This case presentation discusses a rare cardiac malignancy initially thought to be a benign tumor. A 36-year-old presented with syncope, dyspnea, Computed Tomography Pulmonary angiography study obtained was negative for pulmonary emboli but revealed a left atrial mass. A transesophageal echocardiogram (TEE) confirmed a mass with multiple lobes and a broad base attached to the septum, encroaching into the right atrium, aortic root wall, base of the anterior mitral leaflet flowing to the mitral orifice in diastole also obstructing the right pulmonary vein. Despite a quick diagnosis and plan to begin treatment, the patient rapidly declined owing to the extent and aggressive nature of this cardiac malignancy. This case reports the insidious nature of these tumors as well as how challenging and life threatening they are at the time of their clinical manifestation. Primary cardiac sarcomas are rare clinical entities and pose challenges in their management, given their aggressive nature and high recurrence rate . Over 75A 36-year-old male with no past medical history presented to the hospital with two syncopal episodes, worsening palpitations, and progressive dyspnea on exertion (NYHA class II-III). He reported no prodromal symptoms, immediately regained consciousness after a few seconds without any postictal signs. First syncopal episode occurred 2 weeks earlier while in a passenger seat; he sought no medical attention at the time. The second episode was during a coughing fit the evening of his presentation. Both episodes were said to be witnessed without any seizure activity. Six months prior to the onset of the syncopal episodes, he began experiencing dyspnea with mild exertion which progressed, limiting his functional activities. He reported a 40 lbs weight loss over six months which he had attributed to his intent to lose weight (BMI 38). He also admitted to night sweats but denied chest discomfort, increased abdominal girth, or leg swelling.Physical examination revealed BP 123/78 mmHg, HR 120-150 sbpm which was irregularly irregular, RR 26 breaths per minute, hypoxic at 88% on room air with improvement in Bipap, and laying in Trendelenburg position, negative orthostatic. There was a presence of bibasilar crackles in the lung field, no jugular venous distention or peripheral edema noted, cardiovascular examination was limited due to body habitus and rapid irregular heart rate, and the rest of the exam was unremarkable except for morbid obesity. Electrocardiogram (EKG) showed supraventricular tachycardia and subsequently atrial fibrillation ; there wA Computed Tomography Pulmonary angiography study was negative for pulmonary emboli but revealed a left atrial mass . A transPathology  revealedrd and 4th decade of life [Cardiac sarcomas are quite rare, with the male predisposition being 2.5 : 1 , and usu of life . It typi of life .In majority of cases, cardiac tumors can be silent; however, when symptoms occur, they are determined based mainly on the size and anatomical location of the tumor . They clImage studies such as TTE and transesophageal echocardiography, computed tomography, coronary angiography, and magnetic resonance imaging are used for diagnosis and guiding surgical intervention ; howeverSurgical resection is possible in about 33% of these cases; however, they have a tendency to recur, while others are deemed nonresectable . In receGiven the rarity of these cardiac malignancy, very little studies have been conducted regarding the management of these rare tumors especially in nonsurgical candidates; hence, this calls for a meta-analysis on the outcome of surgical candidates and nonsurgical candidates who are treated with chemotherapy and or radiotherapy. This case also calls to question the differences between the left and right atria sarcoma in terms of their presentation, management, and prognosis.


A 28-year-old woman with a past medical history significant for cervical cancer was diagnosed with a 2.5 cm adrenal tumor but was lost to follow-up. Two years later, she presented to the emergency room with worsening right upper abdominal and flank pain. The computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen and pelvis revealed that the right adrenal mass had nearly doubled in size (4.3 cm), was heterogeneous with calcifications, central necrosis and actively uptaking the intravenous (IV) contrast with a delayed washout. The biochemical workup was negative for hyperaldosteronism, hypercortisolism, and pheochromocytoma. She reported an unintentional body weight loss of 40 pounds. Adrenocortical carcinoma or a metastatic malignancy was high on the differential diagnoses list. She underwent a successful laparoscopic adrenalectomy, and final pathology revealed a benign extra-adrenal combined ganglioneurofibroma and schwannoma. These rare benign malignancies alone or in combination may closely mimic the clinical and imaging characteristics of adrenal malignancy and pose a diagnostic and therapeutic dilemma to surgeons as well as cause a significant distress to patients and their families. Thus, it is important to thoroughly document and report these cases in order to increase awareness and improve our understanding of the biology, natural history and management of these extremely rare tumors. The overall prevalence of incidentally found adrenal lesions is roughly 4.4%; however, this prevalence varies with the patient’s age, and incidentalomas occur in less than 1% of patients younger than 30 years old . The twoHere we present a case of benign combined ganglioneurofibroma and schwannoma, with clinical signs, pre-operative imaging, and intra-operative observations highly suggestive of a malignant adrenal mass.A 28-year-old woman with a history of cervical cancer was diagnosed with a 2.5-cm right adrenal mass; however, the patient was lost to follow up. Two years later, she presented to the emergency department complaining of knee pain, and worsening back and bilateral flank pain. She reported experiencing pain over the past two years, but it had worsened and become constant over the past two days. She also reported episodes of headaches, palpitations, hand tremors, and sweating, which had been increasing in frequency and severity over the past 2-3 years. She admitted to regular tobacco and marijuana use and a significant unintentional weight loss of about 40 pounds. She denied alcohol use. She had a past medical history significant for anemia and stage I cervical cancer, and she denied any history of hypertension. Her family history was noncontributory.ᵒF, pulse rate of 117 beat per minute, and hypertensive, with a blood pressure of 140/99. The abdominal exam revealed right-sided tenderness on palpation, and the musculoskeletal exam revealed bilateral lumbar tenderness and right lower leg pain with movement. There were normal bowel sounds on auscultation; no organomegaly, abdominal wall defects or abdominal distension. The remainder of the physical exam was unremarkable. The laboratory evaluation was significant for decreased red blood cell count of 3.64 x 106/µL, mild anemia of 11.2 g/dL, mild hypocalcemia of 8.4 mg/dL, hypoproteinemia of 6.1 g/dL, increased blood glucose of 117 mg/dL, and urine nitrite and bacteria.At initial evaluation, her body temperature was 98.5Computed tomography (CT) of the abdomen and pelvis revealed a 3.7 x 2.9 x 4.3 cm thick-walled and centrally necrotic mass on the right adrenal gland, which appeared to be exerting mass effect on the inferior vena cava (IVC) Figure , 1B. MagThe risks and benefits of laparoscopic versus open adrenalectomy were discussed in detail, and written informed consent was obtained from the patient. A successful laparoscopic right adrenalectomy was performed following the surgical oncological principles. Intraoperatively, ACC or metastasis remained the main differential diagnoses.Surgical pathology, however, revealed an extra-adrenal combined ganglioneurofibroma and schwannoma with no malignant features . The specimen was an intact adrenal gland, with a well circumscribed, encapsulated gray/tan mass measuring 27.6 g intimately attached to the adrenal cortex. The remaining adrenal gland, including the medulla, is intact and uninvolved. The tumor demonstrated a central nodule composed of spindle cells with wavy nuclei set in a collagenous background Figure . The cenThe patient tolerated and recovered from surgery well and was discharged to home on day 2 after surgery.It has been shown that isolated ganglioneuromas or schwannomas are rare and may be seen in approximately 1.4% of adrenal incidentalomas, respectively . A combiThe underlying pathophysiology of this specific form of adrenal mass has not been fully elucidated, especially in patients without neurofibromatosis type 2 (NF2). In patients with NF2, there is a mutation in the NF2 gene, located on chromosome 22, which normally produces a tumor-suppressor protein merlin . PatientAlthough benign adrenal masses account for the vast majority of adrenal incidentalomas, the prevalence is extremely low in patients less than 30 years old . AdditioIn this case, the diagnosis of a benign mass was the best possible outcome for the patient, that does not require follow-up or other treatments after surgery. However, it is important to note that cases can occur exactly opposite to this one - where all clinical signs and studies point to a benign mass, but malignancy is discovered on histological examination. Thus, this case highlights the importance of maintaining an open and dynamic differential diagnosis, which can ultimately lead to the best care and outcome for the patient.This case will contribute to increasing awareness and better understanding of the complexities that surround neuroendocrine tumors. Distinguishing between the various types of adrenal masses remains difficult and rather ambiguous pre-operatively, thus post-operative pathology is critical to determining the patient’s subsequent treatment plan, should they require one. Treatment decisions should be made through a collaborative team effort with surgeons, pathologists, radiologists, and oncologists to ensure the most favorable outcome for the patient.


Vertebral hemangiomas are the most common benign tumors of the spine, having an incidence of 10-12% in the general population. They are asymptomatic, incidental findings in the vast majority of patients; however, in rare cases, they can expand to cause neural compression. Aggressive lesions of this sort are most commonly found in the thoracic spine, and expansion leads to the subacute development of myelopathy.  The authors report a rare case of aggressive vertebral hemangioma at the T1 vertebral body which caused rapidly progressive myelopathy over the course of 7 days. Clinical and radiological findings are shown as well as surgical management of the lesion. The patient regained the ability to ambulate, and there was no evidence of disease recurrence at 2-year follow-up.  Although aggressive vertebral hemangiomas are a rare cause of myelopathy, they must be kept in mind in the differential diagnosis of cord compressive lesions. In this case, contrary to most, the expansion of the hemangioma led to rapid development of neurological decline necessitating urgent surgical intervention. Vertebral hemangiomas (VHs) are the most common benign tumors of the spine . They arTreatment options for aggressive VHs include radiation therapy, endovascular or percutaneous embolization, vertebroplasty, ethanol injection, or surgical intervention . The latOur patient is an otherwise healthy 50-year-old male who presented to the clinic with complaint of severe gait disturbance progressing rapidly over the past week. MRI done in an outpatient setting demonstrated a lesion at T1 with epidural extension and cord compression. He was sent to the emergency department for further workup. He had neither history of smoking nor any risk factors for malignancy. He had no unintended weight loss, night sweats, or fevers. On physical exam, he had full strength in all upper and lower extremity muscle groups but demonstrated decreased sensation globally from his T3 dermatome down. He had 4 beats of clonus bilaterally and was hyperreflexic in his lower extremities. He had profound ataxia and was unable to ambulate more than a few steps. Contrasted MRI of his thoracic spine demonstrated a diffusely enhancing lesion at T1 with near circumferential epidural disease causing severe cord compression Figures . CT scanGiven the patient's rapidly progressive neurological decline, it was decided to proceed urgently to the operating room to allow for decompression and stabilization of his spinal cord and to obtain a tissue diagnosis. The patient underwent a C6-T3 posterior instrumentation and fusion along with T1 laminectomy and partial C7 and T2 laminectomies. This accomplished the goals for spinal cord decompression and stabilization. Blood loss at this point approached 600 mL given the bleeding from the tumor itself. In the frozen section, we were unable to identify what the lesion was, and so it was decided to hold off on the anterior corpectomy until we had a more definitive diagnosis. A few days later, the permanent pathology returned with a diagnosis of aggressive VH.Given the bleeding encountered during the posterior procedure, we opted to have the patient undergo preoperative embolization prior to the planned corpectomy. Angiography at the time of embolization demonstrated a medial branch off the left thyrocervical trunk which supplied numerous vascular lakes inside the T1 vertebral body. Embolization was then carried out with Trufill mixed in a ratio of 1 : 3 with estradiol oil. Postembolization angiography showed no further filling of the hemangioma. The day after embolization, the patient was returned to the operating room for the anterior approach for T1 corpectomy and C7-T2 cage placement/anterior plating . PostopeThe clinical course of neurological symptoms as caused by vertebral body hemangiomas tends to be slowly progressive over weeks to months. In this case, our patient progressed from having normal neurology to frank myelopathy with severe gait ataxia in less than 7 days. The rapidity of presentation of myelopathic symptoms is typical for cord compression from infection or rapidly growing metastatic disease. Rarely is such rapidly progressive myelopathy the result of an aggressive VH and requires a high index of suspicion for diagnosis. The level of our patient's lesion was at T1, which is atypical. Although the thoracic spine tends to have the highest propensity for vertebral hemangiomas with extraosseous extension, with 90% of lesions being in this part of the spine, approximately 75% of them occur between T3 and T9 . HistoloPotential treatments after diagnosing an aggressive vertebral hemangioma include radiation therapy, endovascular embolization, vertebroplasty, ethanol injection, and surgical intervention. Although we were unable to make a diagnosis using diagnostic imaging studies prior to surgery, given the rapid progression of myelopathy and severe spinal cord compression, surgical intervention was elected for treatment. Given the unknown diagnosis at the time of presentation and the rapidity of his neurological decline, we opted to proceed posteriorly first to stabilize the spine with instrumentation and perform a laminectomy to decompress the spinal cord. Once the pathology returned with the diagnosis of aggressive but benign VH, we then performed the anterior corpectomy preceded by preoperative embolization to minimize blood loss.The use of preoperative embolization is still controversial as it related to aggressive VHs. This is due to the most common areas for aggressive VH being in the midthoracic spine, where there is a potential watershed area for spinal cord blood supply. In these cases, embolization may be risky and should be deferred if there is one dominant feeder to the spinal arteries. Corpectomy with cage reconstruction was chosen based on the degree of anterior vertebral body involvement. Postoperatively, we delayed radiation by 3 months to allow for the fusion biology to be well underway and then opted to deliver 40 Gy of radiation to the surgical area to reduce the chances of recurrent disease which has been recommended by previous studies . PostopeRapidly progressive myelopathy due to an upper thoracic aggressive VH is rare but must be included in the differential diagnosis of these lesions. CT findings of bony expansion and trabecular bone striation should raise the index of suspicion for this type of lesion. In the face of rapidly progressive neurological decline, the treatment of choice is surgical intervention to decompress the neurological elements and resect as much of the tumor as possible. Preoperative embolization and postoperative radiation therapy can be useful adjuncts in the treatment of these tumors.


Facial cutaneous lesions of dental origin are rare and hence the correct diagnosis is usually missed on the initial presentation to the surgeon. We present the largest series in the surgical literature to increase the awareness to this entity and emphasize that the wrong diagnosis may lead to medico-legal claims.This is a retrospective study of 28 patients seen between 1994 and 2017.The series had one child and 27 adults. The presentation varied and included: a nodule, a subcutaneous soft mass, a sinus, an abscess, a cyst, a pigmented skin lesion and a scar. Thirteen cases had an initial wrong diagnosis and of these 4 had surgery to the lesion. Two out of the 4 surgically treated lesions ended with medico-legal claims.The surgeon should be aware of this rare entity and have a high index of suspicion. Dental treatment is curative and there is no need to operate the facial lesion. The wrong diagnosis and unnecessary surgery may lead to medico-legal claims. They arThe aims of the current report are: to present the largest series in the surgical literature of facial cutaneous lesions of dental origin, increase the awareness of plastic surgeons to this rare entity, and document that the initial wrong diagnosis/treatment may lead to medico-legal consequences. The case series is compliant with the PROCESS guidelines .2This is a retrospective study of all patients with facial cutaneous lesions of dental origin who presented to the senior author (MMA) between 1994 and 2017. The following data were collected: age, sex, origin and location of the cutaneous lesion, the clinical appearance of the lesions, the initial diagnosis made, investigations done to reach the correct diagnosis, the treatment and its outcome, and finally documentation of any medico-legal complaints.3A total of 28 patients were reviewed. There was a ten-year-old child; and the remaining 27 were adults . There were 14 males and 14 females.In 12 cases, the facial lesion originated from the maxillary teeth: 11 were located in the cheek and 1 below the lateral canthus of the eye. The remaining 16 lesions arose from the mandibular teeth; and their locations were more variable: along the mandibular body in 6, at the mandibular angle in 4, the submandibular area in 4, and the chin area in 2.The most common clinical appearance of the lesion was a non-tender nodule (n = 8) followed by diffuse non-tender subcutaneous soft mass with overlying skin hyperpigmentation (n = 6). Other clinical presentations included: A discharging sinus (n = 4), an acute abscess (n = 4), a nodulo-ulcerative lesion (n = 2), a cystic swelling mimicking a sebaceous cyst (n = 2), a pigmented skin lesion (n = 1), and a hypertrophic scar (n = 1). In the latter presentation, there was a history of a discharging sinus that healed into a scar.Out of the total 28 cases, 15 patients first presented to the senior author. The dental origin was suspected in all patients at initial presentation. This suspicion was based on the presence of dental caries near the skin lesion as well as the palpation of a submucosal cord-like structure under the buccal mucosa extending from the alveolar margin near the affected tooth towards the skin lesion. All patients were referred to the dental department and the correct diagnosis was confirmed radiologically by the presence of radiolucency around the chronically infected tooth root. Dental treatment (tooth extraction) was curative in all cases .Fig. 1a)The remaining 13 patients initially presented outside the senior author’s clinic and these were all wrongly diagnosed as either skin tumor or a sebaceous cyst. Of these 13 cases, 4 cases underwent surgery at the initial presentation (outside our clinic) as follows: Incision and drainage of an “infected sebaceous cyst” (n = 1), incisional biopsy of a “benign skin tumor” (n = 1), and excisional biopsy of a skin mass/cyst (n = 2). The pathology report of the latter 3 cases was a “chronic inflammatory mass”. Upon presentation to our clinic, the correct diagnosis was reached (at our clinic) in all cases and dental treatment was curative.Two out of the 4 operated cases did not result in medico-legal claims. The first case underwent incision and drainage of an “infected cyst” at a local hospital. This resulted in a scar but the patient was informed that the abscess required drainage regardless of the diagnosis. The second case underwent  incisional biopsy of a “benign skin tumor” which also resulted in a linear but acceptable scar ; and no medico-legal claims were filed .Fig. 2A The remaining 2 cases that underwent surgery at their local hospitals ended with medico-legal claims. These two cases were from the second group of patients who had an initial wrong diagnosis and surgery for the lesion at initial presentation to their local hospitals. Both patients underwent excisional biopsy of a ‘facial mass/cyst’, resulting in a long scar . Medico-legal claims were filed in both cases and both claims ended in favor of the patient against the surgeon .Fig. 3A 4Our case series of facial skin lesions of dental origin is the largest one in the surgical literature and aims to increase the awareness of surgeons to this rare entity. Furthermore, we bring the attention that the wrong diagnosis/treatment may result in medico-legal claims.The pathophysiology of facial lesions of dental origin is well described in the literature . The infOur case series aims to increase the awareness of the variable presentation of facial lesions of dental origin; and we stress on the fact that a classic discharging sinus is not the most common presentation. The surgeon should also be aware of unusual presentations of such lesions and these include: midline upper lip and chin lesions , bilaterThe correct diagnosis is only made if the surgeon is aware of the entity and also if there is a high index of suspicion. The senior author always rules out the dental origin in every patient presenting with a facial lesion. The diagnosis is suspected if there is teeth caries and the palpation of a cord-like structure connecting the skin lesion to the alveolar ridge. The diagnosis is then confirmed by dental x-rays. Dental treatment is curative. Finally, our report emphasizes that the wrong diagnosis/treatment may lead to medico-legal claims.5Facial lesions of dental origin are rare and most case reports and all large case series have been reported in the dental and dermatology literature. We present the largest series in the surgical literature and show that the presentation is variable. The correct diagnosis is only made if the surgeon is aware of the entity. Dental treatment is curative and there is no need to operate on the facial lesion itself. Finally, we emphasize that the wrong diagnosis/treatment may lead to medico-legal claims.None.College of Medicine Research Center, Deanship of Scientific Research, King Saud University, Riyadh, Saudi Arabia.The work was supported by the The study was approved by the research committee, National Hospital (Care), Riyadh, Saudi Arabia.Written informed consent was obtained from adult patients as well as from the parent of the patient who is under 16 for publication. A copy of the written consent is available for review by the Editor-In-Chief of this journal on request.The senior author (MMA) performed and managed all patients. Both authors collected the data, did the literature review, and wrote the manuscript.Research registry UIN: 4083.M M Al-Qattan.


Nasopharyngeal masses in young males, first of all presumes Juvenile Nasopharyngeal Angiofibroma (JNA) in the mind, but other benign or malignant tumors should be considered for successful and adequate management of patients and also for minimizing morbidity from unnecessary interventions. We herein present a patient with nasopharyngeal carcinoma (NPC) mimicking JNA. The patient was presumed as JNA and underwent excessive surgical intervention and the final histopathology report was NPC. The aim of our case report is to highlight the importance of complete clinical examination and preoperative imaging in differentiating and ideal management of nasopharyngeal masses. Nasopharynx can be a source of benign and malignant tumors. The most common nasopharyngeal malignancy is nasopharyngeal carcinoma(NPC), which originates from nasopharynx epithelium. NPC is 0.22 % of all tumors in North America. This tumor may appear as a hearing loss or neck mass ,2. The tNasal obstruction and epistaxis can also occur. Cranial nerve involvement may also occur due to the spread of the tumor ,5. So, tA 17-year-old boy was referred to the Ear, Nose, Throat outpatient service of Hazrat Rasoul Akam Hospital, Tehran, Iran; with several month history of left side nasal obstruction and intermittent episodes of epistaxis, which gradually increased. Family history was negative. Extra nasal examination showed normal appearance. No cervical lymphadenopathy was detected. Contrast Enhanced Computed Tomography (CT) scan and Magnetic Resonance Imaging (MRI) with gadolinium were obtained which revealed a homogenousely enhancing soft tissue mass lesion widening the pterygopalatine fossae extending into the nasopharynx with bowing the posterior wall of maxillary antrum anteriorly .Invasion into sphenoid sinuses and left infratemporal fossae were also detected . The patThe diagnosis of JNA is based on clinical and radiological examination and the final proof is histologic. NPC although rare in children but has a predilection for adolescents . MalignaNon-specificity of symptoms besides neglecting the entity for differential diagnosis might be other reason for a delayed NPC in a young patient. The most common symptom of NPC is a painless cervical mass 70-90%), which is bilateral in 50% of cases . Althoug0-90%, whIn conclusion, it is necessary that preoperative imaging of patients suspected for JNA be carefully overviewed to ensure precise diagnosis and accurate management. At the same time, an accurate correlation between clinical and radiological findings is necessary for the best diagnosis.None declared.


Accessory or supernumerary nipples can be applied when more than 2 breasts present in human beings. Usually they are seen in the embryonic milk line; however, their presence outside this line is extremely rare.A 14-year-old boy presented to the surgical consultation room complaining from a round brown skin lesion over the right shoulder area, there were no symptoms associated with this lesion but the family was worried about it. During examination the lesion was diagnosed on the basis of clinical examination and appearance as a supernumerary nipple located over the right scapula. This is an extremely rare location, and no case has been reported before. The family was reassured about the diagnosis that this condition is congenital and the patient discharged with no specific treatment.Accessory nipple is not uncommon, and may present in some rare locations. The main work up should be reassurance of the patient about the diagnosis, and most patients need no intervention however it may be removed for cosmetic concerns, if enlarge in size, or associated with any symptom. Most lesions are smaller than the normal nipple appearing as small spots of 2–3 mm in diameter ,7. CasesThis the work has been reported in line with the SCARE criteria .2A 14-year-old boy presented to the surgical consultation room because his mother was worried about a round brown skin lesion over the right scapula which enlarged in size and became deeper in color over the last year, there were no symptoms associated with this lesion but the family was worried about it. There were no relevant past medical, past surgical, or family histories for the chronic illnesses or skin diseases.2.1During examination the lesion was a round, brown, and slightly elevated from the skin surface. The size was about 1 cm in diameter with central projection. The location of the mass was in the region of the right shoulder, 2.2On the basis of this clinical appearance the condition diagnosed as a supernumerary nipple located in this site.This is an extremely rare location, and no case has been reported before.2.3No specific therapeutic work up done.2.4The family was reassured about the diagnosis and the patient sent home to be followed if any symptom developed in the future.3The supernumerary nipples are more common in males and most of them occur in the left side .It may be familial and reported in many generations of some families ,11.If associated with excessive breast tissue it may become noticeable at puberty due to hormonal effect, or enlarge during pregnancy and lactation .The diagnosis needs high index of suspicion, and sometimes in unclear situations may need histological confirmation which shows all the histological structures seen in the normal nipple like mammary glands and smooth muscles ,6.It may present as cosmetic concern and usually they are not associated with other congenital anomalies ,12.Accessory breasts may have the potential to develop the same benign and malignant disorder as normal breast tissue ,13.In most cases it may not need any intervention, however it may be removed surgically if there is cosmetic concern, uncertainty of the diagnosis, or the development of any kind of symptoms .The author has no conflicts of interest to declare.None.This case reports not needed ethical approval.The father of the patient has provided me with a written informed consent to publish this finding of his son, and the identity of the patient has been protected.The concept of reporting the case, drafting, and revision of the case done by Dr Ayad Ahmad Mohammed.This work is case report and there is no need of registration.Dr Ayad Ahmad Mohammed is guarantor for the work.Not commissioned, externally peer-reviewed.


Tarsal tunnel syndrome is an entrapment neuropathy of the tibial nerve within the tarsal tunnel that lies beneath the retinaculum on the medial side of the ankle. It is often underdiagnosed. Talus bipartitus is a rare anatomical variant; only a few cases have been described in medical literature. We report a case of a 36-year-old female with tarsal tunnel syndrome secondary to a talus bipartitus undergoing surgical treatment with good clinical outcome. To our knowledge, talus bipartitus presenting as tarsal tunnel syndrome has no previous reports. Image studies and physical examination are crucial to reach precise diagnosis. Tarsal tunnel syndrome (TTS) is an entrapment neuropathy of the tibial nerve or its branches within the tarsal tunnel that lies beneath the retinaculum on the medial side of the ankle. This condition is frequently underdiagnosed. Main symptoms are burning, cramping, and pain along the foot plantar region. The typical clinical profile includes worsening of symptoms as the day goes on and nocturnal awakening with tingling feet , 2.Clinical tests include the dorsiflexion-eversion provocative manoeuvre in which the tibial nerve is compressed by positioning the ankle in passively maximally eversion and dorsiflexion while all of the metatarsophalangeal joints are maximally dorsiflexed and held in this position for five to ten seconds . Tinel'sTalus bipartitus (TB) is a rare anatomical anomaly of the talus. It consists of two talar fragments separated by the presence of articular cartilage. There are less than 30 reported cases of TB in medical literature. There is no information about the prevalence of this infrequent condition.We present a case of a 36-year-old female with tarsal tunnel syndrome due to a talus bipartitus with a medial prominence, undergoing surgical treatment with good clinical outcome.A 36-year-old female patient presented with a 4-year history of right ankle pain. She had significate loss of weight and started physical activity just before the symptoms appeared four years ago. No history of trauma was reported. First diagnosis was synovitis, for which the patient underwent physical therapy with torpid outcome. She experienced paraesthesia along the posterior and medial aspect of the ankle and foot. Symptoms got worse at the end of the day, with cramping episodes in the foot. Physical examination revealed a positive dorsiflexion-eversion test provoking numbness of the foot. Tinel's sign was positive. Ankle range of motion was limited due to pain, scored 8 using the Visual Analog Score (VAS). The patient had a preoperative score of 40 points, according to the American Orthopaedic Foot and Ankle Society (AOFAS). Bilateral electromyography (EMG) was performed, disclosing abnormal adductor hallucis and adductor digiti quinti neurophysiologic parameters in comparison to the asymptomatic side.Initial plain radiographs showed a considerable (1.8 cm) posterior bone fragment in relation with the talus . CT scanIn this scenario, a surgical procedure was indicated due to increasing symptoms and several conservative treatment trials with no response.Preoperatory assessment included three-dimensional CT scan images to get full awareness of the bone fragment's specific anatomy. Anatomic relationship between the tibial nerve, posterior tibial artery, flexor hallucis longus, flexor digitorium longus, and tibialis posterior tendon and the bone fragment was assessed with the help of MRI. Though fixation of the accessory bone has been previously reported, in the index case, this was not an option because of its particular shape, with a medial protuberance invading the tarsal tunnel.Excision of the bone fragment was performed. A medial approach was used. Both tibialis posterior tendon and neurovascular bundle were identified and carefully preserved. The bone fragment was removed and the tunnel was released . PostopeAll image studies suggested that the cause of our patient's pain and neurological condition was attributable to the presence of the unusual bone fragment. Furthermore, the particular anatomical shape of this bone fragment with a clear prominence towards the medial aspect of the ankle reinforced the diagnosis.However, image studies were not able to confirm as a gold standard method whether this bone prominence was indeed entrapping any nerve structure or even in contact with. Though it may have seemed that diagnosis in this index case was easy to achieve, the patient lingered for a while with no diagnosis.MRI is a good method for identifying pathologic causes of TTS, specific space occupying lesions . McSweenReichert et al . reporteSurgical treatment of TTS is still challenging. Gondring et al.  showed iTo our knowledge, only 1 case of TTS has been reported secondary to a skeletal anomaly (accessory ossicle) . TB is aIn the clinical practice, TB is vaguely seen and most physicians tend to attribute symptoms to more frequent conditions. Differential diagnosis of TB includes the presence of an os trigonum, which lacks of articular surface and has a higher incidence (13%). Zwiers et al.  identifiIn this index case, surgical technique was focused in removing the bone fragment, preserving structures and recognizing any nerve injury if present. We cannot provide any reliable information about surgical approach to TTS release by reporting one single case, which may vary according to aetiology.We present what it seems to be the first reported case of tarsal tunnel syndrome secondary to talus bipartitus. TTS is relatively common but has many different causes. Clinical findings and proper imaging are crucial to reach precise diagnosis and to conduct preoperatory planning.


Lytic lesions of the skull include a wide range of diseases, ranging from benign conditions such as arachnoid granulations or vascular lacunae, to aggressive malignant lesions such as lymphomas or metastases. An early and correct characterisation of the nature of the lesion is, therefore, crucial, in order to achieve a fast and appropriate treatment option. In this review, we present the radiological appearance of the most frequent lytic lesions of the skull, describing findings from different imaging modalities , with particular attention to diagnostic clues and differential diagnoses.Osteolytic skull lesions may be challenging to diagnose.• Association of different imaging techniques may aid image interpretation.• Clinical information and extensive knowledge of possible differential diagnoses is essential.• Some osteolytic tumours, although benign, may present as locally aggressive lesions.• Malignant lesions require accurate staging, followed by variable treatment approaches.•  Intradiploic skull vault lesions are rare, often incidental findings in diagnostic imaging. These lesions may also be found during staging examinations or investigating local clinical symptoms. Their interpretation requires the evaluation of several pieces of information, among which are imaging characteristics and clinical setting. Osteolytic lesions usually pose greater diagnostic dilemmas, as they share many imaging features.Skull X-ray is usually the first diagnostic tool on which lesions are identified, but its use is decreasing due to the availability of more accurate imaging techniques, such as computed tomography (CT) and magnetic resonance imaging (MRI).CT is useful for the evaluation of lesion density (sclerotic or osteolytic), extension assessment  and recognition of possible pathognomonic patterns, such as the trabecular pattern of haemangioma. Furthermore, it is the best modality for the depiction of possible periosteal reaction. A better tissue characterisation and evaluation of bone marrow involvement is obtainable on MRI. It is also more accurate than CT in the assessment of intra- and extracranial extension.In this review article, we will discuss pseudolesions , benign and malignant osteolytic lesions, focusing on those that most frequently occur in clinical practice.Arachnoid granulations (AGs) are cerebrospinal fluid (CSF)-filled protrusions of the arachnoid in the dura mater. Protruding into the brain’s dural sinuses, they allow for CSF resorption. AGs are frequently found in parasagittal areas, along the superior sagittal and transverse sinuses, near the confluence of a cortical vein into the sinus. They show a high prevalence in the healthy population, being reported in approximately two-thirds of individuals. Usually, their size ranges from 2 to 8 mm, but, sometimes, the maximum diameter can exceed 10 mm [Due to their content, on CT scans, AGs appear as well-defined, round-shaped lesions with CSF density, protruding into the calvarium, causing a filling defect Fig. . SimilarVenous lacunae (VL) consist of enlarged venous spaces within the parasagittal dura, adjacent to the superior sagittal sinus . UsuallyLesions with inclusion of ectopic tissue consist of epidermoid and dermoid cysts , differing in complexity . SeveralIntradiploic epidermoid cysts (IECs) are the most common, occurring at any age from the first to seventh decades of life, with no gender prevalence. They are preferentially found in the frontal, parietal and occipital regions, often affecting multiple bones .IECs, due to their slow growth, usually show a small diameter at diagnosis . HoweverOn plain X-rays, IECs may present as rounded or lobulated lytic areas with smooth and sclerotic margins.At CT scans, non-enhancing hypodense focal lesions are their typical presentation, with associated sharply demarcated bony defects and calcifications, and the inner table generally more affected than the outer Fig. .Fig. 3InMR images show the presence of a mildly T1-hyperintense lesion, with iso-/hyperintensity on both T2-weighted and FLAIR images, restricted diffusion on diffusion-weighted imaging (DWI) and no contrast enhancement  Fig. 4)4).Fig. 4DCs are lined by stratified squamous epithelium but, unlike ECs, contain epidermal appendages, such as hair follicles, sweat glands and sebaceous glands. These lesions, frequently occurring in childhood, with the highest incidence during the first or second decades of life, show a slow growth and tend to develop on the midline along the course of suture lines, near the anterior fontanelle , 10. TheHistological differences with IECs may reflect in different imaging findings . While pFinally, MRI depicts a strong and spontaneous T1-hyperintensity, again related to its lipid contents, coupled to variable signal on T2-weighted images and without significant changes after contrast administration, although a peripheral rim of enhancement may be observed .Intraosseous haemangiomas (IH) are benign vascular tumours characterised by slow or absent growth. The skull is their second most frequent localisation after the spine, with frontal and parietal bones being the more often affected sites. IH show their prevalence peak during the fourth and fifth decades of life, with females being more often affected than males .Most skull IH are cavernous lesions, containing dilated blood vessels separated by fibrous septa. They are generally asymptomatic but can manifest as painful, palpable masses.Plain X-rays usually show a well-circumscribed, round or oval osteolytic lesion, with a classic “spoke-wheel” appearance.On CT scans, they appear as expansive lesions with thin margins and intralesional spicules, radiating from a common centre, with marked and homogenous enhancement after contrast administration. They generally erode the outer layer of the skull, with a relative sparing of the inner table  Fig. 5)5).Fig. 5MR images show the presence of lesions with variable signal intensity, related to the amount of fat content. Usually, IH appear as isointense lesions on T1-weighted images, with possible scattered hyperintense foci due to fat components.T2-weighted images show a hyperintense lesion with multiple lobules, representing the vascular lacunae.Finally, post-gadolinium T1-weighted sequences depict, similarly to CT scans, a vascular lesion with strong homogenous enhancement, better delineated on fat-saturated images.In case of complications, such as neurological symptoms due to mass effect or haemorrhages, excision is indicated, while embolisation can be useful before surgery. If surgical removal is not feasible, radiotherapy can be considered as an alternative treatment option.Aneurysmal bone cysts (ABCs) are benign, cystic lesions composed of multiple blood-filled cavities divided by connective tissue septa, rarely affecting the skull .Local swelling and tenderness represent the most common clinical findings. Pulsation can be observed if the lesion breaks through the inner table of the cranium.In most cases, an association with other primary benign or malignant bone lesions is present. These include giant cell tumours, fibrous dysplasia, non-ossifying fibromas, IH, osteoblastomas, simple bone cysts, chondroblastomas, chondromyxoid fibromas and osteosarcomas .At the level of the skull, it often occurs as a secondary phenomenon in pre-existing fibrous dysplasia Fig. .Fig. 6AnThe imaging hallmark of an ABC is the presence of an expansive osteolytic lesion with a narrow transition zone and blood-fluid levels due to the layering of blood products. However, these findings are not specific, as they have also been reported in other conditions, such as telangiectatic osteosarcoma, malignant fibrous histiocytoma, fibrous dysplasia, synovial sarcoma, haemangioma and simple bone cyst .On CT scans, ABCs appear as well-demarcated, multiloculated, osteolytic lesions, with blood-fluid levels. MRI is the most appropriate imaging technique, depicting additional information, such as the presence of internal septa and a better, more accurate lesion definition and representation of blood-fluid levels with identification of blood in different stages .The ideal treatment for ABCs is surgical excision. If such an approach cannot be performed, radiation therapy is warranted, although with consideration of the high recurrence rate of the disease.Bone desmoplastic fibroma (DF) is a rare, intraosseous and locally aggressive neoplasm, accounting for less than 0.1% of all primary bone tumours .On pathology, it appears as a lesion mainly constituted by spindle cells, with abundant collagen component and dilated vascular channels. It can infiltrate surrounding soft tissues, although conserving its benign characteristics, without showing necrosis, cellular atypia or mitotic activity .DFs frequently affect long bones and mandible, with skull involvement being reported in a very low percentage of cases .When occurring at this level, they usually present as slow-growing mass lesions, possibly associated with headache, hearing changes, ear drainage and head asymmetry .On CT scans, DFs are typically represented as lytic lesions with thinning of both inner and outer tables of the skull Fig. , while oThese imaging findings are not peculiar of DFs, being present in other conditions, such as fibrous dysplasia, haemangioma, eosinophilic granuloma, low-grade osteosarcoma or metastasis. Nevertheless, significant T2-weighted shortening of a non-sclerotic fibro-osseous lesion should recall DFs in the differential diagnosis of lytic skull lesions  Fig. 8)8).Fig. 8Due to the frequent local recurrence rate, wide total surgical resection is the treatment of choice for DFs.Eosinophilic granuloma (EG) is the benign form of Langerhans cell histiocytosis (LCH), a multisystemic rare disorder of unknown aetiology, mainly affecting male children, characterised by the proliferation of Langerhans cells . EG usuaOn plain radiographs, EG usually appears as a well-defined round or ovoid lytic lesion, with non-sclerotic margins and a “punched out” presentation, that rarely extends across cranial sutures or determine transdural or intra-axial invasion. Due to their lytic nature, lesions could contain a small sequestrum of devascularised bone, surrounded by lucency, providing a typical “bull’s eye” appearance. Furthermore, if the inner cranial table is more involved than the outer, the lesion could result in a double contour image (“hole within a hole” sign). Finally, if multiple lesions are present, they can enlarge and merge, providing a geographic skull appearance.CT findings are similar to those evaluable on plain X-rays, providing an excellent evaluation of bone erosions, as well as a good quantification of the involvement of the surrounding soft tissues. CT images are usually acquired for surgical planning purposes, as well as to perform targeted biopsies in equivocal case presentations , 28 Fig.Fig. 9EoMRI is usually performed to obtain an accurate evaluation of the surrounding soft tissue changes, as well as the medullary extent of the lesion . EG usuaPrimary lymphoma of the bone is a rare neoplasm composed of malignant lymphoid cells. It represents 7% of all malignant bone tumours, with involvement of flat bones, especially the skull, being infrequent . It may The usual clinical presentation is the presence of scalp swelling, without neurological deficits. If intraparenchymal infiltration is present, neurological deficits may become the most important clinical manifestation of disease .The radiological appearance of primary bone lymphoma is highly variable and not specific . It rangThe most common radiological feature of primary lymphoma is the occurrence of a lytic to destructive lesion with permeative or moth-eaten appearance Fig. , while tIn the case of lesions with unclear radiographic and CT findings, MRI is a valuable tool to achieve a radiological diagnosis. Indeed, T1-weighted imaging is able to distinguish between normal fatty marrow and infiltrative lesions, with the latter showing a lower signal intensity. On the other hand, lesions show a higher signal intensity on T2-weighted images compared to the normal bone marrow, especially when peri-tumoural oedema is present. However, if fibrotic components are present, a low T2-weighted signal can be present. The use of fat-suppressing techniques, such as STIR, may better delineate lesions from the surrounding fatty bone marrow . FinallyThe treatment of primary bone lymphoma is still controversial, and various radiation therapy approaches have been proposed, with or without associated chemotherapy.Among primary malignant bone neoplasms affecting adults, multiple myeloma (MM) is the most common, accounting for around 1% of all new cancer cases . MM resuThe distribution of MM lesions reproduces those physiologically observed in the red marrow, with the axial skeleton showing the highest prevalence of involvement .When the skull is affected, its most common radiological presentation is represented on both plain radiograms and CT scans by numerous and well-circumscribed lytic bone lesions Fig. . To bettSkull metastases follow a complex series of events, dependent on the characteristics of the primary malignancy. This process involves multiple signalling pathways and molecular interactions, and an extensive and growing list of factors has been reported . These cOsteolytic metastases of the skull usually present as abnormal radiolucencies in the calvarial bones. Lesions are often multiple, with well-defined margins, with diffuse infiltration of the skull more rarely encountered . They caOn MRI scans, skull metastases usually present as lesions involving the diploe and the cortical bone, with T1-weighted hypo- to isointense signal and T2-weighted hyperintensities. Post-contrast appearance is highly variable, depending also on the primary tumour pathology. Indeed, lesions show different behaviours, ranging from marked and homogeneous to no enhancement at all, with some others showing scattered or rim-like hyperintensities .Furthermore, MRI is crucial in the evaluation of the involvement of surrounding and soft tissues, especially of the dura mater , other than other associated intraparenchymal lesions Fig. .Fig. 14MSimilarly to imaging findings, the nature of the primitive cancer determines the treatment options. External radiotherapy represents the current treatment option in adjunction to the systemic chemotherapy . A surgiOsteolytic calvarial lesions are rare findings, possibly challenging from a diagnostic viewpoint. In this paper, we have presented their respective essential imaging findings. Summarising, there are some semeiotics that can help the radiologist in the differential diagnosis. First of all, there are highly suggestive findings that we wish to highlight, such as: a focal intradiploic filling defect with involvement of the inner cortex in typical locations is characteristic of pseudolesions; the presence of fluid–fluid levels in an intradiploic cystic lesion is suggestive of aneurysmal bone cyst (ABC); a trabecular structure is indicative of haemangioma. When these patterns are not recognisable, other signs can help distinguish benign and malignant lesions. Secondly, erosion of the cortex suggests a malignant lesion, while its expansion suggests a benign one. Periosteal reaction also mainly occurs in locally aggressive lesions, as do irregular margins and epidural or soft tissue extracranial extension. Finally, multiple lesions are more frequent in some malignant conditions, such as multiple myeloma (MM) and metastases. Diffusion restriction on diffusion-weighted imaging (DWI) may help identify highly cellular malignant lesions, although it must not be forgotten that not all malignant lesions show this pattern, while some benign lesions, in particular epidermoid cysts, also show restriction.In conclusion, in the evaluation of osteolytic calvarial lesions, different imaging techniques, especially computed tomography (CT) and magnetic resonance imaging (MRI), are useful in differentiating benign from malignant lesions. In difficult cases, their interpretation may be aided by the association of clinical information and extensive knowledge of possible differential diagnoses and pseudolesions.


Ganglioneuromas, which arise from neural crest cells, are typically seen in adolescent and young adults. We describe an unusual case of posterior mediastinal ganglioneuroma with a large fatty component in a middle-aged male. This imaging feature has only been reported in five published manuscripts in the English literature. A 48-year-old male presented with a paraspinal mass seen on preoperative chest X-ray obtained for knee arthroscopy. He reported relatively constant sharp left axillary pain radiating to the anterior chest wall for about 8 months.T4 to T7 without expansion of or extension into the neural foramina. The inherent T1 shortening of the central portion of the lesion was suppressed with fat suppression techniques, confirming the central fatty component  revealed a pseudoencapsulated subpleural heterogeneous lesion. Based on our experience as well as prior reports, the degree of the overestimation of the size of the mass by MRI scan as compared with the measurement of the resected mass stated in the pathology report is customary.e tissue . The neue tissue . Numeroue tissue .The post-operative course was uneventful and the patient left the hospital on the next day after the procedure. At a six month follow-up, the patient was doing well, except for hyperesthesia at the operative site.3 Ganglioneuromas are responsible for up to 35% of the intrathoracic neurogenic tumours.5Ganglioneuromas are slow growing tumours of autonomic ganglia. They are typically asymptomatic and often an incidental finding. Clinical manifestations are usually secondary to the location of the neoplasm. Ganglioneuromas most commonly occur in the posterior mediastinum (60–80%); other sites include the retroperitoneum and less commonly the adrenal medulla.10 In addition to these case reports, two different retrospective studies described four11 and two12 cases of mediastinal and thoracic ganglioneuroma, respectively, containing variable amounts of fatty tissue. Two potential aetiologies have been proposed to explain the presence of fatty component in this type of ganglioneuromas. One theory suggests that the fatty component arises from involvement of paravertebral fat.11 Alternatively, ganglioneuroma may undergo fatty degeneration. The latter explanation can also account for the older mean age of patients presenting with fat containing ganglioneuromas. The average age of these patients is typically reported to be in the mid-forties, which is higher than the typical age for ganglioneuromas.12Posterior mediastinal ganglioneuromas with fatty components as described here are rare. A review of the English literature revealed only five reported cases .6–10 In T1 and T2 weighted images, a feature which we also observed.13 Punctate calcifications, as seen in our case, have also been reported with these types of tumours.14 The oblong shape of this mass with craniocaudal orientation  was obtained from the patient for publication of this case report, including accompanying images.


Incarcerated uterus is a rare complication of pregnancy, usually associated with retroversion. A 26-year-old woman presents at 19 4/7 weeks for evaluation of a short cervix and placenta previa. On ultrasound scan, the placenta was considered previa and the cervix was not visualized. The cervix was not identified by pelvic examination and the presumptive diagnosis of short cervix was done. The patient was followed up closely and remained asymptomatic. Retrospective analysis of the ultrasound images showed a retroverted uterus with an elongated cervix compressed towards the anterior vaginal wall. At 26 weeks of gestation, ultrasound showed a cervical length of 41 mm and a fundal placenta and the diagnosis of spontaneous correction of an incarcerated uterus was made. The patient had an uncomplicated vaginal delivery at 39 3/7 weeks. Identification and close follow-up of incarcerated uterus may potentially help in avoiding serious obstetrical and surgical complications. Incarcerated gravid uterus is a rare complication of pregnancy where a uterus in retroversion fails to ascend into the abdominal cavity . SpontanA 26-year-old woman, Gravida 3, Para 1, Abortus 1, presented at 19 weeks and 4 days of gestation for evaluation of a short cervix and placenta previa. The patient was asymptomatic, denying pain, vaginal bleeding, leakage of fluid, cramping, or uterine contractions. Ultrasound examination suggested a total placenta previa. The cervix was difficult to visualize and was considered unmeasurable in length. The fetus was in a cephalic presentation Figures . During Incarcerated uterus mimicking short cervix and placenta previa has not been reported in the past. Incarceration of the gravid uterus is a rare event with reported incidence of approximately one in 3000 pregnancies to one in 10000 . Risk faAttempts at correction of incarceration have been performed either manually, via laparotomy, or through colonoscopic release in the early second trimester of pregnancy . AsymptoMagnetic resonance imaging (MRI) has been suggested as a useful tool to diagnose incarcerated uterus . A limitOur reported case emphasizes the importance of high suspicion for the diagnosis of incarcerated uterus in asymptomatic patients with difficult visualization of the cervix. The incarceration might present a fundal placenta as a low lying placenta, or as in our case, as a complete placenta previa. Key information for diagnosis includes unreachable or displaced cervix on physical and ultrasound examination and the cervix and lower uterine segment being located in the anterior wall of the uterus . Magneti


Eosinophilic angiocentric fibrosis (EAF) is an exceedingly rare and potentially disfiguring and obstructing benign lesion involving the upper airways. We report two cases of EAF originating from the nasal cavity in a 31-year-old female and a 58-year-old male exhibiting nasal obstructive symptoms, with imaging features and histopathology characteristic of EAF. Surgical excision was performed on one patient with a disfiguring nasal mass at a tertiary referral rhinology practice within a university centre. Summarized are the relevant clinical issues to increase awareness of this disease. The slow progression and rarity of the disease has previously resulted in diagnostic difficulty. We review the limited current literature surrounding the clinical features and treatment options for this progressive and potentially morbid condition. These cases reinforce that, while rare, inflammatory and fibrosing lesions in general should still be considered as part of the differential diagnosis in patients presenting with obstructive lesions in the sinonasal tract. Eosinophilic angiocentric fibrosis (EAF) is an exceedingly rare and potentially disfiguring and obstructing benign lesion involving the upper airways. We report two cases of EAF originating from the nasal cavity in a 31-year-old female and a 58-year-old male exhibiting nasal obstructive symptoms, with imaging features and histopathology characteristic of EAF. Surgical excision was performed on one patient with a disfiguring nasal mass at a tertiary referral rhinology practice within a university centre. Summarized are the relevant clinical issues to increase awareness of this disease. The slow progression and rarity of the disease has previously resulted in diagnostic difficulty. We review the limited current literature surrounding the clinical features and treatment options for this progressive and potentially morbid condition. These cases reinforce that, while rare, inflammatory and fibrosing lesions in general should still be considered as part of the differential diagnosis in patients presenting with obstructive lesions in the sinonasal tract.A 31-year-old female of Indian descent originally presented with chronic right-sided nasal obstruction, congestion and sinusitis. She previously underwent septoplasty and endoscopic sinus surgery 8 years ago. Her symptoms persisted and the deformity of her nasal bridge became more splayed, taking on the appearance of an external nasal mass. A biopsy revealed rich inflammatory infiltrate surrounding the blood vessels with a prominent onion-skin pattern, consistent with EAF extension into bony and skeletal muscle tissue .A tertiary referral was then made to our department 3 years ago. Her main complaints were severe nasal blockage and sinus pain, but no epistaxis. The patient was otherwise in good health with no signs of systemic vasculitis or autoimmune disorder and she was not on any medication. There was no significant smoking or alcohol history. She had an allergy to penicillin. The patient had immigrated from India at the age of 16 years.Physical examination revealed involvement of the nasal bones and cartilage, resulting in an enlargement and expansion of the nose. There was significant right-sided nasal passage obstruction with a soft tissue mass that had an oedematous appearance.MRI showed a lobulated diffuse soft tissue mass of the nasolabial folds bilaterally, extending posteriorly to involve the anterior half of the inferior and middle turbinates as well as the anteroinferior nasal septum, mildly narrowing both nasal vestibules . There wGiven the functional and cosmetic difficulties of gross total removal, the patient underwent subtotal resection, including removal of the nasal bones through an open septorhinoplasty approach. The resultant defect was reconstructed with rib grafts. The post-operative recovery was uneventful and the patient’s symptoms had improved. The pathology report confirmed EAF. 4 months postoperatively, the follow-up MRI documented residual disease along the right nasofacial groove with mild mass effect. Subsequent MRIs over 2 years of follow-up showed minimal progression. The patient continued to complain of mild but stable right nasal obstruction. A radiation oncology opinion was obtained and the patient was presented at the institutional tumour board. The consensus of opinion was that the risks associated with additional surgery, radiation or immunosuppressive therapy outweighed the potential benefits. In the absence of severe symptoms and no evidence of disease progression, the recommendation was for continued observation. The patient is being monitored and further treatment will be reconsidered should there be progression.A 58-year-old male presented with a palpable mass in the anterior nasal septum that had been gradually increasing in size over 1 year. His symptoms included bilateral nasal obstruction and persistent rhinorrhoea. There was no history of epistaxis, significant medical issues, medications or allergies. He had an 18 pack-year smoking history.On examination, the nasal septum was expanded anteriorly with a firm submucosal mass obstructing an estimated 50% of each nasal airway. MRI showed the anterior septal mass extending into the pre-maxillary space with partial erosion of the hard palate .Biopsy of the nasal mass revealed extensive perivascular fibrosis in an “onion-skin” pattern, as well as mixed inflammatory infiltrate, including eosinophils, few plasma cells and lymphocytes, consistent with EAF .Total resection of the mass would have required removal of the caudal septum, anterior nasal spine and areas of hard palate, which would be difficult to reconstruct. Given the minor nature of his symptoms and no significant nasal stenosis or mass deformity, observation was recommended. Subtotal resection will be considered if the patient progresses.1 (1983) as a variant of granuloma faciale. Roberts and McCann2 (1985) then reported three similar intranasal cases and the detailed histological features, coining the phrase EAF. To date, there have been little more than 45 known reported cases, although there are likely some that have remained undiagnosed.EAF is a benign, inflammatory, fibrosing lesion that was first described by Holmes and Panje3 Symptoms at presentation include nasal obstruction, epistaxis and breathing difficulties.9 More rarely, epiphora and proptosis may be implicated in cases of ocular adnexae involvement.10 EAF predominantly affects the upper airways, most commonly presenting in the nasal septum and progressing to the lateral nasal wall.11 Thus, EAF should be included in the differential for septal thickening, despite being an uncommon cause.10 Around 75% of cases are limited to the nasal septum, lateral nasal wall and sinuses.3 There have been fewer case reports of subglottic,12 orbital15 and progressive pharyngeal and soft palate involvement.16EAF has a clinical presentation, anatomical predilection and pathognomonic histopathology leading to its diagnosis. Males and females are affected equally, and the average age at diagnosis is 48 years, with a range of 19–72 years.13 There is some evidence that the lesion stabilizes over time,3 as seems to be the case with our first patient. There are no previous reports of fatality, but subglottic and ocular involvement have resulted in significant morbidity.12The natural history of EAF is that of a benign indolent disease with slow growth, and no malignant transformation has been reported. The slow progression of non-specific symptoms results in an average delay in presentation and diagnosis of 5 years.20 Lesions are likely to be longstanding and slowly progressive, with ill-defined margins.18 In later stages, adjacent cartilage and bone remodeling, erosion or even sclerosis may be present, although there is generally a lack of bony destruction.18 On non-enhanced CT scan, EAF may show as an opacification or submucosal mass with homogeneous isodensity compared with grey matter, and calcification is rarely present.18T1 weighted images generally show EAF lesions to be isointense relative to grey matter, with moderate inhomogeneous enhancement with contrast. On T2 weighted images, a notable feature is low signal intensity. Lesions are seldom isointense or hyperintense, owing to the fibrosis in late-phase lesions.18Both CT scan and MRI can be non-specific. The typical imaging finding is soft tissue thickening of the septum and lateral nasal walls.19 These are excluded based on laboratory investigations and histopathology.17The differential diagnosis for EAF is broad, including polyangitis with granulomatous inflammation (formerly known as Wegener’s granulomatosis), Churg–Strauss syndrome, Kimura disease, granuloma faciale, lymphoma, inflammatory pseudotumour, angiolymphoid hyperplasia with eosinophilia, erythema elevatum diutinum and infective granulomatosis.5 EAF progresses from an early inflammatory lesion—with infiltration of eosinophils, plasma cells and lymphocytes—to a late dense fibrous thickening with a perivascular pattern that is comparable with “onion skin”.3 EAF has a clear histological appearance by which it is diagnosed, but its aetiology remains unknown. Deshpande21 (2011) proposed that EAF could be one of the many manifestations of IgG4-related systemic disease after observing that the lesions showed several characterizing features of IgG4-related systemic disease in four of the five patients with EAF.21 In addition, trauma and allergy have been suggested as possible aetiologies for EAF.22The diagnosis is confirmed with histopathology.20 Recurrence occurring in 70% of patients is usually at the same anatomic site, requiring multiple resections.21 Interestingly, reports of definitive eradication of the lesion have only come from first-time resections.3 Thus, given that lesions are slowgrowing and often stabilize over time,3 it would be appropriate to avoid radical surgery in the absence of progression and severely disabling symptoms. Other non-surgical physical therapies, including yttrium aluminium garnet and pulsed dye lasers have met with limited long-term success.23 There is one case of EAF in the literature that was treated with surgery and radiotherapy, but lost to follow-up.24 Furthermore, any potential benefits need to be balanced with morbidities associated with radiotherapy for a non-cancerous lesion, including the increased risk of developing malignancy as well as the risks to vision with lesions presenting close to the eye. Medical treatment modalities have also been non-definitive. Only marginal improvement has been noted with local and systemic immunosuppressive therapies; glucocorticoids have been used to control growth, but have not been shown to halt the progression of EAF.19 At times, treatment has had to be discontinued owing to intolerable side effects.10 Steroid-sparing agents such as mycophenolate mofetil and azathioprine have been recommended based on limited data. There are also reports of azathioprine, hydroxychloroquine, dapsone, anti-fibrotic agents such as tamoxifen, and antihistamines being used without clear benefit.10 Further research is needed to establish inhibition of growth in EAF.Management of EAF has been challenging, as no definitive treatment exists. Even with the treatment of choice , only about 30% have remained free of recurrence at short-term follow-up.EAF is a rare, benign fibro-inflammatory disease most commonly manifesting as slow-growing but potentially disfiguring lesions of the sinonasal tract. There is currently no definitive treatment. More widespread recognition of this condition will hopefully encourage earlier presentation to specialists and resultant biopsy to help inform management options and improve outcomes.EAF is a benign indolent disease involving the upper airways with slow growth, and no malignant transformation has been reported. Although benign, the potentially disfiguring and obstructing course of this lesion has resulted in significant morbidity with extension into the skeletal muscle and bone, particularly when involving the subglottis and orbit.EAF is most commonly seen in the nasal septum and should be included in the differential for septal thickening. Despite being rare, inflammatory and fibrosing lesions in general should still be considered as part of the differential diagnosis in patients presenting with obstructive symptoms in the sinonasal tract.Although both CT scan and MRI can be non-specific, there are some typical imaging features, which might be helpful in identifying EAF: (a) soft tissue opacification of the septum, lateral nasal walls and sinuses; (b) long-standing and slowly progressive natural history; (c) ill-defined margins; and (d) cartilaginous and bony erosion in late stages, generally with lack of bony destruction.Surgical resection is the treatment of choice, but often results in recurrence. Medical options have been less effective. Also, the risks and morbidity inherent to radiotherapy and medical therapies may outweigh any potential benefit if EAF symptoms remain tolerable and stable.Informed consent was obtained.


Neurocutaneous melanoma is a rare congenital syndrome associated with congenital melanocytic nevi with meningeal melanosis or melanoma. The disease is aggressive and has a high propensity for leptomeningeal metastases. We present the case history of a man with neurocutaneous melanoma managed with radical excision followed by hypofractionated adjuvant radiotherapy. One year, eight months later, he had a recurrence of the condition with leptomeningeal spread and was managed with re-excision of the recurrent lesion. Although our patient was disease-free for 20 months after the initial surgery, he survived only approximately five months after the second surgery, which reflects the associated poor prognosis of the disease. Neurocutaneous melanoma (NCM) is a rare non-inherited embryonic neuroectodermal dysplasia . Since iAn 18-year-old male presented to our institution in 2014 with headaches and vomiting for two weeks. A magnetic resonance image (MRI) of his brain showed a complex extra-axial dumbbell-shaped lesion with the epicenter in the left Meckel’s cave, extending anteriorly to the cavernous sinus and the cerebellopontine (CP) angle posteriorly with mass effect over the brainstem. He underwent a left retromastoid craniectomy and decompression of left CP angle lesion elsewhere. The histopathology was suggestive of malignant melanoma, and he was referred to our institution for further management.His general physical examination revealed a deep gray-blue nevus over the left upper eyelid, extending to the frontal and temporal region. He had dysarthria, left upper motor neuron facial nerve palsy, and right hemiparesis with Grade 4 power in his right upper and lower limbs. The biopsy of the nevus over his left eyelid was reported as superficial, and the deep dermal dendritic melanocytosis with histological features was suggestive of a blue nevus.The MRI of his brain showed a large contrast-enhanced extra-axial mass with solid and cystic components measuring 4 cm x 2 cm x 3 cm in the left cavernous sinus extending through the Meckel’s cave into the posterior fossa Figure . A wholePerioperatively, we noted the blue nevus on the left side of the forehead in the ophthalmic distribution of the trigeminal nerve. The pigmentation extended into the subcutaneous tissue and galea. The diploe of the temporal bone was also pigmented. The entire temporal dural convexity was pigmented completely black as were the dural root sleeves of the trigeminal nerve and the lateral and medial walls of the cavernous sinus. The tumor was localized in the cavernous sinus and had a well-defined capsule surrounding the divisions of the fifth cranial nerve. It extended into the posterior fossa through Meckel’s cave. The tumor was completely removed via the cavernous sinus through an interdural approach.The surgical specimen revealed a tumor composed of sheets of moderately large polygonal cells with markedly pleomorphic nuclei with evidence of mitotic activity with foci of necrosis, and occasional cells with intracytoplasmic melanin Figure . We alsoGiven the coexistent skin lesion reported as a blue nevus, neurocutaneous melanoma was considered as the provisional diagnosis. The postoperative hyperacute MRI showed no residual tumor. His symptoms gradually resolved after surgery. He received postoperative intensity modulated radiotherapy to the tumor bed . He was closely monitored during the follow-up period.He presented again about 20 months later with recurrent symptoms of headaches for two months and diplopia and vomiting for two days. On examination, sensations over the V1, V2, and V3 dermatomes were reduced on the left side. There was masseter and temporalis muscle wasting on the left side with impaired blinking in both eyes. His spino-motor system and higher mental functions were found to be normal.A lobulated heterogenous signal intensity mass lesion was seen in the left CP angle and Meckel’s cave. The mass is predominantly isointense and weighted T1, and T2 images were hypointense Figure . VariousThe brain MRI with contrast showed a recurrent mass in the left Meckel’s cave extending into the CP angle compressing the brainstem. Another lesion of a similar nature was seen in the lateral aspect of the cerebellum. There was evidence of thickening and abnormal enhancement of the adjacent pachymeninges and leptomeninges suggesting disease recurrence with leptomeningeal spread. He was further evaluated with a CT of his thorax and abdomen which ruled out extracranial disease.He underwent a left retromastoid suboccipital re-exploration and subtotal excision of the tumor. A postoperative CT scan of his brain showed no residual disease. However, the patient died five months after the second surgery.NCM is a rare congenital syndrome, thought to represent an error in the morphogenesis of the embryonal ectoderm . Most paOur patient had a rare presentation of NCM with leptomeningeal melanoma manifesting in his second decade of life. A definitive criterion for the diagnosis of neurocutaneous melanoma was established by Kadonaga and Frieden in 1991 . The neuNCM has a bimodal distribution. The first peak usually occurs before age three, and the other peak occurs in the second and third decades of life. The risk factors for NCM are the presence of giant congenital melanocytic nevi, male sex, satellite nevi or multiple congenital melanocytic nevi, and nevi in the head and neck region. Our patient is an 18-year-old male presenting with a congenital nevus involving the left upper eyelid and frontal and temporal regions. The characteristic nevus that is associated with leptomeningeal melanosis is the nevus of Ota, which is a hyperpigmented lesion that involves the eyelid and adjacent skin and is associated with pigmentation of the scleral connective tissue. It most often involves the distribution of trigeminal nerve .The usual histopathological features include marked cellular pleomorphism, the presence of mitoses, necrosis, and hemorrhage. On immunohistochemistry, the tumor cells show diffuse positivity for the HMB-45 antibody, S100 and Melan A, suggestive of melanocytic origin [Treatment optionsSince NCM with leptomeningeal melanosis being a rare tumor, there are no specific guidelines for its management. Complete surgical removal of the intracranial tumor is the mainstay of management. The adjuvant treatment options include radiotherapy  depending on the extent of the disease at presentation . IntrathAdjuvant RadiotherapyAdjuvant radiotherapy should be considered at a BED of >45 Gy, as the local control was suboptimal at doses <45 Gy EQD2 . The surRole of Targeted Therapy in Intracranial MelanomaForty percent to 60% of melanomas carry mutations in the BRAF protein pathway. Ninety percent of these mutations result in the substitution of glutamic acid for valine at codon 600 (BRAF V600E). Vemurafenib is a potent inhibitor of mutated BRAF. It has marked antitumor effects against melanoma with BRAF V600E mutation . DabrafeWe report a rare presentation of neurocutaneous melanosis with leptomeningeal spread presenting as a supra and infratentorial mass in the second decade of life. The patient was treated with radical resection and hypofractionated radiotherapy. There was local recurrence after 20 months which was treated with re-excision and had a survival of five months post treatment. Targeted therapy with BRAF inhibitors and MEK inhibitors may offer a promising treatment.


Endometrial polyps are a common cause of abnormal vaginal bleeding and infertility, which can be identified with different imaging methods. A lack of distention of the endometrial cavity is not a common presentation of endometrial polyps and is associated with endometrial carcinoma. In this article, we present a case of a 30-year-old patient with previous history of infertility and abnormal vaginal bleeding. During a hysterosalpingography (HSG), we were not able to distend the endometrial cavity. Therefore, we performed a transvaginal ultrasound (TVUS) and a pelvic magnetic resonance study, which showed an obstructive endometrial polyp adjacent to the internal cervical os. This structure was successfully removed through hysteroscopy by the gynecology department. Endometrial polyps are a common cause of abnormal vaginal bleeding affecting women in premenopause and postmenopause. These endometrial-dependent masses arise secondary to estrogen overstimulation, which is responsible for the cyclical endometrial growth. Complications of endometrial polyps not related to malignancy include recurrent miscarriages and abnormal uterine bleeding -3. The rA 30-year-old female patient was sent to our radiology department because of chronic abnormal vaginal bleeding and infertility. The patient denied any pre-existing conditions and only mentioned a long history of miscarriages. She mentioned no other symptoms or complaints. We performed a hysterosalpingography (HSG) in which hydrosoluble iodinated contrast material was injected through a transcervical catheter; it did not reach the endometrial cavity. After contrast material administration, there was a minimal filiform transit of it, as well as a lack of distention of the endometrial cavity. Both of the uterine tubes were not opacified. We decided to perform a transvaginal ultrasound (TVUS), which revealed a round endometrial-dependent structure localized next to the internal cervical os. Images of the HSG and TVUS are shown in Figure Because of this finding we performed a magnetic resonance imaging (MRI) scan of the pelvis, which showed a polypoid endometrium-dependent structure with its base adjacent to the internal cervical os, it showed an approximate diameter of 1.4 cm. The signal was heterogeneous secondary to cystic-like interposed structures, as well as the presence of a 0.3 cm band-like structure at the base of the lesion. A more detailed description of the MRI can be found in Figure The patient’s gynecologist decided to perform curettage and excision of the lesion through hysteroscopy. It was carefully resected and sent to the pathology department. They reported endometrial fragments with morphological findings of a polyp, as well as smooth muscle fragments without relevant alterations.An endometrial polyp is an abnormal growth containing glands, stroma and blood vessels projecting from the endometrium that occupies spaces small or large enough to fill the uterine cavity and are usually benign lesions. The majority of polyps are located in the fundus. They range in size from about 5 mm to as large as filling the whole uterine cavity. They can be found in all age groups, most common between 40 and 49 years. They can be pedunculated (if they have a large flat base) or sessile . The endometrium varies from normal cycling endometrium to simple or complex hyperplasia in the presence of endometrial polyps, and rarely endometrial cancer can be found. Endometrial polyps have been implicated in 50% of cases of abnormal uterine bleeding and 35% of infertility ,3.The pathogenesis and natural history of endometrial polyps are not very clear. They are believed to be related to estrogen stimulation because of an increased concentration of estrogen receptors (ERs), predominantly ER-alpha in polyp glandular cells compared with normal endometrium, and a decreased expression of progesterone receptors (PRs). Endometrial polyps are common in the pre- and postmenopausal women; however, they usually do not cause obstruction of the whole endometrial cavity nor its lack of distention. This latter aspect is of great importance because malignancies are a cause of obstruction and lack of distention of the endometrial cavity during imaging studies such as SIS and HSG ,2,4.Imaging is best on the 10th day of the menstrual cycle, when the endometrium is thinnest, to minimize false-positive and false-negative results. TVUS has a reported sensitivity of 19%-96%, a specificity of 53%-100%, a positive predictive value of 75%-100%, and negative predictive value of 87%-97% to diagnose endometrial polyps. Colour-flow or power Doppler may improve the diagnostic capability of TVUS. Colour-flow Doppler may demonstrate the single feeding vessel typical of endometrial polyps. Power Doppler has been reported to increase sensitivity to around 97%, while specificity and the negative predictive value may be increased to 95% and 94%. In contrast to the other imaging methods, MRI has the advantage of determining the extension of an endometrial lesion, as well as the myometrium and adjacent pelvic structures. When using a T2-weighted sequence, endometrial polyps are seen as low-signal intracavitary masses surrounded by high-intensity endometrium and fluid. This technique is useful if neoplastic lesions are suspected, such as endometrial carcinoma. In our case, this was relevant to discard because of the uncommon presentation of the obstructive polyp and the lack of distention of the endometrial cavity [Currently, a conservative approach is considered the best therapeutic option. Hysteroscopic polypectomy remains the gold standard for surgical treatment. Removal of the endometrial basalis at the endometrial polyp origin appears to prevent recurrence of further endometrial polyps. Large polyps (>20 mm in diameter) and those located at the fundus are better removed by the resectoscope. Sessile polyps are best removed with an electrosurgical loop, while, small polyps (<20 mm) may be excised using an operating hysteroscope under direct vision with a pair of scissors. Although the malignancy rate of endometrial lesions in premenopause and menopause is minimal, a curettage can reduce abnormal uterine bleeding with >70% of success rate ,3,7.Dilation and curettage, combined with the use of polypectomy forceps, used to be the standard method for investigating abnormalities. This ‘blind procedure’ has well-known limitations, such as missed excision in 50%-85% of the cases due to their mobility. The most common complications associated with this procedure are risks associated with anesthesia, haemorrhage or heavy bleeding, infection in the uterine or other pelvic organs, uterine perforation, among others .Our case reflects the relevance of imaging methods to have a better understanding of structural abnormalities that could explain the patient’s complaints. HSG remains an effective method to detect polypoid endometrial lesions, which are seen as filling defects. The drawback of this method is the use of ionic radiation and patient's discomfort because of its invasive nature. This method is also not capable of determining if the filling defect originates from the endometrium or myometrium. Therefore, other modalities such as MRI are a good option to assess the extension of these types of lesions, as well as both ovaries and the pelvic cavity ,4-6.Endometrial polyps are a common cause of abnormal uterine bleeding and infertility. Nonetheless, they rarely block the endometrial cavity completely. Because of the unusual presentation of our case, it was imperative to perform additional imaging studies to have a more precise diagnosis. With this article, we want to expand the body of literature on the diagnosis of this condition.


Groin hernias are among the oldest recorded afflictions of mankind. Most of themprotrude through the inguinal canal, and only a few through the femoral canal.Usually, they are present as a painful lump in the groin region, and theircomplications arise if they become incarcerated or strangulated. Incarceratedhernias may contain a variety of contents, such as the omentum, small bowel,colon, bladder, appendix, stomach, or ovary as previously described. Usually,the history and a physical examination are sufficient to make the diagnosis.However, the wide use of CT has become an effective instrument to identify thecontents of hernias and has helped surgeons program the best management. Thisarticle reports, for the first time, the case of an 81-year-old female with anincarcerated femoral hernia that contains the gallbladder. An 81-year-old Caucasian female, healthy weight , withoutsystemic diseases, presented herself in a tertiary hospital ambulatory with acomplaint of bulge and pain in the right groin for 10months. The pain was mild andusually appeared when she performed physical effort. No further symptoms wererecorded. The patient had no episode of acute cholecystitis previously. She hadurinary incontinence surgery 12 years ago and a Lichtenstein hernioplasty on theleft side 10 years ago with no signs of recurrence. She had a descending thoracicaortic aneurysm measuring 7.1×6.3 cm on its major axial diameter and aninfrarenal abdominal aortic aneurysm measuring 6.4×6.1 cm on its axialdiameter and was planning to undergo an endovascular repair in two steps. She alsohad a cystocele. The physical exam showed a bulge on the right inguinal region withno expansion on coughing. The palpation showed a hard bulge and the hernia was notreducible with pain on manipulation .3, with no sign ofbiliary dilation. The common hepatic and common bile duct had a length of 6.4 cm andcaliber of 0.5 cm.An ultrasound was performed and found an elongated tubular structure with numerouscalculi coming from the right hypochondrium and projecting into the femoral canal. There wHistory and physical examination are the main means of diagnosing groin hernias. Somedifferential diagnoses include: groin abscess, hematoma, lipoma, lymphadenitis,pseudoaneurysm, tumor and in males, retracted testes, testicular torsion or acuteepididymitis. After an ultrasound or CT, the diagnosis of hernia becomesevident.After endovascular elective surgery, an elective laparoscopic cholecystectomyfollowed by a transabdominal preperitoneal patch plasty of the femoral hernia repairwere planned.An extensive PUBMED, MEDLINE and Scielo literature search was performed using theMeSH terms “inguinal hernia”, “femoral hernia” and“gallbladder”, on January 17, and 47 articles were found; 2 ofthem were case reports of inguinal hernia with gallstones. Following searches inPUBMED and web searches on Google with the MeSH terms “Hernia” and“Gallbladder”, 363 results were found. Four of them describedincisional hernia which contains the gallbladder. Four paraostomal gallbladderhernia articles were also found, while the description of ventral herniation ofgallbladder was less frequent. The most infrequent was the Spigelian hernia, inwhich the gallbladder bulges out through the semilunar line. In the research, noprevious reports of gallbladder herniation through the femoral canal werefound.1 However, of all groin hernias, 96% are inguinal and 4% are femoral.2 These hernias are far more frequent in females, unlike inguinal hernia,particularly older females. The main reason is the wider shape of the female pelvis.3 The femoral hernia protrudes through the femoral ring and reaches the femoralcanal, which is bordered anterosuperiorly by the inguinal ligament, posteriorly bythe pectineal ligament, medially by the lacunar ligament and laterally by thefemoral vein. It is present as a painful lump in the inner upper part of the thighor groin that can frequently be pushed back in or bulge depending on intra-abdominal pressure.4 It originates through a weak spot in the surrounding muscle wall in thefemoral canal. The history and physical examination are usually sufficient to makethe diagnosis.5 There is a need to be aware of the potential contents of hernia sacs, whichhas implications for definitive operative management.6 Gallbladder herniation is rare and may occur internally through the foramenof Winslow7 or in the subcutaneous tissue through a defect on the abdominal wall.9 This case report describes the case of an 81-year-old female with an inguinalhernia whose symptoms started 1 year ago. Females tend to develop this type ofcondition older than males. In one review, the median age for groin herniapresentation was from 60to79years old for women.10 The treatment of femoral hernia is surgical, independent of which structureprotrudes through it, in order to relieve symptoms and avoid complications such asobstruction or strangulation. The patient was very symptomatic from her right groin.However, the thoracic and the abdominal aorta aneurysms were the priorities andplanned to be treated earlier by endovascular approach. A laparoscopiccholecystectomy and inguinal repair was planned to be performed subsequently.Groin hernia is a very frequent cause of outpatient visits in surgical units. Theprevalence of groin hernia in the USA is estimated to be about 5–10%.11 Surgeons have been exposed to these conditions for a very long time and ithas become a tradition, mainly with inguinal hernias, whenever they identify a newstructure in the hernia sac, to describe them with their name.12 It has been done by several surgeons; Alexander Littré, in 1700, namedan inguinal hernia which had a meckel diverticulum inside it, Rene Jacques Garengeotidentified, in 1721, a cecal appendix in a femoral hernia, Claudius Amyand, in 1735,faced an acute appendicitis inside the inguinal canal and August Richter, in 1778,described a hernia in which the antimesenteric wall of the intestine protrudedthrough a defect in the abdominal wall. At the time, abnormal findings inside herniasacs were discovered during the intraoperative process, and this is the reason whyrare hernias were described by surgeons. However with the use of imaging exams, itis possible to make an early diagnosis and be better prepared for the procedure.Almost 300years after these records, this case report identified a femoral hernia inwhich the gallbladder protrudes through the inguinal canal, which had never beendescribed before. It is important to believe that despite all the improvements andnew findings in Medicine in recent years, this science still has anatomical andsurgical discoveries to be done.Our main intention with this case report was to describe, for the first time, afemoral hernia where its content is the gallbladder . HerniasThe case presented illustrates a different type of femoral hernia in whichits content is the gallbladder.Whenever there are new or abnormal findings on physical examination, imagingexams (Ultrasound or CT) should be requested. The patient had a hard bulgein the groin region due to gallstones.Although it is unusual, Medicine still has anatomical findings to bedone.


Primary pulmonary meningiomas are very rare, and primary intraosseous meningiomas outside the head and neck region have not yet been reported. We report an extremely unusual case of concurrent meningiomas arising in the pulmonary parenchyma and vertebral bone.A 40-year-old Asian woman presented with a destructive lesion of the lumbar vertebral bone and a small nodule in the right lung. Five years later, both lesions slightly increased in size. To evaluate both the pulmonary and vertebral lesions, video-assisted thoracic surgery and curettage of the lytic lesion were performed. Both lesions showed similar histopathological findings corresponding to an intracranial meningioma of World Health Organization grade 1. The patient made good postoperative progress and remained free from disease at 41 months after the operation.Our patient presented with almost synchronous pulmonary and lumbar vertebral intraosseous meningiomas. Regarding the relationship between the two lesions, there are two possibilities: Independent tumors occurred coincidentally or the primary pulmonary meningioma metastasized to the vertebral bone despite its bland morphology. It is important to keep in mind the exceptionally rare condition of extracranial meningioma. Meningiomas are relatively common primary central nervous system tumors, comprising approximately 25% of all intracranial neoplasms . Primary-old Asian woman who had been in her usual state of good health was incidentally found to have a small nodule in the lower lobe of her right lung during a regular medical checkup. The patient was seen in the department of medicine of our hospital for further evaluation. The patient’s family history was noncontributory, and a physical examination revealed no abnormalities. The results of laboratory studies were either within normal limits or negative. A computed tomographic (CT) scan revealed a lytic lesion of the fifth lumbar vertebral bone, as well as a small nodule (1.2 cm in diameter) in the lower lobe of the right lung  imaging also revealed an increase in the size of the lytic lesion in the left transverse process of the fifth lumbar vertebra. To evaluate both the pulmonary and vertebral lesions, video-assisted thoracic surgery for the pulmonary lesion and curettage of the lytic bone lesion were performed. The orthopedic surgeons found that the tumor of the fifth left transverse process was exposed on the posterior surface but not on the anterior surface. They also found that the vertebral lesion was completely confined within the vertebral bone and was not connected to the spinal canal. During the clinical course (105 months), no significant findings other than the pulmonary and vertebral lesions were found, even with imaging examinations, including CT and MR imaging. The patient made good postoperative progress and remained free of disease at 41 months after the operation.The resected specimen of the lung contained a well-circumscribed solid lesion 13 mm in diameter. It was composed of fascicular architecture of bland spindle or polygonal cells Fig. . NeitherThe occurrence of ectopic meningiomas is well known . AlthougWe postulate two possibilities concerning the relationship between these lesions. First, it is possible that the lesions happened to coincide. Although intraosseous meningioma can occur as a primary tumor exclusively in the head and neck region , there hThe differential diagnosis of meningioma includes a number of lesions composed of bland-looking eosinophilic spindle cells. When examining the entire lesion, the diagnosis may be straightforward if the pathologists are aware of the presence of the extracranial meningioma. However, when biopsy specimens are inadequate, diagnosis can be challenging. Primary leiomyoma, which arises in the bronchial wall, is also composed of bland and eosinophilic spindle cells . The locIn summary, we describe an extremely unusual case of a patient with concurrent meningiomas arising in the pulmonary parenchyma and lumbar vertebral bone. Although the history of these tumors cannot be clearly determined, it is important to recognize that such an unusual situation can occur.