Gastric neuroendocrine tumor (gNET) is a rare carcinoid of the stomach whose incidence is increasing due to widespread use of upper gastrointestinal endoscopy (UGIE). There are four types of gNETs with different management strategies and prognosis. Here, we present a patient who came with abdomen pain and intermittent melena. UGIE showed a sessile polyp in the stomach. The patient subsequently underwent polypectomy and was symptomatically relieved. Gastric neuroendocrine tumors (gNETs) were first reported by Askanazy in 1923.A 38-year-old man presented to the surgery clinic with complaints of upper abdomen pain for 1 year. The pain was dull aching with episodes of increased severity lasting for 1 to 2 hours. The pain was relieved with oral analgesics. This was associated with occasional black tarry stools. The patient also complained of easy fatigability, breathlessness, and palpitations. He had a history of repeated blood transfusions for severe anemia. He was a chronic smoker and tobacco chewer.His clinical examination revealed pallor. The rest of the examination was unremarkable.The patient had severe anemia with hemoglobin of 5.7 g/dL for which he was transfused with two units of packed cells. Subsequently, his hemoglobin improved to 8.3 g/dL.UGIE showed a 1 × 1 cm polyp with central umbilication along the greater curvature of the body of the stomach. There was no active bleeding. The mucosa of the rest of the stomach appeared normal. An impression of a gastrointestinal stromal tumor or NET was kept. The serum chromogranin A (CgA) level was 304 ng/L .Contrast enhanced computed tomography (CECT) showed evidence of a hyperenhancing polypoidal lesion along the greater curvature measuring 1.1 × 0.7 cm . There Subsequently, the patient underwent resection of the polyp under a second endoscopy  which wHPE showed a polypoidal structure lined by gastric mucosa . The muThe patient was immediately relieved of symptoms following polypectomy and was discharged 2 days later. His hemoglobin after 2 weeks on follow-up was 10.5 g/dL. He is currently asymptomatic.The majority of gNETs are neoplasms derived from the enterochromaffin-like cells (ECL cells) of the gastric mucosa. The cells comprising these tumors are avid for salts of silver. These ECL cells play an important role in regulating HCl secretion in the stomach.Patients with this pathology present with upper abdomen pain, bloating, nausea or vomiting, symptoms of anemia, weight loss, or hematemesis. Further evaluation may reveal an associated condition such as Zollinger–Ellison's syndrome or multiple endocrine neoplasia type 1.Helicobacter pyloriinfection.Gastric polyps may incidentally be found on UGIE. Their prevalence on UGIE is approximately 6%. The most common type of polyp of stomach is fundic polyp comprising 70 to 90% of all polyps. They occur due to long-term proton-pump inhibitor (PPI) use. Polypectomy is recommended for polyps more than 1 cm in size or with a suspicion of malignancy. Mucosal sampling is also done along with polypectomy to rule out atrophic gastritis andgNETs are classified into four distinct types with different characteristics, treatment, and prognosis .Confirmation of NETs is brought about by immunohistochemical analysis with the help of CgA and synaptophysin. This also helps in classifying lesions according to the WHO histological grades. The proliferative index Ki-67 and the number of mitoses per high magnification field help predict the prognosis. Prognosis and risk of metastasis may also relate to p53 and serum enolase biomarkers. The positive predictive rates for CgA is 40%, 60% for synaptophysin, 60% for CD56, 40% for neuron-specific enolase, and 100% for p53.CECT of the abdomen is necessary for types I and II gNETs more than 2 cm and for all type III lesions.The treatment of gNETs depends on the type, extent, grade of differentiation, and presence of poor prognostic factors. The WHO classified these neoplasms into three histological degrees with graded prognosis .Poor prognostic factors include: lesion ≥2 cm, deep submucosal invasion or beyond, Ki-67 ≥3%, lymphovascular invasion, poorly differentiated and presence of atypia or necrosis.Carcinoid crisis is provoked by tumor manipulation before or during surgery that can be prevented by subcutaneous or intravenous octreotide.The first-line treatment for any polyp that is more than 1 cm or suspicious of malignancy is endoscopic polypectomy. Endoscopic polypectomy is adequate for types 1 and 2 gNETs. Further surgical treatment is necessary for type 3 gNETs and type 1 or 2 gNETs where endoscopic treatment is not feasible or there is presence of poor prognostic factors. Total or subtotal gastrectomy allows adequate removal of G-cells that is not attainable by antrectomy. Lymphadenectomy is added in the presence of poor prognostic factors or extragastric disease.The latest development includes netazepide YF476) that is a potent and highly selective cholecystokinin 2 receptor antagonist belonging to the benzodiazepine class. They cause regression of type 1 gNETs and normalize CgA levels. that is Extrahepatic metastasis or recurrent symptomatic disease is treated with systemic therapy consisting of cytotoxic chemotherapy  or molecular-targeted agents .Carcinoid syndrome occurs in type 3 gNETs due to the release of histamine from the tumor cells. This causes erythema, itching, diarrhea, and bronchospasm. Symptoms are controlled with somatostatin analogs (octreotide or lanreotide) and low-dose interferon-alfa for refractory cases.Median survival of gNETs ranges from 13 months to more than 10 years.The recommendation of the National Comprehensive Cancer Network for follow-up consists of history, physical examination, UGIE, abdominal CECT or magnetic resonance imaging, and serum CgA every 6 months for 1 to 2 years, annually for 4 years and then every 2 years until 10 years after surgery. Types I and II lesions <2 cm and without poor prognostic factors or features suspicious of malignancy may only be followed with history, physical examination, and UGIE every 6 to 12 months.Overall, the following algorithm may be used to treat gNETs .gNETs consist of a rare complex disease that includes different subtypes with distinct management and prognosis. Correct identification of the clinical type and histological grade allows for a tailored management. A suspicion of gNET must be kept in mind in a patient presenting with vague symptoms of abdomen pain and self-limiting hematemesis with a polyp on UGIE.


We report a rare case of pulmonary torsion after nonpulmonary thoracotomy. A 38-year-old woman with schizophrenia committed suicide by a self-infliction of sharp force into the chest and abdomen. During emergent abdominal damage control surgery, a left-sided resuscitative thoracostomy was also performed due to hemorrhagic shock. Although abnormal shadow was detected on postoperative chest roentgenogram and computed tomography, the diagnosis of pulmonary torsion was delayed. Seven days after initial surgery, pulmonary torsion was diagnosed and managed by left upper lobectomy. To our knowledge, this is the first report of pulmonary torsion after resuscitative thoracotomy. Pulmonary torsion is a rare condition, most commonly seen as a complication after lobectomy and life-threatening disease that requires a timely diagnosis . A case A 38-year-old woman with schizophrenia committed suicide by a self-infliction of sharp force into the chest and abdomen. She presented to our hospital in a critical condition. On arrival in the emergency room (ER), she developed hemorrhagic shock, which leads to an emergent abdominal damage control surgery under general anesthesia. She lost cardiac activity in the operating room during exploratory laparotomy. A left-sided basal thoracostomy, cross-clamping of the descending thoracic aorta, and open cardiac massage were also performed. She received gauze packing at the bleeding point and temporarily close the abdomen and chest wall. After the surgery, she was transferred to the intensive care unit with mechanical ventilation and recovered from hemorrhagic shock. Two days later, a second-look laparotomy was performed. ER doctors verified the hemostasis and closed the patient’s abdomen and chest. On the same day, a chest radiograph revealed pulmonary atelectasis of the left upper lobe . ComputePulmonary torsion is a rare but serious condition, most often observed after pulmonary resection, trauma and pneumothorax . The incet al. reported risk factors for pulmonary torsion; including an airless space, long free lobar pedicle, complete interlobar fissures resulting in loss of parenchymal bridge between contiguous lobes, pneumothorax and pleural effusion, heavy compact lung  and transaction of the pulmonary ligaments [Felson igaments . Althouget al. stated that the most suggestive bronchoscopic findings included bronchial occlusion and fish mouth orifice [Both CT and bronchoscopy are the modalities of choice for diagnosis. Apostolakis and Hennink  orifice , 6. CT f orifice , 6. Alth orifice . Therefoet al. reviewed previous publications of pulmonary torsions from January 1950 to December 2014 using three databases  [et al. also reviewed the literature of pulmonary torsions [Only a limited number of cases with pulmonary torsion after nonpulmonary thoracotomy have been reported previously. Dai Science) . Shiomi torsions . To our When pulmonary torsion develops, it leads to rapid necrosis of the lung parenchyma . Thus, pWe experienced a rare case of pulmonary torsion of the left upper lobe after resuscitative thoracotomy.


Epithelioid sarcoma is a rare, slow-growing, malignant tumor with multivariate presentation and a high rate of recurrence following surgery. Diagnosis is often missed or delayed due to its infrequent nature and confusing clinical and pathological presentation. This is compounded by the fact that this tumor is aggressive with a propensity for metastases without being detected. The treatment of this deadly tumor is controversial with no clear-cut consensus. The author presents a case of epithelioid sarcoma in the finger of a young patient with subsequent recurrence after surgery and a review of current literature pertaining to this aggressive tumor. This report would like to stress the importance of a multimodal approach in combatting this tumor as prompt diagnosis and aggressive therapy can significantly reduce the poor outcomes associated with this disease. Enzinger 1970) first described epithelioid sarcoma (ES) as a rare, slow-growing, malignant tumor of the distal extremities with a paucity of symptoms and a propensity for recurrence and metastasis. This variant of sarcoma accounts for less than 1% of all soft tissue sarcomas 970 first. Due to This tumor rarely affects children, and the most common site of occurrence in the pediatric age group is the head and neck . In thisAn 18-year-old boy presented with a history of progressively increasing growth on his right ring finger. He had undergone excisional biopsy of the lesion 1 ½ years ago, which was performed at another hospital. The biopsy reported the lesion to be a schwannoma. He had associated pain and numbness of the affected finger, which was progressively increasing over the past six months.On examination, there was a globular, lobulated swelling of size 6 x 3 cm encircling the proximal phalanx of the right ring finger extending over the mid axial lines on both sides Figure .It was tender on palpation and firm in consistency, and the skin over the swelling was not pinchable. The sensation was decreased over both radial and ulnar sides of the affected fingertip.X-ray of the right ring finger showed only soft tissue swelling with no bony involvement Figure .MRI showed an irregular moderately enhancing soft tissue mass at the volar aspect of the right fourth (ring) finger at the level of the proximal phalanx, extending to both ulnar and radial surfaces, likely representing a benign soft tissue neoplasm or a peripheral nerve sheath tumor arising from the digital nerve on the ulnar side of the ring finger Figure .The pre-operative diagnosis was a peripheral nerve sheath tumor arising from the digital nerve. The patient then underwent surgery. The intra-operative findings were nerve tumor of size 5 x 4 cm over the proximal and middle phalanx region of the right ring finger Figure , 7.The post-operative biopsy reported it to be an ES and suggested immunohistochemical (IHC) studies to confirm this finding. IHC studies confirmed ES and it was found to be pan-CK (cytokeratin) positive, EMA  positive, vimentin positive, and CD34 positive. The post-operative period was uneventful Figure , but unfES is a rare, high-grade soft tissue sarcoma with a predilection for the distal aspect of extremities. However, on the hand, the incidence of ES is very rare, with the dorsum of the fingers being the most common site. It is the sixth most common soft tissue sarcoma of the upper extremity ,6. It isES can have a multivariate presentation in the upper extremity, but it can sometimes present with signs and symptoms of carpal tunnel syndrome due to compressive effects on the median nerve . ES can ES is rarely encountered in clinical practice, hence easily misdiagnosed initially as a benign condition, thereby delaying the definitive treatment. In our case, he was initially misdiagnosed as a case of neurofibroma. A simple excision was performed and after that the histology failed to diagnose an ES, thereby compounding the issue. Subsequently, he came to us with a recurrent tumor, and a repeat excisional biopsy and an immunohistochemical study confirmed the diagnosis of ES. Due to its diagnostic difficulty, an excisional biopsy and immunohistochemical studies must be performed to accurately diagnose this tumor.The role of imaging in the diagnosis of ES is limited and radiography is of limited utility, although magnetic resonance imaging (MRI) could provide details of soft tissue infiltration and the tumor dimensions . Once thThe treatment of ES of the extremity is challenging, especially in the hand due to its complex and intricate anatomy. The majority of ES are extra-compartmental and violate many tissue planes involving critical neurovascular structures. Optimal hand function and sound oncological principles with zero resection margins (R0 resection) must be adhered to when dealing with these tumors. ES is a surgically treatable disease; however, simple surgical excision of the tumor alone is inadequate due to a high risk of recurrence and metastasis ,7,9.The optimal treatment for ES involving the extremity entails wide en bloc excision or amputation with/without lymph node dissection followed by adjuvant chemotherapy and/or radiotherapy as it recurs and metastasizes even after wide excision. The prognosis of ES is dependent on recurrence, vascular invasion, and metastases . Metastases have also been reported in the lungs, heart, pleura, liver, kidney, scalp, brain, pericardium, and bone ,10,11.The successful extirpation of ES from the upper extremity involves not only radical surgery to attain negative margins but also sophisticated, well-planned reconstruction using microsurgical principles (free flap reconstruction). Limb salvage is sometimes not possible in case of advanced or large tumors but must be attempted respecting the oncological principles of R0 resection. In cases where there is an involvement of neurovascular structures, complex reconstruction in the form of vein grafts and nerve grafts with concomitant flow-through free flaps as skin cover must be performed to salvage the limb and restore function. When radical resection entails the removal of the entire flexor muscle compartment of the forearm, a free functioning muscle transfer (gracilis free muscle flap) must be planned to restore flexion. Tendon transfers can also be performed if some flexors are preserved with intact extensor muscles to serve as donor tendons.The addition of radical lymphadenectomy in the treatment of extremity sarcomas was studied by Fong et al., who concluded that lymphadenectomy increases the survival rates of patients with this tumor. Sentinel lymph node biopsy (SLNB) has been extensively studied in the management of melanoma and breast cancer, but its role in ES is uncertain. ES has a propensity for regional lymphatic spread and SLNB offers the advantage of a minimally invasive lymph-node staging procedure, which can improve the dismal prognosis and survival rates associated with this tumor. It also allows for the accurate early detection of micrometastasis, thereby sparing patients the morbidity associated with a regional lymphadenectomy ,12,13.What is the role of radiotherapy and chemotherapy in the treatment of this tumor? The roles of chemoradiotherapy in the treatment of ES is uncertain with no clear consensus ,14. The Stang et al. reported a recurrence rate of up to 85% due to the growth of the tumor along the tendon sheath and concomitant neurovascular invasion. The recurrence rate for ES in the literature varies from 35% to 85% ,16.Amputation must be done for recurrent tumors; however, it does not seem to confer any benefit in patients with metastatic ES of the upper extremity. The overall five-year survival rates in the literature vary between 21% and 92%. Spillane et al. reported median 5- and 10- year survival rates of 70% and 42%. respectively. The median post metastatic survival rate was reported to be eight months .ESs are rare, malignant, indolent tumors with a preference for distal parts of the upper extremity. There is an initial diagnostic dilemma as they are confused with other benign conditions due to their slow-growing and multicentric nature. This often leads to underresection of these tumors with subsequent recurrence. There must be a high index of suspicion in diagnosing this tumor and a multidisciplinary, multimodal approach when treating this tumor. Surgery with wide local excision or amputation to attain negative margins is the mainstay in the treatment of this condition followed by adjuvant chemoradiotherapy, which is still experimental.


Background: Primary pericardial mesothelioma is an extremely rare tumor, and early identification and accurate diagnosis may improve its clinical outcome.Case presentation: In this study, we reported a case of a 70-year-old woman who presented with dyspnea. Conventional transthoracic echocardiography showed massive pericardial effusion. Contrast-enhanced ultrasonography revealed a hyper-enhancing mass in the pericardium. Further imaging methods, including cardiac MRI and positron emission tomography/computed tomography, showed invasion of the pericardial mass into the adjacent tissues and distant metastases. Pathologic examination of a puncture biopsy specimen finally confirmed the diagnosis of PPM.Conclusion: Pericardial masses are difficult to detect when a large amount of pericardial effusion is present and the mass is small. The combination of multiple modalities plays a meaningful role in identifying PPM. Primary pericardial mesothelioma is an extremely rare but highly aggressive primary pericardial malignant tumor . The onsIn July 2020, a 70-year-old woman presented with progressive dyspnea and was admitted to a local hospital. The patient had no medical history. Blood tests and electrocardiography showed no abnormalities. Transthoracic echocardiography (TTE) showed massive pericardial effusion. Chest enhanced computed tomography (CT) revealed pericardial effusion with no signs of tumors or tuberculosis. The local hospital performed 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET), which showed intense FDG uptake in the pericardium , the area surrounding the left atrium, and mediastinum . The corin situ hybridization (FISH)  with massive pericardial effusion . Neithern (FISH) . FinallyThis case report emphasized the value of using multiple modalities in the diagnostic work-up of PPM. Few correlative cases have been reported to date . For patPrimary pericardial mesothelioma is an extremely rare malignant tumor that has a reported incidence of 0.0022%, and up to 75% of cases are diagnosed after death , 4. AnteTransthoracic echocardiography is often the first choice in detecting the etiology because of its rapid use and widespread availability. In one study, pericardial effusion was the most common echocardiographic finding of PPM, followed by masses in the pericardial sac and pericardial thickening . NeverthContrast-enhanced ultrasonography can provide deeper insight into the differential diagnosis of pericardial masses. Previous studies have shown that CEUS is safe to identify, characterize and stage tumors . CompareHowever, because of the limitation of the echo window, CEUS is unable to depict tumors in the mediastinum; it also fails to detect tumor invasion into the adjacent tissues. Other imaging methods are needed for further assessment.The CMR plays a key role in the evaluation of suspected cardiac tumors. Based on excellent soft-tissue contrast and high spatial resolution, CMR can identify the anatomical localization of cardiac mass and its relationship to surrounding structures. It can also depict the tumor infiltration and the presence of fibrotic or necrotic tissue components features. According to previous studies, PPM is homogeneously isointense on T1-weighted images, heterogeneous on T2-weighted images, and gadolinium-enhanced –10. FurtThe 18F-fluorodeoxyglucose PET/CT is an alternative tool for the diagnosis and staging of PPM. Increased FDG metabolism within the tumor may be evident prior to the appearance of anatomical changes . PET/CT The final diagnosis of PPM is based on pathologic examination. Experienced pathologists and FISH are needed to achieve the diagnosis. Because the clinical presentations and laboratory abnormalities of PPM are generally non-specific, imaging methods are critically important for the early diagnosis of PPM.In this study, we reported a case in which multiple modalities were used in the diagnostic work-up of PPM. TTE is considered the first-line imaging method because of its widespread availability and rapidity, especially in the emergency bedside setting. If possible, CEUS should be applied to determine the characteristics of the mass with high accuracy based on the blood flow to increase the possibility of early identification. Moreover, further imaging, including CT, CMR, and PET/CT, may help to detect the primary tumor sites and exclude regional invasion and distant metastases.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Written consent for submission and publication of this case report, including all images and associated text, in Frontiers in Cardiovascular Medicine has been obtained from the patient in line with ICMJE guidance.JL, ZW, and BZ designed the study. YY supplied the ultrasound images. YX and WW offered reliable data for the pathologic diagnosis. JQ and KZ supplied the magnetic resonance images. JL wrote the paper. ZW and BZ revised the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Among the causes of acute surgical abdomen intestinal perforation and mesenteric ischemia are some of the leading causes of morbidity and mortality. Gastric perforation has a mortality rate of 20-30% and mesenteric ischemia has a mortality of 60%. The presence of both pathologies in the same patient at the same time is a rare association and very few cases have been reported till now. This association has been described in cases of polyarteritis nodosa. Here we are presenting our case in which no such vascular pathology was identified. We have tried to hypothesize the reason behind this rare association. Mesenteric ischemia defines insufficient mesenteric perfusion to fulfill the metabolic demand. They are classified as acute mesenteric ischemia (AMI) and chronic mesenteric ischemia (CMI). Clinical presentations are nonspecific, so prompt diagnosis and early management are needed in these cases as they have a high mortality rate of 24%-94% .AMI can be classified into four types according to the cause. Previously arterial emboli were the commonest cause but recent studies have shown that arterial thrombosis is the most common cause of AMI constituting 50% of arterial AMI ,3. The sPerforation due to peptic diseases has become less common due to antacids and proton pump inhibitors. The incidence of perforation in gastric ulcers is less nowadays but is associated with a high mortality rate of 20%-30% . As both3 with neutrophil predominance, serum creatinine was on the slightly higher side that is 2 mg/dl, serum amylase was raised, arterial blood gas analysis was suggestive of metabolic acidosis with pH of 7.1, and serum lactate was raised by 10 mmol/L. X-ray chest showed free gas under the right side of the diaphragm suggestive of pneumoperitoneum due to intestinal perforation . There was no history of pain of a similar nature. On examination, there was tachycardia of 110/min, tachypnoea of 25/min, and generalized abdominal guarding was present. Blood investigations showed a leucocytosis of 23000 cells/mmThe patient had a urine output of around 0.5 ml/kg/min. He was resuscitated for four hours with intravenous (IV) fluid and an attempt was made to correct metabolic acidosis. Further, he was taken for emergency laparotomy. Intraoperatively, there was prepyloric gastric perforation Figure . Along wOn reviewing the literature, we found two case reports on a patient presenting as an acute abdomen having dual pathology of gastric perforation and mesenteric ischemia at the same time ,10. By tGastric perforation with AMI in the patient with acute abdomen is a rare association and it should be evaluated for vascular diseases. Due to poor general conditions at the time of presentation, early diagnosis and damage control surgical management should be preferred.


An acute abdomen is a complex case with multiple possible etiologies and requires the help of many different disciplines. We present the case of a two-year-old female who presented to the emergency department in acute distress, pale in complexion, and continuously guarding her abdomen. Physical examination revealed a distended, rigid abdomen with tenderness to palpation of the abdomen in all four quadrants. A computed tomography scan illustrated markedly dilated loops of small bowel but unclear etiology of obstruction with no evidence of perforation. Stat diagnostic laparotomy showed a strangulated internal hernia secondary to a congenital mesenteric defect. The mesenteric defect was repaired laparoscopically, and 25 cm of necrotic bowel was resected with an end-to-end anastomosis. Internal hernias secondary to mesenteric defects are the most common forms of internal hernias in pediatric patients and present with a 100% mortality rate if left untreated. This case illustrates the importance of a high index of suspicion, thorough physical examination, prompt diagnosis, and treatment in preventing a fatal outcome in these patients. An acute abdomen is a condition requiring prompt intervention. The etiology of this condition varies from infection to vascular occlusion, to obstruction and is often a clinical diagnosis with most of these patients appearing extremely ill on physical examination. The most common etiology of an acute abdomen in the pediatric population is appendicitis; however, the patient we are presenting in this case report developed an acute abdomen due to strangulation of an internal hernia due to a congenital absence of mesentery. Martin et al. found that these transmesenteric hernias are the most common presenting internal hernias with a 35% incidence rate, 5% risk of incarceration, and greater than 50% overall mortality . These cWe present a two-year-old female with no past medical history who was transferred from an outside facility after 15 episodes of projectile emesis which progressed from a clear to a coffee-ground color. According to the mother, the patient was afebrile at home with no sick contacts, no rash, no recent travel, no pets in the house, no diarrhea, or constipation. However, she complained of nausea and her mother noted significant fatigue and lethargy. Her last bowel movement was two nights prior to arrival. The patient was unable to articulate her own symptoms due to diffuse and sharp pain located in her abdomen. She lived at home with her mom, dad, and three dogs. She had no known drug allergies.On examination, the patient was visibly in acute distress. She was pale, uncomfortable, and restless in bed with continual abdominal guarding. On palpation, her abdomen was hard, distended, and diffusely tender with severity being highest in the right lower quadrant. Her vitals revealed sinus tachycardia at a regular rate of 176 beats per minute, blood pressure 96/71 mmHg, respiratory rate 25 breaths per minute, temperature at 100.6°F , and oxygen saturation at 98% on room air.9 cells/L, sodium at 133 meq/L, potassium at 5.4 meq/L, and bicarbonate at 16 mmol/L with an anion gap of 10 meq/L. Ultrasound of the abdomen showed free fluid throughout the abdomen with several thickened bowel wall loops, no evidence of intussusception, and no visualization of the appendix. The patient was then rushed for a computed tomography (CT) of the abdomen without contrast which showed abnormal dilatation of mid-to-distal small bowel loops with no clear point of transition (Figures The patient’s laboratory studies were remarkable for a white blood cell count of 11.62 × 10The diagnosis of small bowel obstruction was clear from the patient’s acute presentation and imaging. However, the cause of obstruction remained unclear Figure . SpecifiThe patient was taken to the operating room where a diagnostic laparoscopy with conversion to laparotomy was performed. There was a 25 cm segment of necrotic ileum identified. Upon further inspection, there was an absence of the mesentery for the distal three-fourths of the small bowel. There was an obvious strangulated internal hernia causing the obstructive ischemia of the aforementioned segment of the bowel. The necrotic section of the bowel was removed and an end-to-end anastomosis was created between the two ends of the bowel. Attention was then turned to the appendix which was subsequently resected and removed. The patient was kept overnight for observation and was discharged with a targeted oral antibiotic course the following day due to an unremarkable post-operative course.Strangulated internal hernias are a fatal diagnosis unless rapidly diagnosed and operated on. It is important to recognize the signs and symptoms of these hernias to issue prompt treatment. In this case, an ill-appearing two-year-old with a history of vomiting, diffuse abdominal pain, bloating, and guarding upon physical examination warranted a thorough examination and imaging. However, the diagnosis of strangulated transmesenteric hernia was not made until surgery was performed. These hernias typically show nonspecific findings on various abdominal imaging which can be mistaken for other intestinal pathologies such as obstruction, ischemia, or perforation . While tCurrent literature categorizes strangulation as a common occurrence in the case of internal hernias due to mesenteric defects . Other dWhile it appears that most children suffer no adverse outcomes of bowel resection, current literature fails to evaluate the degree of long-term morbidity in these cases. The degree of bowel resection and type of closure should be evaluated further in these populations to establish the most effective treatment plan. Current literature also does not account for screening in newborns with mesenteric defects. While screening and repair of these defects would reduce the number of strangulated hernias, it is unclear if adding this to the current newborn screening will yield significant results.Our case highlights the importance of a high index of suspicion with pediatric patients who present with symptoms of acute abdomen with inconclusive imaging results. The knowledge of a definitive criterion for diagnosis and treatment of pediatric strangulated hernias remains to be studied, and a structured protocol for triage of these patients still needs to be widely explored and examined. While strangulated internal hernias as a result of mesenteric defects are the most common, there are various other causes of internal strangulated hernias, both congenital and acquired, that must also be explored with further research. Efforts must also be made to educate parents about having a high index of suspicion, the presentation, and the risks of their children developing a strangulated internal hernia.


Verruca vulgaris, also known as common warts, is most often seen on the skin of hands and feet. Human papilloma virus (HPV) plays an aetiological role in the development of this lesion. Oral verruca vulgaris (OVV) may occur on the palate, buccal mucosa, and tongue. Although asymptomatic and benign, HPV has been linked to squamous cell carcinoma in the oral cavity and oropharyngeal areas. Therefore, prompt surgical removal of OVV is warranted. We report a case of a OVV in a 48-year-old male patient on palate. The lesion was a white nonscrapable lesion in the middle of a torus palatinus. Excisional biopsy was done together with surgical removal of torus palatinus. Histopathological analysis confirmed the diagnosis of OVV. Verruca vulgaris is typically seen on hands, feet, toes, and fingers.Although OVV rarely shows malignant change, it could be transmitted to other sites if left untreated.Torus palatinus is the bone prominence or the exostosis situated in the median palatine region of the maxilla; it has a high prevalence in Asian and Mongoloid ethnic groups.A 48-year-old male patient complained of a whitish growth on his palate. He noticed the lesion approximately 2 months before seeking advice from his dentist. The patient was a smoker averaging 10 cigarettes per day, with occasional alcohol intake. Intraoral examination revealed a whitish lesion confined to the middle of a torus palatinus. The lesion was asymptomatic and was not tender on palpation .An excisional biopsy was done concomitant with torectomy. The surgical wound was sutured without the use of a splint. Overall 14 days after surgery, the site had healed uneventfully. A follow-up at 6 months revealed no recurrence . The soThe palatal torus is quite common in Southeast Asia; the removal of it is done to help fit dentures that cover the palatal region to prevent discomfort. The thin mucosa covering the palatal torus makes it prone to get ulcerations, which could expose the palatal mucosa to pathogens.Nonetheless, the histopathological diagnosis of verruca vulgaris is distinctive and enough to differentiate this lesion from other white mucosal lesions in the oral cavity such as frictional keratosis. The presence of intracellular bodies and hypergranulosis, which we see in our case report is not usually seen in frictional keratosis or traumatic keratosis according to Abidullah et alIn this case, the lesion was hyperkeratotic and nonscrapable, which ruled out the presence of candida infection. To the best of this author’s knowledge and based on a thorough online search of previously published articles on OVV, we are the first to document OVV on a palatal torus. This finding is however not entirely surprising because palatal tori are very easily traumatizedThe strain of HPV involved in the pathogenesis of OVV is usually HPV type 2 and HPV type 4.Although rare, Atullah et al documented a case of OVV on the lip which transformed into oral squamous cell carcinoma in 4 years when left untreated.The benign nature of OVV should not be taken for granted, prompt excisional biopsies are warranted to prevent any potential for malignant change. In this case, concomitant torectomy was done to reduce recurrence, this is based on the belief that trauma to the torus was how HPV inoculated the overlying palatal mucosa.


Rectus sheath haematoma (RSH) is an uncommon cause of abdominal pain. Despite being previously viewed as a benign, self-limiting condition, there is increasing evidence suggesting significant local and systemic complications with RSH. We present a case of an 82-year-old female who developed a large RSH following prescription of therapeutic anticoagulation for her new onset atrial fibrillation. She subsequently developed significant haemodynamic collapse, which necessitated emergency radiological intervention. We describe a novel approach to prevent recurrence of bleeding by inserting a covered endovascular stent across the origin of inferior epigastric artery. We also describe a rare finding of bladder perforation, presumed secondary to pressure necrosis from the haematoma. Our report contributes to the growing evidence which suggests RSH, particularly secondary to anticoagulation in the elderly, can result in catastrophic complications. In addition, bladder perforation is a rare but possible complication that needs to be considered. Rectus sheath haematoma (RSH) is an unusual cause of abdominal pain and frequently viewed as a benign, self-limiting condition . HoweverA previously well 82-year-old female was referred for surgical opinion with worsening abdominal pain and loose bowel motions, after being anticoagulated (enoxaparin 90 mg twice daily) for 6 days under the medical team with new onset atrial fibrillation secondary to lower leg cellulitis. Relevant background includes hypertension and type two diabetes. Within 5 h of initial review, patient developed sudden haemodynamic collapse . Urgent computed topography showed a large right RSH measuring 151 × 137 × 128 mm extending into space of Retzius without contrast extravasation . Due to During subtracted digital angiography (DSA), the right inferior epigastric artery (IEA) could not be cannulated due to a pre-existing atherosclerotic lesion but no active contrast extravasation was noted. An 8 × 50 mm, self-expanding covered stent was deployed in the external iliac artery (EIA) across the origin of the IEA to occlude inflow and prevent recurrence of bleeding . The patDay 1 post intervention, post-renal kidney injury due to mass effect of haematoma was suspected . Emergency cystoscopy (for consideration of ureteric stenting) revealed an anterior bladder wall perforation which communicated anteriorly with the haematoma in the extra-peritoneal space . This waRSH is an uncommon presentation, accounting for about 2% of abdominal pain causes . Due to Complications of RSH are rare and may include infected haematoma, hypovolemic shock or intra-abdominal compartment syndrome . We repoOur case contributes to the growing evidence that RHS can result in catastrophic haemodynamic collapse, particularly with the increasing use of anticoagulation in the elderly. In patients where selective embolization of the inferior epigastric vessel is not feasible, usage of covered stent to occlude inflow might be an option. Finally, bladder perforation is a rare but possible complication that needs to be considered.None declared.None.


Paget’s disease of bone (PDB) is a common skeleton disorder in which the diagnosis is suggested by radiological analyses. Congenital generalized lipodystrophy (CGL) is a rare, but a radiologic differential diagnosis of Paget’s disease. Patients present total or almost total lack of subcutaneous adipose tissue, leptin deficiency, and precocious ectopic lipid accumulation, which lead to intense insulin resistance, poorly controlled diabetes mellitus, and hypertriglyceridemia. CGL subtypes 1 and 2 present sclerosis and osteolytic lesions that can resemble “pagetic” lesions. The clinical correlation is, therefore, essential. We report a CGL patient with bone lesions in which the radiographic findings led to a misdiagnosis of PDB. This case report brings awareness to CGL, a life-threating condition. Its early recognition is essential to avoid clinical complications and premature death. Therefore, it is important to consider CGL as PDB’s differential diagnosis, especially in countries with high prevalence of this rare disease, such as Brazil. Paget’s disease of bone (PDB) was first described in 1876 and was named “osteitis deformans” because of its most impressive feature at that time . It is cThe radiological findings correlate to the phase of the disease. Initially, osteoclastic activity is increased, leading to osteolytic lesions in skull and long bones, in which radiolucency areas can assume the pattern of “blade of grass” . In the PDB diagnosis is usually suggested by radiological analyses or scintigraphy, and the most notable feature is the enlargement of the bone . Hence, CGL is a rare autosomal recessive disease, more frequently found in parental consanguinity cases. It was first described by a Brazilian physician in 1954, and only about 500 cases have been reported since then (100 of those described in Brazil) , 21. ItsAGPAT2 and BSCL2, correspond to almost 95% of cases , was referred to our University Hospital, a reference center in lipodystrophy  because of suspected lipodystrophy and previous PDB diagnosis. He reported five cousins diagnosed with CGL and no familiar history of bone disease.At age of 15 years, the patient noticed generalized lack of subcutaneous fat, unlike his parents and two siblings. Two years later, he was diagnosed with diabetes mellitus (DM). He had both mild hypertriglyceridemia and hyperglycemia. At age of 20 years, he was started on oral antidiabetics and low-carb diet. He lost follow-up and resumed medical care at the age of 28 years, when insulin therapy was initiated, leading to good glycemic control. At 33 years old, he presented progressive right hip pain that irradiated to the lower limbs, which was improved with non-steroidal anti-inflammatory and became bilateral 5 years later, which is when he sought medical help. Hip computed tomography (CT) was performed to investigate the worsening of the symptom, which showed multiple foci of sclerotic lesions, a 2-cm bone cyst on right femoral head, and another 3-cm cyst on the left femoral head. At that time, PDB was suspected, and the skull, lower limbs, upper limbs, and hip x-rays undertaken were normal. Serum C-linked C-telopeptide of type 1 collagen (CTX) was 0.245 ng/ml , and AP concentration was 59 ng/ml . Bone-specific AP, P1NP, and bone scintigraphy were not undertaken, once the previous follow-up was conducted in a poor region of the state of Ceará.Atypical PDB was then suspected, and an iliac crest biopsy was performed. Histopathological analysis, at the time, was thought to indicate increased osteoclastic activity; therefore, the diagnosis of PDB was suggested.2, generalized lack of subcutaneous fat with preserved fat in the palms and soles, muscle hypertrophy, phlebomegaly, and umbilical hernia. He did not have acanthosis nigricans or signs of bone deformity.Three years after the initial investigation, because of the worsening of the hip pain and the suspected lipodystrophy, the patient was referred to our center in lipodystrophy. He brought only medical records but no previous radiological images. Our physical examination revealed a BMI of 22.5 kg/m2) and left femoral neck Z-score of +2.4 .New biochemical parameters showed leptin of 0.3 ng/ml , hyperlipidemia , glycated hemoglobin (HbA1C) of 7.3%, fasting blood glucose of 108 mg/dl, and serum AP of 218 U/L . A new skeletal survey was performed. Skull x-ray revealed a homogeneous increase in cranial cap density. There was no thickening of the cranial vault  in the Once PDB misdiagnosis was suspected, we requested a pathology review. Because CGL is a rare disorder, the pathologist was advised about CGL diagnosis and its radiologic features before the new evaluation. The histopathological analysis revealed a non-lamellar bone tissue (immature type) with bundles of collagens arranged in multiple directions. There were no of signs of osteoclastic activity nor neoplasm Figure 2AGPAT2 gene mutation.We describe a patient with clinical features of CGL born out of a consanguineous marriage in the Northeast region of Brazil, where there is a high prevalence of CGL, probably because of the higher frequency of parental consanguinity. A large series of CGL identified consanguineous parental marriages as its most important risk factor . Our patAn extensive review of longitudinal studies and standard case reports showed that CGL1 and CGL2 have increased bone mass, bone cysts, and sclerosis, which are findings present in our patient . Focal lThe misdiagnosis was probably influenced by the fact that PDB is a common skeletal disease, with a much higher prevalence than CGL. He was 41 years old, which is a relatively young age for the diagnosis of PDB as it is very rarely diagnosed before age 50 . The patUnlike PDB, bone lesions rarely lead to CGL diagnosis. Nevertheless, Hasani-Ranjbar et al.  describeOnce an atypical PDB case was suspected, iliac crest biopsy was performed. According to the Endocrine Society clinical practice guideline, experienced radiologists and physicians generally have no difficulty in recognizing PDB’s lesions, and a need for a biopsy is rare, although it can be helpful in atypical cases . The iniThis case report brings awareness to not only a rare, but also important, PDB differential diagnosis, which is CGL. Bone radiologic findings can be similar, and the histological evaluation of both disorders can resemble, which makes the knowledge of CGL and its clinical presentation very important to the physicians that study PDB and its differential diagnosis.CGL is a life-threating condition, and its early recognition is essential to avoid clinical complications and premature death. Therefore, in suspected cases, an evaluation in a reference center in lipodystrophy should be considered.In conclusion, misdiagnosis of PDB can occur in CGL, mainly in subtype 1 patients, because of the cystic lesions. Therefore, the differential diagnosis of this rare disease is important to consider, especially in countries with high prevalence, such as Brazil.All datasets presented in this study are included in the article/supplementary material.The studies involving human participants were reviewed and approved by The Ethics Committee of University Hospital of Ceará Federal University. The patients/participants provided their written informed consent to participate in this study.All authors contributed to data analysis, drafting, and revising the article, gave final approval of the version to be published, and agree to be accountable for all aspects of the work.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Symptomatic Bochdalek hernias are found mainly in infants in respiratory distress and occur rarely in adults.We report a rare case of Bochdalek hernia associated with developmental abnormalities in an adult who exhibited acute chest pain and dyspnea on exertion.This case highlights the importance of the differential diagnosis of acute left-sided chest pain and antenatal examination. Bochdalek hernia (BH) is one of the most common diaphragmatic abnormalities in infants and is characterized by cyanosis, tachycardia, and asymmetric growth in the chest cavity. By contrast, symptomatic BH is rare in adults. Reduction of the herniated content back into the peritoneal cavity, repair of the hernia, and relief of the intestinal obstruction are important objectives of operative repair. We describe here a case involving a 19-year-old woman with BH who presented with acute paroxysmal left chest pain radiating to the epigastrium. She underwent a mesh-based patch repair and the herniated viscera were returned to the abdominal cavity.A 19-year-old woman presented with acute paroxysmal left chest pain radiating to the epigastrium of 4 days duration. She had a 10-year history of exertional dyspnea that was aggravated in the supine position, but no history of chest or abdominal trauma. She was misdiagnosed with a pulmonary abscess at another hospital, and the oral antibiotic treatment was ineffectual. Clinical examination on admission to our hospital revealed bowel sounds and decreased air entry in the left chest and that the abdomen appeared to be scaphoid. No obstructive gastrointestinal symptoms were observed. An X-ray revealed herniated loops of both the small and large intestines in the left hemithorax, which produced multiple lucent shadows and severely reduced lung space Fig. , arrow.FA left posterolateral thoracotomy was performed through the sixth intercostal space. The diaphragmatic defect was found along with herniation of the jejunum, ileum, ileocecal junction, appendix, and ascending and transverse colon. Pulmonary hypoplasia was also seen in the left lower lung lobe. We separated the adhesions around the foramen and within the pleural cavity. A laparotomy was subsequently performed through a median incision. During the operation, anomalies were found in intestinal rotation and fixation, and the total length of the jejunoileum was measured as 750 cm. The herniated viscera were returned to the abdominal cavity.We performed a sublay patch repair of the left posterolateral diaphragmatic hernia using a Dacron patch . The procedure lasted for about 3 h. The patient had an uneventful postoperative period. An X-ray of the upper gastrointestinal tract with soluble iodine contrast at the 1-month follow-up showed that the repair was satisfactory Fig. . After tBH was first described by the Czech anatomist and pathologist, Vincent Alexander Bochdalek 1801–1883), in 1848 801–1883,. By contPatients with BH can be asymptomatic or present with nonspecific gastrointestinal and respiratory signs and symptoms . Other lRadiological examination has great clinical value for the discovery of BH and exclusion of other differential diagnoses, especially when BH is an incidental finding or is asymptomatic and involves a small congenital diaphragmatic hernia . RadioloWe have described a rare case of a giant BH in an adult who presented with acute chest pain and dyspnea on exertion. The patient was initially misdiagnosed with a pulmonary abscess. After undergoing a mesh-based patch repair, the patient’s pain and dyspnea were relieved, and good therapeutic outcomes were achieved.


Omphalomesenteric cysts are an exceedingly rare type of embryologic remnant of the omphalomesenteric duct. Owing to its rarity and unspecific imaging findings, it is occasionally difficult to diagnose preoperatively. Herein, we report the case of a 15-month-old female with an omphalomesenteric cyst that presented as a painful abdominal mass. Imaging showed a 4 cm cystic lesion just beneath the umbilicus, which also contained a 1 cm enhanced lesion. On the immediate right side of this cyst, a 7 cm hematoma was found within the abdominal wall. Aspiration revealed bloody fluid with an amylase level of 38,250 U/L. She was then diagnosed with an omphalomesenteric cyst, with aberrant pancreas and associated hematoma of the abdominal wall. These findings were confirmed with laparotomy and subsequent pathological examinations. The high level of amylase in the cyst led us to speculate the existence of ectopic pancreatic tissue. Thus, amylase measurement may be considered for the diagnosis of an omphalomesenteric cyst. Omphalomesenteric cysts are an exceedingly rare type of embryologic remnant of the omphalomesenteric duct . Owing tA 15-month-old female presented with a painful abdominal mass. She had a history of ventricular septal defect, which was surgically treated at 8 months of age with a good postoperative course. Her vital signs were normal, except for a high temperature of 38.0 °C. Upon physical examination, an elastic hard mass was palpable on the right side of the abdomen, and the appearance of the umbilicus was normal. Blood examination indicated a white blood cell count of 14,500/μL, a C-reactive protein level of 2.4 mg/dL, a hemoglobin level of 9.6 g/dL, and an amylase level of 98 U/L (44−132 U/L). Abdominal radiography revealed no signs of intestinal obstruction. Abdominal ultrasonography (US) revealed a large intraabdominal cyst, but contrast-enhanced computed tomography (CT) showed that a cystic lesion that was 4 cm in diameter was located in the abdominal wall, beneath the umbilicus. The cystic lesion contained a 1 cm enhanced lesion a. On theThe omphalomesenteric duct is an embryonic structure connecting the yolk sac and the midgut, which normally disappears at approximately 5–9 weeks of gestation. The most common type of remnant, the Meckel’s diverticulum, accounts for 82–96% of all types and is found in 2% of autopsies . In contThe symptoms of omphalomesenteric remnants depend on their location. If the remnant opens or is located in the urachus, urachal effusion, bleeding, and/or inflammation are usually observed. If it communicates with the intestine, abdominal pain and/or gastrointestinal bleeding are the main symptoms . HoweverDifferential diagnosis of pediatric body wall masses includes rectus abdominis hernia; urachus remnants; rectus abdominis hematoma; abdominal wall abscess; hematoma; lymphatic/vascular malformations; and malignant tumors, such as rhabdomyosarcoma and other rare sarcomas. Although diagnosis is important to exclude malignancies, imaging findings of omphalomesenteric cysts are often inconclusive due to their non-specific appearance, as was observed in our case despite the use of other modalities, including US and magnetic resonance imaging (not shown).In this case, where malignancies could not be eliminated, a high amylase level of the content fluid was helpful in the diagnosis of ectopic pancreatic tissue, since it is well-known that ectopic pancreatic tissue may be contained in omphalomesenteric remnants. To the best of our knowledge, there have been no reports on the use of amylase levels for the preoperative diagnosis of omphalomesenteric remnants. Over 70% of the ectopic pancreatic tissue is located in the gastrointestinal tract, mainly in the duodenum and colon . MoreoveApart from imaging findings, a high local level of amylase may indicate the existence of ectopic pancreatic tissue, which is helpful for the diagnosis of omphalomesenteric cysts.


Vascular anomalies are subdivided into vascular tumors (hemangiomas) and vascular malformations. They are frequently located in the head, neck, and oral cavity. They are common complaints reported in patients seeking treatment for aesthetic or functional issues.However, recent advances in the diagnosis and management of these lesions are improving treatment strategies. This review provides both basic and up-to-date knowledge on the most common vascular anomalies encountered by practitioners.Due to the wide variability of treatment options which often generates debate, this paper work aims to provide a comprehensive approach of these lesions based upon current concepts and practical clinical experience.Our article is about 4 patients who had consulted for one or several purplish, elevated, well limited and soft lesion. These lesions was not painful, but worrying for patients. Therapies for VAs continue to generate a dilemma for oral surgeons. Several treatment options were reported, including conventional surgery with or without adjunctive preoperative embolization, and drug therapies, such corticosteroids, intralesional injection of corticosteroids and intralesional injections of sclerosing agents. All of these therapeutic approaches carry a high risk of severe side effects such as scars, pain, and bleeding Nowadays, advances in the use of lasers have allowed doctors an effective treatment with minimal side effects [9].All our cases described in this article were done by Pr Haitami, using the 980 nm Diode laser, and a complete healing was observed in about 8 months at the most. The laser is therefore a great help in the management of this type of lesion. •The last classification and clinical aspects of vascular anomalies•Contribution of the laser in the management of angiomas•The use of the 980 nm diode laser to the sclerosis of the venous malformation by intralesional photocoagulation Interdisciplinary diagnosis and treatment are of real importance in these cases. The classification separates the vascular anomalies into two major groups. The first group includes tumors associated with a process of endothelial cell proliferation, which appears in childhood, with proliferative changes, followed by an involutional process of unknown etiology, called hemangiomas and the second one, consisting of those vascular malformations (VM) that appear as a result of the altered development and formation of blood vessels, present at the birth, normal endothelial mitotic activity, which grows throughout life with no presence of an involutional process 2https://www.researchregistry.com/browse-the-registry#home/registrationdetails/60e745f6c3cfb0001f4b239b/).The research registry number in accordance with the Declaration of Helsinki is researchregistry6957 , at the Center for Dental Consultations and Treatments at the CHU Ibn Rochd Hospital in Casablanca.All of our patients were recruited between 2018 and 2021, and received a follow-up that lasted up to 8 months.No particular precautions were taken before the intervention.This case series has been reported in line with the PROCESS Guideline 2.1A 61-year-old woman, with no particular medical history, was referred to our department for an evaluation regarding two oral bluish lesions. She reported that these lesions appeared about 5 months ago. The oral mucosa examination showed two dark blue-colored papules: one on the dorsal side of the tongue and the other on its lateral side. Each lesion was of 1-cm diameter, elevated, and well-limited. A pulsating sensation was perceived during the palpation .Fig. 1TwDuring palpation, the papule was soft and whitened with applied pressure. The diagnosis of venous malformation was established. A very light anesthesia (Mepivacaine) was performed all around the lesion. We performed a photocoagulation of the lesion using a 980-nm diode laser in noncontact mode. We used a 300-nm fiber in continuous wave, with a power of 1.5 W for 1 min until the lesion whitens .Fig. 2InOne gram of paracetamol every 6 h was prescribed during 3 days. The follow-ups at 10, 20, and 30 days showed a perfect healing process. The patient did not report any post-operatory complications or recurrence .Fig. 3A 2.2A 65-year-old female patient, with no particular medical history, was referred to the Department of Oral surgery for diagnosis and treatment of a soft round tumor of 5 mm diameter approximately in her jugal mucosa. The extra-oral exam has shown respected facial symmetry. According to the clinical examination, the lesion was soft, round, purplish, elevated, and well limited .Fig. 4A A pulsating sensation was perceived during the palpation. The diagnosis of venous malformation was established. The vascular lesion was removed in one session after topical anesthesia. The tumor was irradiated using 4Wpower in noncontact mode. The same diode laser (980 nm) was used, and the fiber had not been activated.We worked 2–3 mms away from the surface of the lesion by sweeping the lesion from the center to the periphery. The lesion started to bleach gradually . An ice Postoperative medication was not mandatory. A superficial layer of fibrin was present after 10 days, and four weeks after surgery the oral mucosa was completely healed .Fig. 6A 2.3A 40 -years-old woman, with no particular medical history, was referred to the department of oral surgery for a purplish lesion increasing in volume, which had appeared 1 year ago on the inner side of the upper lip and the vermilion.The patient's medical and surgical history revealed a trauma to the upper lip during childhood that went unnoticed .Fig. 72 The extra oral clinical examination revealed a bluish swelling in the upper lip causing significant aesthetic damage.The intra-oral examination showed two other purplish lesions, well limited to the inner side of the upper lip, slightly indurated, and pulsated during palpation .The diagnosis of hemangioma was established.A 980 nm diode laser was selected for treatment of the lesion in a defocused mode, with an output power of 4 W, in a continuous mode under local anesthesia.During the first 48 h, the patient reported a slight discomfort because of the swelling.The patient did not return for the follow-up appointment due to restrictions related to the corona pandemic.She was seen 8 months later, partial healing was observed.The residual lesion was coagulated by the same diode laser with the same settings.After 45 days, clinical healing was observed with no signs of inflammation or infection.After 3 months, a full recovery of the area and a reestablishment of the facial aesthetic was observed .Fig. 88 2.4A 30 -years-old woman, with no particular medical history, was referred to the department of oral surgery for a purplish lesion increasing in volume, which had appeared a few months ago on the inner side of his left cheek. The extra-oral exam has shown respected facial symmetry. According to the clinical examination, the lesion was soft, purplish, elevated, and well limited .Fig. 9PuA pulsating sensation was perceived during the palpation. The diagnosis of hemangioma was established.The vascular lesion was removed in one session after topical anesthesia. The tumor was irradiated using 4Wpower in noncontact mode. The same diode laser (980 nm) was used, and the fiber had not been activated. The lesion started to bleach gradually . Postope4 months after surgery, the oral mucosa was completely healed .Fig. 11IAt her follow-up visit, the patient reported: <Thank you doctor, I did not feel any pain after the operation>.3The characteristics and differences concerning vascular anomalies (VAs) have been widely discussed and revisited. Recent reanalysis ruled out the latest classification system of the International Society for the Study of Vascular Anomalies (ISSVA), published in May 2018 .Fig. 12IThe (ISSVA) categorizes vascular anomalies into vascular tumors and vascular malformations. Vascular malformations are further divided into slow-flow  and fast-flow malformations .This interdisciplinary classification has therapeutic implications. Despite its accurateness, it has a clear shortcoming in regard to interdisciplinary communication Congenital hemangiomas differ from infantile hemangiomas as they are fully developed at birth and tend to either regress rapidly, partially or do not regress at all Vascular tumors are comprised of far more entities than hemangiomas. Based on whether they are malignant or benign, they may require more extensive diagnosis and therapeutic evaluation than hemangiomas.Clinical inspection and patient history are essential for appropriate diagnosis.Vascular malformations are always present at birth (even if asymptomatic) and never regress spontaneously. They may be quiescent for a long time, before a mechanical or hormonal stimulus results in their growth. With increasing size, vascular malformations can cause pain and functional impairment which may require treatment. Vascular malformations can be classified as “simple” or “combined vascular malformations” as well as “vascular malformations associated with other anomalies” Furthermore, it is typical of these lesions to only be localized on one side of the body.As is the situation in our case, where all lesions are unilateral.The decision for invasive treatment should be made by an interdisciplinary team and is based on individual symptoms and possible complications of the natural course of the disease. The risks of the invasive procedure have to be weighed against the potential benefits Therapies for VAs continue to generate a dilemma for oral surgeons.Several treatment options were reported, including conventional surgery with or without adjunctive preoperative embolization, and drug therapies, such corticosteroids, intralesional injection of corticosteroids and intralesional injections of sclerosing agents. All of these therapeutic approaches carry a high risk of severe side effects such as scars, pain, and bleeding In his article, on the treatment of hemorrhage after dental extraction, related to a capillary hemangioma, Ghanem A et al., described the management by the conventional method Several materials and embolization protocols are used Longacre et al. used silicone balls impregnated with barium or tantalum For a better stability, we can have recourse to the injection of cyanoacrylate of n-butyl According to McHeik and al., intralesional injection of corticosteroids may induce an ulceration of the lesion Nowadays, advances in the use of lasers have allowed doctors an effective treatment with minimal side effects That is why all our patients have been treated by laser.For effective treatment, the laser must penetrate deep into the target vessel. Additionally, the exposure needs to be long enough to cause sufficient coagulation of these vessels The interaction between laser and tissue is due to the energy absorbed by tissues. For correct treatment of a lesion with high blood content, it is necessary to choose a laser emitting in a wavelength well absorbed by hemoglobin. KTP, diode, Nd:YAG, and CO2 are the most effective wavelengths in these cases The 4 cases previously described were treated with A 980 nm diode laser.Moreover, it is necessary to evaluate many further parameters such as: pulse duration, spot size, and energy density, thus for a correct laser treatment. Shorter pulse durations are preferable for small diameter vessels while longer pulse durations must be employed in larger diameter ones. The spot size selection should be based according to the depth and the size of the lesion During their experience, Umberto, Romeo, and al affirm that lasers are the gold standard in the treatment of benign oral vascular lesions of the oral cavity with venous flow Three different laser approaches were examined in this study: The excisional biopsy(EB), the sole to permit a histological diagnosis of the lesion, must be reserved to vascular lesions suspected to be malignant neoplasms. Among the laser techniques, transmucosal thermocoagulation (TMT) seems to be the most reliable and advantageous.Indeed, this is the technique that has been used for all previously described cases, in(TMT), the optical fiber is not in contact with the lesion, which makes it safe even in patients affected by systemic diseases such as coagulation problems or under anticoagulant therapy. This method also gives good functional and aesthetic results. Intralesional photocoagulation (ILP) is often used for wide and deeper lesions that cannot be treated with TMT. ILP is characterized by a higher risk of bleeding due to fiber penetration into the lesion, but it can be overall considered a safe technique.It is possible to assess that the laser is safe and effective, and in many cases it represents the go-on technique permitting results usually unattainable with conventional treatments In our case, we found that the ulceration paired up with the healing process was less present in the first patient (1.5 W) compared to the other ones (4 W).Furthermore, the use of diode lasers either minimizes or completely avoids thermal damage and morpho-structural changes of irradiated tissues According to several histological studies, the type of diode laser interaction depends on both the type of vascular malformation and the depth of infiltration. Variable absorption capabilities in the underlying tissues are noticed for different vascular malformations, thus highlighting the need for intralesional lasers to treat deep lesions A study conducted by Álvarez-Camino and al, consisted of the introduction of an activated optical fiber via the catheter lumen, until the active tip is positioned within the venous malformation, keeping it accessible to the lighting guide of the laser unit. The laser is radially applied in the deeper areas of the lesion, while the laser fiber is progressively moved upward to the entrance area of the fiber. Subsequently, the optical fiber is removed. This study has shown promising results The diode laser light turns into heat when absorbed by hemoglobin, resulting in coagulation. The penetration depth of the 810 nm wavelength appears to be lower than in the Nd:YAG one, making it more effective in the coagulation of superficial and interstitial lesions The intralesional fiber of the diode laser aims to cause the endothelial injury of the affected vessel. Not only is it induced by the thermal action caused by laser light, but also the secondary thermal effect caused by the bubbles associated with the absorption of light energy by hemoglobin In conclusion, vascular venous anomalies of small dimensions can easily be treated with diode laser photocoagulation (regardless of the wavelength). It has been observed that most hemangiomas stop growing after laser therapy, and that the rate of adverse reactions is very low which was observed in our case. No sign of recurrence was observed either 4Despite its accurateness, there has been up to now a lack of familiarity with this interdisciplinary classification system. Furthermore, when asked how to manage peripheral vascular malformations, we are faced with a large number of studies and case series with low levels of evidence and mixed results, which in the face of individual varying patient presentations makes it nearly impossible to decide what the optimal treatment strategy for each patient is Nevertheless, several questions regarding laser treatment for VeMs remain unresolved, especially those related to challenging differential diagnosis, the sites involved, depth of localization, and lack of standardized treatment protocols The authors declared that this study has received no financial support.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Not commissioned, externally peer-reviewed.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.1.Name of the registry: researchregistry2.Unique Identifying number or registration:69563.Hyperlink to your specific registration (must be publicly accessible and will be checked):Dounia sarfi.Authors of this article have no conflict or competing interests. All of the authors approved the final version of the manuscript.


The clinical diagnosis of acute appendicitis is challenging as patients present with an array of objective and subjective symptoms early or late in the disease course. Ultrasound is routinely performed in all patients with suspected acute appendicitis. Equivocal test results frequently require further assessments using other imaging techniques that are limited in scope during pregnancy because of issues involving safety, availability, and accessibility. Physical examination diagnostic signs in acute appendicitis during pregnancy have not been well studied. Studies failed to describe, standardize, or correlate the technique used to the pathologic disease process. Therefore, gaps remain in current knowledge regarding the usefulness and application of these tests during the physical examination. Improvement in diagnostic acumen is critically important, particularly in cases where there remains diagnostic uncertainty because of equivocal imaging results. This article reviews signs used to diagnose patients with acute appendicitis using a pathophysiologic approach based on visceral and cerebrospinal nerve pathways to explain the mechanism for a positive test result. It also suggests a framework to study them further to better understand their role, if any, in clinical practice. Acute appendicitis during pregnancy is a common cause of nonobstetrical abdominal pain. In some cases, especially during the early stages of the disease, the diagnosis remains elusive despite advanced imaging techniques. Thus, a comprehensive history and physical examination with serial evaluations remain the cornerstone in assessment and diagnosis. Gaps in knowledge remain regarding the role of the physical examination in diagnosis. The purpose of this article is to describe the physical examination signs reported during pregnancy, the pathophysiologic mechanism involved in a positive test result, and a framework for future studies assessing their effectiveness.Various tools have been studied to confirm a diagnosis of acute appendicitis during pregnancy. A recent retrospective case series in 42 pregnancies with acute appendicitis found that laboratory studies alone did not distinguish acute appendicitis from nonappendiceal disease . ClinicaCerebrospinal and visceral nerve pathwaysDifferent descriptions and locations of the pain in acute appendicitis can be explained by whether the splanchnic  and/or cerebrospinal (somatic) nerve pathways are involved -8. In acIn contrast, inflammation of the parietal peritoneum of the abdominal wall activates cerebrospinal nerve pathways with pain afferent signals transmitted through intercostal nerves to the dorsal root ganglion . Additionally, movement, cough, removal of the palpatory hand, or other maneuvers activate anterior spinal root alpha neurons that innervate the abdominal wall muscles causing spasm and guarding . This reflex localizes the pain to the same area at the inflamed peritoneum. In patients with acute appendicitis, with disease involving the parietal peritoneum, pain most commonly occurs at McBurney point, the site “very exactly between an inch and a half and two inches from the right anterior spinous process of the ilium on a straight line drawn from that process to the umbilicus" p. 678) . It is e . It is Signs described in acute appendicitisPhysical examination findings in acute appendicitis, if reported, mainly assessed symptoms of abdominal wall pain and rebound tenderness elicited during abdominal palpation -17. SomeStandardization of technique is essential to ensure reproducibility and consistency in reporting when evaluating the sensitivity or specificity of a bedside sign. To assess the extent of this problem, Prosenz and Hirtler evaluated the accuracy of the description of Rovsing sign in English and German literature . None ofThus, Rovsing sign involves activation of Pacinian receptors in the inflamed appendix in response to distension by the retrograde flow of gas in the colon. In this case, afferent nerve fibers carried through splanchnic sympathetic nerves ultimately activate visceral efferent pathways resulting in pain in the right lower quadrant at the T10-T11 dermatome . Variations in the technique when performing this sign incorrectly described it as using one or both hands applying only downward pressure without a sliding motion in the left lower quadrant or the same maneuver followed by a quick release of the hand from the abdominal wall (rebound tenderness) -24. The The Psoas sign, as described by Cope in 1921 , is a meVariations of this test that are erroneously used in clinical practice include having the patient positioned supine followed by flexion of the thigh against the examiner’s hand placed above the knee . The tesFinally, the thigh rotation or obturator test is another test described by Cope in cases of acute appendicitis: The right thigh is slightly flexed (so as to relax the psoas muscle) by the surgeon, who stands on the right of the patient; the limb is then fully rotated at the hip, first internally and then externally, so as to put the obturator internus through a full range of movement. The sign is positive if the patient complains of hypogastric pain when the limb is moved in this manner (p. 537) .A positive test requires that the inflamed appendix be located below the pelvic brim, adherent to or contiguous with the fascia of the obturator internus muscle . SeveralControversy exists regarding the anatomical location of the appendix during pregnancy. Interestingly, studies evaluating the position of the appendix during appendectomy or cesarean section found no changes in the normal location of the appendix, while imaging with CT or MRI identified upward displacement with advancing stages of pregnancy -31. The Signs for acute appendicitis specifically designed during pregnancyAlders and Bryan described two bedside maneuvers named as signs for their namesake as a method for distinguishing uterine from extrauterine  causes specifically during pregnancy -33. AldeAlders sign is based on the anatomic principle that the appendix is a retroperitoneal structure, remains fixed, and does not shift when the patient moves to the left decubitus position . In contBryan also reported a method for diagnosing appendicitis during pregnancy and the puerperium such that applying “pressure on the pregnant uterus from the left side will often elicit pain in the right lower or middle quadrants” (p. 1205) . The preSummary of signs of acute appendicitis in children and adults and during pregnancySeveral studies identified in the literature to present assessed the outcomes of a positive or negative psoas, obturator, and/or Rovsing sign in children and adults and during pregnancy in patients diagnosed with and without appendicitis. Studies were prospective, retrospective, and cross-sectional in design and chosen if adequate information was available to construct a 2 x 2 contingency table to calculate sensitivity, specificity, and likelihood ratios (LRs) Tables , 2.No studies defined the technique for performing these signs. Both the psoas and obturator signs share similar operating characteristics. Rovsing sign had the highest LR, which is interesting in light of questions regarding its consistency in performance . In bothGaps remain in the current understanding of the physical examination signs during pregnancy. It is unknown whether these signs are useful in supporting the clinical diagnosis of acute appendicitis. These limitations involve several factors, including not performing the maneuver as originally intended, lack of standardization of the test, and a failure to correlate the stage of the disease with findings on clinical examination. Improved knowledge may help reduce diagnostic uncertainty, particularly in cases where there is intermediate suspicion for the presence of the disease. We recommend that these physical examination signs be included and rigorously studied in future research that assesses models, laboratory, or imaging aspects of acute appendicitis during pregnancy. In the interim, MRI of the abdomen remains the gold standard in diagnosing acute appendicitis during pregnancy.


Eyes with a short axial length or anterior chamber depth often develop narrowed anterior chamber angles in association with an enlarging crystalline lens. We report a case of a patient who presented in angle closure, with a distant history of prior intervention for congenital cataracts and was presumed to be aphakic.A 78-year-old male presented with acute onset unilateral eye pain and blurred vision. He was found to have increased intraocular pressure, anteriorly bowed iris, and angle closure. Despite prior documentation of aphakia after treatment for congenital cataracts, detailed workup revealed residual crystalline lens material pushing the peripheral iris anteriorly. Further history confirmed that the patient underwent a procedure in the 1940’s to remove lens material centrally but was not truly aphakic. The patient was treated with anterior chamber paracentesis and intraocular pressure lowering drops. His intraocular pressure remains controlled with medical therapy alone.Patients that appear to be aphakic centrally may still present with angle closure secondary to residual peripheral lens material. This case highlights the importance of keeping this etiology on the differential in a patient with presumed aphakia. In the last century, the surgical approach to congenital cataracts has greatly evolved and progressed with the advancement of technological innovation, instrumentation, and surgical approach . We presA 78-year-old male presented with 3 days of intermittent blurred vision and pain of the right eye (OD). His medical history included Crohn’s colitis, Addison’s disease, and chronic obstructive pulmonary disease. By chart review, his ocular history included aphakia in both eyes (OU) following intervention for congenital cataracts during childhood in the 1940’s, microcornea OU, aphakic glaucoma OD, and no light perception vision in the left eye (OS) secondary to vision loss following a congenital cataract surgical procedure at age 18, currently with an opaque and vascularized cornea. Although axial length and anterior chamber depth have not been measured OU, the patient is known to have a macular coloboma OD with subjective refraction of − 1.00. Intraocular pressure (IOP) was previously well-controlled in the low teens OU on daily latanoprost 0.005% OD, and central corneal thickness was 549 μm OD and 648 μm OS. On presentation, Snellen visual acuity OD was 20/200 at baseline. The IOP by Goldmann applanation tonometry was elevated to 37 mmHg OD. Slit lamp examination revealed anterior bowing of the superotemporal iris with resulting narrowed angle (Fig. Our patient has a history of congenital cataracts OU, for which he underwent surgical intervention in the 1940’s. He described a “needling procedure” OD, rather than removal of the complete lens or lens-capsule complex. The hospital where this procedure was performed had been closed, and medical records were not available. However, findings on slit lamp examination and UBM support this history. Gonioscopy showed a circumferential opalescent mass posterior to iris that was present 360 degrees, but most prominent in the superotemporal quadrant. UBM demonstrated intact anterior and posterior lens capsules, with a round, echogenic mass inside the lens capsule. Together, these findings suggested residual crystalline lens, rather than Soemmering’s ring, as the underlying cause of angle closure. The increase in IOP, however, was likely multifactorial, as appositional closure was noted for less than 180 degrees, and this patient already had known risk factors for glaucoma including prior surgery for congenital cataracts and microcornea .With the modern-day development of vitrectomy and phacoemulsification units, this amount of residual crystalline lens would be atypical. In the 1940’s, however, this technology was not available, so intervention for congenital cataracts included discission and linear extraction [It is important to recognize residual crystalline lens as a potential cause of secondary angle closure, even in a patient with history of aphakia. This differential diagnosis of similar presentations includes lens material, iris mass, ciliary body mass, and choroidal effusion. Two reported cases describe patients with prior intervention for congenital cataracts that years later, were referred for concern for iris lesions , 4. One This phenomenon of angle closure in aphakic patients has an analogous presentation in pseudophakic patients. A series of 3 patients in angle closure due to a Soemmering’s ring were successfully treated with LPI . AnotherIn summary, we present a case of a 78-old-male that presented with angle closure secondary to lens remnants, even after prior intervention for congenital cataracts. Although our patient strongly wished to avoid any medical procedures, both LPI and extraction of lens remnants were considered. This case highlights the importance of conducting thorough history, exam, and imaging in all patients, even those with prior ocular diagnoses.


Stromal tumours of the prostate are exceedingly rare, often presenting in patients in their fifth decade of life. They are classified as either stromal sarcomas, or stromal tumours of uncertain malignant potential (STUMP), the latter of which is known to have diverse clinical behaviour and thus surgical excision is often warranted. We present a case of a 71-year-old male, initially worked up by his family doctor due to mild obstructive voiding symptoms. Following a more thorough urologic workup, including a prostate biopsy, he was found to have a markedly elevated prostate specific antigen and positive cores on prostate biopsy demonstrating prostatic adenocarcinoma. The decision was made to treat with retropubic radical prostatectomy and bilateral pelvic lymph node dissection. Resulting pathology showed concurrent prostatic adenocarcinoma in addition to STUMP. The patient continues to be followed by oncology as well as a sarcoma specialist due to the unique nature of his case. Prostatic stromal tumours, arising from mesenchymal tissue, are exceedingly rare, accounting for <1% of prostate cancers . STUMP iThere remain relatively few case reports of concurrent prostatic stromal tumours and adenocarcinoma in the literature. Here, we present a case of suspicious magnetic resonance imaging (MRI) findings, suggestive of a complex hemorrhagic cyst, and prostate biopsy positive for prostatic adenocarcinoma, managed with radical prostatectomy and a resulting pathologic discovery of concurrent STUMP as well as adenocarcinoma. This patient in particular was unique due to his late age of onset for this particular type of tumour, as well as the concurrent diagnosis.A 71-year-old Caucasian male presented with mild obstructive voiding symptoms to his general practitioner. Past medical history was significant for unmedicated hypertension, chronic obstructive pulmonary disease, gastroesophageal reflux disease and Reiter’s syndrome. Significantly, he had a 50 pack year history of cigarette smoking. At presentation, he denied any hematuria or signs of urinary tract infection. A PSA test was normal at 3.54 at this time. One year later, repeat PSA was found to be 17.8, prompting a referral to Urology. Workup after referral included a transrectal ultrasound guided (TRUS) prostate biopsy, revealing 2/10 cores positive for Gleason 3 + 4 = 7 prostatic adenocarcinoma. No evidence of perineural invasion, lymphovascular invasion or extraprostatic extension was identified. Staging was conducted with a bone scan and an abdominal and pelvic computed tomography scan, revealing no lymphadenopathy or bony metastases. Further investigation using an MRI of the prostate revealed a 104 cm [Ultimately, this patient underwent a retropubic radical prostatectomy and bilateral pelvic lymph node dissection. The pathology was reviewed at BC Cancer Centre. A Gleason score 3 + 4 with tertiary 5 prostatic adenocarcinoma was found, involving ~10% of the prostate. Focal extraprostatic extension was found, with no seminal vesicle invasion. Margins were clear, and no malignancy was found in any of the 14 lymph nodes removed. This resulted in a pathologic staging of pT3aN0 See –3. AdditPSA 3 months post prostatectomy was found to be normal at 0.03. This patient will be monitored by Urology moving forward and have serial PSA levels to ensure no recurrence. This case was discussed at provincial oncology rounds and a sarcoma specialist was consulted. The consensus was that no radiation therapy would be offered post-operatively, given the low post-op PSA, negative margins on pathology and lack of benefit of adjuvant radiotherapy in the current literature.et al. [STUMP is currently classified based on classification first proposed by Gaudin et al. , broken The behaviour of STUMP is unpredictable, and to date, there are no proven factors seen on imaging that indicate future progression or malignant potential with certainty. On occasion, STUMP has been known to progress to stromal sarcoma, characterized by cellular atypia, mitotic activity, necrosis and stromal hypercellularity . Due to PSA values have been known to be unpredictable in cases of STUMP; some have noted elevated PSA values , while oTo date, although there are a number of case reports of STUMP in the literature, there are relatively few cases of concurrent prostatic adenocarcinoma and stromal sarcoma . Our pat


Leiomyosarcoma is a rarely seen neoplasm of the ureter. Malignant tumors of smooth muscle of the ureter are extremely rare, and about 22 cases of leiomyosarcoma of ureter have been reported to date. A 57‐year‐old diabetic Pakistani man presented with a dull ache pain in the right flank. Past surgical history was three ureteroscopic surgeries for a ureteric stricture. Computed tomography showed a stricture with a peri‐ureteral soft tissue mass of 11 mm x 5 mm at the middle third of the ureter at the level of common iliac vessels. laparoscopic excision with safety margin and right ureterovesical reimplantation is performed. Diagnosis of leiomyosarcoma of the right ureter was made, and one iliac lymph node was excised and was positive for tumor by pathologic examination. Although leiomyosarcoma is rarely seen in urinary tract, it should be considered in the differential diagnosis of ureteral stricture disease and retroperitoneal tumors. Although leiomyosarcoma is rarely seen in urinary tract, it should be considered in the differential diagnosis of ureteral stricture disease and retroperitoneal tumors. In non‐transitional cell carcinoma, the most common is squamous cell carcinoma (0.7 to 7%) and adenocarcinoma (1%). Multiple types of sarcomas have also been reported in the upper urinary tract, including leiomyosarcoma, plasmacytomas, and angiosarcomas. The sarcomas are rapidly growing tumors, invade the adjacent structures. Leiomyosarcomas have early metastasis to mesentery, lungs, liver, and regional lymph nodes.Hematuria is absent in most cases due to non‐involvement of ureteral mucosa..1.1A 57‐year‐old Pakistani man presented to our hospital with a dull pain in the right flank, which had persisted for 4 years. He complains of right flank pain and clinically diagnosed as ureteric stricture. The patient is diabetic but controlled by medical treatment. Past surgical history of the patient was three ureteroscopic surgeries and double J stenting three times for the stricture and one laser cut for the same stricture with stenting for 6 weeks in different institutions in the last few years. Past history of appendectomy when he was a twenty‐year‐old with ugly scar in the right iliac fossa was seen. The scar was due to complicated appendectomy wound with incisional hernia and repaired with mesh. The patient has unexplained polyuria, and he passes 5 liters of urine every day without consultation. Our team work formed of urologist, nephrologist, endocrinologist, and oncologist.1.2Urine examination identified microscopic hematuria; Blood sugar is normal, renal function tests are within normal. Urine PH is normal and repeated many times with normal results. Anti‐diuretic hormone is evaluated with normal results. Potassium results are borderline results and when repeated, postoperatively, he had hypokalemia associated with ileus in the postoperative course.1.3Ultrasonography identified right moderate hydronephrosis with dilation of the proximal ureter. Computed tomography abdomen and pelvis (CT‐KUB) Figure  showed t1.4Diagnostic ureteroscopy revealed a narrowing of the lumen of the ureter without any mass seen in the ureteric lumen. Under general anesthesia, diagnostic laparoscopy revealed the ureteric stricture at the area of crossing iliac vessels, and proximal ureter is dilated. The ureteric stricture area is resected with safety margin 1 cm above. The proximal tortuous ureter is straightened and re‐implanted in submucosal tunnel in the bladder with Boari flap using 4/0 Vicryl. A double J stent 5 Fr/ 24 cm is fixed for 6 weeks. Postoperatively, the patient had distended abdomen with urine output exceeding 7 liters every day associated with hypokalemia. Potassium is corrected, and bowel movements are resumed. The patient is investigated for diabetes insipidus, and nephrogenic type is diagnosed. Diabetes mellitus is controlled well in the postoperative course. The patient is discharged after 10 days of the surgery with oral potassium and medicines of diabetes mellitus.1.5Pathologic examination showed that leiomyosarcoma of the ureter. The cancer was composed of fascicles of interlacing, moderately large, spindle‐shaped cells, with abundant eosinophilic cytoplasm. Immunohistochemistry showed strong staining for smooth muscle actin (SMA) Figure . A diagn1.6PET CT scan is performed after diagnosis of leiomyosarcoma to find out any metastasis, but the result was negative. The patient did not have recurrence at 3 and 6 months CT scan examination Figure . We reco2Leiomyosarcoma is a rare soft‐tissue tumor that accounts for 10–20% of soft‐tissue sarcoma, is generally seen in middle‐aged patients, and afflicts women more frequently than men.In our case report, the metastasis to iliac nodes is positive leiomyosarcoma at short‐term follow‐up for 6 months after surgical excision is good.An important aspect of the management of leiomyosarcoma is to differentiate the lesion from rhabdomyosarcoma and other spindle‐cell neoplasms. This is especially difficult with poorly differentiated high‐grade lesions. On immunohistochemistry, leiomyosarcoma is negative for epithelial markers . Positivity for desmin and SMA shows the smooth muscle origin of the tumor and gives a definitive diagnosis. Negative myoglobin, cytokeratin, and S‐100 help to rule out rhabdomyosarcoma, sarcomatoid carcinoma, and melanoma, respectively.Since there is no mode of definitive treatment for this rare disease, one must extrapolate from modes of treatment of leiomyosarcoma of the ureter and epithelial tumors of the ureter. In our case, surgical excision of the ureteric stricture with safety margin is performed, surrounding tissues and iliac lymph nodes are removed.3Although leiomyosarcoma is rarely seen in urinary tract, it should be considered in the differential diagnosis of ureteral stricture disease and tumors.The authors declared no potential conflict of interest with respect to the research, authorship, and/or publication of this article.HA wrote the manuscript, performed the operation, and managed the patient's perioperative course. HA, YE treated the diabetes insipidus and PK examined the tumor histopatholgy. YE and PK gave the final approval of this manuscript and read and approved the final manuscript.All procedures performed in this study were in accordance with the ethical standards of the Institution and/or National Research Committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards.Written informed consent was obtained from the patient for the publication of this case report and any accompanying images.


Granular cell tumors (GCTs) are rare neoplasms of neuroectodermal origin characterized by large polygonal cells with abundant eosinophilic and granular cytoplasm. GCTs rarely affect the lungs, with only a few cases reported in the literature. The pathophysiology of this Schwann cell-derived condition is not well understood but is thought to be due to recurring genetic mutations. GCTs have been linked with Noonan syndrome. Here, we report the case of a 17-year-old caucasian male who presented with partial upper airway obstruction due to a GCT. This case promotes awareness among pathologists and clinicians for this condition in the workup of patients presenting with upper airway obstruction. PTPN11 gene, PTEN gene, or Ras/mitogen-activated protein kinase pathway [Granular cell tumors (GCTs) are neoplasms of neuroectodermal origin characterized by large polygonal cells with abundant eosinophilic and granular cytoplasm ,2. The u pathway ,4. GCTs  pathway ,6. In adA 17-year-old caucasian male presented with progressively worsening shortness of breath, exertional dyspnea, and wheezing for four months. His symptoms gradually worsened despite medical treatment with albuterol, ipratropium, montelukast, and loratadine. A pulmonary function test indicated a fixed upper airway obstruction. Chest radiograph and computed tomography were unremarkable. However, a subsequent bronchoscopy revealed a 0.3 cm polypoid mass partially obstructing the right upper bronchus, for which a biopsy was performed.Microscopic examination of the biopsy revealed subepithelial proliferation of bland spindled to polygonal cells with round to oval nuclei and abundant eosinophilic granular cytoplasm Figures , 2. DiscA GCT is a rare soft tissue neoplasm of neuroectodermal origin characterized by large cells with eosinophilic, granular cytoplasm . They prAlthough the large majority of GCTs are benign, a small portion 1-2%) can be malignant -2% can b,9. One sThis unique case report highlights the importance of screening and follow-up to prevent advanced malignancy. It also aims to bring GCTs into attention when considering the differential diagnosis for obstructive airway symptoms. Here, we reported the case of a 17-year-old male presenting with asthma-like symptoms, ultimately leading to the diagnosis of a GCT. Despite the small risk of malignant transformation, performing a thorough clinical evaluation is essential, especially in pediatric patients.