Pulmonary mucoepidermoid carcinoma (PMEC) is a rare tumor, particularly in children, and its clinical manifestations vary. When the tumor is small, it may be asymptomatic; however, with larger tumors, patients may present with symptoms such as recurring pneumonia, atelectasis, persistent cough, chest pain, and even hemoptysis. PMEC appears as an exophytic intrabronchial mass. This study aims to report on the clinical manifestations, imaging findings, treatment approaches, and prognosis of two children diagnosed with PMEC at our hospital between January 2018 and December 2022. The age of onset for both children was 9 years, and the masses were located in the right upper lobe bronchi. Following surgical treatment, both patients showed a good prognosis. In addition, we conducted a comprehensive review of the relevant literature to enhance the overall understanding of PMEC. Pulmonary mucoepidermoid carcinoma (PMEC) originates in the submucosal bronchial glands and is a rare malignant tumor. It constitutes 2.5%–7.3% and 0.1%–0.2% of endobronchial adenomas and primary lung cancers, respectively  test yielded negative outcomes. Chest contrast-enhanced CT revealed a space-occupying lesion at the bronchial opening of the right upper lobe, with uneven enhancement –C. On thA previously healthy 9-year-old boy was admitted to the hospital owing to two instances of hemoptysis within 4 weeks. The volume of expectorated blood was small, appearing as dark red blood clots. Except for a paroxysmal cough before hemoptysis, the patient did not manifest any cough at presentation. He also was devoid of experiencing any fever, shortness of breath, chest tightness, epistaxis, vomiting, or abdominal pain. No abnormalities were detected by physical examinations. Blood routine as well as biochemical tests yielded results that were within normal ranges. Similarly, assessments such as the T-spot test, oncological biomarkers, and PPD test yielded negative results. Chest enhanced CT revealed the presence of a mass in the right upper lobe, invading the right upper lobe bronchus, causing occlusion of the upper lobe bronchus. This radiological finding raised suspicions of malignancy, supported by concurrent mediastinal lymph node metastasis and atelectasis of the right upper lobe –C. FlexiPrimary neoplasms originating in the tracheobronchial tree and lungs are rare, with the majority being malignant. PMEC tumor, is hallmarked by a combination of squamous, mucus-secreting, and intermediate cell types, and is defined by the World Health Organization . The incPMEC typically presents as an exophytic intrabronchial mass that can have intact or ulcerated bronchial mucosa. The tumors are situated in the submucosal layer of the larger bronchi under microscopy . When thAccording to classification, PMEC can be low or high grade, depending on nuclear pleomorphism, mitotic activity, and the presence or absence of necrosis. Generally, low-grade tumors are more common in children , 11–16. Fluoro-18-fluoro-deoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) combines anatomical position location and morphological date from CT with functional data availed by PET, significantly influencing lung cancer diagnosis and staging . The usePMEC exhibits diverse immunohistochemical staining patterns, and no single stain can be definitively attributed to its pathogenesis. Tumors showed positive staining for markers such as p40, CK 5/6, and p63. In addition, staining with a keratin cocktail, CK 7, Muc5AC, and CEA may also yield positive results . In a stt  translocation, which culminates in the generation of the fusion protein mucoepidermoid carcinoma translocated 1–mammalian mastermind like 2 (MECT::MAML2) genes (MECT1), with exons 2–5 of a gene located on chromosome 11 that is linked to the Notch signaling pathway, known as mastermind-like 2 (MAML2) (MAML2 rearrangement in 13 out of 17 (77%) cases of PMEC. Subsequent research has indicated that the MECT::MAML2 fusion product is specific to PMEC and associated with a subset of tumors that exhibit a more favorable prognosis owing to their extended clinical course  q21; p1 transloc2) genes , 29. Thi (MAML2) . Achcar t11;  (q21; p1l course . In our Surgical resection is the recommended approach for PMEC, with an emphasis on achieving complete excision through lobectomy, sleeve resection, or other surgical methods based on the location of the tumor , 32, 33.In children, PMEC tends to show low-grade malignancy, and the long-term prognosis after surgical resection is excellent , 36–38. In conclusion, PMEC is a rare malignant neoplasm, especially in children. When patients present with repeated cough, sputum production, hemoptysis, or atelectasis, chest CT and flexible bronchoscopy should be performed promptly to facilitate timely diagnosis and consideration of PMEC. Surgical resection is an effective treatment strategy for managing patients with PMEC. However, further studies are warranted to better understand PMEC, particularly in children.


Aggressive surgical resection in locally advanced hepatopancreatobiliary (HPB) malignancies is frequently advocated as the only potentially curative treatment. In recent years, advances in chemotherapy regimens and surgical techniques have led to improved oncologic outcomes and overall survival, by increasing the rates of radical (R0) resections. Vascular resections are increasingly reported to further increase disease clearance rates. Within this perspective, the issue of vascular reconstruction has raised growing interest, drawing particular attention to vascular substitutes and surgical techniques for reconstruction.A case of extrahepatic cholangiocarcinoma with high clinical suspicion of vascular infiltration of the portal trunk at preoperative assessment is reported. An autologous interposition graft, harvested from diaphragmatic peritoneum, was chosen as a vascular substitute leading to successful portal trunk reconstruction and overcoming all possible drawbacks associated with cadaveric and artificial grafts reconstructions.This solution was strategic to ensure complete oncologic clearance averting the risk of positive margins (R1) at final pathology. With the rationale of ensuring radical tumor excision, vascular resections are increasingly common due to extensive infiltration of hilar structures, despite technical complexity . Based oAPG was first described in the mid-twentieth century in preclinical studies . It was A case of extrahepatic cholangiocarcinoma, originating from the common hepatic duct, with high suspicion of portal trunk’s tumor infiltration is presented. The aim is to provide a technical report regarding the use of an APG as a vascular substitute exploiting its advantages as an effective and easily available reconstruction’s method.A 67-year-old woman, referred from a peripheral secondary care center, with a diagnosis of cholangiocarcinoma originating from the common hepatic duct was admitted to the Hepato-Biliary Surgery Division of San Raffaele Hospital, Milan. At admission, laboratory values were within normal ranges except for hyperbilirubinemia  and cholestatic liver enzymes abnormalities .Preoperative CT Fig. a, b scanPreoperative management included endoscopic retrograde cholangio-pancreatography (ERCP) plastic stenting resulting in effective biliary decompression and jaundice resolution. The preoperative management of this patient, including preoperative imaging and ERCP, was entirely planned and executed before referral to our center.Upon referral, the case was discussed at our weekly multidisciplinary meeting specifically dedicated to biliary tumors and including surgeons, oncologists, radiologists, radiotherapists, and pathologists to define the treatment strategy within a patient-tailored management. Common bile duct (CBD) resection was planned, taking into consideration the possibility to extend the resection longitudinally in case of biliary involvement at intraoperative frozen section  and to perform a portal resection in case of radial vascular involvement.Considering tumor’s location and vascular encasement, extemporaneous histological examination, of both proximal and distal margins, represented the turning point in guiding the resection’s extent. In case of intraoperative evidence of cranial extension, en bloc resection of common bile duct, biliary confluence, gallbladder, and liver segments 4b-5, possibly leading to a former major hepatectomy , was planned, whereas, in case of intraoperative evidence of caudal extension, a Whipple procedure was planned.This study was approved by the institutional review board. The need for written informed consent was waived.A right hypochondrium square incision was performed to open the abdominal cavity. At careful surgical exploration, the gallbladder appeared overdistended due to neoplastic tissue embedding the common hepatic duct and infiltrating both the infundibulum and the superior duodenal flexure. Intraoperative liver ultrasound confirmed portal trunk narrowing above the spleno-mesenteric confluence. Station 8 and 12 lymphadenectomy was performed and full access to the hepatic arterial axis was obtained. The common hepatic duct was followed until the confluence; it was then dissected at his root and sectioned below the confluence. Cross section of both ducts’ stumps was obtained, and intraoperative histological examination was performed to assess bile ducts margins (negative margin status). After duodenal kocherization and exposure of the aortocaval area, the gastroduodenal artery was identified and sectioned. The lesser sac was entered, and left gastroepiploic vessels were isolated and sectioned along with the gastric body. The inferior pancreatic border was detached from the transverse mesocolon until full exposure of the superior mesenteric vein (SMV) was obtained; subsequently, pancreatic transection was performed. During careful detachment of the pancreatic head from the portal plane, the anterior wall resulted infiltrated by neoplastic tissue. Anterior mesenteric artery was identified and pancreaticoduodenectomy en bloc with gallbladder and segment 4 resection was completed. Due to the longitudinal extent of portal trunk invasion not allowing an end-to-end vessel reconstruction, total portal vein replacement with parietal peritoneum graft interposition seemed the best viable option. This strategy ensured both safe portal reconstruction and complete tumor excision with negative margins at final pathology. Whipple’s procedure ended with pancreatico- and gastro-jejunostomy. Biliary tract reconstruction was performed through a double termino-lateral hepaticojejunostomy Roux-en-Y anastomosis with PDS 4/0.A 4 × 3 cm section of diaphragmatic parietal peritoneum was harvested from the right subcostal area. The section obtain was tubularized, using a 10-mm trocar as support model, by a running 6/0 prolene suture. Before portal clamping, intravenous heparin (3000 units) was administered. The portal vein was entirely reconstructed with the interposition tube graft obtained and cut to length Fig. a, b.Fig.Ultimately, an end-to-end graft to portal vein anastomoses was completed with 6/0 prolene suture Fig. c, d.Adequate portal flow and patency were proven using intraoperative Doppler ultrasound.The postoperative course was uneventful. A combination of daily low-dose aspirin 100 mg) and LMWH heparin (1 mg/kg every 24 h) were prescribed since the first postoperative day. After 1 week, contrast CT scan was performed to confirm anastomotic patency Fig. a–c. No c00 mg andNowadays, the surgical approach to HPB malignancies is dictated by the need to obtain microscopic tumor clearance (R0), which is the most important predictor of favorable oncological outcomes. Several studies showed that an aggressive surgical strategy, including major resections, extended lymphadenectomies, and vascular reconstructions, was associated with improved long-term survival . To achiA surgical case with extensive portal trunk neoplastic infiltration, rendering both venorrhaphy and end-to-end anastomosis technically unviable, is reported. When simple vascular reconstruction is deemed impossible, an appropriate vascular substitute needs to be promptly available. In case of clear preoperative evidence of vascular invasion, which allows adequate surgical planning, autologous living tissue vascular substitutes  are frequently chosen. Nevertheless, great saphenous grafts require additional incisions while renal grafts are reluctantly used due to the potential risk of acute kidney failure. In our case, the great saphenous vein (GSV) could have been harvested with minimal disadvantages but total portal trunk reconstruction with autologous GSV graft would have required additional and extensive graft remodeling . From anProsthetic grafts are often chosen as desirable vascular substitutes because of their ready availability, excellent operative maneuverability, and kink resistance. PTFE vascular grafts have been routinely adopted as bypass materials, during cardiovascular procedures, with satisfying results. However, PTFE grafts have been linked to an increased risk of thrombosis and infection often requiring long-term anticoagulation or PTFE removal. Furthermore, several studies described accidental graft gastric penetration and severe abdominal sepsis. PTFE graft infection becomes particularly relevant in patients requiring mesentericoportal axis reconstruction for tumor’s infiltration during pancreaticoduodenctomy. Whipple’s procedure is notoriously linked to high rates of postoperative pancreatic fistula frequently leading to severe intra-abdominal sepsis and hemorrhage. In this scenario, any factor that could increase postoperative infectious morbidity rates should be carefully detected and avoided. These additional risks have restricted PTFE graft use for portal vein reconstruction .Cryopreserved veins  allografts from deceased donors are a valid alternative option. However, because of frequent shortage of donors and limited availability outside transplant centers, their use is limited . In summIn our case, after an accurate intraoperative assessment of portal vein longitudinal infiltration, we decided to use a parietal peritoneum interposition graft as a backup reconstruction choice. The autologous peritoneal graft (APG) was easily and rapidly harvested from the right diaphragmatic peritoneum, without any additional incision and within the same surgical field. The APG presents several significant advantages. When compared with the abovementioned vascular substitutes, APG is inexpensive, it has a significantly lower risk of graft infection, and it is readily available. This is particularly relevant in case of unplanned vascular resection or in emergency situations. Furthermore, the peritoneum is an extremely compliant tissue that can be effortlessly handled to build tailored grafts with the exact diameter and length required . In receVery few cases of total portal trunk reconstruction using a tubular PP graft have been reported in literature. Dokmak et al. , 11 descNevertheless, the proportion of venous reconstruction is biased in favor of a lateral PP graft reconstruction rather than a tubular PP reconstruction. According to the series presented by Dokmak et al. , 11, latThe literature search highlighted APGs’ occlusion and stenosis as the main postoperative complications after successful vascular reconstruction. One of the potential drawbacks associated with APG reconstructions is an increased risk of postoperative short- and long-term thrombosis. Peritoneal grafts are composed of connective tissue coated with a monolayer of the mesothelium. Prolonged blood flow through a mesothelial conduit, which lacks endothelial regulatory properties on hemostasis, could explain the increased risk of APG occlusion. Nevertheless, an accurate balance, between the increased thromboembolic risk and the risk of postoperative bleeding, should be achieved. APG are relatively soft and flexible vascular conduits that could be easily damaged leading to pseudoaneurysm formation and bleeding. In order to exploit APG advantages and minimize potential risk, due to the precarious balance between thrombosis and hemorrhage, careful APG reconstruction, without tension areas, and handling, without tearing the mesothelium, is required. Additional randomized research on postoperative outcomes is needed to further assess potential benefits and limitations among vascular reconstruction techniques.Overall, APG is a promising surgical innovation that should always be considered in a technically challenging case requiring aggressive surgical resections. This technical report highlights the advantages of APG grafts through which an R0 resection, on both radial and longitudinal vascular margins, was obtained ensuring optimal oncological clearance in absence of postoperative graft-related complications.To this day, APG remains a surgical technique not fully exploited despite its potential benefits. The peritoneal patch is easy to access, readily available, and perfectly suited for optimal vascular reconstruction. In our case, APG represented the technical key point that ensured a safe and radical (R0) resection in a complex case of distal cholangiocarcinoma. Peritoneal promising features, as vascular graft, are yet to be fully understood and should be further explored.


This case reports on the micro-computerised tomography (CT) images of a periapical calcified dome following spontaneous apexification as a subsequence of trauma. An immature, maxillary central incisor was found to be non-vital one month following trauma. The tooth had minimal signs of structural damage; however, there was radiographic evidence of spontaneous apexification. The tooth suffered a second traumatic episode two years later and was decoronated to facilitate bone retention during osseous development. The patient presented with swelling and pain 36 months later, and the tooth root was extracted. The root was embedded in resin, and cross-sectional images were obtained using micro-CT. Analysis of the images provided insight into the structure of the calcified dome that formed following the first traumatic injury. Traumatic dental injuries to young permanent teeth have become an important public health problem affecting 30% of children worldwide . Dental Traumatic injuries are classified by the degree of damage to the dental and supporting tissues  with croHertwig's epithelial root sheath (HERS) is responsible for the development of the root . HERS isTreatment options for traumatised immature teeth with pulp damage include pulpotomy, apexogenesis (stimulating continued root development), pulpectomy, apexification, or revascularisation procedures. Current research has focused on using signal proteins, such as vascular endothelial growth factor (VEGF), which stimulate angiogenesis and vasculogenesis for tertiary dentin formation. Several studies have shown that VEGF enhances pulp cell proliferation and neovascularization, and increased the formation of reparative dentin in dental pulp , 12). ReApexification is considered the treatment of choice for young permanent teeth with necrotic pulp and an open apex but with adequate root length and root–dentine thickness . The mosWritten informed consent was obtained from the patient for the treatment and publication of this case report. An eight-year-old female Caucasian patient slipped over in the bathroom and suffered a traumatic injury of teeth #11 and #21 with minor enamel infractions (class I) to both teeth due to an intrusive force. Tooth #11 was restored immediately after the injury with a simple resin composite restoration. One month following the traumatic injury, the patient presented with discomfort, infra-occlusion, and swelling in the buccal sulcus over the apex of tooth #21 .Upon examination, tooth #21 did not respond to sensibility testing. Radiographic examination revealed a wide-open apex on tooth #11 consistent with the patient's age, with evidence of resorption on the distal aspect of the root . For tooFollowing endodontic diagnoses for tooth #21 of necrotic pulp and acute apical abscess, the root canal of tooth #21 was accessed under a dental dam, and following light instrumentation was irrigated with sodium hypochlorite. It was noted that there was an apical barrier with a dimension approximately the size of a No. 30 K-file. The canal was then dressed with CaOH  and temporarily sealed with Intermediate Restorative Material (IRM) (Dentsply). After one month, the tooth was symptomless, and the canal was redressed with CaOH. The patient returned six months following the initial treatment, and tooth #21 was again noted as being asymptomatic. The canal was accessed under a dental dam, irrigated with sodium hypochlorite, and dried. There was a detectable barrier at a working length of 20 mm, and the entire root was obturated with MTA , the patient presented with pain and swelling associated with the root of tooth #21. A periapical radiograph revealed a large radiolucent area associated with the apex of tooth #21 .The patient consented to the extraction of the tooth root and a ridge preservation procedure  to maintain the residual bone volume. Excellent bone quality was noted at the marginal aspect of the tooth during extraction , and theμA, respectively, with a focal spot size of <5 μm. The camera was set to a pixel size of 11.45 μm, and the two-dimensional (2D) images were obtained by rotating the sample 180° with a rotation of 0.4° per sector. A total of 2062 2D images of the transverse sections of the root end were recorded with a total acquisition time of 20 minutes.The root end and soft tissue mass of tooth #21 were examined using a Skycan 1172 micro-CT analyser . The voltage and the current of the micro-CT scanner were set to 50 kV and 190 Micro-CT analysis of the root demonstrates evidence of an apical calcification or dome following the initial traumatic injury. The obturation with MTA is demonstrated in Further apically there is further evidence of apical calcification, which can be demonstrated in As slices are viewed further apically there is a region, in which the root face is incomplete resulting in a persistent communication between the root canal and the periodontium .As the slices are viewed further apically, continuous calcification has occurred  with theAn enlarged view of Viewing selected serial selections of the micro-CT images as a whole indicates the total healing response and development of the apical calcification .The use of micro-CT on a tooth that has undergone two separate traumatic events provides insight into the healing potential of immature teeth and the apexification process observed in limited cases of spontaneous apexification. “Spontaneous apexification” is defined as the rare occurrence of continuous growth and development of an apical calcific barrier after trauma or pulpal necrosis without the external intervention of endodontic procedures .The impact of the teeth on the bathroom floor caused an intrusive injury as well as an enamel fracture. One month after the traumatic injury, there was radiographic evidence of apical calcification without any clinical intervention on tooth #21 compared with tooth #11 , and theThe calcification is not regular as would be expected by normal dentine deposition by odontoblasts and there is evidence of a lateral opening or communication with the periradicular tissues, which is consistent with the observations described by Heithersay .There are a limited number of case reports describing this rare finding where apexification occurred without the benefit of endodontic treatment, and the term “auto-apexification” or “spontaneous apexification” has been described by Barker and Mayne  and KahlFollowing the initial trauma, the pulp of tooth #21 would have been in a compromised state, which ultimately resulted in pulp necrosis, most likely within 1 month of the injury. In this case, apical calcification occurred without clinical intervention, such as pulpotomy, pulpectomy, or revascularisation/regeneration techniques . Vojinović and Vojinović  provide Kahler and Heithersay  reportedAs more apical scans are viewed, representative of a time course of calcified tissue development, the incomplete root becomes a continuous root end with a patent canal. This is consistent with the observations of Heithersay in the management of pulpless incompletely developed teeth that are managed with the application of CaOH .The management of the initial trauma on tooth #21 included restoring the access cavity with a layer of glass ionomer (GC Corporation) followed by resin composite (3M ESPE). A recent case series report by Santos et al.  demonstrAs a result of the second traumatic injury, there was a horizontal fracture of approximately 2 mm subgingivally. It was determined that the tooth was non-restorable, and the tooth was decoronated with the root submerged to help maintain alveolar height and width during continued growth for the placement of an implant in the future. Unfortunately, the patient suffered pain and swelling associated with the submerged root, which necessitated the extraction of the root. A ridge preservation procedure using Bio-Oss/Bio-Gide was undertaken to maintain the residual bone volume. An alternative technique to Bio-Oss is the use leukocyte–platelet-rich fibrin membranes and plugs , 24.Comparing the original radiographs after the initial placement of MTA  and the The calcific barrier that was established six months following trauma revealed radiographic and clinical evidence of successful apexification. The MTA root filling was well adapted to the root end, and there was the appearance of intact lamina dura. Only with the ultimate demise of this root following a second injury has it been possible to examine the root end carefully. The use of micro-CT demonstrated that the apexification was incomplete and is a reminder that periapical radiographs provide only a 2D view and may at times be misleading. Apexification should be regarded as complete, or incomplete, and with the development of cone-beam CT, the determination of this may become more predictable. It is interesting to note that the apical dome of calcified tissue had a central canal. It is unlikely that there was any vital pulp tissue in this apical portion and represents another example of the complex interplay between periradicular tissues with cells that are not fully differentiated.Due to a rather unique set of circumstances of a traumatic injury on an immature tooth, followed by a subsequent second trauma, which ultimately resulted in extraction, the presented case report highlights a rare case of spontaneous apexification using radiographic and micro-CT analyses. The calcification was irregular, and slices apical to the level of obturation with MTA demonstrated an area of the root face being discontinuous, with the root canal being in direct communication with the periodontal ligament. Slices further apical demonstrated that the canal became continuous again, with a central lumen. Micro-CT has a high degree of resolution and has provided further insights into the apexification process without destruction of the tooth, which occurs with normal histological processing.


A uterine fibroid is a benign smooth muscle neoplasm of the uterus. Parasitic fibroids (PMs) are a type of myoma that do not have any direct attachment to the uterus. PMs can arise from the implantation of tissue fragments generated during the morcellation process in previous laparoscopic myomectomies or hysterectomies. Transvaginal ultrasound (TV-US) may be helpful in the diagnosis of these benign tumors. Almost all the case reports in the literature suggest surgical management of parasitic fibroids. Conversely, we report an ultrasound-guided histological diagnosis and a non-surgical treatment of a parasitic myoma that arose twenty years after a total laparotomic hysterectomy and bilateral adnexectomy in a patient with multiple comorbidities, in order to offer a follow-up alternative to the management of this rare pathology. Our experience reveals that a non-surgical conservative approach can be considered as an alternative therapeutic option for the management of rare cases such as PMs in highly selected patients. A uterine fibroid or leiomyoma is a benign smooth muscle neoplasm of the uterus that characterizes women of reproductive age, with an estimated prevalence ranging from 4.5% to 68.6% . HoweverUsually, the location of parasitic fibroids is in the pelvis, close to the uterus; however, unusual locations such as the lungs, bladders, urethra, and sigmoid colon have also been reported .PMs can be primary or iatrogenic . PrimarySometimes parasitic myomas are incidentally detected, being totally asymptomatic; as pedunculated fibroids, they can twist on the pedicle, causing lower abdominal discomfort, nausea , and preWith US, a typical leiomyoma has variable echogenicity depending on the entity of degeneration , fibrosis, and calcification . The difAs highlighted in several case reports, management of parasitic fibroids is usually undertaken surgically, either via laparoscopy or open surgery ,14,15. Differently from standard management, we report on a ultrasound-guided tru-cut biopsy with histological diagnosis and a non-surgical treatment of a parasitic myoma that arose twenty years after a total laparotomic hysterectomy and bilateral adnexectomy in a patient with multiple comorbidities, in order to offer a follow-up alternative to the management of this rare pathology.2.A 66-year-old, multiparous woman was referred to our hospital for a follow-up US scan. This patient had normal stature and severe obesity, with a body mass index of 40 kg/mThe patient had been suffering from hypertension and type II diabetes mellitus, for which she was undergoing drug therapy. She also had a previous history of gastric cancer, which had been treated with gastroresection and Billroth-I reconstruction four years previous to the study. At 44 years old, she underwent a total laparotomic hysterectomy and bilateral adnexectomy for multiple uterine myomas. After the gynecological surgery, hormone replacement therapy (HRT) was administered to the patient for a period of 6 years.On examination, her vitals were found to be stable. The abdomen was soft, nontender and not distended; the mass was not appreciated by palpation. The liver and the spleen were palpated as normal. A speculum examination of the vagina showed no abnormalities. The patient’s serum Ca 125 (9.2 U/mL) and HE4 (11.5 pmol/L) were within the reference range.TV-US performed by an ultrasonoghrapher with advanced skills in the gynaecological field (M.L.), highlighted in the right pelvic cavity, near the pelvic wall, an intraperitoneal solid mass of 20 × 17 × 21 mm in size, with a spherical shape, echotexture with radial stripes, and shadowing . A ColorThe patient underwent a CT scan of the abdomen that confirmed a 2-cm solid mass, iso-hypodense and with a regular outer contour, in the right pelvic cavity, medial to the hypogastric artery . There wConsidering the risks associated with surgery and the suspected benign features of the lesion, an ultrasound tru-cut biopsy of the lesion was performed. The immunohistochemical features were compatible with hypocellular leiomyoma , characterized by a low mitotic count (1 mitotic figure per 20 high-power fields HPF) and a Ki-67 proliferative index of 1% . ImmunohIn agreement with the patient, and in consideration of the severe obesity, multiple previous surgeries, anesthesiological risk, and histology, we decided to perform conservative and non-surgical management.At this point, the patient had been in follow-up with regular ultrasound checks, performed every three months, for one year. The volume of the lesion remained unchanged in subsequent checks.We report the ultrasound-guided histological diagnosis and a non-surgical treatment of a parasitic myoma that arose twenty years after a total laparotomic hysterectomy and bilateral adnexectomy in a patient with multiple comorbidities, in order to offer a follow-up alternative to the management of this rare pathology. Our case has some specific peculiarities: the disease occurred after a laparotomic hysterectomy, it was treated with a conservative approach, and it remained stable in the subsequent follow-up.A surgical history of laparoscopic morcellation has been associated with PMs in the recent literature ,15 due tA systematic review, published in 2015 by Van der Meulen et al., included five cohort studies that reported the overall incidence of parasitic myomas after laparoscopic surgery with the use of morcellation to be between 0.12 and 0.95% .Conversely, cases reported in the literature where a PM develops after laparotomy or vaginal surgery are few. Unlike previous recent reports, the present case showed no history of laparoscopic surgery or intracavitary morcellation, and it also showed the necessity of consider other factors; indeed, the finding of a PM is not a frequent occurrence, whereas the loss of tissue fragments during morcellation is presumably extremely common .For this reason, it can be assumed that there are other factors that increase the risk of this complication ; exposurIn our specific case, the patient had taken hormone replacement therapy (HRT) for a long period: this probably suggest the role of hormones in the risk of development or growth of the PM.In almost all the cases reported in the literature, the management of parasitic myomas is always a surgical approach. All parasitic myomas diagnosed in the 69 women identified in Van der Meulen’s systematic review were removed surgically, despite 21.7% of women being asymptomatic ,23. DespIn our patient, the instrumental exams and histopathological characteristics were highly suggestive of a pelvic benign mass, indicated by the absence of cellular atypia, tumor cell necrosis, or increased mitotic figures, in addition to the benign ultrasound features and the high anesthesiologist risk due to the patient’s comorbidities; all these characteristics guided us in the therapeutic choice. Indeed, some rare benign types of leiomyomas, such as cellular leiomyomas or mitotically active leiomyomas, could be confused with a sarcoma .An important role was played by the ultrasound examination performed by an ultrasonoghrapher with advanced skills in the gynecological field, which allowed us to make an easy diagnosis of a PM, even one of a small dimension. Di Legge et al. demonstrated that, even if the lesion is very small, its ultrasound features can still help in the diagnosis .However, in some cases, clinicians and surgeons are not able to make a preoperative diagnosis of a PM, but the investigation could still be highly suggestive of malignancy , so the surgical treatment is justified .The present case report is the result of our personal experience; because of the lack of studies on conservative management in PMs, our report represents an isolated case and emerges from the choice of personalized treatment. Despite that, it is our opinion that our research can be a useful source for a deeper investigation of other expert center groups.Our study considers a non-surgical conservative approach as an alternative therapeutic option for the management of rare cases, such as PMs in highly selected patients. The personalization of the strategy and the achievement of a diagnostic histology for PMs should be the aim of treatment. Despite the limits due to false-negative biopsies, an ultrasound-guided tru-cut biopsy could play a role in establishing a diagnosis that allows appropriate referral of the patient to a specialized center that provides multidisciplinary care of these rare tumors and where a conservative approach instead of surgery may be adopted. Ultrasound is also an optimal modality for the surveillance of benign PMs.To date, knowledge on the behavior of PMs is very limited, therefore further studies will allow for more adequate knowledge in the management of patients whose general incidence appears to be increasing.


Intestinal tuberculosis (ITB) is challenging due to its nonspecific clinical presentation, sometimes manifesting with acute complications such as intestinal perforation or obstruction.We present the case of a 39-year-old male presented with continuous fever, abdominal pain, and peritoneal irritation. A contrast-enhanced thoracoabdominopelvic computed tomography revealed free air and fluid, suggestive of intestinal perforation. Urgent surgical treatment was performed via exploratory laparotomy, including right hemicolectomy and construction of a Brooke ileostomy. Histopathological analysis confirmed intestinal miliary tuberculosis.The most commonly affected areas in ITB are the ileocecal region and ileum. Symptoms include abdominal pain, weight loss, changes in bowel habits, and fever. Contrast-enhanced computed tomography is crucial for diagnosis. The first-line treatment is medical with antituberculosis drugs.Due to its delayed diagnosis, ITB should be considered in patients with nonspecific and progressive symptoms. Early medical management is crucial to prevent acute complications associated with high morbidity and mortality. Tuberculosis (TB) remains a globally relevant infectious disease, with an estimated 10.6 million people falling ill with TB worldwide in 2021, resulting in 1.6 million deaths, including 187,000 individuals with human immunodeficiency virus (HIV) co-infection ..9]. Isol4-84% andRegarding the clinical presentation, the main symptoms include abdominal pain (74%), weight loss 59%), nausea or vomiting (31%), changes in bowel habits (25%), and fever (20%) [9%, nauseMycobacterium tuberculosis antigens, and it shows positive results in 86% of patients with ITB [Among the laboratory studies that can be conducted are the purified protein derivative skin test (PPD), which may yield positive results in 52-88% of cases . Additiowith ITB . It is ewith ITB . In our Imaging studies are recommended to guide the diagnosis and play a crucial role as an adjunctive method. Contrast-enhanced CT can reveal intestinal wall thickening, intra-abdominal lymphadenopathy, intra-abdominal collections, thickened peritoneum, fistulas, and free or loculated ascites ,12, whicEndoscopy is useful as an additional diagnostic tool or to confirm the diagnosis through biopsies for microbiological and histopathological analysis . HoweverIn the literature, first-line treatment for patients without acute complications is traditional antituberculous therapy for pulmonary TB for six to nine months ,13. SurgITB represents a diagnostic challenge that we encounter more frequently in developing countries due to its nonspecific clinical presentation. It should be considered as a differential diagnosis in patients with chronic abdominal pain, a history of HIV, any immunodeficiency, contact with TB patients, or even in patients without apparent previous contact, as in our case. With an early diagnosis, we will have the opportunity for timely initiation of antitubercular treatment, which is the first-line treatment, thereby avoiding acute complications such as intestinal perforation or obstruction, where urgent surgical intervention becomes crucial.


This case report presents a 12-year-old male with a rare manifestation of rhabdomyosarcoma (RMS), emphasizing diagnostic and therapeutic challenges. The patient exhibited firm, tender facial swelling and underwent diagnostic procedures including imaging and biopsy, confirming RMS. Treatment involved a multi-agent chemotherapy regimen and radiotherapy, leading to a significant tumor reduction. However, neurological deficits emerged one month after treatment, suggesting neural invasion. The case highlights the need for vigilant monitoring and a multimodal treatment approach in managing RMS. It also raises questions about neural invasion risks post-treatment, contributing valuable insights to existing literature and advocating for further research in this rare pediatric cancer. Rhabdomyosarcoma (RMS) is a relatively rare form of cancer that predominantly affects soft tissues, particularly skeletal muscle tissue, although it can also manifest in hollow organs such as the bladder or uterus . This maThe origin of RMS can be traced back to rhabdomyoblasts, which are precursor cells to skeletal muscle. Genetic alterations in these cells can inhibit their normal development, leading to the formation of tumors . While tClinically, RMS often presents in the head and neck region or the urinary system. Symptoms can vary widely depending on the tumor's location and may include headaches, swollen eyes, and bleeding . TreatmeA 12-year-old male presented to the hospital with a unilateral facial mass located below the angle of the mandible on the right side. The mass had been present for approximately 18 months. It was non-fluctuant, non-mobile, and tender to touch, measuring 8 cm x 5 cm  vincristine, actinomycin, and cyclophosphamide, as decided by a multidisciplinary team. This was followed by a course of radiation therapy, both of which contributed to a reduction in tumor size. However, one month after treatment, the patient began experiencing severe headaches and neurological deficits, including diminished reflexes and motor function in the left upper and lower extremities. A repeat MRI confirmed these symptoms to be a result of neural invasion by the tumor Figure .The patient is currently on a comprehensive IV treatment regimen that includes dactinomycin, cyclophosphamide, vincristine, pheniramine maleate, ondansetron, corticosteroids, and other chemotherapeutic agents for symptomatic and conservative management. Concurrently, a complete blood count, liver function tests, and renal function tests have shown no abnormalities. Future therapeutic strategies will be determined upon the completion of the ongoing chemotherapy regimen.Rhabdomyosarcoma accounts for approximately 3% of all pediatric malignancies, categorizing it as a relatively rare form of cancer. The highest incidence rates are observed among children aged one to four years, followed by those in the 10 to 14 and 15 to 19 age groups that exhibit lower frequencies . The ageOral RMS manifests not only localized oral symptoms but also systemic signs. Common symptoms include trismus, making it difficult to fully open the mouth or comfortably chew and swallow food. Additionally, patients may experience numbness or paresthesia due to nerve involvement, as well as altered speech and breathing difficulties when tumors are located in the soft palate, tongue, or throat . In aligRhabdomyosarcoma, a cancerous tumor of muscle origin, has several subtypes with unique features. Embryonal rhabdomyosarcoma (ERMS) is most common in young children and often appears in the head or genitourinary area, with a generally better prognosis. Alveolar rhabdomyosarcoma (ARMS) usually affects older kids and is often found in limbs, with a less favorable outlook. Other rarer forms include pleomorphic and spindle-cell variants. Treatment strategies vary by subtype and may include surgery, chemotherapy, and radiation.Chemotherapeutic intervention is a cornerstone in the management of RMS. A multi-agent regimen, often tailored to the patient's risk profile, is commonly employed. Drugs such as dactinomycin, vincristine, and cyclophosphamide are administered over a course ranging from six months to a year, either orally or intravenously . In the Despite the initial success in reducing the tumor size, the patient began experiencing severe neurological deficits one month after completing treatment. A repeat MRI was conducted to investigate these symptoms, confirming neural invasion by the tumor. These developments not only underscore the aggressive nature of RMS but also highlight the need for vigilant monitoring and possibly supplementary adjuvant therapies. The patient's experience is consistent with established studies on the effectiveness of these drug combinations in RMS management. However, it also brings attention to the complexity and challenges involved in treating this condition. Compared to similar cases reported in the literature, our case suggests that while chemotherapeutic regimens are generally effective in reducing tumor size, they may not be sufficient to prevent complications such as neural invasion or metastasis.The complexities and challenges presented by our case offer valuable insights for future research and clinical practice in the management of RMS. Specifically, the occurrence of neurological deficits post-treatment raises questions about the potential for neural invasion, even after significant tumor reduction. This could prompt further studies on the mechanisms of neural invasion in RMS and the development of targeted therapies to prevent such complications. Additionally, our case highlights the need for long-term, vigilant monitoring of patients undergoing chemotherapeutic regimens, suggesting that future clinical guidelines could benefit from incorporating more robust follow-up protocols. Given the aggressive nature of RMS, research into novel adjuvant therapies and more personalized treatment plans based on genetic or molecular markers could also be an avenue for future studies.This case report details a rare presentation of RMS in a 12-year-old, diverging from the typical age group most affected by this malignancy. Despite initial success with chemotherapy and radiotherapy, the patient experienced neurological complications, emphasizing the aggressive and invasive nature of the disease. The case underscores the critical need for early diagnosis, vigilant monitoring, and a multimodal treatment approach. Given the complexities and challenges presented, this case adds valuable insights to the existing literature and calls for ongoing research to optimize treatment strategies for this rare pediatric cancer.


The FDG-PET/CT findings confirmed hypermetabolism circumferentially along the fasciae of bilateral lower extremities while sparing muscles and subcutaneous fat from below the knee till toe with diffused hypermetabolic marrow, and no evidence of focal disease suggesting malignancy. Biopsy turned out to be superficial necrolytic fasciitis. The patient's condition deteriorated and, 20 days following the scan, the patient succumbed secondary to severe pancytopenia and hypotension. The case raises the importance of high degree of suspicion and prompt diagnosis of this condition, where FDG-PET/CT imaging can play a valuable complimentary role. Such awareness could be lifesaving due to early optimal treatment in the disease course.A rare and fatal life-threatening case of necrotizing fasciitis  is described, who was finally diagnosed with the help of fluorodeoxyglucose-positron emission tomography (FDG-PET)/computed tomography (CT) as more extensive infectious process. A 36-year-old male presented with bilaterally symmetrical cutaneous lesions involving lower limbs that rapidly progressed to ulcerative lesions and pancytopenia. In view of suspicion of paraneoplastic manifestation, the patient underwent Necrotizing fasciitis (NF) is a rapidly progressing and potentially life-threatening infectious process of the fascia, perifascial planes, and can also cause a secondary involvement of the overlying and underlying skin, soft tissue, and muscle.3, normal serum ferritin levels 84.4 , high aspartate aminotransferase of 185 (5–40 units per liter), and preserved renal function with serum creatinine of 0.6 mg/dL . The patient was referred for a whole body18F-FDG-PET/CT to rule out underlying malignancy considering the skin lesions as suspicious paraneoplastic syndrome. A whole-body18F-FDG-PET/CT .18F-FDG-PET/CT revealed circumferential hypermetabolism along the fasciae of bilateral lower extremities while sparing muscles and subcutaneous fat extending from below knee level till dorsum of feet . Linear increased FDG uptake was noted in psoas muscles bilaterally (right > left) (SUVmax 6.15)  and2. p < 0.05; relative risk = 9.4).Marszał and Bielecki reported NF as mixed infection of skin and subcutaneous tissue with a characteristic clinical and pathological appearance, caused by aerobic, anaerobic, and mixed bacterial flora or may be polymicrobial with wide variety of infections, making it an increasing problem in medical and surgical practice.Case reports in the literature have illustrated necrotizing dermatitis as paraneoplastic syndrome and association with multiple malignancies like chronic lymphocytic leukemia,Aeromonas hydrophila. Despite broad-spectrum antibiotics and aggressive surgical debridement, he succumbed to this severe invasive infection. Kim et al in their reported case of eosinophilic fasciitis in a 37-year-old woman with a 3-month history of progressive stiffness involving her forearms and lower legs, highlighted the role of FDG-PET/CT images, FDG uptake was increased along the fasciae of bilateral upper and lower extremities while sparing muscles and subcutaneous fat, similar pattern as in the case presented in this report. Biopsy and histological examination confirmed diagnosis of eosinophilic fasciitis. The report stated FDG-PET/CT may be helpful in the diagnosis of eosinophilic fasciitis as it could clearly illustrate anatomical involvement of the disease.68Ga-DOTATATE PET/CT can have diagnostic role delineating suspected glucagonomaOn ruling out malignancy, other conditions like immunosuppression and aplastic anemia-related association of NF is also known. Ugarte-Torres et al reported the difficult-to-treat organisms having significant implications in both clinical and public health settings. A similar case as our patient, a 37-year-old Caucasian male with immunosuppression due to aplastic anemia being treated with cyclosporine, presented to the hospital with relapsed disease, he subsequently developed overwhelming sepsis secondary to bilateral lower extremity NF.With regard to considering the optimal management, Khalid et al reported necrotizing soft tissue infections being associated with considerable morbidity and mortality, and delayed recognition and treatment can have severe implications.In summary, NF is a rapidly progressive and potentially lethal infectious condition, and delay in diagnosis can be life-threatening and a high index of suspicion and prompt management with aggressive early surgical debridement along with antibiotics as early as 24 hours of diagnosis are the most important treatment options, which can reduce mortality among these patients. The present case illustrates a young patient's irrecoverable, debilitating condition secondary to NF with illustration of a characteristic FDG-PET/CT finding in this condition.


Uterine torsion, an infrequent entity, is defined as the rotation of the uterus greater than 45° around the longitudinal axis of the uterus. It is usually found in a gravid uterus being extremely uncommon in nulliparas. Here, we are presenting a case of a 22-year-old woman who presented with complaints of constant, dull aching pain in the abdomen with a palpable huge mass. An emergency laparotomy was done revealing a large 12 x 10 x 8 cm large subserosal fibroid and the uterus rotated on its own axis to about 180 degrees with bilaterally enlarged cystic ovaries. Derotation and subsequent myomectomy were done. The weight of the subserosal fibroid caused the uterus to rotate on its own axis. As it is a rare entity, a high level of suspicion and timely surgical intervention is the need of the hour to prevent further morbidity and mortality. The uterus rotates more than 45 degrees around its long axis . Animal A 22-year-old, young woman, unmarried nullipara, presented to the emergency department of our rural hospital with complaints of severe pain in the abdomen. She had started to experience swelling over her lower abdomen for one month accompanied by on-and-off pain in the abdomen, relieved by taking over-the-counter painkillers but her pain increased drastically three to four hours before presentation. The patient had attained menarche at the age of 14 years. She had regular menstrual cycles of 26-28 days lasting for four days with average flow, changing two to three pads per day, not associated with clots and dysmenorrhea. Her past medical, surgical, and family history were insignificant. On examination, a hard mass was palpated with the mass corresponding to almost 16 weeks of pregnancy with tenderness at the right iliac fossa. A urine pregnancy kit was done at the bedside, which was negative. This was done as a high number of unmarried females hide the fact of being pregnant as it is considered taboo in this rural area. She was started on injectable analgesics for pain relief. Her tenderness increased from the previous examination with no relief in pain with increased pulse rate with dropping blood pressure. Due to the non-availability of a portable ultrasonography machine in the emergency room as the hospital was situated in a rural setup, the radiological investigation could not be carried out. Within 35-45 minutes of her admission, a decision was taken to shift her for an emergency laparotomy.The abdomen was opened by a suprapubic transverse incision. Intraoperatively, a large sub-serosal fibroid of around 15x12x12 cm with multiple small fibroids of 1x1 cm was seen arising above the fundus, with the uterus dextrorotated to around 180 degrees, with large cystic bilateral ovaries (Figure Firstly, dextrorotation was corrected. Then the subcapsular plain of the subserosal fibroid was infiltrated with 1:200 concentration of vasopressin in normal saline, and the whole of the mass was excised in toto. We did not enter the uterine cavity. Fallopian tubes were patent and no cornual structures were injured while taking out the fibroid. The base of the fundal part of the uterus was sutured with baseball sutures in a double layer (Figure The omental patch was mobilized and attached to the suture line so as to prevent adhesion formation Figure .As ovaries were large, cystic, and bulky, we needed to prevent the future development of polycystic ovarian syndrome. After obtaining informed consent from the patient's mother, we cauterized the bulky, cystic ovaries at four sides at around a depth of four millimeters for four seconds. Right-sided round ligament plication was done so as to prevent retorsion. The abdomen was closed in layers. Her histopathology report suggested that the mass was a large leiomyoma with hyaline changes.Postoperatively, the patient was stable and recovered uneventfully. She was put on injectable antibiotics ceftriaxone and metronidazole along with injectable acetaminophen for three days. She resumed her day-to-day activities from day three onwards. Her dressing was done on postoperative day three and day five and complete suture removal was done on day eight, which was healthy. She attended her follow-up visits regularly after her discharge from the hospital. She and her parents were counseled about the remote complication regarding future pregnancy and was advised to get registered at a hospital when she conceives keeping regular follow-up.Uterine torsion in a non-gravid woman is extremely rare. Only 25 cases of uterine torsion in non-gravid women have been reported in the English literature available on PubMed over the last 20 years. The first two cases were described by Virchow in 1861 and later in 1863 in combination with the uterine fibroids during the autopsies .Abdominal injuries, congenital abnormalities, and uterine masses have been reported to be risk factors for uterine torsion. Due to its rare and asymptomatic nature, uterine torsion is typically identified during surgery, despite the fact that CT, MRI, and ultrasonography have shown potential in preoperative diagnosis. The preferred method of treatment is laparotomy and detorsion. CT scans and MRIs frequently reveal characteristic findings, specifically the "whirl sign" of the uterine cervix, which may be valuable for early diagnosis . PatientIn this case, where a young, unmarried female presented with an acute abdomen with a large palpable mass, it was important to rule out other differential causes of acute abdomen along with pregnancy, acute appendicitis, renal stones, or a case of torsion of ovary. As the diagnosis of uterine torsion in a nulligravida is rare and termed as a ‘once in a lifetime diagnosis’, its suspicion was also not raised in the differentials. In a rural setup like our hospital, where a portable ultrasonography machine is not available, screening ultrasonography could not be done before shifting the patient to the operating room. It was quite surprising to find the intra-operative findings. As the fundal part of the uterus was handled during our intervention, special instructions were given to the patient regarding her future pregnancies, which included getting registered at a tertiary care center when pregnant where proper monitoring can take place so as to rule out a possibility of scar dehiscence or rupture. Regular fortnightly or weekly follow-up after 28 weeks of gestation is recommended in such cases.In non-pregnant women, uterine torsion is uncommon and thus remains frequently undiagnosed, which can lead to catastrophic consequences. In non-gravid women, uterine torsion is typically associated with non-specific symptoms and laboratory data according to a review of recent cases. Thus, when a woman of any age appears with acute abdominal discomfort, medical professionals should consider uterine torsion as a differential diagnosis. The case presented in this report serves as an example of how uterine torsion should be taken into account when women with pelvic tumors complain of sudden abdominal pain.


Colorectal endometriosis (CEM) is a rare and complicated form of deep invasive endometriosis. Its treatment methods include drug therapy and surgery. However, it is often difficult to alleviate symptoms and address problems, such as infertility, using drug treatment alone. Surgical intervention provides a histologic diagnosis, allows assessment of pelvic cysts or masses with features concerning for malignancy, and reduces pain by destroying the endometriotic implants. We consider surgery in women with the following: Persistent pain despite medical therapy; Contraindications to or refusal of medical therapy; Need for a tissue diagnosis of endometriosis; Exclusion of malignancy in an adnexal mass; Obstruction of the bowel or urinary tract. But there is no consensus about the surgical methods. With the rapid development of gastroenteroscopy technology in recent years, many local gastrointestinal tumors that previously required surgical resection can now be removed by endoscopic surgery. Herein, we report one case of CEM treated by endoscopic submucosal excavation (ESE) to provide a new treatment option for the radical resection of single CEM. Endometriosis (EMT) refers to the presence of endometrial tissue outside the endometrium and often occurs within parts of the reproductive system, including the ovaries, rectouterine pouch, or pouch of Douglas, and uterosacral ligaments. It can also occur in the abdominal cavity, chest cavity, and limbs . ColorecA 47-year-old female patient was admitted because of “repeated abdominal pain for 5 years and a submucosal protrusion found in the rectum for 3 months” and she had experienced persistent dysmenorrhea which would alleviate spontaneously. On 19 July 2021, the patient underwent a colonoscopy in another hospital, and a submucosal ridge with a smooth surface was found 10 cm above the anus. Endoscopic ultrasonography (EUS) results from the other hospital confirmed that it originated from a hypoechoic light mass of the muscularis propria. Differential diagnoses included rectal protrusion, neuroendocrine tumor (NET), and myoma. Rectal magnetic resonance imaging (MRI) was performed, no obvious abnormality was found in the rectum, and laparoscopic treatment or outpatient follow-up was recommended.The patient was referred to our hospital due to her tomophobia. No obvious abnormality was found in the patient’s physical examinations, routine blood test and blood biochemistry results, and serial examinations of tumor biochemical markers at admission. A EUS reexamination revealed that a submucosal mass emerged from the third and fourth layers of intestinal tissue with a size of 13.1 × 8.2 mm and was found at 10 cm above the anus, which was a low echo cluster but with a high echo inside. , 2. A reAfter obtaining informed consent from the patient, ESE under general anesthesia with tracheal intubation was performed. Markers were made around the lesion under an endoscope. After the submucosal injection of a mixture of normal saline and methylene blue, a yellowish–white mass was observed upon cutting the mucosa . The masOne week after the surgery, the patient’s pathological and immunohistochemical results were consistent with an endometrial nodule. The immunohistochemical results were as follows: CD117 (−), CD34 (−), SMA (−), Ki67 (+) 10%, Dog-1 (−), CK7 (+), CD10 (+) interstitial cells, ER (+), and PR (+). After the diagnosis of CEM, the patient was referred to the Department of Gynaecology for further hormonal therapy and was reevaluated for some other non-infiltrating external nodules on the sigmoid and rectum which may need further open or laparoscopic surgery, but without significant findings. In the postoperative follow-up, the patient’s abdominal pain had improved. Two months later, the results of an abdominal and pelvic computed tomography (CT) enhanced scan and colonoscopy performed in another hospital confirmed that the wound had healed , with noEndometriosis is a disease that affects the health of fertile women. Some patients with CEM may be asymptomatic. In addition to gynecological symptoms, such as dysmenorrhea, pain during sexual intercourse, and infertility, some patients have combined gastrointestinal symptoms, such as changes in bowel habits, abdominal pain, and rectal bleeding . To dateSurgical intervention provides a histologic diagnosis, allows assessment of masses with features concerning for malignancy, especially for those who have persistent pain despite medical therapy, with contraindications to or refusal of medical therapy, need for a tissue diagnosis of endometriosis, and with obstruction of the bowel or urinary tract. Though there is no uniform surgical standard , accordiEndoscopic resection technology has made rapid progress in recent years, enabling many local gastrointestinal tumors that previously required surgical resection to be removed by endoscopic surgery. Gastrointestinal submucosal tumors cannot be accurately diagnosed via routine mucosal biopsy due to the depth of their lesions, and they rely mainly on empirical diagnosis under EUS, which requires the pathological testing of specimens after resection. The main indications of the ESE technique are benign or low-grade submucosal tumors  with a length of no more than 3 cm. According to the shape and growth position of the tumor, the surgical method can be direct excavation, submucosal tunneling resection, or even full-layer resection of the digestive tract wall, with surgical incisions sutured under an endoscope .Before surgery, the case in this study was considered to be a rectal submucosal tumor, which corresponded with the indication of ESE. However, after the surgery, the pathological diagnosis was an EMT nodule, indicating the feasibility of using endoscopic resection for small rectal EMT lesions. Although endoscopic technology is advancing rapidly, its technical requirements and difficulties are relatively high. Therefore it must be performed by an experienced endoscopic physician. Furthermore, the surgery must be performed in an advanced medical diagnosis and treatment center because of the potential for complications, such as perforation and bleeding .In this case, the CEM was resected with ESE with little trauma, rapid recovery, and a satisfactory short-term effect. It provides a new treatment method for the radical resection of small single CEM. However, the long-term therapeutic effect still requires further investigation in a wider range of clinical trials at a higher level.


Autotransplantation is a potential treatment alternative when orthodontic traction of an impacted tooth is difficult. In this article, we describe two cases of guided autotransplantation of an impacted canine using a computer-aided designed and manufactured surgical template. The impacted canine was segmented on preoperative cone-beam computed tomography images to ensure a sufficient periodontal ligament space and placement of the donor tooth with the least pressure on it. The canine was virtually transposed using a simulation program considering the adjacent teeth. The surgical template, which was connected to the occlusal stop on adjacent teeth, was designed and 3D-printed with polymer resin. The recipient site was prepared using the surgical template, followed by immediate transplantation of the surgically extracted canine into the socket. The transplanted donor tooth was positioned in planned infra-occlusion to prevent occlusal interference. It was then splinted with the adjacent teeth for initial stabilization. During follow-up, one transplanted tooth showed pulp canal obliteration and the other had suspected pulp necrosis; endodontic treatment was performed. One year after the procedure, the periradicular condition of both teeth was favorable. Impacted canines are often detected in pediatric dentistry. In cases of canines with a palatal ectopic tendency overlapping the lateral incisor, extraction of the primary canine before 11 years of age has been reported to improve the eruption pathway in 64–91% cases . HoweverRecent advancements in digital dentistry, such as cone-beam computed tomography (CBCT) and computer-aided design and manufacturing (CAD/CAM), have made enabled preoperative evaluation of impacted teeth. For example, the width and length of the donor tooth can be predicted from digital images, and a computer-aided rapid prototyping tooth model can be used to shape the recipient site instead of relying on the impacted tooth itself ,5. The fIn implant prosthodontics, a surgical guide is commonly used to achieve accurate depth, direction, and angulation during abutment placement, and CAD/CAM technology is introduced for its fabrication . A surgiThis report describes the design and fabrication of surgical templates produced to prevent pressure-induced damage to the PDL and promote revascularization of the pulpal space. The aim of this report was to present cases of autotransplantation using virtually planned 3D-printed surgical templates for guided osteotomy preparation of recipient sites. This method can ensure an atraumatic and precise surgical approach for autotransplantation of impacted canines.®, Planmeca, Helsinki, Finland) was performed using the following scanning parameters: voxel size 0.3 mm, 110 kV, 11.0 mA, 3.272 s. The CBCT DICOM images were imported into an open-source imaging software  [®, Blue Sky Bio, Libertyville, IL, USA) (A preoperative 3D radiographic examination (Promaxry 2021) . Using tIL, USA) b. The idIL, USA) c. SurgicIL, USA) d. The suIL, USA) e.A 9-year-old boy visited our clinic with bony swelling in the left mandible. On a panoramic radiograph, a radio-mixed lesion was visible between the roots of the left mandibular lateral incisor and primary canine. The distance between the apices of the roots of the lateral incisor (#32) and primary canine (#73) had increased, and the tooth buds of the permanent canine (#33) and first premolar (#34) were displaced due to the lesion a. A beniDuring the surgical procedure, the primary canine was removed and a full-thickness gingival flap was reflected. The impacted canine was located immediately below the recipient site, so the upper alveolar socket was first enlarged to make room for the transplanted tooth a. The doThe transplantation of the canine at the planned position was verified on panoramic and periapical radiographs on the day of the surgery a,b. PeriA 10-year-old girl was referred from a local dental clinic for prolonged retention of the left maxillary primary canine and eruption disturbance at the left maxillary canine (#23). A panoramic radiograph revealed that the maxillary canine was impacted horizontally toward the anterior region and between the apex of the left maxillary premolars and nasal cavity a. BecausTo fabricate a surgical template, the impacted canine was segmented from the CBCT image, and transplantation was simulated using surgery planning software. In this case, the roots of the lateral incisor and first premolar were so close to the planned recipient site that they had to be repeatedly evaluated on sagittal, coronal, and axial CBCT views a,b. The After extracting the primary canine and raising a full-thickness flap, the alveolar socket was shaped using drills for implant prostheses. The direction and depth were determined using a surgical template a,b. The A periapical radiograph taken intraoperatively showed that the donor tooth (indicated with a yellow asterisk) was positioned as planned a. At theBoth periodontal and pulpal recovery are important factors for good prognosis, and close examination of clinical and radiographic features is needed at every follow-up ,10. An iMaintenance of PDL cell vitality and prevention of infection are other important factors for tooth transplantation. According to the guidelines of the International Association of Dental Trauma in 2020, replantation of avulsed teeth in 15 min can help preserve most viable PDL cells . An advaIn the present two cases, when designing the surgical template, we focused on the shape of the tooth replica, which had a larger root than that of the real canine. During segmentation, the area was cropped to include both the canine and its PDL space. A larger tooth replica was used for osteotomy of the recipient site, which enabled a blood clot to fill around the transplanted donor tooth to allow spontaneous revascularization of the pulp. Passive positioning with low pressure in a spacious alveolar socket is considered effective for initial PDL reattachment . HoweverThe use of a surgical template for guided osteotomy, which was based on the concept of surgical guides for implant placement, has been reported for autotransplantation of the mandibular secondary premolar to replace a maxillary incisor lost due to dental trauma. A series of templates for implant drills with different diameters have been used to guide the path and depth of recipient site preparation. Surgical templates enable precise osteotomy, as they are almost identical to the planned shape . When coIn this study, the transplanted tooth was splinted for initial stabilization using a nickel-titanium wire and resin bonding. Flexible fixation is recommended to avoid replacement root resorption and the recovery of transplanted PDL cells. In cases of tooth crowding, preoperative orthodontic treatment was required for space gain. The orthodontic bracket slot had clearance when thin wire was inserted, allowing a light force to the transplanted tooth during mastication and from the tongue . In CaseWe reported two cases of guided autotransplantation using surgical templates fabricated based on donor tooth replicas and occlusal stops on adjacent teeth using virtual surgery planning. Despite some limitations mentioned above, the simple design and fabrication process of the template are thought quite intuitive and clinically useful. Upgrading to a simple but more planned shape of template such as a “template series”, guiding the osteotomy drill for a more convenient surgical process, could be attempted in future cases. Keeping within the permissible irradiation range, the 3D radiographs taken right after surgery and during follow-up might help in evaluating the operation itself and prognosing its success. These radiographic records could be useful data for a retrospective survey of pre- and post-operative factors, such as a quantitative analysis of the change in alveolar bone at the recipient site and an evaluation of surgery accuracy.In cases of superficial impaction, the laser is a viable surgical alternative because of its many intraoperative and postoperative patient comfort advantages, due to its minimal intervention . HoweverSurgical templates fabricated using CAD/CAM were successfully applied for the autotransplantation of impacted canines with minimal complications. We expected that the advances in the template design would make the surgical procedure easier and more precise. A favorable prognosis of the transplanted tooth may be ensured through suitable case selection, intraoperative infection control, and careful postoperative evaluations.


Spinal ependymomas are rare primary central nervous system tumors that often exhibit vague symptoms before being identified. In extremely rare situations, it can be identified after a neurological decline following a history of spinal anesthesia, indicating intraspinal hemorrhages from an incidental lumbar ependymoma that was not previously diagnosed. Spinal anesthesia is widely utilized in numerous orthopedic surgical procedures, as it is a well-tolerated invasive procedure with a low risk of complications. The patient in this case study underwent elective orthopedic surgery under general anesthesia following two unsuccessful trials with spinal anesthesia. Subsequently, the patient developed paraplegia as a result of an incidental hemorrhagic spinal ependymoma. The patient had an L3 laminectomy for decompression of the dural sheath, and an ependymoma was confirmed based on the histopathological assessment. This case report aims to raise awareness regarding the potential complication of spinal anesthesia arising from incidental tumors of the spinal cord, thereby emphasizing the imperative of early recognition and management in order to mitigate adverse outcomes. Ependymoma is a rare primary tumor that accounts for approximately 2% of all primary central nervous system tumors. When present, it is located 75% of the time within the spinal cord . PatientSeveral studies have reported intraspinal hematomas with neurological decline after spinal needle insertion, indicating intraspinal hemorrhages from an incidental lumbar ependymoma that was not previously diagnosed before spinal anesthesia -13. HereA 44-year-old medically free female patient was admitted to the orthopedic department for a curettage biopsy of a cartilaginous lesion located in the right proximal tibia. The lesion was identified through radiological imaging after the patient reported experiencing knee pain persisting for a duration of one year. She underwent curettage biopsy and grafting under general anesthesia due to two failed trials of spinal anesthesia. The procedure was successful and without difficulties, showing no manifestation of neurological impairment, and the patient was discharged on the same day of surgery with a prescription for pain medication and anticoagulants. Five days later, the patient started to have lower back pain over the sacral area and lower limb weakness. On day 9 postoperatively, she was admitted for acute low back pain associated with sensory-motor deficit. Examination revealed diminished reflexes and sensory-motor deficit, lower back pain severely increasing on mobilization, and inability to be in the supine position. The neurological examination found lower limb deficit, and muscle power revealed the following: right ankle dorsiflexion: 1/5, left foot dorsiflexion: 1/5, right foot plantar flexion: 1/5, and left foot plantar flexion: 2/5. Quadriceps examination was limited due to knee pain, and ankle reflexes were diminished. Sensory examination revealed non-systematic hypoesthesia involving lower leg and foot reflex and no anesthesia in the saddle. The patient also presented with urinary retention, and a Foley catheter was inserted. A digital rectal examination revealed no sphincter abnormality. Clinical examination and a history of two failed spinal anesthesia procedures have raised suspicion of a post-spinal anesthesia-related compressive hematoma.An immediate spinal magnetic resonance imaging (MRI) indicated a possible post-spinal anesthesia hematoma, adjacent to L2-L4 Figure . ConsidePostoperatively, there was partial recovery of the right lower limb (extension: 3/5), no recovery of the left foot (extension: 2/5), reduction of lower back pain, and absence of anesthesia in the saddle. MRI confirmed good decompression of the roots of the cauda equina, but there was an image at the level of the dural sac strongly suggestive of a second tumor location (Figure The patient received psychological support both after the operation and throughout the rehabilitation process. Three months after the intervention, the patient is in marked improvement on the neurological level. She walked with two canes, and steppage is present, especially on the right. Sphincter function returned to normal, and the urinary catheter was removed. The patient does not complain of any pain and continues her rehabilitation through physiotherapy on a multi-weekly basis. The MRI performed three months postoperatively confirmed the perfect decompression of the roots of the cauda equina but above all, unexpectedly, the complete disappearance of the second lesion, which existed at the level of the dural sac Figure . It is pSix months postoperatively, a remarkable improvement in neurological function was observed, with patients now walking without canes and returning to work part-time as a sales manager. However, there is still a residual deficit in muscle strength, rated at 4 out of 5. Follow-up is planned for at least two years, with MRI every six months, to assess the risk of recurrence and evaluate the neurological recuperation progress clinically.The prevalence of incidental ependymoma and spinal anesthesia complications are rare in their own right, yet they have been described in previous literature. This case adds to the small pool of literature on this bizarre couple. As most of the previous cases described are related to obstetric procedures, this article presents a uniqueness as one of only two articles following an orthopedic procedure . In addiThe aim of surgery is to perform a wide resection with negative margins, as it is with the majority of other soft tissue tumors. The extent of excision is determined by the tumor’s size, histology, location, and whether or not it has a capsule or syrinx . Due to Although such incidences are deemed to be rare, this case demonstrates the importance of vigilance when it comes to postoperative neurological manifestations concerning invasive spinal procedures. While patients from this and the abovementioned reports showed favorable improvement with subsequent treatment even with what’s considered a later presentation, it is still advisable to act as quickly as possible with these cases to ensure the best possible result. Efforts to educate patients to seek faster care could help in reaching better outcomes.


Autotransplantation of a mature tooth usually leads to pulpal necrosis. Root canal treatment is recommended to prevent related inflammatory complications a few weeks after surgery. Extraoral root-end resection may facilitate reperfusion and obviate root canal treatment, but cannot be pictured with conventional dental radiography at this point in time. In the case of a lower mature transplanted molar, contrast-enhanced magnetic resonance imaging proved to be a feasible method for visualizing pulp revascularization just 4 weeks after autotransplantation. Consequently, root canal treatment was obviated. Nevertheless, the tooth had to be extracted 18 months postoperatively due to external cervical root resorption, probably caused by the extraction trauma. This allowed the histological processing and examination of the newly generated intracanal tissue. Uninflamed fibrovascular connective tissue was found, while odontoblasts or cementoblast-like cells were absent. These findings indicated that it was most likely stem cells from the bone marrow and the periodontal ligament that drove the regeneration. Tooth autotransplantation (AT) is defined as repositioning of a tooth or tooth germ in the same patient’s mouth. It has been an accepted method since the 1980s. Success is defined by two main aspects: Periodontal and endodontic healing of the transplant at the recipient site.A prerequisite for periodontal healing is a gentle surgical technique. Especially, damage of the root cementum has to be avoided. Thorough preoperative planning and the application of surgical templates have proven to be beneficial . EndodonAssessment and evidence of successful PRV is therefore a critical issue for further treatment of autotransplanted teeth. Two aspects have to be considered: First, successful PRV should not be disturbed by an unnecessary endodontic intervention and second, root resorption has to be avoided in cases of failed PRV. Traditionally, PRV is assessed indirectly. First by ruling out necrosis  and later by pulp canal obliteration (PCO) on intraoral radiographs and/or clinically by the regained sensitivity of the tooth.A more recent approach aims to show PRV directly via magnetic resonance imaging (MRI) with or without the use of a contrast agent ,8,9,10. Several case reports ,12 and rThe PRICE reporting guidelines were followed in the preparation of this report .A 28-year-old male white patient was referred by his orthodontist with pericoronitis at the partially impacted lower right third molar. Removal of tooth 48 ) and orthodontic therapy to resolve crowding was intended. In his past medical history, he had lost the left lower first molar three years prior to admission due to apical periodontitis. Due to aplasia of tooth 45, the deciduous tooth 85 was still present but its roots were severely resorbed . In the The patient was in good general health but was a smoker. He gave informed consent to autotransplantation, knowing that prognosis was reduced due to the mature multi-rooted donor tooth.TM software  to create a virtual 3D replica of the tooth transplant. This model was 3D printed to serve as a reference for recipient-site preparation  scan was obtained using Planmeca ProMax 3D Max , with a voxel size of 0.2 mm and standard settings to confirm the integrity of the donor tooth and adequate dimensions of the recipient site. CBCT data were then segmented using the coDiagnostiXparation .The surgery was performed under local anesthesia . Tooth 85 was removed and a local mucoperiosteal flap was raised at the recipient site. The recipient socket was prepared using an implant drill kit . Sufficient enlargement was verified using the printed graft replica. A ThereafA flexible wire-composite splint was bonded to the vestibular enamel of the transplant and the neighboring teeth. The metallic component of the splint was a twistflex wire .® 1000 mg, Sandoz GmbH, Kundl, Austria) and antiphlogistic therapy was prescribed for 2–5 days . Sutures were removed after 1 week, the wire splint after 4 weeks.The patient received perioperative antibiotic prophylaxis for 4 days .Pulpal sensitivity to an electric pulp tester , external infection-related root resorption, or apical radiolucency (signs of infected pulp necrosis) were investigated .®, Bayer, Leverkusen, Germany; Contrast-enhanced magnetic resonance imaging (MRI) was performed immediately after splint removal to assess revascularization using a contrast medium  was performed to assess tooth mobility and values were compared to neighboring corresponding teeth, respectively. Periotest values were similar and were slightly positive after 12 months (+3).Electromechanical tapping . Infiltration with a light curing resin  was performed in ascending grades mixed with ethanol absolute for analysis . Finally, the tooth was embedded in the same resin and processed into undecalcified thin ground sections with a thickness of about 100 µm, according to the Karl Donath method , using mA specialist in pathology assessed the stained section. Histology confirmed the presence of fibrovascular connective tissue in the root canal . ResorptRevascularization occurred in a transplanted mature third molar after ATMT-EORER, proven by contrast-enhanced MRI 4 weeks after surgery. MRI brought immediate clarity on the PRV process in the tooth and could eliminate the risk of missing the early radiological signs of root resorption.The application of the modern possibilities of cross-sectional imaging data is essential for a high success rate of the autotransplantation of teeth. CBCT- or MSCT-derived dicom data is used to create replicas of the transplant. The use of these replicas for recipient site preparation ensures two key factors for successful periodontal healing: minimal extraoral time and optimal fitting of the transplant, hence minimal damage of the active cells of the root surface. MRI on the other hand, has proven capable of showing revascularization and endodontic healing at an early stage, which is decisive for the further therapeutic procedure.Display of pulpal perfusion with MRI has already been described in 2001 by Ploder et al.  using a Assaf et al.  conclude®; Bayer Healthcare, Leverkusen, Germany) is applied. So far, patients have experienced solely mild (mild itching) but no severe side effects.Furthermore, MRI does not provide interpretable results if artefact causing elements are present. Especially orthodontic devices and dental implants cause major distortions.  Allergy All children are informed about the examination and possible side effects of MRI and MRI contrast media effects in the presence of their parents or guardians. In addition, known allergies and kidney disease are considered as contraindications. Several recent studies are consistent with our findings regarding the high safety of gadolinium-based macrocyclic MRI contrast agents ,21,22.In future studies, it would be interesting to evaluate the extent to which the vascular supply of the pulp can be determined using arterial spin labelling (ASL). This method would theoretically allow the measurement of local blood perfusion/supply without the need for intravenous contrast administration. A major limitation in imaging transplanted teeth is the small volume of the area examined at submillimeter resolution and, consequently, the length of the sequences applied. This is compounded by the small amount of signaling tissue in the oral area, especially in the pulp.In our case, each motion reduced 3D T1 sequence took about 6:52 min, despite a 64-channel head coil and a 3T MRI machine. In patients with avital pulp, there was no measurable signal enhancement in the T1 sequence after gadolinium administration . In compThe transplanted tooth developed a resorptive lesion beneath the buccal cervical margin. Given the configuration of this lesion, it was obviously caused by trauma to the root cementum through the use of luxators during extraction and it worsened the prognosis for this case. In consultation with the patient, it was decided to remove the tooth. Consequently, the opportunity arose to have the transplant examined histologically.ATMT-EORER has been described in animal studies ,24 and wTooth germs with open apices have a greater ability to revascularize. This is clearly demonstrated by the consistently high success rates of pulpal healing in the autotransplantation of immature teeth with 2/3–3/4 developed roots ,27,28,29(a)A larger diameter of the apical foramen facilitates cell migration and ingrowth of new vessels into the ischemic pulp space.(b)Immature teeth display a shorter root; therefore, the migration distance for the ingrown tissue is short.(c)Immature teeth are endowed with more and a larger spectrum of stem cells.Three mechanisms have to be considered to explain the highly predictable endodontic healing in immature transplants:The influence of stem/progenitor cells has been widely discussed in regenerative endodontic treatment (RET), where the term revascularization refers to the ingrowth of new tissue into a formerly infected root canal. Therefore, bleeding is provoked from the periapical tissue by introducing instruments below the apical constriction. The technique delivers undifferentiated mesenchymal stem cells into the root canal systems of adult patients with mature teeth .In RET, these stem/progenitor cells might be derived from the periodontal ligament (PDL), apical papilla, Hertwig epithelial root sheath, or may be bone marrow mesenchymal stem cells or even surviving dental pulp stem cells .After autotransplantation with root-end resection and hence the removal of the apical papilla, bone marrow stem cells, possibly triggered by the preparation of the recipient site, and stem cells from the PDL most likely drove the intracanal repair process in the present study. The use of tooth replicas for recipient site preparation significantly reduces the extraoral time of the transplant; as a consequence, it may be a key factor in the preservation of vital PDL cells for revascularization. Axin2 expressing cells have been identified in PDL . Axin2+ The mechanism of cell homing ,34,35 adThe extracted molar subjected to histologic evaluation showed no cementum-like tissue in the revascularized root canals, but bone-like tissue with osteocytes in lacunae. This finding is consistent with the literature . In our An early study by Skoglund and Tronstad  showed tThe presented histology indicates that in cases of ATMT- EORER, pulp canal obliteration is presumably caused by the ingrowth of IC and not by reparative dentin. Still, the result is a functional tooth entailing no need for root canal treatment. Pulp canal obliteration is a sure sign of revascularization. Still, it takes several months until it can be proofed on radiographs. By then an endodontic infection may already have destroyed the transplant through rapid external infection-related root resorption. As contrast-enhanced-MRI can bring immediate clarity as soon as four weeks after surgery, it represents a preferable method that does not involve any additional harm to the patient. With an examination time of about 7 min for the T1 sequence, it can be easily integrated into clinical routine and evidence of reperfusion can reduce the number of check-ups required. Nevertheless, the application of MRI for dental purposes is confined by the limited availability of modern machines and highly skilled staff. For this reason, the routine application of the method can currently only be carried out at specialized facilities. Picturing the vascular supply of the pulp with other methods like arterial spin labelling (ASL) to avoid the need for intravenous contrast administration may be a matter of future research and developments.A further shortcoming of the presented study is its limited perspective of the histological investigation, as only one case is assessed. In addition, relevant details may have been lost during cutting.If applicable, contrast-enhanced MRI is a feasible method to demonstrate PRV of transplanted teeth and thus to ensure a good prognosis, even of mature transplanted teeth. Histologically, the intracanal tissue of the presented tooth showed no odontoblasts, but fibrovascular connective tissue. These results indicate that PRV in transplanted root-end resected teeth is driven by bone marrow stem cells and stem cells from the periodontal ligament. Likewise, pulp canal obliteration is presumably caused by the ingrowth of intracanal cementum or bone and not by reparative dentin.