Objective: To identify the possible causes of spontaneous bladder rupture after normal vaginal delivery and to propose a diagnostic and therapeutic algorithm. Material and Methods: MEDLINE (PubMed), Web of Science and Scopus databases were searched up to August 2020. Manuscripts considered were published from 1990 and only English articles were included. The research strategy adopted included the following terms: (bladder rupture) AND (spontaneous) AND (delivery). 103 studies were identified. Duplicates were found through an independent manual screening. Subsequently, two authors independently screened the full text of articles and excluded those not pertinent to the topic. Discrepancies were resolved by consensus. Finally, thirteen studies were included. Results: PRISMA guidelines were followed. For each study, fetal weight, catheterization during labor, parity, maternal age, occurrence time, previous abdominal or pelvic surgery, symptoms complained of, diagnostic methods, and treatment were considered. Median age was 26.0 (range 20–34 years); median presentation time was 3.0 days after delivery (range 1–20 days); and median newborn weight was 3227.0 g (range 2685–3600 g). Catheterization during labor was reported only in four of the thirteen cases (30.8%) identified. The symptoms most frequently complained of were abdominal pain and distension, fever, oliguria, haematuria and vomiting. Instrumental diagnosis was performed using X-rays in five cases and computerized tomography in six cases. Ultrasound was chosen in five cases as a first diagnostic tool. In two cases, cystography was performed. Treatment was always laparotomic repair of the visceral defect. Conclusion: Abdominal pain, increased creatinine and other signs of kidney failure on blood tests should lead to suspicion of this complication. Cystourethrography is regarded as a procedure of choice, but a first ultrasound approach is recommended. The main factor for the therapeutic choice is the intraperitoneal or extraperitoneal rupture of the bladder. Classical management for intraperitoneal rupture of the bladder is surgical repair and urinary rest. Spontaneous bladder rupture during labor or postpartum is an extremely rare condition. Increased visceral pressure, weakening of the bladder, and vesical catheterization performed during labor are predisposing factors . An incrSurgery is crucial for the resolution of the clinical picture and consists of urine removal from the peritoneal cavity and closing of the rupture .This complication represents a surgical emergency, and a rapid diagnosis represents a challenge for gynecologists.We performed a systematic review of the literature to identify the possible causes of spontaneous bladder rupture after normal vaginal delivery and to propose a diagnostic and therapeutic algorithm. We report a case of a bladder rupture the second day after a spontaneous vaginal delivery, managed in our department.A 36-year-old woman was diagnosed with a bladder rupture on the second day after a spontaneous vaginal delivery which was performed successfully. The patient reported sudden onset of acute abdominal pain with no apparent cause. She had an uneventful pregnancy without any genitourinary problems. Her medical history included no major pathologies and no previous surgical procedures. During labor, she was unable to empty her bladder spontaneously, and so a urinary catheter was used. The day after delivery, diuresis and peristalsis were regular. The patient reported any other symptoms, such as nausea and vomiting. Physical examination revealed a generalized abdominal tenderness. An office trans-abdominal ultrasound showed a copious abdominal effusion while blood chemistry tests reflected a septic state with high creatinine levels. A broad-spectrum antibiotic therapy was issued immediately, with 4.5 g of piperacillin-tazobactam to be taken four times daily. A CT-scan was urgently performed and confirmed the presence of a massive free abdominal effusion, showing the presence of intestinal loops with thickened walls. The bladder appeared intact. An urgent exploratory laparoscopy was decided on and about 2 L of fluid was suctioned and a diagnosis of uroperitoneum was made . An intrThis research was approved by our Institutional Review Board (RC 08/2020).MEDLINE (PubMed), Web of Science and Scopus databases were searched up to August 2020. The manuscripts considered were published from 1990 up to August 2020. Only articles in English were included in the search. The research strategy adopted included different combinations of the following terms: (bladder rupture) AND (spontaneous) AND (delivery).For the selection of the papers, we included articles that focused on spontaneous bladder rupture during or after a normal vaginal delivery. We examined in our review the age of patients, their obstetrical history, previous surgical procedures, catheterization during labor, symptoms, the type of diagnosis and outcome.We excluded from the review studies concerned with cases of bladder rupture that occurred after an operative vaginal delivery, during cesarean section delivery, in women with a history of previous cesarean section delivery or pelvic surgery or previous genitourinary mutilation. Articles not relevant to the topic were also excluded.All studies identified were examined for year, citation, title, authors, abstract and their full texts. Duplicates were identified through manual screening performed by one researcher and then removed. PRISMA guidelines were followed . The PRITwo manuscripts were detected through the references of the works that had been identified with the research on PubMed and Scopus.Two researchers performed data extraction using a predefined form including the following data: author, month and year.Due to the rarity of this pathology, the studies included are all case reports. For this reason, we present the data in a descriptive manner. The inclusion of only case reports in this review presents a risk of bias. The methodological quality of the included studies was assessed using the JBI Critical Appraisal Checklist for case reports .n = 36 from MEDLINE; n = 62 from Scopus; n = 5 from Web of Science). Three manuscripts were detected through the references of the works that had been identified with the search of MEDLINE, Web of Science and Scopus. Records excluded for selection criteria and duplicates were n = 91. Two other manuscripts were excluded as they showed simultaneous postpartum rupture of the uterus and bladder. We included in our review a total of thirteen cases at the end of the screening process . Referring to the median value, the diagnosis occurs 3.0 days after delivery, with the latest diagnosis occurring at 20 days after delivery and the earliest at 12 h. Fetal weight was not found to be a determining factor for bladder rupture. In the thirteen cases identified, the fetal weight is very variable, ranging from a maximum of 3600 g to a minimum of 2685, with the median weight of the newborn being 3227.0 g. Even parity was not found to be a major risk factor for rupture of the bladder. Of the thirteen cases identified, eight occurred in the first pregnancy (61.5%), and three in the second (23.1%) while two were not known (15.4%). Regarding our patient, it was her first pregnancy. Catheterization during labor is reported only in four of the thirteen cases identified (30.8%).The symptoms most frequently manifested by patients were abdominal pain (53.9%), abdominal distension (38.5%), fever (15.4%), oliguria (38.5%), haematuria (15.4%) and vomiting (15.4%).The instrumental diagnosis was made with an X-ray of the abdomen , computerized tomography, and abdominal ultrasound (US). Abdominal X-ray was used in five cases; computerized tomography was used solely in two cases, one time after abdominal X-ray and three times after ultrasound evaluation. US was used in five cases as a first diagnostic tool. In two cases, a specific diagnostic tool for the urinary tract was used, such as cystography. On the basis of the results of our review, we suggest a diagnostic algorithm .In the cases previously described in the literature, treatment was always laparotomic. In every case reported, laparotomy also had a diagnostic role when a certain diagnosis was not made through radiological examinations. Our case was the first laparoscopically treated.New onset ascites with acute abdomen in puerperium is a very rare condition and the differential diagnosis may be hard for the physician. Several causes of puerperal ascites have been described in the literature, all with a clinical picture similar to that of the spontaneous rupture of the bladder. One case of postpartum hepatic artery thrombosis has been described by Damman et al. in a patient presenting with fever, coma, ascites, ileus, jaundice and renal failure after delivery . The impSpontaneous rupture of urinary bladder (SRUB) following spontaneous vaginal delivery is an extremely rare condition and represents a surgical emergency. The few data in the literature do not help us to fully clarify the causes of this adverse event. It is usually described in association with recent trauma, malignant diseases, anatomical outflow obstructions, indwelling catheters, instrumentation, neurogenic bladder or a combination of these . DespiteAnother cause of bladder rupture is represented by the sustained pressure of the fetal head against the intraperitoneal portion of the bladder during forceful uterine contractions, provoking necrosis of the bladder dome. This is more likely if the patient is not catheterized, resulting in a distended bladder during labor. Other contributory factors include the presence of a pre-existing bladder diverticulum, prolonged second stage and high birth weight babies . Not onlIn our opinion, to prevent this kind of complication it would be better to use catheters of not too thin a gauge and avoid deep introduction of the catheter into the bladder in the final phase of labor.Another risk factor evaluated is the fundal pressure during the second period of labor. In our case, no fundal pressure was applied. The role of this maneuver is understudied. The effects on the maternal perineum are inconclusive; fundal pressure emerged as an independent risk factor for anal sphincter tear at delivery and post-partum urinary retention ,31,32. TThere are some reports about concomitant bladder and uterine ruptures. We have excluded these cases from our systematic review, but with these types of complications, in addition to cystograms, some authors suggested that intravenous contrast-enhanced CT is at least as sensitive as cystography . In factRetroperitoneal bladder rupture is commonly treated with bladder catheterization for 10 days. The classical treatment for intraperitoneal bladder rupture is surgical repair and urinary rest .Muggia et al. managed this rare condition by percutaneous ascites drainage and long-lasting foley. However, the report described a case with small iatrogenic injuries. Large tears caused by blunt trauma clearly should be managed surgically .Corriere et al. suggested strict criteria for conservative management of small intraperitoneal bladder perforation, including absence of infection, no bowel herniation, diagnosis within 12 h from the injury, no concurrent intrabdominal injuries and absence of ascites ,35. OperThe strength of our study is the long period of time overviewed in the literature. We analyzed the cases of bladder rupture after normal vaginal delivery with no prior pelvic surgery or other risk factors that arose in the last 30 years. All the studies selected during the eligibility phase have been further evaluated by manual comparison of populations, study settings and authors to avoid overlapping cases. We also excluded from our review all cases in which patients had predisposing factors  to minimize confounding factors and select bladder ruptures that occurred spontaneously after vaginal delivery.The main limitation of this review is only case reports are included among the papers selected, this being due to the rarity of this complication.Gynecologists must be aware of bladder rupture after spontaneous delivery—a rare but insidious occurrence. Abdominal pain and blood tests indicating kidney failure should suggest the presence of this complication. On the basis of the results of our review, we suggest a diagnostic algorithm . Firstly


Tubo-ovarian abscesses (TOA) is presented with multiple clinical manifestations including gastrointestinal findings.Herein, we present a case of complicated diverticulitis that was misdiagnosed as TOA, owing to overlapping genital involvement.Imaging could be misleading in these patients as a result of severe inflammation of intestines and surrounding organs.Patients who do not respond to antibiotic treatment should be suspected of other gastrointestinal pathologies such as diverticulitis and should be evaluated accordingly. •Concomitant presentation of diverticulitis and Tubo-ovarian abscesses (TOA) has been rarely reported.•Diverticulitis can also be complicated, indicated by the involvement of other organs such as ovaries and fallopian tube.•In such cases, pathological evaluation, following the surgical intervention can indicate the exact disease. TOA (tubo-ovarian abscess) can be a complication of PID, which is an inflammatory mass involving the fallopian tube, ovary, and, occasionally, other adjacent pelvic organs . This may manifest as a tubo-ovarian complex (an agglutination of those structures) or a collection of pus (TOA). TOA typically occurs as a complication of PID but in some cases, is developed due to pathology of adjacent organs or hematogenous spread Fig. 1, , Fig. 3.Diverticular disease of the colon is an important cause of hospital admissions that is suspected in patients with lower abdominal pain , abdominal tenderness on physical examination, and leukocytosis. The diagnosis is usually confirmed by an abdominopelvic computed tomography (CT) scan. Acute complicated diverticulitis  requires treatment of both, colonic inflammation (diverticulitis) and the specific complication which typically requires hospitalization and/or surgery ,6. AbsceIn this case report, we discuss a case of TOA patient who underwent surgery due to lack of response to pharmacological treatment and intra operative finding showed complicated diverticulitis.245 years old woman G1P1  was admitted in emergency room with the history of chronic abdominal pain for two months, which was exacerbated two weeks ago. Her pain was colicky in the LLQ (left lower quadrant). The patient had no gastrointestinal and urinary symptoms. Her menstruation was normal without any history of vaginal discharge and dysmenorrhea. However, she complained of dyspareunia, fever and chills. In previous ultrasound finding, a heterogeneous mass of adnexal origin measuring 60*46 mm in the form hemorrhagic cyst was reported along with adjacent inflammatory changes and mild ascites. Second ultrasound after 3 weeks, performed due to exacerbation of pain, reported similar heterogeneous cystic mass measuring 71*52 mm with loculated fluid adjacent to the iliac fossa, in favor of peduncle degenerative myoma.At the time of admission, the patient's vital signs were: blood pressure: 110/60, heart rate: 114 and body temperature 37.1 °C. On physical examination, the abdomen was soft and had tenderness on the left side of the abdomen along with palpable mass. Gynecological examination showed a firm tender mass in the midline measuring 16 weeks pregnant uterus. The patient was hospitalized with a possible diagnosis of degenerative myoma. Her laboratory findings were WBC: 17500, Hb: 9.8, MCV: 69, pregnancy test: neg, CRP: 187, ESR: 125, CA125: 26.9, CEA: 2.23. Ultrasound showed mixed echo mass measuring 79*44*57 mm with debris and echogenic line of about 150 cc in favor tubo-ovarian abscess or gastrointestinal mass. MRI also showed the evidence of tubo-ovarian abscess indicated by the loss of flat planes between the mass and adjacent pelvic organs and multiseptated lesions with pronounced air-fluid. Thus, ampicillin, clindamycin and gentamicin were started, which was switched with imipenem due to no change in abscess size, and a catheter was placed under ultrasound guidance to drain the abscess, for 5 days , Fig. 5.There were no major postoperative complications and patient was discharged in healthy condition.This case report has been reported in line with the SCARE 2020 criteria . Written3In this case study, we report a patient with acute diverticulitis where symptoms and adnexal mass was seen with the involvement of gynecological organs. Sigmoidal involvement in gynecologic diseases is also possible. Although rare, the sigmoid could be involved in abdominal pregnancies .We searched PubMed database, Embase and Cochrane library using “diverticulitis”, “gastrointestinal complication”, “tubo-ovarian abscess” and “pelvic inflammatory disease” as keyword and excluded the cases where diverticulitis was presented as gynecologic complication. We found few cases that reported this complication. The mean age of patient was 43 (range:15–80 years). 9 patients were presented with abdominal pain and the duration between abdominal pain and diagnosis ranged from 3 days to 1 year. 5 cases were presented with fever, 2 cases had vaginal discharge, a patient had dyspareunia and dysmenorrhea. 5 patients had gastrointestinal symptoms such as diarrhea, constipation and vomiting whereas urinary tract symptoms were not reported. Medical history of these patients showed gastrointestinal disease such as irritable bowel syndrome, Crohn's disease, diverticulitis and Henoch–schonlein purpura. Common lab findings were leukocytosis in 7 patients, elevated CRP in 2 cases and elevated ESR a case. TOA was differential diagnosis in all the cases and mass-like lesion was seen in radiography. Involvement of sigmoid colon was reported in 5 cases and the most common involvement was edematous wall due to inflammation and mesentery fat thickening whereas evidence of diverticula was seen in two cases only. Drainage and broad-spectrum antibiotic for two weeks were the course of treatment in 3 studies, whereas, exploratory laparotomy was performed in the rest. The removal of abscesses wall included salpingo-oophorectomy, hysterectomy and colectomy. Overall, 7 cases of TOA complicated with diverticulitis (1 appendix diverticulitis and 2 sigmoid) were seen .Usually, pelvic abscess in women is attributed to genital organ and other causes are ignored. However, common cause of TOA is genital organ complication, especially in sexually active female . GastroiAll procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.No funding was secured for this study.Dr. Seyyedeh Neda Kazemi: conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript. Dr. Majid Samsami and Dr. Hamidreza Didar: Designed the data collection instruments, collected data, carried out the initial analyses, and reviewed and revised the manuscript. Dr. Masoomeh Raoufi and Haniye Najafiarab: Coordinated and supervised data collection, and critically reviewed the manuscript for important intellectual content.Not applicable.1. Name of the registry: N/a.2. Unique Identifying number or registration ID: N/A.3. Hyperlink to the registration (must be publicly accessible): N/A.Seyyedeh Neda Kazemi.Not commissioned, externally peer-reviewed.The authors deny any conflict of interest in any terms or by any means during the study.


Background: Liver parenchyma that resides outside of the normal hepatic confines is defined as accessory liver if in communication with the native biliary tree, or ectopic liver (EL) if it is not. EL can develop in a variety of tissues, including but not limited to the gallbladder, the hepatic ligaments, the pancreas, and retroperitoneum. EL has an increased propensity for malignant degeneration resulting in hepatocellular carcinoma (HCC).Presentation: A 67-year-old Korean male presented with epigastric discomfort and was found to have an elevation in his transaminases. Cross-sectional imaging demonstrated a 1.3 cm solid mass in the body of the pancreas with features concerning for either a pancreatic ductal adenocarcinoma or pancreatic neuroendocrine tumor. Subsequent endoscopic ultrasound and fine needle aspiration demonstrated cells of epithelial origin with hepatocellular differentiation. A robotic-assisted distal pancreatectomy and splenectomy was performed with final pathology demonstrating a well-differentiated HCC.Conclusions: EL with malignant degeneration resulting in HCC requires surgical excision. The majority of patients reported with EL resulting in HCC in the pancreas have had the tumors located in the body and tail. Therefore, definitive treatment requires distal pancreatectomy and splenectomy. Herein, we describe the presentation, workup, and definitive treatment of HCC arising in the pancreas. In proximity, the ventral and dorsal pancreatic buds develop giving rise to the pancreatic head/uncinate and neck/body/tail, respectively.4 EL has an increased propensity for malignant degeneration compared with the normal liver and is frequently unrelated to cirrhosis, viral hepatitis, or other known risk factors for HCC.6Hepatocellular carcinoma (HCC) is the third most common cause of cancer-related death worldwide and most typically originates in the setting of cirrhosis secondary to hepatitis, alcohol, autoimmune hepatitis, toxin exposure, nonalcoholic steatohepatitis and metabolic diseases such as Wilson's disease and hemochromatosis.Herein, we report a case of a patient who presented with indigestion and epigastric discomfort, found to have a distal pancreatic mass, treated with a robotic distal pancreatectomy and splenectomy, with final pathology demonstrating HCC.This report is exempt from institutional review board. Signed written consent was obtained from the patient to use details from the medical record without identifying the patient by name.A 67-year-old Korean male with no past medical or surgical history presented to his primary care physician with indigestion and epigastric discomfort. His physical examination was unremarkable. Laboratory assessment demonstrated a mild elevation in his hepatic transaminases , which prompted a transabdominal ultrasound. A hypoechoic 1.1 cm cystic mass without significant vascularity was identified in the body of the pancreas without ductal dilation . A subseThe case was discussed in a multidisciplinary tumor board and surgical excision was recommended. Diagnostic laparoscopy demonstrated no evidence of masses in the liver and no evidence of peritoneal or omental metastasis. A total of six ports were placed and the robot was docked. An intraoperative ultrasound demonstrated that the mass was distal to the pancreatic neck. A tunnel under the neck of the pancreas at the superior mesenteric vein and portal vein confluence was established. A stapler was used to divide the pancreas immediately medial to the gastroduodenal artery. The splenic artery and vein were dissected circumferentially and divided using a linear stapler. The remaining attachments to the retroperitoneum were divided and the specimen was removed. A drain was left adjacent to the pancreatic staple line. The patient's postoperative course was unremarkable, his drain amylase level was low, and his drain was removed before discharge on postoperative day 4.The final gross pathology demonstrated a 1.5 cm tan-brown solid soft well-circumscribed lesion. Rare cells contained cytoplasmic pigment suggestive of bile. The final pathology was consistent with a 1.5 cm well-differentiated carcinoma with hepatoid features . All marHerein, we report a case of a patient with HCC in the distal pancreas, arising from EL, who underwent definitive treatment with robotic distal pancreatectomy and splenectomy. This case highlights the workup and treatment of a rare pancreatic lesion.7 The most common location for EL is the gallbladder and can range in size from millimeters to several centimeters,9 whereas EL located in the pancreas is more uncommon.10–14 The exact incidence of EL is unknown but thought to be ∼0.24% to 0.47% (Refs.16).Extrahepatic tissue outside of the normal liver confines but in communication with the biliary system is defined as accessory liver, whereas extrahepatic liver tissue not in communication with the biliary system is known as EL.17–19). This increased risk is likely due to the lack of native vasculature and inability of bile excursion. The functional impairment of the liver may cause chronic inflammation as well as prolonged exposure to carcinogenic factors due to inadequate removal.20 In addition, most patients do not have cirrhosis or the standard risk factors for HCC development. It should be noted, however, that although our patient did not have cirrhosis, the MRI did detect evidence of steatohepatitis, a risk factor for cirrhosis and subsequent HCC.EL harbors an increased risk of malignant transformation, with reported rates of ∼12% to 30% (Refs.21 The radiological appearance of HCC in EL is less well characterized with less apparent arterial enhancement.22 The present lesion demonstrated very subtle T2 hyperintensity and a very subtle hyperintense signal on diffusion weighted images that can be characteristic of HCC; however, other diagnoses such as pNET remained plausible.The appearance of HCC on MRI is well described and can be distinguished between a regenerative and dysplastic nodule. In the native liver, HCC demonstrates variable signal on T1-weighted precontrast images with both arterial enhancement and delayed washout. On T2-weighted images, the lesion can demonstrate an elevated signal or be isointense relative to the native liver.24 AFP was not elevated in this case, likely due to the small size and well differentiation of the lesion. This is consistent with other reports of HCC arising in EL in the literature (25–27AFP is a protein produced by the fetal liver and functions in a similar manner to albumin. After birth, the level of this protein rapidly decreases; however, in the setting of hepatic regeneration and HCC, AFP production is re-established. Therefore, AFP is used as a tumor marker for the diagnosis of HCC and has prognostic significance.terature . Interes20 Therefore, management of these lesions should mirror that of small localized HCC in the native liver without cirrhosis followed by surveillance.23 Considering the majority of pancreatic lesions are located in the distal pancreas, a minimally invasive distal pancreatectomy and splenectomy should be performed.28 The use of Sorafenib or Lenvatinib for HCC in EL has not been evaluated in cases such as ours, although it has demonstrated improved overall survival and increased time to radiological progression in advanced HCC located in the normal anatomic liver parenchyma.30 Considering the increased predilection for malignant degeneration in EL, routine excision of identified EL should be considered.Definitive treatment of these lesions includes surgical excision and prognosis is excellent.Primary HCC arising from EL can occur in various locations. When EL gives rise to HCC, definitive treatment is surgical excision if technically feasible. The role for adjuvant therapy is poorly defined; however, surgery, with margin negative resection, provides excellent prognosis. Further studies are required to identify risk factors for the development of HCC in EL and define risk factors for metastasis.All authors have approved the final article.


Rectovesical fistulae (RVF) are uncommon entities and usually occur after surgery for prostate, radiation, and sometimes due to penetrating trauma. However, RVF occurrence after blunt trauma to the abdomen or perineum is very rare. The management of RVF is challenging, and treatment options should be considered according to the individual. Here we present a case of a 10-year-old boy who presented with fecaluria, pneumaturia, the passage of urine per rectum, and burning micturition for four days after incurring a blunt injury to the perineum. Cystography revealed leakage of contrast material into the rectum and an MRI of the pelvis was done for confirmation, which revealed a 1.3 cm thick fistulous tract of 2.7 cm length with openings at the posterior bladder wall and anterior rectal wall. After conservative management for 14 days failed to show any improvement, primary repair of the fistulous tract along with fecal diversion and urinary diversion were done. The suprapubic catheter was removed after four weeks, and at the two-month follow-up, colostomy closure was done. No recurrence was found in the six-month follow-up period. In cases of small traumatic RVF where conservative management fails, fecal and urinary diversion can be considered, as it is associated with successful outcomes and less recurrence. Rectovesical fistulae (RVF) are uncommon entities. Common causes include prostatectomy for cancer of the prostate or benign prostatic hyperplasia and radiation. Rectovesical fistulae due to trauma are not so common and could be caused by gunshot injury, foreign bodies inserted in the rectum, road traffic accidents, and rarely due to blunt trauma. They usually present with pneumaturia and fecaluria, and detecting the exact location of rectovesical fistulae needs the aid of diagnostic imaging. The management of RVF is challenging and varies according to the etiology, and nearly half of them heal by urinary and fecal diversion while few patients need definitive procedures. After a thorough literature search, we could say that RVF due to blunt trauma in the pediatric population is very rare, and only a few such cases have been reported so far.5cfu/mL. Cystography was done, which revealed the leakage of contrast material into the rectum, thus substantiating the presence of a rectovesical fistula. MRI of the pelvis was done for better visualization of the fistulous tract and surrounding tissues, which revealed a 1.3 cm thick fistulous tract of 2.7 cm length with openings at the posterior bladder wall and anterior rectal wall as shown in Figures A 10-year-old boy presented with fecaluria, pneumaturia, the passage of urine per rectum, and burning micturition. The patient revealed a history of trauma to the perineal region while riding a bicycle two days before the onset of symptoms, following which he developed perineal and suprapubic discomfort. Digital rectal examination showed no blood in the rectum, but a defect was palpated in the anterior rectal wall. Laboratory examination revealed leukocytosis . Urine analysis showed fecal contamination, 10-15 pus cells/hpf, and granular casts. Urine culture revealed a growth of Escherichia (E.) coli > 10The patient was initially treated conservatively with antibiotics, urethral catheterization, and bowel rest for 14 days but showed no resolution. Mechanical bowel preparation was done, and IV antibiotics were given preoperatively. Under general anesthesia, a midline infra-umbilical incision was made, and the posterior aspect of the bladder and the anterior rectal wall was visualized. No necrotic or inflammatory tissues were seen surrounding the fistula. A longitudinal cystotomy was done, and a small defect on the posterior bladder wall was identified and repaired in a single layer. Cystotomy was closed with a suprapubic catheter in situ for urinary diversion. End sigmoid colostomy with mucus fistula was kept for fecal diversion as shown in Figure Rectovesical fistulas are very rare and can be caused by congenital anorectal malformations, bladder and prostate surgery, gynecologic and colorectal surgery, radiotherapy for pelvic tumors, trauma, and neglected foreign bodies . PneumatConservative management of RVF includes bowel rest, urethral catheterization, antibiotics, and a short course of low-dose steroids. This line of management is reserved for minimally symptomatic fistulas that are not associated with malignancy. Surgery is the mainstay of treatment for most RVF. Various endoscopic, laparoscopic, and open surgeries have been depicted in the literature. Historically, primary colostomy for fecal diversion has been used for treating these fistulae . Open suThurairaja et al. described conservative management of RVF in which a 46-year-old man sustained an injury to the rectum after falling onto a chair. The patient was kept on antibiotics for three weeks, and a suprapubic catheter was kept in situ for five weeks, after which a CT scan revealed no air in the bladder -8. TheirIncidence of RVF due to blunt injury to the perineum is very rare and only a few such cases have been reported in the pediatric population. Although many techniques have been described in the literature, no standard treatment technique has been established and the choice of technique differs based on the individual. In our case, we used a transabdominal approach to visualize both the bladder and the rectum. Cystotomy was done and the posterior bladder wall was repaired, following which the cystotomy was closed. Given the small diameter of the fistula and because the surrounding tissues were not inflamed, primary repair of the defect on the posterior bladder wall was done without excision of the fistulous tract or repair of the anterior rectal wall. Diversion colostomy with mucous fistula was done for fecal diversion. Suprapubic catheter and foley's catheter per urethra were used for urinary diversion. This technique is not technically demanding and can be performed easily compared to transanal and transrectal approaches. The transabdominal technique also provides clear visualization when both the rectum and the bladder need to be repaired.Although multiple techniques have been described in the literature for the operative treatment of RVF, no standard technique has been established. In small traumatic fistulas, particularly in children, transabdominal primary repair of the bladder defect along with urinary and fecal diversion can be done with successful outcomes and has less recurrence.


We report the case of a primitive nasal melanoma in an 82-year-old patient, showing how this rare malignancy, with non-specific signs and symptoms, can represent a challenging diagnosis for the physician. A 82-year-old Caucasian patient presented for unilateral nasal obstruction and occasional epistaxis. Computerized tomography (CT) and magnetic resonance imaging (MRI) of the facial massif revealed turbinate hypertrophy and a polypoid phlogistic tissue isointense in T1 with an intermediate signal in T2 and Short-TI Inversion Recovery (STIR)-T2, occupying the middle meatus and the anterior upper and lower left meatus with partial obliteration of the ostium and the infundibulum of the maxillary sinus. The Positron emission tomography (PET) exam was negative for metastases. Conservatory surgery in the left anterior video rhinoscopy was performed, allowing a radical 4-cm tumor excision. Histology reported epithelioid cell melanoma, PanK−, CD45−, and PanMelanoma+. Adjuvant radiotherapy was suggested, even considering a complete resection as the result of surgery. No local or systemic relapse was noticed at the 2-month follow-up visit. Although mucosal melanoma is a rare and aggressive malignancy characterized by a poor prognosis, early diagnosis allows a more conservative approach, with little surgical difficulty and no aesthetic effect. Our case raises awareness of the importance of early intervention even in those cases where the clinic symptoms and diagnostic images show uncertain severity. Mucosal melanomas are malignant primary tumors originating from melanocytes located in the mucosal membranes of the nasal cavity and accessory sinuses, oral cavity, lips and pharynx, vulva, vagina, uterus, anorectum, or basically any other part of the mucosal surface lining. These malignancies are characterized by high aggressiveness and poor prognosis ,2. The iAn 82-year-old Caucasian male presented to our clinic reporting unilateral nasal obstruction and occasional epistaxis. Anamnesis reported a history of severe snoring associated with nocturnal jolts and apnea episodes, type 2 diabetes, arterial hypertension, gastroesophageal reflux, hepatic steatosis, colon polyposis, and a smoker for 50 years at 190 packs/year. At the ear–throat–nose assessment, the patient reported dysphagia, unilateral nasal obstruction, and worsening of the post-nasal drip, associated with red blood streaks in the sputum. Nasal endoscopy showed a unilateral polypoid formation in the left nasal fossa, with irregular edges, friable margins, and easy bleeding, which did not allow the inspection beyond the anterior third of the inferior turbinate. CT and MRI scans of the facial massif were performed. CT showed only turbinates hypertrophy, more significant on the left turbinate with non-specific subtotal obliteration of the homolateral nasal cavity. The MRI images presented polypoid phlogistic tissue, isointense in T1, and mildly hyperintense in T2 and Short-TI Inversion Recovery (STIR) T2, occupying the entire middle left meatus and the anterior side of the upper and lower left meatus with partial obliteration of the maxillary sinus ostium and infundibulum A–C. No sDue to the morphology and unilaterality of the lesion, the differential diagnosis included several neoplastic lesions, such as an inverted papilloma and squamous cell carcinoma. The hypothesis of a foreign body insertion was not taken into account, given the negative anamnesis. Video rhinoscopy and surgery were performed. The polypoid mass originated in the lateral wall of the left nasal fossa, in the left nasal fossa, above the head of the inferior turbinate and extended beyond the choana, to the nasopharynx. The tumor appeared to easily bleed, and it was cauterized with bipolar forceps in order to reduce its size A. The exNasal melanomas are rare conditions characterized by non-specific symptoms, often presented as pigmented masses with a polypoid appearance, similar to benign lesions . The benGiven the patients’ limited disease (T3 N0 M0), the tumor board recommended adjuvant radiotherapy, considering surgery resolutive.Our case report emphasizes how unilateral nasal neoformations require accurate differential diagnoses based on the considerably different prognosis associated with each condition. The occurrence of unilateral nasal obstruction or unilateral epistaxis in patients over 65 years old must be considered a suspicious sign. Sino-nasal mucosal melanoma has a poor prognosis due to its aggressiveness and advanced-stage diagnosis. Although tumor biology usually plays a major role in determining tumor mortality and recurrence, an early-stage identification of this malignancy may lead to a better prognosis. Despite the overall poor prognosis of these tumors, in the presented case, the disease had a particular way of growth, with non-invasive characteristics, resulting in responsivity to surgery and radiotherapy, with no noticeable signs of recurrence or metastasis. More efficient therapies to improve the survival outcomes still need to be validated. Thus, in the current scenario, a prominent role is played by the early individuation of critical cases followed by a prompt radical resection of the malignancy, possibly completed by adjuvant radiotherapy.


Yolk sac tumors (YSTs) of the endometrium and the broad ligament are very rare, with only 29 cases and one case of each other reported before in the English literature. Due to lack of standard guidelines, the treatment strategies of these diseases are controversial. Here, we share two cases of YSTs originating from the endometrium and the broad ligament respectively and review related literature. A 35-year-old woman was diagnosed with endometrial YST in our center and underwent surgery followed by chemotherapy with BEP  regimen for six courses. After follow-up for 21 months, there is still no evidence of relapse. Another 36-year-old woman was admitted to our department with YST of the broad ligament. She was treated with surgery followed by chemotherapy with BEP regimen and was lost to follow-up after completing therapy. The case of endometrial YST we shared was similar to cases reported before, while the case with YST of the broad ligament we shared was the second case reported worldwide. Both of these two cases were treated with surgery combined with chemotherapy with BEP regimen. Yolk sac tumor (YST), also known as endodermal sinus tumor, is a malignant germ cell tumor usually accompanied by elevated serum alpha-fetoprotein (AFP). Most YSTs occurred in the gonads and the midline of the body of young women, young children, and infants . ApproxiThis study was approved by the ethics committee of The Affiliated Cancer Hospital of Nanjing Medical University. Informed consent was obtained from patients for the publication of any potentially identifying information and images included in this article.. The serum AFP was 9,152 ng/ml, while other serum tumor markers including carbohydrate antigen (CA)72-4, CA12-5, CA19-9, CA15-3, neuron specific enolase (NSE), carcinoembryonic antigen (CEA), and β-human chorionic gonadotropin (β-HCG) were 14.39, 29.39, 13.48, and 9.86 U/ml, 16.48 and 0.540 ng/ml and 0.477 mIU/ml, respectively. Based on results of these examinations, the patient was diagnosed with endometrial cancer and scheduled for surgery immediately.A 35-year-old woman was admitted to a local hospital for sudden abnormal uterine bleeding and chronic extended menstrual period in March 2019. Diagnostic curettage was performed at the local hospital, the result of which was endometrial carcinoma not excluding clear cell carcinoma. After consultation with the pathological department of our center, endometrial carcinoma was considered for this patient. Then she was hospitalized in the gynecologic oncology department of our center. Pelvic examination revealed enlarged uterus equal to pregnancy for 2 months without other obvious abnormalities. Computed tomography (CT) scan indicated that the image was similar to that of endometrial cancer with the myometrium invasion, accompanied by a 3-cm mass of uneven density in the right adnexa . According to the FIGO  staging classification published in 2018, the patient belongs to stage IA 7, OCT (octamer-binding transcription factor)3/4, CD30, CD34, estrogen receptor, and progesterone receptor. In addition, endodermal sinusoidal  and hyaloid drop were also observed microscopically stage IA .Two weeks after operation, serum AFP was 231.7 ng/ml. From April 2019 to August 2019, four courses of chemotherapy with BEP  regimen were administered for this patient. During the period of chemotherapy, the serum AFP decreased obviously, and all serum tumor markers had fallen to normal after completing chemotherapy for two cycles. Adverse events of chemotherapy were not serious which included nausea, vomiting, and other chemotherapy related reactions. Follow-up after surgery and chemotherapy including pelvic examination, serum tumor markers, CT scanning, and pelvic ultrasound was also conducted regularly, and the patient was still alive and free of disease for 21 months after surgery.A 36-year-old woman was hospitalized at a local hospital for pelvic mass found by physical examination in November 2017. Exploratory laparotomy was performed at that hospital immediately. Intraoperatively, a free mass at approximately 6 cm × 5 cm × 5 cm in size was observed at the bottom of the right pelvis and adjacent to the uterosacral ligament without any other abnormalities. Due to the examination of frozen sections showing germ cell tumor and consultation with relatives of this patient, pelvic mass resection, biopsy of bilateral ovaries and partial omentum resection were performed. Postoperative pathology reported yolk sac tumor of the pelvic mass, normal biopsy from ovaries and normal tissue of omentum. From December 2017 to June 2018, six courses of chemotherapy with BEP regimen were administrated for her. After five cycles of chemotherapy, serum tumor markers of the patient were all normal, but her alanine aminotransferase (ALT) was elevated nearly to 600 IU/L. She was treated with hepatoprotective therapy for 20 days before completing the sixth cycle chemotherapy. Unfortunately, the serum AFP increased again after sixth cycle of chemotherapy.. Considering relapse of the disease, the patient was hospitalized at our department for a second surgery. During the operation, a dumbbell-shaped, hard, and smooth mass at approximately 3 × 2 × 1.5 cm in size was found at the posterior lobe of right broad ligament and near the uterus. No abnormalities were observed at any other sites of the pelvic and abdominal cavity. After mass resection and right adnexectomy, frozen section was examined and demonstrated yolk sac tumor of broad ligament and normal right adnexa. In consideration of normal adnexa and consultation with her relatives, no other resection was conducted.Due to increase of serum AFP, the patient was admitted to our center in July 2018. Positron emission tomography–computed tomography (PET/CT) demonstrated a round-like mass at the right pelvis accompanied by increased [18F]-fluorodeoxyglucose (FDG) metabolism. CT scan also indicated a 2-cm mass at the right pelvis . Considering diagnosis with yolk sac tumor, four courses of chemotherapy with BEP regimen were administrated for this patient from August 2018 to November 2018. After completing three cycles of chemotherapy, the serum AFP was 15.39 ng/ml. During the period of chemotherapy, adverse events were not serious which included decreased white blood cells and neutrophils. CT and magnetic resonance image (MRI) scan showed thickening of the area of the right adnexa not excluding relapse. She was discharged after four courses of chemotherapy and the follow-up failed later.Postoperatively, pathology report confirmed yolk sac tumor of broad ligament again and normal adnexa. Immunohistochemical staining yielded the following positive results: SALL4 +++, AFP ++, GPC-3 ++, AE1/AE3 +, Ki-67 positivity rate of approximately 70%, patchy positivity for CD117 and VIM+/−. Immunohistochemistry yielded negative results for CK7, CD30, PAX-8, and PLAP Herein, we share a case series of primary YSTs originating from the endometrium and the broad ligament. In order to summarize all reported cases and compare with our cases, we search the related literature using the following combination of MeSH-terms and keywords: “extragonadal”, “yolk sac tumor”, “YST”, “primary”, “endodermal sinus tumor”, “endometrium”, “endometrial”, “broad ligament” in Pubmed, Scopus, and Cochrane Library. Furthermore, references of selected articles were also retrieved to obtain all potentially relevant literature. After review of the English literature, there were only 29 cases of primary endometrial YST including 16 case reports and two case series published before. In addition, extragonadal YST of the broad ligament was reported only once before, which originated from the left broad ligament, so the case we shared was the first case of YST from the right broad ligament in the world . All repPrevious literature reported that YSTs usually occurred in the young population. Among 29 cases of primary endometrial YST, the median age was 59 years (range 24–87 years) which seemed to be in contradiction with the theory of early occurrence of YSTs before. There were 11 cases of endometrial YST from M.D. Anderson Cancer Center, an institution that primarily serves an adult patient population, which possibly contributes to an older median age . The medThe diagnosis of primary YSTs of the endometrium and the broad ligament was still a challenge. On one hand, the literature reported before indicated that symptoms of primary endometrial YST included abnormal vaginal bleeding [82.8% (24/29)], abdominal pain [13.8% (4/29)], abdominal distension [3.4% (1/29)], and abnormal vaginal discharge [3.4% (1/29)]. The patient we reported was admitted to our center due to abnormal vaginal bleeding which was the most common symptom of primary endometrial YST. On the other hand, patients with primary YST usually had an increased level of serum AFP. Among 17 patients with available serum AFP, 88.2% (15/17) of them had an increased value, but only 11.8% (2/17) of them had a normal value. The cases we showed also had an elevated serum AFP, which was a significant symbol for diagnosis of primary YSTs and discrimination from other diseases such as endometrial cancer and undetermined pelvic mass.Due to lack of standard guidelines, the treatment strategies of primary YSTs from the endometrium and the broad ligament are controversial. According to reported cases of primary endometrial YST, surgery combined with chemotherapy was the main strategy for reported cases of primary endometrial YST. Among 26 patients with available surgical information, all of them underwent surgery, and 16 of them were administrated with chemotherapy, yielded a percentage of 100% (26/26) and 94.1% (16/17), except for nine without available information of chemotherapy. For those with detailed surgical information, the proportion of total abdominal hysterectomy, modified hysterectomy, and modified radical hysterectomy was 88.2% 15/17), 5.9% (1/17), and 5.9% (1/17), respectively. There were only three cases that suffered ovarian metastasis, all of whom were diagnosed with stage FIGO IV disease /17, 5.9%. This maAmong 16 patients with available information of chemotherapy, the percentages of BEP regimen, VAC regimen, and other regimens were 56.3% (9/16), 12.5% (2/16), and 31.3% (5/16) individually. In terms of chemotherapy regimen, BEP regimen was the most common regimen. The two cases we shared were also treated with the BEP regimen, but their prognosis was markedly different. The case with endometrial YST was free of disease for 21 months, while the disease from the broad ligament relapsed soon after primary therapy, which indicates that BEP regimen may be not an excellent choice for patients with YST of the broad ligament. Furthermore, radiotherapy was also conducted for 19.2% (5/26) of those who underwent surgery, including 15.4% (4/26) with chemotherapy and 3.8% (1/26) without chemotherapy.Without fertility desire, the case of primary endometrial YST we shared was treated with surgery, including total hysterectomy, bilateral adnexectomy, omental resection, pelvic lymphadenectomy, and paraaortic lymphadenectomy, followed by chemotherapy with BEP regimen, which was the most common strategy for endometrial YST reported before. After follow-up for 21 months, no evidence of disease progression was indicated till now. The outcome of treatment and follow-up differed from each other among all cases published before. As for YST from the broad ligament, the case published before underwent laparotomy, had widespread metastases in the pelvic, and refused to accept chemotherapy and radiotherapy later . The casYSTs originating from the endometrium and the broad ligament are very rare, especially YST from the broad ligament. There are several symptoms of endometrial YST, the most common of which is abnormal vaginal bleeding, usually accompanied by elevated serum AFP. The case of YST from the broad ligament we shared was the second case in the English literature. Due to lack of standard guidelines, the treatment strategies are controversial and needed to be explored.The original contributions presented in the study are included in the article/The studies involving human participants were reviewed and approved by The Affiliated Cancer Hospital of Nanjing Medical University. Written informed consent was obtained from the individual for the publication of any potentially identifiable images or data included in this article.XXC and JN were involved in the identification and selection of patient cases. XZC was involved in drafting the manuscript. XZC and QZ were involved in collecting patients’ information, conducting follow-up. XXC, WWG, and JN reviewed and edited the manuscript. QZ, XX, and HYG were involved in the management of patients and reviewed the manuscript. RZ and CC carried out literature review. DWM and YNW carried out the diagnosis of pathological results and reviewed the manuscript. All authors contributed to the article and approved the submitted version.This study was supported by grants from the National Natural Science Foundation of China , Institute level project of Jiangsu Cancer Hospital (No. ZM201804), Beijing Kanghua Foundation for the Development of Traditional Chinese and Western Medicine -Le Fund (KH-2020-LJJ-021), and Jiangsu Province Maternal and Child Health Research Project (F202004).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Lipoblastoma is a rare benign mesenchymal neoplasm of infancy that most commonly occurs on the extremities and trunk but can arise at variable sites of the body. Retroperitoneal lipoblastomas are particularly rare but can grow to enormous size, and preoperative diagnosis is difficult with diverse, mostly malignant differential diagnoses that would lead to aggressive therapy. Since lipoblastoma is a benign tumor that has an excellent prognosis after resection, correct diagnosis is crucial.HAS2-PLAG1 fusion. The tumor was completely resected, and further histopathological workup led to the final diagnosis of a 13 cm large retroperitoneal maturing lipoblastoma. The child recovered promptly from surgery and showed no evidence of recurrence so far.A case of a large retroperitoneal tumor of a 24-month old infant that was clinically suspicious of a malignant tumor is presented. Due to proximity to the right kidney, clinically most probably a nephroblastoma or clear cell sarcoma of the kidney was suspected. Radiological findings were ambiguous. Therefore, the mass was biopsied, and histology revealed an adipocytic lesion. Although mostly composed of mature adipocytes, in view of the age of the patient, the differential diagnosis of a (maturing) lipoblastoma was raised, which was supported by molecular analysis demonstrating a Although rare, lipoblastoma should be included in the differential diagnoses of retroperitoneal tumors in infants and children, and molecular diagnostic approaches could be a helpful diagnostic adjunct in challenging cases. Although benign, lipoblastoma can show local recurrence, especially if incompletely excised [Lipoblastoma is a rare benign mesenchymal neoplasm of infancy and early childhood, occurring typically in children under the age of 3 years, but occasionally in older children and very rarely even in adults –3. In mo excised .PLAG1) with diverse partners, most commonly HAS2 (8q24.1) and COL1A2 (7q22) [Grossly, lipoblastomas are typically encapsulated with a pale yellow, often lobulated and variably myxoid cut surface. Most tumors measure 3 cm to 5 cm, although very large tumors  are reported . Histolo2 (7q22) , 10.We here report a case of a large retroperitoneal lipoblastoma of a 2-year-old infant that was difficult to diagnose preoperatively, in order to remind that this tumor -albeit very rare in this location- can be an important benign differential diagnosis.A 24-month-old girl presented on a routine physical exam with a mass lesion in the right abdomen, which was not tender when palpated. There were no congenital abnormalities, and the development of the child was normal without evidence of any disease so far. The laboratory parameters  were normal.Abdominal ultrasound showed a relative homogenous retroperitoneal mass adjacent to the liver and right kidney that measured up to 12.3 cm. MRI revealed a heterogeneous myxoid signal pattern . There was no evidence for a rearrangement of the DDIT3 gene and thus no hint for a myxoid liposarcoma. Thus, the diagnosis of lipoblastoma was made, and surgical resection of the tumor was decided. With regard to the surgical approach, median laparotomy versus a right upper abdominal laparotomy was discussed. In order to get a good overview as well safe access to the tumor, the vena cava inferior and the right kidney, it was decided to choose a right upper abdominal laparotomy. After laparotomy, a well-circumscribed mass was encountered in the retroperitoneum that could be completely resected without injury to adjacent structures. Grossly, we found a 13 × 10.5 × 8.7 cm large tumor (weighing 585 g), with a thin, fibrous capsule and a pale yellow, lobulated fatty parenchyma with small cysts  located on 8q12 [PLAG1 promotor by a more active promotor of the fusion partner. The most commonly described PLAG1 fusion partners are HAS2 (8q24.1) and COL1A2 (7q22) [COL3A, RAB2A, RAD51L) are identified to be fused to PLAG1 in lipoblastoma [PLAG1 rearrangement, like the classical HAS2-PLAG1 fusion identified in the presented case, as well as exclusion of the previously mentioned DDIT3 rearrangement and 12q amplification, nowadays most commonly via FISH and/or targeted RNA sequencing approaches, can be a helpful diagnostic adjunct in challenging cases.Lipoblastoma is characterized on the molecular level by 8q11–13 chromosomal alterations targeting  on 8q12 . These a2 (7q22) , but morblastoma , 25, 26.Taken together, Lipoblastomas can occur in a wide variety of localizations with a broad spectrum of clinical differential diagnoses. After complete resection, even patients with very large lipoblastomas have an excellent prognosis. Retroperitoneal lipoblastomas, such as the presented case, are particularly rare but often large tumors, and the clinical differential diagnoses in this setting include highly malignant tumors, like nephroblastoma and clear cell sarcoma of the kidney, that would lead to aggressive therapy. In conclusion, although rare, lipoblastoma should be included in the differential diagnoses of retroperitoneal tumors in infants and children and although the histopathological picture is the mainstay for the correct diagnosis, molecular diagnostic approaches may be a helpful diagnostic adjunct in challenging cases.


Duodenal diverticulosis can be a difficult CT diagnosis and should be considered in the differential diagnosis when a periduodenal mass‐like structure that may contain air, air‐fluid level, or oral contrast material is depicted. Duodenal diverticulosis can be a difficult CT diagnosis and should be considered in the differential diagnosis when a periduodenal mass‐like structure that may contain air, air‐fluid level, or oral contrast material is depicted. An otherwise healthy 71‐year‐old woman presented due to a 4‐h episode of mild right‐upper quadrant pain. Vital signs were normal and physical examination revealed right‐upper quadrant tenderness. Complete blood count was normal, serum amylase five times elevated, and liver‐associated enzymes mildly elevated. Ultrasonography revealed the presence of biliary microlithiasis, increased pancreatic volume with a marked decrease in echogenicity, and the absence of gallbladder wall thickening, pericholecystic fluid, and biliary tree dilatation. Interestingly, CT revealed a couple of ill‐defined, air‐containing, mass‐like, abscess‐like lesions interposed between duodenum and pancreas along with pancreatic head enlargement and peripancreatic inflammatory changes (Figure 1The presence of periduodenal gas limited differential diagnosis in perforated/penetrating duodenal ulcer, simple/complicated duodenal diverticulosis, pancreatic abscess/infected pseudocyst, and iatrogenic/traumatic duodenal injury. Based on initial assessment, most prominent diagnosis was simple duodenal diverticulosis in the setting of mild acute biliary pancreatitis. Upper endoscopy confirmed the presence of three large duodenal diverticula at medial aspect of second and third portion all with wide neck and normal mucosal appearance, as eventually featured after CT review Figure . The patDuodenal diverticula are common and usually asymptomatic. Duodenal diverticulitis is rare due to their large neck size and improved intraluminal flow.The authors declare that they have no conflict of interests.All authors equally accessed the data and contributed to the preparation of the manuscript. BKA and HA were equally responsible for making and performing treatment decisions. HA reviewed the manuscript for critical intellectual content and had the final approval.The present article does not contain any studies with human or animal subjects performed by any of the authors.Informed consent was obtained from the patient.


Diffuse gliomas, and glioblastomas, in particular, represent a diagnostic and clinical challenge. Standard neuroimaging continues to have many limitations for accurate diagnostic assessment, resection planning and treatment follow-up. The present two-review series comprehensively summarizes recent evidence on hemodynamic imaging applications in the context of diffuse cerebral glioma. Part A provides an overview of the concepts underlying hemodynamic imaging modalities and critically discusses the diffuse glioma differential diagnosis and tumor grading results reported in the literature.Diffuse gliomas are the most common primary malignant intracranial neoplasms. Aside from the challenges pertaining to their treatment—glioblastomas, in particular, have a dismal prognosis and are currently incurable—their pre-operative assessment using standard neuroimaging has several drawbacks, including broad differentials diagnosis, imprecise characterization of tumor subtype and definition of its infiltration in the surrounding brain parenchyma for accurate resection planning. As the pathophysiological alterations of tumor tissue are tightly linked to an aberrant vascularization, advanced hemodynamic imaging, in addition to other innovative approaches, has attracted considerable interest as a means to improve diffuse glioma characterization. In the present part A of our two-review series, the fundamental concepts, techniques and parameters of hemodynamic imaging are discussed in conjunction with their potential role in the differential diagnosis and grading of diffuse gliomas. In particular, recent evidence on dynamic susceptibility contrast, dynamic contrast-enhanced and arterial spin labeling magnetic resonance imaging are reviewed together with perfusion-computed tomography. While these techniques have provided encouraging results in terms of their sensitivity and specificity, the limitations deriving from a lack of standardized acquisition and processing have prevented their widespread clinical adoption, with current efforts aimed at overcoming the existing barriers. Cerebral diffuse gliomas are the most malignant primary and frequently diagnosed intracranial tumors ,2. The mThese techniques and others have all been exploited to foster progress in pre-operative diffuse glioma assessment and follow-up, with the use of various multimodality approaches becoming the new standard of care ,9,19. HeIn normal physiology, cerebral vessel regulation and brain hemodynamics are highly sophisticated and fine-tuned by changes in blood gases, neuronal and tissue metabolism and blood pressure , and it Perfusion imaging follows the blood in the vascular system up to the tissue of interest using indicators (or tracers). These can be divided into two classes: intravascular, which remain in the vessels in physiological conditions, and freely diffusible, which can leave the intravascular space and diffuse throughout the entire tissue volume ,38. The DSC-MRI, DCE-MRI and PCT are the available CE perfusion imaging techniques ,56, and In this respect, it is important to note that in the literature, the term “relative”  is usually used to define semiquantitative parameters but the term “normalized”  can be used interchangeably. Confusion can arise between the terms “relative” and “regional”, with the second referring to absolute measurements. In the present work, unless otherwise specified, we refer to the relative semiquantitative parameters and the r/n prefix has been omitted to enhance readability.Two mechanisms govern the cerebrovascular system by controlling the vascular smooth muscle cell tones to help regulate the regional CBF: autoregulation, which ensures the maintenance of blood flow in response to changes in perfusion pressure , and metWith the introduction of end-tidal targeting gas delivery systems, the possibility granted by precise independent control of the end-tidal pressure of carbon dioxide and oxygen  has incrAfter having reviewed the basic principles of hemodynamic imaging, we now present how their application has been investigated in the clinical work-up of patients with high-grade gliomas and discuss the relevant differences in the assessed parameters among the different tumor entities.The first magnetic resonance presentation of a brain lesion showing a heterogeneously enhancing mass surrounded by extensive peritumoral edema on a T2-weighted image is not univocally interpretable. Hemodynamic imaging has been investigated with the aim of differentiating between gliomas and other possible neoplastic entities such as brain metastases (BM) ,99,100 aIn an ideal case scenario, metastases should always be distinguished pre-operatively from high-grade gliomas to ensure a complete patient diagnostic assessment and to optimize the treatment decision-making . BM, difThe distinction between gliomas and cerebral lymphomas is even more sensible, as the latter should be treated with chemoradiotherapy with the role of resection remaining controversial ,123. DSCFurthermore, cerebral abscesses can also sometimes be difficult to distinguish from high-grade gliomas as these also present as a CE rim surrounding a central necrotic core, with diffusion-weighted imaging being particularly useful for this purpose ,133. PerThe standard imaging of gliomas can lead to an educated guess on the expected tumor grade, but as some low-grade gliomas can present with contrast-enhancement and a number of atypical high-grade gliomas do not readily exhibit BBB disruption, hemodynamic imaging can further support the differentiation of these two entities. Low-grade gliomas are mostly characterized by native vessel co-option while the hypoxic angiogenic microenvironment of high-grade gliomas presents with an increased number of leaky vessels . These fTo overcome the limitations intrinsic to the various imaging modalities , efforts were made to achieve protocol standardization aimed at solving the variability of the reported methodologies and their resulting reported cut-offs ,218,219.Hemodynamic imaging-derived measurements are well suited to characterizing abnormal vasculature perfusion, BBB defects and providing complementary information with respect to standard neuroimaging to assist in diffuse cerebral glioma patient diagnostic workup. Several studies have assessed the potential of hemodynamic imaging for brain tumor differential diagnosis and tumor grading. They reported high sensitivity and specificity, especially of DSC but also of DCE and ASL-MRI for the differentiation of high-grade gliomas from brain metastases, cerebral lymphomas and non-neoplastic lesions, as well as for differentiating high-grade gliomas from low-grade gliomas. As recent efforts aim to tackle the standardization issues intrinsic to the imaging modalities investigated , a number of limitations have prevented the univocal interpretation of the previous findings, largely limiting a robust and widespread clinical translation.


The aim of this paper is to present the unique case of a sealed ruptured abdominal aortic aneurysm (AAA) with simultaneous type IIIb endoleak of an endovascular stent, mimicking a paravertebral retroperitoneal tumor. A 75-year-old male was referred to the tumor service of our tertiary orthopaedic department suffering from intractable low back pain with an onset of six months. He had undergone repair of an infrarenal AAA with an endovascular stent 5 years ago. Imaging studies depicted a large retroperitoneal mass adjacent to L2 and L3 vertebrae. The stent’s metal cage had no signs of wear or migration. The pathology report of a CT-guided core-needle biopsy he had undergone before his referral raised suspicion about possible AAA rupture. CT-angiography confirmed the existence of a ruptured AAA, accompanied by retroperitoneal blood loss and a (possibly) failed stent. The IIIb eroded stent was openly removed and a Y-type allograft was used to repair the defect. The patient reported immediate relief and was uneventfully discharged. He demised 4 years later due to reasons unrelated to the hereby reported condition. Increased awareness is warranted when dealing with anterior lumbar spine or retroperitoneal lesions. A close cooperation between a vascular and an orthopaedic/spine surgeon must always be sought. Rupture of an Abdominal Aortic Aneurysm (AAA) is an uncommon cause of lower back pain. It is associated with extremely high mortality rate, unless patients receive immediate and highly specialized care. In the unusual case of chronic leakage, AAAs can become self-contained or “sealed”, leading to the development of chronic paravertebral hematomas, which in most cases are either asymptomatic or accompanied by minor symptoms . InfrequWe present the rare case of a sealed ruptured AAA with simultaneous type IIIb endoleak of an endovascular stent. To the best of our knowledge, this is a unique combination of a “double” lumen failure, clinically presented as a paravertebral retroperitoneal tumor.A 75-year-old Caucasian male patient was referred to the regional musculoskeletal tumor service of our tertiary hospital, suffering from intractable low back pain, with an onset of six months. He was diagnosed with a retroperitoneal tumor of unknown pathology, and had already undergone a CT-guided core-needle biopsy 10 days before his referral.He had a significant past medical history  and had undergone repair of an infrarenal AAA with an endovascular polyester/metal supported type Talent™ stent  5 years ago. He was capable of full weight bearing, albeit with an antalgic gait and a scoliotic posture with the concave deformity towards his left side. No neurological deficit could be established and no signs of inflammation or infection were found. Active and passive flexion-extension movements of the lumbar spine were painful and he was unable to perform lateral bending or rotation. There was tenderness on palpation on the L1-L3 lumbar spinous processes. Abdominal examination revealed no pathological signs. The peripheral vascular supply was normal with bilaterally palpable popliteal, posterior tibialis and dorsalis pedis arteries. The venous drainage was also satisfactory. Routine blood tests were within normal range. A recently made Technetium99 bone scan, showed no uptake in any other part of the skeleton apart from the L2 and L3 vertebrae.Plain antero-posterior and lateral radiographs of the thoracic and lumbar spine revealed degenerative changes compatible with the patients΄age. Severe morphological changes of the anterior column of the L2 and L3 vertebrae were also evident, depicting bone erosion and signs of bone reformation. The metal cage of the stent had no signs of macroscopic wear or migration. The review of his (previously made) CT- and MRI-scans confirmed the existence of a large retroperitoneal mass in direct contact with the L2 and L3 vertebrae and the left iliopsoas muscle, due to which he was referred to our tumor service Figure .The lesion had distinct margins at its upper and mid part. At its lower part, however, there seemed to exist a communication between the lesion and the lower part of the abdominal aorta/left iliac artery. The lesion’s density was similar to that of soft tissue containing hemorrhagic material at different stages of the thrombosis procedure. The anterior parts of the L2 and L3 vertebral bodies also appeared significantly eroded and as if in a bone remodeling phase, thus confirming the findings seen on plain radiographs.The pathology report of the CT-guided core-needle biopsy was negative for malignancy or infection, describing nonetheless, the existence of inflammatory infiltrations by lymphocytes and neutrophils and a few foreign-body type multi-nucleated giant cells. The latter raised suspicion about a possible rupture of the AAA. A CT-angiography was performed next, confirming the existence of a ruptured AAA accompanied by retroperitoneal blood loss and (possibly) a failed stent Figure .The patient was operated on as an emergency. Through a supra-infra umbilical abdominal transperitoneal approach, a large hematoma was identified and evacuated. A pulsating aneurysmal sac with a longitudinal tear of 1 cm at the level of the left iliac artery was found. The endovascular stent, which appeared eroded and with a wide longitudinal IIIb split at its aortic-iliac left junction Figure , was remThe patient was transferred to the intensive care unit postoperatively, where he remained for 7 days. He developed acute renal failure, from which he recovered completely and he was uneventfully discharged two weeks postoperatively. On his follow-up visits, he occasionally reported minor lumbar pain, easily controlled by mild oral analgesics. He demised 4 years later by reasons unrelated to the hereby reported medical condition.A paravertebral mass may pose several diagnostic and therapeutic dilemmas. Differential diagnosis may include tumors, potentially necessitating biopsy, and infection which may be caused by several pathogens . In the Endovascular repair of AAAs has revolutionized their treatment. First described by Parodi et al. in 1991 , it is nThe IIIb failure of a stent with a subsequently ruptured and contained aneurysm is rare and, to the best of our knowledge, has not been reported in literature. It is highly plausible that the endovascular stent failed first. Due to its IIIb endoleak, the aneurysmatic sac expanded and eventually ruptured. This inevitably contributed to the creation of a gradually expanding hematoma, which eventually got contained by the adjacent retroperitoneal tissues. This whole procedure led to the creation of a mass mimicking a paraspinal lesion. Τhe proximity of all surrounding soft-tissues and of the vertebral column and the rigidity of the latter must have probably further added to the “sealing” of the ruptured aneurysm. This assumption is further enhanced by the fact that signs of bone remodeling in the L2 and L3 vertebrae depicting a chronic condition, were evident in both the MRI- and the Technetium99 bone scans. The bone remodeling was probably caused by the continuously pulsating aneurysmatic sac (as confirmed intraoperatively) which was lying adjacent to the vertebral column, leading to the patient’s back pain. Last, but not least, it should be noted that the CT-guided biopsy, without prior consultation with a vascular surgeon, could have had extremely serious consequences for the patient, leading to a potentially fatal full rupture of the aneurysmal sac.Our rare case increases awareness when dealing with anterior lumbar spine/retroperitoneal tumors or tumorlike lesions. The proximity of this anatomic area to major vascular structures, necessitates meticulous pre-operative planning and consultation with several specialties, in order to avoid pitfalls with potentially catastrophic consequences.Especially, when major vessels are involved in the pre-operative planning of orthopaedic operations and/or a patient had previously undergone a major vascular operation, a close co-operation between a vascular and an orthopaedic/spine surgeon must always be sought.


Conjoined twins represent a very rare congenital anomaly, and the dicephalic dibrachius dipus (DDD) type of conjoined twinning is so rare that the exact prevalence is unknown. Only a few published case studies have mentioned this anomaly. Not enough data are available where antenatal ultrasonography (USG) and MRI have been employed in the workup of such cases. This study describes the case of a 24-year-old woman who came to our department for an anomaly scan at 25 weeks of gestation and was diagnosed with a dicephalic type of conjoined twinning with multiple anomalies. However, USG could not differentiate between DDD twinning and craniopagus parasiticus; hence, the patient was referred for fetal MRI. On MRI, the diagnosis of DDD was confirmed. In craniopagus parasiticus twinning, the surgical removal of the parasitic head can allow an everyday life. However, DDD twinning with multiple anomalies is not compatible with life, and the mother was thoroughly explained the grave prognosis. In such doubtful cases, fetal MRI should always be employed to ascertain the diagnosis for proper management and counseling. Conjoined twinning is an abnormal type of twinning that occurs in monochorionic gestations. In this anomaly, some part of the twins is joined. Conjoined twins have an incidence of 1 in 50,000 to 1 in 100,000 gestations. Conjoined twins are often associated with multiple congenital anomalies, and a large percentage die in utero, resulting in an incidence of 1 in 250,000 live births .Conventionally, there are two main theories that describe how conjoint twinning occurs. First, there is the fission theory, which suggests that there is an incomplete separation of a single embryo. Second, there is the fusion theory, where two initially separate embryo disks fuse in places to form a conjoined twin. Third, a theory has also been postulated, which suggests that there is crowding, and thus, duplication of potent morphogenetic primordia .Craniopagus parasiticus is another type of conjoined anomaly in which a fully formed twin has a conjoined parasitic fetus attached to it at its head. The parasitic twin often has abnormal rudimentary body parts, and in some cases, a completely absent body, giving the appearance of a dicephalic twin gestation. The incidence of craniopagus parasiticus twin gestation is estimated to be four to six in 10,000,000 .The DDD twins either die in utero or in neonatal life, and separation is not possible. No known surviving cases of DDD twins are known. One case of dicephalic twins surviving to adult age has been reported; however, the twins were born as dicephalic tribrachius dipus . In contWe report a case of a 24-year-old G3L1A1 patient with one living child (four years old) and one first trimester abortion. Her dating scan at six weeks was normal. She came to us for a detailed anomaly scan at 25 weeks of gestation. Gestational age was assigned by a dating scan.Ultrasonography findings The fetus had growth retardation with abdominal circumference and femoral length corresponding to 21 weeks of gestation. Anterior grade I placenta was noted, and liquor was normal for gestation.Central nervous systemThere were two fetal heads joined side to side, with a thin membrane in between. The skull ossification was normal for gestation. Each head contained two cerebral hemispheres separated by a well-defined falx cerebri. Both heads had a normal ventricular system with no hydrocephalus and a normal choroid plexus. Cavum septum pelucidii were not visualized. The posterior fossa was small, and the two heads seemed to converge posteriorly. Structures in the posterior fossa could not be appreciated on ultrasonography (USG) because of shadowing from bones in advanced gestation Figure .Face Two sets of facial structures were noted, with two eyes and one nose on each head. No obvious facial anomaly was noted Figure . Neck A single neck was noted, with widely spaced posterior vertebral elements in the cervical spine. Cystic hygroma was observed.Spine A single spine was noted, and thoracic, lumbar, and sacral segments appeared normal.Thorax The stomach bubble and the left lobe of the liver were noted in the left hemithorax. Dextrocardia with a dextropositioned heart was observed. A membranous ventricular septal defect was noted Figures -5. AbdomenA single set of abdominal organs was noted. No stomach bubble was seen in the abdomen. The bowel and genitourinary system appeared normal Figure . LimbsTwo upper and two lower limbs were present. All three limb segments were normal.A provisional diagnosis of the dicephalic conjoined twin was made, which included the differentials of DDD or craniopagus parasiticus, and the patient was referred for MRI scanning.MRIMost of the USG findings were confirmed by fetal MRI.Added Findings on MRIThe two fetal heads were noted to be separated by a thin dural membrane with no obvious sharing of venous sinuses. Both cerebelli were hypoplastic. Both spinal cords were seen entering the same widened spinal canal. Other than the stomach, bowel loops, and left lobe of the liver, the spleen was also observed to be completely in the left hemithorax Figures -8.After a detailed study of the MRI, the final diagnosis of DDD conjoined twin gestation with growth restriction and multiple anomalies was made. The mother and family were properly counseled regarding the grave prognosis and options for termination of the pregnancy were given.Conjoined twins have an incidence of 1 in 250,000 live births. DDD is an extremely rare type of conjoined twinning, with only a few reported cases worldwide and an undocumented incidence. DDD is an anomaly noted in monochorionic monoamniotic twin gestations where a conjoined twin has two heads, one trunk, two arms, two legs, and shared internal organs in the thorax and abdomen . These cOther types of dicephalic parapagus gestations with a relatively better prognosis include dicephalus tribrachius dipus, dicephalus tetrabrachius dipus, and other laterally fused conjoined twins. Surgical separation is possible in certain dicephalus parapagus twins, especially with separate vital organs, such as individual hearts . There iOur patient is a 24-year-old woman who had one living child and one first trimester abortion. Her dating scan was normal. An anomaly scan at 25 weeks of gestation suggested a dicephalic pregnancy with multiple anomalies and ruled out other dicephalus parapagus anomalies. However, it could not differentiate between DDD and craniopagus parasiticus gestations because of the advanced gestation and acoustic shadowing from bones; further, the posterior fossa could not be well evaluated. Thus, fetal MRI was performed, which showed hypoplastic cerebelli in both heads and extension of both spinal cords into the same spinal canal. Prior studies have also shown that fetal MRI is more sensitive to central nervous system (CNS) anomalies . It alsoAfter confirming the diagnosis, the grave prognosis of the disease and options for termination of pregnancy was explained to the mother in detail.We tend to increase the knowledge about this rare presentation and various diagnostic modalities that can help identify it through this article. DDD is an extremely rare type of conjoined twin gestation that is often associated with multiple anomalies. Fetal MRI plays a vital role in ruling out close differentials like craniopagus parasiticus, especially in doubtful cases during the late second trimester. Fetal MRI is also functional for better diagnosis of other associated anomalies, such as diaphragmatic hernia. Thus, a multimodality approach including both USG and MRI must be applied to evaluate rare fetal anomalies, especially in doubtful cases.


Clear cell hidradenoma (CCH), a rare yet benign finding, is a tumor that originates from sweat glands. It mainly presents as a slow-growing cystic nodule on the scalp or trunk. We report a case of a 60-year-old man who presented with an abdominal subcutaneous mass. This mass was excised and pathology confirmed the presence of CCH, with cytology negative for malignant cells. Although benign, CCHs cannot be confirmed as such until excision and pathologic analysis, which is the standard treatment of choice. Clear cell hidradenoma (CCH) is a rare benign tumor originating from apical sweat glands. It can display either apocrine or eccrine differentiation . GeneralThe patient was a 60-year-old male who underwent abdominal cyst excision. The cyst was examined during his clinic visit and was noted to measure about 1.5 cm long. His past medical history was notable for diabetes and prosthetic right leg. He had no other complaints at the time of the visit. Excision of the cyst was performed in the clinic. Following injection of local anesthetic at the incision site, an elliptical incision was made and the cyst was removed, after which skin was closed. The patient tolerated the procedure well, and postoperative course was uneventful. The incision was well approximated and well healing at the one-week follow-up, and the patient reported minimal pain.The pathologic evaluation of the specimen revealed skin with a cystic structure elliptical in shape and yellow-white in color. Cyst contents included a granular material consisting of squamous neoplasm with clear cell features, and cells showed no significant atypia or necrosis Figure . The cytCCH is a benign adnexal tumor that most commonly presents on the scalp and trunk, though it also infrequently arises on the upper and lower limbs . It typiCCHs have also been recounted in case reports in which the lesion was found on locations such as the breast and hand. Mammography and ultrasonography were used to detect a 3-cm CCH in the left axillary tail of a patient . The masThough extremely rare, CCH has also been detected among infants and young children, and should be considered among this population within the differential diagnosis of subcutaneous lesions. In one such case, a five-year-old boy was found to have a skin tumor on the left forearm that slowly enlarged over the course of six months . HistopaWhile CCH is benign, there have been cases in which CCH has involved the lymphatic system, causing it to be labeled as a tumor of uncertain malignant potential. In one such case, a 36-year-old woman presented with a subcutaneous mass in her left groin eight years after treatment for CCH in this region . Tumor cThe differential diagnosis for abdominal subcutaneous masses is broad, including abscesses, sebaceous cysts, lipomas and epidermal inclusion cysts . ImagingThe appearance of a subcutaneous mass may raise great concern regarding potential malignancy and uncertainty regarding prognosis. We elected to report this case due to its rare occurrence and the importance of identifying clear cell hidradenoma, a rare occurrence in cysts that can be successfully excised due to its benign nature. It is imperative to consider CCH among the differential diagnosis when evaluating and considering skin cysts, masses and tumors, as it may be difficult to differentiate it from other presentations. Additionally, through our research, we found that the presence of CCH in multiple lesions or recurrence of CCH should be monitored via long-term follow-ups to track potential malignant transformation to hidradenocarcinoma.In our case, the incidental finding of an abdominal subcutaneous mass in a 60-year-old male led to suspicion for cancer or another malevolent underlying pathology. We were able to ascertain the benign nature of the mass and ruled out malignancy in this incidental finding via excision and pathological analysis. Through our findings, we hope to illustrate that although CCH is rare, it is important to include it as a potential diagnosis, due to the possibility of recurrence and malignant transformation, as well as its resemblance to malignant tumors despite its benign nature. Although this finding is rare, it depicts an excellent reason to send even benign-appearing lesions for pathologic examination.


Pyogenic granuloma (PG) is an oral reactive inflammatory hyperplasia of connective tissue that can occur in response to hormonal changes and local irritation such as calculus, fractured teeth, rough dental restorations, and foreign materials. It is nonneoplastic and predominant in the second decade of life in young adult females. The most common site of involvement is the gingiva. Lesions are more common in the maxillary than mandibular gingiva and mainly occur on the facial or buccal aspect. Pyogenic granuloma rarely grows more than 2 cm in diameter and is rarely associated with bone loss. This article presents a rare case of an abnormally large pyogenic granuloma affecting both the labial and palatal gingiva sustaining occlusal trauma due to its size and associated with severe alveolar bone loss that was managed successfully with surgical excision in a 40-year-old male. Inflammatory hyperplasia is an umbrella term that describes reactive oral mucosa consisting of enlarged fibrous and granulation tissues, including pyogenic granuloma (PG) . PyogeniWhile the existence of PG is well documented in the literature, published cases tend to adhere to the above common presentations, with abnormal manifestations rarely detailed. To add evidence of the clinical variation in PG, this article describes an unusual case report of a 40-year-old male with an abnormally large pyogenic granuloma extending from the labial to the palatal side of the upper left anterior gingiva that was associated with occlusal trauma and significant alveolar bone loss mimicking malignancy, which was managed by surgical excision.A 40-year-old systemically healthy male patient presented to the comprehensive care clinic at Penn Dental Medicine for the evaluation of an intraoral growth in the mouth involving the upper left anterior gingiva. The patient had noticed a small painless growth on the palatal gingiva that began about 11 months ago. He reported a gradual increase in the size of the growth, which with time led to discomfort during eating and talking. He described that by the time of presentation the size of the growth interfered with these functions and was causing changes in his bite. The patient also reported evolution in location i.e. the growth enlarged from the palatal to facial side interdentally and caused an increase in the space between the left maxillary lateral incisor and canine. He also endorsed bleeding from the gums both spontaneously and on brushing which was especially frequent in this area. He denied a history of fever, fatigue, tiredness, loss of appetite, paresthesia, and weight loss as well as other systemic symptoms. He denied past medical conditions and current medications or allergies. Social history was positive for a smoking habit of 10 cigarettes per day for 20 to 25 years that he quit two years ago. Extraoral examination did not reveal any significant findings. No evidence of lymphadenopathy was seen. On intraoral examination, a bilobular gingival overgrowth extending palate-facially from the left lateral incisor to canine was noticed. Facially, the growth was round, soft, smooth, pedunculated, dark pink in color, around 1 cm x1 cm in size, and extended from the distal aspect of the lateral incisor to the mesial aspect of the canine  and peripheral odontogenic fibroma also occur exclusively on the gingiva. They are characterized by cellular fibrous proliferations with either metaplastic bone (ossifying) or epithelial rests (odontogenic). Clinically, it is very difficult to differentiate PG from POF as the former becomes more fibrotic as the age of lesion advances. Radiographically, POF rarely shows bony changes which include cupping defect of the alveolar bone around the roots, occasional tooth displacement, and diffuse multiple radiopacities representing calcifications. However, in long-standing cases, POF may show significant bone destruction. Moreover, POF shows high cellularity with calcified material derived from the periodontal ligament or periosteum, balanced with less vascularity, and peripheral odontogenic fibroma shows dispersed odontogenic epithelium within the stroma histologically. Hemangioma shows endothelial cell proliferation without inflammatory cell infiltrate. While rare, metastatic tumors can present in various locations of the mouth including the gingiva and may appear clinically similar to inflammatory hyperplastic growths such as PG or other entities in the differential diagnosis. On excision, however, these are easily differentiated and histologically represent the primary tumor.Due to discomfort in eating and talking, interference with occlusion, and food impaction, gross excision of the lesion and histopathologic evaluation was planned despite the relatively large size and poorly defined margins. Given the severe bone loss and bleeding tendency as well as the spread of inflammation into surrounding tissue, this was determined to be the most thorough path to definitive diagnosis and appropriate to the patient’s complaints. The patient agreed to this plan and was pleased with a solution that would restore his comfort and occlusion. Scalpel biopsy was planned due to the area affected and was chosen over laser and cryosurgery secondary to considerations of access and financial burden. An excisional biopsy was completed under local anaesthesia. The lesion was removed completely with curettage and irrigation to remove granulation tissue. Hemostasis was achieved with silver nitrate cautery and pressure; the initial clot was confirmed before the patient was dismissed. Despite the heavily hemorrhagic nature of the lesion, bleeding was not excessive and was controlled during and after the procedure easily with local measures. Histopathological findings Figures , 5 showeThe above histopathological features were consistent with pyogenic granuloma. After one month, the patient healed well from the procedure, was informed of the diagnosis, and was counselled on the importance of maintaining meticulous oral hygiene and regular follow-ups to avoid further bone loss, recurrence, and secondary complications from periodontal disease. He was strongly recommended to seek definitive dental treatment given his compromised periodontal status. However, to date (six months after biopsy), he has failed to attend additional appointments to start this process. Our interim communication with him has confirmed that he is well without current complaint in the area of the excised lesion.Pyogenic granuloma is non-neoplastic inflammatory hyperplasia . It occuOur patient had sought dental treatment very intermittently, limiting our ability to compare radiographic findings over time. His inconsistent follow up also helps to explain the large size of the lesion on evaluation. Pyogenic granuloma can be categorized into three distinct stages, namely, (i) cellular phase, (ii) capillary phase/vascular phase, and (iii) involution phase . DependiSurgical excision of the lesion followed by curettage of the underlying tissue is the first line of treatment for gingival pyogenic granuloma . The othThe benefits of using laser surgery over traditional options are less chances of infection, reduced bleeding, precise cutting with good judgement of cutting depth, lesser need for antibiotics and analgesics post operatively, no need for suturing, reduced pain during and after the procedure, faster wound healing, less chances of recurrence and scarring . DespiteCryosurgery involves localized and targeted destruction of abnormal tissue by the application of cold substances like liquid nitrogen spray and gases such as nitrous oxide, carbon dioxide, and freons . CryotheGiven the symptoms present in this case, and consistent with clinical guidelines, we elected to treat the patient definitively and immediately via excision and curettage. Any foreign body, calculus, a defective restoration, or other local contributing factors should also be removed, which was recommended for this patient but which he has not yet completed . IntralePyogenic granuloma is a commonly occurring benign inflammatory lesion seen in the oral cavity. It is mostly associated with local irritating factors. It may occasionally have serious outcomes due to its structural attributes and easy bleeding. It is paramount to recognize this lesion at an initial stage to avoid inadvertent and aggressive treatment and to intervene promptly to prevent recurrence and rule out other causes of localized swelling. Complete removal of gingival overgrowth with curettage reduces the risk of recurrences. Close monitoring and good oral hygiene practices are also required. This case illustrates the possibility of PG to grow to a large size and present with severe bone loss around the teeth as well as the ability of these lesions to interfere with normal function.