Splenic artery pseudoaneurysms (SAPs) are rare causes of upper gastrointestinal bleeding (UGIB), with less than 250 reported cases in the literature. The highest incidence of SAPs is in patients with a history of acute or chronic pancreatitis or splenic artery trauma. SAP in the setting of gastric malignancy is an exceedingly rare finding. We present the unusual hospital course of an 82-year-old male with advanced gastric cancer presenting with UGIB secondary to a visceral communication between his known gastric malignancy and a SAP. An upper gastrointestinal bleeding (UGIB) is defined as any bleed that originates proximal to the ligament of Treitz. Acute UGIB is a common occurrence, affecting on average 100-200 individuals per 100,000 annually . Even raAn 82-year-old male recently diagnosed with a gastric malignancy at an outside institution presented to the emergency department as a transfer after a one-day history of worsening weakness and dyspnea on exertion. He had been having intermittent hematemesis for the past month and last vomited the day prior to presentation. He also reported melena and unintentional weight loss, but no abdominal pain or distention. He admitted to chronic ibuprofen use averaging 400 mg a day, but he denied any history of tobacco use, alcohol abuse, or recreational drug use. He had no previous abdominal surgeries and denied any known family history of gastrointestinal (GI) cancers.3, international normalized ratio of (INR) of 1.2, blood urea nitrogen (BUN) of 21 mg/dL, and creatinine of 0.87 mg/dL. All other values were within normal limits. Chest X-ray was unremarkable. While in the ED, he had an episode of worsening hypotension following a bowel movement, but improved following IV fluid resuscitation and a transfusion of packed red blood cells. IV proton pump inhibitors were administered, and the patient was eventually stabilized enough to warrant admission to the step-down unit.On arrival to the ED the patient was afebrile, tachycardic in the low 100s, and hypotensive at 102/40 mm Hg. He was pale and had dry mucous membranes on examination. His abdomen was nontender and nondistended, but he had melena on digital rectal examination. Initial labs were significant for a hemoglobin of 7.9 g/dL, platelet count of 232,000/mmThe GI service was consulted and an esophagogastroduodenoscopy was performed, which revealed large amounts of bright red blood with clots in the gastric lumen obscuring adequate visualization of the mucosa Figure . DespiteAngiography of the celiac axis demonstrated a large distal SAP near the splenic hilum with large volume of active bleeding into the gastric lumen due to arterial erosion from the known gastric cancer. An additional small aneurysm was noted in the celiac artery without active bleeding Figure . MultiplSAPs pose a significant diagnostic challenge for clinicians. From the limited case reports and case series available, the formation of these lesions has been largely attributed to inflammatory damage secondary to acute or chronic pancreatitis (52%), surgical/blunt trauma 3%/29%), and, to a much lesser extent, PUD (2%) . In cont%, and, tWhile primary bleeding from gastric cancer accounts for a very small percentage of all UGIB, these patients can also bleed from concomitant benign causes such as peptic ulcers, esophageal and gastric varices, hemorrhagic gastritis, and angiodysplasia . Based oFor UGIB secondary to ruptured SAPs, multiple case reports have described a failure to identify the bleeding source through endoscopy either due to (1) poor visualization as a result of profuse bleeding or (2) a lack of visible intraluminal abnormalities ,14. In tOnce detected, intervention is considered necessary for all ruptured and unruptured visceral pseudoaneurysms, ruptured visceral aneurysms, and unruptured visceral aneurysms measuring >2 cm in diameter . DependiSAPs are very rare vascular lesions with less than 250 reported cases in the English literature. Although patients usually present with abdominal pain and signs of overt UGIB, evaluation for a ruptured SAP remains a diagnostic challenge and requires a very high level of suspicion. Clinicians must deduce the probability of occurrence through evaluation of the patient’s history of pancreatitis or blunt force or surgical trauma to the spleen and its vasculature. There is an additional level of complexity if the patient has a pre-existing condition that could also explain UGIB, such as a gastric malignancy. Regardless, if endoscopic intervention fails to locate the source of bleeding, CTA or angiography is the preferred imaging modality to evaluate for splanchnic vasculature complications. Endovascular embolization remains the preferred primary intervention, with open surgery left as the last resort. This case highlights the importance of prompt diagnosis and treatment as well as consideration of SAP as one of the differentials of upper GI bleed. To the best of our knowledge, the case we have presented is the second reported occurrence of a UGIB caused by a ruptured SAP in the setting of gastric cancer.


Ependymoblastoma is an uncommon, exceedingly malignant brain neoplasm that adversely influences children’s quality of life. Ependymoblastoma represents a subtype of primitive neuroectodermal tumors, categorized as grade IV, according to the 2007 World Health Organization (WHO) classification of central nervous system tumors. Ependymoblastomas are often located in the supratentorial zone and often associated with the ventricular system. Histopathological sections of the tumor revealed uniform, primitive, small blue cells, with multi-layered rosettes, accompanied by abundant mitoses. The clinical and imaging features of ependymoblastomas are not specific, which can result in misdiagnosis as other brain neoplasms. In this paper, we described the identification of a fourth-ventricular ependymoblastoma that was misdiagnosed as pilocytic astrocytoma, despite the utilization of advanced magnetic resonance imaging (MRI) protocols. Ependymoblastoma was initially defined by Bailey and Cushing, who observed that ependymal-derived tumors can be classified into two subgroups: ependymomas and ependymoblastomas . HoweverEpendymoblastomas present primarily in children ,6,7,8,9.This study was approved by the Institutional review board of Children’s Hospital 2 (Ref: 352/NĐ2-CĐT dated 13 March 2020). Written informed consent from the patient’s legal guardian was obtained for the publication of this case report and any accompanying images.−3 mm2/s, respectively (−1), wash-out rate (s−1), and area under the curve values for the parenchyma compared with the solid mass component, as measured using the axial T1-perfusion map, were 4.34 vs. 57.97, 29.15 vs. 762.28, 1.67 vs. 51.89, 96.69 vs. 180.48, 7.02 vs. 32.97, 3.10 vs. 0.52, and 442.49 vs. 105,287.40, respectively  and without surrounding cerebellar vasogenic edema . Hemosidectively . On MRI ectively . The relectively . The firectively . Two weeEpendymoblastoma, which most commonly adversely affects children, is an extraordinarily unusual and profoundly malignant CNS tumor. According to the 2007 WHO classification guidelines for CNS tumors , ependymmax ≥ 5 cm), without surrounding vasogenic edematous parenchyma [Ependymoblastomas are usually described as large, well-defined masses (diameterrenchyma ,9. Amongrenchyma ,9. Approrenchyma ,9. Ependrenchyma ,8,9. Eperenchyma .The ependymoblastoma identified in this report appeared as a large, heterogeneous, cystic, and solid mass, located in the fourth ventricle, with the strong enhancement of the solid portion and non-enhancement of the cystic element, which is a very typical hallmark of pilocytic astrocytoma. Although innovative MRI sequences were utilized, including DWI, MRI spectroscopy, and T1-perfusion, we misdiagnosed this tumor as a pilocytic astrocytoma, a more common and benign tumor that commonly occurs in children. Therefore, the clinical identification of ependymoblastomas and other primary brain neoplasms remains challenging.This report described an atypical case of infratentorial ependymoblastoma, which contributes to the sparse existing literature on ependymoblastomas. Although several advanced MRI protocols were employed, we misdiagnosed this tumor as a benign pilocytic astrocytoma. Future studies are essential to systematically highlight imaging findings that may be used to distinguish ependymoblastoma from other brain tumors, to enhance the diagnostic and therapeutic workflow, and facilitate the effective and accurate diagnosis of this rare tumor type.


Intraoperatively, the stomach, left lobe of liver, part of transverse colon, small bowel, and omentum had herniated into the thoracic cavity adhering into thoracic viscera and wall. Adhesiolysis was done, and abdominal organs reduced into abdominal cavity. Rent was closed by interrupted Prolene sutures reinforced with a mesh. In patients with delayed presentation of diaphragmatic hernia post blunt thoracoabdominal injury without associated intra-abdominal visceral injury, we recommend the thoracic diaphragmatic repair approach as long-standing herniated bowels might adhere with thoracic cavity walls or viscera. In such cases, adhesiolysis and rent repair is easier through thoracotomy.Breach in diaphragmatic musculature permits abdominal viscera to herniate into the thoracic cavity. Time of presentation and associated injuries determines the surgical approach in management. This case report sets to highlight the challenges in clinical diagnosis, radiological interpretation, and surgical management approaches of posttraumatic diaphragmatic hernia. We report a case of a 43 years old male who was diagnosed with traumatic diaphragmatic hernia 6 months post blunt thoracoabdominal trauma due to motor traffic accident. He was initially diagnosed with haemothorax, drained with an underwater thoracostomy tube, and discharged. He continued to experience on and off chest pain worsening postfeeding, difficulty in breathing and abdominal pain for the next six months until his eventual diaphragmatic hernia diagnosis. He was scheduled for an elective thoracotomy. A left posterolateral thoracic over the 7 Diaphragmatic hernia post blunt thoracoabdominal trauma was described by Sennertus as early as 1541 . Three dA 43-year-old man was involved in a high energy motor traffic accident and sustained blunt thoracoabdominal injury. At the emergency department, his vitals were stable with oxygen saturation of 96% with room air. He had reduced air entry on the left side of the chest. His chest X-ray showed blunted costophrenic and cardio phrenic angle. He was diagnosed with haemothorax, admitted at General Surgical ward, and a thoracostomy under water tube inserted. Approximately 2000 ml of haemolysed blood was drained over 7 days. Apart from minor bruises, he had no other diagnosed accompanied injuries. He was discharged uneventfully. Two weeks later, he presented at the Emergency Department with a history of difficulty in breathing, left-sided chest pain, and left upper quadrant abdominal pain. A chest X-ray was done and revealed a blunted coastal phrenic angle. A recollected haemothorax was reached as a diagnosis. An underwater seal thoracostomy tube was reinserted, and a total of approximately 1000 ml of haemolysed blood was drained over 7 days, and he was discharged.For the next six months postdischarge, during subsequent visits at the General Surgical outpatient clinic, the patient complained of on and off episodes of left-sided chest pain worse after eating, episodes of difficulty in breathing, and abdominal pain. A control chest X-ray was then done and revealed a homogenous opacity, elevated hemidiaphragm, an irregular diaphragmatic outline, and atelectasis of the left lung, all suggestive of diaphragmatic rupture . CT scanth intercostal space was used. Intraoperatively, we found an 8 by 8 cm rent in the posterolateral part of the left dome with herniation of part of transverse colon, left lobe of liver, stomach, part of omentum, and small bowel with pericardial tear 4 by 5 cm exposing coronary vessels. There were multiple adhesions of the abdominal visceral organs on the walls of thoracic cavity. The left lung was adherent to the anterior thoracic wall. Adhesiolysis done and intestinal contents were mobilized back into the abdominal cavity. The rent was repaired with interrupted Prolene sutures and mesh laid over repaired defect. He was discharged two weeks later, and his follow-up was uneventful.The patient was scheduled for an elective thoracotomy. A left posterolateral thoracotomy incision above the 7Diaphragmatic rupture posttrauma was described as early as 1541 by Sennertus and Pare in 1579 in postmortem autopsies . First dIn this case, the patient's initial chest X-rays, which features suggestive of diaphragmatic rupture, i.e., elevation of left hemidiaphragm, an irregular diaphragmatic outline, and left lung atelectasis, were masked by homogenous opacification due to haemothorax. CT scan examinations were not routine investigations at our and relatively expensive. Patient was clinically stable with no clinical indication of advanced radiological investigation. Diaphragmatic rupture was not suspected in the acute setting as associated injuries masked his presentation. These factors together with a low clinical index of suspicion lead to the delay in diagnosis.Surgical approach in management depends on the time of presentation, location of associated lesions, and surgeons experience . Both thA high index of suspicion is required in diagnosing diaphragmatic rupture post blunt thoracoabdominal trauma in acute settings. Accompanied pathologies, i.e., hemopneumothorax opacification, might mask diaphragmatic rupture chest X-ray features. Trauma CT scan chest is superior in diagnosis of diaphragmatic rupture versus conventional X-ray examinations. Choice of surgical approach in management of traumatic diaphragmatic hernia is determined by the presence of associated injuries, center procedure being performed, and surgeons' experience or preferences. In the absence of thoracic or abdominal viscera injuries, either thoracotomy or laparotomy can be employed depending on surgeon's preference or expertise. However, in our settings, we opine in delayed diaphragmatic hernias, thoracotomy is the preferred approach as adhering bowels adhesiolysis on thoracic viscera can safely be performed, and rent repair is easier.


This paper concisely reviews the benign hepatic tumors most commonly encountered by clinicians. It includes the epidemiology, pathology, and imaging characteristics of hepatic hemangiomas, focal nodular hyperplasia (FNH), and hepatic adenomas (HAs). Focal hepatic lesions are frequently encountered due to their wide variety of causes and incidental discovery on cross-sectional abdominal imaging. In this paper, we discuss the three most common benign hepatic tumors, namely hepatic hemangiomas, focal nodular hyperplasia (FNH), and hepatic adenomas (HAs). Along with a pertinent past medical history and physical examination, characteristic radiologic findings can often enable clinicians to noninvasively confirm these benign tumors and prevent unnecessary further workups.Hepatic hemangiomaHepatic hemangiomas are the most common benign tumors of the liver. In a large retrospective cross-sectional study consisting of 83,181 patients who had undergone abdominal CT and/or MRI scans, the prevalence of hepatic hemangiomas was found to be 2.5% [Although often simply described as dilated vascular malformations, hepatic hemangiomas can demonstrate growth when exposed to increasing levels of estrogen and progesterone. There may be an association between the number of hepatic hemangiomas and lifelong exposure to estrogen . They arImaging CharacteristicsAlthough tumor calcifications can be demonstrated on plain abdominal radiographs, they are not specific for hepatic hemangiomas and therefore warrant additional imaging. Ultrasound may show a well-demarcated, homogeneous, and hyperechoic lesion with some variation Figures , 1B. SimFocal nodular hyperplasiaFNH is the second most common benign tumor of the liver. The prevalence of FNH in the general population has been estimated to be approximately 3% in a necropsy study series . SimilarAlthough its pathogenesis is not entirely clear, FNH is thought to develop following a hemodynamic disruption within the liver parenchyma. Our understanding of FNH as a hyperplastic adaptation is supported by an increased incidence in individuals with hepatic hemangiomas and extensive portal hypertension . Large FImaging CharacteristicsFNH has variable echogenicity on ultrasound and infrequently demonstrates a stellate pattern in approximately 20% of patients . CT scanHepatic adenomaHAs are the third most common benign tumors of the liver. Of the three benign hepatic tumors discussed in this paper, HAs have the poorest estimations of prevalence in the general population. The incidence of HAs in nonusers of oral contraceptives (OCs) is approximately one per million and increases nearly fourfold in female users of OCs . The assHAs histologically appeared as benign nodules of proliferating hepatocytes that may demonstrate steatosis and glycogen storage. HAs lack bile ducts and ductules, which helps to distinguish them from FNH. They ordinarily occur as solitary nodules with diameters ranging from less than 1 cm to greater than 15 cm. In a condition called hepatic adenomatosis, however, they are present in numbers greater than 10 .Bleeding Risk and Malignant TransformationAlthough the majority are asymptomatic, HAs do possess additional risks that need to be considered. HAs greater than 7 cm in diameter and those located directly underneath the hepatic capsule may spontaneously rupture and cause hemorrhage. Additionally, the development of hepatocellular carcinoma (HCC) in patients lacking a prior history of chronic liver disease has been documented .Imaging CharacteristicsOn CT scan, HAs appear as well-demarcated, isointense lesions with peripheral enhancement Figure . T1-weigManagementIndividual malignancy risk will help to guide management for patients with any history of liver disease. The American Association for the Study of Liver Disease (AASLD) recommends surveillance ultrasound exams for patients with cirrhosis as they are at the greatest risk for developing HCC, which can deceptively demonstrate benign radiologic findings . For theHepatic hemangiomas less than 5 cm at initial presentation typically do not require follow-up imaging, as they often remain stable. Hepatic hemangiomas that demonstrate rapid growth may require arterial embolization or radiotherapy prior to resection . FNH is Since the growth of HAs is strongly correlated to the use of oral contraceptives and steroids, discontinuing these agents and follow-up imaging are appropriate for confirmed lesions of less than 5 cm. HAs greater than 7 cm are particularly prone to bleeding due to hypervascularization and fragile sinusoids and will require closer monitoring.Hepatic hemangiomas, FNH, and HAs are the three most common benign hepatic tumors. In practice, they are differentiated from each other based on the patient’s demographics, history of oral contraceptive or steroid use, and comorbidities such as glycogen storage disease and hepatic adenomatosis. Additionally, their characteristic radiologic findings allow clinicians to noninvasively diagnose and manage uncomplicated patients who possess no risk of malignancy. Patients with risk factors for HCC may require management as suggested in the referenced guidelines.


Appendectomy is the most common non-obstetric surgical intervention in pregnant patients. In rare cases, deciduosis can develop during pregnancy in the appendix and cause inflammation through appendiceal occlusion by ectopic decidua tissue. We report a 28-year-old woman at 32 weeks of pregnancy, who presented at the emergency room with the diagnosis of an acute appendicitis. After successful appendectomy and histopathological examination of the appendectomy specimen, a diagnosis of appendiceal deciduosis with acute appendicitis was established. Here, we discuss the origin of appendiceal deciduosis, as well as its clinical and histopathological presentation. Decidualization of endometrial tissue is a physiologic phenomenon during pregnancy caused by high progesterone levels. This phenomenon is characterized by hypertrophy of stromal tissue, increased vascular proliferation and glandular secretion ,2. DecidA 28-year-old woman, at 32 weeks of pregnancy, without significant medical history, presented to the emergency room with severe abdominal pain in the right flank, evolving during 48 hours. Abdominal palpation revealed tenderness in the right iliac fossa with guarding. Blood test demonstrated an inflammatory syndrome (175 mg/l of C-reactive protein) and neutrophilic hyperleukocytosis.Two abdominal ultrasounds were performed but were not contributive. Due to lack of clinical improvement and increasing inflammatory parameters, an abdominal CT scan as performed and showed free fluid and inflammation medial to the caecum, next to the gravid uterus. This image was compatible with acute appendicitis. Laparoscopic appendectomy was performed. Conversion to laparotomy was required due to the hemodynamic status of the patient. An inflamed appendix was found just medial to the caecum with necrosis of the tip and a macroscopically healthy base. Free fluid was present in the right iliac fossa. The postoperative period was marked by ileus treated by a nasogastric tube. The patient went into early labor 3 days after surgery and delivered a healthy baby.Macroscopic examination of the appendectomy specimen revealed a 7 cm long appendage with a maximum diameter of 3 cm. The appendiceal wall was significantly thickened. Microscopic examination showed a proliferation of large polygonal decidual cells within the mesoappendix, characterized by abundant eosinophilic cytoplasm and nuclei without any cytonuclear atypia . Mitoticet al. have suggested two theories [An acute appendicitis occurs in about one under thousand pregnancies and appendectomy is the most common non-obstetric surgical procedure for pregnant patients. But acute appendicitis due to appendicular deciduosis is even more rare ,2. The ptheories . The mostheories .et al. ectopic decidua is a physiological phenomenon as decidualized tissue was found on 100% of the omentum biopsy in 60 caesarized women, 97% with microscopic involvement and 3% with macroscopic lesions described [For Buttner escribed ,6. Finalescribed . UsuallyAppendicular deciduosis with acute appendicitis during pregnancy is rare. In the literature, around ten case have been reported ,9. It isOn microscopic analysis, decidual cells are generally found under the mesothelium in the subcoelomic mesenchyma or in the fatty tissues. Decidual cells present as large polygonal cells, with homogeneous, eosinophilic cytoplasm and vacuolar degeneration. Mitotic activity and nuclear atypia are absent ,4. ImmunIn the present case, the smooth muscle actin and PS100 stains showed no immunoreactivity . The cytWe reported a case of acute appendicitis on ectopic decidua during the third trimester of pregnancy. Ectopic decidua is generally asymptomatic and spontaneously regresses within 4-6 weeks after delivery. In rare cases, ectopic decidua can cause acute appendicitis when the appendix is involved. The treatment is surgical and the evolution is favorable in the majority of cases. Definitive diagnosis is performed by histopathological analysis.


Cutaneous metastasis from colon cancer is rare, occurs in less than 6% of patients and its associated with poor prognosis. Most often it presents in the abdomen, inguinal or perineal regions, supraclavicular area, and less commonly on the face, neck, scalp, and prior surgical sites. We present a case of a 41-year-old female with colon cancer who developed cutaneous metastases to the scalp, and was treated with topical 5-FU and radiation therapy. Treatment options for cutaneous metastases usually include systemic therapy, topical chemotherapy, surgical excision, or radiation. Our case is probably the first report who was treated with topical 5-FU in addition to radiation therapy. This treatment modality is easy to use and we would recommend clinical trials to be conducted to further study the use of topical 5-FU. Most often it presents in the abdomen, inguinal or perineal regions, supraclavicular area, and less commonly on the face, neck, scalp, and prior surgical sites. Treatment options include systemic therapy, topical chemotherapy, surgical excision, or radiation. We present a case of a 41-year-old female with colon cancer who developed cutaneous metastases to the scalp, and was treated with topical 5-FU and radiation therapy.Cutaneous metastasis from colon cancer is rare, occurs in less than 6% of patients and its associated with poor prognosis.The patient is a 42-year-old Caucasian woman who presented with significant weight loss, progressive right-side abdominal pain and distention for close to a year. Family history of a maternal aunt with ovarian cancer diagnosed at the age of 44 as well as another maternal aunt with breast cancer. Initial imaging, CT scan revealed a 30 cm mass within the distal small bowel, an 11 cm complex cystic mass posterior to the uterus, a 16 ×7 cm liver mass and numerous small nodules throughout the liver and lungs. Her liver biopsy revealed adenocarcinoma of colonic origin. Immunohistochemistry was positive for pankeratin, CK20, and CDX-2, and negative for TTF-1, ER, PR, CK7 and CA-125. Tumor markers were elevated with CEA of 409.7 ng/mL , CA-125 of 70.6 U/mL  and CA 19–9 of 1726 U/mL . She underwent diagnostic laparoscopic transverse colostomy placement to relieve bowel obstruction. Intraoperative peritoneal fluid pathology was negative for malignant cells. Further imaging with MRI abdomen showed a complex cystic right adnexal lesion most consistent with primary ovarian cancer. She was evaluated by gynecologic oncology who recommended against biopsy due to high risk of rupture because of its cystic nature. Genetic analysis of the colon cancer showed KRAS and TP53 mutations. No loss of nuclear expression of mismatch repair proteins. She had homozygous wild-type polymorphism for UGT1A1 (UDP glucuronosyltransferase family 1 member A1).In the setting of stage IV colorectal cancer and suspicion of ovarian cancer, she was started on chemotherapy with FOLFIRINOX  and completed 12 cycles. Following that she underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy for suspected ovarian cancer. The pathology was consistent with metastatic adenocarcinoma of colonic origin. Her follow up CT scan showed progressive metastatic disease. She initiated second line treatment with FOLFIRI (Irinotecan with 5-FU and folinic acid) with bevacizumab.During this treatment, she noticed a non-healing cyst-like lesion on the posterior right parietal scalp, which was slowly growing over one year . The lesDue to progression of the scalp lesion, topical 5-FU twice daily was started. Her scalp lesion started showing signs of healing with scab formation starting at week 4 with decreased in size and dramatically improved in 8 weeks .Five months after initiation of topical 5-FU the patient reported increasing frequency of local symptoms including a sharp stabbing pain, increased headache and tender to touch with deep aching. She also developed a palpable small nodule in the right sub-occipital region with concern for a new metastatic lesion. MRI head revealed a soft tissue lesion in the right parietal scalp, measuring 2.4 cm (previously 1.6 cm) with a new 1 cm enhancing soft tissue lesion in the right sub-occipital scalp.Despite the numerous systemic treatments including FOLFIRI with bevacizumab, Regorafenib, MIRI , FOLFOXIRI  and bevacizumab and topical 5-FU her scalp lesion progressed. Palliative radiation therapy was started. Following radiation therapy with concurrent 5-FU her scalp lesions remained stable and her symptoms improved.Her overall systemic disease continued to progress while on therapy and after significant decline in functional status, the patient was transitioned to comfort measures.,2 Cutaneous metastases occur concurrently with widespread metastatic disease to other sites such as liver, peritoneum and lung.,4 Most frequent sites of cutaneous metastasis are the abdomen, inguinal or perineal regions, and prior surgical sites, and occur with less frequency on the face, neck and scalp.,6 Adenocarcinoma has the highest rate of cutaneous metastasis compared to other histologic subtypes. The skin metastasis can appear as sessile, pedunculated, single or multiple nodules, as a mass with ulceration, or as a cyst.Colon cancer rarely metastasizes to the skin and occurs in less than 6% of patients.The mechanism is thought to be secondary to lymphatic or hematogenous spread, local extension of the tumor, and surgical implantation during resection of the primary lesion.–10 Aravind et al. in their article have divided cutaneous metastasis cases in to two groups:Group 1: One who primarily present with cutaneous manifestations with primary not identifiedGroup 2:This group is the one which has been treated with resection of the primary tumor and is being followed up by medical oncology.Cutaneous metastases have been associated with a poor prognosis, with overall survival approximately 12–18 months.The investigators pointed out that the former group is usually associated with more poor outcomes and other visceral involvement.No clear guidelines exist for treatment of cutaneous metastasis with primary go to treatment being wide excision of the lesion. Systemic chemotherapies and local radiation have also been used but no topical treatment options have been ever reported. Radiation is mostly used in palliation for painful or bleeding lesions but with modest results.–9 Table  Among a case series, two patients used topical 5-FU. When used alone, 5-FU reduced bleeding and drainage of lesions and when combined with cryotherapy and systemic therapy, rapidly decreased tumor burden. The authors concluded that combined treatment with cryotherapy and topical 5FU is superior to cryotherapy alone, suggesting that 5-FU induces an antitumor activity independent of cryotherapy. Similar to imiquimod, the authors also suggested that the dramatic response in both patients is in part owing to a favorable immune milieu induced by 5-FU that synergizes with systemic therapies.We searched the medical literature with diligence and finally found two more cases who received topical 5-FU for skin metastases in patients with breast cancer.Our case showed that topical 5-FU can result in partial regression or local control when used as monotherapy or in combination with other treatment modalities like in our patient along with radiation therapy. Side effects include irritation to the applied area and burning sensation. This treatment modality is feasible with a favorable side effect profile; however, the role of topical 5-FU needs to be further investigated, including tests to characterize the antitumor responses elicited by 5-FU.Cutaneous metastasis is of rare occurrence. In literature they occur either as primary presentation or develop while he patient has been treated and is being followed up appropriately. No specific guidelines exist for treatment options of cutaneous metastasis with wide surgical excision being the most reported treatment. Topical 5-FU can be used as a potential treatment but clinical trials need to be conducted.


Coccidioides spp. infection. Antibody titers performed post-operatively were consistent with an active Coccidioides spp. Infection. By fungal culture and subsequent PCR and DNA sequencing, C. posadasii was identified as the species infecting the dog. Over the course of 85 days of antifungal therapy, discharge from the draining tract, lymphadenomegaly, and cutaneous and subcutaneous nodules resolved. In conclusion, this is the first reported case of disseminated coccidioidomycosis to the cervical region of a dog with involvement of the thyroid gland, skeletal muscle, adipose tissue, connective tissue, and secondary esophageal fistula. Coccidioides spp. infections should be considered a differential diagnosis in unusual cases for dogs that live in or have traveled to endemic areas.A 5-year-old male, neutered mixed breed dog with a history of a mass with an associated draining tract on the ventral cervical region was diagnosed with an esophageal fistula. The dog exhibited serosanguinous discharge from the draining tract, with enlarged left superficial cervical and mandibular lymph nodes, and was reported to have difficulty with deglutition of solid foods. Computed tomography revealed a communication of the draining tract with the esophagus along with enlargement of the left lateral retropharyngeal, left medial retropharyngeal, and mandibular lymph nodes. This prompted surgical exploration and debridement of the site, with closure of the esophageal fistula. Histopathology of thyroid gland, skeletal muscle, and adipose tissue obtained during surgical exploration showed spherules consistent with  C. immitis or C. posadasii  presented to Midwestern University College of Veterinary Medicine Companion Animal Clinic (MWU-CAC) for evaluation of a subcutaneous mass with a draining tract in the ventral cervical region (day 1). The dog had not displayed any coughing, lethargy or weight loss, however some difficulty swallowing solid food was reported by the owner. The dog could reportedly prehend and chew kibble normally, however, appeared to have difficulty with deglutition. He had lived in Arizona for 3 years and frequently hiked with the owners and was allowed unsupervised time in their yard. The owner first identified a small subcutaneous mass in the region of the right ventral neck 8 months before presentation to the MWU-CAC. This mass enlarged over the next month and a draining tract with thick, purulent discharge subsequently developed. Two months later the primary care veterinarian performed a complete blood count, biochemistry profile, total T4, and a fine needle aspirate of the mass. Biochemical abnormalities included hyperglobulinemia  and hypoalbuminemia . The total thyroxine was within the reference interval  and the complete blood count did not reveal any abnormalities. Fine needle aspiration of the neck mass performed by the primary care veterinarian revealed marked pyogranulomatous inflammation without infectious organisms or neoplastic cells. The primary care veterinarian treated the dog with successive courses of oral clindamycin (4 weeks) and ciprofloxacin (2 weeks). The administration of these antibiotics resulted in transient reductions in mass size and discharge, but never resolved entirely.Physical examination findings at MWU-CAC included heart rate of 90 beats/minute, respiratory rate of 30 breaths/minute, and a normal temperature 101.1°F (38.4°C). Cardiothoracic auscultation did not reveal a murmur, arrhythmia, or abnormal lung sounds. The left mandibular and superficial cervical lymph nodes were enlarged (2 × 2 cm) and firm. A 3 × 3 cm, firm, subcutaneous mass was identified in the left submandibular region. There was a small focal region along the ventral aspect of the mass that actively drained serosanguinous fluid. Differential diagnoses considered at that time included lymphadenitis, sialadenitis, salivary mucocele, neoplasia, and coccidioidomycosis.Computed tomography (CT) imaging of the skull and neck was subsequently performed on day 10 in order to better understand the extent of disease and origin of the mass. Helical images of the skull were acquired with a slice thickness of 1.00 mm and a pitch of 0.85 was used. There was abnormal pre-contrast hypoattenuating tissue that was heterogeneously contrast-enhancing associated with the left aspect of the esophagus . The enhThese results prompted the recommendation of CT imaging of the thorax, but this was declined by the owner in favor of thoracic/neck radiographs and endoscopic evaluation to visually assess the extent of esophageal involvement. Radiographs revealed a mild amount of gas within the cervical and intrathoracic portions of the esophagus . The carCoccidioides spp. spherules)  .Coccidioides present in the aspirate. The PCRs were performed in 20 μL using Promega GoTaq® Green Master Mix , following the manufacturer's protocol. Amplicons were sequenced at Eton Biosciences Inc. . Sequences were edited and assembled using SeqTrace 0.9.0  and C. posadasii  using MUSCLE  agar and incubated at 37°C in ambient air under Biosafety Level 3 containment. Two fungal colonies grew and were subcultured (strains A and B) for DNA extraction as described . PCR price 0.9.0  and theng MUSCLE  to analyescribed . Table 1Coccidioides spp. titers were positive at a titer of 1:2 (IgM) and 1:32 (IgG). Medical management at the time of discharge (day 17) included tramadol (3 mg/kg PO Q8–12hr), fluconazole (6 mg/kg PO Q12hr), amoxicillin/clavulanate (15 mg/kg PO Q12hr), and carprofen (2 mg/kg PO Q12hr). The drain was removed 5 days after hospital discharge. At a recheck appointment 2 weeks later (day 37), the surgery site was again draining fluid, which appeared red and opaque. A 3 cm fluctuant, subcutaneous swelling had developed ~4 cm ventral to the previous drain site, where purulent discharge was still observed. The mass dorsal to the drain site had increased from ~2–2.5 cm, and the left mandibular lymph node remained enlarged. The owners reported that the dog had shown good energy levels at home but had a decreased appetite and occasionally coughed. Serum was submitted to Michigan State University Diagnostic Laboratory to assess thyroid function. Despite Coccidioides infiltration of left thyroid tissue and subsequent hemithyroidectomy, the dog maintained normal thyroid function; total thyroxine , free T4 by dialysis , thyroid stimulating hormone .Serum Coccidioides spherule. The left mandibular lymph node and 2 subcutaneous nodules located on the ventral neck along midline remained unchanged in size. The draining tract was scabbed over but was report by the owner to still be draining. Fluid from the draining tract was evaluated cytologically and revealed marked mixed inflammation with occasional extracellular Coccidioides spp. spherules. In light of this finding the dosage of fluconazole was increased (7.9 mg/kg PO Q12hr).The dog was evaluated again 7 days later (day 44) and new 3 cm by 1.5 cm subcutaneous mass was noted on the craniolateral aspect of right antebrachium. Fine needle aspiration of the mass revealed moderate mixed inflammation and a large, round basophilic structure that appeared to be an empty Coccidioides spp. spherules. The dosage instructions for fluconazole did not change. Follow-up with the owner by phone (day 145) revealed that the dog had no draining tract wounds and normal deglutition.On day 85 (the last day of follow-up) the dog was evaluated as part of a routine reassessment. The owners did not report any abnormalities that had transpired since the last examination. Physical examination revealed a new small 1.5 × 1.5 cm nodule on the ventral neck that ruptured and drained a small amount of serosanguious fluid during the examination. Interestingly, the dog had complete resolution of lymphadenomegaly as well as all previously identified nodules and the draining tract on the ventral neck. Fluid from the ruptured nodule was evaluated cytologically and showed marked mixed inflammation with Coccidioides infection in a dog with dissemination to thyroid gland, adipose tissue, skeletal muscle, lymph node, and connective tissue resulting in fistula formation to the esophagus. Esophageal fistulous communication from the neck to the esophagus via an extension of infection  has not been reported in dogs. Acquired esophageal fistulas in dogs are uncommon and tend to occur secondary to esophageal foreign bodies as well as esophageal diverticula  and itraconazole (5–10 mg/kg/day) are most commonly used, though amphotericin B is used in cases that are unable to tolerate azole antifungals and that have severe or rapidly progressive disease , 8. Debr fistula .In conclusion, this report documents the first case of coccidioidomycosis associated with an esophageal fistula in a dog. This case highlights the importance of including coccidioidomycosis as a differential diagnosis for dogs with pyogranulomatous, chronic inflammation of unknown etiology that have lived in or traveled to endemic regions.All datasets generated for this study are included in the article/supplementary material.AI, JJ, SS, JS, OO, EH, MO, HT, LS, MJO, and MW: medical diagnosis, writing and editing manuscript, and review of final submission.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.


Congenital cysts of the tongue base are an uncommon cause of airway obstruction. The diagnosis of upper airway cysts requires a high index of clinical suspicion. We report a case of a vallecular cyst that uniquely extended to the dorsum of the tongue, and the patient presented with airway distress. We found that this presentation may facilitate an early diagnosis, as asymmetry of the tongue can be picked up easily during proper clinical examination.Therefore, inspection and palpation of the dorsal surface of the tongue is crucial for the approach of pediatric patients with airway obstruction. Congenital cysts of the tongue base are a fairly uncommon cause of airway obstruction ,2. PatieTherefore, the diagnosis of upper airway cysts requires a high index of clinical suspicion because these cysts have a high potential for morbidity and mortality .Anatomically, laryngeal cysts are divided into true vallecular cysts and vallecular pseudocysts depending on their location - whether they are close to the lingual surface of the epiglottis or at the base of the tongue, respectively . The intA 40-day-old baby girl  was delivered by cesarean section after an uncomplicated pregnancy and delivery. Her birth weight was 3 kg, and she was discharged from the nursery along with the mother four days after delivery in good health. She was doing fine until the age of one month when her mother noticed a swelling on the left side of her tongue that progressed in size and resulted in breathing difficulties, mainly during sleep. Positioning the baby on the left lateral side improved breathing. She also had difficulties with cyanotic spells during feeding. After seeking medical advice, the patient was diagnosed with an oral mass with compression to the airway and was then referred to our hospital for further management. The patient was intubated and received nasogastric tube (NGT) feeding.Regarding investigations, routine blood tests were normal, including thyroid function tests. The thyroid scan was normal Figure . ComputeHer clinical picture was consistent with a large oral cyst extending from the base of the tongue to the left side of the dorsum. The risks and benefits of surgical intervention were fully explained to her parent, and after obtaining surgical consent, she was taken to the operating room for surgical excision.The patient was in the supine position and was intubated with a 3.5 mm endotracheal tube (ETT). The mouth was opened using a self-retaining retractor. The tongue was pulled out utilizing a suture at the tip. The cystic mass was visualized and palpitated, measuring approximately 3 x 3 cm on the left side of the tongue, extending to the tongue base Figure . AspiratThe patient remained intubated for one day and was then extubated smoothly. She was kept for observation for one week without any respiratory problems or feeding difficulties and was discharged home in good condition.One month later, when she was seen in the clinic, she had recurrence of the collection that was smaller in size. Therefore, the patient consented for excision of the tongue cyst and was intubated under general anesthesia smoothly with a 3.5 mm ETT. The mouth was opened with a self-retaining retractor and the tongue was retracted utilizing a 2.0 silk suture at the tip. A 2 x 4 cm cystic mass was palpated at the junction of the posterior 2/3 and anterior 1/3 of the left lateral side of the tongue. Then, marsupialization was performed through a 3 cm incision at the midline of the cyst using a mono-polar Colorado needle, and the edges were sutured utilizing an inverted (Vicryl) suture in such a way that the cyst remained open to drain freely. The patient was extubated smoothly and was observed in the postoperative period to be doing fine with no complications.At the two year follow-up, the patient had no recurrence and was doing fine.Congenital cysts of the tongue base are an uncommon cause of airway obstruction. Their incidence in Eastern countries is almost 1.82 per 100,000 live births per year . In the Strider, as a well-known symptom in pediatric patients, has multiple causative conditions. Laryngomalacia represents the most common type. Interestingly, the presence of a supraglottic mass can coexist with laryngomalacia when the mass effect compresses the adjacent epiglottic cartilage and causes supraglottic prolapse .Airway management can be troublesome, especially for patients with a vallecular cyst . As illuThe characteristics of vallecular cysts that determine the mode of presentation are the position and the size, mostly the size, and patients with smaller cysts are usually asymptomatic . In our Flexible laryngoscopy or bronchoscopy are considered the diagnostic tools for vallecular cysts. Therefore, special attention should be paid to the valleculae, as they can be easily missed and lead to misdiagnosis .Early diagnosis of vallecular cysts remains a challenge. Some authors report that large numbers of vallecular cysts are diagnosed at autopsy . HolingeHowever, we expect patients with a vallecular cyst who have a similar presentation as our case to have an early diagnosis since the tongue swelling is easily noted by the parents, as was done in our case. Therefore, early medical advice and management can be obtained. Additionally, asymmetry of the dorsal tongue can be clearly picked up during proper clinical examination, even for inexperienced physicians.Surgical decompression is the treatment of choice. Cyst marsupialization is usually adequate and results in a satisfactory outcome. Simple aspiration or drainage with a simple incision, however, has a high chance of recurrence, as observed in our case .Vallecular cyst is considered a rare and unusual cause of stridor and respiratory distress in children. Early diagnosis remains a challenge and it requires a high index of clinical suspicion. We report a case of a vallecular cyst that uniquely extended to the dorsum of the tongue, and the patient presented with airway distress. Therefore, inspection and palpation of the dorsal surface of the tongue is crucial for approaching pediatric patients with airway obstruction; it can help physicians narrow their differential diagnosis and hence can help with early diagnosis and intervention.


Acute subdural hematoma (aSDH) is a common pathology encountered after head trauma. Only a minority of aSDHs have an arterial source. In this article, we report a case of aSDH originating from a traumatic pseudoaneurysm of the distal segment of posterior cerebral artery (PCA), diagnosed several days after the initial minor trauma and successfully treated with endovascular coiling. This case emphasizes the importance of searching for vascular pathology when the localization, severity or relapsing course of the intracranial hemorrhage does not fully correspond to the severity of initial trauma and when the bleeding has a delayed onset. Characteristics, diagnostics and treatment possibilities of traumatic cerebral aneurysms, an important cause of arterial aSDH, are described in the article. Acute subdural hematomas (aSDHs) often arise after head trauma due to a rupture of the cortical or bridging veins. Spontaneous aSDH of an arterial origin is on the other hand a rare clinical entity, which typically originates from branches of the middle cerebral artery (MCA) with truly spontaneous onset or following apparent minor trauma. A spontaneous aSDH of arterial origin arising from branches from the posterior cerebral artery (PCA) with no pre-existing aneurysms is exceptionally unusual, with only one case previously reported to our knowledge (Yasui 1995). We report a case of an initially misdiagnosed aSDH of arterial origin due to rupture of the P3/P4 segment of PCA after minor head trauma, which was eventually successfully treated by endovascular coiling. The objective of this case report is to highlight the possible causes of arterial aSDHs and the need to examine the patient for vascular pathologies if encountering a hemorrhage with an atypical clinical or radiological pattern.A 30-year-old male without past medical history reported himself to the emergency ward after a minor crash on a bicycle against a runner earlier that day. He was not wearing a helmet and he was not under the influence of alcohol or drugs. There was no loss of consciousness and his Glasgow Coma Scale (GCS) was 15. He had a minor excoriation on the forehead, pain in his left elbow and right wrist, where fractures were subsequently excluded. Initially, no computed tomography (CT) scan of his head was performed due to unremarkable neurological examination. However, before leaving the emergency ward, his headache worsened  and his GCS decreased to 14 points (with eye opening on command). He became somnolent, there was no extremity paresis or cranial nerve abnormality and his pupils were equal in size, but with a slightly delayed response to light. A CT scan was therefore performed, which showed a small right-sided parietal epidural hematoma (EDH) and small posterior left-sided tentorial and posterior interhemispheric subdural hematoma (SDH) with only a minor local mass effect . No subaAcute subdural hematoma (aSDH) can occur in a broad range of head traumas as a result of the rupture of cortical bridging veins or surface veins, with blood accumulation between dura mater and arachnoid membranes. It complicates about 11% of mild to moderate traumatic brain injuries (TBIs) requiring hospitalization, and about 20% of severe TBIs . Most frInfrequently, aSDH may result from the rupture of a traumatic intracranial aneurysm (TIA) . This anIn the case of aSDH originating from PCA described by Yasui et al. , there wBecause of the rarity of TIAs, there are no randomized controlled trials providing treatment recommendations. Our patient’s pseudoaneurysm was successfully treated with coils, though complicated by infarction of the left PCA territory. Unfortunately, some TIAs can be difficult to be treated endovascularly because of strenuous catheterizing to reach the peripherally located aneurysm, risking perforation or dissection of the parent vessel and distal infarction. Additionally, coiling or clipping of the fragile pseudoaneurysm can easily lead to intraprocedural aneurysm rupture. Other treatment possibilities include endovascular or surgical parent vessel sacrifice as well as stenting or placement of flow diverters ,15. SomeSome acute subdural hematomas can have an arterial origin. Traumatic brain aneurysms constitute a possible etiology and can result in delayed rebleeding with a very high mortality rate. Repeated vascular studies should be advised shortly after traumatic brain injury in patients suspected for vascular damage and the aneurysm should be occluded early after the diagnosis.


Osteochondroma (OC) is considered the most common tumor of the axial skeleton, although it is relatively uncommon in the craniofacial region. The present case describes an atypical case of OC in the posterior border of the ramus of the mandible. To the best of our knowledge, only one case has been reported till now in this region. A 35-year-old male patient reported with a complaint of swelling over the left middle one-third of the face and limited mouth opening for six years. Panoramic radiograph (PR) and paranasal sinus (PNS) view showed a well-defined radiopacity located in this region. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a characteristic mushroom-shaped outgrowth from the inner surface of the ramus of the mandible. The patient was treated with osteotomy, with the cut made at the angle of the mandible. Histopathological examination revealed features suggestive of OC. Subsequently, the patient was able to open his mouth, and there was no evidence of recurrence or postoperative complications in the one-year follow-up. Osteochondroma (OC) is a primary benign bone tumor of the long bones commonly involving the axial skeleton such as the metaphysis of the femur and tibia bones . OC of tA 35-year-old male patient reported to the dental clinic with a complaint of swelling over the left middle one-third of the face for six years. History of swelling was provided as gradual in onset, slow-growing, and stable with no regression in size ever. The swelling was not associated with pain, paresthesia, discharge, or difficulty in eating. No significant history of trauma, infection, or medical conditions was reported. Neither similar swelling anywhere in the body was recorded. Facial asymmetry was present with restricted mouth opening on clinical examination, with solitary localized diffuse swelling at the preauricular region, just in front and 1 cm below the level of the left tragus of the ear. The swelling size was approximately 2 cm × 2 cm in diameter with diffuse periphery . The surPanoramic radiograph and paranasal sinus radiograph showed a well-defined radiopacity located at the left posterior ramus of the mandible region Figures  and 3. TSurgical exploration of the growth was performed through the Alkyth-Brameley preauricular and submandibular approach  and osteWHO defined OC as cartilage-capped bony projection arising from the external surface of bone containing a marrow cavity that is continuous with that of the underlying bone . VariousOsteochondromas are very rare in the maxillofacial region. In 1899, Jacob was the first to explain an OC of the coronoid process; for this reason, this condition has been named “Jacob's disease” . In the They have been reported in varied locations of the craniofacial region, where the most common sites are the coronoid process and the condyle . It is aPanoramic radiography is the primary radiologic examination that is required for diagnosis. An OC appears as a stalk or a flat protuberance emerging from the surface of the bone. On occasion, it ends up as a hook-like formation. Its margins are usually well defined, although the tumor seems to be continuous with the cortex of the bone. A usual finding is that of radiopaque calcified flakes or linear interruptions inside the cartilaginous component of the OC. Panoramic radiography helps in diagnosing the lesion as benign or malignant. Sometimes, an osteochondroma turns into osteosarcoma indicating enlargement of the tumor and the irregularity of its margins. Multiplication of the ossifications, pain, scattered calcifications, and a coexisting radiopaque soft tissue mass may suggest a sarcomatous transformation. In addition, the presence of periosteal reaction with lobulated margins may be present in osteosarcoma , 9.CT and cone beam computed tomography (CBCT) are accurate methods for depicting OC. They can show the bony lesion in detail, as well as show the presence of calcifications and thickness of the cartilaginous cap. But CT and CBCT cannot estimate the metabolic activity, a serious indication of malignancy of any tumor. A scintigraphic method is being used to examine the metabolic activity of the tumor. A poor metabolic activity is only present in benign lesions. Ultrasound radiography helps to examine the cartilaginous cap of the OC as a hypoechoic area above the cortex of the relevant bone , 9.MRI can know the exact morphology of a tumor and any compress over the surrounding structures. MRI is used to verify the continuity of the growth with the cortex of the affected bone. MRI shows a well-defined irregular lesion showing signal intensity similar to that of bone marrow in the center, surrounded by an iso- to hyperintense rim with few hypointense areas predominantly in the posterior aspect suggestive of the cartilage cap. The cartilaginous cap, as it is rich in water, presents a high signal on T2-weighted MRI and a low one on T1-weighted imaging. T2-weighted MRI is preferable because it provides better differentiation of signal intensities, and differentiation in the signaling of a nerve may suggest its suppression or damage. Woertler et al. indicated that the cartilage cap thickness exceeding 2 cm in adults and 3 cm in children should raise the suspicion of malignant transformation. Chondrosarcoma is also characterized by low T1 signal after intravenous contrast infusion (gadolinium), something that is rarely recorded in a benign cartilaginous tumor. So MRI is the gold standard technique for detecting a malignant transformation , 9.Regardless of the etiology, the goal of treatment is complete resection of the lesion and recovery of acceptable mouth opening. After surgical excision, the recurrence rate is found to be 2% in solitary osteochondroma cases all over the body. No signs of recurrence were found in our case until now. Malignant change may occur in about 5% of cases with multiple hereditary lesions, but solitary osteochondromas have a 1% risk of malignant transformation .Craniofacial osteochondroma, in the mandibular posterior ramus region, is extremely a rare entity. Panoramic radiography at best can be considered a screening modality in the detection of these lesions. Because of the characteristic radiographic appearance of mandibular osteochondroma, CT and MRI provide a valuable tool to assist in evaluation and treatment planning. The recommended treatment of choice for symptomatic osteochondromas is surgical resection and follow-up because it may transform into osteosarcomas.


Patients with focal nodular hyperplasia (FNH) develop benign hepatocellular nodules. FNH most frequently occurs in young women. There are no reports of the onset of FNH in elderly men. We report a case of FNH in an elderly man, whose nodules increased in number and size. The patient underwent surgery for carcinoma of the left renal pelvis at 69 years of age; no liver masses were noted on yearly follow-up contrast-enhanced computed tomography (CECT). Ten years later, CECT revealed a hepatic mass, and magnetic resonance imaging suggested FNH. The nodules increased in number and size in subsequent follow-up examinations. Patients with focal nodular hyperplasia (FNH) develop benign hepatocellular nodules. FNH shows characteristic immunohistological findings without genetic mutations. On contrast-enhanced computed tomography (CECT), the nodules show a hypervascular pattern. When central scarring is present, a spoke wheel appearance is observed . On ultrEpidemiologically, FNH occurs more frequently in women of between 20 and 50 years of age; there have been no reports of the progression of FNH in elderly men. The natural course of FNH remains largely unclear as few reports have investigated this issue , 9–11. TThe patient was an 89-year-old man who had undergone curative radical resection via left nephroureterectomy for carcinoma of the left renal pelvis at 69 years of age and who was subsequently attending regular follow-up examinations. Plain and single-phase CECT scans were examined once per year. CECT, performed during a regular follow-up examination when the patient was 79 years of age, revealed a mass of 25 mm in diameter in segment 7 of the liver with uniform contrast. Ultrasound revealed a nodule with an unclear border and irregular shape and fairly hyperechoic signals. CT and ultrasound examination showed no splenomegaly. Positron emission tomography-CT (PET-CT) was performed as liver metastasis of carcinoma of the renal pelvis was suspected, but no uptake of F-18 fluorodeoxyglucose (FDG) was observed at the lesion site. As the EOB-MRI findings were suggestive of FNH, a conservative approach with regular follow-up examinations was taken. At 80 years of age, the patient developed acute myocardial infarction and his left ventricular ejection fraction (32%) was severely decreased. No changes were noted in the nodules until the patient was 87 years of age when EOB-MRI revealed a nodule of 12 mm in diameter exhibiting the same findings behind the existing FNH. The nodule was found to have increased to 20 mm in size on EOB-MRI performed when the patient was 88 years of age, and a nodule of 9 mm in diameter was also observed on the border of the right lobe. When the patient was 89 years of age, EOB-MRI again revealed 1 new nodule on the right lobe and 1 new nodule on the left lobe of the liver. Subsequently, a liver biopsy was performed . The nodule diameter on EOB-MRI, when the hepatic mass was first identified, was 25 mm. On T1-weighted images, it was hypointense, and on T2-weighted images, it had a hyperintense center. A dynamic study utilizing T1-weighted images revealed the lesion to be hypervascular , performed during the liver biopsy, revealed a nodule of 35 mm in diameter with unclear borders, an irregular shape, and fairly hyperechoic signals in segment 7 on B mode images. The nodule had no halo. We did not note any posterior echo enhancement or lateral shadows  Fig. d.In the post-vascular phase (Kupffer phase), there was no defect in the lesion Fig. e.The background liver was normal Fig. a. The hiHistological findings showed that there was no recurrence of carcinoma of the renal pelvis.FNH is a hyperplastic lesion with a hypervascular appearance on various images. Previously, it had been difficult to differentiate FNHs from hypervascular hepatocellular carcinomas; thus, hepatectomy was commonly performed. In addition, it tends to be difficult to differentiate FNHs from hepatocellular adenomas (HCA). However, advances in diagnostic imaging and pathology have made it possible to definitively diagnose the condition with biopsy, and a conservative approach with regular follow-up examinations is now commonly selected. According to the WHO Classification of Tumors of the Digestive System 2010, HCA can be classified by genetic type into 4 subtypes . HCA canOur patient developed FNH while undergoing follow-up after surgery for carcinoma of the renal pelvis. There was no hepatic mass on CECT at 78 years of age. The following year, CECT showed a 25-mm hypervascular mass in the right lobe of the liver. In this extremely rare case, we observed increases in the size and number of FNHs while following the patient for FNH. The patient’s diagnostic imaging findings were suggestive of FNH and the condition was diagnosed pathologically. Background factors related to the development of benign hepatocellular nodules include FNH, nodular regenerative hyperplasia, and partial nodular transformation. These lesions are caused by anomalous components of the portal tract and are called “anomalous portal tract syndrome” , 15. FNHMultiple FNHs commonly complicate cases of congenital heart disease or liver disease with blood flow abnormalities. It has been reported that FNH may arise in cases of congenital heart disease following Fontan surgery for cases of the single cardiac ventricle . Liver dA Glisson’s capsule abnormality might have played a role in the development of FNH. However, our case did not involve congenital heart disease or liver disease with blood flow abnormalities; thus, the cause of the increase in the size and number of lesions was unknown.While most aspects of the natural course of FNH remain unknown, a small number of cases have been reported. Two reports said that FNHs increased in 2 of 18 cases  and 1 ofFNH occurs more frequently in women of between 20 and 50 years of age. The abovementioned reports included a large proportion of female patients of 15–54 years of age  and 16–6While the cause of progression of FNH in our patient remains unclear, we reported a very rare case in which FNH nodules increased in size and number in an elderly man.We reported a valuable case involving an elderly male patient with FNH who was observed from a time in which liver mass was observed on imaging. In the present case, FNH appeared and the size and number of the nodules increased during the observation period.


Spontaneous rupture of acquired bladder diverticulum in an adult patient is an extremely rare pathological entity with only 15 cases reported in the available literature. Etiologies are dominated by bladder outlet obstruction, represented mainly by benign prostatic hypertrophy (BPH) in elderly men. Clinical presentation is nonspecific, leading to delayed diagnosis and treatment. Surgical management is the standard approach for intraperitoneal rupture of bladder diverticulum. The prognosis depends on the earliness of treatment, associated comorbidity, and the nature of underlying diseases. Herein, we report a rare case of a 65-year-old male patient, who presented a spontaneous rupture of a large acquired bladder diverticulum, secondary to acute urinary retention complicating benign prostatic hypertrophy. The diagnosis was suspected in the presence of generalized peritonitis associated with lower urinary tract symptoms (LUTS) and was confirmed accurately and promptly by a computed tomography (CT) of the abdomen and pelvis. The patient underwent a successful surgical excision of the diverticulum and bladder repair without delay. The postoperative course was uneventful, and he was discharged from the hospital without any complication. Spontaneous rupture of acquired bladder diverticulum in an adult patient is a very rare pathological entity; to the best of our best knowledge, only 15 cases have been reported in the literature, and we add case 16 . A bladdHere, we report a rare case of spontaneous intraperitoneal rupture of bladder diverticulum secondary to an episode of acute urine retention complicating benign prostatic hypertrophy, described in a 65-year-old male patient with a history of untreated BPH, and which was successfully managed by a prompt diagnosis and surgical treatment. Through this report, we aimed to highlight this rare cause of acute peritonitis, as well as to discuss the different clinical, etiological, and therapeutic aspects of this surgical emergency.A 65-year-old man, with a history of benign prostatic hypertrophy (BPH) not followed for 2 years, without other medical complaints, was admitted to the emergency for acute urinary retention (AUR); he underwent urethral catheterization and returned home with alpha-blocker therapy, and two days later, he represented to the emergency department with diffuse acute abdominal pain, especially in the hypogastric region, nausea and vomiting, associated with generalized weakness and fever.Physical examination of the abdomen revealed diffuse tenderness associated with muscle guarding and rebound pain especially in the hypogastric area, without distended urinary bladder; the digital rectal examination (DRE) was painful and found a firm and enlarged prostate gland. His temperature was 38°C, with blood pressure of 125/62 mmHg, heart rate of 94 beats/min, and respiratory rate of 17 breaths/min.3, increase in serum urea of 0.73 g/dL and in serum creatinine of 27 mg/dL, with elevated of white blood cell (WBC) of 17,300/μL, and C-reactive protein (CRP) of 96.2 mg/dL. After conditioning, an intravenous antibiotic was administered, and a urinary catheterization had given 80 mL of cloudy urine, and the urine test strip was positive.Laboratory testing revealed hemoglobin of 12.8 g/dL, platelet count of 520,000/mmUltrasonography (US) showed bilateral hydroureteronephrosis with empty bladder containing a small amount of urine and a large bladder stone; these findings are associated with the presence of a large full bladder diverticulum and a small amount of free peritoneal fluid. CT of the abdomen and pelvis without contrast (due to the kidney failure) confirmed the presence of a small amount of free fluid in the abdominal cavity, associated with massive fluid accumulation in the right anterolateral paravesical space, between the bladder and the anterior abdominal wall Figures , and 3, The patient was transferred to the operation theater, and an emergency midline laparotomy was performed, revealing an intraperitoneal rupture of a large bladder diverticulum which was located on the right superolateral wall of the bladder, with fluid collection around it, and free purulent fluid in the abdominal cavity; there was no evidence of pathologic lesions at the site of the injured diverticulum and peritoneum. A copious saline lavage of the peritoneal cavity was done, the diverticulum was excised, the bladder stone was removed, and the bladder defect was repaired in two layers with continuous 2/0 Vicryl sutures. Successful repair of the bladder defect was confirmed intraoperatively by the absence of leakage when filling the bladder, and a pelvic drain left in situ at the end of intervention.The postoperative course was uneventful. The inflammatory markers and renal function showed decreases over the following days to reach its normal level. Cystogram performed at the eighth day showed a watertight bladder.The patient was discharged from the hospital at the 10th day with an indwelling bladder catheter, and a transurethral prostatic resection (TUPR) was planned after 6 weeks.Urinary bladder ruptures are in most cases secondary to blunt abdominal trauma, pelvic fractures, or iatrogenic causes, and 96.6% of all cases of bladder ruptures are posttraumatic , 9. A spBladder rupture can be classified into intraperitoneal or extraperitoneal types depending on the defect location, which occurs usually in the bladder dome which is the weakest point of the bladder wall, causing an intraperitoneal bladder rupture , 10, 11.The clinical presentation is nonspecific, including painful abdominal distension, decreased urine output, and voiding complaints , 11, andConsidering its rarity, the diagnosis should be suspected in the presence of the past urological history of risk factors suggestive of bladder rupture, associated with symptoms of acute abdomen. The positive diagnosis is based on CT cystography which remains the gold standard for the diagnosis, and it is most sensitive for detecting the presence of bladder perforation than ultrasound or conventional CT . CT cystWhen diagnosed, treatment depends on type of bladder rupture as well as the presence of an underlying pathology which may require additional treatment . IntrapeAfter the acute episode, a special consideration must be given to the treatment of the associated diseases to prevent recidive. In our case, conservative management has not been attempted because of the presence of clinical and biological sepsis, and the presence of bladder stone requiring surgical treatment. The uneventful postoperative course without complication can be attributed to the prompt diagnosis and treatment and the absence of other associated pathologies.Spontaneous intraperitoneal rupture of bladder diverticulum is a rare surgical emergency, and diagnosis should be suspected without delay in the presence of acute abdomen associated with lower urinary tract symptoms. Prevention requires better management of underlying pathologies and risk factors, and prompt and accurate diagnosis is the key for successful management.


Giant ovarian cysts, which are described in the literature as measuring more than 10 cms in size in their largest diameter, are rare in occurrence. With the availability of multiple imaging modalities and routine physical examinations, it has become even rarer to find such cases. Ovarian serous cystadenomas, which are benign tumors arising from the ovarian epithelium, represent the most common type.We present a case of a 58-year-old female who came to establish primary care in our clinic. She reported ongoing symptoms of constipation, abdominal discomfort, bloating, as well as intermittent postmenopausal bleeding for the past few months. The patient reported taking over-the-counter medications for her predominant gastrointestinal symptoms with no improvement at all.Transvaginal ultrasonography (TVUS) and magnetic resonance imaging (MRI) of the pelvis revealed the presence of giant bilateral ovarian masses measuring more than 17 X 10cms each. Further testing revealed highly elevated levels of tumor markers cancer antigen 125 (CA-125) and human epididymis protein 4 (HE-4). The patient subsequently underwent total abdominal hysterectomy (TAH) and bilateral salpingo-oophorectomy (BSO). Her histopathology report revealed the presence of bilateral benign cystadenomas.From a primary care physician's perspective, this case highlights the importance of possible rare pathologies that can present with symptoms of a completely unrelated organ system. Even with the rarity of these cases, a clinician may encounter such a case in their everyday practice. Patients can endorse a plethora of vague complaints, often masquerading other entities seen commonly in the clinic. An ovarian cyst is a common condition seen in clinical practice and is a common cause of pelvic/adnexal masses . Giant oAdvancement in imaging modalities and routine physical examinations have enabled clinicians to diagnose ovarian cysts while they are at a relatively smaller size.Giant cysts are often misdiagnosed due to their vague symptoms and non-specific findings. Also, a delay in diagnosis, especially among asymptomatic patients, is seen due to their varied presentations.Our patient is a 58-year-old Caucasian female with a past medical history of hypertension, hyperlipidemia, class III obesity, diabetes mellitus, tobacco use, obstructive sleep apnea, gastroesophageal reflux disease, and hypothyroidism who presented to the Family Medicine clinic for evaluation of vague abdominal symptoms, such as constipation, abdominal discomfort, bloating, as well as intermittent postmenopausal bleeding, for the past six to eight months.She denied being sexually active for the last five years. She did not endorse vaginal discharge, fever, chills, abdominal pain, flank pain, dysuria, hematuria, pelvic discomfort, low back pain, or noncompliance with thyroid medication. Gynecologic history was significant for menarche at age 12 and premature menopause at age 38, and surgical history was significant for having undergone a cesarean section at 30 years of age. Family history was significant for lymphoma in mother, breast cancer in paternal aunt, and pancreatic cancer in maternal grandmother.During her office visit, her pelvic exam revealed a normal bimanual exam without masses, fullness, or cervical motion tenderness. The uterus was normal by palpation. Papanicolaou smear was also done at this visit. Her cervical cytology was negative for any intraepithelial lesion as well and negative for high-risk HPV.Lab work, including thyroid-stimulating hormone (TSH), complete blood count (CBC), comprehensive metabolic panel (CMP), follicle-stimulating hormone (FSH), and luteinizing hormone (LH) were unremarkable. Her bilateral mammogram was reported as being benign.Transvaginal ultrasound was significant for bilateral multilocular cystic masses with thin septations and hypoechoic fluid suspicious for serous or mucinous cystadenoma and thickened endometrium of 17 mm.Magnetic resonance imaging (MRI) without contrast of the pelvis confirmed bilateral multicystic ovarian masses measuring 16 x 10 cm and 17 x 9 cm with the presence of thick septations and papillary-like projections Figures . The patCancer antigen-125 (CA-125) and human epididymis protein 4 (HE4) performed at that visit were elevated at 272 U/ml and 229 pmol/L. The patient was then referred to Gynecological Oncology for surgical intervention. She underwent exploratory laparotomy, bilateral salpingo-oophorectomy, and total abdominal hysterectomy Figures -4.The histopathology report revealed bilateral serous cystadenomas with focal epithelial proliferation to the right ovarian mass and endometrial polyps, adenomyosis, and multiple leiomyomas in the uterus Figures -6 No furEpidemiologyOvarian cysts are a very commonly encountered condition in females . WorldwiGiant ovarian cysts, which are generally described as more than 10 centimeters in size in their largest diameter , are rarDemographyPer the 2014 World Health Organization (WHO) classification and tumor morphology, primary ovarian tumors are categorized into three types of tumors: epithelial (60%), germ cell (30%), and sex-cord stromal (8%) . The ovaBenign serous tumors, which include cystadenomas, adenofibromas, and surface papillomas, account for about 25% of all benign ovarian tumors and 58% of all serous ovarian tumors ,9.Ovarian serous tumors are bilateral in 10% of patients. Of all serous tumors, about 70% are benign, 5%-10% have borderline malignant potential, and 20%-25% are frankly malignant. They tend to be multilocular and can include papillary projections but unilocular serous cystadenomas are not uncommon .A review of racial distribution revealed that malignant epithelial cystadenomas were highest among American Indian women, followed by white, Vietnamese, Hispanic, and Hawaiian women. The incidence is lowest among Korean and Chinese women. However, no data for ovarian cysts could be obtained .Clinical presentationThese masses can have a wide range of presentations that a clinician needs to be aware of. They can be entirely asymptomatic , or patiDifferential diagnosesThe differential diagnoses of giant ovarian cysts are extensive and can include benign and malignant gynecologic and non-gynecologic diagnoses  ranging DiagnosisAfter the initial clinical evaluation, imaging modalities, such as transvaginal and transabdominal ultrasonography, computed tomography (CT), and MRI of the abdomen and pelvis are used to corroborate the diagnosis -10,12,15Tumor markersTo detect the potential malignancy associated with ovarian tumors, tumor markers can be used preoperatively. CA-125, also known as mucin16, is a widely used marker and is useful in distinguishing malignant from benign pelvic masses. If a postmenopausal patient with an adnexal mass has serum CA-125 levels above 200 U/mL, the positive predictive value is of it being malignant is 96% . In premHuman epididymis protein 4 (HE-4) has shown superiority over CA-125 as a biomarker, specifically with its higher sensitivity to distinguish benign diseases from malignancies .ManagementThe mainstay of treatment is the removal of the mass. This requires proper planning of the modality of approach, which can include en bloc removal versus slow percutaneous drainage. The approach depends on the size and skills of the operating surgeon while keeping in mind the risks of the development of potential surgical complications.Giant ovarian cysts are rare findings in current clinical practice, as advancement in imaging modalities and routine physical examinations have enabled clinicians to diagnose them while they are at a relatively smaller size. Our patient had predominantly vague gastrointestinal symptoms, completely unrelated to the actual diagnosis. This case highlights the importance of considering giant ovarian cysts as a differential diagnosis of vague abdominal symptoms, as these patients can have varied presentations.


Pulmonary artery intimal sarcoma (PAIS) is a rare and highly aggressive tumor, and approximately 80% of pulmonary cases occur in the pulmonary trunk. We report herein a case of retrograde extension of the sarcoma to the pulmonary valve and right ventricle, which is an uncommon manifestation of this lethal tumor.A 41-year-old woman was initially diagnosed with pulmonary thromboembolism (PTE) and transferred to our hospital.Computed tomographic pulmonary angiography (CTPA) showed that there are low-density filling defects in both pulmonary arteries, and the patient was diagnosed with PTE. However, the ultrasonographers considered that the lesion is a space-occupying type that involves the right ventricular outflow tract and pulmonary valve instead of PTE. Postoperative pathology confirmed the diagnosis of PAIS.The patient underwent resection of pulmonary artery sarcoma and endarterectomy.During the follow-up via telephone 1 month after discharge, the patient reported to have been feeling well.Owing to the rarity of the disease and its non-specific clinical manifestations, approximately half of the PAIS cases are misdiagnosed or have a delayed diagnosis. Thus, improving our understanding of the disease and facilitating its early diagnosis are essential. Owing to the low incidence of the disease, we still do not understand its etiology and risk factors. It is often misdiagnosed because its clinical and imaging manifestations are similar to pulmonary thromboembolism (PTE). At present, the diagnosis of pulmonary artery (PA) endometrial sarcoma is based on the results of the autopsy and postoperative histopathology is considered the “golden standard”. Given its rapid growth, it can result in right heart failure and pulmonary obstruction in a short time, thus, early diagnosis and surgical resection are the key to its treatment.Pulmonary artery intimal sarcoma (PAIS) is very rare and arises from primitive pluripotent mesenchymal cells with multi-directional differentiation capacity.We report herein a rare case of retrograde extension of the sarcoma to the pulmonary valve and right ventricle.2A 41-year-old woman who complained of chest tightness after performing an activity, presented with aggravation of symptoms in our hospital. She was diagnosed with pulmonary embolism in a different hospital, prior to her transfer in our institution. The patient occasionally had cough, expectoration, blood in the sputum, and nocturnal sweating, but she had no edema in the lower extremities, fever, smoking history, and related genetic history in the family. There were two transient syncope episodes in the course of the disease. Blood oxygen saturation was 72% and carbohydrate antigen 125(CA125) was 230.2 U/ml at admission. Other physical examinations and laboratory data were unremarkable. Computed tomographic pulmonary angiography (CTPA) showed that there are low-density filling defects in both PAs, and then the patient was diagnosed with PTE  results were as follows: ER(−), PR(+), CD31(−), CD34(−), DOG(−), SMA(+), Desmin(+), H- Caldesmon(+), EMA(-), CK(AE1/AE3)(+), Vimentin(+), S-100(−), K167(30%), LCA(−), ALK(-), CD30(−), CD17(−), DOG-1(−), WT19(−)and calretinin (−). The patient stayed in the intensive care unit (ICU) for 3 days and transferred back to the general ward. However, she refused to undergo radiation and chemotherapy. During the follow-up via telephone 6 month after the operation, the patient reported that she has been feeling well.3 Approximately, 400 cases of PAIS have been reported since Mandelstamm first reported the disease, after he detected it during an autopsy in 1923.,6 The average age at diagnosis is 49.3 years with a wide age range of 13 to 81 years. No significant difference in the sex ratio has been found until now, possibly because of the difficulty in obtaining diagnostic material and general unfamiliarity with the entity. Most of the PA tumors occur in the pulmonary trunk and bifurcation. A previous report demonstrated that PAIS had an intraluminal polypoid growth pattern macroscopically. At present, Kim et al introduced a new point of view based on computed tomography(CT) images. They believe that PAIS has different growth stages. At first, polypoid tumor foci of PAIS form in the intimal layer of the PA first; these subsequently extend along the vessel, forming a cauliflower-like mass or diffuse/focal wall thickening; Finally, the tumors become compact and occupy almost the entire PA lumen. Typically, intimal sarcomas of the pulmonary artery show histological features of undifferentiated/unclassified sarcoma with focal or diffuse myxoid changes. Microscopically, they show multifocal gelatinous, polypoidal nodules or plaques, comprising spindled or epithelioid cells with marked nuclear atypia. The morphology of differentiated sarcoma can be manifested as myofibroblastoma, malignant fibrohistiocytoma, angiosarcoma, leiomyosarcoma, rhabdomyosarcoma, myxoid chondrosarcoma, and so on. Therefore, a variety of tumor components can be observed in the differentiated sarcoma, among which angiosarcoma is the most common one.Intimal sarcomas are most commonly found in the pulmonary arteries and aorta, and pulmonary cases are almost twice as common as aortic cases. Physical examination showed pulmonary hypertension and hyperactivity of the second heart sounds in the pulmonary region due to the high right ventricular load, and systemic congestion. The most common manifestation is a systolic murmur in the pulmonary area. Xin et al analyzed patients’ data and found elevated serum inflammatory markers, including an elevated erythrocyte sedimentation rate, lactate dehydrogenase level and C-reactive protein level. Serum levels of carcinoembryonic antigen were within the reference range in all of the patients. These clinical features and laboratory results have no obvious specificity. Now, there are some studies showing that the in situ hybridization results for MDM2 amplification were helpful in determining the accurate diagnosis. The diagnostic findings in PAIS are over expression of MDM2 and gains and amplification of the 12q13–14 region.The onset of PAIS is occult. Its clinical symptoms and signs are not specific. Moreover the early symptoms may be clinical manifestations of pulmonary embolism, such as chest pain, hemoptysis, sexual dyspnea, and with the increase of tumor, it can cause stenosis of the lumen, thereby increasing the pulmonary artery pressure. The corresponding clinical symptoms, such as cyanosis, edema, jugular vein rage, hepatomegaly and splenomegaly, may occur in the late stage of pulmonary circulation obstruction, which may result in distant metastasis. Based on the abovementioned situation, although we cannot rely on it to make a clear diagnosis due to the limitations of TTE, a series of image prompt messages brought by it are still indispensable. Diagnosis of pulmonary artery sarcoma (PAS) by endobronchial ultrasound-guided transbronchial needle aspiration has also been reported previously.Until recently, considerable advances have been made in the use of imaging technologies for the diagnosis of PAIS before surgery. We performed a comparative analysis to each kind of image examination in the following texts. Transthoracic echocardiography's (TTE) main function is to provide the relevant information of the pulmonary valve and the right heart, such as whether the pulmonary artery has been eroded and whether the right heart is dysfunctional. It also can be used to evaluate PAIS by location, morphology, relationship with surrounding tissues, hemodynamics and other aspects. However, it requires ultrasonographers to have high technical and clinical experience. Moreover, the effects of the PA lesions on other cardiac structures and pulmonary physiology were not recognized.,17 A review of literature helps in differentiating these diseases from each other. PAS lesions are continuous, with rounded, bulging, or lobulated surfaces that project in the direction of blood flow, they develop as the tumor tissue accumulates, expands and invades surrounding tissues. Pulmonary emboli appears as cup-like structures in CT images when were viewed against the blood flow. This may be the result of friction caused by blood flow at the surface clot, which is undergoing dissolution by the fibrinolytic system of the blood. The presence of extraluminal tumor extension and distant metastases is a reliable sign in the differential diagnosis, but these are manifestations of advanced cancer of intimal sarcoma. Although both show enhancement on the CTPA, intimal sarcoma tends to present as a unilateral, central, lobulated, PA filling defect which increases in size along with the increasing diameter of the PAs and has acute angles with the vessel wall, in contrast to the PTE.–22 Moreover, intimal sarcoma shows heterogeneous densities due to areas of necrosis, hemorrhage, and ossification within the mass. Therefore, the detection of morphological differences in lesions during CTPA is critical for distinguishing PAS from PTE. The positron emission tomography (PET)-CT was used to distinguish PTE on the basis of the increased radio pharmaceutical uptake of tumors. Moreover, it is also sensitive to distant metastases. Now, magnetic resonance imaging (MRI) plays an increasingly important role in the diagnosis of PAIS. The excellent spatial and tissue resolution in MRI is advantageous for the diagnosis of PAS and it allows for tissue characterization, providing insight into the tumor type.,24 Cine MRI can be used to observe the movement of a PAS tumor in response to the changes in blood flow between pulmonary diastole and systole. The MRI signals of a PTE vary across the different stages of thrombosis, and can appear as high signals in both T1W and T2W scans. After MRI enhanced scanning, PAS showed a heterogeneous enhancement, whereas PE did not. However, many patients with PAS have difficulty, holding their breath long enough to allow MRI scanning, which limits the use of MRI for the diagnosis of PAS.CTPA is often our preferred method of examination, although the findings of CTPA for PAS and PTE are similar with respect to the filling defects in the pulmonary trunk, which is the main reason why we often misdiagnose them. Even after complete surgery, the prognosis of PAIS is poor because of frequent relapses, more often local than distant. Postoperative chemotherapy and/or radiotherapy have been shown to improve the efficacy of the available treatments for PAS, but there are no guidelines for this.,29 Anthracyc-lines, especially doxorubicin, are a standard drug in the treatment of soft tissue sarcomas. It is reported that combining cisplatin and vinorelbine as the 2nd therapeutic line, which was better tolerated and led to a remarkable partial response. Molecular evidences have shown a potential effect of tyrosine kinase inhibitors on intimal sarcoma. However, the use of MDM2 small-molecule antagonists to block the interaction between p53 and MDM2, restore the p53 pathway, and inhibit tumor cell proliferation has been reported.PAIS is a malignant tumor that progresses rapidly. If the intervention is delayed, the prognosis is extremely poor and the recurrence rate is high. At present, the main treatment for PAS is resection of sarcoma. Compared with isolated tumor resection, pulmonary endarterectomy seemed to yield a better survival rate. In previous reports, the mean survival in untreated patients was approximately 1.5 months, and even in cases when surgical resection of the tumor was performed, more than half of the patients died within 1 year after surgery.,35 Recently, Bandyopadhyay et al reviewed a total of 391 cases previously reported in the English language literature and revealed that patients who underwent complete surgeries had significantly improved survival compared to those who underwent partial resection. The specific factors affecting prognosis are not clear, including:Even if treated, the postoperative survival rates is still poor, with a median overall survival ≤18 months.1.Whether the tumor can be completely resected, whether the tumor has local recurrence and whether there is distant metastasis2.Pathological types, such as smooth muscle sarcoma has a relatively good prognosis, whereas rhabdomyosar-coma has the worst prognosis and well-differentiated muscle fibers retinoblastosarcoma may have a good prognosis.3.Age of onset, patients aged <40 years have usually a better prognosis4.Postoperative chemoradiotherapy can improve the prognosis.PAS is often misdiagnosed because of the same hemodynamic changes and clinical manifestations with chronic pulmonary embolism. We have reviewed the related literature, summarized and analyzed the differences in the following aspects1.Medical history: Patients with PAIS have a long course of disease, which is manifested by recent aggravation without a history of bed rest, surgery, fracture, and so on. PE patients usually have a sudden onset and have a history of corresponding thrombosis, with more acute and rapid clinical manifestations.2. This information deserves our utmost attention.Clinical manifestation: PAIS patients with insidious onset, have clinical symptoms and signs without specificity. In addition to the symptoms, including dyspnea, syncope, palpitations, chest pain and hemoptysis, the constitutional symptoms, such as fever fatigue and weight loss were most prominent in our patients.3.Laboratory examination: In patients with PAIS, the level of d-dimer is usually within the normal range, whereas serum inflammatory markers are elevated. Therefore, anticoagulation therapy is ineffective. Moreover, arterial blood gas usually indicates hypoxemia and hypocapnia, which are related to the imbalance of ventilation/blood flow ratio.4.Imaging examination:a.TTE is mainly used for right ventricular outflow tract pulmonary artery and its branch lesions to show the relationship with the surrounding tissues and whether there is an invasion. PAIS has an uneven internal echo and certain blood flow signals, and the ’oscillation phenomenon’ is present when it invades the pulmonary valve.b.MRI or CT: Pulmonary sarcomas are characterized by mass filling shadows in the main PA, the left and right PAs and even right ventricular outflow tract, show an uneven density, irregular boundary, lobulated, nodular or septal phenomena. CT can be enhanced to show pulmonary sarcomas with erosion-like changes in the walls of the PAs, and even the extraluminal infiltration can be seen.c.–40PET-CT: In brief, PAIS was positive for FDG uptake and negative for thrombus like malignant tumors;on the other hand, the mean SUV value of PAIS was (7.63 ± 2.21) and the thrombus was (2.31 ± 0.41).In conclusion, high-risk factors and specific molecular markers need further study on the tissue origin of PAS. Our data could contribute to the improvement of the understanding of the disease, symptoms of patients, and short-term survival.Conceptualization: Shuang Liu.Writing – original draft: Rui Xu, Chenyu Hu.Writing – review & editing: DongMei Lv, HuiYing Wu.