Actinomyces. The symptom of actinomycosis is nonspecific and radiological images present as a slow-progressive mass lesion similarly to malignancies. Thus, it is difficult to distinguish pulmonary actinomycosis from malignancies.Actinomycosis is a rare bacterial infection caused by 18F–fluorodeoxyglucose positron emission tomography/computed tomography was initially diagnosed with esophageal cancer with a lung metastasis because he was asymptomatic. However, aspiration of pleural effusion revealed that the pulmonary lesion was actinomycosis.A 74-year-old male who had esophageal cancer and a pulmonary mass that was positive for We present a case of pulmonary actinomycosis mimicking a lung metastasis from esophageal cancer. Diagnosis of asymptomatic pulmonary actinomycosis is difficult, and needle aspiration could be useful for a definitive diagnosis of pulmonary actinomycosis. Actinomyces species. Actinomyces are facultative anaerobic Gram-positive bacteria [18F–fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT), pulmonary actinomycosis presents as a slow-progressive mass lesion similarly to malignancies. Non-specific symptoms and radiological images make diagnosis of pulmonary actinomycosis difficult [Actinomycosis is a rare chronic granulomatous infection caused by bacteria . The symifficult , 3. In pifficult . Here we3/L, C-reactive protein of 6.07 mg/dL, hemoglobin A1c test of 8.8%, fasting blood sugar of 237 mg/dL on admission. Serum tumor markers, including CEA, CA19–9, SCC, CYFRA, were unremarkable. He underwent esophago-gastro-duodenoscopy for follow-up after endoscopic submucosal dissection for early gastric cancer. The upper endoscopy showed a 0-IIa lesion with relatively large granular nodules on the lower thoracic esophagus  700 mg/m2 day1–4 on the day 4 after admission. On the day 8, CT revealed a slight pleural effusion in the right side  to prevent relapse. Risk factors associated with the acquisition of Actinomyces are diabetes mellitus, male sex, and immunosuppressive condition such as a use of steroid and alcoholism [Actinomyces. The patient had primary esophageal cancer and past history of primary pulmonary adenocarcinoma, which made a diagnosis difficult. However, a high fever after starting chemotherapy gave us a clue of the infection and prompted us to perform needle aspiration of the pleural effusion.Actinomycosis is a rare and chronic bacterial infection caused by omycoses . As actind chill , which iG uptake , 3. The G uptake . For a dG uptake , 10. Regcoholism . In thisEven though rare, pulmonary actinomycosis should be included in differential diagnosis of PET/CT positive pulmonary mass without any symptoms. Especially, if a patient has other primary malignant lesions, it is difficult to distinguish pulmonary actinomycosis from a lung metastasis. If available, needle aspiration could be useful for a definitive diagnosis of pulmonary actinomycosis.


We report a rare case of large immature retroperitoneal teratoma in a neonate. The diagnostic and therapeutic challenges of dealing with such a case have been discussed and the relevant literature reviewed. A 14-day-old female neonate, born at term, product of non-consanguineous marriage with normal antenatal scan and an uneventful pregnancy, was admitted with complaint of progressively increasing mass in left abdomen for 5 days. Abdominal examination revealed single nonmobile, non-peristaltic, non-pulsatile, non-compressible mass with variegated consistency and involving left lumbar, left hypochondrium, left iliac fossa and umbilical region, crossing the midline 2cm on the right side. Haematological investigations were normal. Serum alpha fetoprotein was 3338 IU/ml, and β-human chorionic gonadotrophins as 0.136 IU/ml. Her 24 hours urinary vanillyl mandellic acid was also normal. Plain x-ray showed bowel gas shadow pushed to right side by large space occupying lesion on left side of abdomen with calcification. Ultrasonography of abdomen showed large solid and cystic mass in left abdomen with internal vascularity, the left kidney was not seen separately. Contrast enhanced computed tomography of abdomen revealed a large relatively well-defined heterogeneously enhancing mass lesion of size 13x 9.5x 9 cm, involving the entire left half of abdomen (Fig. Intraoperatively, a large solid cystic mass was engulfing the left kidney (Fig. The post-operative period was uneventful. The patient has been doing well on 7 months follow-up with no clinical, radiological and biochemical evidence of any recurrence. et al. [Incidence of retroperitoneal teratoma is bimodal with peaks in the first 6 months of life and in early adulthood , 2. Retret al. ; of theset al. .The prognosis of neonatal teratoma is favorable with an 80-100% survival reported after surgical excision of the tumor and treatment of any recurrence . AdjuvanSource of Support: NoneConflict of Interest: None


We describe a ten-year-old male with bilateral giant hydronephrosis due to pelviureteric junction obstruction presenting with abdominal distension and renal failure. The diagnosis was confirmed on computed tomography and required a two-stage procedure, initially percutaneous nephrostomy followed by Anderson–Hynes pyeloplasty with recovery of kidney function. Pelviureteric junction obstruction is the usual cause of childhood hydronephrosis. Giant hydronephrosis is defined as either pelvicalyceal system dilatation containing more than one litre of urine  or causiA ten-year-old male child was admitted with a history of abdominal swelling of 5-year duration. The rest of the history was remarkable for absence of other complaints. His height and weight was between 3rd and 10th centiles as per the CDC chart, and blood pressure was 150/92 mmHg in right upper limb supine position (above 95th centile). On abdominal inspection, he had distension mostly in the lumbar areas, hypogastrium with eversion of umbilicus, flaying of ribs, cystic on palpation, and dull on percussion with absent bruit or rub . At admiHydronephrosis can reach surprisingly massive proportions without causing symptoms. Stirling in 1939 defined giant hydronephrosis as presence of more than 1000 mL of fluid in the collecting system [Crooks et al.  did a reGiant hydronephrosis occupying the entire abdomen can mimic ascites to a great extent. Paracentesis in these cases could be detrimental causing pyelonephrosis, sepsis, and shock. Other cystic lesions like mesenteric, choledochal cysts , renal adrenal, or pancreatic pseudocysts  are the differential diagnosis. Each one of these entities could be differentiated by abdominal ultrasonography.Giant hydronephrosis is usually asymptomatic. Abdominal ultrasonogram is the first diagnostic modality but may be inconclusive, and CT or MRI may be needed .Management of giant hydronephrosis requires a two-stage procedure with initial slow decompression by percutaneous nephrostomy . Harper In contrast to our case, nephrectomy of right giant hydronephrosis was done in a 6-year-old male by Sharma et al. . Severe With advancement in antenatal screening, dilatation of the urinary tract is detected in utero and managed. According to the Consensus statement on management of antenatally detected hydronephrosis , surgicaIn conclusion, giant hydronephrosis can present as a painless abdominal swelling. As a close mimic to gross ascites, the condition should be considered as a differential diagnosis with caution prior to procedures such as paracentesis. Early relief of obstruction using a two-stage procedure of nephrostomy followed by pyeloplasty may lead to preservation of renal function.


Atraumatic splenic rupture is a rare complication of a pancreatic pseudocyst (PP), described in the setting of chronic pancreatitis. There is common understanding, within the literature, that an inflammatory process at the tail of the pancreas may disrupt the spleen and result in such splenic complications. The authors present a case report of a 29-year-old male with a PP, associated with chronic pancreatitis. The patient had a history of excessive alcohol intake and presented to the emergency department with a short history of abdominal pain and vomiting. He denied any significant history of trauma and serum amylase levels were normal. An admission computed tomography (CT) scan of the abdomen confirmed the presence of a PP in direct contact with the spleen. The CT also demonstrated a heterogenous hypodense area of the splenic hilum, along with perisplenic fluid. The patient was admitted for observation. His abdominal pain progressed, and he became haemodynamically unstable. An emergency ultrasound scan (USS) at this time revealed intra-abdominal haemorrhage. A subsequent CT confirmed splenic rupture, which was managed surgically with a full recovery. Few such cases are documented within the literature and more understanding of preempting such events is needed. Splenic rupture is a relatively common and well-documented phenomenon, typically following substantial blunt abdominal injury . There aPancreatic pseudocysts (PPs) are found in 20–40% of patients with chronic pancreatitis . PPs areA 29-year-old male, with a history of excessive alcohol intake and chronic pancreatitis, presented to the emergency department at The Chrissie Tomlinson Memorial Hospital, Cayman Islands. He exhibited a 24-hour history of abdominal pain, which was increasing in intensity, without a history of significant trauma. He also had associated vomiting. An abdominal examination revealed upper abdominal tenderness but no signs of peritonism.The patient was investigated with ultrasound scan (USS) that revealed a PP . A compuOver the following 24 hours, the patient became haemodynamically unstable and showed signs of peritonism. An USS revealed intra-abdominal haemorrhage , which wChronic pancreatitis, as in this case, can be complicated by the development of a PP in 20–40% of patients . A PP isRupture of the spleen is a well-documented event but is most commonly associated with blunt abdominal trauma . HoweverThe pancreas and the spleen are anatomical allies and for this reason complications involving the spleen can occur as a result of pancreatitis or PP. Involvement of the pancreatic tail via pseudocysts or necrotizing pancreatitis has previously been shown to predispose patients to complications involving the spleen, such as splenic or portal venous obstruction and subcapsular haematomas , 21, 23.At presentation, the CT scan showed an area of concern within the spleen. Hypodense areas of the spleen are commonly encountered on abdominal CT images, but the nature of these can be difficult to interpret and should be correlated with clinical findings. The majority of such lesions are benign and do not require specific follow-up or management; however, some findings along with clinical circumstances may necessitate further consideration . VariousWe have reported a case of PP directly contributing to ASR, with no evidence of trauma. There have been several mechanisms of ASR secondary to PP described in the literature. It is possible that they all contribute towards ASR, and they have been included below for consideration: (1) dissection of the retroperitoneal sheath comprising the splenic vessels, leading to significant haemorrhage from the splenic artery, due to its anatomical location , (2) disASR secondary to PP in the absence of acute pancreatitis is a rare complication. We have hypothesised the pathogenesis for this infrequent occurrence. ASR should be considered and carefully monitored in patients complaining of abdominal pain where imaging highlights a PP in direct contact with the spleen or in patients with known PP who develop haemodynamic instability. We postulate that the hypodense appearance of the spleen in this case was suggestive of imminent rupture. We hope that increasing the awareness of such phenomena will enable emergency departments to diagnose similar cases.


Mucinous cystic neoplasm of the liver with extrahepatic growth is a rare benign epithelial neoplasm of the biliary system that presents with a mass effect or is incidentally found on imaging. The tumor affects mostly the common hepatic duct, which is difficult to diagnose preoperatively by radiology, endoscopy, or cystic fluid analysis. Endoscopic ultrasound is a noninvasive tool for the evaluation of features of a cystic lesion and the extent of disease. Optimal treatment is complete tumor resection.A 27-year-old Thai woman was referred to our hospital for investigation and treatment of clinical symptoms of obstructive jaundice and ascending cholangitis, as well as an unknown cause of obstruction. Multiple investigations were performed, including endoscopic retrograde cholangiography and magnetic resonance imaging. Endoscopic ultrasound showed a multiloculated cystic lesion with internal septations without communication to the bile duct, which helped to support a diagnosis of mucinous cystic neoplasm. Eventually, the pathological diagnosis made was mucinous cystic neoplasm of the bile duct. A follow-up clinical examination with imaging at 6 months revealed that the patient was asymptomatic and without recurrence.We report a rare case of a patient with a large mucinous cystic neoplasm of the liver with extrahepatic growth causing biliary obstruction, which was diagnosed on the basis of endoscopic ultrasound features. Following definitive diagnosis, treatment with complete surgical resection using a multidisciplinary approach was successful. Mucinous cystic neoplasm of the liver (MCN-L) with extrahepatic growth is a rare benign epithelial neoplasm of the biliary system. This tumor commonly originates in the intrahepatic bile duct, with less than 10% of cases occurring in the extrahepatic bile duct or gallbladder . These tWe report what is to the best of our knowledge the first published case of MCN-L with extrahepatic growth in Thailand. Our patient presented with ascending cholangitis at a local hospital and was then referred to our university teaching tertiary care hospital. We needed to perform multiple procedures for investigation and biliary drainage before arriving at a definitive diagnosis and treatment. A literature review on investigations and management of MCN-L is included.On 1 November 2016, a 27-year-old Thai woman was referred to our hospital from a local hospital with progressive jaundice, abdominal pain, and intermittent fever with chills. She had initially been treated with antibiotics, and she had seemed to recover for a few days, but the symptoms returned, and she was referred to our hospital. She was unemployed and had no history of comorbid disease, blood transfusions, intravenous drug use, or family history of viral hepatitis or liver disease. On physical examination, she appeared unwell with a high-grade fever and moderate icteric sclera. Her abdomen was soft with significant abdominal distention and mild tenderness at the epigastrium with a negative Murphy’s sign; liver 10 cm with a firm consistency, smooth surface, and blunt edge; was shifting dullness-negative; and had no cutaneous signs of chronic liver stigmata.Results of the patient’s liver function tests were abnormal: total bilirubin 8.11 mg/dL , direct bilirubin 7.06 mg/dL , aspartate aminotransferase 169 U/L , alanine aminotransferase 182 U/L , and alkaline phosphatase 992 U/L . The patient’s viral hepatitis B and C profiles were negative. Magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) of her abdomen had been performed at a local hospital before her referral. These images showed dilation of the left intrahepatic and common hepatic ducts with the presence of an enhancing oval-shaped filling defect 3 × 5 cm in size at the common hepatic duct, which was initially suspected to be a common hepatic duct stone. She was referred to our hospital, where she underwent endoscopic retrograde cholangiopancreatography (ERCP) for removal of the stone, which was found to be a large oval-shaped filling defect in the common hepatic duct with left intrahepatic duct dilation. The stone could not be removed. A biliary double-pigtail plastic stent was successfully placed above the filling defect for biliary drainage. A second ERCP was performed for stone removal, but the lesion was fixed and could not be removed. Intraductal ultrasound was used to identify the lesion after removal failure. These images showed hypoechoic content in a large filling defect with internal septation Fig.  and b. IThe advanced endoscopy team thought that this lesion might be a cystic tumor, so endoscopic ultrasound (EUS) was performed, which demonstrated dilation of the intrahepatic bile duct and a thin-walled, multiseptated cystic lesion in the common hepatic duct with anechoic intracystic fluid content and without mural nodules or papillary projections Fig. . Cystic Previous MRI with MRCP that showed an enhancing wall, multiloculated, and septated cystic lesion about 5.6 × 2.3 cm in size in the common hepatic duct, which was not communicating with the bile duct Fig. , was revAfter receiving a complete course of intravenous antibiotics and biliary drainage, the patient was clinically well with improved jaundice and fever. At her 2-week follow up, she was anorexic with abdominal distention.The definitive treatment was complete tumor resection and left hepatectomy. Gross examination of the surgical specimen demonstrated a large, oval, thin-walled cyst in the common hepatic duct extending to the left proximal intrahepatic duct causing biliary dilation Fig. . The cysAt her 6-month follow-up after complete tumor resection, the patient was doing well, with normal liver function tests and without evidence of recurrence.MCN-L is a rare benign cystic neoplasm of the biliary system, with an estimated incidence of about 5% of all hepatobiliary cystic neoplasms. This cystic tumor is very rare in the extrahepatic biliary system and gallbladder –3, 7. MCMCN-L with extrahepatic growth is usually a single, multiloculated cystic tumor characterized by the presence of a single layer of cuboidal or nonciliated columnar epithelium resting on a basement membrane Fig. . MesenchThe majority of MCN-L cases do not communicate with the bile duct . RadioloEUS is a noninvasive tool for diagnosis of MCN-L, with few reported cases of EUS features in this tumor. EUS can reveal significant features of an MCN-L, most notably a well-defined, multilocular cystic lesion with a thick-wall containing multiple septations or papillary projections, without communication between the cystic tumor and bile duct. EUS can identify mural nodules and wall irregularities more clearly than other imaging modalities, which can help predict the risk of malignancy. EUS intervention can also be used for cystic fluid aspiration and/or target wall biopsy before surgical planning , 6. A feERCP is useful for diagnosis and therapeutic procedures in biliary cystadenoma in patients who present with obstructive jaundice, ascending cholangitis, or hemobilia. The ERCP finding in MCN-L with extrahepatic growth is a well-demarcated filling defect with proximal bile duct dilation (obstruction) and a tumor that is not communicating with the bile duct , 8.MCN-L with extrahepatic growth is potentially malignant, for which complete surgical resection is the treatment of choice with the lowest recurrence rate , 6. The We report a rare case of a large MCN-L with extrahepatic growth causing biliary obstruction that was diagnosed on the basis of EUS features. Following definitive diagnosis, we were successful with complete surgical resection using a multidisciplinary approach.


Internal jugular vein (IJV) phlebectasia is a rare condition presenting as a self-reducible soft tissue swelling of the neck due to fusiform dilation of the venous wall. We report the case of a 7-year-old boy who presented with painless soft mass in the side of the neck which appears during coughing and straining and reduces spontaneously. Diagnosis was confirmed by Doppler ultrasonography and magnetic resonance imaging of the neck. Conservative management and regular follow-up were considered. In this case report, we highlight this rare benign condition as an uncommon differential of neck swellings in order to avoid unnecessary diagnostic workup and interventions. Phlebectasia is an abnormal fusiform dilation of a vein. It is a rare venous malformation, and etiology is not clear. It occurs more commonly in the upper extremity and cervical veins and tends to be asymptomatic without serious consequences as opposed to lower limb venous aneurysms which may complicate with pulmonary thromboembolism in adults. Phlebectasia differs from venous aneurysms, which are usually secondarily acquired, segmental, saccular, and typically seen in adults. It also differs from varices which are tortuous dilations of the veins.A 7-year-old otherwise healthy boy presented to outpatient department with a complaint of a painless lump appearing on the right side of the neck while coughing, noticed for the past 3 days. It was not associated with fever, coryza, dyspnea, dysphagia, dysphonia, or facial congestion. There was no history of pain or antecedent trauma or surgery. Family history was unremarkable. On examination, his anthropometric measurements were within the normal range. He had 3 × 3 cm, nontender fusiform swelling in the right side of the neck, anterior to the sternocleidomastoid muscle, appearing only at the time of coughing, extending to the anterior triangle of the neck, and the clavicle . There wPhlebectasia indicates outward dilatation of the vein without tortuosity and thus is different from the varix. Zukschwerdt first reported this condition in 1929 and was subsequently described by Gerwig .Jugular venous phlebectasia has been more commonly described in pediatric population, presenting as a soft compressible swelling in the neck and increasing in size during coughing, crying, sneezing, or Valsalva maneuver. It has been reported to be found in all neck veins, though most commonly occurring in the IJV, followed by the external jugular vein, anterior jugular vein, and other communicating veins. It is twice more common in boys as compared to girls and usually occurs on the right side . The etiIt is a relatively benign condition, and conservative management is the norm. Surgical treatment is indicated in case of complications like phlebitis, thrombosis, and Horner's syndrome or for cosmetic reasons. Surgical options include ligation of the jugular vein, excision of the dilated segment , and sheThis case report highlights phlebectasia of the IJV, a rare benign condition as a differential of neck swelling. Enlargement of the neck mass on Valsalva maneuver observed in this condition limits the differential diagnoses to laryngocele and superior mediastinal cyst or tumor, branchial cyst, cystic hygroma, and cavernous haemangioma. The Doppler study is useful to differentiate it from laryngocele. Since this condition is an extreme rarity, one must keep high index of suspicion to diagnose it and avoid unnecessary interventions.


Mixed epithelial and stromal tumors (MESTs) of the kidney are rare renal neoplasms characterized by mixed cystic and solid components. These tumors are typically present in middle-aged women as a flank mass, or as a cause of flank pain or hematuria. We outline the case of an older male who presented with an enlarging abdominal mass causing symptoms that suggested a partial small bowel obstruction. Management of the patient and a brief review are discussed.


We report a rare case of a mature cystic teratoma found in the retroperitoneum of a 28-year-old woman with vague symptomatology. We review the radiologic and pathologic features of this rare lesion. Teratomas are nonseminomatous germ cell tumours that arise from abnormal development of pluripotent embryonal germ cells . The retA 28-year-old woman presented with a vague history of right upper quadrant fullness, vomiting, and worsening upper abdominal pain for eight-week duration. There were no other associated symptoms present.Physical examination findings were limited to the abdomen. A firm, immobile, nontender mass was palpable in the right upper quadrant. Laboratory investigations revealed a mildly elevated CEA of 7.3 ng/ml . The remaining blood investigations were normal: haemoglobin was 13.8 g/dl ; CA19-9 was 10 IU/ml , CA125 was 6.95 U/ml , 6 AM cortisol was 11.6 ug/dl , and AFP was 8 ng/ml .Contrast-enhanced computerized tomography (CT) scans revealed a well-circumscribed cystic mass occupying the entire right upper quadrant of the abdomen . The masThe lesion was deemed resectable. Therefore, she was prepared for anaesthesia and taken for exploratory laparotomy. At operation, a large cystic mass was encountered within the retroperitoneum. Thorough exploration of the general abdominal cavity revealed no evidence of metastatic disease or ascites. The mass could be dissected from the diaphragm, liver, pancreatic head, duodenum, transverse mesocolon, and vena cava. There was a tissue plane separating the mass from the right kidney, but there was not a distinct plane that separated it from the right adrenal gland. Therefore, the right adrenal gland was excised en bloc with the mass.A heterogeneous mass was removed and sent for histopathologic evaluation. The cyst wall was 4 mm thick. On sectioning, the cyst contained thick yellow fluid, hair, and sebum . The masThis patient had an uneventful postoperative recovery period. She was discharged at day five after operation and has remained well two years after resection.Teratomas are nonseminomatous germ cell tumours that arise from pluripotent embryonal germ cells . Germ ceTeratomas in the retroperitoneum are uncommon. They constitute between 1%  and 10% In the retroperitoneum, these lesions usually remain asymptomatic until they have attained a large size, thus producing compressive symptoms or mass effect. There are no pathognomonic features of a retroperitoneal teratoma on plain radiographs, although they may demonstrate calcification. Ultrasound is a useful first investigation because it can differentiate between solid and cystic components and may be able to detect calcification, teeth, and/or bone . But theTumour markers, such as alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), CA19-9, and CA125, are routinely evaluated in patients with suspected teratomas. We reviewed four large retrospective studies that evaluated tumour marker levels in a total of 970 patients with mature cystic teratomas , and torAlthough some authors have reported elevated CEA levels in patients with malignant conversion in retroperitoneal teratomas , 14, theMalignant lesions are notoriously resistant to systemic chemotherapy and irradiation . TherefoMature retroperitoneal teratomas are rare lesions. They are typically asymptomatic, although they may be diagnosed preoperatively by imaging with CT and MRI. Surgical resection is the mainstay of treatment for mature retroperitoneal teratomas, yielding near 100% 5-year survival when margins are oncologically clear.


We report a case of a 1-month-old infant with spontaneous thymic hemorrhage secondary to severe vitamin K deficiency. He was brought to medical attention due to scrotal bruising and during evaluation was noted to be tachypneic and hypoxemic. Chest X-ray revealed an enlarged cardiothymic silhouette, and a follow-up echocardiogram revealed a mass in the anterior mediastinum. Routine laboratory work-up revealed severe coagulopathy. Further questioning revealed the patient had not received prophylactic vitamin K at birth. The coagulopathy resolved with administration of vitamin K, and a biopsy confirmed the anterior mediastinal mass was due to spontaneous thymic hemorrhage.  Vitamin K deficiency bleeding (VKDB), formerly known as hemorrhagic disease of the newborn, is a coagulopathy infants acquire due to insufficient vitamin K stores. Vitamin K is necessary for the synthesis of functional forms of coagulation factors II, VII, IX, and X in the liver . These pA term 28-day-old male, born at home, was referred by the family midwife to the emergency department for ecchymosis of his left hemiscrotum. This exclusively breastfed infant, without significant family history, had been thriving at home when the parents noted acute discoloration of his right testicle at 26 days of age. In the 24 hours prior to admission, the discoloration of his right testicle migrated to the left testicle. His parents reported that he had become progressively fussy with decreased oral intake and appeared more pale. The parents denied increased work of breathing, fevers, apnea, cyanosis, emesis, or rash.The parents stated that he had been previously healthy. Prenatal care was provided by a midwife, and prenatal labs were reported as negative. A prenatal ultrasound performed at home by the midwife at mid-gestation was reported as normal. Pregnancy was uncomplicated, as was his spontaneous vaginal delivery. The infant did not receive vitamin K prophylaxis at birth, though his mother was taking oral vitamin K, a prenatal vitamin, and herbal supplements daily. The baby was taken care of by his parents, who were Mennonite. There was no consanguinity. The baby's father had flu-like symptoms the week of his admission; otherwise there had been no known sick contacts.3/μL), a markedly abnormal prothrombin time , a profoundly abnormal partial thromboplastin time , and a normal fibrinogen . Based on the severely abnormal coagulation studies, the patient was treated acutely for suspected vitamin K deficiency related bleeding. The patient received three IV doses of vitamin K, packed red blood cells , fresh frozen plasma (15 mL/kg), and platelets (15 mL/kg). Within 6 hours, the infant's hematologic indices normalized and his clinical bleeding resolved.On arrival to the newborn intensive care unit, the infant appeared lethargic, pale, and jaundiced and had evidence of oozing from peripheral IV attempts. His left hemiscrotum was purpuric; otherwise, there was no evidence of bruising or petechiae. He had increased work of breathing with retractions and had a normal cardiac and abdominal exam. He had no dysmorphic features and other than lethargy had an appropriate neurological exam. An anterior-posterior (AP) chest X-ray  performeDespite resolution of the coagulopathy, the anterior mediastinal mass remained. The differential diagnosis included venous or lymphatic malformations, thymic enlargement, or rarer tumors. Therefore, further diagnostic imaging of the anterior mediastinal mass was pursued. A chest ultrasound revealed a solid mass without cystic components, making an infantile lymphangioma unlikely. A CT of chest/abdomen/pelvis  demonstrThe infant underwent ultrasound-guided biopsy of his mediastinal mass on the hospital day following admission once his coagulopathy had resolved. This biopsy was critical in making the diagnosis of spontaneous thymic hemorrhage. Representative histology of the mass is shown in μg/L) compared to adult levels [μg/L) is significantly lower (60 μg/L) than found in formula [Newborns, in particular those who are exclusively breastfed, have multiple risk factors for VKDB. First, placental transfer of vitamin K is limited with extremely low cord concentrations . Classic VKDB occurs between 2 and 7 days of life and is primarily secondary to inadequate feeding. Late VKDB arises between day 8 and 6 months of life, with peak incidence between 3 and 8 weeks. This form nearly always occurs in exclusively breast-fed infants and is often associated with undiagnosed hepatobiliary dysfunction impairing absorption of vitamin K .To prevent all forms of VKDB, administration of intramuscular vitamin K at birth has been a standard practice in the United States since 1961 when the American Academy of Pediatrics' recommended the injection for all newborns . WithoutThe clinical presentation of early and classic VKDB is variable, with bleeding most commonly occurring from the gastrointestinal tract (53%) and umbilicus (23%) . The mai1 (synonyms include phylloquinone and phytonadione) [Given the potential catastrophic consequences of VKDB and the attenuation of the disease with treatment, rapid diagnosis is paramount. A confirmed case fulfills the following diagnostic criteria : (1) elenadione) . For lifnadione) .Despite the most common manifestations of VKDB outlined above, our patient's thymic hemorrhage is an exceedingly rare clinical presentation. Our literature review identified four case reports of neonatal thymic hemorrhage –16. ThreIn the present case, the overwhelming concern was the anterior mediastinal mass. Although the vitamin K deficiency was diagnosed and corrected early in the infant's hospitalization, the work-up of the anterior mediastinal mass continued. While the differential diagnosis included spontaneous hemorrhage into normal thymic tissue, malignancy or vitamin K associated bleeding into benign or malignant tissue could not be ruled out.Anterior mediastinal masses in neonates and infants could represent venous or lymphatic malformations and thymic enlargement . Rarer possibilities include germ cell tumors (primarily teratomas), neuroblastoma, rhabdomyosarcoma, lymphoma, Langerhans cell histiocytosis, or Wilm's tumor . HoweverVenous and lymphatic malformations represent a diverse category of rare lesions that are nevertheless most commonly described in neonates and infants. The most common of these are infantile lymphangiomas (formerly known as cystic hygromas) and kaposiform hemangioendotheliomas (KHE). Lymphangiomas are benign congenital malformations characterized by proliferation of normal lymphatic tissue and are frequently cystic in nature . They arPrimary thymic enlargement represents about 2–4% of all pediatric mediastinal masses and can occur secondary to a variety of etiologies . Thymic While lymphoma is a common cause of mediastinal mass in older pediatric patients , it is eIt is crucial as a medical provider to be aware of the varied presentation of VKDB in the neonatal period. Although they are a relatively rare constellation of signs and symptoms, a nonconsumptive coagulopathy, respiratory distress, and an anterior mediastinal mass should prompt the work-up of acute thymic hemorrhage. Vitamin K deficiency bleeding should be suspected and treated as an emergency in this situation. As in our reported patient, prompt recognition and diagnosis can lead to rapid clinical resolution and avoidance of thoracotomy. Our case also led to an educational opportunity on the critical importance of vitamin K prophylaxis at birth.


Meningiomas are most often benign primary intracranial tumors that are frequently found incidentally on imaging. Larger sized meningiomas may present with symptoms such as seizures and headaches. Smaller meningiomas are commonly asymptomatic and usually observed with serial imaging. We present two female patients, both of whom were found to have very small left frontal meningiomas that marginated Broca’s area. The first patient in this case series experienced episodes resembling seizures which consisted of weakness, vision loss, and slurred speech, as well as subtle language dysfunction in her day-to-day conversations. The second patient presented with headaches and an enlarging meningioma. Both meningiomas were surgically resected and the patients’ symptoms resolved. Small meningiomas should not be overlooked as they may very well be the source of neurologic symptoms. Meningiomas are primary central nervous system (CNS) tumors that arise from arachnoidal cells of the leptomeninges . With anCase 1A 48-year-old right-handed female presented in May 2015 with severe weakness, vision loss, and slurred speech. Her spells were accompanied by dysphasia and a sense that her tongue was large or heavy. She had recurring episodes of migraine headaches and episodes of tunnel vision and anxiety, although it was not clear if these were secondary to anti-epileptic drugs (AEDs). Electroencephalogram (EEG) testing, done twice, showed no seizure activity despite the seizure-like episodes she described. Her magnetic resonance imaging (MRI) revealed a left frontal calcified extra-axial lesion superior to the Sylvian fissure measuring 5 mm x 8 mm x 8 mm  of the tumor in September 2016 Figure . PatholoCase 2A 36-year-old right-handed female presented with vertigo and left-sided pulsatile headaches in November 2015. The patient’s neurological exam did not reveal any abnormalities. MRI of the brain showed a left frontal 6.2 mm x 9.8 mm x 13.4 mm lesion Figure -B. The aThe patient underwent GTR of the tumor in September 2016 Figure -B. PathoIn this case series, we illustrate the role of surgical resection of two very small left frontal meningiomas in two right-handed female patients. The first patient had a calcified meningioma, suggesting that the tumor would grow slowly, if at all . In a stThe second patient’s meningioma grew during a six-month period. Given the tumor’s location in the speech and language areas and her young age, the neurosurgeon advised resection. Interestingly, the meningioma of this patient stained positively for progesterone receptors. There has been speculation about a relationship between meningiomas and hormone receptors due to the increasingly higher incidence of these tumors in the female population , 9-10. TDespite the treatment plan for tiny meningiomas being vague, stereotactic radiosurgery (SRS) has been established as an option for patients who decline surgical resection. SRS has shown to have more favorable side effects and a 90% tumor control rate for small meningiomas . Thus, pThis report of two patients with two very small meningiomas, in an eloquent area, demonstrates that small meningiomas should be considered for surgical resection when symptomatic and/or growing. Although not initially apparent, small meningiomas may be the source of seizure-like symptoms. Hormone receptors on meningiomas should not be overlooked as further investigation may show progesterone’s role in meningioma growth and WHO grade.


Ventricular band cyst is a rare condition in children but can result in severe upper airway obstruction with laryngeal dyspnea or death. The diagnosis should be considered in any stridor in children with previous history of intubation or respiratory infections. We report a case of a 4-year-old girl, received in an array of severe respiratory distress, emergency endoscopy was done, and a large ventricular tape band cyst obstructing the air way was found. Complete excision was made, and postoperative prophylaxis tracheotomy was done. The postoperative course was uneventful with improvement of clinical and endoscopic signs. Ventricular band cyst is a rare laryngeal malformation, which can be life-threatening with severe obstructions. This is a surgical emergency which has variable clinical manifestations, presented mainly by stridor and respiratory distress. Diagnosis is based on clinical examination, but direct endoscopy plays a diagnostic as well as therapeutic role.This is a 4-year-old patient with no significant previous medical history. She was followed for 1 year for intermittent dyspnea, which became persistent and progressively worsened a week before admission. She was presented to the emergency room on 03.02.2015 for severe laryngeal dyspnea.Clinical examination revealed an acute asphyxia with hyperextended neck and stage 4 laryngeal obstruction. Direct laryngoscopy was done urgently, and we found a round cyst, with vascular maze on the wall, originating in the left ventricle, encroaching on the root of the epiglottis, and completely blocking the vocal cords . The cysPostoperative prophylaxis tracheotomy was performed. The postoperative course was uneventful. Postoperative control endoscopy was done at day 20 and a recurrence of the cyst was seen, for which complete resection was done endoscopically. The child is decannulated during this operation. A second control endoscopy was done at day 50 and the respiratory air way was free . The finIt has been 20 months and there is no recurrence.Congenital or acquired laryngeal cysts are rare and are classified as glottic, supraglottic, and subglottic cysts. Zalagh et al. classified the laryngeal cysts according to their location: vocal cords 58.2%), ventricular fold 18,3%), vallecula (10.5%), epiglottis (10.1%), and aryepiglottic fold (2.2%) [8,3%, val%, ventriThe epiglottic and ventricular band cysts are retention type . ChronicThis phenomenon occurs especially during episodes of superinfections , 7 or laWe have not found a history of intubation in our patient but had episodes of respiratory infections, which could explain the formation of the cyst.Clinical signs, depending on the size and location of the cyst, manifest as stridor, dysphagia, and respiratory distress due to the narrow laryngeal conduit in children , 2, 5, 8Such patients are often treated wrongly as asthma or laryngomalacia  as was tDirect laryngoscopy remains the gold standard for the diagnosis of these laryngeal cysts , 5, 8–10Treatment of these cysts is essentially surgical, endoscopic, or external approach. Excision of the cyst as a whole is the best method to prevent recurrence; , 12 the In our case, the intervention had consisted of an incision with aspiration of the content and marsupialisation followed by prophylactic tracheotomy, giving priority to opening the airway of the patient. Tracheotomy may be used for intubation in large obstructive cysts , 13, 14.Laryngeal cyst is a rare cause of laryngeal dyspnea but can be life-threatening because of its size and location. Endoscopy helps in diagnosis and treatment. Complete resection remains the treatment of choice. The frequency of recurrence requires regular follow-up.


Cancers of the nasal cavity and septum are associated with poor prognosis and are usually treated with surgery followed by post-operative radiotherapy with or without concurrent chemotherapy. Definitive radiotherapy is used in cases where the tumor is unresectable, patient is unfit for surgery, and/or the patient declines surgical intervention. Here, we present a case of a patient, who for non-medical reasons, opted to have non-surgical management of his rapidly progressing nasal cavity tumor. He was successfully treated with concurrent chemoradiotherapy utilizing a combination of intensity modulated proton therapy (IMPT) with passive scatter boost to reduce dose to the adjacent critical neural structures. Post-treatment clinical examination and imaging demonstrated complete clinical and metabolic response at the primary site and neck. This case highlights the use of IMPT and passive scatter boost in combination to achieve delivery of therapeutic dose to nasal cavity tumor and neck whilst limiting dose to numerous adjacent organs-at-risk. Cancers of the nasal cavity and septum are rare, accounting for less than 1% of head and neck mucosal cancers and are associated with poor prognosis -3. With A 67-year-old Caucasian man, of good performance status, presented with a two-year history of a gradually enlarging left-sided nasal mass. He was a current smoker. The patient reported that over the past month prior to presentation, the mass grew rapidly and was causing intermittent epistaxis and pain within his left nose, prompting a visit to the doctor while he was overseas. A biopsy of the mass performed overseas revealed squamous cell carcinoma. Upon returning to the United States, the patient saw a surgeon who recommended upfront surgery including total rhinectomy with delayed reconstruction. For occupational/personal reasons, the patient presented to our institution for a second opinion, particularly interested in an ‘organ preservation’ treatment approach.On initial consultation, the mass was ulcerated and involved the nasal vestibule, columella, philtrum and the left nasal septum Figure . The lefMagnetic resonance imaging (MRI) Figures , 3 reveaPositron emission tomography (PET) imaging demonstrated a hypermetabolic inferior anterior nasal septal and columellar mass with slight avidity of bilateral level IB (submandibular) nodes Figure . There wHis case was discussed at the multidisciplinary tumor board conference and the consensus was to recommend upfront surgery. Due to his occupation as a public figure, the patient declined surgery and opted for definitive chemoradiotherapy. During his initial week of evaluation and consultation at our institution, the patient had rapidly progressive disease with increasing pain and size of nasal mass over a week Figure . TherefoComputed tomography (CT) simulation was performed. A custom mouth-opening and tongue-depressing stent with bite block was fabricated to displace the oral tongue away from the palate/high dose target volumes. A customized posterior mold and thermoplastic mask were used. An MRI was also obtained in the radiation treatment position and MRI images were fused with planning CT images to aid with the target and organs-at-risk delineation. The primary gross tumor volume (GTV) and bilateral nodal GTVs, as well as multiple target dose levels were delineated Figure . The priThis was accomplished using a combination of active scanning beam IMPT  to 50 Gy RBE in 25 fractions to the nasal cavity and bilateral neck targets, followed by separate passive scatter boost fields to the primary tumor (20 Gy RBE in 10 fractions) and positive lymph nodes (16 Gy RBE in eight fractions). Custom apertures and compensators were used for the passive scatter boost fields to provide the greatest degree of lateral conformality and sparing of the anterior eyes, particularly the bilateral corneas.Due to patient's difficulty with claustrophobia, the number of treatment fields was reduced as much as feasible Table . To imprDuring treatment, he developed Grade 3 dermatitis and oral mucositis requiring a five-day treatment break. With adequate pain management and topical treatments, he completed his course of treatment with accelerated (twice-daily) treatments in the final week to account for accelerated tumor cell repopulation during treatment break. Two weeks after the completion of radiotherapy, he was recovering well from the acute toxicities of treatment and the nasal mass had responded dramatically with no clinical evidence of disease Figure .Due to the aggressive nature of the disease at presentation, short interval restaging imaging and clinical examination was performed. PET imaging at five weeks post-treatment showed complete metabolic and radiographic response with mild fluorodeoxyglucose (FDG)-avidity within left submandibular node consistent with post-radiotherapy changes at this interval following treatment completion. Repeat PET imaging and clinical follow-up at three months post-radiotherapy showed complete metabolic and radiographic response. The patient had since returned to pre-morbid activities with no significant treatment-related toxicity.In this case, a combination proton plan using IMPT (MFO) for the initial fields followed by separate passive scatter boost fields to the primary tumor and the involved left and right submandibular nodes provided excellent coverage of a geometrically complex and large target volume with sufficient sparing of the immediately adjacent and numerous critical and avoidance organs. His cutaneous reactions were consistent with desired therapeutic dose for this externally located tumor and resolved by three months after the treatment ended. Clinical tumor response was complete at the end of treatment and was metabolically complete at both five weeks and three months after treatment completion.Overall, the annual incidence of sinonasal cavity cancers in the United States is approximately 2000 cases, consisting 3% of head and neck malignancies . SquamouThere are no prospective randomized data to guide treatment recommendation in nasal cavity tumors. The current standard of care for advanced nasal cavity cancers is surgical resection followed by post-operative radiotherapy. The upfront surgical approach is usually preferred partly due to the difficulty to deliver a definitive dose of radiation to the tumor while respecting the dose tolerance of nearby normal structures including the optic apparatus, brain, and swallowing structures. Due to personal and functional concerns, our patient had opted for definitive radiotherapy with surgery reserved for salvage if needed.Although there is no prospective level I evidence supporting the use of proton or photon radiotherapy in sinonasal cavity tumors, a meta-analysis by Patel, et al.  found thIn this case report, we highlighted the exceptional response of a rapidly progressing nasal cavity tumor to chemoradiotherapy. The use of IMPT and passive scatter in this case enabled the delivery of high dose of radiation to the nasal region whilst limiting dose to the nearby dose-sensitive orbital apparatus and neural structures.


In the colon, lymphoid tissue occurs mainly as isolated lymphoid follicles that are composed mainly of B lymphocytes.6 were the first to describe the term MALT lymphoma. In the gastrointestinal tract, the most common site of occurrence is the stomach and small intestine; only rarely does MALT occur in the colon.9 To put its rarity in context, all colonic lymphomas account for approximately 0.2% to 0.6% of colorectal malignant tumors and only 2.5% of all lymphomas.11 Among the lymphomas seen in the colon, the most common type is diffuse large B-cell lymphoma, and MALT-type lymphoma accounts for < 20% of cases in this subgroup.12In 1983, Isaacson and WrightIn the sub-Saharan region of Africa, the rarity of colonic MALT lymphoma is further highlighted by the dearth of published reports on the condition. Herein, we present one such rare case.A 55-year-old Nigerian man was referred for a colonoscopy at a private center in Lagos, Nigeria, after a routine medical examination showed a positive fecal occult blood test. He had no family history of a gastrointestinal cancer and no history of hematochezia or dyschezia of any kind. He was asymptomatic at presentation. The patient’s earlier blood work included normal hemoglobin levels along with other normal parameters. His abdominal scan was also normal. The significant finding on colonoscopy was multiple polypoidal lesions of varying sizes scattered in isolation and in clusters across the rectum, sigmoid, and descending colon. The largest was an 8-mm diameter, semipedunculated lesion in the rectum . The smoHelicobacter-like organisms were found. Further immunohistochemistry findings were markedly positive for CD20 and negative for CD3, CD5, CD10, cyclin D1, and bcl-2 . The overlying mucosa was ulcerated. The adjacent mucosa showed diffuse and moderate mixed inflammatory cells, including lymphocytes, plasma cells, and neutrophils in the lamina propria . No idennd bcl-2 , and 5.A follow-up gastroscopy was normal. The only abnormality seen on a contrast-enhanced computed tomography scan of the entire abdominal and pelvic regions was localized symmetric thickening of the rectal wall with no evidence of local infiltration or lymphadenopathy at any other site. Thus, the diagnosis of colonic MALT lymphoma was made. The patient was advised to have a specialist surgical and radiotherapy oncologic review with a view to definitive management of his condition, but the referring physician reported that the patient declined and has not been heard from since.13 These are rare tumors that constitute only 0.2% of all malignant tumors that arise from the colorectal region, with the MALT type accounting for < 20% of cases.14 Thus, the novelty of this case report underlines that such occurrence from the sub-Saharan region of Africa is particularly rare.Primary colorectal lymphoma comprises low-grade B-cell lymphoma that arises from diffuse large B-cell, MALT, mantle cell, and T-cell lymphomas.15 The endoscopic appearance of these lesions also varies widely from protruding or ulcerative masses that appear either singly or in clusters to multiple widespread masses with diffuse pancolonic involvement.16 The current case is an example of another type of multiple polypoidal appearance that is restricted to the colon.17Clinical presentation ranges from asymptomatic and discovered only through routine tests (as was the case in the current patient) to presentation with nonspecific abdominal complaints to more dramatic presentations that include profuse bleeding from the rectum, intestinal obstruction, and intussusceptions.19 The neoplastic B lymphocytes of MALT lymphomas are found in marginal zones that adjoin reactive follicles and often in diminished rims of mantle zone lymphocytes. The marginal zone cells of MALT invade not only residual reactive follicles but also the epithelium. Epithelial invasion with frequent destruction by the B cells of MALT has been referred to as a lymphoepithelial lesion and is a vital morphologic attribute in the diagnosis of many MALT-derived lymphomas.19 These features were clearly demonstrated in the current patient and prompted further elucidation with immunohistochemistry.A critical morphologic characteristic of MALT lymphomas is the simulation of normal MALT.+-reactive T cells.19 Unlike chronic lymphocytic leukemia/small lymphocytic lymphoma and mantle cell lymphoma, the lymphomas of MALT origin usually lack CD5 and are without bcl-2 gene rearrangements.20 MALT lymphomas differ from follicular lymphomas in that they are negative for CD10 and do not exhibit bcl-2 rearrangements.20 The immunophenotypic results of the current biopsy samples along with the characteristic histologic features led to the confirmation of MALT lymphoma.The marginal zone cells of MALT share immunophenotypic characteristics. MALT lymphomas are B-cell derived with CD20 expression and frequently contain numerous admixed CD321 Antibiotic treatment of Helicobacter pylori is controversial because studies exist in support of and against its usefulness.24 Various chemotherapeutic agents have been tried with some degree of response, but there remains no standardized therapy.15 Surgical resection may be effective when a colorectal MALT lymphoma does not respond to H. pylori eradication therapy or chemotherapy and is localized without dissemination.24Treatment of lymphoma tends to be gratifying because unlike their nodal cousins, lymphomas tend to be localized at the time of diagnosis and may be effectively treated with local therapy. However, because of the lack of an accepted etiology and given their rarity, little consensus exists on the optimal treatment regimen of colonic MALT lymphomas.Important insight to gain from this report is that the absence of structured colorectal screening programs in sub-Saharan Africa has cost us the ability to detect more of such findings in the asymptomatic population. Thus, this has denied patients the benefit of early detection and intervention in more amenable neoplastic lesions.


Cementoblastoma is a benign lesion of the odontogenic ectomesenchymal origin. It rarely occurs in primary dentition. This report describes a case of a cementoblastoma relating to the right mandibular second primary molar in a 7-year-old girl. Her panoramic radiograph revealed a well-defined radiopaque lesion with a radiolucent border extending from the distal surface of the mandibular right first primary molar to the distal surface of mandibular second primary molar. The tumor was attached to the mesial root of primary second molar and was excised along with the teeth involved and sent for histopathological evaluation, which showed irregular trabeculae of mineralized tissue interspersed with fibrovascular connective tissue, trabeculae of mineralized tissue with prominent reversal lines, and peripheral rimming of the mineralized tissue with blast cells. On a six-month follow-up, there has been no recurrence of the lesion. Odontogenic tumors are the ones arising from the tissues of the odontogenic apparatus. These tumors are derived from ectodermal tissue  or from mesodermal tissue (connective tissue tumors) or are composed of both components (mixed or composite odontogenic tumors). Cementoblastomas are benign lesions of the odontogenic ectomesenchyme that rarely occur in the primary dentition. Cementoblastoma is a true neoplasm of cementum or cementum-like tissue formed on the tooth root by cementoblasts . OccurreCementoblastoma and osteoblastoma are very similar histologically; however, the cementoblastoma has a strict association with the root, whilst osteoblastoma arises in the medullary cavity of a wide range of bones.Odontome is usually not linked to the root and has also a heterogeneous radiopacity showing the presence of multiple dental tissues .Periapical cemental dysplasia is a smaller lesion and tends to mature to create a mixed radiographic appearance of radiolucent and radiopaque. In the later stage, the lesion shows a circumscribed dense calcification surrounded by a narrow radiolucent rim but the periodontal ligament is intact and fusion to the tooth is not present.Condensing osteitis is a circumscribed radiopaque mass of sclerotic bone surrounding and extending below the apex of the root but does not show the well-defined peripheral radiolucent rim typical of the cementoblastoma and also periodontal ligament space is widened and this is an important feature in distinguishing it from the cementoblastoma , 4.Hypercementosis radiographically demonstrates a thickening or blunting of the root. The enlarged root is surrounded by radiolucent periodontal ligament space and adjacent intact lamina dura. On rare occasions, the enlargement may be significant enough to mimic a cementoblastoma. However, cementoblastoma is distinguished on the basis of associated pain, cortical expansion, and continued enlargement. Hypercementosis is a small lesion without pain or swelling and involves nearly the entire root area, although in some instances the cementum formation is focal, usually occurring at the apex of a tooth , 4, 5.A healthy 7-year-old girl reported to the Department of Paedodontics and Preventive Dentistry  complaining of swelling on the right side posterior region of the mandibular arch. The swelling was firm and tender on palpation, which was first noticed 2 months back and increasing in size. The child presented with primary dentition and oral hygiene was adequate. Positive response was evident in both primary right mandibular molars to vitality test and the teeth were structurally sound . On radiThe decision was made for an excisional biopsy and for histopathological evaluation to confirm the final diagnosis. The excisional tissue was well demarcated and easily excised measuring 3.0 × 2.2 × 3.0 cm, almost shelling out with the attached second primary molar . The hisCementoblastoma is a rare lesion that represents <1% of the odontogenic tumors. The most involved area is the mandible (50% molar and premolar area) and is never associated with the anterior teeth . ComprehThe cementoblastoma is a rare neoplasm derived from odontogenic ectomesenchyme of cementoblast that forms cementum layer on the roots of a tooth. The primary distinguishing feature for cementoblastoma is its connection to the root of the offending tooth . The his en masse. Radiological and clinical follow-up is therefore a mandatory investigation in these cases for better patient management. The present case met all the clinical, radiographic, histological, and surgical criteria that are suggestive of a cementoblastoma.The radiographic appearance of a cementoblastoma is a well-defined radiopacity surrounded by a radiolucent zone. Cementoblastoma occurs most often in the mandible, attached to the roots of premolar or molar teeth , 21. CliDespite being a rare condition in the primary dentition, it is essential to increase the awareness of this type of lesions among general and paediatric dentists as well as acquaintance with the clinical, radiographic, and histological findings and treatment options which can be rendered for better patient compliance.


Cardiac papillary fibroelastomas are rare. And only 15% of the papillary fibroelastomas are located on tricuspid valve. However, the treatment of papillary fibroelastomas varies.We report a 75-year-old Chinese male who was hospitalized because of a right atrial mass found by echocardiography. Complete tumor excision along with Kay's tricuspid valvuloplasty surgery on beating heart under cardiopulmonary bypass was performed to the patient. Pathologic examination confirmed the definite diagnosis of cardiac papillary fibroelastoma. The recovery of the patient was uneventful and echocardiographic examination performed 6 months after surgery revealed no recurrence of the tumor.Beating-heart surgical excision is an effective and safe treatment of tricuspid papillary fibroelastomas. Papillary fibroelastomas (PFEs) are the third most common primary tumor of the heart and they most commonly affect cardiac valves. Approximately 15% of the PFEs are located on the tricuspid valve. Although usually considered asymptomatic, PFEs can be associated with transient ischemic attack, stroke, myocardial infarction, sudden death, heart failure, presyncope, syncope, pulmonary embolism, blindness, and peripheral embolism. Surgical resection of the tumor has been proved safe and curative.Primary cardiac tumors are very rare. Their frequency in autopsy studies are below 0.03%Here we present the diagnostic evaluation and successful surgical resection on beating heart of a cardiac tumor, which was found on a 75-year-old Chinese patient with a recent ischemic stroke history. Histopathological result revealed papillary fibroelastoma at tricuspid annulus.2A 75-year-old Chinese man was referred to our local for surgical treatment of a right atrial mass. The mass was incidentally found on echocardiography when the patient was being treated for acute ischemic stroke 1 month ago. His past medical history was insignificant except for hypertension.On admission, a physical examination did not reveal any significant abnormalities. Electrocardiography revealed normal sinus rhythm and all laboratory blood results were unremarkable. Carotid ultrasound was performed and did not show obvious carotid artery stenosis or atherosclerotic plaques. Transthoracic echocardiography (TTE) demonstrated a normal left ventricular ejection fraction and a slight aortic valve regurgitation. The other heart valves appeared unremarkable. However, a small mobile nodular tumor mass at the right atrium was seen Fig. A. SubseqPerioperative transesophageal echocardiography (TEE) at the time of surgery demonstrated a small spherical, pedunculated mass (1.8 cm × 1.7 cm) near the tricuspid annulus in the right atrium. The right atrium was not enlarged and the tricuspid valve appeared complete and functional. The patient underwent surgery through a median sternotomy under cardiopulmonary bypass established via aorto-bicaval cannulation. The heart was not arrested. When the right atrium was opened, the tumor was found close to the interatrial septum. The short stalk of the tumor arose from the septal portion of the tricuspid annulus. Complete tumor excision on beating heart was then performed. Then, a Kay's tricuspid valvuloplasty on the beating heart was performed by placing a double pledget-supported mattress suture of 2-0 Ethibond from the anteroposterior commissure to the posteroseptal commissure along the posterior annulus and obliterated the posterior leaflet. Repeated intraoperative TEE showed no residual mass, no septal defect, and no tricuspid regurgitation. The patient was weaned from bypass without difficulty and the recovery was uneventful. The patient was extubated within 12 hours after surgery and discharged home on postoperative day 7. A 6-month follow-up after surgery with echocardiogram showed no recurrence of the tumor and no tricuspid regurgitation.On gross examination, the tumor was ∼2 cm × 1.5 cm large, and the stalk was nodular. When viewed under physiologic saline, it has a frond-like appearance and resembled a sea anemone  and the tricuspid valve has been shown an localization for only 17% of PFEs. However, it has become increasingly apparent that tumors arising from tricuspid valve can sometimes cause cardiac-related symptoms such as chest discomfort, exertional dyspnea, palpitation or cerebrovascular accidents due to tricuspid incompetency, arrhythmia, intermittent right ventricular outflow partial obstruction, and pulmonary embolism.Papillary fibroelastoma is a rare cardiac tumor, representing <10% of primary tumors. However, echocardiography was not always precise in diagnosing PFEs. Study had shown that the sensitivity and specificity of TTE were both <90%, with an overall accuracy of 88.4% for the detection of PFEs > 0.2 cm. Other diagnostic measures mainly included chest roentgenograms, CT scan, and magnetic resonance imaging (MRI). Chest x ray may reveal cardiac chamber enlargement or pulmonary hypertension related to mitral valve PFEs. Also, calcification of PFEs can be seen on radiographic examination. Although PFEs are most often difficult to identify on cardiac CT due to small size and mobility, they may appear hypodense with irregular borders attached by a thin stalk and mobile on cine ECG-gated CT imaging if visible. MRI, especially Gadolinium enhanced, can typically demonstrate a PFE mass on a valve leaflet or on the endocardial surface. Further a cine gradient-recalled echo MRI may demonstrate turbulence of blood flow caused by vavular PFEs.Most cases of PFEs were found incidentally while the patients were being evaluated for an unrelated problem or physical finding. Transthoracic echocardiography is usually the initial diagnostic method in patients with suspected cardiac mass. PFEs may appear speckled with echolucencies and a stippled pattern near the edges on echocardiography but were generally well-demarcated and homogenous in appearance. No or minor valve repair is usually possible when cardiac valves are involved. In our case, although the patient is 75 years old and had a recent stroke history, the tumor size (> 1 cm) along with the high chances of preserving the native valve at operation, led us to decide in favor of the surgical option.Considering the risk of serious embolic complications, surgical removal is recommended once these tumors have been detected.Preoperative coronary CTA of the patient showed mild to moderate stenosis and multiple calcified plaques of all main coronary arteries Fig. B. This m Another advantage was the maintenance of the tricuspid valve competence just after the removal of the fibroelastoma.The use of cardioplegic arrest with aortic cross-clamping is the standard procedure for myocardial protection in cardiac tumor resection surgery. However, due to coronary artery stenosis and advanced age of the patient, we preferred to excise the fibroelastoma using the on-pump beating-heart technique. This strategy allowed better myocardial protection by avoiding cardioplegia and its ischemic consequences. Continuous perfusion of the heart without cross-clamping has been considered an old but effective technique of myocardial protection.4We reported a rare case of papillary fibroelastoma arising from the tricuspid annulus, which was detected by echocardiography preoperatively and confirmed by histology afterward. Using on-pump beating-heart surgery, the tumor was resected completely along with tricuspid valvuloplasty.


Hepatobiliary cystadenomas (HBC) is a rare neoplasm which comprising less than one percent of liver cystic neoplasms. Although it’s known as a benign tumor, but they have a potential for neoplastic transformation. Making a proper diagnosis and ruling out of other differential diagnosis is important because of different treatment. In the present study, we described a case of HBC manifested as idiopathic dominant biliary stricture in common hepatic duct (CHD), on the basis of spiral CT scan and MRI, and elevated CA19-9. With a probable diagnosis of malignant biliary stricture, she underwent ERCP and cholangioscopy that were non-diagnostic and final diagnosis was made surgically. HBCs usually found incicentally as a cystic lesion and biliary stricture without visible cyst in imaging like that seen in cholangiocarcinoma is very unlikely. In truth, this patient is an unusual manifestation of one rare disease. Hepatobiliary cystadenomas (HBCs) and cystadenocarcinomas are rare lesions which comprise one percent of liver cystic neoplasms and 5% of symptomatic hepatic cysts ,2. In apA 32-year-old female referred to our center with progressive generalized pruritus and jaundice, which had been started 4 months before the admission time. She also noted the loss of appetite which followed by 5 kg weight loss over the preceding four months. She did not have any fever, nausea, diarrhea, anorexia, abdominal pain, rash, respiratory symptoms, arthralgia or clay-colored Stools. However, the color of the urine became over concentrated. The patient did not indicate the history of traveling, consumption of alcohol, herbal medicine, antibiotics or any other drugs. She had been well until 4 months ago without remarkable habit, family or past medical history. Physical examination revealed an icteric patient with excoriated skin. There were no other significant physical findings including thyroid, heart, lung and abdomen. Laboratory data revealed elevated alkaline phosphatase, inflammatory parameter and CA19-9 with normal serum aminotransferases, total bilirubin, prothrombin time and serum albumin level. Alcohol, acetaminophen, and other toxicology screens were negative. Serum creatinine and blood urea nitrogen were normal, and urinalysis did not reveal blood or leukocytes. .Ultrasound of the abdomen revealed dilation of intrahepatic bile ducts of the left and right lobe without evidence of hepatosplenomegaly, cirrhosis, or ascites. Triphasic spiral CT scan of the abdomen confirmed mild dilatation of intrahepatic ducts without any pathologic lesion and MRCP images showed dilatation of intrahepatic ducts along with suspicious stenosis at common hepatic duct (CHD) .The patient then underwent ERCP and cholangioscopy. In cholangioscopy, partial obstruction probably due to external compression was detected in common hepatic duct without any evidence of ulceration or infiltrative lesion See. CholangThepatientreferredforsurgery.Intraoperative cholangioscopy revealed small bile duct cystic lesion with compression of common hepatic duct. Finding of surgery was a 3*5cm cystic mass in proximal of CBD with extension to CHD and right hepatic duct and a 5*5 cystic mass in segment III of liver which had luminal communication with the bile duct and periportal lymphadenopathy. The bile duct neoplasm and liver cyst were resected and following lymph node dissection, a Roux-en-Y hepaticojejunostomy was conducted. Intraoperative frozen section was then diagnosed as low grade mucinous cystic lesion of common bile duct. It was consisted of an irregular multi-cystic tan brown elastic tissue measuring 2.3x0.6x0.3 . MicroscBiliary cystadenomas account up to 5% of intrahepatic cystic lesions of biliary origin. Among hepatobiliary cysts, mucinous cystic neoplasms are very rare with an incidence rate of 1 in 20 000–100 000 for non-invasive types . In the


CVST) is a rare but recognized phenomenon. A high index of suspicion among clinicians and an awareness of subtle CT features can avoid delayed diagnosis of underlying CVST . Prompt but careful anticoagulation can prevent significant associated morbidity and mortality.Subarachnoid hemorrhage as a presentation of cerebral venous sinus thrombosis ( A previously well 58‐year‐old man was admitted with deteriorating level of consciousness a day after profuse diarrhea and vomiting secondary to food poisoning. He scored 9/15 on the Glasgow Coma Scale, and in the right upper and lower limbs, there was no withdrawal from painful stimuli. He had bilateral papilledema but no neck stiffness. Three generalized tonic–clonic seizures were witnessed and terminated with intravenous phenytoin and levetiracetam.Urgent noncontrast CT of his head reported subarachnoid hemorrhage in the left temporal and parietal lobes Fig. A. The stSubarachnoid hemorrhage as a presentation of and secondary to CVST is a rare but recognized phenomenon AA: was a foundation year two doctor, wrote, and reviewed the literature. VS: was a consultant neuroradiologist and performed the image selection and analysis. AH: was a acting consultant neurologist and provided clinical details and manuscript editing.None declared.


We report the case of an adult patient with embryonal rhabdomyosarcoma of the perineum admitted to our practice at Joliot Curie Institute in Dakar. It is a rare tumor at this age and has a bad prognosis at this localization.We describe the case of a 22-year-old African man admitted for a perineal mass that had evolved over 6 months. He complained of tenesmus, obstinate constipation, and dysuria. A clinical examination revealed perineal swelling spread over his anus, scrotum, penis, testicles, and inguinal lymph nodes. A perineal ultrasound and computed tomography scan showed a large mass driving his testicles forward with regional lymph node metastases. An ultrasound-guided biopsy showed embryonal rhabdomyosarcoma on histology and immunohistochemistry, with strong positivity of neural cell adhesion molecule and myogenin while results for cytokeratin AE1/AE3, cluster of differentiation 45, synaptophysin, and chromogranin were negative. Our patient was classified T2N1M1. Outcome was quickly marked by occlusive syndrome and colostomy. Our patient did not opt for chemotherapy and died after 6 months of follow-up.The embryonic RMS of the adult is a rare disease. Despite the sensitivity to chemotherapy and surgery. Localization to perineum remains poor prognosis. Embryonal rhabdomyosarcoma (ERMS) is a rare type of soft tissue tumor . It predWe report the case of a 22-year-old patient with ERMS of the perineum extended at the scrotum and penis with inguinal lymph node involvement.A 22-year-old African man without specific medical history was admitted for a perineal mass evolving over 6 months, which was painful, and had appeared spontaneously. An examination found tenesmus, obstinate constipation, and dysuria. It revealed a dry perineal swelling, which was painless, and extended back to his anus, scrotum and penis. His testicles were mobile, and there were enlarged and fixed lymphadenopathies Fig. .Fig. 1DrA pelvic computed tomography (CT) scan found a large mass on his perineum, fairly limited, driving his testicles forward, with regional lymphadenopathies without secondary lesion.A pathological examination of the biopsy fragments taken under ultrasound showed a tumor proliferation composed of small-sized cell nuclei with an increase in the nucleocytoplasmic ratio, with a fairly monomorphic appearance and associated with mitotic figures. These cells were disposed around slots. Some cells had an eosinophilic cytoplasm appearance Fig. .Fig. 2InAt immune marking, NCAM and myogenin Figs.  and 4 weOutcome was quickly marked by anal obstruction and colostomy. He died after 6 months of follow-up with only supportive care.Embryonal rhabdomyosarcoma is an extremely rare tumor with an estimated incidence of 0.45 to 0.69 cases per 100,000. This case is the first case in more than 20,000 patients in our practice. The incidence of RMS in general, and embryonic RMS especially, has a peak in young children between 0 and 4 years. The incidence decreases followed by another smaller peak between 15 and 19 years. After 19 years, the incidence decreases rapidly from 0.16 per 100,000 population between 20 and 24 years to 0.08 per 100,000 in the class of 25–29 years [Embryonal RMS generally has an intermediate prognosis . Howeveret al. [The metastatic testicular damage in the ERMS has been rarely described. Gow et al.  reportedet al. . In the For our patient, a temporary colostomy was indicated; it is often necessary in case of anal obstruction .The oncological surgical treatment includes a complete resection of the original site with a circumferential margin of at least 0.5 cm . In the Nowadays, almost all patients with ERMS receive chemotherapy . The mosWe reported a case of embryonal RMS extended to the perineum, scrotum, and penis with lymph node and testicular metastasis in 22-old-year African man. This is a rare condition. Treatment is based on surgery, chemotherapy, and radiotherapy, and prognosis depends on location and regional extension. Death occurs in the case of extended and nonresectable disease.


We report a 32-year-old female case of a right adrenal gland mass detected on CT scan at medical checkup. CT and MRI showed a mass of 5.1 cm made of fat and calcification in the right adrenal gland, leading to the clinical diagnosis of adrenal myelolipoma. Because of its relatively large size and the patient's desire, the patient underwent gasless single-port retroperitoneoscopic adrenalectomy using the RoboSurgeon system. Histopathological examination revealed that the cystic tumor is composed of keratinized epidermis, mature fat, nerve, cartilage, bone, and sebaceous glands compressing the normal adrenal gland, leading to the diagnosis of retroperitoneal mature cystic teratoma. The patient remains free of recurrence 29 months after surgery. Retroperitoneal teratoma is relatively rare but clinically important because of high possibility of malignancy. In a case of an adrenal mass difficult to clinically distinguish retroperitoneal teratoma from adrenal myelolipoma, surgical resection via a minimally invasive approach would be the best therapeutic option. An adrenal mass containing fat, cysts, and calcification on imaging studies is occasionally encountered in clinical practice and is usually diagnosed with myelolipoma. Here, we report a case of such a right adrenal mass, in which an unexpected pathological diagnosis was made following surgical resection via a minimally invasive approach. The current case highlights limitations of image-based diagnosis of adrenal masses and the diagnostic and therapeutic role of minimally invasive surgery for them.A 32-year-old female patient presented with an incidental right adrenal mass pointed out on CT scan at medical checkup. The patient had no medical history. Results of complete blood count and routine biochemistry tests were normal. The endocrine function and tumor markers were also within normal ranges. According to imaging studies including CT and MRI , a rightBecause of its relatively large size and the patient's desire, she underwent gasless single-port retroperitoneoscopic adrenalectomy using the RoboSurgeon system . The tumMacroscopically, the resected tumor contained multicystic and solid components including fatty tissue. The right adrenal gland was compressed but was not destructed by the tumor . MicroscAmong a fat-containing adrenal mass, the most common diagnostic entity is adrenal myelolipoma. In the current case, clinical diagnosis of adrenal myelolipoma was made based on radiological findings. Unexpectedly, histopathological diagnosis was retroperitoneal teratoma.Teratoma is composed of plural germ layers: ectoderm, mesoderm, and endoderm . It mostIt is challenging to clinically differentiate retroperitoneal teratoma from adrenal myelolipoma when a mass which is composed of fat and calcification is located closed to the adrenal gland, as was seen in the present case. Yumura et al. proposed several characteristics to differentiate teratoma from myelolipoma in terms of radiological findings on calcification, fat, and solid components . AccordiGenerally, adrenal myelolipoma does not need surgical excision because of its benign nature. However, surgical removal is needed when the differential diagnosis from retroperitoneal teratoma is difficult. In the present case, curative resection of retroperitoneal teratoma was eventually made via a minimally invasive retroperitoneoscopic approach using the RoboSurgeon system . MinimalRetroperitoneal teratoma is a relatively rare but clinical important tumor which needs curative resection due to a potential risk of malignancy. Considering the diagnostic difficulty of retroperitoneal teratoma by radiological imaging, surgical resection via a minimally invasive approach may be a viable treatment option in a case of an adrenal mass difficult to distinguish retroperitoneal teratoma from adrenal myelolipoma.


We herein experienced a case with pseudo-Meigs’ syndrome that developed both synchronous and metachronous metastases to the ovary from ascending colon cancer. A 57-year-old female visited a hospital for a 2-month history of abdominal distension and voiding difficulty. Massive pleural effusion on the right side and a small amount of left-sided pleural effusion were detected on CT. She underwent emergent laparotomy due to the severe symptom of abdominal distention. The tumor originated from the left ovary, and left-sided oophorectomy was performed.The histologic finding was moderately differentiated adenocarcinoma suggesting metastatic carcinoma from the colon. Left thoracic effusion disappeared at 3 days after the removal of the ovarian tumor. Subsequently, colon carcinoma of the cecum was detected by colonoscopy. The patient underwent second laparotomy of right colectomy and lymph node dissection. However, 6 months after the operation, pleural effusion on the right side re-developed again, and the serum levels of CEA and CA125 were elevated at 105 ng/ml and 125 U/ml, respectively. CT again revealed a large ovarian tumor. She subsequently underwent third laparotomy of right-sided oophorectomy and hysterectomy. Pleural effusion and ascites disappeared in a few days after the operation.The patient developed both synchronous and metachronous ovarian metastases and achieved a 7-year disease-free survival after the operation. The pathogenesis of pseudo-Meigs’ syndrome should be distinguished from carcinomatous peritonitis and/or pleuritis of malignant disease. Meigs and Cass first reported cases that developed non-malignant ascites and/or pleural effusion in association with benign ovarian tumors such as fibroma, thecoma, and Brenner tumor . These eThe etiology of Meigs’ and pseudo-Meigs’ syndrome is not fully elucidated, and no large case series studies are currently available. We herein report a case with pseudo-Meigs’ syndrome that developed both synchronous and metachronous metastases to the ovary from ascending colon cancer and review of the pertinent literature.A 57-year-old female visited a hospital with a 2-month history of abdominal distension and voiding difficulty. Because of a large pelvic tumor detected on CT, she was referred to the Department of Gynecology at our hospital.Massive pleural effusion on the right side and a small amount of left-sided pleural effusion were detected on CT Fig. . FurtherLeft thoracic effusion disappeared at 3 days after the removal of the ovarian tumor. Subsequently, we examined the whole body to find the primary tumor site, then colon carcinoma of the cecum was detected by colonoscopy. The patient underwent right colectomy and lymph node dissection again. The operative finding indicated a normal right ovary. The pathologic finding indicated type 2 colon cancer measuring 4 × 4.5 cm Fig. , moderat2 div at day 1, 5-Fu 600 mg/m2, and levofolinate 100 mg/m2 div at days 1 and 2) and has remained alive for 7 years with no recurrence.Pleural effusion and ascites disappeared in a few days after the operation. She received 9 cycles of FOLFOX-4 chemotherapy , 28 cases were reported cases (7 reports published in English and 21 reports published in Japanese with English abstracts). We reviewed the clinical data of the 29 cases, including the present case (Table The mean age was 49 ± 9 years (range 32–65 years), and the primary site of colorectal cancers included the cecum 2, ascending colon 6, transversus colon 1, descending colon 2, sigmoid colon 13, and rectum 4 patients. The histologic type of colon cancers was well to moderately differentiated adenocarcinoma, except one case which was reported to be poorly differentiated adenocarcinoma.The onset of pseudo-Meigs’ syndrome was 75 % (21/28) synchronous and 25 % (7/28) metachronous, while a case that developed both synchronous and metachronous, similar to the present case, was not reported.Nearly all cases had ascites except two cases that developed only pleural effusion. Additionally, all cases had pleural effusions, unilaterally in 16 cases (55 %)  and bilaterally in 13 cases (45 %). The serum level of CA125 was elevated at 557 ± 323 U/ml (range 67–1400 U/ml) in nearly all cases.Concerning metastatic ovarian tumors, the mean tumor size measured 18 ± 5 cm (range −30 cm), and 15 of 29 cases (52 %) had metastatic ovarian carcinoma on both sides, while no laterality was found in unilateral cases. According to these results, bilateral salpingo-oophorectomy (BSO) should be performed in cases diagnosed with pseudo-Meigs’ syndrome. The present case, which demonstrated repeated pseudo-Meigs’ syndrome, also emphasizes the necessity of BSO.The primary clinical challenge for pseudo-Meigs’ syndrome is the misdiagnosis with carcinomatous peritonitis or pleuritis. The condition of patients with pseudo-Meigs’ syndrome is often confused with terminal stage malignant disease, for which surgical treatment is not indicated except for a palliative surgery. In the previously reported cases, pleural effusions and ascites rapidly recovered after the removal of the ovarian tumors. Moreover, the patients achieved long survivals Table , especiaWe herein reported a case with pseudo-Meigs’ syndrome due to ovarian metastases from colon cancer. The patient developed both synchronous and metachronous ovarian metastases and achieved 7-year disease-free survival after the operation. The pathophysiology of pseudo-Meigs’ syndrome must be distinguished from carcinomatous peritonitis and/or pleuritis of malignant disease.Written informed consent was obtained from the patient for publication of this case and any accompanying images. A copy of the written consent is available for review by the Editorial-in-Chief of this journal.


Meningeal melanocytoma is considered a rare lesion arising from leptomeningeal melanocytes. Nearly two thirds of meningeal melanocytomas were reported in the intracranial compartment and the remaining one third in the spine. Spinal melanocytomas can be extradural or intradural, with extradural variant being more common, and the majority of cases have been single reports.A 5-year-old male presented with a 4-month history of non-radiating low back pain persistent at rest, with otherwise non-remarkable medical history. The patient was neurologically intact with no deficits. Preoperatively, routine laboratory investigations were non-remarkable. MRI imaging was done and showed a lesion at the level of T11 to L4, hyperintense on T1 and hypointense on T2 with homogenous contrast enhancement. Intraoperatively, the lesion was hemorrhagic, brownish, and rubbery in consistency attached to the ventral dura. Microscopic picture revealed dense cytoplasmic brown melanin pigments, with no significant mitoses or nuclear atypia. What is unique about our case is the age of the patient (5 years).To the best of our knowledge, after reviewing the literature, this is the youngest case to be reported.SMM is an extremely rare tumor with a benign course. Complete surgical excision should be attempted. Age of presentation may be as young as in our case and the diagnosis of such a tumor should never be excluded in this early age group with persistent low back ache. Meningeal melanocytoma is considered a rare lesion arising from leptomeningeal melanocytes. It is the benign pole of the spectrum of neoplastic leptomeningeal melanocyte proliferations that involves primary malignant melanoma at the other pole, from which it differs in behavior and aggressiveness by owing a much better prognosis than its malignant variant  showed a lesion involving the distal dorsal cord as well as the conus medullaris and the cauda equina roots at the level of T11 to L4 averaging 9 cm in long axis. The lesion was hyperintense on T1 with isointense signal at the cephalad end; in T2, it was hypointense and it showed intense homogenous contrast enhancement. There was a small syrinx proximal to the lesion, with no peritumoral edema Fig. . PreoperGrossly, the lesion was irregular, hemorrhagic, brownish black, and rubbery in consistency, measuring 7.5 × 3 × 2 cm. Microscopic picture using hematoxylin and eosin stains revealed hypo- to moderately cellular tumor composed of spindle cells with bland oval nuclei with some macrophages and dense cytoplasmic brown melanin pigments, with no significant mitoses or nuclear atypia Fig.  × 100. IMelanocytoma is a pigmented neoplasm of the meninges, which arises from melanocytes derived from the neural crest , it is usually intradural extramedullary and to a lesser extent intramedullary  and this goes along with our case, with cervical levels being affected more than dorsal levels, and the lumbar levels were the least  or intramedullary lesions (Yang et al. SMM is an extremely rare tumor with a benign course. Surgical excision in an en bloc manner should be the model. The outcome is generally good with complete remission and long-term free survival. Age of presentation may be as young as in our case and the diagnosis of such a tumor should never be excluded in this early age group with persistent low back pain.


We present a case of intraventricular meningioma resected via a transcortical approach using tractography for optic radiation and arcuate fasciculus preservation. We include a review of the literature.A 54-year-old woman with a history of breast cancer presented with gait imbalance. Workup revealed a mass in the atrium of the left lateral ventricle consistent with a meningioma. Whole brain automated diffusion tensor imaging (DTI) was used to plan a transcortical resection while sparing the optic radiations and arcuate fasciculus. A left posterior parietal craniotomy was performed using the Synaptive BrightMatter™ frameless navigation  to minimally disrupt the white matter pathways. A gross total resection was achieved. Postoperatively, the patient had temporary right upper extremity weakness, which improved, and her visual fields and speech remained intact. Pathology confirmed a World Health Organization (WHO) Grade I meningothelial meningioma.While a thorough understanding of cortical anatomy is essential for safe resection of eloquent or deep-seated lesions, significant variability in fiber bundles, such as optic radiations and the arcuate fasciculus, necessitates a more individualized understanding of a patient’s potential surgical risk. The addition of enhanced DTI to the neurosurgeon’s armamentarium may allow for more complete resections of difficult intracerebral lesions while minimizing complications, such as visual deficit. Intraventricular meningiomas are quite rare, accounting for less than 5% of all intracranial meningiomas . As oppoIn this study, we review a case of a dominant hemisphere intraventricular meningioma treated via a transcortical approach with the assistance of enhanced automated whole-brain diffusion tensor imaging (DTI) in preoperative planning for the avoidance of the visual pathways and the arcuate fasciculus. We also review the literature on approaches to intraventricular lesions with the use of tractography for trajectory and intraoperative planning to avoid visual compromise.A retrospective review was conducted of a patient who underwent a transcortical approach for surgical resection of a primary intraventricular tumor. Whole brain automated diffusion tensor imaging was utilized for surgical planning and approach purposes using the Synaptive BrightMatter™ navigation system . Surgical records, histologic records, and imaging studies were analyzed.The case is of a 54-year-old woman with a history of breast cancer who noted gait imbalance, which began two years previously. As part of this workup, a magnetic resonance image (MRI) of the brain demonstrated a homogeneously enhancing lesion in the atrium of the left lateral ventricle, presumed to be a meningioma. The remaining workup was negative. The patient was offered treatment at that time but elected to observe and follow the lesion. More recently, she developed increasing gait imbalance, short-term memory loss, and personality changes. Repeat MRI showed growth of the lesion Figure . On physTraditional transtemporal and superior parietal lobule trajectories were simulated using BrightMatter™, but the trajectories would cause transection of critical white matter fibers. Figure The patient was positioned supine with the head in a neutral position. A left posterior parietal craniotomy was performed using Synaptive BrightMatter™ frameless navigation. The dura was opened in a U-shaped fashion and flapped medially. The sulcal entry site was confirmed with the intraoperative navigation system. A BrainPath™ cannula probe  was stereotactically inserted transcortically into the atrium of the left lateral ventricle. The stylet was removed and the tumor was immediately visible under high magnification. The tumor capsule was cauterized, opened sharply, and then internally debulked with ultrasonic aspiration. The tumor capsule was cauterized and folded internally. Tumor arachnoid/capsule adhesions to the ventricular wall were further cauterized and divided, allowing the remainder of the tumor mass to be removed through the cannula. A visual gross total resection was achieved. An external ventriculostomy catheter was placed.Postoperatively, the patient was extubated without issue. She did have some temporary right upper extremity weakness, which improved rather quickly over a few days. Her visual fields were full. Postoperative MRI of the brain showed a complete resection of the left lateral ventricular lesion. Pathology confirmed a World Health Organization (WHO) Grade I meningothelial meningioma.Intraventricular meningiomas were first described by Shaw, et al. in 1854 . Since tThe use of preoperative tractography for surgery via a transcortical route, while implicated in potential improved visual outcomes, has not been widely reported . FurtherIn addition to epilepsy surgery, tractography has also been described for safer resections of intracerebral tumors. Multiple studies have investigated the use of white matter tracking during glioma surgery -8. In a This study has multiple limitations. As it presents only one example of the use of tractography for the avoidance of optic radiations in the resection of intraventricular meningiomas, no substantial conclusions can be made from this case. Larger controlled studies need to be conducted to reliably present potential changes or additions to surgical practice. There also needs to be a sufficiently powered control group to accurately report improved outcomes.Advancements in intra- and preoperative planning will increasingly allow for safer and more effective resections of intracerebral pathology. The addition of enhanced DTI to the neurosurgeon’s armamentarium will only further allow for more complete resections while minimizing complications, such as visual deficit. While a thorough knowledge of cortical anatomy is absolutely essential to safely address these lesions, the significant variability in the fiber bundles, such as the optic radiations, necessitates a more individualized understanding of the patient’s potential risk. While fMRI and stereotactic neuronavigation have become mainstays in surgical resection of brain tumors, enhanced DTI will eventually occupy a similar role. Dependence on methods such as these becomes especially apparent when addressing difficult lesions, such as intraventricular meningiomas.