region. Nevertheless, it could also be found in the nasopharynx, oropharynx and thyroid gland in some cases with rare occasions found in nasal cavity and maxilla similar to our presented case.Presenting symptoms are mostly determined by location of tumor . Reddy eNo specific etiology has been attributed to the development of synovial sarcoma. However, radiation exposure was found to have an obvious association .A spectrum of histopathological variations of synovial sarcomas have been described from monophasic, biphasic to poorly differentiated ones and many others ,2,6. CatDiagnosis of similar cases is mostly done by radiographic images of paranasal sinus CT. Further diagnostic tools such as MRI and histopathological examination are needed to confirm the diagnosis and rule out further extension.The differential diagnosis of tumors in this location includes rhabdomyosarcoma, Ewing sarcoma, malignant peripheral nerve sheath tumor and melanoma, which are less likely in the presented case based on the histology and immunoprofile status.The mainstay treatment of a nasal and other head and neck synovial sarcoma is total excision of the lesion by different modalities with consideration of chemoradiotherapy. Surgical approach depends on tumor location and its extension varying from direct endoscopic resection to craniofacial approaches. Diaz et al’s case of nasal synovial sarcoma was approached by complete endoscopic resection of the mass, ethmoids, medial walls of maxillary sinuses, anterior and medial walls of sphenoid sinuses and orbital extension of the tumor ,3. No reThe role of adjuvant chemoradiotherapy varied in literature. Saito et al. reviewed 11 cases of head and neck synovial sarcomas, seven of which had adjuvant radio and/or chemotherapy with no reported therapeutic response . HoweverPrognosis of head and neck synovial sarcoma depends on size, location and extension of the tumor. Nevertheless, it was found to have similar rates of all sarcomas with a 5 year-survival rate reaching up to 50% .4Synovial sarcoma is a rare mesenchymal synovial tumor found in soft tissue. The case presented here highlights an especially rare situation of this tumor involving nasal cavity synovial sarcoma with presenting symptom of recurrent epistaxis. It stresses on the importance of early detection of this tumor for better management. Thus, it is crucial to be aware of the clinical, imaging and histopathological features of this tumor in head and neck for better diagnosis and treatment of the variable craniofacial neoplasm. Furthermore, reporting of this rare tumor should be encouraged for further more accurate epidemiological, clinical, management and prognostic data.No conflicts of interest.No source of sponsorship.Research has been approved by the Research Ethical Committee of King Abdullah International Medical Research Center.Consent was taken from the patient for publication purposes.Salwa AlRashed ALHumaid: Data collection, data analysis & interpretation and writing the paper.Mohammad Almahdi: Study concept & design, data collection, data analysis or interpretation, writing the paper.Maryam Alsafi: Data collection, data analysis & interpretation and writing the paper.Fahad ALObaid: Data analysis & interpretation and writing the paper.Alaa Alsalim: Data analysis & interpretation and writing the paper.Non Applicable.Mohammad Almahdi.Salwa ALRashed ALHumaid.Not commissioned, externally peer-reviewed.


A 31-year-old male amateur bodybuilder presented with a 2-year history of chronic pain over the sternum and a clicking sensation in the chest wall on movement. Ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) showed no cause for his symptoms. Dynamic ultrasound scan performed at a specialist sports center revealed pseudoarthrosis of the manubriosternal joint (MSJ). After a period of conservative management , he failed to improve and underwent debridement and fusion of the MSJ with plates and screws. At follow-up 23 months later, he remains pain-free and has returned to weight lifting and bodybuilding. Motor vehicle crashes and chest seat belt restraints are the most common causes of sternal fracture. Reports of sternal injury among sportsmen and athletes are less common, however, with fracture resulting from non-contact trauma described in only sporadic cases in the literature –5.While surgery for sternal fracture after acute trauma is rare, surgical repair of painful chronic non-union after sternal fracture has been described , as has We describe the management of painful manubriosternal joint (MSJ) disruption in an amateur weight lifter and describe the challenge of diagnosis, pitfalls in imaging, and a technique of repair to render the patient symptom-free and able to resume his hobby.A 31-year-old man, a bodybuilder, presented with a 2-year history of chronic sternal pain and clicking on movement. On examination, he appeared pain-free and had an athletic body with very well-developed muscles of the torso and upper limbs. On the chest wall, a non-tender, bony thickening was palpable at the MSJ. After repeat consultation and a normal thoracic ultrasound scan, computed tomography (CT) and magnetic resonance imaging (MRI) scans were reported to show no abnormality. The patient's symptoms remained, and after 2-years of repeated consultations  and non-locked (2.7 cm) screws to increase stability while permitting initial slight movement with breathing. Autologous bone graft was performed by harvesting cancellous bone from the iliac crest and inserting this into the defect at the MSJ. At the end of the procedure, a stability check was performed with no pathological movement of the MSJ. The patient made an uneventful postoperative recovery and was discharged 7 days later after completion of a course of physical therapy. He was pain-free and without any limitation of movement. He returned to normal activities 2 weeks later. After 1 month, he was regularly lifting weights at preinjury levels. At 23 month follow-up, the patient remains pain-free and has returned to regular exercise and weight lifting.While much has been written about the management of sternal fractures after blunt trauma and non-union after median sternotomy for cardiac surgery, guidance on the management of MSJ pseudoarthrosis remains relatively scarce.The first challenge is in understanding the pathology in the absence of a single traumatic incident:There are two known mechanisms of MSJ dislocation or disruption; both entail the high-energy trauma expected in a motor vehicle crash. The first type of injury results from direct impact with posterior displacement of the body of the sternum. The second and more common injury type follows flexion–compression trauma of the thorax and neck where the neck is forcefully hyperflexed while the chin, clavicles, or ribs displace the manubrium posteriorly.In the absence of a single incidence of major trauma, a careful history of how and when the pain started is important: the mechanism here is repeated low-level trauma or stress on the chest wall. A key feature of the symptoms is clicking of the fibrocartilaginous pseudoarthrosis on movement of the unstable MSJ [also reported by , in a ruThe strength and stability of the MSJ rely on the attachment of the clavicles and first rib to the body of the manubrium and the strong ligamentous attachments of the second ribs to the MSJ. These attachments result in a non-mobile joint. In our patient, years of bodybuilding and weight lifting resulted in these muscles and ligaments stretched repeatedly under considerable force in opposite directions. Cranial stretching involved the attachment of the manubrium to the spine through the first and second ribs and the attachment to the shoulders through the clavicles, the sternal head of the sternocleidomastoid and part of the pectoralis major attached anteriorly to the manubrium and sternum, and the sternohyoid and sternothyroid muscles attached posteriorly to the manubrium. Caudally, stretching in the opposite direction involved the transverse thoracis muscle attached to the posterior surface of the body of the sternum and the strong rectus abdominis attached to the distal part of the sternum . RepetitBilateral first rib fractures and pseudoarthrosis and callus formation at the thoracic inlet were described by Satija et al.  in a 17-Rarer still are reported non-traumatic inflammatory lesions of the manubriosternal synchondrosis reported among athletes complaining of chronic post-exercise pain at the MSJ . While cImaging findings of MSJ dislocation have been described , but pseThe final challenge was in selecting an appropriate operative technique to render the patient pain-free with a fused stable MSJ able to withstand the resumption of sporting activity:While most sternal injuries are managed conservatively, there are three key indications for surgery: (I) the presence of a sternal deformity, (II) loss of sternal continuity for a period of more than 6 weeks, and (III) persistence of chest pain for 2–8 weeks after trauma.Surgical fixation of the dislocated MSJ using plates and screws has yielded demonstrably better results than that achieved with wire fixation . The supTwenty-three months after surgery, the patient reports no further clicking or pain, and, on examination, there is no further evidence of movement at the MSJ.ronitbarh@gmail.com.The datasets presented in this article are not readily available because they are stored in confidential patient medical records. Requests to access the datasets should be directed to Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Intracranial aneurysm with the first manifestation of acute subdural hematoma (aSDH) is rare in the field of neurosurgery. Usually subarachnoid hemorrhage or intracranial hematoma happens after the rupture of an intracranial aneurysm, whereas trauma is the primary cause of aSDH.Here, we present the case of a 71-year-old woman who presented with spontaneous aSDH with progressive headache and vomiting.Urgent head computed tomography (CT) identified an aSHD, but the patient had no history of trauma. CT angiography (CTA) identified the cause of the aSDH as rupture of an intracranial aneurysm in the left middle cerebral artery.Emergent craniotomy with hematoma evacuation was performed.Due to prompt diagnosis and appropriate intervention, the patient recovered fully with no disability.This unique case demonstrates that aSDH caused by intracranial aneurysm rupture requires timely identification and appropriate action to prevent adverse outcomes. We performed a comprehensive systematic literature review to examine the etiology and pathogenesis of non-traumatic aSDH. Furthermore, digital subtraction angiography should be considered in patients diagnosed with an aSDH with no known cause. Non-traumatic aSDH is far less common that spontaneous aSDH occurring in the absence of an intracranial aneurysm. The etiology and pathogenesis remain uncertain given the infrequency of spontaneous non-traumatic aSDH. Arteriovenous fistulas, rupture of an arachnoid cyst,4 or vasculature structure, hematological malignancies, coagulation defects,–8 and cocaine abuse have been reported to contribute to the occurrence of non-traumatic aSDH in specific cases. In particular, the rupture of an intracranial aneurysm may have severe consequences if misdiagnosed, with an associated mortality estimated to range from 60% to 76.5%. Typical clinical manifestations are symptoms caused by intracranial hypertension, such as vomiting, headache, conscious disturbance, visual impairment, and brain hernia. Treatments include surgical decompression, hematoma evacuation, ventricular drainage, and conservative therapy.Although spontaneous acute subdural hematoma (aSDH) in the absence of trauma is a rare condition,In the report, we present a case of aSDH in a patient who presented with progressive headache and vomiting but no history of recent trauma. In consideration of the low incidence of the condition, the current literature was reviewed to elucidate the etiology and pathogenesis of non-traumatic aSDH as well as current standards for its diagnosis, treatment, and prognosis.2A 71-year-old woman presented to the out-patient department with progressive headache and vomiting without a recent history of traumatic injury. The patient had no history of hypertension and medication use. She complained of a sudden headache occurring 2 weeks previously as well as occurring approximately 6 weeks previously. Two weeks prior to her presentation at our hospital, she visited a local hospital for computed tomography (CT) and magnetic resource imaging (MRI) examinations with no positive results Fig. .Emergent craniotomy with hematoma evacuation was performed in the left brain. The intracranial aneurysm in the left middle cerebral artery was clipped in the operation. Obvious adhesions were observed intraoperatively between the aneurysm and arachnoid membrane Fig. . The pat3A review of English reports of aSDH case caused by aneurysm was conducted by searching the PubMed databased between January 2013 and January 2018. The terms “aneurysm and acute pure subdural hematoma” were used to search for the publications. Eight publications were eventually included in our analysis (Table  Aneurysms commonly lead to subarachnoid hemorrhage, ventricular hemorrhage, or intracranial hematoma, while trauma is the primary cause for aSDH. It is easy to overlook the existence of aneurysms in aSDH. Ohkuma et al reported that the incidence of subarachnoid hemorrhage or ventricular hemorrhage caused by aneurysm is only 1.5% to 2.7%, whereas the incidence of spontaneous aSDH caused by aneurysm was even lower due to the invisibility. With an aSDH, blood usually accumulates in the surface of dura mater and cerebral cortex, which may result in severe consequences due to compression.Few publications have addressed the prevalence of spontaneous non-traumatic aSDH, and spontaneous aSDH caused by aneurysm is quite rare. Ultimately, the normal structure of the arachnoid had been destroyed by a previous microvascular aneurysm hemorrhage, allowing the broken tissue from the aneurysm to penetrate the subdural space when a second rupture of the aneurysm occurred, which may likely be the pathogenesis of the aSDH in this case. The patient complained of a sudden headache twice in approximately 6 weeks. Although it was not seen on CT and MRI examinations, there is a high possibility that a microvascular aneurysm hemorrhage existed. Arachnoid adhesion and damage may also exist in this situation secondary to microvascular aneurysm hemorrhage, which was confirmed during the surgery. However, the second hypothesis cannot be completely ruled out, and the occurrence of aSDH in this case may have been influenced by a variety of interacting factors.The cause of aSDH in the case reported here was confirmed to be aneurysm rupture. The pathogenesis of aSDH caused by aneurysm rupture remains unclear for now, but there are a few possible hypotheses. It was suggested that the high blood pressure created during aneurysm rupture may lead to aSDH as a result of damage to the arachnoid. Alternatively, the aSDH could be caused by the rupture of an aneurysm located in the subdural space.,23,28,29 There is a risk of missed diagnosis for aSDH caused by aneurysm. DSA has been considered the golden standard for diagnosing aneurysm, as it is capable of tracking the location of an aneurysm and identifying the relationship between the aneurysm and nearby artery. However, there is a risk of radiocontrast agent leakage during DSA procedures. Compared with DSA, CTA has the advantage of a shorter diagnostic time frame, which is especially beneficial for critically ill patients. Treatments options for aSDH include surgical decompression, hematoma evacuation, ventricular drainage, and conservative therapy. Conservative therapy is reasonable for minor defects. Ventricular drainage can be used in the absence of coagulation defects. However, surgical decompression and hematoma evacuation are advised to prevent adverse outcomes such as motor or sensory deficits.The definition of aSDH caused by aneurysm remains controversial. Spontaneous aSDH was suggested to represent aSDH caused by aneurysm, while a contrary opinion stated that spontaneous aSDH should be referred to as aSDH caused by spontaneous rupture of vasculature. Neutrally, spontaneous aSDH may include all forms of aSDH caused by non-traumatic reasons.Although a rare cause of aSDH, aneurysm should be considered in efforts to diagnose the cause of non-traumatic spontaneous aSDH. It is necessary to track the origin of bleeding while the patient is in relatively stable condition. DSA examination should be considered for patients diagnosed with an aSDH with unknown cause.Conceptualization: Yang Zhang, Wei Wang.Formal analysis: Fagui Yue.Investigation: Yang Sun.Methodology: Fenglei Zhang, Yang Zhang, Xiaobo Zhu.Resources: Xiaobo Zhu.Software: Fenglei Zhang.Supervision: Wei Wang.Validation: Yang Sun.Visualization: Fenglei Zhang.Writing – original draft: Xianfeng Gao, Fagui Yue.Writing – review & editing: Wei Wang.


Lipomas are common benign mesenchymal tumor that arise from the adipose tissue. Differential diagnosis between the benign and malignant form (liposarcoma) must be made to prevent complication and recurrence.We reported a 63-year-old man who presented with recurrent large-sized mass on the right forearm with the first presentation approximately 28 years before being treated in our center. Main complaints were discomfort, social embracement, and difficulty in dressing. There were no compression symptoms observed. We performed marginal excision and sent the sample for histopathological examination. The work has been reported in line with the Surgical Case Report (SCARE) criteria.During one year of post-operative period, no recurrence was detected and a complete relief of symptoms was as expected.Diagnostic challenge in such a large-sized (giant) lipoma is in differentiating it with the malignant form. Surgical excision is the choice of treatment. However, long-term follow up is needed due to the risk of recurrence. It commonly occurs subcutaneously, however its appearance on any other plane has been reported. Large-sized lipoma or ‘giant lipoma’ is considered if the size is greater than 5 cm in diameter. We presented a case of a 63-year-old male with giant lipoma on the flexor compartment of his right forearm which was treated with complete removal of the lipomatous mass with marginal excision. Post-operative histopathological diagnosis was well-differentiated liposarcoma lipoma-like. No recurrence had been observed on the 1-year follow up. Our work has been reported in line with the Surgical Case Report (SCARE) Guidelines [2A 63-year old male was referred to orthopedic outpatient clinic at our institute with a large lump on the right forearm region. The lump initially appeared 28 years ago and had re-appeared for three times after three times removal. The latest removal was 7 years before admitted to our center and the latest recurrence was in the next 2 years. The patient was only complaining about mild discomfort and difficulty in wearing clothes. The non-tender lump was increasing in size slowly from the size of quail eggs with well-defined border around the wrist until it occupied the whole flexor compartment of the right forearm. The right forearm circumference was 20 cm compared to 7 cm on the contralateral . There wThe laboratory markers showed no abnormality except for high blood glucose since the patient has diabetes mellitus since the past 11 years. He also had a hyperlipidemia with increase of both total and LDL cholesterol level.Patient underwent radiograph assessment with plain x ray which suggest lipomatous mass  and MagnSurgical exploration was therefore performed under general anesthesia and with the application of a hemostatic tourniquet. A lazy-S design was made approximately one cm lateral to the antecubital fossa and extended distally until distal wrist crease. The incision started on the ulnar-volar side on the distal forearm where the initial mass appeared and where it most superficially located under the skin. After skin incision and entering the subcutaneous plane on the wrist region, there was a lipoma-like lesion which continued sub-muscularly underneath the FDS muscle. Blunt dissection through muscle fiber confirmed a deep-seated lipoma lying over the Flexor Pollicis Longus (FPL) muscle. Running through the lipoma was a shiny cord-like structure, which was identified as the median nerve. The mass was carefully dissected off the median n. until releasing the transverse carpal ligament to ensure that the nerve was left intact. The mass was found to compress the surroundings; however, it was relatively easy to remove due to the pseudo-capsule and the intermuscular location .Fig. 4YeThe 15 × 8 × 5.5 cms mass was sent for histopathological analysis. The mass was well-vascularized as observed that there were big vessels that gave blood supply to the mass and these vessels infiltrated the mass especially at the superior pole, where it gave a yellow-red appearance on that region. The mass consistency was generally rubbery with a firmer consistency at the superior pole. .Fig. 5LoHistopathological analysis suggested a lipomatous tumor, low grade, most suitable with well-differentiated liposarcoma (WDL)-lipoma like subtype .Fig. 6HiDuring routine follow-up in the outpatient clinic at one and three months, the wound had healed well and there were no neurological deficit, functional impairment or recurrence of the lump observed. At one-year follow-up the scar healed nicely without recurrence of the mass .Fig. 7Cl3The etiology and pathogenesis of lipomas remain unknown, although genetic endocrine and traumatic factors have been suggested. Our patient had diabetes mellitus in the past 11 years which was treated by oral anti-diabetic drugs. He also had a long-standing hyperlipidemia with the increase of total cholesterol and LDL cholesterol level.Typical lipoma occurs more often in young adults, women (thigh), and in overweight populations. They vary in size ; when thAlthough the definitive diagnosis of giant lipoma can be made only by histopathological examination, the differential diagnosis between giant lipoma and liposarcoma is of great importance. Once suspected, other investigations must be conducted to provide more information about the tumor such as ultrasonography (USG), computed tomography (CT) scan and magnetic resonance imaging (MRI) as well as technetium-99 diethylenetriaminepentaacetic acid scanning ,3,5.In our case, the plain radiograph showed a radiolucent soft tissue mass along the shaft of radius ulna on the volar part of the right forearm. The MRI showed homogeneous hyperintense fat signal on T1-weighted MR images whereas T2-weighted images showed hypointense fat-suppression signal. The mass appeared inter-muscularly between FCR and FDC with well-defined margin and no infiltration to surrounding structures, raising the susceptibility of a lipomatous tumor with benign characteristics.Surgical is the mainstay treatment for giant lipoma due to the size, recurrence risk and potential malignant transformation. Complete surgical resection, with preferably wide-margin, is recommended to prevent dedifferentiation and recurrence. Adjuvant radiation therapy may benefit in large high-grade liposarcoma and in any other liposarcoma when the wide resection cannot be obtained. The value of chemotherapy is still debatable as adjuvant to surgical therapy .In our case due to the complicated structure and relatively narrow space at the forearm, we could not perform wide resection with much negative margins. Intraoperatively, we found that the mass was deep-seated, well-vascularized, well-circumscribed, lobulated and had a rubbery consistency. Those characteristics were suitable for the lipomatous mass but not specifically present liposarcoma. The cut surface was yellow with more hyperemic areas on the superior pole of the mass. A pseudo-capsule which was formed by the continuous pressure on surrounding tissue made the dissection and enucleation of the mass uncomplicated. Since the mass was intermuscular, we were able to remove the tumor without affecting the adjacent muscular tissue while preserving the neurovascular bundle, in this case, the median nerve particularly ,4,7.Post-operative histopathological exam revealed this giant lipomatous mass as the well differentiated liposarcomas (WDL) lipoma-like subtype. Account for 40–45 % of liposarcomas, WDL usually diagnosed at the 5th decades of life with slight male predominance. WDL are locally aggressive mesenchymal tumors composed of mature adipocytes and stromal cells with at least focal cytologic atypia. WDL are considered as low grade lipogenic tumors with morphologic subtypes dependent on the adipocytic component and background cellularization characteristic. Several histologic subtypes have been described: lipoma-like, sclerosing, inflammatory, mixed, lipo-leiomyosarcoma, WDL with low grade osteosarcoma-like and spindle cell subtype. Lipoma-like subtype, being the most common form of WDL, is grossly indistinguishable from lipoma. It frequently contains lipoblast and scattered atypical cells may be diffuse or extremely rare .In this report, surgical excision resulted in complete relief of symptoms and significant esthetic also became evident in the affected forearm. There was no recurrence in the 1-year follow up. However, we still closely observe this patient for any recurrence since the possible risk of recurrence in the WDL as well as inter-muscularly located lipomatous mass.4The slow growing nature and radiological characteristic of lipoma brought confusion with the benign lesion. However, the giant size and other unusual characteristics  raised the awareness of malignant lipomatous mass. Appropriate diagnosis and complete surgical resection of this tumor provided symptoms relief and esthetic improvement on the affected limb. Long-term evaluation must be conducted in order to detect recurrence. We plan for the wide excision followed by radiotherapy for possible recurrence mass in the future.The authors declare no conflicts of interest.The authors report no external source of funding during the writing of this article.Ethical approval was not required in the treatment of the patient in this report.Written consent has been received from the subject.Dina Aprilya contributes to the study concept or design, data collection and writing the paper.Wildan Latief contributes in the study concept or design, data collection, analysis and interpretation, oversight and leadership responsibility for the research activity planning and execution, including mentorship external to the core team.Wahyu Widodo contributes in the study concept or design, data collection, analysis and interpretation, oversight and leadership responsibility for the research activity planning and execution, including mentorship external to the core team.Not required.Wahyu Widodo is the sole guarantor of this submitted article.Editorially reviewed, not externally peer-reviewed.


Root perforation is a common endodontic accident. Its management depends mainly on root canal disinfection and sealing the perforation area by preventing any communication with the periodontium to prevent recontamination. A patient was referred to treat root perforation due to a previous treatment of tooth #22. The diagnosis was symptomatic periapical periodontitis, and the treatment plan was to retreat the root canal of #22 and make a surgical intervention (apicoectomy) associated with antimicrobial photodynamic therapy as a complementary technique. Five mineral oxides (5MO) cement was used as a root-end filling material. The procedures were performed in two sessions and controlled in two visits (after 30 days and 12 months). A bone neoformation was observed at the periapical area of tooth #22. 5MO bioceramic cement was effective in inducing the repair of the periapical lesion and had the ability to seal the exposed periapical area of the tooth. Its success depended mainly on root canal and surgical site disinfection. The symptomatic periapical periodontitis is an endodontic disease of the necrosed pulp and its management depends mainly on root canal disinfection  in whichDuring the endodontic treatment , some coEndodontic (paraendodontic) surgery was started in the last century as the last alternative of endodontic intervention . It resuThe bioceramic cements played a major effect on the success of endodontic surgery, since the introduction of mineral trioxide aggregate (MTA) , 18–20, The photodynamic therapy is a complementary technique, which aids in additional disinfection using a light source like laser or light-emitting diode (LED) acting over a photosensitizer and thus liberating reactive oxygen specimens that disinfect some facultative microorganisms  and resuThe aim of this case report was to evaluate the effect of 5MO bioceramic cement on periapical lesion repair and its ability to seal the exposed periapical area of the tooth.A Brazilian white 31-year-old male was indicated to treat the left upper lateral incisor #22. The patient stated a “bad experience” with the root canal treatment and a “continuous discomfort”. The patient's clinical history did not present relevant findings.The clinical examination revealed a positive response to percussion and digital palpation in the periapical region of #22 with no fistula. The intraoral examination did not show any caries or color alteration related to the respected tooth. The depth of its gingival pocket varied between 1 and 3 mm with various exploring locations and grade I mobility. Teeth 21–23 were tested by the pulp vitality test (the cold test) performed by refrigerant gas  and relative isolation using cotton rolls and a dental saliva ejector. Teeth 21 and 23 presented positive responses with characteristics of healthy pulp tissue. However, tooth 22 had a negative response .Panoramic and periapical radiographic examination revealed a radiolucent circumscribed lesion around the periapical region of tooth #22 presenting features of periapical periodontitis. As well, unsatisfactory endodontic treatment of the same tooth was founded with signs of root perforation due to a previous treatment . The conThe final diagnosis was symptomatic periapical periodontitis, and the treatment plan was to retreat the root canal and posteriorly to perform an endodontic surgery (apicoectomy), disinfect the periapical region by antimicrobial photodynamic therapy (aPDT), and seal the perforation area with bioceramic cement to prevent recontamination of the canal.Firstly, the root canal of tooth #22 was retreated to disinfect the contaminated system because of the perforation. The canal was instrumented with the RECIPROC system R40/0.06 file  and irrigated by sodium hypochlorite 2.5%  and ethylenediaminetetraacetic acid with detergent (EDTA-T) . The canal was then washed with 10 mL of sterile saline solution to be neutralized of any chemical substance and dried with paper points #40.2 activated for 2 min without interval, using a helical movement from apical to cervical direction. An energy density of approximately 120.0 J/cm2 was applied [The aPDT was then performed by filling the canal with methylene blue 0.005%  and maintained in the canal for 5 min as a preirradiation time. The irradiation procedure was performed using a low-power diode laser  and an optical fiber (0.40 mm diameter and 16 ± 0.5 mm active surface length) placed into the canal. The irradiation was performed by a visible red wavelength of 660 nm and an output power of 100 mW/cm applied .The root canal was obturated in the same session with gutta-percha and Ah Plus sealer . No medication was prescribed before or during the treatment. The patient was advised to take acetaminophen  in case of pain.One week later, after tomographic planning, the apicoectomy surgery was performed under local anesthesia using one anesthetic tube , with intraoral access to the lesion achieved via intrasulcular incision of the buccal region from teeth 11 to 24. After detachment of the flap, the perforation was clear and a minimum osteotomy was performed to obtain a surgery window using a surgical carbide drill no. 06  under intense irrigation with sterile saline solution.The apical third of the root was sectioned using Zekrya Surgical Bur  under intense irrigation with sterile saline solution, and then, the root canal was retroinstrumented by ultrasonic diamond tip P1  using CVDentus 100 ultrasound activator . The surgery site was filled with methylene blue 0.005% and irradiated with a low-power diode laser following the same protocol described above to obtain further decontamination. Then, the root canal was retrofilled with 5MO bioceramic cement  manipulated following the manufacturer's guidelines . FinallyTen days later, the patient had no postoperative intercurrences and an intraoral evaluation was performed to investigate any hematoma or edema. The patient related a slight edema in the first two days following the surgery that disappeared posteriorly. No exudate was observed or related.Two follow-up sessions were performed after 30 days and 12 months. In these sessions, clinical intraoral examination was performed in addition to radiographic examination. In the second session (12 months later), the patient progression was evaluated by CBCT images and a bone neoformation was observed at the periapical area of tooth #22 .The diagnosis of such cases has a direct effect on the treatment plan and outcome. In this case, the CBCT scan was indicated as it provides a three-dimensional mapping of the lesion and its relationship with the adjacent teeth and anatomical structure . The perThe treatment plan was to retreat the infected tooth and associate this retreatment with surgical intervention, as the conventional endodontic retreatment alone is effective in limited cases, and this depends mainly on perforation type, its location, and the professional ability to approach it for repair . HoweverIn this case report, 5MO cement was used as it presented a reparative feature and provided sealing of surgical areas . HoweverAnother point to emphasize is the marginal adaptation of the retrofilling materials. Amalgam as an example was criticized and not indicated due to its expansion over time regardless of its thickness ; conversIn the literature, bioceramic cements have low antimicrobial action; however, this ability to obtain reasonable results in terms of successful management of endodontic complications and accidents is related to the disinfection of the surgical site and root canal in the first place . In thisThe apical third was retroinstrumented using the ultrasonic tip which is an effective method resulting in additional disinfection of the surgical site . A diamoEven more, aPDT was used both in root canal retreatment as it was indicated as an effective complementary technique over resistant microorganisms  and in tLastly, the endodontic infection has a complex nature, as diverse microorganisms, endotoxins, MMPs, and growth factors are involved . Thus, t5MO bioceramic cement induces repair of periapical lesion, has the ability to seal the exposed periapical area of the tooth, and has a good marginal adaptation. The success obtained in this case depended mainly on root canal and surgical site disinfection by the photodynamic therapy.


Symplastic hemangioma is a benign superficial abnormal buildup of blood vessels, with morphological features which can mimic a pseudo malignancy. A few cases have been reported in the literature. We report here, a unique case of calvarial symplastic hemangioma, which is the first case in the calvarial region.A 29-year-old male patient, with a left occipital calvarial mass since childhood, that gradually increased in size with age, was associated with recurrent epileptic fits controlled by Levetiracetam (Keppra), with no history of trauma. He presented to the emergency room with a recent headache, vomiting, frequent epileptic fits and a decrease in the level of consciousness 1 day prior to admission. A CT scan showed three diploic, expansile, variable sized lytic lesions with a sunburst appearance; two that were biparietal, and one that was left occipital, which were all suggestive of calvarial hemangiomas. However, the large intracranial soft tissue content, within the hemorrhage of the occipital lesion was concerning. The patient had refused surgery over the years; however, after the last severe presentation, he finally agreed to treatment.The two adjacent, left parietal and occipital lesions were treated satisfactorily using preoperative embolization, surgical resection, and cranioplasty. Histopathology revealed cavernous hemangiomas, in addition to symplastic hemangioma  on top at the occipital lesion. The right parietal lesion was not within the surgical field; therefore, it was left untouched for follow-up.Histopathology and radiology examinations confirmed the diagnosis as symplastic hemangioma, on top of a pre-existing cavernous hemangioma. To the best of our knowledge, this is the first case of a calvarial symplastic hemangioma, which we report here. Intraosseous hemangioma is a rare bone neoplasm and accounts for < 1.0% of all bone tumors. They are usually found in the vertebral column and are rarely found in the calvarium . CalvariSymplastic hemangiomas have been described more recently, and the main features are degenerative pleomorphism, with atypia in the vascular smooth muscle and stromal interstitial cells in a pre-existing vascular lesion , 10. In A 29-year-old male patient, with a left occipital calvarial palpable, hard, non-tender mass since childhood, that gradually increased in size with age, was associated with recurrent epileptic fits controlled by Levetiracetam, with no history of trauma. He presented in the emergency room (ER) with recent headache, vomiting, frequent epileptic fits, and a decrease in the level of consciousness 1 day prior to admission. He was vitally stable (GCS15/15) and afebrile, was able to move all of his limbs actively and was neurologically intact. Computed tomography (CT) of the brain revealed a left occipital and parietal hemangioma and he was admitted under the care of the neurosurgery team to be operated on.A skull X-ray was not performed; however, the scout view of the preoperative CT scan showed parietal and occipital expansile lytic bony lesions, involving the inner and outer tables. The occipital lesion was larger, with internal trabeculations and a major intracranial part with spiculated margin Fig.. The CT The MRI showed hyperintensities on T1-weighted image (WI) and T2WI of the fat and vascular contents, respectively, and the post-contrast enhancement, without restricted diffusion, was suggestive of calvarial hemangiomas. The left high parietal lesion was compressed and invaded the superior sagittal sinus Fig.a. The laFrom the contrast-enhanced MR angiography, there were two tortuous arteries arising from the prominent left occipital artery Fig. , providiThere was also an increased intracranial pressure evident by the empty Sella turcica and distended optic nerve sheaths on the MRI Fig.a and b. Over the years the patient refused surgery; however, after the last severe presentation, he finally agreed to treatment. Based on the radiological report, cerebral angiogram and embolization of the feeders were performed to minimize the intraoperative bleeding Fig.a and b.After 48 h, the patient underwent surgery. Considering that the outer palpable part of the mass was much less than the intracranial extension, it was adjacent to the diploic calcified mass and the bone had thickened, a craniectomy was planned over the adjacent left-sided parietal and occipital mass lesions, under general anesthesia. The head was fixed in the prone position, with the head fixed on a Mayfield head-holder. During the craniectomy, the involved bone was much thicker and was too hard (ivory-like); therefore, the neurosurgeon used numerous tools  to perform the craniectomy. The part of the mass that was extending intracranially was firm with moderate vascularity and found to be eroding the dura and evaginating the brain tissue. However, there was a clear boundary, with an arachnoidal plane between the tumor and the brain tissue, that facilitated the separation of the tumor with complete excision and ensuring that the brain tissue was intact without violation. The two adjacent lesions were totally excised and hemostasis secured Fig.a. Dural Postoperatively, the patient recovered smoothly, was fully conscious, neurologically intact, feed orally and was discharged in a satisfactory condition. Superficial scalp wound infection was observed in the later stages, which was managed by broad-spectrum antibiotics. These wounds were completely healed, and became dry and clean. The patient had a normal life without recurrent symptoms, suggesting a compressive mass effect caused the fits. A follow-up CT brain scan after a few years and months revealed the atrophic left occipital lobe, with encephalomalacia and ex-vacue dilatation of the occipital horn of the left lateral ventricle Fig..Fig. 12Histopathology of the small left parietal lesion revealed cavernous hemangioma, while the left large occipital lesion showed a vascular lesion, with a thick wall and interstitial cells within a pre-existing vascular lesion. A microscopic examination revealed a well-defined lesion composed of variable sized dilated blood vessels, lined by endothelial cells exhibiting minimal nuclear atypia, with no multilayering or mitosis Fig.a and b. In Table Calvarial symplastic hemangioma, when compared with calvarial hemangiomas, is rarely reported in the literature. They are benign, slow-growing, malformed vascular lesions, often and incidentally discovered on radiological images obtained for other reasons. They account for < 1% of all primary bone neoplasms. Hemangiomas malignant degeneration has not been reported so far , 18. HisThe cavernous hemangiomas are characterized by the cluster of dilated blood vessels separated by fibrous septa. This is in contrast to capillary hemangiomas, which consist of small vascular lumens, without many fibrous septa. Cavernous hemangiomas are more common in the skull, whereas the capillary type is more common in the vertebral column , 22. TheFrom a CT scan, calvarial hemangioma is classically shown as an expansile lytic lesion, with the sclerotic rim of sunburst or a spoke wheel appearance of trabecular thickening radiating from a common center . Our preAs in our case, histopathology showed a symplastic hemangioma, within a pre-existing vascular tumor with minimal endothelial cell atypia, which can be suggested radiologically by the intracranial soft tissue content with hemorrhage. Immunohistochemistry showed focal positivity for SMA in the atypical cells, confirming a symplastic hemangioma, within a preexisting vascular lesion. CD34 antibody staining was performed to confirm the diagnosis and the endothelial cell lining of the vascular channels was found to be positive; thus, confirming our diagnosis. The distinctive lack of endothelial nuclear atypia allowed the distinction from malignant vascular tumors , 13–16. In a unique case of a male patient, who underwent CT of the chest for a cough and night sweat symptoms, the CT scan showed a large intrathoracic mass in the right middle lobe of the lung, initially raising the suspicion of tuberculosis. This tumor resembled a mediastinal angiosarcoma, with histology features of a highly vascular nature of the lesion, with the focal areas of complex anastomosing vascular channels. However, careful histological and immunological investigations confirmed this case was symplastic hemangioma . Few prePreviously reported cases of skull base calvarial hemangiomas are rare. They occur most frequently in the vertebral column (30–50%) and the skull 20%), whereas the involvement of other sites, such as the long bones, short tubular bones, and ribs is uncommon. Calvarial hemangiomas are more common in females compared with that in males, with a 3:2 ratio, and usually affect individuals 20–40 years of age %, wherea, 13, 16;Other large intra-diploic skull lesions to be considered in differential diagnosis of calvarial hemangioma include osteosarcoma, giant cell tumor (GCT), epidermoid cyst, and aneurysmal bone cyst (ABC). Although osteosarcomas are rarely affecting the skull, but they show sunburst appearance, and specular calcifications on CT Scan . The GCTOverall, our case report has addressed calvarial symplastic hemangioma, which when compared to calvarial hemangiomas, is rarely reported in the literature. This has similar imaging features to calvarial hemangiomas, which classically show expansile lytic lesions with the sclerotic rim of sunburst or a spoke-wheel appearance on a CT scan. On MRI, the signal intensity depends on the fat, soft tissue and hemorrhagic content, and shows post-contrast enhancement. As in our case, a symplastic hemangioma can be suggested by a slow-growing soft tissue mass with hemorrhage in a pre-existing hemangioma. Symplastic hemangioma is a histopathological diagnosis, but radiology also confirmed this in our case. MRI was performed consecutively for 3 years, which showed progressive enlargement of the soft tissue component and increased mass effect in a pre-existing hemangioma.