Myelolipomas are very rare benign tumours consisting of hematopoietic cells and mature adipose tissues. They are most commonly found in the adrenal glands. However, there have been several reported cases of extra-adrenal myelolipomas, most commonly in the presacral region. Nearly all presacral lesions are small and asymptomatic; thus, most are discovered incidentally on imaging studies.We report two cases of presacral myelolipomas. The first is a 48-year-old female presenting with atypical back pain, found to have a mass in her presacral region with a size of 3,3 cm. The second case is a 59-year-old female, who presented for evaluation of a hip fracture, found to have a 4,7 cm presacral lesion. Both presacral myelolipomas were discovered incidentally and were confirmed by percutaneous guided fine-needle aspiration biopsy. Both were treated conservatively.Accepted indications for the surgical excision of myelolipomas are symptomatic tumour, size >4 cm, metabolically active tumour, and a suspicion of malignancy on an imaging study. However, previous reports have documented that nearly half of the conservatively managed myelolipomas with a mean initial size of 5,1 cm, has increased in size or became symptomatic over a 3-years period.We conclude that symptomatic presacral myelolipomas or lesions larger than 4 cm should be en-bloc resected, and we present an intuitive decision-making algorithm. •Presacral myelolipoma is an orphan disease.•We emphasize the role of imaging in the differential diagnosis of presacral tumours.•Percutaneous biopsy is rarely indicated to distinguish the diagnosis.•We recommend enbloc resection for lesion larger than 4 cm.•We present an intuitive decision-making algorithm. The incMyelolipomas are found most commonly in the adrenal glands, there have been at least 43 reported cases of extra-adrenal myelolipomas, about more than half of which occurred in a presacral location . There aThough myelolipomas are in general hormonally inactive, some reports were linking them with Conn's syndrome, Cushing syndrome or adrenal hyperplasia ,9. We de2The first case is a 48-year-old female who visited our outpatient clinic with atypical low back pain. On physical examination, there were normal sensations in the buttock and groin area without any neurological deficit. The range of motion of the lumbar spine and hip is without impairment. Conventional radiographs showed no abnormalities. Magnetic resonance imaging presented mild degenerative changes of the lumbar spine and a presacral soft tissue tumour at the level of S4–S5, sharp and clearly well defined, exophytic with a broad base anteriorly of the sacrum and sized 1,8 × 3,3 × 1,8 cm . The sacThe second case is a 59-year-old female who visited our outpatient clinic for an evaluation of a femoral neck fracture. There were no complaints of back pain. A CT scan was performed to evaluate the hip fracture, which incidentally presented a presacral lesion, partly soft tissue and noted with some fat content. MRI showed a mass on the anterior side of the level sacral S5 and coccyges, adjacent to the cortex but without bone destruction. The mass of size 4,2 × 4,2 × 4,7 cm is partly composed of fat with a solid, homogenous central component. Neither the sacral nerve roots nor the spinal canal was involved. .Fig. 2 were treated with excision. Neither local recurrence nor specific complaint was recorded after excision without specific complaint.According to the reviewed publications, most cases of presacral myelolipomas are reported in females  with a sex-based ratio of around 4:1 with female predominance, and a median age of 68 .5. They are asymptomatic in 26–50% of the cases [Presacral myelolipomas are slow-growing benign tumours, with an incidence of 1: 40.000 ,40. Theyhe cases ,42,43.The youngest patient was reported by Adetiloye et al. (1996), which was a 1.5 years old boy with a history of urinary retention and constipation. The presacral mass was later successfully resected and confirmed to be a myelolipoma tumour. The oldest patient was an 85 years old female reported by Gheith et al. (2008). Clearly, the tumour can occur in individuals on a wide range of age. tumour.The characteristic finding of a presacral myelolipoma (besides its location) is the presence of fatty tissues within the mass, which would appear lucent on conventional radiographs, hyperechoic on ultrasonographic images, but hypo-vascular on conventional angiograms ,44. HoweIn general, the MRI is the modality of choice for the diagnosis and preoperative evaluation of retrorectal–presacral tumours. This is due to its ability to delineate peritumoural planes and to determine local invasion  and nerve involvement, with higher contrast resolution compared to CT-scan or endorectal ultrasound (ERUS) ,50.Fine-needle (image-guided) aspiration cytology can play a significant role in the diagnosis of such lesion if said lesion is approachable ,7. Gong The differential diagnosis of fat-containing presacral masses should include several pathologies, including liposarcoma, teratoma, extra-medullary hematopoiesis and neurogenic tumours like chordomas or neurofibromas ,3,53. BoMyelolipomas are usually asymptomatic, thus diagnosed incidentally. However, in the particular cases of large-sized myelolipomas, symptoms may arise due to the mass effect on adjacent structures  ,3,7. In From the pathological point of view, presacral myelolipomas tend to be circumscribed by a thin fibrous pseudocapsule, as viewed in figure (C). The colour varies from yellow to pink-tan to red, determined by the amount of fat and erythrocytic components . On histAs myelolipomas are benign, the question is whether or not they should be resected. The mean size of the presacral myelolipoma in the 39 cases of reviewed literature was 8.5 cm (range of 3.5 cm–16 cm), with symptoms are often present in patients with a tumour size of more than 4 cm. In general, the smaller lesions (<4 cm) confirmed to be myelolipomas by cytology were managed by careful follow-up, and larger lesions (>4 cm) are often removed to avoid risk of spontaneous rupture and haemorrhage.Varone et al. (2015) have reported a 55 years old female patient with a 5 × 4 cm presacral myelolipoma which were treated conservatively. Follow-up MRI at 5, 12 and 18 months of the presacral mass had shown lesion stability without significant interval changes in size, appearance, nor signal characteristics. Asuquo et al. (2011) have reported a 74 years old female with a presacral myelolipoma sized less than 4 cm treated with resection surgery. The patient w as resected due to a biopsy-confirmed diagnosis of myelolipoma, and that it was symptomatic. Sagarra et al. (2014) have reported another patient with a 4,5 × 3,2 cm lesion in the presacral area who were treated with surgery.This patient also received surgery due to being symptomatic and with a risk for haemorrhage. Larger presacral myelolipomas tend to become symptomatic as they compress of adjacent structures. Along with other symptoms, urinary retention, constipation, radiculopathy, sciatic pain, intralesional haemorrhage, and infarctions have been described.haemorr .The AACE/AAES Guideline (2009) recommends that myelolipomas that are observed  should undergo radiological evaluation at 3 and 6 months continued by an annual interval for 1–2 years. Melck et al.  concludeAccepted indications for the surgical excision of myelolipomas are symptomatic tumour, size > 4 cm, metabolically active tumour, and a suspicion of malignancy on an imaging study  . HoweverBased on the literature review and our clinical expert opinion about presacral myelolipoma, we established an intuitive decision-making algorithm to guide the management .Fig. 4Pr6Presacral myelolipoma is an orphan disease. We report two cases of presacral myelolipoma, emphasizing the role of imaging in the differential diagnosis of presacral tumours. Two women presenting with an asymptomatic circumscribed presacral mass and based on MRI characteristics diagnosed of an extra-adrenal myelolipoma. The radiological presentation on gadolineum MRI is characteristic typical, percutaneous biopsy is rarely indicated to differentiate. We conclude that symptomatic presacral myelolipomas or lesions larger than 4 cm should be en-bloc resected, and we present an intuitive decision-making algorithm.It was not required.The authors declare that sponsors had no such involvement.A contributed to performed the operation, data collection, analysis and interpretation, manuscript drafting, revising, and approval for publishing; PDS Dijkstra contributed to performed the operation, data collection, analysis and interpretation, manuscript drafting, revising, and approval for publishing.1.Name of the registry: Andriandi Andriandi2.Unique identifying number or registration ID: Researchregistry57673.https://www.researchregistry.com/browse-the-registry#home/registrationdetails/5efa884c5445ba0015d22b27/Hyperlink to your specific registration (must be publicly accessible and will be checked): Andriandi.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.The authors declare that there is no conflict of interests regarding the publication of this paper.


Leiomyosarcoma is a rare type of connective tissue cancer, accounting for 5–10% of all soft tissue sarcomas. We present a case of leiomyosarcoma as unusual multifocal presentation. Retroperitoneal, mediastinal, pulmonary, uterine and bony regions were all involved at the time of presentation. The liver was normal without detected lesions. A 50-year-old lady presented to the emergency department with a history of right shoulder pain for 4 days. Right shoulder X-ray was done and showed a mediastinal mass at the edge of the film . The patHematological evaluation revealed an elevated erythrocyte sedimentation rate with severe anemia. Chest CT scan with intravenous contrast showed a multilobulated heterogeneously enhancing mediastinal mass with multiple hypoenhancing/necrotic areas . It causCervical spine MRI with intravenous contrast showed the superior mediastinal mass with T1 sequence heterogeneously isointense signal, short tau inversion recovery sequence heterogeneously mildly hyperintense signal relative to muscle signal and T1 post-contrast sequence heterogeneous hyperenhancement with involvement of D1 vertebral body and extension into the spinal canal through the right neural foramen . SagittaLumber spine MRI with intravenous contrast showed a uterine mass with irregular margins and central cystic/hemorrhagic areas . The difHistopathology of ultrasound-guided biopsy of the retroperitoneal mass confirmed the diagnosis of high grade leiomyosarcoma .1 Leiomyosarcoma is a malignant neoplasm that shows smooth muscle differentiation.2 It is predominantly observed in elderly females, typically females between ages of 50 and 70 s, however, males may also be affected. The vast majority of these lesions are located in the abdominal cavity and pelvic regions.Soft tissue sarcomas comprise 0.7% of adult malignancies.Mediastinal leiomyosarcoma is a rare neoplasm, accounting for about 1.4% of soft tissue sarcomas and for about 11% of primary mediastinal sarcomas.3 Mediastinal leiomyosarcomas are usually large masses showing heterogenous contrast enhancement due to the presence of hemorrhagic and necrotic components. When present in the mediastinum, leiomyosarcomas typically present clinically as a result of local mass effect. Lung parenchymal primary leiomyosarcomas usually present as a well-defined lesion with smooth or lobulated margins. They may show a necrotic center as well.4 Leiomyosarcoma is one of the more common histologic subtypes of sarcoma to occur in the lung.5,6Retroperitoneal leiomyosarcoma is the second most common sarcoma to affect the retroperitoneum, comprising about 28% of cases.7 It has three patterns of growth. Entirely intraluminal leiomyosarcoma is the least common (5%). Leiomyosarcoma growth with both intra- and extravascular components is accounting for 33% of cases. In over 60% of cases, entirely extravascular retroperitoneal sarcoma represents the most common growth pattern. Metastases from extravascular retroperitoneal leiomyosarcoma are seen in follow-up studies in most of the cases and in only about 9% of patients at time of presentation.8 The majority of retroperitoneal leiomyosarcomas are typicaly seen arising from the perirenal or posterior pararenal spaces.8 Lungs are the most common site for retroperitoneal leiomyosarcoma metastasis, accounting for 65%, followed by peritoneum (53%), liver (53%), muscle (41%), bones (35%) and lymph nodes (35%).8Uterine leiomyosarcomas account for only 1–2% of uterine malignancies and occur mainly after menopause. The great majority arise de novo, but rarely (in 0.2% of cases) it may result from a sarcomatous transformation in a benign leiomyoma.9 Pre-operative distinction between benign leiomyomas and malignant leiomyosarcomas is very difficult (if not impossible) based solely on clinical features and remains a challenge for clinicians.10,11 Because of increased cellular density, these lesions may display restricted diffusion. The combination of diffusion-weighted imaging and T2 signal intensity lead to increase MRI accuracy in differentiating between benign and malignant or uncertain tumors affecting the myometrium. Thomassin-Naggara et al12 concluded that diffusion-weighted imaging sequence has to be the first measure to be used to help reduce the wrong diagnosis of uterine sarcomas as benign leiomyomas.Extremities and trunk leiomyosarcoma usually present as a painful single mass. It appears as indistinct mass that is rarely calcified or locally invades adjacent bony structures on radiography. On MRI scan, these lesions appear as heterogenous soft tissue masses with central necrosis. The survival rates of patients with extremities and trunk leiomyosarcoma in 5 and 10 year are 64 and 46%, retrospectively, with a metastatic rate of about 34%.13 Soft tissue sarcoma of extremities and trunk rarely metastasize to the liver as compared with visceral and retroperitoneal soft tissue sarcoma, which usually show hepatic metastasis.14 The majority of extremities and trunk soft tissue sarcoma metastasis go to the lung (88%) while lymph nodes and other soft tissues metastases from these lesions account for approximately 12%.15In our patient, although there were supradiaphragmatic, infradiaphragmatic lesions and multiple lung metastases, the liver was spared with no signs of metastasis. In addition, the behavior and the radiological appearance of the lesions in the mediastinum, lung, retroperitoneum and uterus were almost similar to a solitary leiomyosarcoma affecting each area alone.16 Most often it appears as well defined and homogeneous with mild contrast enhancement.17 Commonly, it displaces structures, including aorta from the spine and typically does not invade the major vascular structures.18 Moreover, it may be associated with other places of extra nodal lymphoma, mainly in gastrointestinal tract involvement.16 It rarely presents with calcification or necrosis without prior treatment. The associated clinical history of fever, night sweating, weight loss and the associated increase in the serum LDH level may raise the suspicion of lymphoma over leiomyosarcoma.19Mass-like conglomeration of lymph nodes, more strongly resembling leiomyosarcoma.20,21 History of primary tumor and tumor markers elevation suggest distant metastasis over leiomyosarcoma.21,22Generally, testicular carcinoma, prostate adenocarcinoma, renal cell carcinoma, and cervical carcinoma commonly spread to retroperitoneal lymph nodes.23High grade liposarcoma and leiomyosarcoma are the most common soft tissue sarcoma affecting the retroperitoneum. Radiologically, it is difficult to differentiate between liposarcoma and leiomyosarcoma if there is no macroscopic fat. Approximately, 30% of liposarcoma present with calcification, which is an uncommon finding in leiomyosarcoma.Neurogenic tumors include nerve sheath tumors, tumors of the sympathetic ganglia and extra-adrenal paragangliomas. Clinical and imaging features include young patient age, paraspinal location and calcification. Absence of vascular involvement may help distinguish nerve sheath tumors and tumors of the sympathetic ganglia from a leiomyosarcoma. Paraganglioma mostly located at the organ of Zuckerkandl.Retroperitoneal leiomyosarcomas usually appear as large heterogenous lesions due to intralesional areas of necrosis, hemorrhage or cystic areas. These lesions rarely show calcifications without osteosarcomatous differentiation. Classically, they arise in the perirenal or posterior pararenal spaces.Lung parenchymal primary leiomyosarcoma usually present as well-defined lesion with smooth or lobulated margins.Liver metastases from extremities and trunk leiomyosarcoma is rare in comparison with retroperitoneal and visceral leiomyosarcoma. Only approximately 9% of cases show metastases at time of presentation. The majority of cases show metastases on follow-up studies.Because of increased cellular density, these lesions may display restricted diffusion. This is a very important characteristic used to differentiate uterine leiomyoma from leiomyosarcoma.


While cavernous hemangioma are frequently observed in various tissues and locations in the body, mediastinal cavernous hemangiomas (CHMs) are rare, particularly in the middle mediastinum. Here, we report a case of a middle CHM which was diagnosed and treated in our hospital. A male patient age 57 years was admitted with a mediastinal circular low‐density lesion. Preoperative examination was performed with a subsequent diagnosis of a mediastinal lesion. The lesion was resected and post‐operative histopathology suggested that it was a cavernous hemangioma. Post‐operative recovery was uneventful, and a follow‐up examination nearly one year later showed that the patient had no recurrence. A mediastinal cavernous hemangioma (CHM) is a rare benign tumor caused by congenital vascular dysplasia, which accounts for less than 0.5% of mediastinal tumors. The disease mostly occurs in young adults, and the gender difference is not large. More than 50% of CHM are located in the anterior mediastinum, followed by the posterior mediastinum, while the middle mediastinum is the least common location. Here, we report the case of a 57‐year‐old male diagnosed with a middle mediastinal cavernous hemangioma at our hospital.A 57‐year‐old male patient was admitted to hospital following a routine medical examination with a history of a mediastinal lesion having been located on examination at his local hospital one week previously. Chest computed tomography (CT) scan had confirmed a circular low‐density lesion in the mediastinum. The patient presented with no evidence of fever, or other symptoms such as chest pain, dyspnea, or dysphagia. In order to determine a definite diagnosis and treatment, the patient subsequently visited our hospital. On arrival, the patient confirmed that there was no history of chest lesions in the family. Chest auscultation and percussion were essentially negative. Cardiopulmonary function test was generally normal, and tumor index NSE (neuron specific enolase) was 24.11 ng/mL . Chest‐enhanced CT Fig  confirmeA mediastinal cavernous hemangioma (CHM) is a rare benign tumor caused by congenital vascular dysplasia, and accounts for less than 0.5% of mediastinal tumors. Histopathological features of CHM include a composition of cystic masses made up of dilated cavernous sinusoids of varying sizes, with the inner wall lined with vascular endothelium. More than 50% of lesions are located in the anterior mediastinum, followed by the posterior mediastinum, with the middle mediastinum being the least common location.et al.et al.The clinical symptoms of CHM are related to their size, location and nature with usually no obvious symptoms in the early stages. Following enlargement of the tumor, certain symptoms of compression often appear. Zeyaian et al.et al.et al.Kim In the diagnosis of CHM, there are common differential diagnoses: (i) Mediastinal lymphoma10 Complete surgical resection is a radical treatment. Most CHM have a complete capsule and are easy to separate.Although CHM is benign in histological structure, some lesions may show invasive growth, which may cause complications such as hemorrhage or asphyxia.The authors declare that there are no conflicts of interest.


Placental polyp is one of the rare diseases that affect women after parturition or abortion. In this series of case reports, we aim to demonstrate the presentation, imaging findings, and management of these cases of placental polyps, which were presented to our institution. These cases vary in age and clinical findings. Our objective is to shed light on this disease, which could be initially disregarded. Also, we analyze the screening modalities that may aid in reaching the appropriate diagnosis, and possible treatment options. A placental polyp is defined as a retained fragment of the placental tissue within the endometrial cavity after parturition or abortion, resulting in the formation of polypoidal mass in the uterus. Organized villi and decidua, in addition to degenerated clots and regenerated endometrium, are seen histologically .Although many conditions cause postpartum hemorrhage, a placental polyp is considered rare . EpidemiThis condition is usually diagnosed by using color Doppler ultrasound, computed tomography (CT), or magnetic resonance imaging (MRI); however, the best diagnostic method for placental polyps is to do diagnostic hysteroscopy and polyp resection with the histopathological examination, which is also considered therapeutic .Case 1A 31-year-old woman G4P3+1 presented with a history of continuous vaginal bleeding for six months duration post complete abortion. The patient was diagnosed as a case of incomplete abortion in another hospital, where she was given one dose of misoprostol and passed the tissue (the histopathology was not documented). The patient had a follow-up due to her persistent vaginal bleeding and was found to have a low hemoglobin level, for which she was given a blood transfusion. Ultrasound was done twice before presentation to our hospital. The first ultrasound showed a bulky uterus with an endometrial thickness of 18 mm, no intrauterine tissue, and normal adnexa. The second ultrasound showed a bulky uterus with an endometrial thickness of 15 mm, well defined cystic lesion measuring 5 mm inside the uterine cavity, which appears as a gestational sac of the retained product of conception.The patient presented to our clinic six months later with continuous heavy vaginal bleeding with passage of clot. She denies any passage of tissue or abdominal pain. She had symptoms of anemia but no symptoms of infection. Her examination was unremarkable, apart from mild vaginal bleeding. Her pregnancy human chorionic gonadotropin (hCG) was negative. Endometrial biopsy was done to prove the presence of trophoblastic tissue. The endometrial biopsy showed benign weakly proliferative endometrium with focally embedded necrotic chorionic villi with no hyperplasia or dysplasia identified.Ultrasound in our hospital showed an endometrial thickness of 0.4 cm. There was an endometrial polyp 1.5x2.0 cm with a large single feeding artery. Minimal free fluids in the pouch of Douglas were noted. Ultrasound images for this case were not available as they were not uploaded to our hospital system.. So, Foley’s catheter size 12F was inserted in the cavity, and 15mls of saline was used to inflate the balloon. Six hours later, the balloon was deflated and removed after confirming that there was no active bleeding. The patient was discharged on the next day in stable condition with no bleeding.The patient underwent hysteroscopy resulted in a normal endometrial cavity, and in the right corner, there was irregular fungating firm necrotic chorionic villi, typical old white trophoblastic projection, which was resected, and the patient started to bleed. The bleeding was difficult to control by cauterization with a resectoscopeTwo weeks later, the patient was seen in the outpatient clinic - there was no bleeding, and the histopathology finding was prominent necrotic retained products of conception (chorionic villi), background benign proliferative endometrium, no hyperplasia, and no dysplasia.Case 2A 40-year-old woman G2P2+0 with a previous history of two Cesarean sections presented with a complaint of continuous vaginal bleeding for three months after elective Cesarean section with the passage of small tissue. The bleeding was not associated with abdominal pain, fever, or foul-smelling vaginal discharge. The examination was unremarkable, with a normal size of the uterus.Her pregnancy test human chorionic gonadotropin (hCG) was negative. Hemoglobin was 11.5 gm/dL. Ultrasound showed uterus 7.5x4.3 cm with thickened endometrium. Echogenic heterogeneous structure mass was seen that measured about 3.6x1.7 cm with no vascularity orcystic changes with minimal free fluids most likely product of conception  10 weeks with a history of hypothyroidism presented during coronavirus disease (COVID-19) closure with a history of missed incomplete abortion. She was managed with misoprostol, and she developed severe bleeding, due to which she was taken for emergency evacuation. She had curettage, not suction, and the bleeding persisted for two months. The bleeding was minimal without clots, fever, abdominal pain, or foul-smelling vaginal discharge. Upon examination, the patient was conscious and oriented. Her vital signs were within normal. Abdominal and per vaginal exams were unremarkable with a normal size of the uterus.Her pregnancy test human chorionic gonadotropin (hCG) was negative. Ultrasound showed heterogeneous thickened endometrium with nidus measuring about 2.0x1.2 cm. There is evidence of bridging vessels at this site. The endometrial wall measured 1.4 cm . She was kept on oral contraceptives (OCP’s) postoperatively.She was seen a few days later and advised to start combined oral contraceptives and was given an outpatient department (OPD) follow-up after two weeks.A placental polyp is defined as a pedunculated placenta or chorionic fragment retained for an indefinite period of time as the residua of an incomplete abortion or term pregnancy . In the past, most cases were treated with hysterectomy, usually performed because of intractable bleeding unresponsive to or exacerbated by dilatation and curettage. The placental polyp is considered to be one of the rare diseases with a low incidence of occurrence; it was estimated to be found around 1 in 40,000-60,000 deliveries . The placental polyp is usually categorized into one of two types based on the time of its occurrence: acute and chronic placental polyps. Usually, placental polyps that occur before four weeks postpartum are considered acute, which is the more common type. Any placental polyp that occurs later than that is considered chronic. Even though the acute type is found in the majority of women diagnosed with a placental polyp, some cases reported occurrence as late as 20 years postpartum or even five years postmenopause. Interestingly, such tissue can remain in situ for many years in a relatively well preserved and recognized state . There are numerous factors that are thought to cause placental polyp. However, two main theories could explain the pathogenesis. The first is that due to the atonicity and thin wall of the cornual or fundal myometrium, the placenta that is adherent to the wall would be more complicated to extract. The second may be attributed to the fact that placental polyps originate from either partial or focal areas of placenta accrete, where the adherence of the villi over the myometrium occurs due to defective decidua. In the presented cases, the microscopic results showed invasion of trophoblastic villi into the base of the myometrium. Unfortunately, there is still no clear cause for the risk factors why they occur in the first place . Clinical features depend on the duration of the polyp, including postpartum bleeding, menometrorrhagia, vaginal spotting, lower abdominal pain, and mass protruding from the external os , 5. UsuaIn our cases, pregnancy tests were negative, as documented in previously reported cases . HoweverVarious imaging techniques, including ultrasonography with color Doppler signal, power Doppler imaging, and magnetic resonance imaging (MRI), have been described, but none has ever made a preoperative diagnosis of the placental polyp. The definite diagnoses in previously reported cases were ascertained by tissue histopathology, obtained inadvertently after curettage or hysterectomy due to other diagnoses of bleeding. By nature, placental polyps contain abundant blood supply, more accurately detected by power Doppler imaging or MRI than by the conventional color Doppler signal , 6. ThesLater therapeutic reports endeavored to preserve fertility, such as conservative vaginal resection , selectiGiven the previously mentioned information, we can see that the management may differ from one case to another. In our first two cases, the patients presented with a chronic placental polyp. However, it was difficult to diagnose in the first case as the patient presented to our hospital after being investigated twice in another hospital. Unfortunately, the case is more than 10 years old, and thus ultrasound imaging was not uploaded to our hospital system. The second case was investigated properly from the first presentation to our hospital. In both cases, ultrasound was key in giving the provisional diagnosis, and hysteroscopy was used to diagnose and manage placental polyp. Histopathology was used for confirmation of the diagnosis. However, the third case had more of an acute presentation. The patient was admitted and was investigated. One of our differential diagnoses that should always be considered is an arteriovenous malformation, as they can present similar to placental polyp [The implementation of Foley’s catheter in controlling bleeding showed great efficacy in our cases. This could aid in both localizing and controlling the site of bleeding. Preservation of the uterus should always be one of the main goals nowadays, especially with the availability of more advanced and less invasive options for management and more expertise in the use of hysteroscopy. Clear guidelines for managing placental polyp are not currently available. We hope that by sharing our experience in managing such patients, especially with good outcomes, we could shed light on some of the available treatment options for these patients. A placental polyp is a rare and enigmatic disease, which may present with various signs and symptoms, similar to other diseases. The most common and serious conditions should be explored. Tissue pathology should be obtained to ascertain a definite diagnosis. The optimal investigation and well-planned management are needed to alleviate morbidity and preserve fertility if desired. The high index of suspension should be kept as a differential as well as arteriovenous (AV) malformation. Hysteroscopy remains a good tool to reach definitive diagnosis and treatment, as in our cases.


The urachus is a remnant of the embryonic allantois that connects the urinary bladder to the umbilicus. In most cases, it commonly obliterates before birth. Here we present the case of a 60-year-old man with a past medical history of human immunodeficiency virus (HIV) and anal human papillomavirus (HPV). He was referred for an abdominal mass that had been found incidentally while being admitted for an acute kidney injury; it had been excised, and pathological examination showed urachal mucinous cystadenocarcinoma. Surgical excision is performed for the majority of cases with a higher survival rate when diagnosed early. The urachus is an embryonic allantois duct remnant that attaches the urinary bladder dome to the umbilicus, and it should be obliterated during late-stage gestation. Failure to be obliterated is not uncommon. Thus, if it persists to adult life, a primary urachal cancer (UC) can arise. UC was first described by Hue and Jacquin in 1863. It is rare and typically presents at an advanced stage and has poor outcomes ,3. At thA 60-year-old man with a past medical history of HIV and anal HPV was referred from his primary care provider to the urology office for an abdominal mass that was found incidentally upon abdominal ultrasound (US) after being admitted to the hospital for an acute kidney injury from dehydration. The patient denied any weight loss, abdominal pain, umbilical discharge, hematuria, or voiding difficulties. He is a former tobacco smoker with a 15-pack-year smoking history and has a history of alcohol abuse. Upon presentation, his vital signs and physical examination were unremarkable. Labs were also unremarkable, and his urinalysis was pertinent for a urine pH of 6 with minimal proteinuria and microscopic hematuria. A retroperitoneal US showed a 7.0-cm midline pelvic mass located just superior to the urinary bladder (Figure We performed a subsequent CT scan of the abdomen and pelvis, which demonstrated a 7.3-cm multiseptate anterior bladder wall lesion Figure . The patient underwent cystoscopy, which ruled out a bladder mass, diverticulum, inflammation, or stones and concluded a mass effect on the anterior bladder wall from a suspected urachal mass with no communication between the mass and the urinary bladder. Eventually, the patient underwent an elective open excision of the lesion which was found to be a sizeable urachal cyst. Because of the adherent nature of the mass to the surrounding tissue, the procedure was combined with partial cystectomy. A pathological examination from the tissue taken from the urachal cyst showed mucinous cystadenocarcinoma favoring urachal origin Figure . The patBladder cancer is one of the most common cancers worldwide . UC, howThe most common demographic is white men over the age of 50 years ,8,10. A Diagnostic criteria have been modified over time, but the most accepted criteria, according to Hamilou et al., are described by Sheldon et al. in 1984 and Mostofi et al. in 1955 ,13,14. TThe unique clinical aspect of our patient is the mucinous cystadenocarcinoma diagnosis, a less common UC type with only 10 cases reported in the literature. Our patient was identified early with a Sheldon stage I, Mayo stage I, and T1N0M0, which was discovered incidentally on the abdominal US, treated with open excision of the lesion with partial cystectomy and remains disease-free at a 10-month follow-up. Mucinous cystadenocarcinoma is a rare and aggressive type of UC. Therefore, early diagnosis is crucial in improving patient outcomes. There are no definitive connotative strategies in assessing patients for the presence of UC. Our patient is the 11th case of mucinous cystadenocarcinoma to be published in the literature. This report will help improve our understanding and guide future endeavors in the management of this rare tumor.


Intraosseous pneumatosis is a rare and often fatal condition characterised by air accumulation in the bone that may be brought about by infection, trauma , degenerative disease or neoplastic processes. Here, we present a case of pelvic emphysematous osteomyelitis following repair of an infected abdominal aortic aneurysm.A 56-year-old Saudi male, known to have diabetes and hypertension, presented to the emergency department complaining of intermittent abdominal pain over the right lower quadrant. The patient was later diagnosed intraoperatively with an infected abdominal aortic aneurysm and treated appropriately. During multiple follow-up imaging studies, the patient was noted to have multiple intra-abdominal fluid collections, as well as intraosseous pneumatosis in the pelvis and right femur. 3 months later, intervention was again required due to patient deterioration and possible aortic graft leakage. Graft abscess was diagnosed and managed.We present a case of an infected abdominal aortic aneurysm that eventually led to emphysematous osteomyelitis of the pelvis. This case report sheds light on intraosseous pneumatosis and emphysematous osteomyelitis, which is characterised by the former, in addition to signs of an underlying infection or abscess formation. Although EO is a rare occurrence, it must be investigated and managed appropriately when it does occur. Here, we report the case of a 56-year-old male with EO of the pelvis following mycotic abdominal aortic aneurysm repair and provide a review of similar cases in the current literature.Intraosseous gas was first described as a characteristic of emphysematous osteomyelitis (EO) in the literature around 40 years ago.A 56-year-old Saudi male with a 15 year history of insulin-dependent, poorly controlled diabetes mellitus Type 2 and a 10 year history of uncontrolled hypertension, presented to the emergency department complaining of intermittent right lower quadrant abdominal pain. The pain radiated to the back, moderate to severe in intensity, colicky in nature, and associated with nausea and vomiting. After a double-contrast abdominal CT scan was obtained, the patient was admitted with a provisional diagnosis of an infected infra renal abdominal aortic aneurysm . Open reAround 1 month later, the patient developed pelvic pain. CT scan of the abdomen showed a stable periaortic collection post-repair. MRI of the pelvis showed signs of osteonecrosis, as well as multiple large fluid collections in the right pelvis and around the ischial tuberosity as well as intraosseous collections , with coUpon follow-up imaging, multiple stable loculated periaortic collections were detected surrounding the infra renal aorta and iliac bifurcation extending down to the pelvis, the largest of which measured 7 × 5 cm. Additionally, CT of the abdomen and pelvis showed small pockets of abscesses mainly involving the right iliacus, gluteus minimus, obturator internus, piriformis, and posterolateral and lower anterior abdominal wall muscles. More importantly, the CT scan showed intraosseous pneumatic changes of the sacral and iliac bones bilaterally as well as the right pubic and proximal femur bones . SimilarEscherichia coli and Pseudomonas aeruginosa. In addition, polymerase chain reaction of a sample of the collected intra abdominal fluids was positive for Bacteroides fragilis.The intra-abdominal collections were drained with mild success. Multiple cultures were grown from various specimens: blood, urine, sputum, fluid collections, wound, multiple skin swabs, and anal abscess aspirate. All were negative except for the anal abscess drainage site, which showed growth of Roughly 3 months after initial presentation, the patient deteriorated again. He developed sudden-onset abdominal pain, hypotension, and a drop in haemoglobin level. A large abdominal collection was seen on CT with contrast, which revealed a patent aorta and iliac arteries with no contrast leak. 2 days later, the patient’s periaortic collection had blood density and seemed to have grown in size on CT aortoangiogram, raising concerns of a periaortic haematoma; however, there was no apparent radiological evidence of active arterial extravasation. Moreover, the presence of a new fluid of blood density surrounding the jejunal loops on the left was suggestive of acute haematoma.Exploratory laparotomy was performed following the patient’s deterioration. An intraoperative diagnosis of an infected aortoiliac bypass graft was made with an accompanying haematoma surrounding the infected graft. The infected aortic Dacron graft was removed with ligation of the aortic and iliac stumps, and left axillo-bifemoral bypass was performed.Upon discharge, the patient was administered 10 more days of oral amoxicillin/clavulanate (1 g BID). He was doing considerably well, with stable vital signs. He had no new complaints and was conscious, alert, and oriented to time, place, and person. In addition, systemic examination was unremarkable. His active issues were a Stage III sacral bed sore, anal fissure managed by laxatives, intra-abdominal fluid collections, and intraosseous gas in the right pelvis and femur. The patient was discharged with the medications he was already prescribed during the hospital stay for his chronic conditions and was provided multiple close follow-up appointments. The patient is currently alive and well. A CT scan  15 month1,2 Intraosseous pneumatosis most commonly affects the vertebral bodies, followed by the pelvis and femur.4 Although extra axial cases of pneumatosis are highly specific for EO, differentials may include traumatic injury, surgical intervention, neoplasms, lymphangiomatosis of the bone, and osteonecrotic and degenerative diseases of the bone.3 In the absence of traumatic fractures and surgical intervention, the occurrence of gas within non-vertebral bones is rather rare.1–3 On the other hand, vertebral pneumatosis should direct one towards a non-infectious cause, such as degenerative disease.5EO is intraosseous gas that is often accompanied by signs of an underlying infection.6 Diabetes and neoplastic disease are observed as the most common comorbidities in reported EO cases.2 Due to the altered immune status, vascular complications, and autonomic and sensory neuropathy transpiring with uncontrolled hyperglycaemia, poorly managed diabetes leaves the patient at a higher risk of developing severe infections and osteomyelitis.7 Our patient’s 15-year history of poorly controlled diabetes mellitus could have acted as a predisposing factor for the patient’s infectious process post-repair.Although the pathogenesis of intraosseous pneumatosis is poorly studied, accumulation of nitrogen gas and the vacuum phenomenon as part of a degenerative process have been postulated as possible causes.2,8 The most commonly implicated pathogens include E. coli (28.6%), Klebsiella pneumoniae (20%), Bacteroides spp (20%), and Fusobacterium necrophorum (14.3%).4 In the absence of comorbid conditions, the most common microbial organism extracted from specimens was F. necrophorum.2 In patients with no operative history or an underlying infected collection, a polymicrobial infection is usually suspected.2 In reports of post-operative patients, the causative organisms were Staphylococcus aureus, Streptococcus spp, and Enterococcus spp.1 In diabetics, Staphylococcus and Enterococcus spp are often implicated, in addition to stronger microbes such as P. aeruginosa and methicillin-resistant S. aureus.7,8 Moreover, K. pneumoniae was reported to be associated with gas formation in the vertebrae and pelvis in a septic patient after multiple abdominal interventions.9 In our case, a contiguous spread from the post-aneurysm repair graft abscess is the implicated route of infection. Our patient’s intra-abdominal fluid collections tested positive for B. fragilis, although a sample from the affected bone itself was never tested.The route of infection leading to EO could be either haematogenous or contiguous from an intra-abdominal focus or skin or soft tissue organismal colonies.10 They reported it to be present in 96% of cases. They also indicated that, unlike traditional osteomyelitis, most (79%) cases of EO were not associated with cortical destruction of bone.10 Although our patient’s imaging studies obviously showed the ‘pumice stone’ sign in the affected bones of the pelvis, there were also signs of cortical destruction.The diagnosis of EO is mainly radiological. Recently, Small et al have proposed the ‘pumice stone’ as a radiological sign to identify cases of EO due to the imaging resemblance of EO (irregularly irregular air locules) to the surface appearance of pumice stone (irregularly irregular pores).11 CT is excellent at detecting bony changes and gas. Intraosseous gas can appear on MRI as hypointense foci on T1- and T2 weighted images with a corresponding blooming artefact on susceptibility-weighted images (e.g. gradient-weighted images).12 However, this appearance on MRI is non-specific for gas, as it can be demonstrated with blood products, metallic materials, or sclerotic bone. Hence, CT is more sensitive and specific for the detection of intraosseous gas.13While MR remains the best imaging modality to identify osteonecrotic lesions and soft tissue changes,2 Surgical intervention by rich debridement with adjunctive organism-specific antibiotic treatment are the modalities of choice in current therapy.Aggressive management is advised for this rare, often fatal presentation, as mortality rates approach 32% within 7–56 days following a hospital diagnosis of EO.Although intraosseous gas was rather an incidental finding upon follow-up imaging in our case, it remains an ambiguous, often severe and sudden in onset condition. Knowledge of its clinical radiographic characteristics and associations ought to not only aid physicians in swiftly diagnosing and managing patients, but also shed light on the condition’s vague pathogenesis.Intraosseous pneumatosis occurs mainly in the vertebra, pelvis, and femur.A cause for intraosseous gas must be investigated as the disease can be fatal, regardless of the location.EO should always be suspected in cases of intraosseous gas or osteomyelitis caused by gas-forming organisms; the ‘pumice stone sign’ is considered a pathognomonic sign of EO.Predisposed patients who have undergone interventions, with possible underlying abscesses, are more likely to develop EO.


Renal cell carcinoma (RCC) can be an aggressive malignancy that has a propensity to spread to atypical locations, most commonly to lung, bone, lymph node. RCC presenting as obstructive jaundice with gastric outlet obstruction has rarely been cited in literature. This study presents a case of advanced RCC in a patient with obstructive jaundice and associated gastric outlet obstruction from a large right renal RCC with malignant retrocaval lymphadenopathy invading the duodenum and distal common bile duct. The patient underwent anterograde stenting of the biliary system via a percutaneous transhepatic cholangiography and an insertion of a duodenal stent. Immunotherapy was commenced and the patient was discharged home. This case highlights the importance of a multi-disciplinary team approach to the management of a complex surgical patient. Renal cell carcinoma (RCC) can be an aggressive malignancy that has a propensity to spread to atypical locations, most commonly to lung, bone and lymph node . RCC preA 56-year-old male, smoker, presents to our emergency department with an insidious onset of malaise, early satiety, weight loss, jaundice and a 2-day history of epigastric pain. He was observed to be jaundiced and cachectic with a palpable right upper quadrant mass on abdominal examination.Biochemistry results revealed a lipase and bilirubin of 1105 units/L and 93 umol/L, respectively. Subsequently, a 12.5 × 11.3 cm heterogenous mass arising from the right kidney was found on a contrast enhanced computed tomography (CT) scan . This maDue to the acuity of the patient’s presentation with pancreatitis along with the need to investigate the underlying aetiology of his presenting symptoms, he was subsequently admitted into the hospital. A multidisciplinary discussion involving general surgery, urology, medical oncology and gastroenterology was conducted to guide patient’s care. Differential diagnosis included RCC, lymphoma and pancreatic cancer. Decision was made to, then, perform an MRCP (Magnetic resonance cholangiopancreatography) revealing a positive double duct sign secondary to malignant invasion of retroperitoneal mass. Furthermore, the second and third part of the duodenum showed reactive changes and luminal distortion indicating gastric outlet obstruction.A retroperitoneal percutaneous biopsy of the retrocaval lymph node mass was performed without any complications. Awaiting histological diagnosis, his gastric outlet obstruction worsened, and hyperbilirubinemia increased to 317 umol/L, developed acute renal failure with creatinine rising to 484 umol/L and progressive anuria. The renal failure was believed to be multifactorial from malignancy and cholemic nephropathy that can be seen in patients with obstructive jaundice . The patThirty percent of RCC are metastatic on presentation. Presently, with the advent of immunotherapies, the mean survival of metastatic disease has increased from 1 to 3 years . HoweverThe management of such lesion posed a diagnostic challenge. Lymphomatous mass resulting in a similar presentation may be responsive to chemoradiotherapy and may be managed differently to a carcinomatous lesion . TherefoPrioritization of intervention needs to be based on the patient clinical status. Acute clinical deterioration can occur quickly, prompting acute surgical intervention.Radical surgical intervention in the form of a cytoreductive nephrectomy and pancreaticoduodenectomy in the setting of wide-spread metastasis was collectively agreed to be of limited benefit for this particular patient. A less aggressive approach in the setting of advance disease is also supported by evidence presented in a recent study, the ‘Carmena’ trial which shows no survival benefit of a cytoreductive nephrectomy versus immunotherapy alone .In conclusion, multi-organ failure can result from advanced RCC with biliary and gastric outlet obstruction, a coordinated effort from a multi-disciplinary team is required to direct the acute management of the patient so that a targeted oncological treatment plan can be commenced in a timely manner.None declared.None.


Leydig cell tumor (LCT) is an infrequent stromal neoplasm of the testis with an incidence of less than 3% of all gonadal tumors in the general male population. Only 25% is found in prepubertal children, where Leydig cell tumors are always reported benign. The hospital records of two prepubertal male children, who underwent organ sparing surgery for testicular LCT the last five years, were retrospectively reviewed. In both of them, the lesion was incidentally found during a scrotal ultrasonography for testicular pain. The diagnosis of a benign LCT was based on the pre-operative physical examination and imaging  as well as the negative tumor markers. A testicle-sparing procedure was decided and the pathologic examination of the surgical specimen confirmed the diagnosis. No tumor recurrence was noted on follow-up. Testis-sparing surgery provides the possibility of complete excision of such lesions and should be considered as the treatment of choice. Leydig cell tumor (LCT) is an infrequent stromal neoplasm of the testis with an incidence of less than 3% of all gonadal tumors in the general male population ,2. In chThe hospital records of two prepubertal male children who underwent organ sparing surgery for testicular LCT the last five years were retrospectively reviewed. Their age was 10 and 11 years old, respectively, and both of them underwent a scrotal US exam due to testicular pain, which could not be related to any pathology on clinical examination, as the first child was complaining about pain on the ipsilateral side of the lesion and the latter to the contralateral side. Physical examination of the external genitalia in both patients revealed normal testis in position, size and consistency. No palpable masses were noted. The testicular sonographic findings revealed a hypoechoic mass with a diameter of 3 and 3.4 mm, respectively. In both cases, there was a clear demarcation from the surrounding normal testicular tissue, and on Color Doppler evaluation they both presented a rim of marginal blood flow. No intratesticular calcifications were noted . Due to Through a standard inguinal incision, the spermatic cord was isolated and clamped at the level of the internal inguinal ring, using a soft vascular clamp. The affected testis was then delivered into the wound and placed into a separate operative field in order to avoid tumor spillage. The gubernaculum testis was sectioned, and the tunica albuginea was opened longitudinally, having in mind a dissection plane corresponding to the US findings. The lesion was easily recognized due to its characteristic macroscopic appearance as a yellow to soft brown mass, well demarcated from the surrounding normal testicular tissue. The nodule as well as a 2–5 mm rim of normal tissue around were excised and sent for pathologic examination. The tunica albuginea was repaired using a 6.0 absorbable running suture and the vascular clamp was removed . The iscThe pathologic examination of the surgical specimens confirmed the pre-operative diagnosis. Macroscopically the tumor was well- circumscribed, within the testicle. Microscopically, the tumor was composed of large polygonal cells with eosinophilic glanular cytoplasm and round nuclei. The histological diagnosis of benign LCT was made based on the typical morphological characteristics of the tumor cells   and inclThe follow-up of these patients—24 and 84 months post-op, respectively—with clinical examination, ultrasonography  and measThe interstitial cells of Leydig are situated adjacent to the seminiferous tubules in the testicle and produce testosterone under the influence of luteinizing hormone (LH) . TesticuSonographic findings of the affected testicle usually demonstrate a small hypoechoic nodule, well defined, relatively homogeneous, which can contain faint internal echoes corresponding to small areas of hemorrhage or fibrosis, with intense peripheral rim of vascularization due to a hypertrophic arterial vessel originating from a capsular artery ,14,15. UTumor markers AFP, bhCG and LDH, should always be measured not only in order to exclude malignancy, but also for the post-operative follow-up of the patients. In case of hormone-active lesions, an endocrinological evaluation should be carried out in order to exclude other hormone secreting diseases that may cause secondary Leydig cell hyperplasia.Since we had to treat asymptomatic patients with unilateral, incidentally found on US examination testicular LCT lesion, which was non-palpable, testicle-sparing surgery (TSS) was the best option. It provides the possibility of complete excision of the lesion and has no impact on the child’s psychological encumbrance, since there are good functional and cosmetic results. We consider radical orchidectomy as an overtreatment. Parents should be aware of the possibility of synchronous or metachronous bilaterality of these lesions and give their consent on TSS . Intra-oThe permanent histology for benign LCT is based on the criteria suggested by Kim et al., which include the dimensions of the nodule, the margins of the mass (whether or not free), the extra-testicular extension, the presence of angioinvasion or necrosis, atypias and the high mitotic index . These cDespite the fact that these lesions have shown a favorable outcome, a follow-up is essential for a long period with physical and imaging (US) examination. Until now, there is only one case of malignant LCT in a 9-year-old child, but with bilateral testicular involvement and with mass dimensions on one side greater than 6 cm .A multidisciplinary approach including pediatric surgeons, endocrinologists, radiologists and pathologists leads to a precise diagnosis which is essential for choosing the right way of surgical treatment.Testis-sparing surgery should always be performed in such benign cases. There is no impact on the child’s psychological encumbrance since there are good functional and cosmetic results, and the prepubertal patient has a better chance of fathering children.


The 2019 novel coronavirus (COVID-19) presents a major threat to public health and has rapidly spread worldwide since the outbreak in Wuhan, Hubei Province, China in 2019. To date, there have been few reports of the varying degrees of illness caused by the COVID-19.A case of 68-year-old female with COVID-19 pneumonia who had constant pain in the right upper quadrant of her abdomen during her hospitalization that was finally diagnosed as acute cholecystitis. Ultrasound-guided percutaneous transhepatic gallbladder drainage (PTGD) was performed, and the real-time fluorescence polymerase chain reaction (RT-PCR) COVID-19 nucleic acid assay of the bile was found to be negative. PTGD, antibacterial and anti-virus combined with interferon inhalation treatment were successful.The time course of chest CT findings is typical for COVID-19 pneumonia. PTGD is useful for acute cholecystitis in COVID-19 patients. Acute cholecystitis is likely to be caused by COVID-19 . In December 2019, an outbreak of the 2019 novel coronavirus (COVID-19) occurred in Wuhan, Hubei Province, China, and rapidly spread throughout the world . Here, wOn January 31, 2020, a 68-year-old woman presented to the hospital with a 6-day history of fever, chest stuffiness and diarrhea without chills, cough, or nasal discharge. She had a history of good physical health and no underlying diseases. She had stayed with her son who had been diagnosed with 2019 novel coronavirus (COVID-19) pneumonia after business travel to Wuhan, China.9/L , differential neutrophil count of 70.7% , and lymphocyte count of 20.3% . The alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin levels were 19.0 (9.0–52.0) U/L, 27.0 (14.0–36.0) U/L, and 19.9 (3.0–22.0) μmol/L, respectively. There were elevated blood levels for C-reactive protein .Her body temperature was elevated to 38.1 °C (100.6 °F) for 6 days before her hospitalization. The real-time fluorescence polymerase chain reaction (RT-PCR) assay of pharyngeal swabs and feces was positive for COVID-19 nucleic acid upon hospitalization. The patient’s temperature on admission was normal at 36.3 °C (97.3 °F), and there were coarse breath sounds from both lungs on auscultation. Laboratory studies showed a normal white blood cell count of 3.64 × 10In the present case, the chest CT findings were typical for COVID-19 pneumonia  in the right lower lobe, which may represent hyaline membrane formation. Follow-up CT in this case demonstrated mild disease progression, as manifested by the increasing extent and multiple patchy consolidations, especially in the peripheral zones of the lungs, which may represent alveolar injury and inflammatory exudation. After symptomatic treatment, the consolidations and GGOs were almost absorbed, leaving cord-like shadows, which represent an improvement of the disease. The time course of lung changes on chest CT images of this patient were typical, as described in previous studies –8.In our unique case, the patient developed constant pain in the right upper quadrant of the abdomen and Murphy’s sign after 10 days of hospitalization, and her body temperature was elevated to 38.3 °C. Because of the typical clinical presentation, this patient was likely to be diagnosed as acute cholecystitis or cholangitis in the clinic. Acute cholecystitis was subsequently confirmed by plain abdominal CT scan. It was difficult to identify the cause of acute cholecystitis in COVID-19 patients by abdominal CT imaging. And it could potentially cause severe gallbladder perforation, subsequently it was treated with PTGD. There has not been a study to report the RT-PCR nucleic acids for bile, while sputum or feces were with the highest positive rate of RT-PCR results. The precise mechanism of acute cholecystitis in COVID-19 patients was unknown. The RT-PCR results failed to find virus of COVID-19 in the bile. So our speculation about the potential association in the COVID-19 patient developed acute cholecystitis was a possible complication of COVID-19. However it remains to envisage acute cholecystitis as a possible complication of COVID-19, pending further studies that could prove or disprove this hypothesis.It has not been reported whether the gallbladder might be vulnerable to COVID-19. We highlight a further complication possible with COVID-19. But the notable limitations of this study should be acknowledged. Only one unique COVID-19 patient presented an acute cholecystitis, the PCR test of the bile show no evidence of COVID-19 virus invasion of the gallbladder, and lack of pathological diagnosis for gallbladder tissue, which are not in favor of the possible association between COVID-19 and acute cholecystitis, it remains however possible that the infection by COVID-19 virus triggers the cholecystitis via a yet unknown mechanism.In conclusion, we report the clinical course of a female patient with COVID-19. The time course of chest CT findings is typical for COVID-19 pneumonia. PTGD is useful for acute cholecystitis in COVID-19 patients. Acute cholecystitis is likely to be caused by COVID-19.


The palmaris longus muscle is considered one of the most anatomically variable muscles in the human body. Localized swelling of the forearm due to hypertrophy of the palmaris longus muscle is rare.Here, we report a rare case of a 24-year-old Arab man who presented with a painful mass on his forearm with symptoms of median nerve compression. A full radiological assessment was performed, and he was treated conservatively.This case confirmed that a hypertrophied palmaris longus muscle can be the cause of swelling on the forearm and should always be considered in the differential diagnosis. With this report, we aimed to increase awareness regarding the unusual variations of palmaris longus muscle and the importance of using radiological investigations to establish a diagnosis. Swelling on the forearm is usually because of a trauma, such as fracture, tendonitis, or muscle tear. It could also be due to inflammatory conditions like cellulitis, abscess, osteomyelitis, or phlebitis. Non-traumatic causes of swelling on the forearm are generally uncommon. Recently, several authors have described different variations in the morphology, agenesis, and location of the palmaris longus muscle (PLM) –3. LocalHere we report a rare case of an unusual variation of the PLM that presented as a painful swelling on the distal forearm. In this case, a radiological approach was used to diagnose the cause of the swelling. This approach was effective for this case and can help diagnose similar cases in the future.A 24-year-old right-handed Arab man, working as a computer engineer, presented with a painful mass on his right wrist that had appeared 2 years ago. The mass had slowly grown over the past 2 years and the pain had increased over time. It started affecting the range of motion of his right wrist, specifically during flexion, but without a significant effect on the range of motion of his fingers. He described experiencing a tingling sensation at the tip of the second and third fingers of his right hand. The mass started to affect his daily activity, especially at work while using a keyboard for long periods. He had no history of trauma to his right hand or of any chronic medical illnesses.He initially visited a local clinic, where he was diagnosed as having a lipoma-like tumor on his right forearm. He was referred to our hospital for further evaluation. On examination, we noted an ill-defined firm fusiform mass along the volar aspect of his distal forearm, approximately 3-cm proximal to his wrist joint. The mass was approximately 2 × 3 × 3 in volume and was not pulsatile. It became more prominent during flexion of the wrist Fig. . MoreoveSimple radiography of his forearm performed initially revealed no bony abnormalities. Ultrasonography showed a superficial soft tissue mass at the level of the subcutaneous plane. It was isoechoic to the muscles of the forearm Figs.  and 3. TMagnetic resonance imaging of his right forearm was performed. T1-weighted images and T2-weighted images in the axial, sagittal, and coronal positions revealed signal intensities of the mass similar to those of the adjacent muscles Fig. . ThinninThe mass was located medial to the tendon of the flexor carpi radialis and in the region of the tendon of palmaris longus. The muscle appeared tendinous in the upper  portion and muscular in its lower  portion. The sagittal plane images showed the longitudinal fusiform extent of the mass, which reached the upper margin of the flexor retinaculum at its distal extent Fig. .Fig. 6TThe mass was located close to the median nerve, as observed in the axial images. We diagnosed our patient as having reversed PLM. We detected marked hypertrophy of the belly of the muscle extending almost up to its point of attachment with the flexor retinaculum and restricted movement of its tendon over the flexor retinaculum. In addition, the median nerve near the wrist joint was being compressed. The pressure on the median nerve was the most probable cause of the wrist pain experienced by our patient.We planned to treat our patient conservatively. A systemic anti-inflammatory medication and a wrist splint was the first line of treatment with regular follow-up. Furthermore, we referred him to a physiotherapy department to start stretching exercises. During his follow-up visits, he was able to tolerate pain. One year later, he eventually regained full function of his right hand, and it no longer affected his daily activities.Our patient presented with a painful swelling of the distal forearm and median nerve compression symptoms. In such cases, where no traumatic or inflammatory causes are present for the swelling but the mass continues growing gradually, other rarer causes must be considered.Full radiological investigations help establish the diagnosis in such cases. Initially, simple radiography should be performed to rule out the presence of any bony deformities, including fractures, enthesophytes, and bony tumors. If radiography gives a negative result, ultrasonography must be performed before proceeding to more advanced imaging. In ultrasonography, a mass that is isoechoic to the surrounding muscles will be highly suggestive of a muscle anomaly. PLM has many anatomical variations as has been described in the existing literature. These variations include reversed, duplicated, bifid, hypertrophied, or complete absence of PLM –3. ReverHypertrophied PLM can cause compression to the near neurovascular structure through an increase in its size. A Doppler ultrasonography must be performed to evaluate the adjacent vessels and to ensure that the muscle mass is not compressing them.For symptomatic masses, conservative management should be used to treat the most painful cases; surgery is usually not necessary. Systemic, anti-inflammatory medications, activity modification with stretching exercises, and wrist splint all are considered conservative management , 9. AlthWe present here a rare case of an unusual swelling that stemmed from hypertrophied PLM in the forearm of a healthy 24-year-old man, which was treated conservatively and with satisfactory improvement of symptoms. Very few similar cases have been reported in the literature.To conclude, this case confirmed that a hypertrophied PLM can be the cause of swelling on the forearm with median nerve compression and should always be considered in the differential diagnosis. This report aimed to increase the awareness of unusual variations of PLM and the importance of using radiological investigation to obtain a diagnosis.


Granular cell tumors (GCT) in the gastrointestinal tract are rare. Herein, we describe a case of a gastric GCT diagnosed preoperatively by endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNAB) and successfully resected by single-incision laparoscopic surgery (SILS).A 46-year-old Japanese woman had a tumor located in the angle of the stomach that was approximately 1.5 cm in diameter. Abdominal computed tomography (CT) revealed a submucosal tumor (SMT), which was finally diagnosed as a gastric GCT using EUS-FNAB. The tumor was not identified by CT 1 year and 4 months before diagnosis; therefore, because there was a possibility that the tumor was malignant, we performed surgical wedge resection using SILS. The patient had an uneventful recovery postoperatively and was discharged without complications 3 days after surgery. The tumor was pathologically diagnosed as a benign GCT that remained within the muscular layer. No recurrence or complications have occurred in the first 16 months since the surgery.Because gastric GCTs are generally benign and are rarely associated with lymph node metastasis, SILS seems to be a safe and feasible surgical approach for treating GCTs. Granular cell tumors (GCTs), which were first reported by Weber in 1854 –4. They Herein, we describe a case of GCT that was successfully diagnosed by endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNAB) preoperatively and resected by single-incision laparoscopic surgery (SILS), which is a minimally invasive surgical technique.A 46-year-old Japanese woman underwent computed tomography (CT) or ultrasonography (US) examinations every year since the detection of a giant hepatic hemangioma Fig. a, b. A fConservative management was considered as a therapeutic option due to the benign nature of most GCTs; in addition, the tumor size was smaller than 2 cm and no swollen lymph nodes were observed. However, it was clear that this tumor was new and had grown quickly between CT examinations; thus, there was a possibility that this tumor was malignant. Consequently, we decided to resect the tumor using local resection without lymph node dissection. Considering the cosmetic appearance of the wound in the young female patient, we decided to use the SILS method to perform a minimally invasive surgery.We placed a 3-cm skin incision on the transumbilical plane and equipped the incision site with the Lap Protector mini™  and EZ access . We used an 11-mm trocar and two 5-mm trocars and inserted them into the abdominal cavity through the EZ access. No other assist ports were placed. When the flexible scope for laparoscopic surgery was inserted into the abdominal cavity, the tumor could be seen at the angle of the anterior wall of the stomach as a small white colored nodule slightly protruding from the gastric wall. It was covered with a thin serosal capsule and had a smooth surface , and was located in the proper muscular layer of the stomach wall Fig. d–f. HemaWe have reported a case of a GCT that was diagnosed preoperatively using EUS-FNAB and treated with local excision using the SILS technique.gastric granular cell tumor in PubMed and Ichushi-Web  from inception to 2019 yielded 39 cases, including ours, in Japan  originated pathologically from the mucosal or submucosal layer of the stomach wall, and all tumors were ≤ 2 cm in diameter (Table On the other hand, as shown in Table The fourth issue concerns the need for lymphadenectomy. There were some reports of malignant GCTs of the esophagus and the breast with regional lymph node metastasis; thus, regional lymph node dissection and tumor resection are recommended in cases of malignant GCTs , 16. HowThe final issue regards the determination of the proper surgical approach; open surgery, conventional laparoscopic surgery, and SILS are the most commonly used surgical techniques for GCTs. Recently, some reports have resected gastric SMTs, including gastrointestinal stromal tumors, using the SILS technique –20; we aIn conclusion, our case study suggests that the SILS technique is a safe and feasible surgical procedure for gastric GCTs. However, because the necessity of lymph node dissection is still controversial, the malignant potential of gastric GCTs remains unclear, and the reliable implementation of SILS requires surgeons to have adequate skills and experience for conventional laparoscopic surgery, indications for surgery should be carefully tailored for each case. Because gastric GCTs are rare, it is also important to accumulate cases of GCTs and continually examine optimal treatment methods, in the future.


Arteriovenous malformations (AVMs) are rare congenital lesions that affect multiple regions. AVMs often affect the brain and the buttock is the least common. They are usually congenital, but discovered later in life as they are asymptomatic, small and resemble a benign lesion. However, they can abruptly grow and become symptomatic and life-threatening as they can bleed and get infected.An eight-year-old girl presented with ulcerated and bleeding AVM at the sacro gluteal region. However, due to financial difficulty, it grew to reach an enormous size of (15*15*2 cm) in the buttock. It was later managed by multiple embolisation followed by total surgical resection.This case reflects the first case of enormous AVM in the sacro-gluteal region in a child in the Middle East as they rarely reach such huge sizes. Total resection was possible by repeat embolisation and surgery.Embolisation can render even huge AVM operable. AVMs should be treated as early as possible as they continue to grow and drastically decrease the quality of life of the patient. They appear as clusters of dilated arteries or arterioles that drain into a nidus connected to a net of vein(s) .Extra-cranial AVMs are rarely found in clinical practice; they may exist in any part of the body, with head and neck being the most common sites of the extra-cranial AVMs, followed by lungs, limbs, and gluteal area which is less affected . AVMs thThis paper reports a rare case of a huge and complicated gluteal AVM, measuring (15*15*2 cm) in an eight-year-old girl which was found at birth but misdiagnosed as a naevus. It remained small until later in life when it unexpectedly grew rapidly without known stimulating factors. Then it progressed to necrosis, ulceration, and bleeding. This work is reported in line with SCARE criteria which helped to improve the transparency and quality of this case report .2An eight-year-old girl presented to the clinic suffering from tenderness and bleeding from a vast necrotic sacro-gluteal mass. She had small pigmentation at this region since birth but it was asymptomatic and diagnosed as a naevus. However, at the age of eight years, the lesion aggressively progressed and became painful and haemorrhagic. No family history was significant. The patient went to a dermatologist who prescribed local steroids without any benefits. The lesion continued to become larger and more painful. No signs of puberty were present at time of presentation and no trauma other than sitting for long periods during school was reported.Currently, the lesion became around 12 cm at the longer diameter and 10 at the shorter one with irregular episodes of mild bleeding which prevented the patient from her normal life. Current physical examination found a murmur on auscultation over the mass and Doppler ultrasonography showed a fast and high-flow lesion which speculated to be AVM. Magnetic resonance imaging (MRI) showed non-capsulated superficial soft tissue mass in the sacro-gluteal region. The mass was large and measured approximately (12*10*4) cm. It consisted primarily within the skin and subcutaneous fat in the retro sacro-gluteal region and encased the coccyx. There was no extension to the pelvis or to the spinal canal. The mass was heterogeneous in signal intensity with numerous dark flow voids. Contrast enhanced images showed multiple enhancing abnormal blood vessels. It was consistent with an arteriovenous malformation (AVM). Otherwise, the pelvic structures were within normal limits . Brain MThe patient had financial difficulties and the surgery and embolization was postponed for another six months. During the six months, the lesion grew rapidly and became necrotic with occasionally heavy haemorrhage. Haemoglobin (Hb) reached as low as (5 g/dl) and the mass reached (15*15*2 cm) in size . No signPathology showed scattered arteries and veins with variable walls’ thickness with channels connecting them without capillary beds and only small quantities of normal tissue were observed in the lesion. Anti-biotic therapy and daily compressive dressing at plastic and reconstructive surgery department were performed. Day 10 after surgery, mild bleeding recurrence was noticed during the dressing and was managed by simple suturing. Post-operative MRI was conducted and showed a remnant of small nidus  which wa3Congenital Vascular Malformation (CVM) terminology is used to describe malformed vessels resulting from the arrested development during various stages of embryogenesis. According to Hamburg classification, AVMs represent one of the five classes of CVM  and accoTrauma, hormonal changes during puberty and pregnancy, biopsy and inappropriate treatments are considered as stimulation factors for the progression of AVMs ,8,10. DiTreatment options include embolization, surgical resection or a combination and currently there is no pharmacologic treatment. Pre-operative embolization is needed in large lesions in order to reduce blood loss. Excisional surgery should be implemented from 24 to 72 h after embolization before recanalization and angiogenesis take place, mainly when (PVA) particles are used like our case [In conclusion, any cutaneous pigmentation should be evaluated carefully in order to have a correct diagnosis to distinguish between a benign lesion and congenital vascular malformation (CVM). In case of CVM, earlier treatment leads to better results and can help preventing such a trauma and low quality of life for a child in such a young age and financial hurdles should be overcome as this is a priority for the child. This is the largest reported sacro-gluteal AVM reported in the Middle East, and considered one of the largest AVMs worldwide, presenting at unusual site at a young child. Repeated emboization before and after surgery was efficient to excise this large AVM.We declare no conflict of interest.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Damascus University deanship ethical approval was taken.Consent for using and publishing data from the patient’s parent was taken.NA.Ameer Kakaje.Not commissioned, externally peer-reviewed.Amjad Ghareeb: Conceptualization, Formal analysis, Software, Writing - original draft, Writing - review & editing, Investigation, Project administration. Ameer Kakaje: Conceptualization, Formal analysis, Software, Writing - original draft, Writing - review & editing. Ayham Ghareeb: Methodology, Software, Visualization, Validation, Writing - original draft. Mohamad Ali Nahas: Resources, Supervision, Investigation, Writing - review & editing.


Müllerian duct anomaly is a rare condition. Many cases remain unidentified, especially if asymptomatic. Thus, it is difficult to determine the actual incidence. Müllerian duct anomaly is associated with a wide range of gynecological and obstetric complications, namely infertility, endometriosis, urinary tract anomalies, and preterm delivery. Furthermore, congenital anomalies in pregnant mothers have a high risk of being genetically transmitted to their offspring.We report a case of a patient with unsuspected müllerian duct anomaly in a term pregnancy. A 33-year-old Malay woman with previously uninvestigated involuntary primary infertility for 4 years presented with acute right pyelonephritis in labor at 38 weeks of gestation. She has had multiple congenital anomalies since birth and had undergone numerous surgeries during childhood. Her range of congenital defects included hydrocephalus, for which she was put on a ventriculoperitoneal shunt; imperforated anus; and tracheoesophageal fistula with a history of multiples surgeries. In addition, she had a shorter right lower limb length with limping gait. Her physical examination revealed a transverse scar at the right hypochondrium and multiple scars at the posterior thoracic region, levels T10–T12. Abdominal palpation revealed a term size uterus that was deviated to the left, with a singleton fetus in a nonengaged cephalic presentation. The cervical os was closed, but stricture bands were present on the vagina from the upper third until the fornices posteriorly. She also had multiple rectal prolapses and strictures over the rectum due to previous anorectoplasty. An emergency cesarean delivery was performed in view of the history of anorectoplasty, vaginal stricture, and infertility. Intraoperative findings showed a left unicornuate uterus with a communicating right rudimentary horn.Most cases of müllerian duct anomaly remain undiagnosed due to the lack of clinical suspicion and the absence of pathognomonic clinical and radiological characteristics. Because it is associated with a wide range of gynecological and obstetric complications, it is vital for healthcare providers to be aware of its existence and the role of antenatal radiological investigations in its diagnosis. The presence of multiple congenital abnormalities and a history of infertility in a pregnant woman should warrant the exclusion of müllerian duct anomalies from the beginning. Early detection of müllerian duct anomalies can facilitate an appropriate delivery plan and improve the general obstetric outcome. Müllerian duct abnormalities (MDAs) are a broad and complex spectrum of defects that are often associated with primary amenorrhea, infertility, endometriosis, and obstetric complications. Women with congenital uterine malformation usually experience a higher incidence of complications during pregnancy and delivery. An obstetrician should have a high index of suspicion for an undiagnosed congenital defect such as MDA in the presence of infertility with a background of maternal congenital malformations. Early diagnosis and recognition of the condition may allow proper planning of treatment to ensure a favorable obstetric outcome.We report a case of MDA diagnosed during an emergency cesarean section of a pregnant woman with multiple congenital anomalies. A 33-year-old Malay woman with 4 years of previously uninvestigated involuntary primary infertility had spontaneously conceived. She presented with acute right pyelonephritis in labor at 38 weeks of gestation. Of note, she has had multiple underlying congenital anomalies since birth and had undergone various surgeries during childhood. The abnormalities included hydrocephalus, for which she was put on ventriculoperitoneal shunting; an imperforated anus; and tracheoesophageal fistula with a history of multiples surgeries. In addition, she had a shorter right lower limb length with limping gait. A detailed ultrasound scan at 20 weeks of gestation revealed a grossly normal fetus. Her medication history was not significant, and her social and family history revealed no remarkable findings.Clinically, she was alert and not in sepsis. Her vital signs were stable. However, she had a low-grade fever of 37.5 °C. She had a transverse scar on her right hypochondrium and multiple scars at the posterior thoracic region at levels T10–T12. Her abdominal examination revealed a term size uterus that was deviated to the left, with a singleton, nonengaged fetus in cephalic presentation. The result of a right renal punch was positive. Her cervix was unfavorable, with fibrotic stricture bands at the upper one-third of the vagina up to the fornices. She also had multiple rectal prolapses and strictures from a previous anorectoplasty. Her kidneys were of normal shape and size on her ultrasound examination. Her blood parameters, including her renal profile, were within normal ranges. She was administered a broad-spectrum intravenous antibiotic.In view of the above-mentioned maternal conditions, an emergency cesarean section was performed. Intraoperatively, MDA of left unicornuate uterus with fused right communicating horn was diagnosed. Both of the patient’s fallopian tubes and ovaries were normal Figs.  and 2. Ain utero to form the uterus, fallopian tubes, cervix, and upper two-thirds of the vagina. MDAs are rare conditions. The actual prevalence of MDAs is difficult to ascertain because many of the cases are asymptomatic and thus remain undiagnosed. The reported prevalence of MDAs varies widely across studies. In a systematic review, the prevalence of MDAs was 5.5% in an unselected population, 8% in infertile women, 12.3% in women with a history of miscarriage, and 24.5% in women with a history of miscarriage and infertility [The müllerian ducts are embryologic structures that exist in pairs before undergoing a mechanism of fusion and resorption The American Society for Reproductive Medicine (formerly the American Fertility Society) classification system for müllerian defects has been applied as the standard definition in the United States for decades . When MDMDAs are frequently associated with adverse gynecologic and obstetric complications, such as infertility, endometriosis, and miscarriage. They are also commonly associated with renal anomalies in as many as 30–50% of cases. The common renal anomalies are renal agenesis, ectopic kidney, hypoplasticity, fusion, duplication, and malrotation of the kidneys , 5. ThusThe diagnosis of MDAs remains challenging in most cases. Although hysterosalpingogram is useful in diagnosing a unicornuate uterus, it does not help in detecting a noncommunicating horn. Two-dimensional (2D) ultrasound is the initial imaging modality of choice because it is widely available, noninvasive, relatively inexpensive, and able to provide information about other relevant nonuterine structures such as ovaries, kidneys, and pelvic mass. It can also provide information on the subsequent imaging modality or modalities that should be chosen for definitive diagnosis. In contrast, three-dimensional (3D) reconstructed images provide more detailed information and often prevent the need for additional imaging , 9. HistAmong the various types of MDAs, the unicornuate uterus is associated with the poorest fetal survival. Even if the pregnancy is healthy, the obstetric performance is universally poor in this group. Common obstetrical complications include malpresentation, intrauterine growth retardation, and preterm birth. These reproductive problems are attributed to abnormal uterine vasculature and diminished myometrial mass of the unicornuate uterus . As a reIn view of these complications, it is crucial for female patients with multiple congenital anomalies to receive an early referral to exclude MDAs. A thorough assessment is compulsory during the initial pregnancy checkup to assess the severity of the condition. Early recognition and categorization of the condition allow appropriate management during the antepartum, intrapartum, and postpartum periods to ensure a good outcome for mother–baby dyad care.However, our patient, even though she underwent regular antenatal review at the local health center, was referred only much later to our tertiary-level center for further evaluation. Her old admission records regarding her childhood conditions were not available. On the basis of limited records, her clinical findings were suggestive of vertebral, anorectal, tracheoesophageal, renal, and limb associations. Hence, the possibility of an underlying MDA should be highly suspected from the beginning. The MDA was proved intraoperatively with the presence of unicornuate uterus with a rudimentary horn and communicating uterine horn. This condition is frequently associated with ipsilateral renal and ureter agenesis . HoweverThe majority of MDAs remain undiagnosed due to a lack of clinical suspicion and the absence of pathognomonic clinical and radiological characteristics. Hence, knowledge of its existence and the role of antenatal radiological investigations is vital to prevent the wide range of gynecological and obstetrical complications. As illustrated in our patient’s case, the presence of multiple congenital abnormalities and a history of infertility in a pregnant woman should warrant the exclusion of MDAs from the beginning. Early detection of MDAs will facilitate the most appropriate delivery plan to ensure the best maternal and neonatal outcomes.


Case 1: A 15-year-old male patient was presented to our clinic complaining of a painless yet distinctive, macroscopic form of hematuria. Following a routine examination, which included ultrasound (US) and intravenous pyelography, the urethrocystoscopy revealed an intravesical solitary lesion positioned in the vicinity of the left ureteral orifice. Additionally, histology confirmed urothelial papilloma. During the follow-up, laboratory, urinary control tests, and US results all proved negative.Case 2: A 13-year-old male patient was admitted to our clinic and examined, in regard to complaints associated with recurrent abdominal pain. The pathology was discovered incidentally on abdominal US. Preoperative US and magnetic resonance imaging (MRI) studies ensued, resulting in a scheduled MRI, followed by urethrocystoscopy, which confirmed an intravesical solitary lesion positioned near the right ureteral orifice. Histology revealed urothelial papilloma. During the follow-up control cystoscopy, one resection was repeated due to the presence of a residual tumor. Today, 10 years since the presence of uroepithelial papilloma, both patients are asymptomatic and tumor-free. If there is likely suspicion of recurrence, cystoscopy is recommended.Urothelial neoplasms of the bladder (UNB) are considerably rare throughout the pediatric population. UNB develops from the urothelial tissue in the form of a benign disease, generally favoring a successful prognosis in the majority of cases. The authors present the diagnosis and treatment regarding two medical case reports in which urothelial papilloma was diagnosed and effectively treated. While more frequently seen in an adult population, epithelial  tumors of the urinary bladder are among the top 10 most common types of neoplasms, including a significant potential regarding malignancy and a dismal prognosis. Distinctly, urothelial neoplasm of the bladder (UNB) is extremely rare among the pediatric population (below 18 years of age).Rhabdomyosarcoma is the most common tumor associated with the urinary bladder among children. Rhabdomyosarcoma, which is malignant, develops in the mesenchymal tissue, and generally features a bleak prognosis.In contrast, UNB  arises from the epithelial tissue, and except in consideration of HGUC, these tumors generally result in a favorable prognosis.Among these, only 11 cases were found, in which UP was prevalent during the diagnosis.The authors present two cases in reference to urothelial papilloma, diagnosed and treated in their respective department from 2007 through 2017.Data regarding two patients were retrospectively analyzed, including the symptoms, imaging methods, local extension of the lesion, histological evaluation, treatment, and follow-up.In 2007 a 15-year-old-male was presented with macroscopic hematuria and dysuria, without signs of systemic infection, to an external medical institute. His family history proved negative for any type of urogenital diseases or tumors including risk factors .5cfu/mL)Escherichia colibacteriuria, which was treated according to its antibiotic sensitivity, for a span over 2 weeks. Shortly thereafter, an abdominal ultrasound (US) examination revealed an intraluminal lesion in the bladder.Laboratory tests were negative and kidney function and inflammatory markers were within the normal range. The urine analysis test detected significant  was made and no obstruction was detected. On the fifth day following admission, the urethrocystoscopy was performed and the papillary tumor of the bladder was endoscopically resected.In regard to the resection, a 11.5 Fr resectoscope was used. The removal was made by the use of diathermy. The histological examination revealed urothelial papilloma (R0 resection). The follow-up included laboratory and urine tests, US examinations at 3-month intervals, all within the first 3 years, then once a year thereafter.Distinctly, no further abnormalities were detected. At the time, a cystoscopical follow-up was not routinely indicated. The patient is now 25 years old, asymptomatic, and tumor free, for the past 10 years .In 2017, a 13-year-old-male was presented suffering from recurrent abdominal pain of unknown origin. His family history proved positive for maternal Crohn's and celiac disease; however, all risk factors proved negative.Laboratory and urine tests were negative. The US showed an 18 × 20 × 21 mm large, lobulated, hyperreflective lesion adjacent to the orifice of the right ureter. A magnetic resonance imaging (MRI) examination was made to clarify the extent of the neoplasm. It featured a local lesion without any sign of infiltration. Urethrocystoscopy revealed a papillary tumor in the vicinity of the bladder, which was resected with the use of a diathermy, through a 11.5 Fr resectoscope. The histological examination revealed urothelial papilloma (R1 resection).However, control US and urine test results proved negative, a control cystoscopy was performed 1 month following the incomplete (R1) resection. During this intervention, a residual tumor was discovered at the same location as the primer lesion. A re-resection was endoscopically performed through the same means as previously achieved.The histology discovered a residual urothelial papilloma (R0 resection). Three months following the re-resection, control laboratory and urine tests, dipstick, and US all proved negative. A repeated cystoscopy procedure showed no residual or recurrent tumor in the bladder. The patient is now 14 years old. He is asymptomatic and has been tumor free for the past years .Epithelial tumors associated with the bladder are considered among the top 10 most commonly seen neoplasms throughout the adult population.Notably, these neoplasms are considerably rare among the pediatric age group.According to WHO 2016 classification of tumors associated with the urinary bladder, UNB  is, indeed, an extremely rare condition among those within the pediatric age group.Startlingly, very few publications can be found in English literature, in reference to UNB in the pediatric population.Fine et al analyzed surgical and histological data regarding three pediatric urology units' cases, all under the age of 20 years, and afflicted with various forms of UNB. Twenty-three cases were reviewed, and urothelial papilloma were prevalent in only two cases.Berrettini et al retrospectively analyzed the data regarding three tertiary pediatric urology units with the diagnosis of UNB from 1999 through 2013. In consideration of the eighteen cases associated with UNB, only eight patients were diagnosed with urothelial papilloma.Based on these studies, gross painless hematuria appears to be the most common presenting symptom regarding UNB (nearly 80% of the cases).Cystoscopy and transurethral resection of the lesion appear to be a successful form of treatment in the majority of cases.Although pediatric guidelines are not available regarding the management of UNB, US may bear sufficient sensitivity toward effectively establishing the clinical diagnosis. However, the endoscopy has the highest level of sensitivity and specificity, an additional MRI or CT scan may prove benefit toward clarifying the malignant potential of the detected lesion.In 2007, we made IVP routinely to visualize if there is any likelihood of an obstruction or intraluminal lesion in the bladder; however, today, this diagnostic tool is rarely used. In cases due to the low incidence of papillomas, there is, as of yet, no standardized guidance regarding the follow-up.Studies focused on the adult population highlighted the recurrence of papillomas in several cases; therefore, US is advocated as a form of follow-up.If there is any suspicion of recurrence or residual disease , it is highly recommended to perform cystoscopy, which the author encourage enthusiastically.Due to the low incidence of UNB among children, there is no specific pediatric guideline in reference to an effective form of treatment or follow-up. Complete transurethral resection of uroepithelial papilloma may likely provide suitable levels regarding minimally invasive and successful treatment during childhood; however, a urinary dipstick for hematuria and US scan may indeed prove beneficial in the follow-up procedure toward detecting residual and/or recurrent forms of pathology.According to our limited experience, cystoscopy is highly recommended in the early postoperative period to detect incomplete resection of the tumor, and considered as an optional form of treatment during long-term follow-up. However, if and when there is any suspicion of the presence of a tumor, a cystoscopy is deemed absolutely necessary to perform.