Groove pancreatitis (GP) is an uncommon appearance of pancreatitis represented by fibrous inflammation and a pseudo-tumor in the area over the head of the pancreas. The underlying etiology is unidentified but is firmly associated with alcohol abuse. We report the case of a 45-year-old male patient with chronic alcohol abuse who was admitted to our hospital with upper abdominal pain radiating to the back and weight loss. Laboratory data were within normal limits, except for the level of carbohydrate antigen (CA) 19-9. An abdominal ultrasound and computed tomography (CT) scan revealed swelling of the pancreatic head and duodenal wall thickening with luminal narrowing. We performed an endoscopic ultrasound (EUS) with fine needle aspiration (FNA) from the markedly thickened duodenal wall and the groove area, which revealed only inflammatory changes. The patient improved and was discharged. The principal objective in managing GP is to exclude a diagnosis of malignancy, whilst a conservative approach might be more acceptable for patients instead of extensive surgery.  A 45-year-old male smoker with a past history of severe chronic alcoholism presented to our gastroenterology department with a 2-month history of intermittent episodes of upper abdominal pain radiating to the back, nausea, postprandial vomiting, and poor appetite that persisted for 3 months, followed by a 10 kg weight loss. The patient reported no history of hypertension, previous abdominal surgery or diabetes mellitus. His family and drug history were unremarkable. Physical exams were unremarkable except for bilateral upper quadrant abdominal tenderness and hypoactive bowel sounds, while no abdominal mass was identified. Laboratory results showed that hemogram, amylase, lipase, albumin, renal and liver function tests were within normal limits. A tumor marker test found a slightly increased level of carbohydrate antigen 19-9 (CA 19-9) at 40 U/mL . Carcioembryonic antigen (CEA) and alpha-fetoprotein (AFP) levels were both normal. US demonstrated mild hepatic steatosis with no cholelithiasis or acute cholecystitis but revealed general thickening of the second part of the duodenum and voluminous pancreas head. Esophagogastroduodenoscopy showed a narrowed second part of the duodenum due to an irregular, edematous, “reddish” polypoidal-appearance mass rising at the D1–D2 junction with intact extending mucosa . AdditioNonetheless, there was still a concern of malignancy due to the position of the mass. Endoscopic ultrasound (EUS) was performed , which dFirst described by Becker and Mischke in 1973, GP is an infrequent and still under-recognized type of recurrent or chronic pancreatitis that involves the anatomic space between the head of the pancreas, the common bile duct (CBD) and the duodenum, the so-called groove area [Diagnosis is frequently challenging, and many physicians are not familiar with the disorder, which possibly contributes to its low incidence ,2. The aIn various studies, no difference was found in age and gender dispersion among GP and common chronic pancreatitis ,2. GP isLaboratory data often show little elevation of serum pancreatic enzymes and periodically of serum hepatic enzymes. Bilirubin levels can be high if the CBD is obstructed, and alkaline phosphatase levels can also be elevated despite the nonappearance of ductal reduction. CEA, AFP and CA 19-9 tumour markers are barely elevated ,6,7. Imaging plays a fundamental aspect in recognizing this entity. The literature on sonography has barely reported the appearance of GP. US commonly reveals a hypoechoic mass with thickening of the duodenal wall ,6.CT scans generally show mural thickening of the duodenal wall or a hypodense, insufficiently enhanced mass between the head of the pancreas and a thickened wall of the duodenum. Supplementary data include distension of the head of the pancreas and irregular calcifications. CBD may be narrowed with a smooth, tapered, and constant stenosis ,9,10. The most typical finding on magnetic resonance (MR) is a sheet-like mass corresponding to the fibrous scar in the groove among the head of the pancreas and the duodenum. MR imaging generally presents a hypointense mass on T1-weighed MR images in comparison with the pancreatic parenchyma and is iso- or slightly hyperintense on T2-weighed MR images. By contrast, administration enhancement is principally postponed due to the presence of fibrous tissues. Cystic lesions of the groove or duodenal wall may be noticed, especially on T2-weighted images. Duodenal wall thickening and duodenal wall stenosis are also commonly observed . Irie etMagnetic resonance cholangiopancreatography (MRCP) helps separate GP from CBD carcinoma, as GP shows smooth CBD tapering and shouldering is uncommon ,8.Esophagogastroduodenoscopy is also necessary as it can identify a congested and polypoid mucosa of the duodenum, with narrowing of its lumen or buldging of duodenal bulb ,8,9. BioThe probability of accumulating samples from suspicious lesions using EUS-FNA makes EUS an ideal procedure to distinguish pancreatic adenocarcinoma from GP, allowing a diagnosis by cytopathology in approximately 90% of cases ,9,15. EURadiologically, inflammatory modification in the groove between the duodenum and the pancreatic head can look indistinguishable from a malignancy. Nevertheless, it is crucial to recognize the integral clinical picture and the patient’s symptoms. A significant characteristic is the absence of major vessel encasement in GP, although some displacement may be noticed. Graziani et al.  describePancreatic adenocarcinomas are much more likely to invade the retroperitoneum and involve the vasculature, which was not the case with our patient. A unique finding of GP is a thickening of the medial duodenal wall, as opposed to pancreatic adenocarcinoma ,4,5. In When the diagnosis is obvious, GP can be treated by conservative medical measures, including endoscopic therapy as the first line of intervention. Abstinence from alcohol, pancreatic rest, and opioid analgesics are the most commonly used conservative measures. While conservative management is preferred, resection is the gold standard in the appearance of obstructing manifestations or any suspicion of malignancy ,5. ThereGP should routinely be considered in the differential diagnosis for patients presenting with pancreatic head enlargements with no cholestatic jaundice, mainly when a duodenal obstruction is present and neither duodenal biopsies nor pancreatic head FNA establishes adenocarcinoma. It is fundamental for physicians to become more acquainted with clinical, paraclinical and imaging findings that are evocative of GP because it can imitate pancreatic malignancy, whose prognosis and management are entirely different. Therefore, this report aims to make this entity and hidden anatomical area more recognizable to clinicians, creating a conclusive imaging diagnosis and decreasing further diagnostic work-up such as unnecessary surgeries and delayed diagnosis.


One of the most important complications of endometrial tumors, especially in UCS, is venous thromboembolism (VTE), with an incidence of 8.1%.6 Magnetic resonance imaging (MRI) is the best imaging modality for staging. Furthermore, it shows a typical high enhancement with a “spotty” distribution, which may suggest bleeding and is a distinct hallmark of carcinosarcoma.7While Trans-Vaginal Sonography (TVS) is the first-line method for the assessment of UCS, as it can detect neoformations of the myometrium, diagnosis can usually be made by the histopathological examination of targeted endometrial biopsies, possibly associated with hysteroscopy.8 the management of UCS requires a multimodality treatment comprised of surgery, systemic therapy, and radiotherapy. The estimated 5-year survival rate ranges from 33 to 39%, but the recurrence rate remains high.8Depending on the histopathologic assessment of the tumor (depth of invasion and presence or absence of metastases) and clinical presentation,Histopathologic examination of the mass revealed features of carcinosarcoma consisting almost entirely of a sarcomatous component and small foci of endometrioid- type adenocarcinoma, with neoplastic embolization of the intraparietal venous vessels. An inflammatory infiltrate associated with marked tumor necrosis was also noted  and 1D. At the end of all investigations, the cause of death was identified as massive pulmonary arterial thrombosis in a subject with uterine carcinosarcoma.For completeness, we also considered peritonitis and sepsis as possible co-participation in the cause of death. However, we considered this hypothesis unlikely based on the macroscopic and microscopic findings. Specifically, the peritoneum, abdominal viscera, and serosa were shiny, without fibrinous deposits, and of normal consistency. The purulent-looking material appeared free and not adherent to the abdominal wall and intestinal loops, as would be the case with recent extravasation, and was not organized. The histologic findings confirmed these considerations, which revealed no evidence of septic embolism. Overall, there were no postmortem findings suggestive of peritonitis and sepsis. Had the massive and acutely fatal pulmonary arterial thrombosis not occurred, local or systemic septic complications most likely could have developed.The case was considered of interest because of the rare neoplasm, its size, and the very advanced stage of the disease. Another peculiarity was that one of the most lethal direct complications of this neoplasm, pulmonary arterial thrombosis, was observed. Unfortunately, the absence of family members and health information does not allow further clinical considerations, but the severity of the disease found is glaringly the result of neglected and untreated disease. This case demonstrates that such scenarios are still possible today, despite the increased importance of prevention campaigns. In this context, the observed anatomopathological findings are crucial as they enrich the knowledge of uterine carcinosarcoma, and their images may help forensic pathologists who have not previously encountered this rare disease.


Connective tissue nevus is a hamartoma composed of excess amounts of one or several components of the dermis, such as collagen, elastin, and proteoglycans. This report introduces a 14‐year‐old girl with grouped flesh color papules and skin color nodules distributed unilaterally with a dermatomal pattern. These lesions involved more than one segment. Histopathology is the gold standard for diagnosing collagenoma and mucinous nevus. We reported the first case of mucinous nevus with multiple collagenoma that shows the specific clinical features. Deposition of amorphous materials in the high‐power field. Each subtype can present as solitary or multiple lesions.2The patient was a 14‐year‐old girl with a chief complaint of rashes and itching on her body and extremities. She stated that her problem started a year and a half ago. She denies any significant past medical or medical history or any similar history of skin disorders in her family.On physical examination, skin involvement was in the form of grouped flesh color papules and skin color nodules distributed unilateral and multi‐segment with dermatomal patterns on the upper back, breast, upper chest and upper limbs, which were also pruritic. Figure  The lesiTwo biopsies from both papular and nodular lesions were performed; the differential diagnoses were leiomyoma, adnexal tumor, and collagenoma. The specimens from the papular lesion showed a normal epidermis with an “empty appearance” due to the deposition of amorphous materials, which separated collagen fibers in the papillary dermis. Fibroblasts were increased in number, and an inflammatory infiltrate composed of lymphocytes and mast cells was seen in the mid‐dermis beneath the material deposition Figure . Alcian Results of laboratory studies, including complete blood cell count, liver and renal function tests, radiologic examination of the chest and lower extremities, and echocardiography, were normal. Considering the clinical and pathologic findings, a diagnosis of mucinous nevi with multiple collagenoma in dermatomal and unilateral distribution was rendered.3Cutaneous mucinoses are a heterogeneous group of disorders associated with an abnormal amount of mucin in the skin.The mucin is thought to be composed of hyaluronic acid staining positively with alcian blue at a pH of 2. In the present case, mucin deposits were present in the papillary dermis.There was no evidence of angiofibroma, hyperpigmented lesions, or any other dermatome involvements or similar lesions as mucinous lesions sometimes occur in the context of other skin diseases, such as vascular melange. The patient also did not have any signs or history of rheumatological disorders, joint involvement, or any history of seizure as collagenoma is occasionally related to hereditary diseases such as tuberous sclerosis.To our knowledge, no cases of mucinous nevus with collagenoma have been reported in Iran. The most common site of lesions is the upper trunk, arms, back and thighs, with the most common configuration of linear or zosteriform or grouped distribution.There is no need for treatment due to the presence of mucus nevus lesions, except for cosmetic purposes. Surgical excision, dermabrasion, and carbon dioxide have been used for treatment.4We reported the first case of mucinous nevus with multiple collagenoma that showed specific clinical features. Histopathology is the gold standard for the diagnosis of collagenoma and mucinous nevus.Gita Faghihi: Conceptualization; supervision. Reza Moeine: Conceptualization; data curation. Fatemeh Mohaghegh: Supervision; validation. Parvin Rajabi: Data curation; writing – original draft. Reza Shahriarirad: Writing – original draft; writing – review and editing.Not applicable.The authors have no conflict of interest to declare.Written informed consent was obtained from the patient's legal guardian or next of kin for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor‐in‐Chief of this journal.Written informed consent was obtained from the patient's legal guardian for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor‐in‐Chief of this journal.


Pulmonary arteriovenous malformation (PAVM) is an abnormal communication between pulmonary vasculatures and has an unclear boundary with surrounding lung tissues. At present, surgeons can only determine its location by preoperative imaging and intraoperative palpation, despite its soft texture. Indocyanine green(ICG), a near-infrared fluorophore, has been demonstrated useful in the accurate identification of vascular tissue. Therefore, we explored its application in PAVM cases.We present two PAVM cases using near-infrared fluorescence (NIF) with 25 mg ICG at 5 mg/ml to achieve intraoperative visualization of the lesion in video-assisted thoracoscopic surgery (VATS). Under the NIF mode, ICG systemic injection led to successive signaling of the anomaly and normal tissues in merely 10 s, which helped us distinguish them efficiently and precisely. A peak signal-to-background ratio of 2.2 confirmed the significant fluorescence difference and excluded interference from carbon dust.We are the first to report the use of such an approach in delineating the margin of vascular malformation with high contrast, and this new finding may help minimize the damage to lung function in PAVM treatment. Further exploration and validation are needed to determine its role.The online version contains supplementary material available at 10.1186/s13019-023-02351-w. Pulmonary arteriovenous malformation (PAVM) is characterized by an aberrant connection between a pulmonary feeding artery and the drainage vein, which bypasses the normal intervening capillary bed. It has been reported that over 80% of such cases are related to hereditary hemorrhagic telangiectasia . The halHowever, surgeons often experience difficulties in locating small PAVMs and accurately discriminating them from normal tissue to completely remove lesions while minimizing damage to lung function. Traditionally, they can determine the boundary by either visual inspection or manual palpation. Challenges exist because such lesions are too soft to be distinguished by palpating. Moreover, deposits of carbon dust often interfere with their judgment. Therefore, the majority of previously reported PAVM cases treated by VATS are peripherally located –5. Near-To date, this new strategy has not yet been implemented in PAVM patients. Here, we report a new clinical attempt worldwide using intraoperative NIF imaging with ICG to visualize the margins of lesions in two PAVM patients.2 of 92.1% and PO2 as low as 66.8 mmHg. A computed tomography (CT) thorax with contrast scan revealed a low-density nodular opacity in the lingual segment of the left upper lobe measuring 8 mm. The lesion was demonstrated as a PAVM on a contrast-enhanced scan, presenting with the feeding lingual artery and the twisted draining vein . Percutaneous transcatheter embolization (PTE) was not adopted due to the high risk of recanalization. Furthermore, such a peripherally located solitary nodule was an excellent candidate for VATS resection. The second patient was a 72-year-old man. His checkup enhanced CT scan detected both a vascular malformation and a striped high-density shadow in the right lung. Due to increased FDG uptake in positron emission tomography-CT analysis, the nodule was further determined as cancer, which indicated a confined operation. Similarly, the thoracic CT imaging showed a tortuous vascular mass at the pleura of the anterior basal segment of the right lower lobe formed by an aberrant artery and a branch of the vein . After contraindication assessment and multidisciplinary discussion, we decided to perform thoracoscopic wedge resection for the PAVM under the aid of near-infrared (NIR) fluorescence imaging with ICG during the confined operation for the tumor. For both patients, the reconstruction of PAVMs by preoperative 3-dimensional CT scan could be a reference .The first 52-year-old woman, who revealed exertional dyspnea and occasional chest pain for four months, came to us for surgical treatment. She reported no symptoms at rest and no hemoptysis. Her arterial blood gas analysis at admission showed SaOThe two patients were anesthetized with double-lumen endotracheal intubation, and operations were completed on constant single-lung ventilation. Two trocar ports were used to enter the thoracic cavity. The entire procedure was performed using a D-light P® NIR thoracoscope system  through the observation port.For the 52-year-old woman, a sac-like lesion (green arrow) could be seen at the surface of the lingual segment of the left upper lobe under normal thoracoscopic mode Fig. . The per and 1.3 for the man .Signal-to-background ratios (SBR) over time were calculated using ImageJ digital analysis software for them, the maximum of which was 2.2 for the woman Fig. a and 1.32 was 99.9%, PO2 was 295.3 mmHg without oxygen inhalation for the woman, and FiO2 elevated to 462.2 mmHg for the man. Their postoperative pathological findings confirmed dilated vascular malformations. Ultimately, both patients were discharged after uneventful postoperative courses.After the operation, the arterial blood gas analyses found oxygenation greatly improved; the SaOHere we report new clinical cases using NIF imaging with systemically injected ICG to achieve thoracoscopic sublobar resection of PAVMs.As a rarely occurring disease, most cases of PAVM are congenital. According to previous retrospective studies, at least one-third of such patients had multiple lesions. Up to 80% were peripherally located and closely related to the pleura . TreatmeHistorically, lobectomy was preferred to ensure the complete removal of abnormal tissue . Given tFor wedge resection, precise excision is desirable, because under-resection may cause recurrent diseases, and over-resection decreases respiratory capacity. Discerning the border between the normal lung and the PAVM is crucial during the operation. Given the difficulties of visual inspection confused by carbon dust and manual palpation thwarted by soft texture, it is difficult to achieve this goal. The palpation of the finger may not discriminate small and soft nodules and is more limited in thoracoscopic surgeries. In our experience, vascular lesions are quite soft and those amenable to wedge resection are usually small. This may lead to fuzzy recognition. In the study conducted by Okusanya OT , patientICG, as a rapidly cleared fluorescence contrast, has been approved by the U.S. Food and Drug Administration as an intravenously injected drug . Real-tiICG binds primarily to globulins and remains within the vessels upon rejection. It is cleared exclusively by the liver and is neither metabolized nor reabsorbed from the intestine. The infrared light is directed to the surface of the lung from the light source through a special filter, and the reflected light by the contrast is detected by a camera. The signals form images according to the setup transducer on the monitor. If the tissue receives cardiac output, its appearance is affected by ICG. Therefore, this method can delineate the lesion boundary according to the degree of blood flow. Once injected into the vein, ICG returns to the right heart through systematic circulation and is immediately pumped into the pulmonary artery. Without passing through the pulmonary circulation into the left heart and the peripheral arteries, ICG can fill and outline the PAVM. In the overlay imaging window, the normal tissues show uniformly fluorescent green, while the lesion will be depicted as the first station to be filled. Consequently, NIR with ICG rapidly differentiates the PAVM from the surrounding lung tissue by their relative filling time.In our patients, fluorescence signals of the lesion and normal tissue were not detected simultaneously at the beginning. The video demonstrated that the PAVMs were first visualized approximately 10 s after ICG injection. The surrounding lung tissue began to show obvious signals 20 s later through blood circulation. The imaging distinction was apparent in both two patients. The dynamic SBR curves confirmed that NIR ICG imaging has a high resolution, consistent with the video. Although the peak value was lower in the second case due to his severe carbon dust deposition, both the two dynamic SBR curves increased to a crest followed by decreasing trend, thus exhibiting the outstanding potential of ICG under NIF imaging in locating vascular anomalies during lung resection surgery. Consistent with previous studies, the contrast between the nodules and the surrounding tissues was less obvious at lower SBR. Furthermore, the fluorescent signal was considered detectable with SBR ≥ 1.5 , 25. TheIt is worth mentioning that failure to completely resect the vascular lesion may be one of the reasons for postoperative recurrence. With the aid of ICG-based NIR fluorescence imaging, surgeons can precisely resect such lesions and prevent the recurrence of pneumothorax. By removing malformed vascular structures completely, the risk of recanalization, collateralization, and peri-interventional paradoxical embolism may be reduced.In most cases, the diagnosis is established after pathohistological examinations. Previous studies have pointed out that a multitude of vascular and nonvascular pulmonary lesions can mimic the appearance of PAVMs including pulmonary vein varix, fibrosing mediastinitis, lung granulomas, bronchoceles, ground-glass opacities, and atelectasis . IdentifIn conclusion, we showed in our cases that systemic ICG injection was helpful in PAVM surgical treatment, from the perspective of accurate demarcation of the resection boundary. Moreover, NIF imaging may be helpful in cases of peripheral PAVMs that are difficult to identify using conventional methods. This is the first published report of NIR fluorescence with ICG in the sublobar resection of PAVMs. Considering the low risk for adverse side effects, ICG is beneficial in PAVM surgical treatment.Below is the link to the electronic supplementary material.Additional File Video 1: The surgical video clip of the 52-year-old womanAdditional File Video 2: The surgical video clip of the 72-year-old manAdditional File Video 3: The preoperative CT imaging of the 52-year-old womanAdditional File Video 4: The preoperative CT imaging of the 72-year-old man


Background: Trophoblastic tissue reimplantation after laparoscopic salpingectomy is a very rare complication. These cases may present a diagnostic challenge and the majority of patients need a surgical treatment. Case presentation: A 31-year-old patient came to a tertiary referral center for nausea and pain in the upper left abdominal quadrant. Ultrasound and abdominal CT scan showed a 68 × 60 × 87 mm size heterogenic mass below the spleen with arterial extravasation from the lower spleen pole. Recent history of surgery for ectopic pregnancy and serum hCG testing allowed to diagnose extratubal secondary trophoblastic tissue reimplantation below the spleen. Embolization of the bleeding vessel and successful treatment with methotrexate was achieved. Conclusions: In cases of a nondisseminated trophoblastic tissue reimplantation, consider embolization and treatment with methotrexate if the patient is hemodynamically stable; thus, secondary surgical treatment is preventable. Ectopic pregnancy occurs in 1–2% of all pregnancies ,4. EctopIn the latest ectopic pregnancy treatment guidelines, there is no necessary follow-up after salpingectomy, as it is considered a definitive treatment for tubal pregnancy . In thisA 31-year-old woman was sent to the emergency department of a tertiary referral center due to an unknown diagnosis. The patient was feeling nauseous and complained of intensifying pain in the upper left abdominal quadrant.9/L was abnormal.The woman was hemodynamically stable. During physical examination, abdominal muscle tension was observed, and there was no rebound tenderness. Ultrasound revealed a mass in the upper left side of the abdomen and a small amount of unclear fluid around the intestines. In the blood test, only leukocytosis of 17.3 × 10Three weeks earlier, in a regional hospital, she was diagnosed with ectopic pregnancy (7 weeks of gestation) in her left fallopian tube. Left laparoscopic salpingostomy was planned, although salpingectomy was performed due to heavy bleeding. Data on ultrasound findings before surgery was not available. The serum human chorionic gonadotropin (hCG) concentration was not tested. Histological reports showed no chorionic villus, and only several trophoblasts were seen in the surgically removed material. In the past, the woman had had two normal deliveries, pelvic inflammatory disease and one more ectopic pregnancy in her right fallopian tube. Therefore, she underwent laparoscopic right salpingectomy.2 BSA i/m) on day 1 and day 4 was administered. Abdominal pain did not intensify; subjectively, the woman started feeling better. The decrease in serum hCG concentration between days 4 and 7 was 24.1% ; thus, hCG testing was repeated weekly (A computed tomography (CT) scan was performed to differentiate the mass found on ultrasound. Abdominal and pelvic CT showed a 68 × 60 × 87 mm heterogenic mass, likely a hematoma, which was below the spleen. Pelvis was filled with hemorrhagic fluid, and the uterus was enlarged. Arterial extravasation was spotted from the lower spleen pole. Conventional angiography of the splenic artery was performed, and extravasation was identified in the region below the spleen. The vessel was embolized A–E. Due d weekly . Menstrud weekly F.The extratubal secondary trophoblastic tissue reimplantation following surgical removal of an ectopic pregnancy is estimated to be found in 1–1.9% of the cases, and it seems that there is an equal distribution between salpingostomy and salpingectomy . CurrentIn our clinical case, salpingostomy was considered first, because the patient previously had an ectopic pregnancy and underwent contralateral laparoscopic salpingectomy. When the bleeding began, salpingectomy was performed, and there was a possible dissemination of trophoblastic tissue. Our case supports the recommendation of some authors regarding postoperative hCG monitoring if the specimen was fragmented during salpingectomy and if there could have been spillage of the trophoblastic tissue ,12. It wTo diagnose the peritoneal reimplantation of trophoblastic tissue can be very difficult. The symptoms vary from abdominal pain and vaginal bleeding to hemorrhagic shock. The time period from the first operation until the patient returned to the hospital varied from 7 to 51 days. Therefore, it is important to consider the possibility of persistent or reimplanted trophoblastic tissue even though weeks have passed since the primary operation ,11. In oThe treatment of trophoblastic tissue reimplantation depends on whether the patient is hemodynamically stable ,9. SchyuThe diagnosis of the peritoneal reimplantation of trophoblastic tissue can be very challenging; thus, it is very important to avoid iatrogenic dissemination of trophoblast tissue through operation and to follow up serum hCG even after salpingectomy, especially when the conditions of trophoblastic tissue removal are questionable. If a nondisseminated trophoblastic tissue implant after salpingectomy is diagnosed prior to the development of massive intra-abdominal hemorrhage, we suggest considering embolization of the bleeding vessel and treatment with methotrexate.


A rare cause of metallic artifacts over the scalp on magnetic resonance imaging (MRI) is welding fume particles that contain paramagnetic iron oxide particles. These introduce distortion of the magnetic field homogeneity and result in susceptibility artifacts. They may erroneously be reported as a pathology such as calcified lesions; therefore, awareness among radiologists is required. We report a case of a 52-year-old male, an industrial inspector by profession, who presented to the neurology clinic with headaches for which an MRI of the brain without contrast was advised. There was no brain parenchymal signal abnormality; however, numerous small rounded altered signal foci were identified along the scalp, especially in the vertex region, which returned central hypointense and marginal hyperintense signal on all sequences. The imaging signals were suspicious for calcified scalp lesions, and the patient was recalled for clinical examination, which was unremarkable for cutaneous or subcutaneous abnormality on the scalp or elsewhere over the body. A detailed history was taken retrospectively, revealing that the patient had walked through a room where welding was being done before presenting for an MRI exam, without taking a shower. The various altered signal foci over the scalp on MRI based on their shape were hence identified as welding fume particles. These were fine enough not to be visible by the naked eye but determined by the MRI machine because of their magnetic susceptibility artifact. We aim to increase radiologists' awareness of such artifacts that may be seen in patients with occupational exposure to these particles to avoid misdiagnosis of other pathologies. Magnetic resonance imaging (MRI) is a non-invasive cross-sectional imaging technique with potential benefit of no ionizing radiation exposure . HoweverAn imaging artifact refers to false anatomy or pathology that is otherwise not present in the body. The artifacts in MRI can be technique-related or caused by foreign bodies near the patient's body or within the body at the time of scanning. These may deteriorate the image quality or introduce false pathology in images . MetalliMetallic artifacts in brain imaging may be introduced by several objects, including metal drill materials used in craniotomy, surgical wires and sutures of previous surgery, dental grafts, and cosmetics such as eyeliner or hair dye. A less commonly identified cause of artifacts over the scalp is welding fume particles that may be seen in welders and other professionals with potential exposure to these fume particles, the principal constituent of which is iron oxide , which hWe report a rare case of a 52-year-old male, an industrial inspector by profession, who presented to the neurology clinic for headaches. His general physical and neurological examination was unremarkable; however, since the episodes of headaches were frequent, the neurologist advised an MRI brain without contrast to exclude any intracranial pathology. The patient came to the radiology department for an MRI brain performed on a 70cm wide bore Optima™ 450W 1.5 Tesla MRI machine . T1, T2, fluid attenuation inversion recovery (FLAIR), diffusion-weighted imaging (DWI), and apparent diffusion coefficient (ADC) images were acquired as per the departmental protocols. There was no acute infarct, intracranial hemorrhage, mass effect, or midline shift. No intracranial abnormal signal mass or brain parenchymal signal abnormality was identified. However, numerous rounded altered signal foci of sizes measuring up to 1.5 cm were identified along the scalp, especially in the region of the vertex, which returned central hypointense and marginal hyperintense signals on all sequences Figures  .The imaging signals were suspicious for calcified scalp lesions as the signal remained low on multi-sequential imaging. Hence, the patient was recalled for a clinical examination of the scalp. Detailed examination revealed no cutaneous or subcutaneous abnormality on the scalp or elsewhere over the body. A detailed history was taken retrospectively, revealing that the patient had walked through a room where welding was done before the MRI exam. The patient also did not take a shower before presenting to us. The various altered signal foci over the scalp on MRI based on their shape were hence identified as welding fume particles. These were fine enough not to be visible by the naked eye but identified by the MRI machine because of their magnetic susceptibility artifact Figure .The classification of an artifact into mild, moderate, or severe depends on its size and the matter responsible for its introduction in the image. A size smaller than the size of the material classifies it as mild, the same size as the material categorizes it as moderate, and more significant than the object is identified as severe . MoreoveThe cause of metal artifacts in the imaging of our patient is attributable to paramagnetic iron oxide contents, which influence the magnetic field homogeneity. The fume particles become magnetically susceptible and result in associated geometric distortion. These may go unnoticed by the patients and are too small to be visible on other imaging modalities such as radiography or computed tomography (CT). However, they are discretely seen on MRI. Hence, multiple artifacts observed within the scalp, especially along the vertex in our patient, are susceptibility artifacts with a size larger than the welding fume particles and an appearance similar to the post-surgical defect Figure , a findiIt is vital that these be correctly recognized and not reported as pathology in the scalp, in which case detailed history and clinical examination are crucial to exclude other possibilities.Awareness amongst radiologists of the susceptibility artifacts that may be caused by paramagnetic iron oxide particles of welding fumes is essential to avoid misdiagnosing other pathologies in patients with occupational exposure to such particles. This is especially important as calcified lesions can appear as similar signals on MRI and therefore these artifacts may be misinterpreted as a pathology. Radiologists must take a detailed history and clinically examine the patients in cases of doubt to exclude possible differential mimickers. Our case hi lights this unique example that must be kept in mind while reporting MRI images.


Moreover, we have compared it with the characteristics of all reported cases of IMT of the gallbladder.Inflammatory myo-fibroblastic tumor (IMT) of the gallbladder is an extremely rare condition. Only seven cases have been reported. All of these were presented either with polyp/mass inside the gallbladder or gallbladder wall thickening, involving just one adjacent organ. We herein present a case of IMT of gallbladder presenting with a huge mass replacing the gallbladder with multiple organ involvement, successfully treated by  Inflammatory myo-fibroblastic tumor (IMT) is a rare variant of a rare condition, inflammatory pseudotumor. Although IMT has been described since 1939, the nature of this disease remains unclear, with unknown true etiology, unknown natural history and unknown appropriate definite treatment. It is now designated as an intermediate-grade malignancy, according to WHO classification . Even thA 63-year-old man presented with significant weight loss, from 68 kg to 60 kg (11.2% in 1 month), and abdominal discomfort for 1 month. Physical examinations were unremarkable. His liver function tests were within the normal limit, except for low albumin/globulin ratio of 3.2/5.1. Ultrasonography of the abdomen showed a hetero-echoic gallbladder mass invading the liver Figures . He subsnd part of the duodenum, and, unexpectedly, the common hepatic duct and the portal pedicle of the right lobe liver. We, therefore, performed en bloc extended right hepatectomy, extended right hemicolectomy, with resection of the gallbladder, extrahepatic bile duct and a portion of the 2nd part of the duodenum. We started the operation from the colon toward the liver because of technical simplicity. At our center, we prefer to perform ileal-colon anastomosis rather than colon-colon anastomosis, therefore we opted to perform right hemicolectomy rather than segmental colon resection. After the colon had been transected, the 2nd part of the duodenum was fully visualized, and we found that just only lateral wall of the 2nd part of duodenum got involve by the tumor. Instead of pancreaticoduodenectomy, therefore, we performed resection of duodenal wall by sharp opening into the duodenal lumen using the Metzenbaum scissors, to ensure the adequacy of surgical margin, then we repaired the duodenal defect using an absorbable, synthetic braided suture, in continuous locking fashion. We had an opportunity to carefully re-assessed the relation between the tumor extension and hepatoduodenal ligament, and found that it was impossible to performed the safety dissection of the adherence between the tumor and right-side of the hepatoduodenal ligament. We, therefore, performed extended right hepatectomy with bile duct resection. Biliary reconstruction was performed using absorbable, synthetic braided suture, in interrupted fashion.We had made the discussion, in our team, regarding the possibility of benign conditions, such as xanthrogranulomatous cholecystitis, role of preoperative tissue biopsy and neo-adjuvant treatment. Presence of benign condition on biopsy results, was unable to ensure that this whole mass can be assumed as benign condition and be treated successfully by medication only. On the other hand, if the mass was malignancy, percutaneous biopsy might increase risk of tumor seeding, and, in addition, neo-adjuvant did not ensure tumor response. The tumor might become unresectable after systemic treatment administration. Since there was no evidence of lymph node involvement or distant metastasis, despite local advancement of the mass, we considered it as some kind of gallbladder tumor with good biology, which was resectable both technically and oncologically, and, consequently, may gain benefit from surgical resection. Taken together, the operation was carried out; we firstly performed laparoscopic diagnosis to eliminate the chance of preoperatively undetectable small peritoneal metastases. Then we proceeded with laparotomy, and we found a gallbladder mass invading the liver, the hepatic flexor colon, the lateral wall of the 2nd part of the duodenum and the common hepatic duct. The postoperative course was uneventful. He is on regular follow up and has been disease free for 2 years.A surgical specimen showed an ill-defined inhomogeneous firm mass with whitish and yellowish cut surfaces occupying over the fundus and body of the gallbladder . Histopaen bloc multi-visceral resection. The patient still has disease-free status. We have searched extensively through medical databases, using the keywords; IMT OR “inflammatory myofibroblastic tumor” OR “pseudotumor” OR “inflammatory fibroblastic” AND gallbladder, and found seven reported cases of IMT of gallbladder. In all of these, the disease mainly involved the gallbladder and one adjacent organ [We have described a case of IMT of the gallbladder with multiple organ involvement, successfully treated by nt organ –9 , we therefore performed such an aggressive operation. Although the patient still has a good outcome at 2 years post-operation, we believe that all patients with IMT require a longer follow-up period to ensure curation.All reported cases of IMT of the gallbladder share many unique features, which differ from IMT of other organs. All cases were in the middle-aged, were symptomatic, and involved no more than one adjacent organ. We have reported the first case of IMT of gallbladder with multiple organ involvement, successfully treated with multi-visceral resection.


PF isThe diagnosis of penile fracture is mainly clinical, made from a thorough history and physical exam alone -9. The pIn the present paper the authors studied the further evidence concerning the diagnostic accuracies of magnetic resonance imaging (MRI) and ultrasound (US) in the diagnostic assessment of patients with suspected PF and concluded that the results of this study suggest that MRI is more suitable to confirm PF and identify the site of the associated tunica albuginea tear while US is a good tool for ruling out PF.


Introduction: A congenital intrathoracic kidney (ITK) is a rare anomaly that is recognized to have four causes: renal ectopia with an intact diaphragm, diaphragmatic eventration, diaphragmatic hernia, and traumatic diaphragmatic rupture. We report a case of a prenatal-diagnosed ITK related to a congenital diaphragmatic hernia (CDH) and conducted a systematic review of all cases of the prenatal diagnosis of this association. Case presentation: A fetal ultrasound scan at 22 gestational weeks showed left CDH and ITK, hyperechoic left lung parenchyma, and mediastinal shift. The fetal echocardiography and karyotype were normal. Magnetic resonance imaging at 30 gestational weeks confirmed the ultrasound suspicion of left CDH in association with bowel and left kidney herniation. The fetal growth, amniotic fluid, and Doppler indices remained within the normal range over time. The woman delivered the newborn via an at-term spontaneous vaginal delivery. The newborn was stabilized and underwent non-urgent surgical correction; the postoperative course was uneventful. Conclusions: CDH is the rarest cause of ITK; we found only eleven cases describing this association. The mean gestational age at diagnosis was 29 ± 4 weeks and 4 days. There were seven cases of right and four cases of left CDH. There were associated anomalies in only three fetuses. All women delivered live babies, the herniated kidneys showed no functional damage after their surgical correction, and the prognosis was favorable after surgical repair. The prenatal diagnosis and counseling of this condition are important in planning adequate prenatal and postnatal management in order to improve neonatal outcomes. Congenital intrathoracic kidney (ITK) is a rare malformation representing partial or complete protrusion of the kidney above the level of the diaphragm into the mediastinum. This pathological abnormality represents <5% of all renal ectopias. It is more common in the male sex than in the female sex (2:1), and it has a slight left-side predominance.In most cases, a congenital intrathoracic kidney is asymptomatic and diagnosed incidentally, often after birth; however, it can be misdiagnosed as pneumonia because of its presentation on a chest X-ray as an opacity or lobar consolidation ,2.An ITK is recognized as having four main causes: “real” renal ectopia with an intact diaphragm, diaphragmatic eventration, congenital or acquired diaphragmatic hernia, and traumatic diaphragmatic rupture .Congenital diaphragmatic hernia (CDH) is frequently associated with gastric, bowel, or hepatic herniation, whereas renal protrusion is extremely rare.We report a case of a prenatal diagnosed ITK associated with CDH.We also conducted a systematic review of all cases of this association diagnosed antenatally using MEDLINE, EMBASE, Scopus, ClinicalTrials.gov, OVID, and the Cochrane Library as electronic databases from January 1970 to December 2022. We used the medical subject heading (MeSH) term Kidney (MeSH Unique ID: D007668) in combination with Hernias, Diaphragmatic, and Congenital (MeSH Unique ID: D065630). No restrictions concerning language or geographic location were applied. The systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines  Figure . One autA 37-year-old Caucasian woman, gravida 2 para 0, with a history of a previous miscarriage due to an unknown cause, was referred to our second-level center at 22 gestational weeks for a suspicious fetal intrathoracic mass and left CDH at a second-trimester ultrasound (US) screening. Her previous medical and family histories were unremarkable; she was a nonsmoker, had not consumed any alcohol during the pregnancy, and had never been exposed to drugs or toxins. The measurements of the dating examination in the first trimester were consistent with the dates of the last menstrual period, the nuchal translucency was normal, and toxoplasmosis, other agents, rubella, cytomegalovirus, and herpes simplex (TORCH) screening was negative. Our US examination was performed via the use of a Voluson E10 scanner  equipped with a curved linear array transabdominal transducer (2–5 MHz). The fetal heart rate was within the normal range, fetal movements were visualized, the placenta was identified on the anterior portion of the uterus and showed a normal insertion, and the amniotic fluid, as well as the Doppler indices, were within normal limits. The fetal biometry was consistent with the gestational age (GA). An intrathoracic left hypoechoic mass with a maximum diameter of 26.8 mm was seen .The heart was displaced to the right , in normal levocardia. Furthermore, the left renal fossa was empty. In the left parasagittal view, the left kidney appeared lifted up toward the thorax .Power Doppler showed the abnormal course of the left renal artery, which started from the abdominal aorta and ended in the thoracic kidney .The scan did not show a clear herniation of the stomach, bowel, or liver. The lung-to-head circumference ratio (LHR) was greater than 1.4, and the observed-to-expected (o/e) LHR was 52.1%. The left lung parenchyma beside the mass was hyperechoic . The lefA congenital ectopic kidney is a rare malformation, caused by the malposition of the kidney during embryogenesis. Most ectopic kidneys are found in the pelvic and lumbar regions secondary to failure to ascend during fetal life. ITK is extremely rare, with a prevalence ranging from 0.5 to 5% and an incidence of 1 in every 10.000 cases of an ectopic kidney . Males , have increased survival rates for infants with severe CDH. Overall, the implications of these advancements for clinical practice and patient outcomes are significant. Early and accurate diagnosis, as well as effective surgical and perioperative care, can greatly improve the prognosis for patients with an intrathoracic kidney and CDH. As such, continued research and innovation in this field are essential for further improving the outcomes and quality of life of affected individuals.ITK associated with CDH is a rare malformation. An accurate study of fetal anatomy is necessary to exclude associated anomalies, and a fetal invasive karyotype must be offered. Fetal MRI can be complementary to the US for prognostic evaluation and differential diagnosis. Renal function is usually preserved, and the prognosis is favorable after surgical repair. In line with prior research, this case report underscores the favorable prognosis for fetuses with kidney herniation, offering guidance to obstetricians for the counseling of this uncommon anomaly. The differential diagnosis of the reported case is a highly involved undertaking that requires a broad spectrum of specialized healthcare professionals. Prenatal counseling should involve a multidisciplinary team involving maternal-fetal medicine, pediatric surgery, genetics, and neonatology. The long-term outlook varies considerably and is based on associated anomalies, preterm delivery, hernia position, and fetal lung volume.


Management of a bladder tumor during pregnancy is an uncommon clinical situation. Leiomyosarcoma of the urinary bladder is a rare histological type of bladder tumor and a rare secondary cancer in survivors of retinoblastoma (RB). However, there has been no report of RB-associated bladder leiomyosarcoma during pregnancy.th week of gestation. Cystoscopy revealed a 40-mm papillary tumor on the left lateral wall of the urinary bladder. At the 25th week of gestation, she underwent transurethral resection of the bladder tumor, and the pathological diagnosis was bladder leiomyosarcoma with loss of RB1 expression. At the 31st week of gestation, she gave birth by caesarean section. One month after the delivery , she underwent partial cystectomy, and the specimen contained no residual leiomyosarcoma tissue.A 37-year-old pregnant woman with a medical history of RB in infancy presented with gross hematuria at the 17We have reported a case of RB-associated bladder leiomyosarcoma that was successfully treated during and after pregnancy.The online version contains supplementary material available at 10.1186/s12894-023-01298-3. Management of a bladder tumor in a pregnant woman is a rare clinical situation. With the exception of schistosomiasis-related cases, fewer than 50 cases of bladder tumors during pregnancy have been reported in the literature to date –3. Such Leiomyosarcoma of the urinary bladder is a rare malignancy that accounts for only 0.1% of bladder lesions –7, and nth week of gestation. At 0 years of age, she had undergone treatment for the bilateral RB by enucleation of the left eye followed by radiotherapy and photodynamic therapy to the right eye; no chemotherapy was administered. She had been proven to have a pathogenic germline variant of RB1, whereas she had no apparent family history of RB.A 37-year-old pregnant woman (gravida 2 para 1) with a medical history of bilateral RB in infancy presented with macroscopic hematuria at the 17nd week of gestation. CT imaging revealed the fetus, a uterine fibroid, and the above-mentioned bladder tumor without any metastatic lesions  under general anesthesia. Pathological analysis of the TURBT specimen showed stromal proliferation of spindle tumor cells with enhanced mitotic activity and an overlying benign urothelium , the patient gave birth by caesarean section. Contrast-enhanced CT and magnetic resonance imaging after the delivery detected neither local recurrence nor metastatic lesions. Cystoscopy after TURBT and delivery showed a surgical scar on the bladder lumen without obvious local recurrence , and this CT examination provided essential information for subsequent treatments. TURBT under general anesthesia has been the mainstay of managing bladder tumors during malignancy [We have described the first case of RB-associated bladder leiomyosarcoma that was successfully treated during and after pregnancy. Bladder tumors during pregnancy are very rare, and fewer than 50 cases of bladder tumors unrelated to schistosomiasis (bilharziasis) during pregnancy have been reported to date –3. Altholignancy . At the Bladder leiomyosarcoma is a rare malignancy that accounts for only 0.1% of bladder lesions –7. GivenRB1 gene itself, radiotherapy, and chemotherapy [RB1 gene. Actually, the loss of RB1 expression in the tumor cells was immunohistochemically confirmed in the TURBT specimen.Bladder leiomyosarcoma is also a rare secondary cancer in survivors of RB –12. The otherapy . Given tIn conclusion, we have reported a case of RB-associated bladder leiomyosarcoma that was radically and safely resected during and after pregnancy. Although the management of this case was clinically challenging, close cooperation with obstetricians resulted in a successful outcome.Additional file 1:Table S1. Immunohistochemistry results of the TURBT specimen.


Osteoid osteoma is a relatively common benign bone-forming lesion that often occurs in young adults with a predilection for the lower limbs and spine. It is characterized by the formation of osteoid tissue, a precursor to bone, and can cause pain and restricted mobility in affected areas. Osteoid osteoma of the hand and fingers is rare, thus representing a diagnostic challenge. A written informed consent was provided from the patient’s father for the publication and sharing all images and clinical data concerning the patient.We are reporting a case of an 11-year-old girl who presented with persistent pain and swelling in her left index finger, as well as limited mobility, over the course of 1 year. Nonsteroidal anti-inflammatory drugs eased the pain, but it resurfaced once the medication was discontinued.A series of investigations, showed a lytic lesion at the second proximal phalangeal neck, with features indicative of osteoid osteoma.Excision with bone grafting was performed as definitive therapy with pathological confirmation of the osteoid osteoma diagnosis. Nevertheless, the patient returned 2 years later with a recurrence of her previous symptoms, and further tests suggested a recurrence of osteoid osteoma. To address the recurrence, a modified open thermoablation technique was used. Thermoablation is a minimally invasive procedure that uses heat to destroy the tumor cells, and it has been shown to be effective in treating osteoid osteoma. The modified open approach involves making a small incision to access the tumor and delivering heat directly through a previously CT-guided inserted Kirschner wire to the affected area.The patient reported no pain at 1 month and 1 year after the surgery, with no radiological signs of recurrence, indicating complete excision of the lesion.Overall, this case highlights the challenges of diagnosing and treating osteoid osteoma in the hands and fingers. Further research is needed to better understand the underlying causes, potential risk factors, and optimal treatment for osteoid osteoma recurrence. It primarily affects men  and manifests in children and young adults. First described in 1935 by Jaffe HL, it is characterized by a reactive bone border surrounding an osteoid-rich core with varying degrees of calcification. The first and most frequently observed symptom of OO is localized pain associated with fusiform swelling. Pain typically worsens at night and is relieved by nonsteroidal anti-inflammatory drugs.,5 It is radiologically described as a spherical single tumor, with a diameter of less than 1.5 cm, exhibiting a core zone of atypical bone known as the “nidus.” Although a computed tomography (CT) scan is thought to be the most precise imaging modality for diagnosing OO, magnetic resonance imaging (MRI) is considered more sensitive than a CT scan in phalanx OOs.Osteoid osteoma (OO), a common, benign, yet painful tumor, constitutes 3% of all bone tumors and 10% to 12% of benign bone tumors.,8The pathological features of OO are a small, round, soft, and hyperemic tumor surrounded by a harder and more sclerotic reactive bone. Microscopically, the nidus comprises a tissue of immature osteoid (woven bone) trabeculae with active osteoblastic rimming. Osteoclasts, capillaries, and nerve fibers can also be found.,5 Involvement of the phalanx is a rare occurrence, with most instances documented in individual case reports. Delayed diagnosis and treatment are not uncommon because of the rare location and the unusual symptoms associated with it. Among these cases, a minority have displayed evidence of recurrence.Approximately 50% of OO cases occur in the lower extremities (thigh and tibia), and only 5% to 10% occur in the hand and wrist.In this case report, we present the clinical course of a patient with OO located on the proximal phalanx of her second finger Figure . InitialTimeline of the case presentation is shown in Figure An 11-year-old girl presented with a 1-year history of left index finger pain associated with progressive swelling and limited mobility in the region of the proximal phalanx. She mentioned that her pain is relieved by nonsteroidal anti-inflammatory medications and recurs upon medication cessation. No previous trauma to the left index finger was mentioned. Upon physical examination, tenderness and swelling at the proximal phalanx of the index finger were noted, along with a range of motion limitation in the proximal interphalangeal joint.At that time, radiographs were taken and showed a lytic lesion localized in the proximal phalanx neck of the left index. An MRI was performed and showed extensive bone marrow edema at the level of the second proximal phalanx with evidence of a well-defined subcortical rounded-shaped lesion of 5 mm, appearing hypointense on T1-weighted imaging, slightly hyperintense on proton density, fat suppression, and T2-weighted imaging, raising suspicion for an OO with associated surrounding soft tissue edema  typically develop in patients younger than 20 years,Upon physical examination and primary X-ray imaging studies, the differential diagnosis included OO, enchondroma, and osteomyelitis, requiring further investigations. Recent literature guided the choice of MRI and scintigraphy, with MRI being a highly sensitive modality for hand OO, while scintigraphy has a detection rate of 96.5%. However, long-term nonsteroidal anti-inflammatory drugs lead to heavy GI disturbances, and some reports mention an increased probability of osteoblastoma transformation. Consequently, conservative treatment was excluded in our case.Conservative management with salicylates and nonsteroidal anti-inflammatory medications is an option, but the average time needed until the resolution of symptoms is 2 to 3 years. While no surgical technique has shown clear evidence of a reduced recurrence rate over another, curettage may increase this risk compared to en-bloc resection due to incomplete mass removal. This assumption led us to opt for an alternative technique when treating the patient’s recurrent lesion. Moreover, en-bloc resection was not considered due to the small bone stock and the high risk of fracture at this unusual location. Furthermore, a percutaneous radiofrequency ablation presented a high risk of soft tissue injury.Nearly one in 10 hand OOs treated surgically showed evidence of recurrence in the known literature. reported a 5% recurrence rate for OO treated with percutaneous radiofrequency alone, the reason for which the combined excision technique was chosen by our team.Thus, the recurrence in our case was addressed using the combined thermoablation and surgical resection technique described previously in this article. Lanza et alThis case report sheds light on a rare instance of OO in the hand and fingers, providing valuable insights for clinical practice. It underscores the need to consider this diagnosis in patients experiencing finger pain and swelling, which can often be misdiagnosed. The report provides a detailed account of the diagnostic process, which includes imaging studies and histopathological examination, assisting clinicians in identifying OO in the hand and fingers. The report also describes a new, less invasive, modified open thermo-ablation technique for treating recurrent OO, which could be a useful alternative to traditional surgical excision. However, it is important to consider the limitations of the case report, including its single-case basis, the applicability of the treatment approach to all patients, and the lack of extensive documentation on long-term outcomes. Despite its limitations, this report offers valuable information on the diagnosis and management of OO in the hand and fingers, which can guide clinicians in improving patient care.Patient was very satisfied, pain free and has returned to daily life activities.When a patient presents with an unusual mass on the phalanges of their hand, it is crucial to consider OO as part of the differential diagnosis. If conservative treatment methods prove ineffective or unsuitable, surgical options should be considered. The primary goal of the surgical treatment chosen must be to eliminate all tumoral tissue, particularly the nidus, in order to decrease the risk of recurrence. Thus, the combined thermoablation and surgical excision technique using CT-guided K-wire marking is a promising technique for the definitive treatment of OO.The authors would like to extend their sincerest gratitude to Dr Noha Bejjani for her willingness to collaborate and her openness to sharing her knowledge. Dr Bejjani’s expertise in pathology and her commitment to accurate diagnoses were critical to the success of this research. In addition, the authors also gratefully acknowledge the expertise of the interventional radiologist Dr Abdallah Noufaily for his valuable contributions to the successful application of the surgical technique described in this article. Prior permission has been obtained from all individuals mentioned in the acknowledgements section.Formal analysis: Perla Naji Audi, Joe Georges Ghanimeh, Khalil Tanios Khalil.Investigation: Perla Naji Audi, Khalil Tanios Khalil.Methodology: Joseph Antoine Mouawad, Khalil Tanios Khalil.Supervision: Khalil Tanios Khalil.Writing – original draft: Joseph Antoine Mouawad, Mohamad Omar Youssef Honeine, Joe Georges Ghanimeh.Writing – review & editing: Joseph Antoine Mouawad, Mohamad Omar Youssef Honeine, Joe Georges Ghanimeh, Perla Naji Audi, Khalil Tanios Khalil.


Pericardial effusions secondary to tumors are commonly metastatic, originating primarily from the lung, breast, and lymphomas. Pericardial tamponade is a rare oncological emergency warranting early identification and treatment. We describe a 66-year-old male found to have a large bloody pericardial effusion causing tamponade physiology, and multimodality imaging was consistent with intrapericardial malignancy with no identifiable primary source. He was subsequently diagnosed with type B3 thymoma after mediastinal resection. In cancer patients, 1 out of 10 patients can have malignant pericardial involvement, with the most common tumors being breast, lung, and lymphomas.2) with a normal heart rate and respiratory rate. It was difficult to assess the jugular vein due to his body habitus. His blood pressure was 138/81, and he had distant heart sounds on auscultation. A 12-lead electrocardiogram showed normal sinus rhythm with low voltage QRS. An echocardiogram to evaluate cardiac causes of dyspnea showed a large circumferential pericardial effusion with features of elevated intrapericardial pressures   , Video 1As a result, the patient was hospitalized and underwent next-day pericardiocentesis with the removal of 1,850 mL of bloody fluid and an additional 1,355 mL through a pericardial drain. Fluid analysis revealed a lactate dehydrogenase of 382 IU/L, protein count of 4.8 g/dL, and cell count with largely bloody fluid . Cultures including bacterial, acid-fast bacilli, and fungal as well as cytology were negative for infectious or malignant cells. Laboratory studies showed normal complete blood counts , and normal liver and renal function tests with mildly elevated C-reactive protein of 3.63 mg/dL.Given constitutional symptoms of weight loss and bloody effusion, additional imaging was recommended to evaluate primary cancerous etiology. Computed tomography (CT) of the chest with contrast revealed a large (7.7 × 2.8 × 8.5 cm) lobulated, heterogeneous, slightly hyperdense anterior mediastinal mass . The pat68Ga-dotatate positron emission tomography/CT (NETSPOT PET/CT) scan, all with no radiographic or biochemical evidence of neuroendocrine tumor.After referring the patient to the endocrinology clinic for neuroendocrine tumor workup, a comprehensive biochemical workup was performed, including chromogranin A, plasma-fractionated catecholamines, plasma-free metanephrines, and NETSPOT max)  . As a re8 Pericardial effusion is an established complication of malignancy, which can occur as a direct consequence of malignancy itself or as an adverse effect of treatment.9 Pericardial tamponade complicating thymoma is rare, with only a few published case reports over the years.12 Despite a higher yield of fluid cytology in malignant cases (50-80%), prior reports of thymoma invading pericardial space have shown nondiagnostic fluid analysis.10Thymomas are a rare malignant neoplasm of thymic epithelial origin located in the anterior mediastinum. They account for 255 of all mediastinal tumors with an incidence of 0.13 per 100,000 person-years. Usually seen in adults aged 45 to 50 years, the tumor has variable clinical presentation ranging from being incidentally detected during chest imaging to causing symptoms  due to direct invasion into surrounding organs like pleural, pericardial space or lungs, or mass effect.13 Usually, thymomas are smooth and homogeneous on CT imaging, unlike our case that had more heterogeneity and irregular/lobulated contour.14 Cine-CMR has an unrestricted field of view with superior tissue characterization utilizing gadolinium contrast when compared to CT.15 It has been studied in evaluating benign from malignant cardiac neoplasms, with the presence of pericardial effusion, first-pass perfusion, and late gadolinium enhancement all supportive of the malignant etiology.16The multimodality imaging approach to this case was essential for clinical decision-making and prognostication. However, significant overlap occurs among different thymic tumors, which can limit diagnostic accuracy.18F-FDG) identifies areas of increased metabolic activity in malignancies. A meta-analysis of 11 studies was conducted to differentiate between low-grade thymomas , high-grade thymomas (type B2 and B3), and thymic carcinomas (type C).13 The threshold proposed was SUVmax of 1.2 between low-risk and high-risk thymomas. Our patient’s SUVmax was 7.8, which was consistent with high-grade and aggressive thymoma. However, given the significant overlap of these semi-quantitative values, an absolute cutoff to discriminate different groups could not be defined.PET/CT using fluorine-18-fluorodeoxyglucose (17 Treatment of nonmetastatic thymoma is complete resection whenever feasible. Furthermore, ongoing research is exploring the potential of immunotherapy as an emerging treatment for thymomas. In our case of unresectable thymoma, the patient is being considered for additional chemoradiation treatments.Type B3 thymomas carry a worse prognosis compared with the lower-risk type A. The treatment may include a combination of chemotherapy, radiation, and/or surgery, with known extreme radiosensitivity of such tumors.Thymomas are rare mediastinal tumors that are largely asymptomatic and small, but on occasion it can invade intrapericardial space and result in large hemopericardium and pericardial tamponade. Multimodality imaging and a multidisciplinary team approach are needed for accurate diagnosis and better treatment outcomes.


Genital myiasis in females is a parasitic infection of the vulval region with the larva of various files species. Only a few cases of urogenital myiasis have been reported in the literature.We present a case of 55 years postmenopausal, farmer female otherwise healthy presenting to the outpatient department with complaints of maggots and severe itching in the vulval region. Examination revealed erythema in the labia major and groin without lymphadenopathy. In the vaginal examination; inflammation and a large number of maggots were observed in the urethral meatus, labia minora, and vaginal canal, progressing to the cervix. With this, she was diagnosed to be a case of urogenital myiasis. She was managed with the extraction of maggots using turpentine oil, along with broad-spectrum antibiotics and Foleys catheterization for a week. Later during follow up, she was asymptomatic and examination revealed no maggots, and the lesions were healed.Extraction of maggots along with symptomatic management is the mainstay of treatment of myiasis. A significant number of the adult population in the rural areas of developing countries are illiterate and are not familiarized with education regarding genital hygiene. So, along with physicians, policy makers should also be involved in public awareness for genital hygiene.Despite being rare, urogenital myiasis is preventable and treatable condition. Efforts at increasing genital hygiene awareness in a low resource country are utmost for its prevention. •Urogenital myiasis is rare case with maggot infestation of the vulval region.•Manual extraction of maggots using turpentine oil, along with symptomatic treatment is the mainstay of treatment.•Public health awareness regarding maintenance of genital hygiene among the women of rural areas must be encouraged. Entry of the larvae occurs through skin wounds or body cavities, such as the mouth, ears, eyes and urogenital tract. This kind of infestation in humans is more spread in humid and warm geographical conditions Genital myiasis is a rare condition with a handful of cases reported to date. The disease is associated with socio-economically poor regions, certain cultural habits, and favorable weather conditions for flies 2A 55-year-old rural woman presented with the complaints of maggots in the vulval region along with severe genital itching. Her family's occupation was farming and animal  husbandry, and belonged from a low economic status. She didn't have any other comorbidities like diabetes, and hypertension. She had a history of vulval ulcer and reported foul-smelling vaginal discharge for the past six months but had not visited the clinic due to fear of social stigma. She reported no history of underlying diseases, trauma, or insect bite to the vaginal area. Neither did she had a history of smoking cigarettes or hookah. In the past twelve months, the patient did not have sexual intercourse as her husband died 1 year ago. She is nulliparous and is in menopause. She reported wearing unclean underpants and skirts.The physical exam revealed erythema in the labia major and around the groins due to severe itching. In the vaginal examination, inflammation and a large number of maggots were observed in the urethral meatus, labia minora, and vaginal canal, progressing towards the cervix. Still, the cervix seemed intact on colposcopy. Infection and necrosis were observed in the labia minora and vaginal canal due to the existence of larvae that ate away the healthy tissues. She was mildly anemic. No significant lymphadenopathy was observed. Her blood pressure was 110/60 mm Hg and her pulse rate was 78 bpm. Per abdominal examination revealed a soft and tender lower abdomen.The patient was managed initially by irrigation with turpentine oil by placing a Foley catheter in the vaginal tract. With intentions to kill the existing maggots and force the ones that might may lie deep in the tract to come out. Side by side broad spectrum antibiotics ceftriaxone (1 g daily) and clavulanic acid (1.2 g twice a day) were started and continued for 7 days. After irrigation with turpentine oil the necrotic tissue of labia minora and majora was excised and existing maggots were manually removed. A catheter was kept in situ for 7 days. She was advised to keep good hygiene and avoid wearing skirts while handling animals and their waste products. The patient returned to her normal routines and on subsequent follow up examinations, there was no larva present.3Dermatobia hominis (human botfly) is found in Central, and Southern America and parts of Mexico. Cordylobia anthropophaga (tumbu fly) is endemic in the sub-Saharan region and is attracted to animal faces and urine. Cochliomyia hominivorax/Phaenicia sericata lays their eggs near poorly managed wounds and larva feed on the dead necrotic tissue causing wound infection. Hypoderma bovis/Gasterophilus intestinalis infections usually occur in rural areas where animals are domesticated, but in humans, they are unable to complete their cycle so the infection is self-limiting in one to two weeks Myia is Greek for fly and myiasis is an infestation of the skin by the developing larvae. Multiple species of fly are indigenous to various parts of the world. Myiasis started to be reported in medieval times and is usually restricted to warm environments like tropics and subtropical regions, but following the advent of frequent international travels individuals from any part of the world can be affected Prevalence of urogenital myiasis is predominantly more in the rural population, associated with poor self-cleanliness hygiene and nourishment. However, a systematic review showed no significant difference in myiasis cases in rural and urban areas The commonly accepted mechanism for genital myiasis is that it occurs through fly eggs transferring through dusty clothes to the genitalia Primary treatment of myiasis includes mechanical extraction of maggots, antibiotics for coexisting infection, pain management, treatment of predisposing factors, and alleviation of risk factors A significant number of the adult population in the rural areas of developing countries like Bangladesh are illiterate and are not familiarized with education regarding hygiene. So, clinicians should emphasize the need for a careful genital exam to identify possibility of rare diseases. The doctor's role in educating patients is also important and must include the stimulation of the development of good hygienic habits among all patients. Simple acts such as regular soap-and-water bathing can prevent diseases such as the one we have described.4Parasitic infestation in humans is a rare phenomenon unless immunocompromised, a large portion takes place due to a lack of personal hygiene and sanitation. The utmost importance of public awareness for women in rural settings and the removal of social stigmata seeing such problems in women must be dealt with meticulously.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Not commissioned, externally peer-reviewed.According to the institutional review committee publishing a case report does not require a letter of approval. So, ethical approval is not applicable to our case report.None.First author.Not applicable.ABS: conceptualization; ABS, AM, SH: Patient care ; SH, AM: patient information collection; SS, MHN, PP, SH: manuscript writing and revision. All authors approved the final version.None.


Acute gastric volvulus is a surgical emergency and is known to occur secondary to diaphragmatic hernia and eventration. Adult presentation of congenital diaphragmatic hernia is rare, with an estimated incidence of around 0.17%, and pregnancy may predispose to the development of symptoms due to increased intra-abdominal pressure. Pregnancy complicated by diaphragmatic hernia is associated with a high risk of maternal and fetal mortality, necessitating timely diagnosis and treatment.We present the case of a 23-year-old female presenting with a symptomatic left Bochdalek hernia complicated by organo-axial gastric volvulus during her second trimester (27 weeks). Emergency laparotomy was performed, with Caesarean section, reduction of gastric volvulus, and mesh repair of the left posterolateral defect. Late presentation of congenital diaphragmatic hernia (CDH) is rare in adulthood, with a reported frequency of 0.17% to 6% in the literature . Common The onset of symptoms in previously asymptomatic women with congenital Bochdalek hernia can occur during pregnancy, with 43 cases reported in the literature between 1941 and 2020 ,7. The aA 23-year-old primigravida at 27 + 6 weeks gestation, who has been receiving regular antenatal follow-up, presented with a history of acute upper abdominal pain and multiple episodes of nonbilious vomiting for one day. She had been diagnosed with incidentally detected left-sided diaphragmatic eventration eight years prior and was not advised surgical intervention as she was asymptomatic. Regular antenatal sonological evaluation had reported elevated left hemidiaphragm with no evident visceral herniation and normal fetal development; hence, the patient had been advised expectant management till term.At presentation, she was tachycardic, with a soft gravid abdomen on examination and reduced breath sounds over the left thorax. The initial ultrasound showed that the stomach and left kidney were located in the left lower thorax, indicating a significant gastric outlet obstruction. Additionally, the ultrasound confirmed good fetal cardiac activity. Nasogastric aspiration was initiated and an erect chest X-ray was taken with abdominal shielding Figure , which s2 23.7 mmHg; lactate 0.2 mmol/L; HCO3 41 mmol/L). Emergency contrast-enhanced computed tomography (CECT) imaging was performed, which showed a left posterolateral diaphragmatic defect measuring 10.2 cm × 9.7 cm. The scan showed herniation of the colon, stomach, spleen, and pancreas and an organo-axial gastric volvulus, resulting in outlet obstruction, and an ectopic left kidney . The decision took into account the potential risks associated with maternal mortality, premature birth, and fetal/neonatal loss. Neonatology was consulted, and antenatal corticosteroids were administered.Emergency LSCS with laparotomy was performed under general anesthesia, with the delivery of a live female baby of gestational age 28 weeks and birth weight 980 g. Intraoperatively, herniation of the stomach with organo-axial volvulus, distal transverse colon, splenic flexure, proximal descending colon, and spleen through left posterolateral diaphragmatic defect was noted Figure .Herniated viscera were noted to be viable; the gastric volvulus and other contents were gently reduced after separating adhesions. An ectopic left kidney in the posterior thoracic wall was also identified and left in situ. The left-sided Bochdalek defect was primarily closed with 1-0 polypropylene and reinforced with a 10 cm × 15 cm composite dual mesh of oxidized regenerated cellulose (ORC) and polypropylene Figure .Postoperatively, the patient was kept on ventilator support for 24 hours. She was extubated on postoperative day 1 and transferred out of ICU on postoperative day 3. She made a full recovery and was discharged within two weeks, with minor respiratory complications. The neonate was preterm at 28 weeks with an Apgar score of 1 and 3 at 1 and 5 minutes, respectively, and required ventilator support and intensive care due to extreme prematurity and respiratory distress. The child expired in the neonatal ICU (NICU) after one day, despite best efforts.The patient reported no long-term sequelae on follow-up after one year. Her chest X-ray was normal at review Figure . She wasGastric volvulus is defined as the abnormal rotation of all or part of the stomach around one of its axes and can be categorized as primary (idiopathic) or secondary based on etiology ,8. They Pregnancy has often been cited as a precipitating factor in the delayed presentation of Bochdalek hernia and, as per a 2016 literature review, was reported in 5.3% of patients presenting with the same. Other recorded risk factors include congenital anomalies such as situs inversus, liver hypoplasia, ectopic kidney, and vascular anomalies .Nevertheless, the actual incidence of symptomatic CDH during pregnancy is unknown and can occur regardless of maternal age and parity. Patients may be initially asymptomatic and develop symptoms during advanced gestational weeks as herniation occurs or even present postpartum . The majThe major maternal complications are compression atelectasis of the lungs, respiratory failure, and strangulation of the herniated internal organs. The risk of maternal mortality increases with the development of gastrointestinal obstruction, possibly due to respiratory distress, bowel strangulation and perforation, fetal hypoxia, and acidosis . In our Chest radiographs, ultrasound, CT, and magnetic resonance imaging (MRI) can be used for the diagnosis of Bochdalek hernias . Chest rUltrasonography is widely used in obstetric imaging due to the absence of nonionizing radiation, easy accessibility, and real-time scanning. Ultrasonography features of CDH include a fragmented diaphragm, inability to identify the liver, spleen, kidney, the superior mesenteric and portal vessels within the normal position in the abdomen, displacement of the heart across the mediastinum, and the identification of bowel and liver in the chest; nevertheless, ultrasonography is insufficient for an adequate diagnosis ,7.In this patient, a diagnostic dilemma was posed by the previous sonological diagnosis of left diaphragmatic eventration and the detection of elevated lipase. CT evaluation confirmed left diaphragmatic hernia with herniation of splenic flexure, stomach, spleen, and pancreas, thus explaining the elevated lipase; the presence of concurrent acute gastric volvulus was also detected on CT.CT remains the gold standard for diagnosing various types of diaphragmatic hernias, with a sensitivity and specificity of 78% to 82% and 87%, respectively ,2. As peRecommendations regarding the management of diaphragmatic hernia in pregnant patients are based on clinical presentation and gestational age . If diagFollowing the repair of the diaphragmatic hernia, vaginal delivery (without bearing down) may be safely conducted as uterine contractions do not increase the intraabdominal pressure and are unlikely to cause rupture at the repaired site ,15. RepaIn conclusion, diaphragmatic hernia should be ruled out with CT in women of reproductive age diagnosed with diaphragmatic eventration, as ultrasonography is insufficient for an adequate diagnosis. If detected during pregnancy, an elective repair can be offered in the second trimester to prevent antenatal and peripartum complications. The onset of obstructive features in otherwise expectantly managed patients is a surgical emergency irrespective of gestational age and fetal maturity.


Large duct adenocarcinoma (LDA) is a rare histopathological variant of pancreatic ductal adenocarcinoma (PDAC) that closely mimics intraductal papillary mucinous neoplasm (IPMN). We present a 74-year-old female diagnosed with LDA in 2017. She was initially managed with chemotherapy and laparoscopic distal pancreatectomy. After five years of stable disease on systemic chemotherapy, she was referred to us to explore further definitive treatments. We used a multidisciplinary approach with curative-intent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC), followed by oral maintenance chemotherapy. Subsequent scans showed stable disease; she eventually underwent neoadjuvant radiation and surgery with intraoperative radiation therapy (IORT) and achieved remission. Pancreatic cancer (PC) is currently the third leading cause of cancer death in the United States with a dismal five-year relative survival of 11.5% . Here, wA 74-year-old female with a past medical history of gastrointestinal reflux disease and irritable bowel syndrome was referred to our cancer center. She had a family history of prostate cancer in her father and liver and urinary bladder cancers in her brother. In February 2017, the patient presented to the emergency department with nausea, diarrhea, and abdominal pain. CT imaging revealed a hypoattenuating pancreatic tail mass measuring 2.6 × 3.6 × 2.1 cm and a distal duct dilatation measuring 5 mm. This mass was biopsied using endoscopic ultrasound with fine-needle aspiration (EUS-FNA), and a few small (<3 mm) dilated side branches were observed in the pancreatic neck and body. Cytology revealed abnormal mucinous glandular epithelium suspicious of a mucinous neoplasm. Laboratory examination showed elevated carbohydrate antigen 19-9  and carcinoembryonic antigen . One month later, the patient underwent laparoscopic distal pancreatectomy and splenectomy. The margins were negative, all 11 regional lymph nodes were negative for malignancy, and the spleen was tumor-free. Surgical pathology revealed a low-grade mucinous neoplasm with areas suspicious of adenocarcinoma. To reach a more definitive classification of this lesion, slides were sent for expert consultation. From the histopathological findings , MutS homolog 2 (MSH2), MutS homolog 6 (MSH6), and PMS2 in the neoplastic cells (microsatellite stable). The patient started adjuvant chemotherapy with gemcitabine, and after completing six cycles (six months), she went on surveillance. Three years later, surveillance CT scan of the abdomen/pelvis detected a nonspecific mesenteric soft tissue lesion within the right lower quadrant (RLQ) and a subcentimeter peritoneal soft tissue lesion within the left upper quadrant (LUQ), both concerning for metastasis. A surgical biopsy of the LUQ peritoneal implant confirmed metastatic adenocarcinoma with mucinous features consistent with the pancreatic primary and CA19-9 . Subsequently, the patient started gemcitabine/protein-bound paclitaxel and had stable disease on surveillance scans. The patient was then referred to us to explore additional treatment options since she had indolent disease for five years. An MRI of the abdomen/pelvis at our center demonstrated slowly increasing metastatic implants  in blood was ordered to look for targetable mutations but did not reveal any somatic alterations, microsatellite instability was not detected, and tumor mutational burden (TMB) was non-evaluable. A CT-guided biopsy of LUQ abdominal nodule performed for molecular testing was negative for V-Raf murine sarcoma viral oncogene homolog B (BRAF) V600E, tropomyosin receptor kinases (TRK) A/B/C, and programmed death-ligand 1 (PD-L1). Due to strong family history of cancer, germline genetic testing from blood was performed but came back negative. The patient continued gemcitabine/protein-bound paclitaxel, and three months later, follow-up MRI showed stable disease, and CA19-9 dropped . Given that her disease was limited to the peritoneum and that she maintained excellent performance status and was motivated for treatment, her case was discussed at the tumor board, and a decision was made to proceed with cytoreductive surgery  and hyperthermic intraperitoneal chemotherapy (HIPEC) with mitomycin C 30 mg and cisplatin 171 mg for 90 minutes and outflow temperature of 41°C-42°C. Surgical pathology showed metastatic adenocarcinoma involving portions of the stomach, omentum, and distal ileum  score was 9. The patient recovered well and started oral maintenance chemotherapy with capecitabine 1000 mg twice per day (BID) for the remaining disease in the pancreatic bed, which could not be resected due to the risk of pancreas leak. After three months, her follow-up scans showed stable soft tissue implant in the pancreatic bed and adjacent nodule abutting the left adrenal gland, so her case was discussed again at the tumor board for a curative intervention. It was decided to stop chemotherapy and undergo surgical resection with intraoperative radiation therapy (IORT). Six months later, the patient underwent distal pancreatectomy, partial duodenectomy, partial left adrenalectomy, cholecystectomy, and IORT. Surgical pathology showed invasive well-differentiated mucinous adenocarcinoma forming a 5.3 cm ill-defined soft tissue mass adjacent to the pancreas; the tumor invades the muscularis propria of the small bowel and abuts the left adrenal gland Figure .Pancreatic and duodenal margins were negative for tumor, and a single celiac lymph node out of the six removed was positive. The patient is currently in excellent status and achieved remission.PDAC is the most common histological subtype of PC ; it presVery few cases of LDA variant have been reported in the literature. Another case reported by Hara et al. described an 82-year-old female presenting with upper abdominal pain and elevated CA19-9 . Contrast-enhanced CT scan showed a 5.2 × 3.7 cm ill-defined multilocular cystic lesion with cyst wall showing gradual enhancement on arterial, portal, and equilibrium phases, as well as “honeycomb appearance” on T2-weighted MRI. The patient underwent distal pancreatectomy, and pathology revealed dilated malignant glands surrounded by fibrotic stroma, supporting the diagnosis of LDA . The patThe prognosis of LDA is similar to that of classic PDAC but drastically worse than IPMN . TherefoWe believe that there needs to be a new paradigm shift in the diagnosis and management of patients with LDA, focusing on a multidisciplinary approach in lieu of our current standard of care approach with only chemotherapy for advanced disease.


Cardiac masses are not common but remain important in cardiology practice as they can cause havoc to a patient's life through obstructive and arrhythmogenic symptoms. These lesions mostly include vegetation, thrombi, and tumors. Myxomas are the most common primary cardiac tumor, primarily arising from the left heart chambers. It is exceedingly rare for a myxoma to emerge from the right-sided cardiac valves. The standard treatment is surgical resection, regardless of size, which is not always possible. We report a unique case of a male with multiple co-morbidities who presented with an incidental finding of a pulmonary valve mass suspicious of being a myxoma. The myxomatous mass was asymptomatic with no right ventricular outflow tract obstruction. Echocardiogram can help identify and characterize these lesions, but this may not be easy, especially in the case of atypical location or morphology of the mass. Similarly, in some cases, the patient may not be able to undergo surgical excision. In such cases, there is no consensus or guidelines to help clinicians best manage the patients medically, creating a diagnostic and therapeutic dilemma. Cardiac masses are not uncommon. These can be divided into neoplastic and non-neoplastic. The non-neoplastic category includes mainly vegetations and thrombi. The neoplastic group is classified into two subgroups: 1) primary cardiac tumors (PCT), which could be benign or malignant, and 2) secondary cardiac tumors, which by definition are malignant. In the heart, metastatic or secondary tumors are more common than PCT . CM is gA 77-year-old Caucasian male presented to the emergency department with worsening shortness of breath, night sweats, low-grade fever, and aggravating fatigue for four months. He denied chest pain, cough, orthopnea, and paroxysmal nocturnal dyspnea. His medical history was significant for chronic kidney disease stage 3 (CKD3), type 1 diabetes mellitus (DM1) complicated by neuropathy, uncontrolled hypertension, and peripheral vascular disease. On admission, his vital signs included a blood pressure of 160/90 mmHg, a temperature of 98.6 °F, a heart rate of 78 beats/min, and oxygen saturation (SaO2) of 90% on room air. On physical examination, the cardiac examination was unremarkable; however, the patient had significant bilateral pedal edema up to the knee. Initial chest x-ray was concerning for bilateral pleural effusions and pulmonary vascular congestion. The electrocardiogram showed left ventricular hypertrophy with secondary repolarization abnormalities, multiple premature ventricular contractions, and ST-segment depressions in V4-V6. Pertinent lab findings included a brain natriuretic peptide level of 2932 pg/mL (0-100pg/ml) and troponin I of 0.458 ng/mL (<0.013ng/ml) with a flat trend. Serum creatinine was 1.72, and Hb was 15.0, both of which were around his baseline. The patient was admitted for non-ST elevation myocardial infarction and acute new onset decompensated heart failure. Transthoracic echocardiogram (TTE) showed a left ventricular ejection fraction of 20-25% with global hypokinesis and a 1.5 x 1.7 cm mass in the right ventricular outflow tract (RVOT).Further evaluation with transesophageal echocardiogram (TEE) revealed the mass to be a homogenous avascular echo-density 1.5 x 1.7 cm on the ventricular side of the anterior pulmonic valve leaflet suspicious of CM. The mass's motion depended on the pulmonic valve Figure , and onlIn the absence of echocardiographic RVOT obstruction or pulmonic valve stenosis along with normal right ventricular systolic function and right ventricular systolic pressure of 25mmHG, the patient's acute symptoms were thought to be secondary to ischemic cardiomyopathy (ICM) with depressed ejection fraction leading to acute congestive heart failure (CHF). Unfortunately, a cardiac CT or MRI could not be performed due to poor renal reserve.Due to advanced age and multiple co-morbidities, the patient was a poor surgical candidate for open-heart surgery, especially with the attempted tumor resection likely requiring valve replacement. He subsequently underwent high-risk staged percutaneous coronary intervention (PCI) followed by dual antiplatelet therapy (DAPT) with conservative management of CM as an outpatient. The patient had no stroke, pulmonary embolism or hospital admissions, or any other complications from myxoma at six months follow-up. In addition, his constitutional symptoms have improved. Repeat limited echocardiogram at six months showed an improvement in ejection fraction (EF) from 25% to 40-45% and stable pulmonic mass at the same location Figure .Primary cardiac tumors are rare. Most tumors are benign, and more than half of those benign tumors are myxomas. Most of them involve the left side, but the involvement of the right side is not uncommon. Valves are rarely affected, and the involvement of pulmonic valves is highly unusual ,6. SometCM affects the middle-aged population, with a female predilection of approximately 3:1 . Right-sThe most critical differentials to consider are a thrombus and valvular vegetations, both of which usually occur in severe atrial dilation, central catheters, atrial fibrillation, and pacemaker . OccasioCM produce vascular endothelial growth factor (VEGF) and platelet-derived growth factor (PDGF), among other cytokines that are responsible for constitutional symptoms . In addiThe standard treatment of CM is surgical resection. With increasing life expectancy, however, the incidence of myxomas is rising in the elderly, creating challenges for surgical treatment ,15. A reHowever, further work is required to evaluate potential treatments for CM in patients who are poor surgical candidates for resection.Our patient has been on DAPT for six months with no complications, including strokes, pulmonary emboli, or worsening dyspnea. Repeat echo shows the stable mass at the same location Figure . UnfortuCM is the most common benign tumor of the heart. It can involve valvular surfaces, although not common. The standard treatment is surgical resection. However, it can sometimes be challenging to confirm the diagnosis and treat it definitively due to the patient's poor renal or cardiac reserve to undergo advanced imaging and surgical excision, respectively.Antiplatelet agents may help reduce both thromboembolic and constitutional symptoms in patients who are poor surgical candidates for resection by decreasing the expression of agents like PDGF and VEGF via antiplatelet activity. However, more studies and follow up of patients not undergoing surgical management are needed to devise the best medical strategy to help these patients avoid thromboembolic complications.