Duodenal adenomas are benign tumours of the duodenum which carry a malignant potential. They are found either sporadically or associated with familial syndromes. Majority of these cases are treated endoscopically but surgical resection is a better alternate to endoscopy in select cases. Endoscopic treatment is associated with higher chances of local recurrence and require frequent check endoscopies in the follow up period, while surgery offers a one-time treatment option. Identification of the ampulla and a duodenal resection sparing ampullary area becomes difficult in larger lesions of the 2nd part of the duodenum. Passage of a catheter from cystic duct through common bile duct to duodenum aids in identification of the ampullary area and is helpful in performing a local/wedge resection of the duodenum containing adenoma without injuring ampullary orifice. •Duodenal adenomas carry malignant potential.•Found sporadically or with familial syndromes.•Surgery offers one time treatment options for larger lesions.•Isolating the ampullary orifice through catheterization of the cystic duct is useful. Adenomas are benign epithelial tumours, and the most common variety of polyps in the duodenum. They are either sporadic or may be associated with hereditary syndromes, like Familial Adenomatous Polyposis (FAP) and Peutz- Jeghers syndrome. They can be ampullary or non-ampullary according to the site of their origin. Non-ampullary duodenal adenomas are commonly found in patients of FAP, while sporadic occurrence is rare [We operated two cases of large non-ampullary duodenal adenomas in the department of Surgical Gastroenterology and Liver Transplant at a tertiary care teaching hospital. The identification of the ampullary area was difficult in both the cases due to large size of the adenoma causing almost complete occlusion of the duodenal lumen. One case was of sporadic variety, and the other was associated with FAP. The aim of the article is to report these cases and review of literature on this subject. This case series has been reported in line with the PROCESS Guidelines .1.1A 46-year-old male presented with recurrent abdominal pain and vomiting for six months with recent exacerbation of symptoms. Clinical examination was unremarkable and blood investigations revealed microcytic hypochromic anaemia with normal tumour markers.Contrast enhanced CT scan of the abdomen revealed a large, ill-defined heterogeneously enhancing, hypodense mass within 2nd part of the duodenum which appeared resectable , Fig. 2.Intra-operatively, a large mass  arising from the mesenteric border of the junction of the first and second part of the duodenum was found, which was causing luminal obstruction. Ampullary area could not be identified separately so a small catheter was introduced from cystic duct to ampulla (after cholecystectomy)  and an a1.2trans-duodenal FNAC were inflammatory only.A 26-year-old male presented with pain abdomen and vomitings for 4–5 months. Ultrasound abdomen suggested agenesis of left kidney with transient duodenal intussusception. CT scan showed a circumferential pyloroduodenal thickening, intussuscepting into duodenum with? neoplastic mass as a lead point. UGI Endoscopy showed a polypoidal growth at D1-D2 junction causing luminal narrowing and scope negotiated beyond with mild resistance. Endosonography (EUS) showed 38 × 32 mm lesion at D1-D2 junction, arising from 3rd layer of the duodenal wall. Biopsy and EUS guided Intra-operatively, posterior wall of second part of the duodenum had a 6x5x1.5 cm sized polypoidal friable mass. Ampulla was not separately visualised, so the ampullary area was spared after passage of a small catheter via cystic duct to ampulla. Wedge resection of the duodenum with retro colic gastrojejunostomy and feeding jejunostomy were done. Post-operative period was uneventful, and he was discharged on 6th post-operative day. Biopsy was suggestive of adenomatous polyp with low grade dysplasia.The patient had no complications or recurrence in the one-year follow-up till the article was submitted for publication.2Incidence of duodenal polyps varies from 1.02% to 4.6% of all the patients referred for upper gastrointestinal endoscopy . The spoRecent evidence suggests that, regardless of their types and location, duodenal adenomas are similar in morphology and molecular characteristics to colorectal adenomas and similar mechanisms are involved in their conversion to adenocarcinoma . Higher Genetic mutations, like those in Adenomatous Polyposis Coli (APC), p53 and KRAS, are thought to be responsible for progression of adenoma to carcinoma. CpG Island Methylator Phenotype (CIMP) is well recognized phenotype found in patients with colorectal polyps and cancers. Its role has also been suggested in small bowel cancers and a positive status is associated with larger lesions, associated dysplasia, ampullary location and villous subtype and are associated with poor prognosis. These patients require more aggressive surveillance and treatment .FAP is an autosomal dominant disorder which is caused by mutant APC gene on the long arm of chromosome 5. The lifetime risk of developing duodenal malignancy in these patients of FAP is about 3–5% . A stagiHistopathology plays an important role in the management of duodenal adenomas. In patients with non-ampullary solitary adenomas and low-grade dysplasia, the risk of malignant conversion is low but about 20% develop high grade dysplasia and 4.7% develop noninvasive malignancy. A close follow up is required in these patients. Patients with high grade dysplasia and a lesion larger than 2 cm have a higher risk of progression to malignancy, hence should be treated immediately .Most lesions are amenable to endoscopic resections. The endoscopic treatments recommended are 1) Endoscopic Polypectomy (lesions <1 cm), 2) Endoscopic Mucosal Resection (EMR) for larger lesions and 3) Ablation by Argon Plasma Coagulation (APC). The risk of complications with EMR increases with the increase in size of the lesion. It is indicated for lesions less than 2 cm in size and less than 33% of duodenal circumference involvement [Disadvantages of EMR are bleeding (43%), recurrence (14–37%) and perforation risk (4.3%) . DisadvaSurgery is a one-time treatment option and is the preferred mode of treatment for lesions which are >2 cm in size, recurrent or show severe dysplasia. Surgical procedures recomemded are trans duodenal submucosal or wedge resection, segmental duodenal resection sparing pancreas and pancreaticoduodenectomy or Endoscopy assisted laparoscopic resections . WhippleFor lesions larger in size and located near the ampullary area, difficulty arises in performing an ampulla preserving wedge/local resection. To overcome this same problem in both the above cases, we attempted a cholecystectomy and passed a small catheter from the cystic duct stump to the lower end of bile duct. It was then taken out through ampulla which helped in identifying the ampullary area. The catheter acted as a guide and an ampulla sparing resection was done. We found this technique useful, but it needs further research and data support before being recommended in clinical practice.3Surgery is a better and one-time option than endoscopy to treat large duodenal adenomas. Adding cholecystectomy and passage of a catheter from cystic duct across ampullary region helps in identification of the ampulla thus, avoiding its injury during local resection.Written informed consent was obtained from the patients for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.for this research.There are no sources of funding Not Required for case reports as per our institution policy.Not commissioned, externally peer-reviewed.1.Amitabh Yadav - Corresponding author - study concept, data collection, data analysis or interpretation, writing the paper2.Samiran Nundy - Study design and editing1.researchregistry.comName of the registry: 2.Unique Identifying number or registration ID: researchregistry68373.https://www.researchregistry.com/browse-the-registry#home/Hyperlink to your specific registration (must be publicly accessible and will be checked): Dr Amitabh Yadav.Consultant.Surgical Gastroenterology and Liver Transplant.Sir Ganga Ram Hospital.New Delhi.All authors declares that there is no conflict of interest.


True primary enterolithiasis is an uncommon condition, and nontraumatic perforation of the small intestine (NTPSI) is also an unusual entity. Therefore, NTPSI due to true primary enteroliths is an exceptionally rare complication. Moreover, enterolithiasis and radiation enteritis are also unique combinations. Herein, we present an exceedingly rare case of NTPSI induced by multiple true primary enteroliths associated with radiation enteritis.A 92-year-old woman with acute abdominal pain was transferred to our hospital because a computed tomography (CT) scan performed by her family doctor revealed free air and fluid collection within her abdomen. Our initial diagnosis was upper gastrointestinal perforation, and we selected nonoperative management (NOM) with adnominal drainage. Although her general condition was stable, jejunal juice was drained continuously. Given that the CT performed 10 days after onset demonstrated perforation of the small intestine and adjacent concretion, we performed an emergency partial resection of the small intestine and jejunostomy. The resected bowel was 1 m in length and had many strictures that contained multiple enteroliths in their proximal lumens. The patient’s postoperative course was uneventful. The enteroliths were composed of deoxycholic acid (DCA). She was diagnosed with peritonitis due to NTPSI derived from multiple true primary enteroliths associated with radiation enteritis, as she had previously undergone hysterectomy and subsequent internal radiation therapy.Clinicians should consider the rare entity of true primary enteroliths associated with radiation enteritis in NTPSI cases with unknown etiologies. Enterolithiasis is an uncommon medical condition and is classified into primary and secondary types . PrimaryA 92-year-old woman presented to her family doctor with acute abdominal pain, vomiting, and diarrhea. She was admitted to the hospital with a primary diagnosis of infectious enteritis suggested by examinations, including computed tomography (CT). The day after hospitalization, the radiologist noted free air and fluid collection within her abdomen on the CT scan from the previous day. The patient was transferred to the emergency room of our hospital for further examination and treatment.The patient underwent brachytherapy using cobalt-60 (Co-60) gamma irradiation after hysterectomy for the treatment of uterine cancer at the age of 49. She was 145 cm tall, weighed 55 kg, and had a body mass index of 26.16.2, 8.2 g/dL, 4.2 g/dL, and 1.3 g/dL, respectively. Electrocardiogram and arterial blood gas results were within normal limits. Abdominal CT performed at a previous hospital showed free air mainly in the upper abdomen and fluid collection in the right subphrenic space. In addition, it confirmed the presence of multiple slightly high-density contents with spheroid or discoid shapes with sizes that varied from 1 to 4.5 cm within the intestinal tract  of 15,500/μL, 93.5% neutrophils and C-reactive protein (CRP) level of 22.07 mg/dL. Blood urea nitrogen and creatinine levels were also increased to 37.2 and 1.3 mg/dL, respectively, whereas estimated glomerular filtration rate, hemoglobin, total protein, and albumin levels were decreased to 29.4 mL/min/1.73 mOn admission, we inserted a drainage tube into the right subphrenic space, and grayish white and odorless mucus-like gastric juice was discharged from the tube. The chemical analysis of the drainage fluid revealed an alkaline phosphatase level of 332 IU/L and amylase level of 60 IU/L. Therefore, we initially suspected upper gastrointestinal perforation without continuous leakage of digestive juice. Moreover, she had stable blood pressure and no fever one day after onset. However, she was elderly and exhibited dehydration and renal failure, so the risk of surgery itself cannot be underestimated. Therefore, we started nonoperative management (NOM). After hospitalization, her vital signs remained stable, body temperature also remained normal, and abdominal pain improved. The WBC was transiently reduced to 2500 μL one day after admission, but remained within the normal range thereafter. The CRP and procalcitonin levels also exhibited peak levels of 32.5 mg/dL and 37.0 ng/mL, respectively, on the second day after admission, but both values improved thereafter. Her general condition improved day by day; however, the color of discharge from the drain turned from grayish white to dark green, similar to jejunal juice. Furthermore, the volume of drainage increased to approximately 500 mL/day. CT taken 7 days after onset showed an undrained fluid collection localized in the right paracolic gutter; nevertheless, the perforation site was not identified. Therefore, we performed additional intra-abdominal drainage and continued NOM. Thereafter, her general condition was unchanged and stable, and the volume of drainage was decreased to 200 mL/day. However, the appearance of drainage fluid remained similar to jejunal juice. An abdominal CT performed 10 days after onset demonstrated a suspicious perforated lesion as a partial defect of the small intestinal wall, and a slightly high-density structure was located immediately beside the lesion  Fig. a. Some dIn this patient, surgical site infection of the wound occurred 4 days after operation; therefore, she underwent wound lavage and negative pressure wound therapy. She resumed oral ingestion of food 19 days after the operation. Her postoperative progress was almost uneventful; however, several days were required for wound healing and improvements in daily living activities because she was frail and elderly. She was transferred to a nearby hospital 104 days after the operation.Enterolithiasis is the presence of an enterolith within the intestinal lumen and is a rare condition; its prevalence in selected populations varies widely from 0.3% to 10% because it is largely dependent upon clinical presentation, etiology, and underlying risk factors . EnterolRadiation enteritis is a rare cause of enterolithiasis. A literature search of the PubMed database analysis yielded 4 results published between 1962 and 2020 when searching for “enterolith AND radiation enteritis”. Excluding nonrelevant results and limiting the scope to articles written entirely in English, only 2 reports describing enterolithiasis associated with radiation enteritis were identified , 8. In oSmall bowel obstruction is a common surgical presentation. Nevertheless, as Nonose et al.  describe. [The mortality of NTPSI was reported to range from 15 to 39% in the early era because surgery was often delayed due to difficulties experienced with the initial diagnosis of the precise cause and site of perforation . However.  mentione. . In our . . As a reClinicians should consider small bowel perforation as a differential diagnosis when perforated lesions cannot be identified accurately in patients with intra-abdominal free air. In addition, if a patient with suspected NTPSI has slightly to very high-density components in the small bowel on CT, it is crucial to consider that enterolithiasis, a rare entity, can be a cause of intestinal perforation. Furthermore, if such a patient has a past history of undergoing radiation therapy (such as brachytherapy) to the abdomen, radiation enteritis-associated enterolithiasis must also be considered.


We herein report a case of giant congenital hepatoblastoma in a 3-month-old male treated with neoadjuvant chemotherapy and hepatic resection. After considerable reduction of the tumor with chemotherapy, a right bloodless hemihepatectomy using saline-linked radiofrequency technology (SLRT) and without clamping of the hepatic pedicle was performed. Intraoperative blood loss was minimal, and consequently, no blood transfusions were required. The surgery lasted 140 min, and SLRT was used for a total of 60 min. No complications were observed during or after the surgery. In conclusion, congenital hepatoblastoma is a very rare cancer for which surgery is an essential therapeutic step, and in our presented case, we showed that SLRT allowed for a safe and effective bloodless liver resection. Malignant liver tumors represent approximately two-thirds of all liver masses and account for 1% of childhood tumors overall .Congenital HBL (cHBL) can be identified in utero, at birth, or during the first month of life. It is a very rare condition and has some important distinctive features compared with HBL diagnosed in children beyond neonatal age . cHBL caIn the case of malignant liver tumors, the most effective treatment is surgical removal combined with chemotherapy  before and/or after surgery. The goal of surgery is to completely remove the tumor by partial or complete resection of the liver with possible transplantation.Over the past 20 years, technological advances have led to the development of specific devices for bloodless liver transection, such as ultrasonic cavitation devices, water jets, harmonic scalpels, and vessel-sealing devices. The Floating Ball, Dissecting Sealer, and Bipolar Sealer devices used for liver transection are based on saline-linked radiofrequency energy . This enSLRT has already been described in adults, but to our knowledge, only three cases have been reported in the pediatric population, and three were older than 1 year old .Our case involves a male term infant with an abdominal mass detected by sonography at 36 weeks of gestation. The dimensions of the mass were approximately 6.8 × 7 × 9.1 cm, and it appeared to be associated with the liver. The differential diagnoses included a benign liver mass  or a malignant neoplasm (hepatoblastoma). The patient had an uneventful cesarean delivery in order to avoid rupture of the abdominal mass. The amniotic liquid was normal, and the birth weight was 3900 g. Upon abdominal examination, the infant had a palpable abdominal mass but was otherwise asymptomatic with no respiratory distress.At 3 days of age, the patient was transferred to our unit. Blood tests were performed reporting increased levels of transaminase, lactic dehydrogenase, gamma-glutamyl transferase, and total bilirubin associated with increased levels of AFP .Ultrasound and magnetic resonance imaging (MRI) showed an abdominal mass of 6.5 × 7.1 × 9.5 cm related to the liver. Chest computerized axial tomography (CAT) and brain MRI were both normal.At 7 days of age, the diagnosis of “epithelial fetal hepatoblastoma” was confirmed by open biopsy. The cancer was classified as third-stage per the SIOPEL PRETEXT protocol .2/day). At the end of the pharmacological treatment, a reduction in AFP and total bilirubin in the blood was observed. A new total-body computerized tomography (CT) showed a marked reduction in the mass .Intraoperative blood loss was minimal; no transfusions of blood products were required (bloodless resection). The total surgical time was 140 min, and SLRT was used intermittently for a total time of 60 min.The postoperative course was free of noteworthy complications, and on the 2nd postoperative day, gradual stabilization of the liver enzyme levels was observed.On the 7th postoperative day, the patient was discharged. The patient was completely asymptomatic and administered postoperative chemotherapy with two subsequent cycles of cisplatin. At 6 months follow-up, the total body MRI showed no recurrence of disease and hepatic compensatory hypertrophy of the left liver .cHBL is an extremely rare cancer. From 1966 to 2021, approximately 51 cases have been described in the literature ,12,13,14In the literature, recent data have highlighted the importance of preoperative chemotherapy in the treatment of hepatoblastoma ,12. In tLiver resection is classified into major and minor hepatectomy according to the Couinaud classification . Major hSLRT combines an electrosurgical generator for the delivery of radiofrequency energy and saline solution (0.9% NaCl) . DevicesA bloodless right hemihepatectomy by SLRT was performed in the case reported. SLRT allowed excellent control of the intraoperative bleeding with insignificant blood loss without the PM. The good bleeding control during the operation allowed for a shorter anesthesia duration and minimized the overall surgical stress to the patient.In conclusion, congenital hepatoblastoma is a very rare cancer for which surgery is an essential therapeutic step. In our case, SLRT allowed for a safe and effective bloodless major liver resection.


A 12‐year‐old mixed‐breed dog was presented for a follow‐up examination after ablation of an auricular mast cell tumour. An abdominal ultrasound and computed tomography were performed and an irregular, ill‐defined and partially mineralised lesion was observed around the caudal duodenal flexure without evidence of metastasis. The cytologic examination was highly suggestive of a granular cell tumour. Partial surgical ablation with histological and immunohistochemical examination of the lesion confirmed the diagnosis. According to our review of the literature, this is the first report documenting an abdominal granular cell tumour in a dog. An abdominal granular cell tumour with imaging, cytological and histopathological characteristic of malignancy was diagnosed in a 12‐year‐old mixed‐breed dog. This is the first report describing this type of tumour in the abdomen of the dog. The oral cavity (notably the tongue) is the most common location in dogs, cats and people, but a wide range of other locations have been described , Hb 13.7 g/dl (12–18), PCV 36% (37–55), reticulocytes 19,856 ] and moderate increase of alkaline phosphatase [1356.5 UI/L (20–156)] were detected. Otherwise, the blood work was unremarkable.A complete blood cell count, serum biochemistry and abdominal ultrasound were performed as part of the oncologic examination. Mild normocytic, normochromic, non‐regenerative anaemia [RBC 5.84 × 10On the abdominal ultrasound an irregular and elongated lesion with ill‐defined margins was observed in the mesentery adjacent to the serosa of a small intestinal loop in the right caudal abdomen Figure . The lesUltrasound‐guided fine needle aspiration of the lesion was performed. On cytological examination a numerous and individually organised neoplastic cells were detected. They were large, round to slightly polygonal with eccentric round nuclei, reticular chromatin and occasional prominent nucleoli. The nucleus to cytoplasm ratio was low. There was abundant cytoplasm with distinct cytoplasmiizc borders and multiple variable shaped and sized granules. Mild anisocytosis and anisokaryosis were noted. Binucleated cells were frequent and multinucleated cells were occasionally encountered. No microorganisms were seen. The findings were highly suggestive of granular cell tumour. There was also mild mixed inflammation with neutrophilic and macrophagic predominance and evidence of previous haemorrhage.A thoracic and abdominal computed tomography (CT) was performed for staging and surgical purposes. An irregular and heterogeneous lesion with ill‐defined margins was observed adjacent to the serosa of the caudal duodenal flexure. The lesion was mainly soft tissue attenuation with multiple pint‐point foci of mineral attenuation and mild contrast enhancement Figure . The surLaparoscopic approach was performed as the owners elected a less invasive approach. A multinodular, yellowish lesion was observed around the caudal duodenal flexure. The mass was firm and deeply attached to the intestinal wall and the surrounding mesenteric tissue, preventing its complete resection with the performed surgical approach. For the same reasons, full‐thickness biopsy or enterectomy were not performed.The main histopathological finding was a neoplastic proliferation of the mentioned cells with a highly infiltrative pattern in adipose tissue. The cytoplasmic granules were periodic acid‐Schiff (PAS)‐positive, and immunohistochemistry revealed a strong reaction of the cells against ubiquitin Figure . No posiSix months after surgery the dog was alive and healthy without evidence of clinical signs.3According to our review of the literature, this is the first report describing an abdominal granular cell tumour in a dog. In this case, the tumour was in the mesentery and deeply attached to the serosal layer of the caudal duodenal flexure. Unfortunately, it was not possible to determine if the lesion originated from the mesentery or the intestinal serosa, as enterectomy or full‐thickness biopsy was not performed. In human medicine, up to 8%–11% of the granular cell tumours involve the gastrointestinal tract, most commonly the oesophagus, colon and stomach. Small intestine involvement is extremely rare (<1%), with only few cases of this tumour affecting the duodenum and ileum  is a potential origin for canine granular cell tumour. Therefore, this tumour should be included in the differentials for a solitary, ill‐defined and irregular mass or lesion affecting the mesentery and/or the serosal layer of the gastrointestinal tract. Ultrasound and computed tomography are helpful for the diagnosis and presurgical planning. Histology is mandatory to confirm the diagnosis.No conflict of interest have been declared.Alejandro Ororbia: Conceptualization; Data curation; Investigation; Validation; Writing‐original draft; Writing‐review & editing. Alba Sanz: Data curation; Investigation; Validation; Writing‐original draft; Writing‐review & editing. Rosa Novellas: Data curation; Supervision; Validation. Josep Pastor: Data curation; Supervision; Validation. Marti Pumarola: Data curation; Formal analysis; Supervision; Validation; Writing‐original draft; Writing‐review & editing. Laura Fresno: Data curation; Resources; Supervision; Validation; Writing‐original draft. Yvonne Espada: Conceptualization; Data curation; Investigation; Supervision; Validation; Writing‐review & editing.https://publons.com/publon/10.1002/vms3.543.The peer review history for this article is available at


Ischemic colitis represents the most frequent form of intestinal ischemia occurring when there is an acute impairment or chronic reduction in the colonic blood supply, resulting in mucosal ulceration, inflammation, hemorrhage and ischemic necrosis of variable severity. The clinical presentation is variable and nonspecific, so it is often misdiagnosed. The most common etiology is hypoperfusion, almost always associated with generalized atherosclerotic disease. The severity ranges from localized and transient ischemia to transmural necrosis of the bowel wall, becoming a surgical emergency, with significant associated morbidity and mortality. The diagnosis is based on clinical, laboratory suspicion and radiological, endoscopic and histopathological findings. Among the radiological tests, enhanced-CT is the diagnostic investigation of choice. It allows us to make the diagnosis in an appropriate clinical setting, and to define the entity of the ischemia. MR may be adopted in the follow-up in patients with iodine allergy or renal dysfunctions, or younger patients who should avoid radiological exposure. In the majority of cases, supportive therapy is the only required treatment. In this article we review the pathophysiology and the imaging findings of ischemic colitis. Ischemic colitis (IC), first described by Boley et al. in the 1960s . IC is tIC occurs when there is an acute impairment or chronic reduction in the colonic blood supply, resulting in mucosal ulceration, inflammation, hemorrhage and ischemic necrosis of variable severity , not alwThis condition is in almost all cases related with an impairment of the arterial blood flow rather than of the venous drainage ,16. ApprTwo major arteries feed the colon: the superior mesenteric artery (SMA) supplies the ascending and the proximal two/thirds of the transverse colon, and the inferior mesenteric artery (IMA) the distal segment of the transverse colon, descending colon, sigmoid colon and superior segment of the rectum. The internal iliac arteries give blood to the middle and inferior rectum through the middle and inferior rectal artery .There is an anastomotic network that connects the branches of these vessels, constituting the marginal artery, also known as the marginal artery of Drummond. However, there are colonic segments more sensitive to ischemia, particularly the right colon, the splenic flexure (Griffith’s point) and the sigmoid colon (Sudeck’s point), where the marginal artery can be less developed, making these areas more vulnerable to ischemia ,25,26.The degree of ischemic vascular impairment, and the damage resulting from it, depend on several factors: the state of the systemic circulation, the anatomical or functional nature of the vascular alteration, the number and size of the affected vessels, the compensatory response of the vascular bed to the reduced perfusion, the nature and capacity of the collateral circulation, the duration of the ischemic insult, the metabolic demand of the intestinal segment involved and the presence/absence of reperfusion phenomena ,27,28. FThe diminution of arterial blood flow often depends on a decrease in systemic perfusion , but can also be due to a local dysregulation of blood supply, or to vessel occlusion. Although it can be associated with several medical and surgical conditions, as listed above, a specific cause cannot be identified in most cases ,29.Patients with IC usually complain from abdominal pain, rectal bleeding, diarrhea and abdominal distention; nausea and/or vomiting can also be found. Clinical examination usually reveals a soft abdomen. Patients are typically hemodynamically stable, unless presentation with gangrenous IC leads these patients to present abdominal tenderness or signs of frank peritonitis . LaboratThere are multiple classification systems of IC that allow a risk stratification of patients ,31,32,33Treatment of IC depends on the severity of presentation. Transient ischemia involving the mucosa and submucosa has a good outcome with conservative management, while fulminant ischemia with transmural infarction leads to a poor prognosis, with a mortality rate reaching 50% .The diagnosis arises from a combination of clinical, laboratory suspicion and radiological, endoscopic and histopathological findings. Sometimes, the clinical presentation is nonspecific or misleading, and it is difficult to distinguish among patients with possible infective, inflammatory, and IC.Laboratory tests may demonstrate abnormalities depending on the preexisting patient condition, and on the stage of ischemia/necrosis of the bowel wall. Therefore, there are no specific laboratory markers for ischemic colitis. However, inflammatory makers such as C-reactive protein and neutrophil count are likely to be raised. The combination of metabolic acidosis, renal failure and elevated lactate suggest intestinal ischemia and infarction, but these abnormalities are not specific to a diagnosis of IC and are only present in severe and advanced disease. Indeed, for example, a normal lactate value does not exclude full thickness ischemia of the colon ,35.At present, diagnostic imaging has considerable potential in the diagnosis of and intervention into abdominal pathologies, and was recently also supported by integration with artificial intelligence methods ,48,49,50XR may be the first imaging technique required for patients complaining of abdominal pain. The imaging findings  intravenous (IV) contrast medium (CM) , injected at 3.5–4 mL/s through an 18-gauge needle in the antecubital vein, followed by a bolus of 40 mL of saline adopting the same flow rate, to ensure a good vessel depiction. The acquisition of the arterial phase is timed with the bolus tracking placing the region of interest (ROI) on the aortic arch and starting at an attenuation threshold of 100 Hounsfield units (HU). The portal-venous phase is acquired with a delay of 60 to 70 s from the beginning of the injection. The suggested acquisition volume in emergency settings includes chest and abdomen in the portal phase, to obtain a complete examination ,75,76,77CT acquisitions should be examined with a window setting for the soft tissue , to identify changes in the bowel wall, splanchnic organs, mesentery and vessels, and for lung parenchyma , to look for wall pneumatosis  and extrThe American College of Radiology (ACR) guidelines recommend CT as the first imaging technique as an alternative to mesenteric angiography for the assessment of IC . CT givethe etiology ;the location and extension of the intestinal damage;the phase of the damage .In the diagnosis of IC, it is important to indicate ,89:the 1.EtiologyMost cases of ischemic colitis are “low-flow” states and lack the signs of vascular occlusion. Therefore, it is important to focus on the evaluation of the bowel wall instead of vascular occlusive signs.The type of damage to the bowel wall can be arterial–ischemic or reperfusive.In arterial–ischemic damage there is an impairment in the colonic blood supply and, if there is no reperfusion, the colonic wall appears thin or “paper thin” in unenhanced and enhanced CT scans. This condition may be observed in patients with non-occlusive mesenteric ischemia (NOMI) (before reperfusion) and in vasculopathic patients with SMA or IMA occlusion, in which the marginal artery is insufficient in providing an adequate blood supply . In addiIschemia may be followed by reperfusion, which is dependent on the hemodynamic support given to the patient and on the effectiveness of the anastomosis circles between IMA and SMA branches . LuckilyWith reperfusion, various grades of bowel wall injury may occur depending on the time elapsed from ischemia, which consist of vascular congestion of the bowel wall and of the mesentery following restoration of blood flow. This is related with hypoxic damage of endothelial cells and subsequent blood extravasation ,96. The The venous etiology of ischemic damage is rare and depends on the impaired blood outflow with bowel wall thickening and congestion, very similar to the reperfusion damage from which it may be distinguished by the presence of superior or inferior mesenteric vein obstruction or the presence of portal venous system congestion ,74,99.Recent evidence supports the use of dual energy CT, adopting iodine maps and low monoenergetic images to improve the evaluation of bowel wall enhancement and, particularly, to evaluate the effectiveness of the reperfusion and the related, more appropriate treatment ,103,104.2.Location and extension of the damageCT is also useful to assess the colonic involvement:A segmental involvement is usually seen in occlusive IC. This is explained by the vascular anatomy, while in the case of non-occlusive damage, no regions are spared from involvement ;Multisegmental involvement is more frequently observed than single-segment involvement;Contiguous multisegmental involvement is more frequent than skipped segments involvement;The most frequently involved segment is the descending colon, followed by sigmoid colon, right colon and the entire colon ;Isolated right colonic ischemia  has a higher frequency of surgical intervention and a higher mortality when compared with non-isolated right colonic ischemia ,15.3.Phase of the damage The phases of the damage can be acute, subacute or chronic.In the acute phase, it is important to differentiate ischemic (occlusive and non-occlusive) and reperfusion damage, whereas in the subacute phase it is crucial to monitor the status of reperfusion: the thickening of the wall and adjacent peritoneal/retroperitoneal fluid should progressively decrease with progressive restoration of the physiological wall thickness. In the chronic phase, it is possible to identify ischemic colonic stricture, due to fibrosis of the bowel wall with loss of the haustral fold.CT imaging findings are summarized in In recent years, there has been increasing use of MRI imaging for the study of bowel and gastrointestinal pathology ,111,112.Performing MRI with a 1.5 T magnet has been suggested, adopting a surface coil with T2-W multiplanar sequences, as in T2W sequences we can clearly detect the wall edema and pericolic fluid, which are the main features of ischemia with reperfusion ,53 Figu. Oral anT2W sequences allow us to detect the hyperintense signals of the bowel wall, which are mainly superficial in mild ischemic–reperfusion damage, and more pronounced and extended into the submucosal layer in more advanced stages of reperfusive damage. In addition, a variable amount of pericolic fat stranding and peritoneal/retroperitoneal free fluid may be detected ,29,113 .The IV CM is useful for evaluating the bowel wall vascularity; however, its use may be limited to selected cases and doubtful findings from T2W sequences.The main technical limits of MRI are related with patient compliance, the presence of MR-unsafe implanted devices, and machine availability. Regarding the imaging findings, it may be easier to miss pneumatosis and free air when compared with CT. However, there are also other findings  that have be considered in order to evaluate the patient’s evolution.Before technical advances in CT angiography, mesenteric angiography (MA) represented the gold standard for diagnosis and treatment. By now, due to the availability of less invasive imaging methods such as CT and MR, its role is reserved for specific therapy of stenosis/occlusion of the arterial mesenteric vessels, or the treatment of venous thrombosis.The described imaging findings of ischemic colitis are suggestive, but not pathognomonic, for the diagnosis, and so a panel of different conditions should be considered, mainly represented by infectious colitis, diverticulitis, appendicitis, typhlitis, graft-versus-host disease (GVHD), radiation colitis and inflammatory bowel diseases (IBD) ,107.To reach the correct diagnosis, emphasis should be placed on the patient’s clinical history, on the geographic distribution of the abnormalities, and on the presence of extra-intestinal findings. The patient should be asked about previous pathologies, surgeries and drugs consumption, and about the timing of onset of the acute symptoms and their characteristics.The presence of vessel findings such as arterial filling defects, aortic dissection with the involvement of mesenteric arteries, small arterial aneurism and occlusion (in the setting of vasculitides), and venous thrombosis may help in the diagnosis of ischemic bowel, as will the presence of signs of ischemic damage involving other visceral organs  (NOMI) .The clear demarcation of ischemic and non-ischemic tracts is typical of occlusive ischemic conditions , even ifTyphlitis is typically localized in the cecal area, while in acute appendicitis we may see a variable inflammatory involvement of the adjacent bowel , in radiUpon finding colonic thickening, its characteristics should be analyzed.A strong mucosal enhancement with “accordion sign” is more suggestive of pseudomembranous colitis, whereas irregularity in the mucosal layer with ulcers is suggestive for IBD; a slight mucosal hyperemia may be found in other conditions ,118. TheTherefore, diagnostic imaging may suggest the final diagnosis, however it needs to be contextualized to a multidisciplinary approach taking into account the medical history, clinical and endoscopic signs, anatomical-pathological findings, and the patient’s laboratory tests.Colonoscopy is considered the test of choice in confirming the diagnosis of IC, due to its high sensitivity. An early colonoscopy is suggested by ACG guidelines within 48 h of IC presentation, with minimal insufflations and stopping at the most distal extent of the disease . It is aAccording to the ACG clinical guidelines , IC treaIC diagnosis is strictly related to clinical suspicion/manifestation and clinical history, especially when other conditions are superimposed .More frequently, IC can presented with abdominal pain, diarrhea and hematochezia, or remain silent.Even if endoscopy is considered the diagnostic test of choice in diagnosing IC, imaging tests are usually performed before. US and XR use is limited because they yield non-specific and late findings. CT examination is the technique of choice for the noninvasive diagnosis of IC, and to make differential diagnoses between other causes of acute abdominal pain. However, it requires the use of ionizing radiation and an iodinated contrast agent, limiting the possibility of repeatedly using this technique in a short-term follow-up; in this sense, MRI may be useful.


Angiosarcomas are aggressive neoplasms that arise from endothelial cells and can develop in any part of the body. Gastrointestinal angiosarcomas are very uncommon and can have a variable clinical presentation. We report a case of an 84-year-old female who presented with acute blood loss anemia. She underwent a gastrointestinal workup with esophagogastroduodenoscopy (EGD), which revealed two polyps in the stomach. Histologic evaluation of the polyps was indicative of angiosarcoma, and the diagnosis was eventually confirmed by immunohistochemical analysis with positive CD31, ERG, and FLI1 stains. This case is reported to demonstrate the importance of considering angiosarcoma in the differential for patients presenting with gastrointestinal bleeding. Angiosarcoma is a form of malignant tumor that arises from the endothelium of blood vessels. These tumors can occur in various sites in the body and can present with a variety of clinical pictures depending on their location. They are incredibly aggressive, can metastasize early, and have a poor prognosis, especially if they are diagnosed late in the course of the disease. Because angiosarcomas are rare overall and are even more uncommon in the gastrointestinal tract, they are often overlooked in the differential diagnosis of gastrointestinal tumors. The main risk factor for the development of angiosarcomas appears to be radiation. With radiation being used increasingly more over the last decades, it is reasonable to expect a rise in the incidence of angiosarcomas in the near future. Moreover, with the disease being so infrequently encountered, the diagnosis can be easily missed, leading to poor outcomes . We presAn 84-year-old Caucasian female presented with an acute drop in hemoglobin from 7.9 g/dL to 6.9 g/dL, noted during a routine laboratory investigation. The patient's baseline hemoglobin was 8-10 g/dL. On presentation, the patient endorsed fatigue, lasting about three months, as well as shortness of breath on exertion. The patient denied fever, chills, night sweats, unintentional weight loss, abdominal pain, nausea, vomiting, diarrhea, constipation, hematochezia, hematemesis, or hemoptysis. Two years prior, she was diagnosed with iron deficiency anemia and was managed with iron supplements by her hematologist. At that time, she also underwent a workup to rule out a gastrointestinal bleed with EGD and colonoscopy, which revealed mild chronic reactive gastritis with erosions and grade II internal hemorrhoids. Her past medical history also included atrial fibrillation, gastroesophageal reflux disease, essential hypertension, hyperlipidemia, a cerebral vascular accident, and vascular dementia. Surgical history was negative for any gastrointestinal procedures. Her medications included rivaroxaban, omeprazole, metoprolol, and atorvastatin. She had never smoked cigarettes and drank alcohol socially. There was no history of any gastrointestinal malignancies, inflammatory bowel diseases, or other gastrointestinal illnesses in the family.In the emergency department, her blood pressure was 117/66 mmHg, heart rate 75 beats per minute, temperature 37 °C, respiratory rate 20 breaths per minute, and oxygen saturation 95% on room air. On physical examination, the patient appeared pale but was not in acute distress. The abdominal exam revealed a soft, non-distended, non-tender abdomen with no palpable masses. The rectal exam was positive for melenic stool. A complete blood count revealed hemoglobin of 6.6 g/dL , hematocrit of 21.3% , and mean corpuscular volume of 104.7 fL . A peripheral blood smear reported macrocytic anemia with mild anisocytosis and polychromasia. The vitamin B12 level was 976 pg/mL  and the folate level was 23.3 mg/mL . Other laboratory findings, including white blood cell count, platelets, electrolytes, blood urea nitrogen, creatinine, and liver function tests, were all within normal ranges. The patient underwent a blood transfusion with one unit of packed red blood cells. She received a bolus of intravenous pantoprazole, followed by an infusion of the same. Her home medication of rivaroxaban was held on admission. The following day, her hemoglobin and hematocrit improved to 9.2 g/dL and 26%, respectively. The patient did not have any bowel movements. An EGD was performed and revealed a large oozing hemorrhagic polyp in the pyloric channel and a second similar, smaller polyp in the fundus (Figure Pathology reported two dark red polyps measuring 0.7 cm and 1.2 cm in their greatest dimension. Histologic analysis of the polyps showed that the tumors consisted of moderately atypical, large epithelioid cells with ovoid vesicular nuclei and prominent nucleoli. The neoplasm was associated with extensive hemorrhage and high mitotic activity Figure , ERG, an   Angiosarcomas are a rare form of malignant connective tissue neoplasms that arise from the endothelial cells of blood vessels. These tumors are known for their rapid proliferation, aggressive infiltration, hematogenous metastasis, and relatively poor prognosis with low life expectancy. Depending on the primary lesion site, they can metastasize to various organs in the body, including, but not limited, to lymph nodes, liver, lungs, and brain . The meaStudies have shown that radiation, especially when it leads to subsequent lymphedema, known as Stewart-Treves syndrome, can lead to the development of angiosarcomas. Moreover, environmental factors such as exposure to arsenic or vinyl chloride, as well as genetic syndromes such as xeroderma pigmentosa, bilateral retinoblastoma, and von Recklinghausen neurofibromatosis are also known to be significant risk factors ,5.Angiosarcomas can present in various ways depending on their primary location. All lesions, however, are prone to ulceration and bleeding, which is especially important in patients with intestinal angiosarcomas whose only presenting symptom may be anemia. Other reported symptoms with intestinal involvement may include generalized abdominal pain or discomfort, nausea, vomiting, diarrhea, or symptoms suggestive of luminal obstruction in cases of rapid cellular growth .Imaging studies such as computed tomography and magnetic resonance imaging can reveal and localize lesions in the GI tract. Other forms of imaging studies, such as positron-emission tomography, are useful for disease staging; however, they lack the ability to differentiate between different types of tumors . The onlHistologically, angiosarcoma may range from a presentation of vascular proliferation in less malignant forms to an undifferentiated tumor in malignant cases. It is characterized by spindled, polygonal, or epithelioid cells with nuclear division and pathological mitotic figures ,5. The pThe primary treatment modality of angiosarcoma is surgical clean-margin excision, which in some cases can be curative. Radiotherapy is often used as adjuvant treatment, even when margins are clean, to decrease recurrence. It may be used as the main management option in non-resectable tumors . Of noteThe prognosis for patients diagnosed with angiosarcoma is very poor, and it is determined by a number of factors. Different studies have shown that the overall survival at five years since diagnosis is estimated to be 31%-43%, with a median survival time of approximately 16-42 months . The lifThis case is presented to raise awareness of angiosarcoma as a possible source of gastrointestinal bleeding. Our patient lacked any obvious risk factors for angiosarcoma, and thus without relevant immunohistochemical staining, her lesion could have been interpreted as Kaposi sarcoma, leiomyoma, gastrointestinal stromal tumor, or a Dieulafoy's lesion. Such misdiagnoses have been reported in the past, which can be explained by the fact that gastrointestinal angiosarcomas can present with various macroscopic morphologies such as ulcers, submucosal nodules, or hemorrhagic lesions. A delay in diagnosis could lead to potentially preventable recurrence and metastasis of the tumor, which can have catastrophic consequences for the patient. We believe it is essential to consider angiosarcoma as part of the differential of gastrointestinal bleeding. Additionally, screening for risk factors for angiosarcoma can help to expedite the diagnostic process leading to improved prognosis and outcomes for the patients.


Pyogenic granuloma is a common, benign, vascular growth that often appears as a rapidly growing mass on mucus membrane-lined surfaces such as the conjunctiva. Conjunctival pyogenic granulomas are common following trauma, burst chalazion or ill-fitting prosthesis. Also known as 'lobular capillary hemangiomas', these lesions typically appear bright red, fleshy and pedunculated. Treatment options include excision, topical steroid therapy and topical beta-blocker therapy. In this communication, the authors describe a rapidly enlarging, pedunculated black coloured conjunctival mass lesion in a 44-year-old woman, who had a recent history of chalazia. Given the location and the clinical appearance, a melanocytic tumour was suspected and the mass was excised. Histopathology and immunohistochemical studies confirmed the diagnosis to be consistent with that of a a necrotic pyogenic granuloma. Pigmented lesions of the conjunctiva, especially rapidly enlarging ones, need to be viewed with a high degree of suspicion to rule out malignant melanoma. Rarely though, benign lesions such as pyogenic granulomas that undergo necrosis may masquerade as conjunctival melanomas. Pyogenic granuloma is a benign, acquired, vascular lesion commonly seen on the conjunctiva. The term ‘pyogenic granuloma’ is a misnomer, as it typically is not associated with pus formation. Also known as ‘lobular capillary hemangiomas’ (LCHs), these lesions are commonly observed on the palpebral or bulbar conjunctiva following surgery, burst chalazion or even trivial trauma. Treatment options include excision, topical steroid therapy, intra-lesional steroid injection and topical beta-blocker therapy. Classically, conjunctival LCHs present as vascular, bright red, lobular masses . In someA 44-year-old female presented with a pigmented dark mass lesion in the lower forniceal conjunctiva of the left eye. She had noticed it three days prior to presentation and had been referred to the ophthalmology clinic by her general practitioner to rule out conjunctival melanoma. On examination, the mass appeared smooth and had a glistening deeply pigmented surface with a small stalk attached to the conjunctival surface. Localised conjunctival hyperaemia was observed Figure . There wThe differential diagnoses for LCHs of the conjunctiva include suture granuloma, squamous papilloma, squamous-cell carcinoma and amelanotic melanoma . In addiCharles and Kahn reported the case of a healthy 34-year-old white man who presented with a 10-day history of an enlarging brown mass of the left lower eyelid, along with mild discharge, bloody tears, oedema and erythema . ExaminaTypically a pyogenic granuloma of the conjunctival surface may be treated conservatively: topical steroid therapy or topical timolol therapy. However, in this case, it was the atypical clinical appearance and the recent history of increase in size that prompted a surgical intervention. Conjunctival melanomas arising from the nonbulbar  conjunctiva are associated with a cumulative mortality rate of 43.6%  at 10 years of follow-up [Melanocytic lesions of the conjunctiva span across a wide spectrum of clinical conditions ranging from benign lesions such as conjunctival nevus or primary acquired melanosis (PAM) without atypia; to pre-malignant conditions such as PAM with atypia; as well as frankly malignant conditions such as conjunctival melanoma and pigmented variants of conjunctival squamous cell carcinoma. Therefore, pigmented lesions of the conjunctiva, especially rapidly enlarging ones, need to be viewed with a high degree of suspicion to rule out malignant melanoma. Rarely though, benign lesions such as pyogenic granulomas that undergo necrosis may masquerade as conjunctival melanomas.


Oral cancer is a common site of cancer worldwide with oral squamous cell carcinoma (OSCC) comprising the major segment. The risk factors include tobacco and alcohol abuse, betel quid, and areca nut consumption. Warthin tumour (WT), also known as papillary cystadenoma lymphomatosum is a benign tumour of the salivary gland. It is one of the most common benign parotid neoplasms with cigarette smoking and radiation exposure as possible cited etiologic factors. Rarely, two or more histologically distinct neoplasms may occur synchronously. The synchronous occurrence of OSCC and WT is infrequent.The aim of this case series is to report the incidence rate of synchronous OSCC and WT in our centre between 2010 and 2019 and their socio-demographic, clinical, histopathological features, management, and prognosis and discuss the relevant literature. Out of 143 OSCC cases reported in our centre from the year 2010 to 2019, two had synchronous OSCC and WT with an incidence rate of 1.4%. These two cases occurred in a 63-year-old female and a 68-year-old male both with smoking habits. One OSCC was present in the left buccal mucosa and the other in the right ventral surface of the tongue, whereas the WT in both cases occurred in the tail of the parotid. One patient had a recurrence and died while the other is under follow-up without any recurrence.These unusual findings of synchronous occurrence of WT at a distant site from the primary tumour may mimic a malignant disease, more likely a metastasis from the primary OSCC, which could further complicate the management of these patients. Therefore, radiologists, head and neck surgeons, and pathologists should be aware of the occurrence of these unusual presentations to avoid overtreatment in such cases. Oral cancer including the cancer of the oropharynx is ranked the sixth most common cancer worldwide . ApproxiCase 1A 63-year-old woman presented to the Oral and Maxillofacial Surgery Clinic in June 2015 for a growth on the left buccal mucosa involving the skin of the left cheek for two months duration. Intraoral examination revealed a fungating growth with an irregular surface and necrotic centre of 4cm x 4cm extending superiorly to left retromolar region and posteriorly to the pterygomandibular area. Mild tenderness and no discharge were observed upon palpation. Extraorally, left cheek area presented with a firm swelling accompanied by an erythematous punctum-like centre. Medical history was not contributory. She was a heavy smoker since young age.Wide excision of the tumour together with left partial maxillectomy and stripping of the left mandibular periosteum and left modified radical neck dissection Type II was carried out. The defect was reconstructed using Gracillis flap. A separate specimen labelled as lower pole of left parotid gland was also submitted together with main surgical excisional specimen.Histopathology of the surgical specimen showed moderately differentiated OSCC of the left buccal mucosa  by the oncologist. However, she passed away in January 2016 due to complications from chemotherapy. Case 2A 69-year-old man presented to the Oral and Maxillofacial Surgery Clinic in December 2014 for a non-healing ulcer on right lateral border of the tongue. The ulcer was first noted two years ago and gradually increased in size. He had no known medical illness. He was a heavy smoker for about 40 years. Intraoral examination revealed an irregular ulcer measuring 2cm x 2cm with rolled margin extending from the right lateral border of the tongue to the floor of the mouth. An incisional biopsy and subsequent histopathological examination confirmed the diagnosis of a moderately differentiated OSCC.A right partial glossectomy, together with right selective neck dissection of levels I to III with attached submandibular gland and parotid tail was performed. Histopathology of the surgical specimen showed moderately differentiated OSCC . The majority of the WTs arise almost exclusively in the parotid gland . It has On the other hand, OSCC is an aggressive tumour and its prognosis has not demonstrated any significant improvement over the last three decades. A clear dose-response relationship between the use of tobacco and the risk of oral cancer has been demonstrated in several epidemiological studies . OSCC isWT may present either as synchronous or metachronous tumours and as unicentric or multicentric lesions. Synchronous occurrence of WT in the cervical and peri parotid lymph nodes with oral or laryngeal squamous cell carcinoma has been reported. WT may also occur synchronously with other neoplasms . ShikhanTo date, there have been only nine cases that have been reported as the synchronous occurrence of WT with OSCC Table  11, 13--13-20. OWT is also significantly associated with smoking. In a retrospective analysis of 96 patients with WT, 79% had a history of smoking. . Most ofA common site for the occurrence of OSCC is ventral or posterolateral surfaces of the tongue. However, OSCC with synchronous WT has been reported in various sites such as bucco-gingival complex ,13, loweThe synchronous occurrence of WT either in the cervical lymph nodes -16,18-20All the cases of OSCC with synchronous WT that were previously reported were treated surgically with some form of neck dissection. In view of the possibility of the presence of synchronous tumours, it is crucial to investigate the presence of other tumours during patient examination and initial investigation. Synchronous occurrence of WT may lead to false positive diagnosis of metastatic disease clinically or by imaging, which may lead to overtreatment of patients with OSCC. The staging of these cases is given in Table In conclusion, these unusual findings of synchronous occurrence of WT at a distant site from the primary tumour may mimic a malignant disease more likely a metastasis from the primary OSCC, which could further complicate the management of these patients. Therefore, radiologists, head and neck surgeons, and pathologists should be aware of the occurrence of these unusual presentations to avoid overtreatment in such cases.


Low-grade endometrial stromal sarcoma is a rare neoplastic growth in the uterine cavity, representing less than 1% of uterine tumors. Such tumors usually affect premenopausal and perimenopausal women, with a mean age of 46 years. Treatment generally starts with surgical resection of the tumor, followed by chemotherapy, radiotherapy, or hormonal therapy.In the current report, we again present a case of low-grade endometrial stromal sarcoma in a 51-year-old Mediterranean woman presenting with abdominopelvic pain. Computed tomography scan revealed a primary uterine tumor measuring 17 × 9 × 9 cm metastasizing to the lungs, bladder, and ureteral orifice, along with lymphovascular involvement. The patient underwent total abdominal hysterectomy, omentectomy, and lymph node dissection. Estrogen deprivation was accomplished by bilateral salpingo-oophorectomy. Lifelong hormonal therapy consisting of letrozole 2.5 mg per day was prescribed, which demonstrated remarkable efficacy, resulting in a partial remission of lung metastasis within 8 months after surgery. Full remission was observed after 18 months of hormonal therapy, with no recurrence. Another scan was performed after 2.5 years, revealing complete remission with no recurrence.We again report a case of complete remission of low-grade endometrial stromal sarcoma after surgical removal of the tumor along with first-line hormonal therapy without the use of chemotherapy or radiotherapy, emphasizing the role of hormonal therapy in the treatment of such tumors. Endometrial stromal sarcoma (ESS) is a rare neoplastic growth originating from the mesenchymal elements of the endometrium . It usuaA 51-year-old married Mediterranean woman with a nonsignificant past medical history presented to our center through the outpatient clinic, complaining of menorrhagia and abdominal pain for the past 2 weeks. The pain was radiating to the back and was associated with loss of appetite and stress incontinence. The patient reported no episodes of dysmenorrhea. She had no remarkable surgical history prior to her current symptoms and no family history of malignancies. The physical examination revealed no significant findings. Ultrasonography revealed multiple uterine masses and polyps along with an enlarged uterus and thin endometrial lining.Basic laboratory investigations were performed and all were within the normal range except for complete blood count, which indicated microcytic hypochromic anemia. She was suspected of having uterine fibroids. Accordingly, hysteroscopy along with dilation and curettage (D&C) was performed. Operative findings included a 22-week-sized uterus that was deviated to the left side. In addition, cystocele and rectocele were noted, both assessed as grade II. Hysteroscopy findings included multiple uterine fibroids and polyps. Endometrial biopsy revealed infarcted endometrial polyps. Plasma tumor markers were evaluated to rule out any possible malignancies. Results indicated high levels of lactate dehydrogenase LDH: 441 U/L), alpha-fetoprotein (AFP: 1.9 ng/mL), and CA-125 (106.8 U/mL), along with normal values for beta-human chorionic gonadotropin (β-hCG), cancer antigen (CA) 15-3, CA 19-9, and carcinoembryonic antigen (CEA). Abdominal and pelvic computed tomography (CT) scan showed an irregular hypodense lesion in the uterus containing an area of necrosis measuring 17 × 9 × 9 cm, suggesting a primary uterine tumor  stent insertion was performed. The operative findings included a mass around the right ureteral orifice with multiple varicosities and neovascularization around and in the bladder, respectively. Microscopic examination of bladder biopsy showed fragments of urothelial mucosa infiltrated by nodules of small monotonous round cell tumor. The tumor cells were immunoreactive against CD10 and ER but negative for keratin 20 (CK20), CD34, cyclin D1, and SMA. The results were consistent with the diagnosis of ESS. Chest CT scan showed a left lower lobe nodule peripherally mostly representing a malignant deposit (Fig. Hormonal therapy with letrozole 2.5 mg daily was initiated. The patient was then discharged with a 10-day course of clindamycin and lifelong enoxaparin treatment. She was followed up in the outpatient clinic with right DJ stent exchange every 3 months. Partial remission of lung metastasis was achieved after 8 months of hormonal therapy, which was confirmed by a clean CT image (Fig. ESS is an extremely rare uterine malignancy, constituting 0.2% of all genital tract neoplasms, with an incidence of 2 per million women worldwide . Such utClinical presentation of ESS varies according to the affected area, but patients commonly complain of abdominal pain, vaginal bleeding, vomiting, diarrhea, constipation, hematuria, and increased urinary frequency and urgency with incontinence . The patTreatment for ESS starts with surgical removal of the neoplasm and the associated invaded tissues . Since tet al. reported long-term survival of a 28-year-old patient with metastatic ESS treated with goserelin and anastrozole after surgical intervention [et al. described total response in two women with ESS and lung metastasis after surgical removal of the tumor followed by treatment with aminoglutethimide, an aromatase inhibitor [et al. described outstanding response to letrozole in a 76-year-old patient with a huge pelvic mass accompanied by post-renal kidney failure [et al. reported that anastrozole improved prognosis in a case of recurrent low-grade ESS in a 34-year-old woman [et al., which highlights the importance of regular follow-ups [Our patient complained of abdominal pain and menorrhagia, which are typical presentations for ESS, and since she was in her early 50s, she was prone to such neoplastic growth . What isnhibitor . Leunen  failure . Hormonald woman . Hormonald woman . Despitellow-ups .We report yet another case of complete neoplastic remission of low-grade ESS with extensive metastasis to the lungs, bladder, and ureter along with lymphovascular involvement after surgical and hormonal therapy, in hopes of expanding the knowledge about such rare neoplasms.In the current case, we reported a 51-year-old woman diagnosed with low-grade ESS, where the neoplasm had started as a primary uterine tumor measuring 17 × 9 × 9 cm and had metastasized to the bladder, ureteral orifice, and external and internal iliac lymph nodes. Malignant depositions were also observed in the lung. The patient achieve total remission of the neoplasm, which suggests an excellent synergistic effect between surgical intervention and hormonal therapy that includes letrozole 2.5 mg per day. Further studies and trials are needed to establish a protocol for treatment of such tumors.


The thymus is the last organ in the human body to have its mechanisms fully understood. Its intrinsic complex morpho-functional structure reflects the complexity and variety of the pathological lesions of the gland. These include some variants of neoplastic and nonneoplastic processes, which are considered the rarest of the rare ones. The aim of this work is to describe the rarest lesions of the thymus in a large case series in order to update the epidemiology, to improve diagnostic awareness, and finally to promote a collaborative network between referral centers.The thymus is a specialized primary lymphoid organ located in the midline pre-vascular mediastinum. The organ is the site of various pathological processes, neoplastic and not, whose rarity has not allowed in-depth studies on clinical or histological features of rarest and unusual variants. Herein, we report a 10-year Padova experience in the surgical pathology of the thymus, focusing on the pathological description of nonneoplastic lesions and rare epithelial and mesenchymal tumors recorded in our database, which comprises over 600 thymectomies. The extrapolated rare cases have been categorized into four groups that included 15 cysts, 18 carcinomas, 5 neuroendocrine tumors, and 2 soft tissue tumors. The cases are described from a clinical and pathological point of view and discussed in dedicated sections with a review of the most important literature. In this case, review series, we aim to update the epidemiology of these rare entities, improve diagnostic awareness, and finally, promote a collaborative network between referral centers. In 2014, a network named “TYME”  was founded in Italy with the aim of improving care and research in thymic tumors. Since 2021, this network has been enriched with a scientific regulation document, a steering committee, and two working groups for research and registry, all of them including referral members of the thoracic oncology team placed in Padova.The thymus is a specialized primary lymphoid organ located in the midline anterosuperior mediastinum, essential for the maturation of T lymphocytes, which orchestrate adaptive immune responses . The pecThe improved knowledge of thymic pathology has been followed by the development of new surgical procedures. Historically, the gold-standard technique for thymectomy has been the transsternal approach, which ensures optimal exposure and availability of the complete dissection of the thymus and mediastinal fatty tissue . Less-inAll thymectomy cases in our center over the last decade (January 2011–December 2020) were reviewed, and the specimens were updated according to the recent World Health Organization [A total of 616 thymectomies were performed in our center over the last 10 years . After cThe main demographics and histopathological features of the patients with thymic cysts are listed in The main clinical and histopathological features of patients with TC are listed in The main clinical and histopathological features of the patients with TNET are listed in A 69-year-old female presented with ocular myasthenia, and otherwise, her medical history was unremarkable. The chest computed tomography (CT) scan showed a rounded mass of 1.5 cm in the prevascular mediastinum, compatible with thymoma. The patient underwent robotic thymectomy. Grossly, the nodule was well-circumscribed with a reddish-brown, spongy/honeycombed cut surface. Histology revealed dilated and thin-walled vessels lined by a single layer of flat endothelial cells. Vascular spaces were separated by fibrous septa containing small vessels . No cytoA 40-year-old man underwent radiological examinations for a persistent cough. Chest CT showed two masses of the right upper lobe and prevascular mediastinum. Transbronchial biopsy showed a poorly differentiated spindle cell neoplasm with immunohistochemical expression of CD56 and a high proliferative index (Ki67: 80%). The differential diagnoses included a neuroendocrine and mesenchymal neoplasm. The patient underwent lobectomy and thymectomy. The thymus was almost entirely replaced by a lipomatous neoplasm with nodular areas of increased consistency . The lunThymic cysts were first described in 1850  and reprCRTC1–MAML2 gene fusion may be found in thymic mucoepidermoid carcinoma, although less frequently than in salivary gland mucoepidermoid carcinomas [TCs are rare neoplasms with an incidence of 0.07–0.38/100,000/year . They marcinomas . When itPrimary neuroendocrine tumors of the thymus are rare, accounting for less than 5% of all mediastinal masses  and for 2, no necrosis), atypical carcinoid , large cell neuroendocrine carcinoma , and small cell carcinoma  [Neuroendocrine neoplasms of the thymus are classified in the same way as neuroendocrine neoplasms of the lung, recognizing four groups with different prognostic significance based on mitotic count, necrosis, and morphological findings: typical carcinoid  ,58. Howes/2 mm2) ,59. Alths/2 mm2) . Similars/2 mm2) . A debats/2 mm2) ,62,63, ws/2 mm2)  that excHMGA2 gene on chromosome 12q15 was detected, supporting the theory that thymolipoma is a neoplasm of thymic fat [The mediastinum can be the site of virtually any soft tissue tumor. However, the preferential thymic localization is very rare and is a characteristic of only a selected category of histotypes. The most frequent mesenchymal tumor of the thymus is thymolipoma, an encapsulated tumor composed of mature adipose tissue with interspersed nonneoplastic thymic tissue. It accounts for 2–9% of all thymic neoplasms and may occur at any age without sex predominance ,66. Its ymic fat . The malymic fat , liposarymic fat . In rareymic fat ,71, simiymic fat . The othymic fat . In the ymic fat  in whichymic fat , lymphanymic fat ,76, angiymic fat , ganglioymic fat , and neuymic fat  or with ymic fat ,81,82.The pathology of the thymus is a fascinating field of research. The rarity of the thymic lesions did not allow us to thoroughly study the epidemiological aspects, clinical characteristics, or biological behavior of some of these rare neoplasms, such as those described in this paper. Reporting a detailed description of these cases is extremely important to update the epidemiology of these rare lesions, to improve diagnostic awareness, and above all, to promote a collaborative network between referral centers.


This article describes an unusual clinical-radiographic presentation of a lateral periodontal cyst, as a differential diagnosis of a residual cyst, following the ‘CARE guidelines for case reports’. The radiolucent lesion was identified on the imaging exam of a 53-year-old male patient. Based on radiographic findings and aspiration puncture, the probable diagnosis was a residual cyst; however, histological analysis revealed a thin, non-inflamed fibrous capsule covered by some epithelial layers in most of the lesion. The definitive diagnosis was a lateral periodontal cyst with unusual clinical and radiographic features. The cyst was surgically enucleated and local bone neoformation was observed, with no signs of recurrence after 12 months. The results of this study suggest that a radiolucent lesion, suggestive of a residual cyst or keratocyst in the maxilla, may correspond to a lateral periodontal cyst. In this context, the histopathological analysis of the cyst is essential for the definitive diagnosis. Key words:Cysts, odontogenic cysts, periapical cysts, periodontal cysts. The lateral periodontal cyst (LPC) is an uncommon entity, representing 0,4% to 0,7% of all oral and maxillofacial cysts and 0,6% to 2% of the odontogenic cysts -6. It isIn very rare instances LPC can mimic the clinical and radiological features of residual cysts, turning differential diagnosis a challenging issue. In these specific cases, LPC is usually not considered in differential diagnosis . So, theA 53 year old male was referred for evaluation of an asymptomatic radiolucent image observed in the right maxilla during routine dental treatment planning. Clinical examination showed that the area was covered by normal mucosa and that there was a slight asymptomatic swelling in the buccal cortical plate in the edentulous area of upper right premolars. The patient reported that the upper right canine, premolars and molars were extracted approximately 10 years before and a partial removable appliance was placed. Panoramic and periapical radiographs showed a 1,0 cm well-defined round unilocular radiolucency in the edentulous premolar area, in close association with the superficial cortical bone Fig. a. The raAfter oral antisepsis with 15 ml of 0.12 % chlorhexidine digluconate  for one minute, the local anesthesia with vasoconstrictor  was performed, followed by aspiration puncture with a disposable 18G needle , that revealed a slightly yellowish liquid content. Due to the buccal expansion, a modified Wasmund incision  was performed for surgical access to the lesion. Ostectomy for access and enucleation of the whole lesion was performed with Fedi chisels and surgical detachers , respectively. The capsule was completely removed, and the pathological bone cavity was curetted under abundant irrigation with sterile 0.9 % sodium chloride solution for injection . The primary closure of the mucoperiosteal flap was performed with a single interrupted suture using 4-0 non-resorbable mononylon-ethylon suture .The surgical specimen was immersed in 10% buffered formaldehyde and submitted to conventional histological processing in the Oral Pathology Laboratory, Dental School, Rio de Janeiro State University, Rio de Janeiro-RJ, Brazil. Hematoxylin and eosin-stained five micrometers sections were analyzed under light microscopy and histological features revealed a cystic cavity lined by a thin stratified squamous epithelium showing focal areas of epithelial thickening and clear cells Fig. . The adjPost-operatory period was uneventful and sutures were removed after 7 days. The patient was scheduled for periodic follow-up and a cone-beam computed tomography scan taken 6 months after the surgery showed an area of bone neoformation Fig. . The patLPC is an uncommon developmental odontogenic cyst, comprising less than 2% of all odontogenic cysts ,3-5. Wheet al. (et al. (et al. (In very rare situations, LPC can mimic the clinical and radiological features of a residual cyst, presenting as a well-defined unilocular radiolucency in an edentulous area. In these cases, alveolar bone resorption during a long period after dental extractions can cause reduction of the height of the alveolar bone and proximity of the cyst to the oral mucosal surface, as shown by the present case. Mendes & van der Waal  have repet al.  have rep (et al.  have rep (et al.  reported (et al. ,9.Histological analysis is the gold standard for the diagnosis of LPC and this cyst is characterized by an epithelial lining showing focal thickenings and clear cells. The most frequent radiological differential diagnosis for LPC, lateral periapical cyst and odontogenic keratocyst, show different histological characteristics and can be quite easily excluded from a microscopic perspective ,11,15. GIn conclusion, it is important for clinicians and oral surgeons to be aware of the typical and not typical clinical and radiological features associated with LPC. Although it is usually characterized as a unilocular radiolucency between the roots of erupted teeth, some rare cases, as the one included in the present report, can mimic the radiological aspects of residual cysts and should be included in their differential diagnosis.


To retrospectively investigate the grey-scale, Doppler, contrast-enhanced and microvascular ultrasound of five patients with primary testicular lymphoma of our institute through review literature analysis.From January to November 2020, five patients with primary testicular lymphoma confirmed by histology were preoperatively investigated with a standardized sonographic protocol including contrast-enhanced and microvascular ultrasound.Conventional ultrasound showed localized hypoechogenicity represented with solitary (2 of 5), multiple lesions (2 of 5), or entire testicular involvement (1 of 5). Increased blood flow appeared in color Doppler ultrasound with straight vascular sign (4 of 5). In contrast-enhanced ultrasound images confirmed this pattern (4 of 5) and presented hyper enhancement with enlarged range. On microvascular ultrasound imagings, all lesions were presented with straight and parallel course of intralesional vessels (5 of 5).Here, we identified an increased vascularity with enlarged range on contrast-enhanced ultrasound along with a linear nonbranching pattern by vascular sign on microvascular ultrasonographic of testicular lymphoma. Primary testicular lymphoma (PTL) is a malignant tumor occurs in an immune-privileged site , which iIf there was a history of testicular swelling or clinical evidence of testicular mass or enlargement, ultrasonography (US) was recommended. For PTL lesions, conventional US presented a specific appearance with focal and diffuse hypoechoic like a ‘moon on the water’ . HoweverMicrovascular ultrasound, a latest development of color Doppler technology, is a non-invasive microvascular imaging technique using low flow Doppler signal processing . Slow anThe researchers retrospectively analyzed images of patients with testicular tumors who underwent conventional US, CDFI, CEUS and microvascular ultrasound in the department of ultrasound and urology of the First Affiliated Hospital of Nanjing Medical University between January to November 2020. The study was approved by the Ethics Committee of the First Affiliated Hospital of Nanjing Medical University  and performed according to the Helsinki Declaration. Informed consent was waived. All the participants gave their informed consent for the publication of their images in an online open-access publication. The enrolled clinical information and laboratory data such as clinical history, tumor side, swelling or pain were also recorded in detail. According to the immunohistochemical results, confirmed diagnosis of PTL cases and the corresponding images were enrolled.Two doctors with more than 10 years' experience (L.Y. and Y.T.) in testicular US performed the examinations included in this study. Gray-scale US, CDFI and CEUS were performed using a real-time US device  equipped with a 6–15 MHz linear array transducer. Microvascular US image was collected using a real-time US device  equipped with a 4–15 MHz linear array transducer. CEUS examinations were also performed by the same transducer at a low mechanical index (0.08), focus positioned behind the region of interest after the injection of 2.4 mL of the sulfur hexafluoride contrast agent SonoVue , followed by 10 mL of 0.9% saline. When the microvascular US was activated, the transducer was placed on the surface of scrotum without compression or movement.The doctors examined the conventional US images first and focused on homogeneity, size, echogenicity , boundary, margin, extent of infiltration, calcification and presence of the formerly described “straight vessel ” or “linCEUS was performed on the lesions including normal testicular tissue and at least more than 50% of the tumor area. During the CEUS examination, probe was placed on the skin surface of scrotum without movement, and the dynamic images were observed more than 2 min after SonoVue injection. The CEUS evaluation was analyzed by two doctors with more than 10 years working experience in CEUS (L.Y. and H.J.). Size change was compared to the same section in grey-scale US at peak time in CEUS. Time-intensity curve (TIC) analysis was performed for evidence of the degree of overall enhancement (microperfusion) within the target lesions. And peak intensity (PI), time to peak (TTP), and rise time of tumor and surrounding normal testicular tissue were recorded. According to TIC results, we classified increased, decreased, or similar enhancement patterns of the mass . Boundary (clear or unclear), size change and homogeneity were also assessed. Furthermore, we also focused on the presence of formerly described “linear nonbranching ” patternThe microvascular US was assessed for evidence of the degree of overall enhancement (microperfusion) within the target lesions, which was characterized as increased, decreased, or similar to normal parenchyma, and the macrovascular pattern was described as linear nonbranching or random similar to CEUS.The enrolled five cases were confirmed by immunohistochemical pathological results. All specimens were fixed with 3.7% neutral formaldehyde solution, routinely dehydrated, embedded in paraffin, 3um thick sections, HE and immunohistochemical staining. Immunohistochemical staining: En Vision two-step method was used, and negative and positive controls were also set up. All primary antibodies  were purchased from Fuzhou Maixin Biotechnology Co., Ltd., and TBS was used as negative control instead of primary antibody.We reviewed and analyzed the clinical and US data of 18 patients with testicular mass in this study. According to pathological immunohistochemistry results, images of 6 patients with PTL were selected. One case was excluded because of incomplete imaging data. Finally, US and CEUS images of 5 patients were included. The baseline clinical characteristics of the enrolled cases were shown in Table In gray-scale US images, all the enrolled patients showed irregular solid hypoechoic testicular lesions without calcification or cystic degeneration. Four lesions were located in testis and one lesion involved extra-testicular, including ipsilateral epididymal head and spermatic cord. Straight vessel pattern were showed in 4 of 5 Figs. , 3 and 4According to TIC analysis, five PTL lesions showed hyper enhancement pattern in CEUS Figs. , 3 and 4Grossly, the resected testicular lesions showed white or brown solid masses on the section, with size ranging from 3 to 6 cm. Histopathologically, the tumor had a diffuse growth pattern, mainly involving interstitial tissue, surrounded by atrophic seminiferous tubules. The tumor cells of PTL showed an obvious vascular centrality and vascular invasive growth pattern. In one case, invasion of epididymis and spermatic cord was found. All the five cases were diagnosed by immunohistochemical examination. One case was extra-nodal NK/T cell lymphoma (EBER+), and the other four cases were DLBCL .PTL is a rare malignant hematological tumor, and its treatment is different from other testicular tumors . In thisSo far, there had seven reports about CEUS features of PTL , 25–27, The pathological changes of PTL were different from other testicular tumors. It was characterized by tumor cells surrounding and compressing seminiferous tubules and normal testicular vessels, involving interstitial tissue . This paCEUS improved the characteristics of testicular lesions and could evaluate the microvascular information in detail . Tenuta Our report was the first attempt to investigate the advanced US technique of microvascular image in PTL. As a noninvasive technique, microvascular imaging can detect slow and fine vascular flow, even the hepatic subcapsular . As a maPTL is a kind of testicular malignant tumor with poor prognosis, while lacking an early non-invasive diagnosis. In this report, the CEUS images of PTL showed a hyper enhancement with enlarged range and unclear boundary along with a linear nonbranching pattern of vascular sign on microvascular US image. Combined with straight vascular signs on grey-scale US and painless testicular mass of physical examination, it can provide some help for early non-invasive diagnosis of PTL.


A 36-year-old male was critically unwell with acute central abdominal pain and distension. CT demonstrated severe pneumoperitoneum leading to compression and total occlusion of the inferior vena cava and occlusion of the aorta. At laparotomy, a perforated posterior gastric ulcer was found with four quadrant contamination. A damage control procedure was performed and a re-look laparotomy was carried out 2 days later where bowel ischaemia was found. Despite being supported on the intensive care unit, unfortunately the patient died. Tension pneumoperitoneum leading to occlusion of the aorta is very rare and the severity of this condition should be recognised; it has never been survived in the reported literature. Rapid assessment and investigation is essential to ensure the timely treatment of this disease. Examination revealed a peritonitic abdomen and loss of femoral pulses bilaterally.A 36-year-old male was admitted to the emergency department critically unwell with a distended abdomen and central abdominal pain for the preceding 3 h. His blood pressure on admission was 136/77 mmHg and his lactate was raised at 14 mmol lThe differential diagnosis prior to imaging included pneumoperitoneum secondary to gastric or bowel perforation. Vascular compromise including type B aortic dissection or type A aortic dissection with extension was also considered due to the lack of femoral pulses. Imaging with CT was promptly requested and performed due to the diagnostic uncertainty.Arterial and portal venous phase CT of the abdomen and pelvis extending to the mid-thigh was performed. The scans demonstrated extensive free fluid within the abdomen and severe pneumoperitoneum leading to compression of the inferior vena cava (IVC) and the aorta. There was a short segment aortic occlusion at the level of the L4 superior endplate . There wThe normal blood pressure on presentation, acute (3 h) onset of abdominal pain and rapid clinical deterioration coupled with the initial imaging findings of compression of the aorta with a rapid transition point as it descended through the hiatus into the abdomen support the diagnosis of aortic compression secondary to tension pneumoperitoneum.6 days post-treatment, a follow-up CT of the abdomen and pelvis showed normal appearances of the opacified aorta .The patient was taken to theatre for an emergency laparotomy where a perforated posterior gastric ulcer with four quadrant contamination was found. There was no bowel ischaemia found at initial laparotomy. Femoral pulses returned following surgical decompression of the abdomen. The ulcer was biopsied and closed and the abdomen was washed out; the abdomen was not closed and a plan for a re-look laparotomy was made for the following 24–48 h. When the patient returned to theatre 2 days later for the re-look laparotomy with the intention of closing the abdomen, the right colon was found to be ischaemic. A partial small bowel resection and right hemicolectomy had to be undertaken. The cause for the bowel ischaemia was possibly secondary to a combination of superior mesenteric arterial and venous compromise.Tension pneumoperitoneum (TP) itself is a rare condition; cases reaching pressures that lead to compromise of the arterial supply to the abdominal organs and lower limbs are extremely rare. Initially, the patient performed well following decompression and subsequent surgical interventions to remove ischaemic bowel. He was cared for in the intensive care unit. Unfortunately, the patient died 24 days following his initial admission, secondary to haemorrhagic complications from his abdominal ischaemia.1 The pathophysiology of this condition is believed to involve a ‘ball and valve’ mechanism, whereby air can enter the abdominal cavity  but cannot escape via the same route, leading to an increase in intra-abdominal pressures.2,3TP refers to the build-up of gas within the abdominal cavity leading to reduced venous return and haemodynamic instability. It was first described by Oberst in 1917 after a patient developed TP following a gastric perforation.4 Pathological intra-abdominal pressures are considered to be >12 mmHg and the pressure required to cause organ failure is >25 mmHg.4 In extremely rare cases, intra abdominal pressures may rise far enough (100 mmHg in canine models) to cause aortic compression and occlusion.5 Following an extensive literature search, we believe that there have only been four previous reports of TP leading to raised intra abdominal pressures high enough to cause compression of the aorta. In all of these cases, the patients died shortly after presentation.TP is a rare condition, but has been reported several times in the literature causing reduced venous return.6,7Treatment of TP is concerned with decompressing the abdomen. This can be achieved with various techniques from cannula decompression to percutaneous catheter insertion and ultimately laparotomy.To our knowledge, TP and aortic compression caused by perforated peptic ulcer has only been previously reported once, and this may be the first case causing TP secondary to a gastric ulcer. The patient described in our report has survived longer than any previously reported patient following aortic occlusion secondary to TP. Early diagnosis and treatment is key in these cases if patients are to survive.TP can lead to pressures that are high enough to cause aortic collapse and compression. When this occurs it is associated with a very high mortality rate.Patients presenting with tension pneumoperitoneum should be given the highest priority for emergency surgery, in order to decompress the abdomen, address any contamination, attempt to treat the cause of the pneumoperitoneum and transfer to the intensive care unit swiftly.There should be a high index of suspicion for the presence of ischaemic bowel if patients with tension pneumoperitoneum are taken to theatre for re-look procedures.Physiological processes can be assessed with the use of CT; this case demonstrated that, despite a portal venous timed scan, venous return was not occurring due to high intra-abdominal pressures.Radiologists should consider vascular compromise early when pneumoperitoneum is seen, in order for rapid communication of serious findings such as aortic compression to be made to the surgical team and early treatment to be possible.


Osteoma is a benign tumor of the bones, which can be classified as central or peripheral. The occurrence in the jawbones is uncommon, but when it occurs, there is a greater prevalence of the mandible. The etiology is still unknown, and the hypothesis of its development is debated.A 35-year-old Caucasian man presenting a tumor lesion in the right jawbone that had been growing for 8 years sought medical service complaining of speaking impairment. According to the patient, the tumor appeared shortly after a minor trauma caused by tooth extraction. The diagnosis of the lesion was made through clinical, radiographic, and histological methods, and the surgical treatment was successful and satisfactory for the patient as well as the surgical team, despite a short follow-up.Etiopathogenesis of osteoma is not determined in the majority of cases. In the present report, it was possible to hypothesize the association between a minor trauma and the development of the tumor, reinforcing the reactive theory of tumor development. The uncommon location of the osteoma, as well the possibility of identifying the possible cause of the lesion, makes this case particularly interesting. Osteoma is a benign, slow-growing, usually painless lesion characterized by the proliferation of compact or cancellous bone , 2. PeriThroughout the literature, we noticed variance on the matter of gender predilection. Most authors affirm that there is equal incidence among men and women , 7, whilThe etiology of peripheral osteoma is unclear, but there are currently three theories on its origin: developmental, neoplastic, and reactive to trauma , 13–15.The purpose of this paper is to present the clinical, radiographic, and histopathological features, as well as the surgical treatment, of a peripheral osteoma in the mandible that has been directly associated with local minor trauma: a tooth extraction.A 35-year-old Caucasian male presented to the Maxillofacial Surgery service of Campo Limpo Hospital, in São Paulo, Brazil, with the main complaint of an intraoral swelling that had been growing for the last 8 years. The lesion was asymptomatic, and even though the patient had been aware of its constant growth, he decided to look for professional help only when its proportion began to cause him speaking impairment.The physical examination revealed a firm mushroom-like mass, with bony consistency covered by smooth regular mucosa spanning almost the entire right alveolar border of the mandible. The area was edentulous and, according to the patient’s report, had initiated its growth shortly after the extraction of a molar, which the patient could not specify. As it developed, the remaining teeth had been extruded until complete avulsion . No extraoral abnormalities were observed. The patient was in good health, with no history of previous diseases, smoking, or substance abuse. The diagnosis of Gardner syndrome was discarded due to the lack of any other symptoms, such as gastrointestinal implications or supernumerary teeth  Figs. 11 and 2.FComputed tomography revealed a well-defined pedunculated mass attached to the right body of the mandible with radiographic characteristics resembling the original bone, consisting of a central area of moderated radiopacity similar to medullary bone, surrounded by a denser, more radiopaque thin area, comparable to cortical bone. According to Rodriguez (2011), these particular growth characteristics make it easy to diagnose a peripheral osteoma clinically and radiographically Figs.  and 4.FiSince the tumor presented both clinical and radiographic features of a benign lesion, the patient underwent an excisional biopsy, with complete removal of the mass and an osteoplasty of the mandible. The access was intraoral, with an incision directly over the lesion, and divulsion of the mucoperiosteal tissues, preserving their integrity for suture later Fig. . After tHistopathological analysis revealed mature adipose tissue, permeated by viable compact bone lamellae, consisting of medullary tissue, delimited by a thin and well-vascularized lamellar cortical bone. Thin and congested blood vessels were noted throughout the whole sample.Osteomas are benign neoplasms that continue to grow slowly and painlessly over time and are characterized by the proliferation of compact or cancellous bone. The tumor presents as three different types: central osteoma originates from the endosteum, whereas the peripheral type derives from the periosteum and the extraskeletal develops in soft tissues , 4, 8.The development of osteomas is usually asymptomatic and is only detected as a radiographic finding. It does not cause bone reabsorption or destruction, allowing conservative treatment for small lesions , 10, 16.Histologically, osteomas can be compact, cancellous, or mixed. Compact osteoma has been defined as hard, dense bone with minimal marrow spaces and occasional Haversian canals, while the cancellous (or spongious) lesion, as in our case, contains trabeculae of bone, fibrofatty-marrow-enclosing osteoblasts, and architecture resembling mature bone , 16, 17.Peripheral osteomas manifest themselves as unilateral, well-circumscribed swelling, resembling the bone in origin, usually with a pedunculated shape and narrow contact area between the lesion and the compact bone , 14.Differential diagnosis of osteoma includes exostosis, which is histologically identical , but theThe pathogenesis of osteoma is still unclear, but a few hypotheses have been proposed and refuted. The theory that the lesion is developmental and caused by congenital anomalies seems unlikely, since most cases were observed in adult patients, and a genetic condition should manifest itself in the formative period of growth , 13, 14.The reactive theory has been accepted as the best explanation for the pathogenesis of peripheral osteoma, consisting of a combination of trauma and muscle activity. Trauma would cause subperiosteal bleeding or edema, and the muscle traction would locally elevate the periosteum, initiating an osteogenic reaction. The initiating trauma could be minor, being easily forgotten by the patient, and the continuous muscle traction in the area could perpetuate the reaction, causing the growth of the tumor , 14, 17.In this case, particularly, the development of the lesion was incisively traced back by the patient to after a tooth extraction, thus corroborating the theory that it can be a reactive mechanism triggered even by small traumas, which the patient can forget over the years . There aAlthough the etiopathogenesis of peripheral osteoma is not completely elucidated, the present case strongly suggests an association between a trauma  and the development of the tumor in the mandible, with a favorable evolution after surgical excision.